Leprosy

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Hello and welcome to Gone Medieval by History Hit. I'm Dr Kat Jarman. Leprosy, also known as Hansen's disease, is a chronic infectious disease caused by Mycobacterium leprae. It's a disease that can have a devastating effect on those who catch it. affecting the skin and eventually the bones, the peripheral nerves, the eyes and the respiratory tract. It's also a disease with a lot of stigma and myths attached to it, many of them going back to the Middle Ages.

And the image of the medieval leper as an outcast from society is a common one. But is that really true? Were those affected by leprosy really considered to be outcasts in medieval society? How exactly were they dealt with and treated in somewhere like medieval England? To find out more, I've invited along Dr. Simon Roffey, who's a reader in medieval archaeology at the University of Winchester.

Thank you for joining me on Gone Medieval here today, Simon. Thank you. So you've got lots of different specialisms in this field, but you've also directed excavations of an actual medieval... leper hospital in Winchester, which we're going to go back to a little bit later on. But to sort of start off this episode, I was hoping we could talk a little bit more generally about leprosy, just in terms of how we can study it.

because of course studying disease in the past is actually quite hard. But what about leprosy? How can we get evidence and see anything about that in past populations? Well, there is some documentary evidence, first of all, and of course there is the archaeological evidence. And the documentary evidence, the earliest, is in the form of the Vedas, the Indian Vedas, dating from around about sometime in the first millennium BC.

And there was a reference to what is possibly leprosy in certain hymns that are concerned with healing. There's also references to leprosy in the Pali Canon, which is the writings concerned with the life of the Buddha. And they date to between about the 5th century BC to about the 1st century BC. And of course, there's references in the Gospels which date from the 1st century AD. So there are others as well. So there's quite a lot of early references to leprosy.

The earliest archaeological evidence is actually earlier, and this dates from about 2000 BC, and this is from Rajasthan in India, from a burial that was part of the Indus civilisation. And what's interesting about this burial is that it's linked to the Indus civilisation. which suggests that leprosy may have been linked to urban growth and expansion from a very early date.

And so it's quite specific leprosy, isn't it? Because we can physically see it. So when you talk about archaeological evidence, we're talking about evidence from bones and changes and that sort of thing. Yeah, from bones, of course, ancient DNA as well. But leprosy normally affects the skeleton, particularly is visible on the skull. So it affects the area around the jaw, the maxilla. all around the face, the nasal cavity, so it is easily identifiable in the archaeological record.

Yeah, and of course, it's one of these diseases that doesn't kill you immediately. So something like smallpox or something like that, if you are going to die from it, you die quite quickly. But leprosy, it sort of stays with you for long enough to make those changes. That's why we can see it, isn't it?

Exactly. So leprosy can stay with somebody for many years before they die. They have a diet of that eventually, or they might die of something different. But I mean, it has an incubation period of about a year to five years. And then, yes, people can live with it for many years after and the leprosy will get worse and the bones will fragment more. Yeah, so there's obviously implications concerning that, of course.

And this, of course, also makes it very visual. So it's a sort of thing that in past societies, people would know that somebody, you know, at least when it gets to that advanced stage, which I think has affected how people were treated. And if we just go back, sort of focusing on England now, so you talked about some of these international cases. Do you know what the earliest evidence we have for leprosy in England is?

There is possibly evidence in the prehistoric period, but the firmer evidence arises when we get to the early medieval period. And there has been some recent work on a place called Great Chesterford in Essex. A burial may date to the 5th or early 6th century. where leprosy has been found in an individual burial there. And what's interesting about that burial as well is it's early, but there's also evidence for various strains of leprosy.

and possibly a link to a form of epilepsy that could be found in red squirrels, which may... suggests there is a link to red squirrel fur trade, the movement of that material around as well. So that's interesting. But that's one of the earliest dateable examples.

When we come to the 10th, early 11th century, there's some early examples from Norwich as well, which may relate to a cemetery site that there's no evidence for any hospital-associated buildings. So it seems that when we get into the 10th, 11th century, leprosy. is picking up, if you like, it's becoming a lot more known to spawn the archaeological record. Do we have any written records from England in that early period? Yes, there is. Some of the old English...

Herbarium medical texts, such as the Lachnunga, for example, and Borg's Leech book, refer to ailments that may be leprosy. And certainly in the later Anglo-Saxon period, there was a Bishop of London that was reported to have leprosy as well and left his position as a result of that. So, yes, certainly there is documentary evidence in the Anglo-Saxon period, but it's very sparse.

at all like we get in the later medieval period. As soon as we hit the late 12th century, then there was a lot more documentary evidence for leprosy, as well, of course, as the foundation of leprosy hospitals. Yeah, so let's get to that in a moment, because that's a really, really interesting aspect.

But in general, do we know from any of those early sources, at least, how people were treated with that? Because I think in our minds, we sort of think of these as being completely sort of cast away in society. Is that something we know about from any of the early sources as well? how these people were treated? It doesn't appear to be from the early Anglo-Saxon sources. It doesn't seem to be any prejudice or any stigma attached to the disease.

And actually, I'm sure we'll get onto that at the moment, there is a lot of discussion and controversy concerned with... How we in the present, scholars, academics and like view leprosy in the medieval period, of course, this view that leprosy sufferers were outcast and stigmatised. And in fact, when we look at the archaeology in a moment, the archaeology supports the fact that actually in some cases they weren't stigmatised and actually they lived very different lives than we might expect.

So is that something that comes into some of those later sources then, the sort of later medieval period? Yeah, so we get more regulations concerning those with leprosy and how they should be treated as we move into the later 12th century, and then particularly the 13th and early 14th century. But quite interestingly, there is very little documentary evidence for regulations concerning leprosy sufferers in the late 11th and early 12th century, the first time we begin to see hospitals.

particularly hospitals that are dedicated for the care of leprosy sufferers. And there seems to be two... phases, if you like, concerning olipathy sufferers in medieval England. A first phase in the late 11th, early 12th century, where we see the foundation of hospitals, which are very much like religious communities, rather than... what we perhaps would know to be hospitals. They don't seem to be particularly monastic. They seem to be more quite simple, basic religious communities.

And then when we get into the later 12th, 13th century, we see more regulation concerning leprosy sufferers. And we see the hospitals come a lot more regularised, cloisters and organised under monastic rule. first phase, that late 11th, early 12th century, where archaeology can really shed light on how leprosy sufferers were treated in medieval society.

And so you've been involved in some of these excavations then. So tell us about some of that evidence and some of those hospitals that have been found. The first documentary evidence for a leprosy hospital in England is from the writings of a monk called Edmer, who writes of the hospital found by Archbishop Lan Frank of Canterbury. around about 1080. And he tells us this hospital was comprised of a well-ordered cemetery, a chapel and timber structures.

on the side of a hill. And this hill is a harble down just outside Canterbury where the Romanesque chapel still survives today. Compared with this, we have the archaeological evidence from the site that I worked at in Winchester that I directed my colleague Phil Marta between 2008 and 2015. where we have archaeological evidence for, in its early phase, for a chapel.

a well-ordered cemetery and timber structures on the shelf of a hill, very similar to that documentary reference by Edward Canterbury. And our site dates to between about 1070 and 1090, based on the radiocarbon evidence. So this seems to be the first wave, Canterbury, Winchester, no doubt a few others yet to be found, the first wave of leprosy hospitals in England. In fact, the first evidence for actually four hospitals entirely is from this period.

And they're both quite wealthy and very significant towns in England at the time. Is that a key? Is it the key that they are sort of crucial and places where there's a religious significance as well? Is that why they appear there, do you think? I think so. It's certainly the case of Canterbury, of course, with the archbishops, a number of important monastic communities there. With Winchester as well, the Bishop of Winchester was one of the most influential bishops in medieval England.

But also Winchester does have a possible tradition of healthcare. A lot of the early medieval texts like Ball's Leech Book, the Luck Nunga. the Old English Herbarium, many of these have possible early Winchester provenance. So it may be there was a sort of early background of healthcare in Winchester, certainly King Alfred and King Alfred the Great.

We know that he had physicians associated with his court, and it may be that there is, again, this long-standing... tradition in Winchester of healthcare that morphs into more formalised hospitals as we move into the late 11th century and particularly under the influence of the Normans. If you love ancient history, then don't worry, we've got you covered. I'm Tristan Hughes, host of The Ancients Podcast, the podcast for all things ancient history. And these are the only surviving boxing gloves.

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How much do you know that sort of leprosy was a key part to this? Could these just have been very general hospitals or would there be specifically leprosy hospitals? Out of all the medieval hospitals that were founded throughout the medieval period, perhaps numbering around about 1,400, 1,500, a quarter were leprosy hospitals. And many of the early hospitals were leprosy hospitals. So it does appear that we get a...

The growth of these hospitals in the late 11th century, from about 1070 onwards, possibly as a direct response to the sudden growth of leprosy. These hospitals have really come about because of the increase of disease and the need somehow to deal with that. We have at Winchester, we have over 85% of our examples from our early cemetery.

have evidence for leprosy. These are men, women, children and babies as well. And that suggests that somebody there knew what they were doing. They could diagnose leprosy very well. This is, again, one of the myths. concerning leprosy is that people really didn't understand it, couldn't diagnose it, the medical knowledge just wasn't there. But with over 85% of Winchester, that sort of challenges that little bit.

But also, I think clearly Winchester was a specialist hospital for leprosy sufferers. One can argue over 85%. There may be a few others in that cemetery also had leprosy because it's not all the time it shows on the skeleton. So I think leprosy was an early response, a dedicated hospital for leprosy sufferers.

And that's really interesting what you were saying just then that you had women and children as well. So does it seem like they might have been open then to anyone in society with that disease? That seems to be the case. I think certainly that it seems to be responding to perhaps a universal need for an institution to care for leprosy sufferers. Certainly, I think if you look at somewhere like...

Norwich as well, later on in the medieval period, Norwich had five, possibly six leprosy hospitals in and around the town. And Norwich was a particularly populous city. So it does seem to suggest a leprosy may have been linked to urban growth as well as an urban disease. And then in these populous towns, that's where we see these hospitals emerge as a reaction to that.

Yeah, so that makes sense for it happening in the kind of 11th century, doesn't it? That before that point that there was just not the same degree of urbanity anywhere really in the country. Yeah, exactly. That makes a lot of sense. Yeah. So talking then over time a little bit, how this is, so you touched upon this a little bit. Is it quite a rapid growth then? Do you sort of suddenly see them popping up everywhere, these leper hospitals?

Yes, I think certainly in the late 11th century, we see a really rapid response. From documentary and archaeological evidence, there's about seven or eight. Hospitals that are founded in the late 11th century, very early 12th century. I suspect there's more. I suspect if we were able to look at more hospitals archaeologically, we'd find earlier evidence. So, for example, at Winchester.

The earliest documentary reference to Winchester is in 1148, the winter doomsday. But we know through the archaeology, the hospital actually dates to about 60, 70 years before that. If you like, the prehistory of the hospital is somewhat earlier. So I suspect that a lot of other hospitals that have later documentary sources for their presence are probably archaeologically a lot earlier as well and may indeed date to the late 11th century.

And is this something that's quite specific to England, or do we see the same thing happening in other parts of Europe as well? Yeah, we certainly see the same thing happening in Normandy, for example. Rouen has an early hospital, Montemalade. There's hospitals further afield, the Mary Magdalene Hospital in Jerusalem, just outside the city. Constantinople had leprosy hospitals, so that they are fairly prevalent all across Europe.

And again, there's a response probably to the spread of the disease, particularly in the medieval period. And does that link to religious institutions? Does that continue as well over time? Is it always a religious link? Yes, it is. A medieval hospital is a religious institution. So at Winchester, right from the start, there's evidence for a chapel, and clearly it is linked to religion.

And leprosy, like many diseases, was seen as a disease that you couldn't treat, you couldn't cure, but you could, I suppose, look after people, you could care for the community. And you could give them spiritual help as well for the presence of chapels. I think this is very much linked to religion in the medieval period.

So I wanted to go back to what you were saying a bit earlier on about some of these myths about people being complete outcasts of society. So is that really not the case then, do you think, based on all this archaeology? I think that needs challenging perception. And I think particularly because today there's around about 200,000 diagnoses of leprosy in the world every year. Several million people in the world have leprosy.

And leprosy has always been seen as a disease associated with stigma, normally through sort of religious stigma. And many charities such as UK Leprosy Mission and Lepra have... argued that one of the issues is education, that people misunderstand the disease.

The disease today is treatable, I think, at the course of medicine that costs about 20 pounds, I believe. You can stop leprosy, stop the disease. You can't stop any of the things that happen to the skeleton, of course, and any of the injuries, but you can cure the disease. But a lot of people don't come forward because of the stigma attached to the disease.

So one of the things that we're interested in in our work at Winchester is really trying to find ways to how the archaeology can perhaps challenge this. Now, several historians, people like Carol Rawcliffe, for example, have previously argued that this idea... that leprosy suffers in the medieval period was stigmatised as a later creation. And she calls it a biomedical segregationist agenda, largely the 19th century.

For example, there are people such as the churchman Hugh of Lincoln, St Hugh of Lincoln, Jacques de Vitry, people of the late 12th, early 13th century, who actually have written about the disease as being a mark of election. Almost as a passport to paradise, in that leprosy sufferers were suffering Christ-like suffering. They were also experiencing, it was argued, the pains of purgatory here on earth. So in that light...

They are very much the elect. They're very much like, one could say, saints in a sense. I don't want to go too far with this argument. But in the medieval period, the only people who didn't go to purgatory or souls didn't go to purgatory were saints. and possibly people with leprosy because they were.

suffering with it here in life. That is the argument. It's very interesting. But how does the archaeology relate to that? So this is one of the things that we were interested in when we came to work at Winchester to excavate the hospital. What the excavations tell us. is that what we have is a community dating from the late 11th century. Over 85% of the individuals had leprosy, men, women, children and babies, all were catered for.

There was a chapel constructed, a well-appointed building, a masonry chapel. So their spiritual provisions were catered for. And the graves are interesting as well because the graves are anthropomorphic. They're human-shaped. They have head niches.

All the graves were marked because none of them were truncated, and we have evidence of around about 100 graves. This is very unusual for the medieval period, where many graves are sort of mixed up and truncated. These are... ordered, these are well ordered, they are organised, and it points to a certain level of perhaps dignity and respect that is given to these individuals.

But moreover, these grave types, these anthropomorphic graves, the only other context you see those is in monastic sites. So what we're seeing here are not outcasts, stigmatised people. These are people who are... Who are looked after? There is a chapel for their spiritual welfare. They are treated well in death. They are given graves akin to monastic graves.

There's also evidence for large timber structures, an infirmary hall on the site at the same time, and deep cellars used for the storage of foodstuffs. So this isn't a sort of ghetto community. This is, we believe, a religious community. And it may fit in very well with this idea that leprosy sufferers were seen as religious. In fact, leprosy was possibly a, I wouldn't go so far as saying these were the elect, these were saints, but I'd say that leprosy perhaps was seen as a...

a religious vocation, in a sense. And certainly the evidence is of a religious community of leprosy sufferers. So that's how we can... begin to challenge these myths that these poor unfortunate individuals were outcasts and mistreated. One of the other... Reasons that leprosy suffers in the medieval period have been viewed as being outcast is the location of hospitals.

Now, hospitals are almost always on the outskirts of town. And this led many people to think, well, they're ostracised. They're on the boundaries of their urban communities. They've been pushed away. But when we look more closely at the topographic relationship, the location of these hospitals in context, they're either close to main roads. The one at Winchester is close to London to Winchester Road. Southampton, right outside the town gate.

Bath, right outside the town gate. All of Norwich's hospitals are right outside the entrance of towns. So these are not places you put people you're trying to ostracise. They are very much part of the urban fabric, the urban hinterland. They're in these locations probably because they can get arms easy. They're also recognisable charitable institutions at busy spaces. So certainly that doesn't suggest they're outcast at all.

One of the other issues that feeds into this is the notion of contagion, that maybe these hospitals were placed on the outskirts because individuals were contagious, people were frightened of catching the disease. But other historians have argued that... Ideas of contagion weren't really about properly until the later 14th century and onwards. The idea you could catch an airborne disease really wasn't that current.

at the period we're seeing leprosy hospitals being founded. So again, the idea of contagion can be challenged again if we think about things differently, I think. So that's some of the value of our work, I think. challenging that notion of leprosy sufferers as being outcast and actually giving a different picture of how they were treated and their relationship to wider society.

That's fantastic. Now, that really does show, doesn't it, how we so easily just apply our current world concept or something like that to the past, but actually, especially the archaeology alongside written evidence can change that quite a lot. Exactly.

And in terms of new methods and things that are coming along, things like bioarchaeology, DNA analysis, how's that contributing now to the study of leprosy in the past? Well, work on ancient DNA in particular has been the subject of a series of numerous papers over the past few years. It's recognised that ancient DNA work is really important in looking at leprosy, but particularly looking at various strains of leprosy and the transmission of the disease as well.

So, for example, the site of Great Chesterford in Essex, where we have a particularly early example of leprosy in an individual dating from the late 5th, early 6th century. At that site, it's been identified that there are 10 strains of leprosy through the genetic work that's been... conducted there. At least 10 strains come from all different areas, the Americas, Western Asia, or the same strains rather that we find in the Americas, Western Asia, Eastern Europe.

And it's really sort of opening up the understanding of how leprosy moves through populations, how it gets where it does and where it goes from there. So genetic work in many ways in terms of leprosy is right at the beginning of... what it's going to be telling us. But I think in future years, as we go forward, it's really going to shed light on

the transmission of disease and not just leprosy, I think, but, you know, other diseases as well in the medieval period. And, yeah, it's extremely exciting, I think, in terms of where we're going with that. And it's a really... useful discipline to compare with the archaeology, the human remains and the buildings and the sites themselves.

So you get the whole thing, you get, you know, how it's spreading, how people are moving, how it's affecting people, how it's affecting society. You can sort of tie all that together in a great big package then, can't you? Which is really exciting. Yeah, exactly. Yeah, it is exciting and it gives a real... It just gives real insight into the nature of disease and how it gets where it gets, how it moves around patterns of its transmission.

Yeah. And of course, now in 2021 and living through a pandemic ourselves and thinking a lot about these different strains of diseases and travel and movement, it's quite an interesting parallel, isn't it? Just think of that a thousand years ago. It is interesting the way that we talk about stigma and we talk about leprosy sufferers being outcast and how much this is, again, a modern perception in some ways.

At the moment with the pandemic, the coronavirus pandemic, we are seeing in society there is this sort of outcasting of certain people who have different views on... rightly or wrongly, as if there's no discussion involved. There's just opinions right, opinions wrong. And I think that's interesting because we can learn from the medieval period, I think, and see how...

These sort of notions of stigmatisation are quite current as well. That's such a really brilliant perspective. I love that. Brilliant. Simon, thank you so much. Do you have more work going on at Winchester in the hospital there or is that all finished now? Now we're working on the post-excavation phase. So we've got a lot of material we're working on. We've almost finished our work on the skeletal remains. So we hope to move towards publishing them soon. We're doing work now on some of the...

some of the metal work. We've had a PhD student recently finish her work on the faunal remains of the site. Again, that's fascinating. One of the... The interesting result from her work was she showed a diverse diet leprosy sufferers had in the hospital, but also the evidence for the making of soups and broths through the boiling of bones. And of course, from what we know about lepsis, how it affects the jaw, the mouth, the ability to eat, soups and broths would be extremely important.

And again, that feeds into this idea that we talked about earlier about these being outcasts, because someone there clearly was looking after them, making these soups and broths and giving it to them. We've got all that to really get together to publish. We're doing work on the metal work as well there. So I think we're going to be busy for many years looking for this material.

Fantastic. Well, I can't wait to see the rest of the results. Brilliant. Simon, thank you so much for joining me today. Thank you, Pat. Thank you so much for listening. My name is Dr. Kat Jarman. This has been an episode of Gone Medieval by History Hit. Don't forget you can subscribe to the podcast and you can also subscribe to our Medieval Mondays newsletter to get more medieval information.

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