One major problem in the Middle Ages was sewage disposal. Much of the waste of London ended up in the Thames, but not everyone was conveniently situated close to this open sewer. Others dumped their sewage into slower-moving waterways. For example, in 1355 it was found that the Fleet Prison ditch, which was designed to be 10 feet (3 metres) wide, was so choked with the sewage of eleven latrines and twelve sewers that water no longer flowed along it. Faced with the need to remove household toilet waste, some turned to piping it into the unused cellars of unwary neighbours. Two men were fined for this in 1347. More often householders dug cesspools in their yards and constructed latrines over them. One such enterprising Londoner was Roger the Raker. Unfortunately, over the years this pit filled to capacity and rotted the floorboards. When Roger eventually plunged through these floorboards and drowned in his own accumulated excrement, it raised questions not only about the quality of London carpentry but also about the way in which health and well-being in the Middle Ages were affected by the sanitation of the time.1 But before this is explored it is necessary to address the complex issue of the rise and fall of the medieval population.
Population statistics: an overview of change
The total number of Norman immigrants and their followers probably made up only about 5 per cent of the English population of about 2.5 million in the late 1060s. With the Norman core of William’s supporters came others who had connections with him in Normandy and for whom the conquest of England offered opportunities both financial and social. These included Flemings, Bretons and Frenchmen and later a small population of Jewish and Italian bankers and merchants. But there was no major change to the ethnic make-up of England, and there was genetic continuity for almost the entire Middle Ages.
Evidence to support population estimates for the Middle Ages is limited and means that there are wide variations in possible figures. Three major pieces of evidence used are Domesday Book (1086), the Poll Tax returns for 1377 and the registration of baptisms, marriages and burials which began in 1538. These provide a basis for ‘guesstimates’ of population levels at key points in the Middle Ages.2
These ‘guesstimates’, as we have seen, hover around 2.5 million for 1086. By 1300 the population probably stood at 5.5 million and may have been as many as 6.5 million. By 1377, however, the population of England had fallen to about 2.5 million (following disastrous harvests, livestock diseases and the Black Death) and it would not exceed this figure until after1520 (with a likely low point in1450 of somewhere in the region of 2 million). The figure for 1377 can be gauged from the number of tax payers listed under the Poll Tax figures for that year, and the reasonable nature of the first Poll Tax suggests that tax evasion was probably relatively low. The pattern of declining population continued into the fifteenth century and it is actually possible that the population in 1525 was even a little lower (at about 2.3 million) than it had been in 1377. By 1541 a likely figure is 2.7 million and by 1551 about 3 million. The steady increase in population levels as the sixteenth century progressed was probably due to a mixture of reasons: higher rates of marriage for the size of the population, younger age of marriage for women, and possibly a slight reduction in occurrences of epidemics. What is so striking about this pattern is the realization that in 1300 the English population was comparable with 1750 but it took 450 years to reach this level again following the great fall in numbers in the 150 years after 1300. The fact that the mid-eighteenth-century population only then entered a rapid trajectory of growth as a result of the Agricultural and Industrial Revolutions suggests that, without these twin developments, population had hit a ‘glass ceiling’ at about the 1300/1750 level. Prior to the upward leap in population after 1750, it seems that the available agricultural techniques – coupled with the limited movement of foodstuffs on pre-industrial transport systems – were unable to support the kind of population levels that have been sustained since 1750.
The distribution of the medieval population was in striking contrast with the modern English population. In 1086 the greatest concentration of population lay in eastern England (Norfolk, Suffolk, Kent and Lincolnshire). By 1377 this had evened out a little as a result of a rising population in the Midlands, but the north and west still remained more thinly populated. This distribution of population in 1377 is, unsurprisingly, similar to the distribution of wealth seen in the tax returns of the Lay Subsidy in 1334.
Life expectancy in the Middle Ages followed a similar roller-coaster pattern and there was certainly no inevitable upward trajectory. On the eve of the Norman Conquest life expectancy was in the region of 35 years for a man and 25 years for a woman. By the 1390s life expectancy amongst Essex peasants has been calculated to have been 54 years (an average of male and female expectancy), and monks at Westminster Abbey at this time had a life expectancy of about 50 years. But by the 1490s this had declined to 48 years for the same Essex peasants and 40 years for the Westminster monks. The repeated cycles of infectious diseases after 1348 had taken their toll.
Diet and health: fat friars and hungry peasants?
Life expectancy is clearly affected by many factors, among them diet and nutrition. Gluttony was one of the Seven Deadly Sins, and episcopal visitations condemned monks for gluttony and for eating food intended for the poor. This criticism of monks increased from the late fourteenth century and was a product of ‘a critical middle class willing to denounce the failings of both secular and religious authorities’.3 But were these accusations of gluttony justified? It seems they may have been. Accounts from Westminster Abbey suggest that monks – even when fasting – consumed above the modern nutritional recommended daily allowance (RDA). Late fifteenth-century monks at St Swithun’s Priory, Winchester, consumed per day: 1.5 lb (0.68 kg) of meat, five eggs, vegetable soup, bread and ale. Research on skeletons of 376 men over the age of 45 from three London monasteries – Merton Priory, Bermondsey Abbey and St Mary Graces – found that monks (compared with secular evidence) were almost five times as likely to develop obesity-related joint disease. These included a specific form of degenerative arthritis characterized by excessive bone growth along the sides of the vertebrae of the spine and other bones, known as diffuse idiopathic skeletal hyperostosis (or DISH), and other types of osteoarthritis.4 DISH occurs today in about 2–4 per cent of modern populations but is as high as 10 per cent in the medieval monastic cemeteries of London. Over 11 per cent of those buried at Eynsham Abbey (Oxfordshire) suffered from DISH and similar evidence comes from other monastic cemeteries. Large-scale studies of DISH on medieval skeletons reveal that 87 per cent of sufferers were men, and that it was more likely to be found among the better-fed and less physically active monks of the Benedictine and Cluniac orders than among the vegetarian Carthusians and physically active friars.5
On the other hand, among the majority rural population diet varied with the success of the harvest. Poor weather in the early fourteenth century, for example, led to starvation. Indeed it was not until 1437–40 that the last great period of famine in the English Middle Ages occurred, due to the impact of the weather. At Chester in 1437 there are records of peasants making bread from peas and even from fern roots, so scare were supplies of wheat and the price so high. Paradoxically, the previous 60 years had seen improvements in access to food due to falling prices in basic foodstuffs from 1375. This variability means that it is difficult to generalize about the dietary experiences of ordinary people in the later Middle Ages. However, we can glimpse something of their nutritional reality.
Osteo-archaeologists (bone specialists) can identify evidence for problems in diet and nutrition in the form of Harris lines, or ‘growth arrest lines’ on skeletons. These lines appear in bones due to temporary retardation of bone growth. They appear as dense lines parallel to the growth plates in the long bones such as the leg (i.e. they appear as horizontal lines across the bone). They are caused by starvation or malnutrition, and some types of sickness. By identifying these lines it is possible to see how often an individual underwent severe stresses of this sort and how severe this stress was. It is also possible to get some idea as to how old the person was when the line was formed, by looking at where it appears on the bone. Regular occurrences of Harris lines may be an indication of seasonal stresses, which may imply that food was short at certain times of the year or at certain periods in the life of an individual. Studies comparing medieval and modern populations in Switzerland have found that: ‘A high incidence of Harris lines was found in the medieval population, perhaps reflecting difficult living and hygienic conditions, but also the poor care and neglect of the child population’.6 However, in England the evidence suggests that, while there were periods of real shortage, this problem was not generally widespread or persistent. Based on a study of over 16,000 Late Medieval skeletons this gives a picture of a reasonably well-fed population with occasional crises.7
There is evidence to suggest that, despite the problems in trade experienced by a number of industries in the early fifteenth century, many in the population were in fact able to use an improvement in wages to increase their consumption of ale and meat. No longer were they spending the greater proportion of their available cash on basic foodstuffs. In this respect standards of living seem to have been rising for a while after 1400, until recovering population and rising inflation depressed it again by the later fifteenth and early sixteenth centuries. Analysis of the food consumption of harvest workers at Sedgeford (Norfolk) in 1424 shows that the daily food intake was 1lb (0.45 kg) of meat and at least 6 pints (3.4 litres) of ale for every 2lb (0.9 kg) of bread consumed. The increase in meat consumption is in marked contrast to evidence for food intake a century earlier. Wheat-flour bread was replacing barley bread, and fresh beef was replacing bacon. In this improved consumption standards of living were coming into line with those which had previously been enjoyed only by better-off townspeople, clergy and gentry.8
Evidence about health, as well as nutrition, comes from a small selection of written sources but mostly from archaeological evidence. Bones reveal signs of infection in cases of tuberculosis, leprosy and syphilis. However, not all diseases show themselves in this way and those which impact on the soft tissues only cannot be detected. At times, though, the information from bones is quite specific. At Edix Hill, Barrington (Cambridgeshire), for example, in a cemetery used from the fifth to the seventh century, two skeletons show signs of leprosy in the bony growth found on the skull and extremities of the limbs.
Other evidence from skeletons can be even more revealing. Work at the cemetery of the deserted medieval village (DMV) of Wharram Percy (Yorkshire) has provided a detailed insight into both the health and diet of this farming community from the eleventh to the thirteenth centuries. Of the 687 skeletons examined, 15 per cent were babies. Their bones suggest that they were breastfed for up to 18 months. Modern research on the effects of breastfeeding show that this will have doubled these children’s chances of survival in their first year. Even more revealing is the evidence for the long-term relationship between nutrition and overall health. By the age of ten the average height of children at Wharram Percy was 120cm (47.2 inches); less than the modern average figure of 137cm (53.9 inches) for a ten-year-old. Furthermore, the medieval children did not reach the height of a modern ten-year-old until the age of 14. In this they were similar to nineteenth-century factory children. However, despite a longer growing period the medieval inhabitants still grew relatively tall. The average height achieved at Wharram Percy was 169cm (66.5 inches) for men; national data for the Late Medieval period gives an average of 171cm (67.3 inches), compared with 175cm (68.8 inches) today. At Wharram Percy the average height for women was 158cm (62.2 inches); the Late Medieval average was 159cm (62.5 inches), compared with162cm (63.7 inches) today.
For those surviving into adulthood the chances of a relatively long life were good, as about 40 per cent of adults lived to 50 years or more. Regarding adult health, women suffered a high incidence of osteoporosis (loss of bone density in old age), while the men suffered it in the same proportion as modern men. An interesting statistic relating to women is that it seems that the minimum interval between births was probably 2.5 years. So, ignoring other factors, women would probably only have had eight children at most in their lifetime.
Skeletons from nearby York, from the same period, are also very revealing concerning social and health trends. At York there was a gender-ratio of ten women to nine men in the later Middle Ages; in the countryside the ratio was three men to every two women. It is possible that women were more geographically mobile, leaving villages for markets, workshops and service in grand houses. Skeletons also suggest that urban women did less physically demanding work than rural women. In contrast, rural women had osteoarthritis concentrated in their legs and back, suggesting gender-specific jobs such as grinding corn. Overall, the evidence for anaemia and infection was frequently found in skeletons from York, suggesting that crowded conditions and contaminated water produced ‘a greater pathogen load in the urban environment’. Similar evidence from the cemetery at St Mary Spital, London, revealed high levels of rickets (averaging at about 24 per cent of the skeletons excavated) and suggests that these medieval Londoners also experienced poorer health than their rural neighbours, lacking sunlight and a balanced diet. Life could be more dangerous in an urban setting in others ways too: evidence for violent injury, for example, was higher in York than at Wharram Percy.9
Unlike the overweight monks discussed earlier, diet for the rural population was carbohydrate based. Rye bread and porridge were consumed, along with large quantities of ale. There was fairly easy access to dairy products but not in the quantities consumed by the DISH-exhibiting monks. On the other hand, cabbages, leeks and onions frequently occur in medieval descriptions of peasant food. Meat featured more in the diets of the better-off. Honey was the usual sweetener. Generally, dental caries (the term for tooth decay or cavities) remained relatively low until the seventeenth century, when it increased due to more dietary intake of refined carbohydrates, especially sugar. The relative rarity of sugar meant that in 1334 it cost 7 pence a pound (0.45 kg), which was more than a day’s wages for a skilled archer in the Hundred Years’ War. Even its increasing availability over the next century did not prevent it from remaining an expensive luxury. However, teeth still suffered – but from grits in cheap bread and poor oral hygiene, which will have encouraged infection and abscesses.
So, there does seem to be some validity in the stereotypes of portly monks and thin peasants. Rural populations were more prone to fluctuations in their nutritional consumption, as revealed by such things as Harris lines, than were the well-fed members of monastic houses. On the other hand, the evidence does not support the idea of a starving peasantry. However, it is clear that until the middle of the fifteenth century such a fate was never far away and that, in times of climatic deterioration or animal disease, it could suddenly become an all-too-present reality.
Sanitation and concepts of cleanliness
Health, of course, is also affected by levels of cleanliness. The importance of soap was recognized in the Middle Ages, and fifteenth-century ‘white soap’ was made from a mixture of fern ash and unslaked lime which was allowed to stand for two days. After this it was mixed with oil and tallow (usually beef or mutton fat) and heated before finally being mixed with bean flour and moulded into cakes.
In Britain references to soap begin to appear from about the year 1000. The chronicler John of Wallingford (died 1214), recording traditions from the early eleventh century, referred disparagingly to the fact that Danish immigrants bathed every Saturday. He accused them of carrying out this strange practice, alongside combing their hair daily and frequently changing their woollen clothes, in order to seduce English women! In 1192 the chronicler Richard of Devizes referred to the number of soap makers in Bristol. In the late thirteenth century soap making was reported in Coventry, while other early soap-making centres were in York and Hull. In the fifteenth century a London sopehouse was located in Bishopsgate and others were found on Cheapside. The Cheapside site left evidence in Soper’s Lane, now Queen Street.10 The Proceedings, Minutes and Enrolments of the Bristol Company of Soapmakers survive from the years 1562–1642 and record the names of over 180 people engaged in the trade in the city. A type of black soft soap was called ‘Bristol soap’ and a harder type, known as ‘Bristol grey soap’, was supplied to London by 1523 at the price of one penny per pound.11
However, personal cleanliness has only limited impact without clean water and sewage disposal, and before the later nineteenth century these two factors were the greater influences on public health. Also, medieval people had a different concept of the link between cleanliness and health. For them, the actual smell itself was the threat – the smell spread disease. Most had no idea that hand washing, bathing or cleaning food would combat illness. Archaeological studies reveal the outcome of such limited understanding of the link between dirt and disease: conditions such as amoebic dysentery, tapeworms, boreworms and whipworms were widespread.
In addition, society in the Middle Ages lacked coordinated systems of delivering clean water and (as we have seen) removing sewage. In this sense medieval towns and cities were inevitably dirty and unhealthy. This is not to suggest that men and women were complacent about these matters. A large amount of evidence suggests that, while the absence of a germ theory meant that there was no real understanding of what caused disease, there was a clear association between filth and bad health. At the very least, dirty water tastes foul, and rubbish and sewage stink. For these reasons alone authorities in towns made frequent efforts to clean up the environment. By 1285 the Great Conduit had been built to supply London with clean water (its intact fountain house has been excavated under the modern road of Cheapside). But this could not overcome the terrible conditions facing Londoners. We saw at the start of this chapter that complaints exist in the medieval records of cesspits leaking into the cellars of nearby properties, and of citizens even piping their sewage into their neighbours’ cellars. The fact that such complaints exist show that the authorities were not taking the state of London for granted. The appropriately named Assize of Nuisances was established in London to settle disputes between neighbours over sewage and other actions which polluted the city. Even Edward III (1327–77) was moved to complain to the authorities about the foul state of the capital, which he suspected would lead to disaster:
When passing along the water of Thames, we have beheld dung and lay stools and other filth accumulated in diverse places within the city, and have also perceived the fumes and other abominable stenches arising therefrom, from the corruption of which great peril to persons dwelling within the said city will, it is feared, ensue.12
Furthermore, industry and housing was not separated, so pollution impacted on the lives of citizens. This would have been particularly the case with industries such as butchers and fishmongers which produced health-threatening waste byproducts. As one modern historian, Professor Hutchinson, has put it:
It’s difficult for us today to understand the medieval city as a multitude of simultaneous activities. People living, people bringing up families, being educated, worshipping and, most important of all, making and trading. But all cheek by jowl. They don’t separate industry and living.13
The shifting – after protests from the prior of St John of Jerusalem – of the butchers’ quarter out of the city to Stratford, or Knightsbridge, would have helped overcome at least this menace to health. But the fact that the butchers’ waste was then dumped in the Thames will have threatened the health of those who used it as their water supply. The waste of tanners and dyers was added to this foul cocktail. And this is the key point in explaining much of medieval ill health: sewage/waste and drinking water were often in dangerously close proximity. This was either because the same river was used as a water source and a disposal system, or because groundwater supplies in springs and wells were easily contaminated by nearby latrines and cesspits.
The London city authorities attempted to meet the challenges by employing street cleaners and night-soil (sewage) collectors, and citizens were fined for polluting communal water supplies. One peddler was killed in a brawl when passers-by objected to an eel skin he had thrown into the street, which could have led to a communal fine. But the task was beyond the available resources and technology. Philip Ziegler, who has made a detailed study of the Black Death, sums up the state of fourteenth-century London:
By our standards, London would have been a very unpleasant, dirty, smelly place to live. The streets were always narrow; now they were cramped. The houses grew together. The streets would have a gutter on each side, and between these a muddy track that divided the houses. It was a pretty squalid scene.14
The killer diseases of the Middle Ages
The contrast between our modern affection for surviving medieval towns and the reality of medieval sanitation and cleanliness is well expressed in the words of David Dimbleby, in the 2007 BBC series How We Built Britain. Regarding the much-visited East Anglian town of Lavenham (Suffolk) he commented:
To our modern eyes, Lavenham is a perfect picture-postcard town. Thousands of visitors go each year to photograph the houses with their beam and plaster walls; a style of building that still seems to appeal to us above all others. But there was nothing twee about the town in the fourteenth century. The stench from the roadway would have been overpowering, as waste from the dye vats mixed with offal from the butchers, dung from horses, and human excrement.15
The general state of sanitation in the Middle Ages (polluted drinking water in towns, problems in urban waste disposal, close proximity of rat and human populations, and absence of any germ theory) meant that, at any time, epidemics could break out and spread. This helps explain the high rate of infant mortality and the death rate of women in childbirth (due to infections introduced during labour); it also helps explain the generally low life expectancy – similar to those in less economically developed countries of the twenty-first century. This situation meant that life in the Middle Ages was lived in a context where killer diseases were endemic and accidents and minor infections could easily escalate into life-threatening conditions.
However, the fact that the population more than doubled between 1066 and 1300 reminds us that, in the competition between endemic disease and a high birth rate, the human population was capable of growing against these medical odds. This would have been assisted by the fact that the vast majority of people living in the countryside would have been less prone to illness which thrived in cramped and unsanitary urban conditions. Had this continued to be the overall medical experience of the Middle Ages then the population would have continued to grow despite the appalling death rate and would have been comparable with the booming populations in many modern developing countries. The reality, however, was far more complex and more terrible. The collapse of population after the 1350s, and its failure to recover to the level of 1300 over the next 150 years, reminds us that the medieval community did not only face an ongoing battle with endemic illness but also faced the intrusion of new and deadlier diseases which it had neither the medical knowledge nor the social organization to resist.
Of all the intrusive new killer diseases of the Middle Ages none compares with the Black Death, which swept the British Isles after 1348. First arriving in the port of Melcombe Regis (opposite Weymouth, Dorset) shortly before 24 June (the Feast of St John the Baptist), the disease had been moving westward across Europe for several years. This disease is usually identified as bubonic plague (Yersinia pestis), although other possibilities have been suggested, including anthrax, haemorrhagic fever and even Ebola. However, current evidence from plague victims in southern France supports the traditional identification. Contemporary chroniclers were understandably confused, as it seemed to come in a number of forms. The first exhibited characteristic swellings of the lymph glands in the groin and armpits (the infamous buboes). The second was a pneumonic form which infected the lungs and spread through coughing and sneezing. The third was a form which gave rise to septicaemia. Since all had different symptoms they appeared to be different diseases. The bubonic form may have thrived in summer and given way to the pneumonic form over the winter.
The spread of the disease seems linked to movements of infected rats. Black rats (Rattus rattus) live in close relationship with people. Thatched roofs and cob-and-timber-walled houses were easily infiltrated by rats; waste in urban streets would have supported large rat populations. Excavations in Southampton suggest that the rat population increased noticeably from the thirteenth to the fourteenth century. As rats fell victim to bubonic plague their rat fleas transferred to human hosts and the disease jumped the species barrier. It is interesting that in the European legend of the Pied Piper, the Piper (plague) first kills the rats before he carries off (kills) the children. And this reminds us of another feature of variants of bubonic plague – its (at times) disproportionate impact on the young and healthy.
The exact circumstances by which this disease reached western Europe is disputed, but the general consensus is that its medieval origins lay among the rodent population of central Asia. Environmental factors caused a movement of infected rodents out of this area, which then infected other rodents (e.g. rats). As these rodents died the disease passed to humans. The developing trade routes between the Middle East and China meant that a disease which was soon ravaging the Far East eventually spread to the Mediterranean and western Europe. The immediate link to the Mediterranean may have been via a Mongol army besieging the Crimean port of Caffa, which was occupied by the Genoese. Near-contemporary chroniclers suggest this connection. From there the disease spread to Italy. Environmental factors such as mild, wet weather may have encouraged the survival of the disease in host populations.
By the summer of 1348 the disease was in Dorset, by August it had reached Bristol, by September it was raging in London and the eastern ports of Ireland, and by 1350 it had reached northern Scotland. Nowhere escaped. The precise death toll is disputed but was very high: suggestions range from 35–50 per cent of the English population, and individual statistics bear this out. The manors of Glastonbury Abbey lost 50 per cent of their tenants, 40 per cent of the English parish clergy died, as did 27 per cent of the nobility (helped to avoid plague by less cramped conditions and fewer rats in close proximity). In January 1349, Ralph of Shrewsbury, Bishop of Bath and Wells, wrote a circular letter to his diocese in which he described how the disease ‘has left many parish churches and other livings in our diocese without a priest or a parson to care for the parishioners.’16 On the wall of the church at Ashwell (Hertfordshire) are scratched these enigmatic words: ‘There was a plague, 1000, three times 100, five times 10 , a pitiable, fierce violent . . .; a wretched populace survives to witness and in the end a mighty wind, Maurus, thunders in this year in the world, 1361.’17
The outbreak of 1348–50 was not all that was heard of bubonic plague. That of 1361 was remembered as ‘the mortality of the children’, as it seemed to target the young (probably those born since 1348 and without the immunity gained from surviving the first outbreak). Later outbreaks occurred in 1369 and in 1375. It would continue to return in cycles until its last great outbreak in 1665.
It is easy to assess the impact of the Black Death solely in its economic and class terms: the impact on wages, or the end of villeinage. This is very important but we must never lose sight of the emotional impact. It must have felt as if the world was coming to an end. Even to a community used to high mortality rates the seismic effect of what happened in the middle of the fourteenth century must have been impossible to comprehend. Because we cannot measure this, we are forced to recognize that we cannot fully grasp it – but this does not mean we should ignore it. People’s spiritual, emotional, mental, economic and social worlds were changed as a result of the cataclysm that had befallen them. As the poet John Gower noted in the 1390s:
The world is changed and overthrown,
That it is well-nigh upside down,
Compared with days of long ago.18
The bubonic plague was not, of course, the only killer disease of the Middle Ages. In fact, a study of death rates at Christchurch, in Canterbury (Kent) between 1395 and 1505 concluded that one year in every four was a ‘crisis’ year. From about 1450 these ‘crisis years’ happened less frequently but the crises themselves were more acute and killed more people than the earlier – more frequent – outbreaks of disease.19 Other evidence from Canterbury suggests that its killer diseases included ‘sweating sickness’ (possibly influenza), plague, tuberculosis and fever. Records from fifteenth-century Westminster point to summer and autumn as the seasons most closely associated with epidemics.
An occurrence of the epidemic known as the ‘sweating sickness’ in 1485 killed two mayors of London and six aldermen within one week. Thomas Hille, who was mayor at the time of the outbreak, died on 23 September and was succeeded by William Stokker, appointed the following day. Within four days Stokker himself was dead, and on the 29 of September John Warde was elected mayor for the remainder of the official year. There was no mayoralty banquet, which is hardly surprising in the disastrous circumstances.20Other outbreaks of this disease are recorded in 1508, 1517 and 1528. Tentative evidence suggests that mortality rates in the fifteenth century were highest in the population group aged 25–34 and this may have suppressed fertility and population recovery in the 150 years after the outbreak of the Black Death.
Tuberculosis (TB) may also have been a significant killer disease in the fifteenth century. Its alternative name of ‘consumption’ sums up the effects of untreated tuberculosis – the victim is (almost) literally consumed by loss of weight and breathlessness. The disease has also gone under the name of the ‘White Plague’. Tuberculosis bacteria most commonly affect the lungs (termed pulmonary TB), with about 75 per cent of those affected experiencing this. However, it can also affect the central nervous system, the lymph system, the circulatory system, bones and joints. It is a common and deadly disease. The bacteria is easily spread by coughing, sneezing, kissing and spitting, and a reservoir of the disease no doubt existed then – as potentially now – amongst cattle, in the form of bovine tuberculosis. This form may also be spread by badgers, amongst which the disease is also endemic. The dependence of the spread of the disease on environmental factors and inadequacies in knowledge of treatment has led a recent chronicler of the history of the disease to comment that ‘Tuberculosis has been called the perfect expression of our imperfect civilization.’21 Evidence from excavated skeletons is supporting the belief that the disease was present in the medieval population. Molecular biologist Ronald A. Dixon of the University of Bradford, has commented that ‘The historical record suggests a much larger number [of cases] than the cemeteries indicate.’ This is because only about 3–5 per cent of its victims develop lesions on their skeletons. However, in an effort to test the archaeological evidence, he and his colleague Charlotte Roberts have isolated fragments of DNA from eight skeletons taken from a medieval graveyard in northern England. One of these skeletons had lesions which suggested tuberculosis and from this individual they identified a section of DNA unique to Mycobacterium tuberculosis, the pathogen responsible for TB. There is now the likelihood that future studies of genetic material will confirm more examples of TB in medieval skeletons than were previously revealed by conventional bone analysis.22
Leprosy too was a killer in medieval England. Spread by skin contact, coughing and sneezing, it can take as long as five years before symptoms appear. In later medieval England leprosy may have declined because those who suffered from tuberculosis developed a cross-immunity. And to this list of killer diseases should be added dysentery, typhus and malnutrition.
Occasionally, evidence emerges in contemporary accounts which may point to other diseases that are difficult to identify without more detailed descriptions. One of these occurs in Knighton’s Chronicle, 1337–1396:
In the summer, that is, in the year of grace 1340, there occurred a repugnant and widespread sickness almost everywhere in England, and especially in Leicestershire, during which men emitted a sound like dogs barking, and suffered almost unbearable pain while it lasted. And a great many people were infected.
While it is impossible to be certain, the ‘barking’ voice may indicate an outbreak of diphtheria, or a streptococcal throat infection. The same chronicler also records under the summer of 1355 a disease with the following characteristics:
. . . people went out of their minds, and behaved like madmen in field and township. Some thus deranged fled into woods and dense places, as though they were wild beasts shunning the presence of men, whilst others ran from the fields into the townships, and from the townships into the fields, now here, now there, without regard for themselves, and it was extremely difficult to catch them. And some wounded themselves with knives or tore with their teeth those who tried to capture them. And many were taken and led into church, and left there bound until they received some relief from God, and in some churches you might see ten or a dozen of them, or more, or fewer, and it was a great sorrow to behold their suffering.
Knighton concludes that the sickness was possibly due to evil spirits, but the symptoms suggest the crisis may have been an outbreak of ergotism. This occurs when damp, cool weather leads to cereals (particularly rye) being contaminated with a hallucinogenic fungus.23
There has long been an assumption that syphilis entered the European population following the discovery of the Americas. However, definite medieval examples have been discovered in York, Ipswich, Hull and Carmarthen in Wales. One expert in the field believes that ‘venereal syphilis is a late medieval, newly evolved form, probably derived from endemic syphilis in Southwest Asia’, and that its late appearance in England was not due to transfer of the disease from the Americas but rather that the disease ‘was late in adapting to populations living in colder northern European climates and societies, and had to become more aggressive and venereal in transmission.’24 The symptoms of syphilis (which can take up to 20 years to show themselves) would have resembled leprosy, and it was probably treated as if it were this disease.
Hospitals, medicine and surgery
Medieval medical care was a complex mixture of Christian theology, Greek and Roman medical concepts, astrology and traditional practices. In such a profoundly Christian environment spiritual causes of disease were frequently sought and an association often suggested between disease and sin. Christian compassion also led to active care for the sick and the establishment of early hospitals from the fourteenth century onwards, staffed by those in religious orders. In the same way infirmaries were an important feature of monasteries. These focused as much on spiritual health as on physical recovery, and even though medical remedies would have been limited in their effects the care, improved diet and increased cleanliness would in many cases have assisted recovery.
St Mary Spital was one of the great hospitals of medieval London, alongside St Bartholomew’s. Founded in 1197 as a refuge for women in childbirth, it was greatly enlarged in the thirteenth century. A two-storey infirmary was built and this was extended in the fourteenth century when new stone buildings were constructed for the lay sisters. Later still, tenements were built for wealthier residents. By the fifteenth century doctors were working in the hospital. The cemetery increased in size at the same time, suggesting that St Mary’s was operating more as a hospital than as a shelter for travellers. By the time of its dissolution in 1538 it had 180 beds and was one of the largest hospitals in England. Excavations on the site of the infirmary suggest a more likely figure of 90 beds but these might have been shared. A large north–south channel seems to have been dug as part of a water-supply system. While this was silting up by the fourteenth century it may still have assisted drainage.25
But the key question was, how was illness to be treated? There was no clear-cut answer. Increased interaction with the Middle East from the twelfth century led to a resurgence of Greek ideas, which had survived in the Islamic world. On one hand this encouraged a more critical – observational – approach towards diagnosis and treatment. On the other, the veneration given these ancient texts made their assertions unassailable even when wrong. A classic example lies in the Greek ‘Theory of Humours’, which asserted that human bodies were composed of blood, yellow and black bile and phlegm, and that illness was frequently caused by an imbalance between these humours. This flawed understanding led to frequent recourse to phlebotomy (blood letting), which would dominate medical practice for centuries. The colour of patients’ urine often dictated diagnosis. Astrology too dominated many treatments. Finally, in a pre-scientific environment, actual medicine was a mixture of tried-and-tested herbal remedies and others ranging from the bizarre to the dangerous. In this way helpful remedies such as feverfew to cure a headache, henbane smoke and raspberry-leaf tea to soothe pain, and poultices on inflamed wounds stood alongside fried mouse to cure whooping cough, quartz crystals to stop bleeding and badger droppings to stop toothache. Treacle appears as a much-sought-after remedy for reducing fever in the Paston Letters, and other sources refer to mustard for use in poultices. At Merton Abbey, London, archaeologists have discovered a dump of mustard seeds which were presumably shipped in along the river Wandle and used in the abbey’s infirmary.
Medical professionals were divided between physicians (who had completed years of study of the Greek texts) and lower-status surgeons who set bones and operated. Medicines and some medical advice would also have been dispensed by apothecaries. Only the wealthiest could afford such professionals and most would, instead, have relied on traditional folk remedies and local herbalists. By the fifteenth century increased understanding of anatomy assisted in wound treatment; literary evidence suggests the existence of cataract operations and archaeology reveals trepanation(drilling a hole in the scull). However, the absence of anaesthetics and antiseptics will have meant that much surgery was defeated by shock and infection. In this – as in many areas of sanitation, health and medicine – what we might call ‘the long Middle Ages’ lasted, for most ordinary people, into the nineteenth century. At the largest excavated medieval cemetery outside London (at Barton-upon-Humber, Lincolnshire) this reality was apparent in the fact that the skeletons revealed no significant differences in health over 900 years, from c.950 to c.1850.26 In this sense the Middle Ages lasted a very long time indeed.