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Disease

Abstract and Keywords

This article explains that visible skeletal characteristics may have been unnoticed by their bearers, while socially — and physically — debilitating problems may leave no trace on the skeleton. Burial in consecrated ground, close to relics and the celebration of Christian ritual, had been an ecclesiastical privilege since the advent of monasticism in Anglo-Saxon England. The study showed that the Anglo-Saxon populations were slightly healthier, which may be linked to lifestyle. Nutrition plays an important part in maintaining a healthy immunity. Textual evidence seems to suggest the continuation of ‘folk medicine’ into the later Anglo-Saxon period, such as charms and rituals. The connection between religious buildings and health care may have been anticipated in special temples that were associated with the cure of disease in ancient Greece. It is feasible that Anglo-Saxon society had spaces for all kinds of people: the sick and the hale, the old and the young.

Keywords: skeleton, disease, Anglo-Saxon England, religious buildings, health care, Christian ritual, nutrition

Detection and examination

Interest in the health and disease of Anglo‐Saxon populations has grown from a preoccupation with medical texts (Cockayne 1864–66; Grattan and Singer 1952) to the study of evidence from skeletal remains (palaeopathology). Additionally, there is a relative newcomer in the field: the study of pathogens (palaeoepidemiology), which was difficult, if not impossible, to do before the arrival of forensic methods such as DNA analysis (Dutour et al. 1998: 242). It is important to remember that the way in which disease and impairment are studied may be reflected in the results. There is a difference between looking at disease as an imbalance in the body and regarding it as a social or cultural discontinuity (Dingwall 2001). Equally, results from clinical approaches, which rely on biological remains mainly from inhumation or cremated contexts, may not necessarily concur with perceptions of disease in Anglo‐Saxon society.

The study of disease and disability in Anglo‐Saxon England remains difficult. This is partly due to a lack of contemporary information, but also because the majority of known diseases leave no traces on the bone. Most of the primary information on what kinds of illnesses were suffered by the Anglo‐Saxons comes either from lists of cures in medical textbooks, or from the burial record. In the latter, there is a considerable discrepancy between actual living populations and the surviving number of dead bodies. It is commonly assumed that the population profile of Anglo‐Saxon England is similar to those of modern pre‐developing and developing countries, where the highest number of mortalities is represented by (p. 705) children and the elderly. However, few neonate and new‐born skeletons have been discovered among the Anglo‐Saxon burials excavated so far. Many assumptions about the fecundity and health of early medieval populations are speculative, and are rooted in perceptions that life in this period was brief and brutal, assumptions which are, as will be discussed below, not necessarily borne out by the often healthy (and elderly) populations buried in Anglo‐Saxon cemeteries.

Nevertheless, it should be considered that not every body was necessarily included within the community cemetery, and that not all of the cemetery may still be extant for archaeological investigation. Bodies may have decayed, and post‐excavation methods may have further damaged the remains (Waldron 1994: 13). The study of the events leading to the disruption and loss of skeletal material (taphonomy) tries to calculate the ratio between the total number of dead which were once interred and the number recovered (Waldron 1994: 14). Usually, small bones, such as the phalanges and cartilaginous material, decay first, whereas long bones and the upper skull are more durable. This causes problems in the detection of some diseases, such as milder forms of leprosy or tuberculosis, which in skeletal remains are most easily detected in changes to the extremities and mandible (Anderson 1969).

Human remains do not decay at the same rate. Soil conditions can determine the survival of bone material, but even in the same conditions children's bones decay at a much faster pace than those of adults (Saunders 2000). Olivier Dutour has also observed that there are gender‐specific differences in the decay of bone material, with a better rate of survival for male bones (Dutour et al. 1998: 248). At sites with poor preservation, such gender discrepancies may make the difference between detecting and failing to detect disease.

Any examination of human remains is dependent on the skill of the person who analyses the bones. In many early excavations, the primary interest was to detect ‘treasure’, and scant interest was given to the bone assemblage. The development of the discipline of palaeopathology was largely due to the efforts of medical doctors who had an interest in archaeology, such as Calvin Wells, in the second half of the twentieth century. The pioneers of the discipline, of course, had only modern samples for comparison, and some original assumptions on diet and ageing have had to be adjusted over time. It is not only the skill of the osteologist who examines the bones which determines whether disease is identified, but also the conditions of the excavation and the subsequent handling of the fragile material on its way to the laboratory.

There is also a problem when only selective samples are submitted for palaeopathological examination, since whole‐scale assessments can be costly, which may mean that diseases which are not immediately visible to the untrained eye may not be picked up. More importantly, often not all of the burials can be excavated, either because some have already been disturbed, or the site has been built over in places. The majority of Anglo‐Saxon cemeteries excavated are incomplete, and this (p. 706) is problematic for the study of populations. For example, it has been observed that very young children are under‐represented in pre‐Christian sites, which has led to all kinds of theories about what may have happened to the bodies of dead infants (Crawford 1993). Yet some cemeteries, such as Great Chesterford, Essex (Evison 1994), do contain clusters of infants and neonates, which may suggest not only that other areas were reserved for the burial of specific social groups, but that burial may also be differentiated by age group. It has been observed that many Anglo‐Saxon cemeteries show a high degree of internal organization (Stoodley 1999), and there is a possibility that a spatial separation of the old and young, as well as the infirm and hale, has taken place. The majority of the adult populations in Anglo‐Saxon sites were relatively healthy during life (until their final illness or fatal event), tall, and appear to have been well‐nourished. The popular assumption that Anglo‐Saxons suffered brief and brutal lives is simply not tenable from the burial record as it presents itself.

Changes in burial ritual, such as the move from cremation to inhumation, or the setting up of churchyard cemeteries in the later Saxon period, may therefore reveal more or fewer afflicted bodies simply because there is a change in the location of the dead. Some Christian sites show a tendency to group burials by gender (Hadley 2004), and in some places there are also clusters of children and people who had suffered disease or impairment (Lee 2008: 25). Christian burial is commonly associated with churchyards, but there had been no compulsion for burial in consecrated ground until the reign of King Cnut (Gittos 2002). It seems that churchyard burial remains an exception until the late Saxon period, and it is therefore interesting to note that persons with disease or congenital deformity are included in many churchyards, such as Raunds Furnells (Boddington 1996), or Hartlepool (Daniel and Loveluck 2007).

Burial in consecrated ground, close to relics and the celebration of Christian ritual, had been an ecclesiastical privilege since the advent of monasticism in Anglo‐Saxon England. During the eighth and ninth centuries, such privilege may have been requested by the founders and supporters of churches (Hadley 2004: 306; Blair 2005: 463–73) and burial in consecrated ground may have been regarded as special. Of course, those buried at these sites may have been members of families with personal connections. However, the frequency with which the sick and impaired are now included suggests that there are other reasons as well. One of them may be connected to changing views of salvation and the body in late Anglo‐Saxon England. Victoria Thompson has observed a growing concern about the status of the dead body in late Anglo‐Saxon literary texts (Thompson 2004: esp. 102–3). Some later literary texts, which were based on patristic perceptions of disease, characterized bodily afflictions as a visible sign of sin. Such views may have led to new forms of care for the dead body and soul, such as burial in special places and physical markers of memory that could admonish the living to prayer and acts of remembrance.

(p. 707) Recent approaches have looked at the burial of the diseased in comparison to the non‐afflicted. Dawn Hadley has shown that men and children especially receive prestigious or special treatment in churchyard burial, but that adult males are more likely to be excluded from features such as central places (Hadley 2010).

Specific diseases

The most frequent forms of physical change in the human skeleton are not caused by disease, but by old age. Arthritis and the general decay of health may be as ‘disabling’ as any other form of disease, and they are the most frequently observed condition in early medieval populations. However, bodies do not age at the same rate. A person who was living in relative comfort will age less quickly than a body which is exposed to hard labour. Modern osteologists have looked for signs of wear and tear on the bones and these provide useful data which can be studied in comparison to the wealth of grave‐goods and burial options. While we should not infer status from the condition of the skeleton, it can be observed that in the period of furnished inhumation burial, there seems to be a connection between the relative wealth of burials, and arthropathies (joint diseases). While rheumatoid arthritis is virtually unknown, osteoarthritis and osteophytosis (new bone growth) are the most commonly recorded conditions. Margaret Cox and Charlotte Roberts, in their study of published material from British skeletal remains, record a slight fall of osteoarthritis since the Roman period, and note that, during the Anglo‐Saxon period, osteoarthritis is more frequently observed in men than women (Roberts and Cox 2003: 195). In many cases these will have caused only some pain in life, but conditions such as ankylosing spondylitis (a gradual fusing and stiffening of the spine) could be debilitating. DISH (diffuse idiopathic skeletal hyperostosis) results in another ankylosing (calcification) of the spine. It has been connected to Forestier's Disease, and there has been a discussion about whether these conditions can be linked to prolonged periods of obesity, since most cases have been observed from men who lived in monastic communities (Rogers and Waldron 2001: 362).

Second to joint disease in the list of observable conditions are dental diseases. Most of them are caused by eating and drinking (such as the loss of tooth enamel through acid erosion, and the abrasions caused by coarsely‐milled bread), as well as poor dental hygiene. Caries, tartar, and abscesses will have been commonplace. Not all of them occur at the same rate. A diet rich in carbohydrates will increase the risk of tartar (calculus) and caries (Mays 1998: 149). Roberts and Cox observe that Anglo‐Saxon populations show a higher rate of calculus than the Romano‐British populations (Roberts and Cox 2003: 193). Untreated caries may lead to infections of the maxillary cavity and lead to conditions such as meningitis. Abscesses (p. 708) may become infected, and may lead to septicaemia. It seems that, for most of the Anglo‐Saxon period, dental hygiene was poor, and dental care was even less advanced. An elderly lady in grave 105 at Apple Down, Sussex, suffered part of her mandible breaking when her tooth was extracted, and seems to have suffered chronic infection (Down and Welch 1990). Teeth can also mirror periods of nutritional deficiency and severe infection. Enamel hypoplasia (visible as lines or depressions in the tooth enamel) can indicate that the person suffered a period of ill‐health during the period of enamel formation.

Whereas many diseases are caused by genetic defects or changes, it is clear that diet and living conditions play a major role in the health of populations. A recent detailed study of disease of three Anglo‐Saxon cemeteries (Norton, Apple Down, Castledyke) in comparison with three contemporary Alamannic (southern Germany) sites has shown that there are subtle differences in the health profiles of medieval people (Jakob 2004). The study showed that the Anglo‐Saxon populations were slightly healthier, which may be linked to lifestyle.

Metabolic diseases

Metabolic diseases may be firstly identified as diseases caused by a genetic disposition which makes the afflicted predisposed to certain conditions, as, for example, the fact that women are more likely to suffer from anaemia, since menstruation, childbirth, and lactation require women to have higher levels of iron intake. Iron depletion may also be caused by parasite infection. Severe chronic anaemia manifests itself as pitting and porous lesions on the skull, especially around the eye sockets (cribra orbitalia). Other indicators of malnutrition are Harris Lines (transverse lines on the long bones), which indicate periods of arrested growth due to disease or childhood malnutrition (Roberts and Manchester 2005: 240).

It has been observed that early medieval people of Northern Europe were much taller than their counterparts from the seventeenth century onwards. The male Anglo‐Saxons examined by Rogers were on average 3 cm taller than their Romano‐British equivalents; the difference between women was 2 cm (Roberts and Cox 2003: 195). Nutrition and height have been linked in a number of modern studies, as well as genetic disposition. However, there may be a further link by looking at the diet of the earliest stages of life. Research by Mary Lewis (2002) on infant mortality in medieval to industrial populations has suggested that there was also a much lower rate of infant mortality than previously expected. She suggests that it is not urbanization, as often assumed, which is responsible for the increased rate of mortality, but a change in neonatal feeding practices. In the seventeenth and eighteenth century, colostrum, the first breast milk, was thought to be harmful, and newborn children were fed on liquids made with butter, sugar, or wine on a spoon for the first days before being breastfed (Lewis 2002: 221). Additionally, the (p. 709) period of breastfeeding had fallen from eighteen to seven months. Breast milk is not only highly nutritious, but also contains antibodies which protect children against diseases.

Nutrition plays an important part in maintaining a healthy immunity. Many diseases are brought on, or are exacerbated by, a poor diet. The body's response to disease depends on the immunity of a person. A healthy person is less likely to become infected. Nutrition is, of course, just one aspect of health, which also depends on environmental conditions, such as pollution and sanitation. The living conditions of a population may be reconstructed from the study of houses or middens, as well as palaeobotany. Records from the Anglo‐Saxon period tell of widespread famines and cattle murrain, but the impact of such outbreaks has not been studied yet. Advances in dating skeletal remains more precisely might help to understand the severity of such recorded events, as well as to show whether there was any long‐term impact on the population.

The body's natural reaction to infection is inflammation, which is only visible on the skeleton if the bone is affected (which means that the infection has not been lethal in the first impact, and perhaps even that the person survived), or if there is mummified tissue. Outbreaks of infectious diseases, such as plague and smallpox, which are highly lethal, are therefore hard to detect. Our understanding of other potential pieces of evidence, such as multiple burials, is yet too limited (Stoodley 2002; Crawford 2007), but perhaps it should be considered that some multiple burials may be ‘plague’ graves.

While infection is not always easy to detect, occasionally we get glimpses of other conditions affecting organs. For example, a massive bladder stone may have been the cause of death of a middle‐aged male at Melbourn, Cambridgeshire (Duncan et al. 2003).

Trauma

Broken bones occur in all kinds of contexts, but the way in which they heal may be an indicator of whether a leech (doctor) was present or not. A skilled doctor must have been involved in the amputation of a left arm at School Street, Ipswich, Suffolk, since this operation was successful and the patient survived the event (Roberts and Cox 2003: 216). Roberts and Cox record 395 cases of trauma in their study, which is a total of 5.9 per cent of the overall recorded cases. Broken long bones are the most frequently recorded fracture (111 cases), followed by broken ribs (53 instances), and injuries to the collarbone (48 cases). Men had more recorded fractures than women, and a total of 73 instances of skull fractures were recorded (Roberts and Cox 2003: 202). Some of these fractures may have been associated with work‐related accidents, others with warfare.

(p. 710) Infectious disease

In a recent study of 7,122 burials from published Anglo‐Saxon cemeteries, Charlotte Roberts found evidence for infectious disease in 460 cases, a figure similar to that collected from the Roman period (Roberts and Cox 2003: 172). Infectious diseases were spread not just through close and unhygienic living conditions, but were also exacerbated through malnutrition.

A frequently observed condition in Anglo‐Saxon skeletons is periostitis, an inflammation of the thin membrane on the bones. It can be caused by Staphylococcus aureus (90 per cent of modern infections are caused by this pathogen), but can also develop in response to trauma, or even as a result of metabolic diseases, such as scurvy. Staphylococcus is a group of bacteria living on skin and in mucus, and approximately 15–40 per cent of people are carriers. Unhygienic conditions will increase the chances of becoming infected. Spread of Staphylococci to the bones can lead to periostitis and osteitis, which can be seen as primary and secondary stages of the onset of osteomyelitis, inflammation of the bone with subsequent pus formation and simultaneous new bone growth (Roberts and Manchester 2005: 168–72). Osteomyelitis was observed in 22 of 1,637 examined bodies (Roberts and Cox 2003: table 4.3).1 The majority of afflicted people were male. It is assumed that the bacteria will have been carried in the blood stream from other infected organs or soft tissue to the place of infection on the bone. The new bone growth indicates that the person survived a severe infection.

Proximity to open fire and smoke may be the reason behind the rise of maxillary sinusitis during the Anglo‐Saxon period. Both the cemeteries of Raunds Furnells, Northamptonshire, and St Helen‐on‐the‐Wall, York, have very high numbers of people with sinusitis (Roberts and Cox 2003: table 4.4; Roberts and Manchester 2005: 174). The cemeteries are very different, Raunds serving a mainly rural community, and St Helens functioning as a burial ground for the urban poor of York. Sinusitis is an inflammation of the mucous membranes of one or more sinuses (Roberts 2007: 795). The inflammation could be caused by smoke from domestic fires, but certain occupations, such as tanning and potting, had a higher exposure to harmful chemicals (Roberts 2007: 804). Occupational diseases are still an under‐researched area in the study of the health of early medieval populations, and the study of bone deformation may be used to assess the exposure of certain population groups.

Polio (poliomyelitis) has been observed at several sites, including grave 5218 at Raunds Furnells (a male aged 17–18), where the afflicted person had been buried at the outermost boundary of the cemetery (Boddington 1996), and at Worthy Park, Hampshire (Hawkes and Grainger 2003). The polio virus is spread by faecal‐oral (p. 711) transmission. Unhygienic conditions, such as not washing hands after defecating, will increase the risk of transmission. Given the picture of filth that has emerged from Anglo‐Saxon settlements it is surprising not to find a higher incidence of the disease.

Tuberculosis is a multifaceted disease which is hard to detect in a palaeopathological environment (Roberts 2002a: 31). The disease is caused by the mycobacterium tuberculosis, and appears in bovine as well as in human form. Like its first cousin leprosy, it can vary in severity and appearance. It is contracted via pulmonary infection or via gastrointestinal infection from milk or meat. Today it kills around three million people each year, and almost half of the world's population is infected (Roberts 2002a: 31). While the bacterium can lie dormant in persons with good immunity, poverty, a deficient diet, as well as poor living conditions, are contributing factors to the outbreak of the disease, which also requires a high population density. Tuberculosis may have developed in the transition from hunter‐gatherer to agricultural societies, when humans began to live in close proximity to their animals. Tuberculosis can manifest itself in characteristic deformations of the spine, but the majority of affected people will die before such visible bone formations can develop (only about 2 per cent of the diseased will develop bone changes—Roberts 2002a: 36). Thus skeletons with changes caused by tuberculosis are most likely the survivors of the disease.

Leprosy (Hansen's Disease) is often linked with the Middle Ages since it was used as a staple in textual descriptions. The disease is caused by infection by the mycobacterium leprae, and can be latent for a period of up to twenty years. Leprosy develops in two major forms (with intermediate stages): the lepromatous or tuberculoid form. Genetic disposition and immunity determine the severity of symptoms, which can involve bone changes (especially to the maxilla and phalanges) which are archaeologically detectable, and soft tissue changes, blindness, and paralysis of the face, which are not. The examination of bone material is made more difficult since the small bones which are first affected by the disease often decay first, and since some of the ‘characteristic changes’ of leprosy are very similar to those caused by tuberculosis (the pathogens of both diseases are related). The examination of leprosy on skeletal remains goes back to the strict criteria of Vilhelm Møller‐Christensen (1961, 1967), who was the first to systematically examine the remains of a leper cemetery. Leprosy is mentioned in medieval texts, but it is doubtful whether medieval leeches understood the full aetiology of this complex disease.

Based on text sources, there has been a wide‐spread assumption that lepers were ‘cast out’, which is largely fictitious (Rawcliffe 2006: 5). Early burials suggest an inclusion of lepers, as for example at Beckford, Hereford and Worcester, or Edix Hill, Cambridgeshire, which may mean that their status may not have been negatively affected by their illness (Crawford 2007: 88; Lee 2006). However, we can observe that by the end of the Anglo‐Saxon period, lepers seem to have been (p. 712) buried collectively at some sites, as for example at Norwich, St John the Baptist (Popescu 2009) or at the margins, such as at Raunds Furnells, Northamptonshire (Boddington 1996). It remains to be seen whether the location of such burials is indicative of a loss of status, or may be based on different factors. There are no known leprosaria from pre‐Conquest England, despite the fact that there are several well‐known contemporary houses on the continent. The proximity of a number of lepers at Norwich may suggest that this may have been affiliated with a leper colony, but so far there is no evidence for such a building. The absence of leprosaria also suggests that the care of lepers was mainly undertaken in the home. It may also indicate that the disease was not known very well, since so far there are only few cases in the pre‐Christian cemeteries, but the evidence from Norwich suggests that there may be larger numbers towards the Norman Conquest.

It has been claimed that the clearance of land led to the development of marshlands in the south and east of England, which may have been endemic for malaria (Roberts and Cox 2003: 170). Malaria may be indicated in the disease named lencten adl, ‘spring disease’, in leechbooks, but the parasite infection does not leave any evidence on the bone. However, parasite infection has been linked to chronic anaemia, which can be indicated in the pitting of eye sockets (cribra orbitalia). The presence of such bony changes has a number of causes, but recently, the isolation of ancient DNA from the protozoan parasite has been successful (Roberts and Cox 2003: 170) and further studies may examine the connection between cribra orbitalia and parasite infestation.

Other diseases, such as Paget's Disease (osteitis deformans) are less common, but are occasionally found. Paget's is a chronic bone disorder, which manifests itself in a thickening of the bone and can affect the hearing as the bone growth is in the skull, though 60–80 per cent of people with the disease in the UK today, where the disease is more common than anywhere else in the world, have no symptoms at all. It is more common in people of European descent (Roberts and Cox 2003: 127). The causes of this disease are as yet unknown, but it is commonly assumed to be the result of a slow viral infection. However, genetic preponderance may also be a factor. Examples have been found at late Anglo‐Saxon sites, including the monastery at Jarrow, Tyne and Wear, where skeletons show the characteristic thickening of the bone, as well as kyphosis (Wells and Woodhouse 1975), and Portchester (Hooper 1976).

Physical impairment

Some of the most severe disorders suffered by the Anglo‐Saxon population will have been difficult to ameliorate due to the available medical knowledge base in Anglo‐Saxon communities. It is however, striking to observe the range of conditions (p. 713) that have been detected, all of which point to the inclusion of the afflicted in social and community life.

Deafness is well recorded in textual sources, but is difficult to prove in skeletal remains. However, the skeleton of a young woman at Castledyke showed a congenital malformation of the ear‐bone (Drinkall and Foreman 1998: 235). Like all delicate bones, the bones in the ear are more prone to decay in archaeological deposits, and only one side of the head could be examined for this condition.

The earliest British examples of cleft palates have been recorded for this period, for example at Burwell, Cambridgeshire (Brothwell 1981). Cleft palates are more frequent in males, and they occur if the tissue which forms the roof of the mouth on either side of the tongue, and which usually grows together in the sixth week of the baby's development in the womb, fails to join. Among human populations, cleft palates are less frequent in people whose genetic background is African, and most common in people of Asian descent. Breastfeeding babies who have a cleft palate is very difficult (usually children have to be laboriously spoon‐fed) and a mammiform vessel found at Castledyke, Barton‐on‐Humber (Lincolnshire) has been discussed as a possible help to feed a baby with this condition (Drinkall and Foreman 1998: 309–10).

Down's Syndrome (trisomy 21), which occurs in a range of severity, and is based on a chromosomal abnormality, is also first recorded in Britain during the Anglo‐Saxon period (Roberts and Cox 2003: 179). Dwarfism, a condition which is relatively rare, has also been detected in one case (ibid.).

Other conditions, which are relatively frequent in modern populations, such as congenital dislocation of the hips, are recorded less frequently. Roberts and Cox, in their collection of data, only show evidence for two cases, both of them from the post‐Conversion period at Nazeingbury, Essex, and St Oswald's Minster, Gloucester (Roberts and Cox 2003: 180, table 4.5)

Other diseases

Cancer is a ubiquitous disease today and there is evidence in Anglo‐Saxon England as well. Roberts and Cox list several occurrences from the Anglo‐Saxon period: a malignant tumour (osteosarcoma) from the pagan cemetery at Standlake Down, Oxfordshire, on a middle‐aged man, and multiple myeloma on an elderly woman from Abingdon, Oxfordshire. At Melbourn, an elderly male showed neoplasms on his neck, which indicate the development of a malignant condition in the spinal cord (Duncan et al. 2003). Further examples come from the seventh‐century sites at Edix Hill, Cambridgeshire, and Eccles, Kent, as well as the post‐conversion cemetery at Ailcy Hill, Yorkshire (Roberts and Cox 2003: 182). Roberts and Cox note that the frequency and variety of the condition increases during the Anglo‐Saxon (p. 714) period, which may reflect changes in diet and lifestyle (ibid.: 183). Amongst them, the most severe conditions that have been excavated must be a hydrocephalus from Eccles, Kent, in an adolescent of 14–16 years of age (Manchester 1980). The condition may have been caused by an intra‐cranial tumour.

If anything, the list of diseases and resulting conditions shown above underlines that the sick and impaired were reared and cared for. For some of the afflicted to live into adult age there must have been a will, as well as a method of caring for them. Additionally, those who had the misfortune to suffer from disease were cared for, as indicated, for example, in the skeleton of a woman at West Heslerton (G 114), who was severely impaired after suffering a stroke that paralysed her from the chest down (Haughton and Powlesland 1999; Roberts and Cox 2003: 217). This burial clearly demonstrates how much our interpretation of such evidence depends on our understanding of burial rites in general, since the care that the woman received (who clearly had to be helped in her daily ablutions, as well as being carried) may be contrasted with her burial position, which was being laid out prone in a ditch with her feet bound (Houghton and Powlesland 1999). The binding of the feet is interpreted as a ‘ritual’ in the cemetery report; however, it may be argued that a person with a severe impairment may have had her feet bound to keep her legs together as part of her care.

Healing and health care

Questions of healing and attitudes towards the diseased may be culturally complex and they are intrinsically linked to the position of the sick in society. Evidence for disease should be contrasted with the impact that such afflictions had for the sufferer. There is a fundamental question of whether disease, disability, or deformity were seen as problematic at all. This question is closely linked to the issue of a framework of help, if not cure, that the afflicted could utilize. Recent studies into disability in the medieval period (Metzler 2006) have queried the assumption that physical impairment equals disability.

The question of who is worthy of treatment may be examined by looking at how well injuries were cared for. The relative paucity of weapon wounds stands in contrast to the high number of weapons buried with skeletons in cemeteries, and may underline the largely peaceful nature of life in Anglo‐Saxon England, and the symbolic value of weapons. However, wounds caused by weapons were found on several skulls. An examination of the pre‐mortem cranial wounds has shown that some of these may have been battle injuries (Anderson 1996: 13), but that in only a small number of cases is there evidence for healing, which is (p. 715) indicated by a vascularization of the internal surface and remodelling of the bone. It is uncertain whether these few survivors received superior medical intervention, or whether they were just lucky enough to survive their injuries. It is also unclear whether the other group died due to a lack of medical expertise, or because of deliberate neglect. Perhaps their injuries were deemed too serious for treatment, but it is also possible that the relatively small number of people with weapon injuries received their wounds as a form of punishment. Forensic studies of injuries (Patrick 2006) do not always point to a combat situation for the injured. Mutilation was a form of punishment, especially in the late Saxon period. The cutting‐off of hands for thieves was stipulated by the Laws of Cnut, and repeat offenders risked having their eyes poked out or their noses cut off (Crawford 2009).

The most finite form of punishment was, of course, execution, and the growing number of execution cemeteries excavated show that it was widely practised, especially in the post‐Conversion period. However, occasionally the damage to the skeleton was post mortem, as for example at the late pre‐Christian cemetery at West Heslerton, North Yorkshire, and the Christian burial ground at Raunds Furnells. The question of why the skeletons have been deliberately mutilated remains unanswered, but it is possible that this may have been a rite of defacing a criminal or enemy.

The question of who is given medical attention is hard to answer, but in another form of drilling through the skull (trepanning) a different picture emerges. Trepanning was practised by the Anglo‐Saxons (Parker 1989: 74) and in the majority of cases the wounds healed neatly. The reason behind trepanning is still not clear, with explanations from a cure for migraines to medico‐magical rituals being offered. However, what should be observed is that this method is with all likelihood a medical procedure (Roberts and McKinley 2002: 69), not a mutilation, and care is given to the persons treated in this way. Later sources, such as the laws of King Cnut, do not allow medical intervention for three days for a person sentenced to mutilation (Crawford 2009), which would have increased the likelihood of infection, which is not evident in the cases of trepanation from the Anglo‐Saxon archaeological record.

The ‘magical’ items which were included in the burial rite have been interpreted as evidence for early physicians. Amulets, and especially so‐called ‘relic boxes’, have been identified as items of healing (Meaney 1981: 9–10; Dickinson 1993), and most of these were found with female burials. Evidence for female healers and woman‐specific medicine is hard to come by. Among the four leeches named in later text sources there is not a single female doctor. There are texts within the Anglo‐Saxon Prognostics which are concerned with the development of the foetus (Chardonnes 2007: 229), but they may concern the legal status of the unborn child, rather than being evidence for gynaecological training (ibid.: 225).

(p. 716) Textual evidence seems to suggest the continuation of ‘folk medicine’ into the later Anglo‐Saxon period, such as charms and rituals. In a number of cases these are only visible from clerical texts and it may be debatable how widespread such practices were. For example, the Penitential of Theodore refers to the penance for a woman trying to heal her child by dragging it through a clod of earth, as well as that for a woman placing her daughter in an oven (Wasserschleben 1954: 200). The Lacnunga, a collection of manuscripts from the turn of the first millennium, contains charms against mysterious diseases such as ‘elf‐shot’, as well as ‘flying poison’ (which may be a bacterial infection, as Meaney has suggested; Meaney 1992: 16).

While we see evidence for healing in the pagan period, Christianity brought a new framework of ideas on disease to converted areas. The success of Christianity in its early days was partly based on the fact that the adherents seem to have specifically given care to the sick and needy (Porterfield 2005: 44–51). From the third century, influential writers such as Origen used medical analogies to show that, unlike their pagan deities, Christ was a physician of the soul as well as of the body (Amundsen 1996: 133). Christ is described as the ‘Great Physician’, and those who are in his ministry were also endowed with powers of healing (Porterfield 2005: 51). In the writings of the Church Fathers, medicine is a beneficial and God‐given gift. However, there is also a notion as early as Jerome that sickness is an outward sign of sin, and a means of adjusting priorities. The sick body acts as a warning sign, and allows the sufferer to turn around and atone for his sin. Sickness is at the same time a token of sinfulness as well as a pre‐mortem form of purgatory. Narratives of the uncorrupted bodies of saints thus are regarded as a token of spiritual haleness. There is little evidence that the sick were stigmatized in the Anglo‐Saxon period, although they may have utilized a new form of healing which was administered at the shrines of saints. Saints were thought to be endowed with healing powers and the emergence of shrines and sepulchres also attracted a number of the sick.

The connection between religious buildings and health care may have been anticipated in special temples that were associated with the cure of disease in ancient Greece. However, there is no evidence for a deliberate provision of care before Christianity became the official religion of the Roman Empire. One of the first hospitals was founded under the directive of Basil of Caesarea around 370, who was also an important canonical influence on the study of healing and disease in Christianity. The primary aim of these early hospitals was not cure, but caring for people who could otherwise not look after themselves, which included the old, the poor, as well as the sick and impaired. Medieval monasteries had infirmaries which were under the supervision of the cellarer. The earliest record for a hospital in Anglo‐Saxon England is St Peter at York, which was founded by King Athelstan in 937 and was situated roughly beneath the modern Theatre Royal (Bonser 1963: 95); others have been attributed to Flixton in Holderness, and Worcester, founded by (p. 717) St Oswald. While there is not much documentary evidence for the founding of hospitals, there are plenty of monastic sites which contain graveyards with a high proportion of women or children, which are supposedly drawn from the lay population (good examples are Whithorn, Dumfries and Galloway, where the associated Life of St Ninian tells of miracle curing; and the recently recovered Hartlepool). At Ailcy Hill (Ripon, North Yorkshire), the former monastic cemetery was used in the second phase for a series of distinct burials, one of which was a young person with tuberculosis which had affected the spine (Hadley and Buckberry 2005).

The extant medical textbooks are all from a late Saxon context. Apart from the Lacnunga, there is the mid‐tenth‐century Bald's Leechbook (named after the person who owned the book), as well as an Old English translation of the Peri didaxeion. All of these treatises assume some prior form of training or knowledge, since there are no measures given for the list of ingredients. Some of these ingredients are costly and had to be imported, especially in the case of Bald's Leechbook, and there has so far been no consideration whether faunal remains found in graves may have come from possible potions or salves or a special diet for the sick. Examinations of monastic sites should also consider whether there is any evidence for herbs grown as part of an apothecary.

Future research

One of the most strident problems of comparing data is that there is no standard system of recording (Roberts and Cox 2003: 402). For example, there is no coherent recording of osteology (some reports note every piece of bone growth, others just note the most outstanding pathology), and there is so far no coherent system of presenting disease and impairment in reports. Future research needs to find a unified system so that data can be compared between sites.

Recent research has made much use of the scientific and forensic methods now available to archaeologists, such as isotope analysis and DNA analysis. Future examinations may include microbiological examinations which may corroborate archaeological and historical evidence. Stable isotope analysis as well as research in ancient DNA have already shown some interesting conclusions on the genetic background of the Anglo‐Saxons (Montgomery et al. 2005), as well as their diet, and further research will show a more detailed picture of life in Anglo‐Saxon England. In the light of such advancements, older research may have to be revisited. Some modern geneticists have drawn parallels between migration and genomes, methods which have been used to calculate the number of settlers in (p. 718) the Anglo‐Saxon period (Thomas et al. 2008) and the later Viking migrants (Goodacre et al. 2005; Bowden et al. 2008). Genetic disposition, as well as lifestyle, plays an important part in the prevalence and development of diseases, and future research may examine correlations between population groups and disease.

Some diseases that may not be detectable in the bone material and information may be recovered from other sources. Pandemic outbreaks often have significant demographic, as well as economic, consequences, and changes in the economy, agriculture, or even settlements may have their origins in a decimation of resources or labour after an outbreak of epidemic disease. It has been suggested, for example, that some form of epidemic disease ravaged seventh‐century Anglo‐Saxon England (Bonser 1963; Maddicot 1997). While this outbreak, according to textual sources, led to a whole‐scale destruction of monastic communities, as for example described in the Anonymous Life of St Cuthbert (composed between 698 and 705), the social, demographic, and economic fallout has not yet been studied. Two phases of plague were documented (the first between 664 and 666, the second from 684 to 689; Maddicot 1997: 11) and the absence of rat remains in the early burial record has led to suggestions that this is pneumonic plague, rather than the less lethal bubonic plague (Maddicot 1997). John Maddicot suggests that evidence comes from the excavated settlements from early Anglo‐Saxon England (West Stow, Charlton, Mucking, Yeavering, Puddlehill), which were all given up around the turn of the eighth century, and that some contemporary cemeteries have indications for plague burial, such as the seventh‐century site at Camerton (Somerset) where 115 bodies, including 40 children, appear to have been hastily buried (ibid.: 44). However, Maddicot assumes that the surviving population recovered quickly after the outbreak, contrary to evidence from later pandemics which show a very slow regeneration of populations (Benedictow 1992). The reason for this speedy recovery may be sought elsewhere. During the ninth century we see a migration of Scandinavian settlers to areas in the north and midlands of England. Contrary to assumptions largely based on texts from their West Saxon opponents, these may not have had to disperse the original population, as often claimed, but may have been able to move into largely empty lands.

Research in the efficacy of Anglo‐Saxon medicine (Cameron 1993; Brennessel et al. 2005), let alone the vocabulary of some of the more obscure terms in the medical texts, may be studied complementarily to the results from osteological and scientific examinations. In addition, the data from palaeopathology should be compared to other information we have for the afflicted, which may include the burial space, structures above ground, as well as furnishing of the grave. Most importantly, a more holistic approach, which is better funded and based on a more coherent form of data collection, is required to take our understanding of Anglo‐Saxon disease and healing from case studies to a more complete picture of health.

(p. 719) Conclusions

Just as in the twenty‐first century, disease was a common companion in life. In many instances, we can see a desire to cure the afflicted, or at least to make them comfortable in Anglo‐Saxon society. The popular image of the diseased and disabled as outcast or poor needs some serious challenging, in the same way as the assumption that most people lived their short lives in squalor and disease. It is debatable whether observations from modern populations can be transferred to the past. There is a need to get better acquainted with Anglo‐Saxon attitudes towards the diseased and impaired, rather than making assumptions drawn from texts written for a particular audience, steeped in the exegesis of patristic sources, or which use the language of sickness to create literary images. Neither should there be an assumption that any form of pathology observed on the bone would have automatically required adjustment or medical attention. Conditions that may be observed by the modern osteologist may not have been an impediment in life at all. Depending on the space that a bone report may command within a publication, an osteologist may record minute changes (which were not felt by the person at all, such as for example the ample occurrence of spina bifida occulta, which, unlike its more sinister cousin, only affects parts of the lower spine and has very few symptoms apart from possible back pain). Even if the condition is more severe we need to consider whether this would have affected the status of the sufferer. It is feasible that Anglo‐Saxon society had spaces for all kinds of people: the sick and the hale, the old and the young. It is therefore conceivable that adjustments were made on a regular basis.

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                                                                                                                                                  Notes:

                                                                                                                                                  (1) It should be observed that Roberts and Cox's data is collected from archaeological reports and the primary examination was conducted by several paleopathologists between the late 1970s and 2003.