Piers D. Mitchell

Retrospective diagnosis and the use of historical texts for investigating disease in the past

Disease in past populations can be studied using a wide range of sources, including archaeology, written texts, and art created in the past. This is an important topic as it helps us understand the course of human history. This study discusses some of the hazards associated with interpreting texts that provide evidence for disease episodes in past populations. It then suggests a framework with which to assess how reliable written passages may be in allowing us to reach a modern biological diagnosis for a historical disease event. The difference between diagnoses made by people living in the past (social diagnosis) and a modern biological diagnosis is stressed, and emphasis is placed upon explaining why it is just not possible to come to a modern biological diagnosis for many past disease episodes. It also considers the controversy regarding the reliability and relevance of attempting modern biological diagnosis, the Cunningham debate. This framework may help those studying written records of disease in past civilizations to minimise the misinterpretation of the recorded thoughts of those witnessing diseases in centuries prior to our own.

The study of anatomy in England from 1700 to the early 20th century

The study of anatomy in England during the 18th and 19th century has become infamous for bodysnatching from graveyards to provide a sufficient supply of cadavers. However, recent discoveries have improved our understanding of how and why anatomy was studied during the enlightenment, and allow us to see the context in which dissection of the human body took place. Excavations of infirmary burial grounds and medical school cemeteries, study of hospital archives, and analysis of the content of surviving anatomical collections in medical museums enables us to re‐evaluate the field from a fresh perspective. The pathway from a death in poverty, sale of the corpse to body dealer, dissection by anatomist or medical student, and either the disposal and burial of the remains or preservation of teaching specimens that survive today in medical museums is a complex and fascinating one.

The origins of human parasites: Exploring the evidence for endoparasitism throughout human evolution

It is important to determine the origins of human parasites if we are to understand the health of past populations and the effects of parasitism upon human evolution. It also helps us to understand emerging infectious diseases and the modern clinical epidemiology of parasites. This study aims to distinguish those heirloom parasites that have infected humans and their ancestors throughout their evolution in Africa from those recent souvenir species to which humans have only become exposed following contact with animals during their migration across the globe. Ten such heirloom parasites are proposed, which appear to have been spread across the globe. Six further heirlooms are noted to have limited spread due to the constraints of their life cycle. Twelve souvenir parasites of humans are described, along with their animal reservoirs. While the origins of 28 species of endoparasite have been determined, many more species require further assessment once a more systematic analysis of ancient parasites in other regions of Africa has been undertaken.

Psoriatic arthritis in a fifth-century Judean Desert Monastery

Psoriatic arthritis is a greatly underreported seronegative erosive arthropathy, due to the ambiguous lesions it leaves on bone in all but the most severe cases. For a confident diagnosis of psoriatic arthritis to be made, sacroiliac and intervertebral joint fusion must be present together with erosive lesions of the peripheral skeleton including most especially the terminal interphalangeal joints. In modern times it is only a small percentage of cases who experience such debilitating disease, which may explain who so few cases of psoriatic arthritis can confidently be identified from past populations. This report describes this pathological condition as observed in the comingled skeletal remains of nine males and one female from the tomb of Paulus in the Byzantine Monastery of Martyrius, in the Judean Desert. Visual study was complemented using radiographic techniques along with scanning electron microscopy. Two adult males show characteristic lesions of psoriatic arthritis, demonstrating the form known as arthritis mutilans. A third individual shows less widespread erosive lesions which may signify a pauciarticular example of psoriatic arthritis, as is true of most cases in modern times, or the remains may represent Reiters disease. During the Byzantine period the earlier practise of expelling those with disfiguring diseases (biblical leprosy) evolved into a philanthropic, caring philosophy where the sick were housed and fed out of charity, often within monasteries. The presence of these cases of psoriatic arthritis within such a Judean Desert monastery confirms earlier suggestions that psoriasis was one of the diseases included by those in the ancient eastern Mediterranean under the umbrella term of biblical leprosy.

Migration to the Medieval Middle East with the Crusades

During the 12th and 13th centuries thousands of people moved from Europe to the Middle East to fight, undertake pilgrimage, or settle and make a new life. The aim of this research is to investigate two populations from the Crusader kingdom of Jerusalem, by determining who was born in Europe and who came from the Middle East. Oxygen and strontium stable isotope analyses were conducted on the enamel of teeth from skeletal remains excavated from Crusader contexts. Twenty individuals from the coastal city of Caesarea (10 high status and 10 low status), and two local Near Eastern Christian farmers from the village of Parvum Gerinum (Tel Jezreel) were analyzed as a control sample. Results were compared with known geographic values for oxygen and strontium isotopes. The population of the city of Caesarea appears to have been dominated by European-born individuals (probably 19/20, but at least 13/20), with few locals. This was surprising as a much higher proportion of locals were expected. Both controls from the farming village of Parvum Gerinum had spent their childhood in the area of the village, which matches our understanding of limited mobility among poor Medieval farmers. This is the first time that stable isotope analysis has been applied to the study of the migration of peoples between Medieval Europe and the Middle East at the time of the crusades. In view of these findings, we must now rethink past estimations of population social structure in Levantine coastal Medieval cities during the Crusader period.

The scoliosis of Richard III, last Plantagenet King of England: diagnosis and clinical significance

Richard III was king of England from 1483 to 1485, after declaring his nephew, Edward V, illegitimate. On Aug 20, 1485, Richard was killed in battle with the rebel Lancastrian claimant Henry Tudor at Bosworth. His body was carried back to Leicester and buried in the Greyfriars Minor Friary, where it remained until its excavation in 2012, when it was seen to have a severe scoliosis. Famously, Shakespeare described Richard III as “hunchbacked” in his eponymous play of 1593. There has been considerable disagreement whether this “hunchback” was real or an invention of his enemies after death, with political motivations. However, the chronicler John Rous wrote around 1490 that Richard “was small of stature, with a short face and unequal shoulders, the right higher and the left lower.” This description is compatible with the presence of a rightsided scoliosis. We analysed the skeleton macroscopically for evidence of spinal curvature and related lesions. From CT 3D reconstructions of each bone, we created polymer replicas and built a model of the spine to recreate its alignment in life (fi gure, appendix). The apex of the right-sided thoracic curve noted at excavation was at vertebrae T8–T9. The Cobb angle, determined from vertical excavation photos, was 75° from the upper border of T6 to the lower border of T11. Since this was measured supine, whereas clinical angles are taken standing, we estimate the Cobb angle to have been in the range 70–90° during life. The curve was well balanced, with cervical and lumbar spines reasonably well aligned (King Moe type 3). Abnormalities of individual vertebrae (eg, wedging of vertebral end plates, lateral angulation of spinous processes, asymmetry of facet joints) were restricted to the thoracic region (appendix). The foramen magnum was normal in size and shape. The 3D reconstruction closely matches the 2D images recorded at excavation, and shows the spiral nature of the scoliosis (appendix, video). Determining the cause of Richard’s scoliosis allows us to estimate the age at which it developed, and how it may have aff ected him. Since the spinal ligaments are some of the last to decompose after death, and in this case had partly ossifi ed, the position of the vertebrae should show only minimum change from the time of burial, having been surrounded by soil. Such small change is supported by the similarity to the reconstructed model, which relied on joint morphology to determine each joint position. The absence of structural spinal abnormalities, such as hemivertebrae and unilateral bars, makes congenital scoliosis improbable. Neuromuscular causes, such as cerebral palsy, are unlikely because of the normal structure, muscle markings, and cortical thickness of the legs and hips, compatible with a normal weight-bearing gait. Skeletal changes associated with syndromes such as Marfan’s (eg, high arched palate and tall stature) were not present, and a normal foramen magnum makes a Chiari malformation unlikely. The subtle nature of the changes in vertebral anatomy suggest onset in the last few years of growth, which is compatible with adolescent onset idiopathic scoliosis, probably starting after 10 years of age. The physical disfi gurement from Richard’s scoliosis was probably slight since he had a well balanced curve. His trunk would have been short relative to the length of his limbs, and his right shoulder a little higher than the left. However, a good tailor and custom-made armour could have minimised the visual impact of this. A curve of 70–90° would not have caused impaired exercise tolerance from reduced lung capacity, and we identifi ed no evidence that Richard would have walked with an overt limp, because the leg bones are symmetric and well formed.

The intestinal parasites of King Richard III

The research was funded by the University of Leicester, Richard III Society, Leicester City Council, Leicester Shire Promotions, and Leicester Adult Schools.

Human intestinal parasites in crusader Acre: Evidence for migration with disease in the medieval period

The aim of this research is to highlight the role of ancient parasites as evidence for human migration in past populations. The material analysed was soil sediment from the excavation of a medieval cesspool in the city of Acre, in Israel. Archaeological stratigraphy and radiocarbon dating of a fragment of animal bone from the cesspool confirm its use in the 13th century CE, during the crusader period. At that time Acre was located in the Frankish Kingdom of Jerusalem. Soil samples from the cesspool were analysed and eggs of the roundworm (Ascaris lumbricoides) and fish tapeworm (Diphyllobothrium latum) were identified. The fish tapeworm has only been found in the mainland Near East once before, in a latrine of the crusader Order of St. John (Knights Hospitaller). It has been absent in all earlier cesspools, latrines and coprolites so far studied in the region. In contrast to its rarity in the Levant, the fish tapeworm was common in northern Europe during the medieval period. The presence of fish tapeworm eggs in a crusader period cesspool in Acre suggests its use by crusaders or pilgrims from northern Europe who travelled to the Levant carrying these parasites in their intestines.

Human parasites in the Roman World: health consequences of conquering an empire

The archaeological evidence for parasites in the Roman era is presented in order to demonstrate the species present at that time, and highlight the health consequences for people living under Roman rule. Despite their large multi-seat public latrines with washing facilities, sewer systems, sanitation legislation, fountains and piped drinking water from aqueducts, we see the widespread presence of whipworm (Trichuris trichiura), roundworm (Ascaris lumbricoides) and Entamoeba histolytica that causes dysentery. This would suggest that the public sanitation measures were insufficient to protect the population from parasites spread by fecal contamination. Ectoparasites such as fleas, head lice, body lice, pubic lice and bed bugs were also present, and delousing combs have been found. The evidence fails to demonstrate that the Roman culture of regular bathing in the public baths reduced the prevalence of these parasites. Fish tapeworm was noted to be widely present, and was more common than in Bronze and Iron Age Europe. It is possible that the Roman enthusiasm for fermented, uncooked fish sauce (garum) may have facilitated the spread of this helminth. Roman medical practitioners such as Galen were aware of intestinal worms, explaining their existence and planning treatment using the humoural theory of the period.

Human intestinal parasites from a Mamluk Period cesspool in the Christian quarter of Jerusalem: Potential indicators of long distance travel in the 15th century AD

The aim of this research is to determine which parasites were present in a mediaeval latrine from the old city of Jerusalem. This latrine contains fragments of pottery from the Middle East and also from Italy, suggesting links of some kind with Europe. Excavation identified two separate entry chutes emptying in a shared cesspool. Radiocarbon dating and pottery analysis is compatible with a date of use in the late fifteenth century and early sixteenth century. Twelve coprolites (preserved stool) and mixed cesspool sediment were analysed with light microscopy and enzyme-linked immunosorbent assay (ELISA). Six species of intestinal parasites were identified. These were the helminths Ascaris lumbricoides (roundworm), Trichuris trichiura (whipworm), Taenia sp. (beef/pork/asiatic tapeworm) Diphyllobothrium sp. (fish tapeworm), and two protozoa that can cause dysentery (Entamoeba histolytica and Giardia duodenalis). While roundworm and whipworm were found in every sample, the other parasite species were present in only one or two samples each, suggesting that only a minority of those using the latrine were infected with those species. The role of Jerusalem as a site for long distance trade, migration or pilgrimage is considered when interpreting the Italian pottery and the parasites present, especially E. histolytica and Diphyllobothrium sp.