THE
BIOARCHAEOLOGY
OF TUBERCULOSIS
A Global View on a
Reemerging Disease
Charlotte A. Roberts
and
Jane E. Buikstra
University Press of Florida
Gainesville/Tallahassee/Tampa/Boca Raton
Pensacola/Orlando/Miami/Jacksonville/Ft. Myers
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THE
BIOARCHAEOLOGY
OF TUBERCULOSIS
Florida A&M University, Tallahassee Florida Atlantic University, Boca Raton
Florida Gulf Coast University, Ft. Myers Florida International University, Miami
Florida State University, Tallahassee University of Central Florida, Orlando
University of Florida, Gainesville University of North Florida, Jacksonville
University of South Florida, Tampa University of West Florida, Pensacola
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FROB FM ppi-xxiv 8/5/03 10:00 AM Page ii
THE
BIOARCHAEOLOGY
OF TUBERCULOSIS
A Global View on a
Reemerging Disease
Charlotte A. Roberts
and
Jane E. Buikstra
University Press of Florida

at the outset guided Charlotte into this field; and
Gerrett B. (Grandpa) Buikstra, whose encouragement
was essential to Jane’s choice of career.
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CONTENTS
List of Figures ix
List of Tables xiii
Preface xvii
Acknowledgments xxi
1. Reemerging Infectious Diseases
Tuberculosis Is One of Many
1
2. Tuberculosis
A Disease of Poverty and More
44
3. Tuberculosis in the Old World
Absence of Evidence Is Not Evidence of Absence
87
4. Tuberculosis in the New World
An Interpretative Challenge
187
5. To Cure Sometimes, to Relieve Often, to
Comfort Always
The Written and Illustrative Evidence for Tuberculosis,
Its Diagnosis, and Its Treatment
214
6. The White Plague Continues
262
Glossary 273

.. Temporary accommodation for migrant workers in India 68
.. Miners of Kuttenberg, by Matthaus of Kuttenberg, c. 1490 70
.. Collecting cocoons and weaving silk 73
.. Dairy produce for pastoralists in Xingjiang, China 76
.. Dung piles and yurts, Xingjiang, China 77
.. Skeletal distribution of tuberculosis 90
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.. Skeleton of 25-year-old female with tuberculosis 91
.. Psoas major muscle origin and insertion points in the
skeleton 93
.. Tuberculosis of spine in an African woman 94
.. Possible tuberculosis of pubic symphysis 98
.. Pelvic girdle with new bone formation 99
.. Tuberculous destruction of the skull 101
.. Lupus vulgaris of the neck 102
.. New bone formation on the endocranial surface of the
skull 103
.. New bone formation on the ribs 104
.. New bone formation on a rib, in cross section 104
.. Rib involvement in pulmonary disease 106
.. Terry Collection: frequencies of new bone formation on ribs 106
.. Age profile of individuals with new bone formation on ribs 107
.. New bone formation on rib from a pig (archaeological) 108
.. Calcified pleura 109
.. Radiograph of spinal tuberculosis 111
.. St. Helen-on-the-Walls, York: later Medieval cemetery plan 113
.. Milking a cow 120
.. Plowing in China 121
.. Butchery of a pig 122
.. Reconstruction of a late medieval longhouse, Wharram Percy,

.. Pott’s disease of the spine, Norris Farms site 202
.. Proliferative rib lesions, Norris Farms site 203
.. Spina ventosa, Norris Farms site 204
.. Relative percentage of affected individuals compared to overall age
distribution, Norris Farms site 205
.. Comparison of relative percentages of individuals affected by
resorptive and proliferative costal changes, Norris Farms site 205
.. Individuals with lytic lesions, Norris Farms, Schild, and Estuquiña
sites 208
.. Map of tuberculosis worldwide, excluding Europe 213
.. London Bills of Mortality for 1665 217
.. Angel of death 220
.. Pictographs from Arizona caves 223
.. Kokopelli 224
.. Patient treated at Stannington Children’s Sanatorium 230
.. Children enjoying sunlight, Stannington Children’s
Sanatorium 231
.. Sanatorium in Keighley, West Yorkshire 231
.. Dr. Edward Livingstone Trudeau, 1885 237
.. Little Red 241
.. Lung tissue affected with tuberculosis 256
Figures xi
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.. Men-an-Tol, Lanyon, Cornwall 257
.. Tuberculosis huts in Mammoth Cave, Kentucky 258
.. People touched for the King’s Evil 259
.. Touching for the King’s Evil 259
.. Royal touch pieces 260
xii Figures
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patients 92
xiii
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.. Number of vertebrae affected in tuberculosis 95
.. Differential diagnosis of spinal damage in tuberculosis 96
.. Differential diagnostic features of pyogenic arthritis and
tuberculous arthritis 97
.. Summary of data from studies of rib lesions 105
.. Correlation of radiological findings and changes in tuberculosis of
the spine 112
.. Domesticated species commonly found in modern Europe, with
probable wild ancestors, region of origin, and approximate date of
earliest domestication 115
.. Tuberculosis in the British Isles 134
.. Nonspecific changes in British skeletal material 137
.. Tuberculosis in Hungary 152
.. Tuberculosis in Lithuania 155
.. Mycobacterium tuberculosis DNA in skeletons from Lithuania 157
.. Tuberculosis in Poland 159
.. Tuberculosis in Russia 160
.. Spinal tuberculosis in Egypt 167
.. Tuberculosis in France 168
.. Tuberculosis in Italy 174
.. Tuberculosis in Spain 178
.. Tuberculosis in Japan 181
.. Tuberculosis in Hawaii 182
.. Earliest cases of Old World tuberculosis in skeletons/mummies
183
.. Sites with evidence of ancient tuberculosis in the New World
195

rated. “Disease,” furthermore, “has always been present in society and it
will remain part of all societies in the future” (Mayer 2000: 938), and dis-
ease has shaped, and will continue to shape, people’s sociopolitical and eco-
nomic situations. Being unhealthy is detrimental to “normal” functioning.
So why concentrate on tuberculosis in particular, both of us having much
broader interests in biological anthropology?
In 1976, Charlotte Roberts, then a student nurse, was surprised to find
herself nursing a patient with tuberculosis. Surprised because earlier in the
20th century, a vaccination and antibiotics to deal with tuberculosis had
been developed. Tuberculosis as a major cause of morbidity and mortality
had declined considerably as a result both of these developments and of
improvements in living conditions during the 20th century. Why this man
had contracted tuberculosis is not recalled, but, as will become clear in this
book, there could have been a whole range of reasons. He died not long
after being admitted to hospital; he was in his fiftieth year. That first expe-
rience of dealing with a living person with tuberculosis was extended
(through a career change) by work on skeletal remains from archaeological
sites in Britain in the 1980s. Roberts was particularly interested in present-
day diseases that were common in the past as well as in disease loads in the
poorer parts of populations. If we believe the documentary data, tuberculo-
sis certainly has been a major contributor to illness and death throughout
history, and the conditions for its appearance have been clearly present.
For example, high population density, the development of agriculture,
overcrowding, specific work patterns, poverty, nutritional deprivation, and
xvii
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depressed immune systems all contributed to enabling tuberculosis to
spread from animal to human and human to human. During those 1980s
research years, however, it was noted that the evidence for tuberculosis in
skeletal material from British funerary contexts was very scarce compared

infectious disease may also change and become more or less virulent or
develop new ways of transmitting themselves, while people's immune
systems may be compromised by any number of factors, thus making them
more susceptible to disease generally (Morris and Potter 1997).
Of course, many books have been written on tuberculosis, and each
tends to take a different focus. For example, historically based texts trace
the rise and fall of the infection (e.g., Crawfurd 1911, Ryan 1992,
xviii Preface
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Rosencrantz 1994, Feldberg 1995, Dormandy 1999) and its incidence in
specific countries (e.g., Rothman 1994, Johnston 1995). Clinically based
volumes concentrate on the epidemiology, pathogenesis, and diagnosis of
tuberculosis (e.g., Bloom 1994, Davies 1998c). For many who have written
more recently about the disease, the focus has been on documenting tuber-
culosis over the last 200 years, when historical data has been plentiful, but
for people working with the evidence for tuberculosis in the distant past
using archaeological data, a window on this infection has been provided
and its effects on the population considered.
In archaeological contexts little has appeared on the tuberculosis book-
shelf (apart from Pálfi et al. 1999), the evidence for tuberculosis in human
remains usually being reported as individual case studies. This book aims
to take a multidisciplinary approach to tuberculosis, placing it in the con-
text of today and considering the evidence for it, both primary (human
remains) and secondary (written and artistic representation). In this way it
is hoped that the extant evidence, in all its forms, will be fairly represented
and assessed. Tuberculosis more than adequately reflects the many facets of
how and why many diseases occur. Stead et al. (1995) goes further and
suggests that the history of tuberculosis is very important for modern
medicine and public health because the knowledge we can gain from the
study of the past, that is, how Mycobacterium tuberculosis spread around the

lands); Philip Masy (Belgium); Joel Blondiaux, Olivier Dutour, Gyorgy
Pálfi, and Marc Pavaut (France); Maria Teschler-Nichola and Karin
Witschke-Schrotta (Austria); Elisabeth Langenegger and Frank Ruhli
(Switzerland); Alessandro Canci (Italy); Joaquim Baxarias, Lourdes Her-
rasti, and Ana Luisa Santos (Spain); Marija Djuric-Srejic (Yugoslavia);
Judyta Gladykowska-Reczecka (Poland); Gyorgy Pálfi (Hungary); Riman-
tas Jankauskas (Lithuania); Andreas Nerlich, Michael Schultz, and Albert
Zink (Germany); Anthea Boylston, Don Brothwell, Andrew Chamberlain,
Mary Lewis, Simon Mays, Ann Stirland, and Bill White (U.K.); Alexandra
Buzhilova (Russia); Ann Katzenberg and Shelley Saunders (Canada);
Michael Pietrusewsky and John Verano (United States); Miho Tanihata
(Japan); Soren Blau (United Arab Emirates and Australia); Hallie Buckley,
Kate Domett, and Nancy Tayles (New Zealand and Thailand); Marc
Oxenham (Vietnam); Peng Long-Xiang (China); Nara Bazarsad (Mongo-
lia); Stephen Webb and Judith Littleton (Australia); Jerry Rose (Jordan);
xxi
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Piers Mitchell and Joe Zias (Israel); Eugen Strouhal (Egypt and Czech
Republic); Ana Luisa Santos (sub-Saharan Africa); Carmen Pijoán and
Josefina Mansilla (Mesoamerican data and references for accounts of
hunchbacks and dwarfs); Robert Pickering and George Gill (western Mex-
ico); Felipe Cardenas and Rudolph de Hoyo (Colombia); and Patty Crown
and Wirt Wills (southwestern United States). Robert Jurmain and Lynn
Kilgore (United States) provided help on information on tuberculosis in
nonhuman primates, and Keith Dobney and Angela Gernaey (U.K.) on
archaeologically derived nonhuman tuberculosis. Kevin MacDonald (U.K.)
helped on the date of cattle domestication in Egypt, and Clara Lau pointed
us to a recent paper on botanical remedies for tuberculosis. Jacqui Huntley
(University of Durham, England) also helped on identification of common
names for some botanical remedies. Peter Atkin (Geography, University of

ing and reproducing figures. In New Mexico, Alicia Wilbur, Lisa Hoshower,
Chris Stojanowski, Ken Nystrom, Paula Tomczak, Gordon Rakita, and
Kevin O’Briant helped Jane Buikstra with many aspects of the New World
data and Alicia very kindly took on the job of indexing the book. Despite
the library at the University of Durham being excellent, interlibrary loans
were a godsend, and many thanks go to their efficiency with a smile. We
commend the University Press of Florida, Meredith Morris-Babb and Judy
Goffman particularly, for their efficiency and help during the editorial
process.
Charlotte Roberts thanks her colleagues in the Department of Archaeol-
ogy, University of Durham, for enabling her to settle into a new job and
allowing her the time to write. Lastly (but certainly not least), thanks from
Charlotte to Stewart for supporting her and having faith in her crazy life!
Acknowledgments xxiii
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