Do Dead Men Really Tell No Tales? An Analysis of Health in Medieval London
by William Walker
Devastating events such as disease or famine caused significant changes in population dynamics in premodern societies. The Black Death ravaged Europe during much of the Middle Ages, culminating in a wave of plague in the 14th century that eliminated as much as half of the population of the continent. Even kingdoms considered insulated from the mainland, such as England, were not spared. By 1348, London had fallen victim to the Black Death, as rat-borne fleas spread the disease from English ports. The reigning family of that island nation, the Plantagenets (1154-1485) were either directly or indirectly responsible for the poor health of the population that allowed the plague to strike so menacingly. Once the Tudors (1485-1603) usurped the throne, their transformation of English society engendered improvements in health of Londoners. Evidence to support this claim will be derived from the skeletal record, as physiological stress is embodied in the human skeleton. These physical manifestations include lesions, decreased stature, and evidence of malnutrition such as linear enamel hypoplasia. The claim will also be supported by the Developmental Origins of Health and Disease (DOHaD) Hypothesis, which states that physiological stress incurred during years of development can lead to negative health outcomes that persist for life, ultimately increasing vulnerability to infectious disease. This analysis will therefore use evidence from the skeletal record to support the claim that the Tudors restored stability to medieval London in the post-Black Death period by improving the health and well-being of their subjects.
Catastrophic events inherently hinder the growth of a population, and in many cases essentially reverse burgeoning patterns. Perhaps no event was more poignant in respect to population dynamics in medieval Europe than the outbreak of the Black Death during the mid-14th century. By some estimates, it eliminated between one-third and one-half of the population of the continent; simply, it devastated the political and economic landscape of the region (Deaux, 1969). During Plantagenet rule (1154-1485), the health of Londoners declined significantly from myriad complicating factors – famine, internal conflict, and foreign wars – which served to enervate the empire. This decline in health derived from years of significant physiological stress imposed by Plantagenet rule predisposed the inhabitants of London to the bubonic plague, which ravaged the capital city from 1348-1351.
The reign of the Tudors (1485-1603) restored stability to the country through a plethora of improvements in legislation and policy. This analysis focuses on the efforts made in respect to improving health, whether derived from direct improvements made by the sovereign and agents of the crown or indirect effects as a result of policy decisions. The stability provided by the Tudors improved many areas of life of the English subjects, and consequentially, the quality of health of the citizens of the crown. Therefore, the contributions of the Tudors enacted a significant positive influence on the health of Londoners that stimulated population growth in medieval England. This examination utilizes the skeletal record in order to make inferences about subjects of medieval England and to support the claim that the Tudor dynasty made astounding improvements in the well-being of those living under its rule.
This analysis will be accomplished with the ‘natural sciences’ approach to bioarchaeology, as it frames health in respect to population dynamics and sustainability and the evaluation of the skeletal record (Stojanowski and Duncan, 2015). First, it is necessary to define health and discuss how indicators of health will be used in order to make inferences about population health gleaned from individuals who lived and perished centuries ago. Quantifying such indicators of health enables comparison between the dynastic periods. Studies involving burial populations from each epoch are discussed as supporting evidence for the argument. The juxtaposition of the evidence used to evince health in medieval London in the two periods will emphasize the significant improvements made under Tudor rule.
Assessing Health in the Biorchaeological Record
In order to appraise and compare the health of individuals who are no longer extant, health must be defined in a manner that can be applied to burial populations. Temple and Goodman (2014) define health as “a comprehensive state of well-being that included physiological status and individual perception, factors that cannot be readily observed in skeletal samples” (p. 186). This critical analysis of health in the frame of bioarchaeology limits its use, which the authors assert has been too broadly applied in recent decades. Considering this definition set forth by Temple and Goodman, the use of ‘health’ within this analysis is simply comparative, as it is nonviable to quantify health in a population that is no longer extant. The evaluation of the ‘health’ of Londoners is thus completely inferential based on the evidence in the skeletal record, which is limited by the nature of the study material. While holistic analysis of health cannot be completely accomplished, it is possible to make deductions based on what evidence is present. These deductions are derived from the inverse relationship between physiological stress and health and are therefore the focus of this analysis.
The Developmental Origins of Health and Disease (DOHaD) Hypothesis possesses a significant degree of utility in an analysis of health. This tenant of biological anthropology states that physiological stress incurred during years of development can lead to negative health outcomes that persist for life, ultimately increasing vulnerability to infectious disease (Barker and Osmond, 1986). Its applications are wide in bioarchaeology and other fields of study that integrate human physiology. The inverse relationship between physiological stress and health is thus derived from the DOHaD hypothesis.
Furthermore, there exists a plethora of indicators of physiological stress that can be embodied in the human skeleton. Linear enamel hypoplasia (LEH) is perhaps one of the most significant skeletal manifestations of stress. LEH occurs during periods of stress; amelogenesis, the process of enamel production, is halted and calcium deposits build on the outer layer of the tooth. Cribra orbitalia is another commonly-cited indicator of stress. It is characterized by porous areas in the orbital cavities, or eye sockets, and results from significant dietary deficiencies, typically anemia. Nonspecific periosteal lesions, such as excess growth on the exterior of a bone known as periostitis, can occur from a wide range of etiologies and are often cited as evidence of stress. Such indicators of stress are classified as ‘nonspecific’ because they vary widely in origin and their embodiment in the human skeleton. However, not much more can generally be derived from their presence, as such lesions are not indicative of the source of stress (Roberts and Manchester, 2005). It is also important to note that the accumulation of such indicators is the result of prolonged exposure to physiological stress. Victims of the Black Death typically succumbed within a few days of the onset of symptoms (Prentice and Rahalison, 2007) and therefore such lesions would likely not be present in the skeletal records of these individuals.
The Plantagenets (1154-1485)
In order to examine the magnitude of the Black Death’s impacts on London, it is imperative to evaluate the context associated with the period prior to the arrival of the plague. The reign of Edward II (1307-1327) supplies significant context for engendering physiological stress on the citizens of London in the period before the onset of the Black Plague. The Great Famine swept through the European continent for almost a decade, though its effects were most significant in England from 1315-1317. Food scarcity eradicated approximately 10-15% of the population of England, making it a significant event that incurred physiological stress in the citizenry (DeWitte and Slavin, 2013). During this time, Edward II scantily attempted to assuage the dearth, exerting little control over the food markets. Edward’s negligence and refusal to set limits on the prices of grain only served to exacerbate the shortage of food (Braid, 2013). During the reign of Edward III (1327-1377), England became involved in the first phases of what was to become the Hundred Years’ War, an attritional series of conflicts that would exert abiding stress on the subjects of the crown. It was also during the reign of Edward III that the Black Death arrived in the country. By November 1348, London itself was completely tormented by the “invisible and spectral death” (Packe ,1983, p. 86). The plague devastated the capital city for the next several years. As can be seen, the reigns of the father and son pair of Edwards II and III included pivotal events that assuredly introduced periods of corporeal stress for inhabitants of medieval London.
This historical evidence of physiological stress in pre-Black Death London is supported by bioarchaeological data, confirming the poor overall health of citizens during the period before the outbreak of plague. DeWitte (2015) discovered that Londoners experienced a decline in overall health in the period immediately preceding the Black Death. Specifically, age-at-death distributions for a 13th century population show on average a higher proportion of individuals ranging from 15-35 years of age compared to that of 11-12th century burial populations. Though this may initially indicate a greater overall health, a higher proportion of young adults in a burial population signifies a smaller proportion of the population surviving into middle-age. To support this claim, Kaplan-Meier survival analysis (a method of expressing survival as a function of time in terms of probability) was performed on individuals from both periods, which revealed a decrease in survivorship during the stressful epoch preceding the plague. In other words, the mean survival time decreased – from 38.19 (11-12th century) to 31.63 years (13th century) in this latter period. The declines together reveal that “there were reductions in survivorship and increases in adult mortality” in the 13th century when compared to that of the 11th and 12th centuries (p. 446); furthermore, this decrease in survivorship “might reflect general deterioration in health as a consequence of periodic, severe food shortages” (DeWitte, 2015, p. 449). As seen by supporting bioarchaeological data, the reigns of Edwards II and III introduced physiological stress that in turn decreased the quality of health of Londoners.
Though this downward trend began in the latter decades of the 13th century, it is relevant to mortality and survivorship in the face of the Black Death outbreak of the mid-14th century. There was a significant decline in the health of Londoners that began approximately two generations before the plague (Smith, 2012), for which DeWitte writes that “any deterioration in demography and health that occurred in the beginning of the 13th century did not reverse before the Black Death” (DeWitte, 2018, p. 8). This assessment aligns excellently with the results of the previously examined studies that showed a decline in health and survivorship during the late pre-Black Death period. DeWitte (2018) concludes that Londoners could be classified as “a population in relatively poor general health and thus vulnerable to the effects of the Black Death” (p. 8). As a result, the health of Londoners was likely poor due to significant physiological stress in the pre-Black Death period.
It is likely that the decrease in survivorship was due to physiological stress factors imposed upon the population of London. The most notable of these was the Great Famine of 1315-1317. In fact, the bioarchaeological record reveals an elevation in skeletal indicators of physiological stress during the pre-Black Death period. For example, there was a considerable increase in the proportion of individuals with linear enamel hypoplasia (LEH) during the aforementioned period (an increase from 30.2% to 36.2%), a further indication of physiological stress in the general population (Yaussy et al. 2016). Through this analysis of indicators of physiological stress such as LEH, cribra orbitalia, and periosteal bone growth, Yaussy et al. (2016) also found that individuals with higher incidences of such markers were more likely to succumb to disease. The authors were able to draw a connection between physiological stress and quality of health.
Preexisting health factors at the time of the onset of plague were also extremely influential in regards to mortality to the Black Death. DeWitte and Wood (2008) examined various skeletal lesions in order to determine the relationship between preexisting deleterious health conditions and mortality risks in regard to the epidemic. The authors classified the state of preexisting health risks as frailty in a manner slightly different than the standard definition presented by Vaupel (1979), which expresses frailty as a function of mortality of an individual by accounting for other variables. In contrast, DeWitte and Wood compared each individual’s relative risk of death before the onset of plague with the living population, noting that “frailty will be indicated by the presence of at least one skeletal lesion.” They found that the mortality of Black Death was at least somewhat selective with respect to skeletal indicators of frailty. The authors concluded that the plague did not kill arbitrarily, but did distinguish less intensely than death typically does in respect to frailty, which showed that the Black Death increased mortality of those with skeletal lesions, indicators of past physiological stress (DeWitte and Wood, 2008). In other words, individuals who suffered physiological stress were therefore more likely to succumb to the Black Death.
An analysis of a similar plague burial site examined plague victims in order to determine the impacts of physiological stress on disease mortality. It revealed that victims of the plague born before the Great Famine suffered from a decreased average stature (an indicator of poor nutrition) when compared to those born after the provisional dearth. The survivors of the famine period suffered from an increased mortality as a product of this physiological stress, and thus were more prone to the plague infection (DeWitte and Slavin, 2013). This discovery is supplemented by DeWitte and Hughes-Morey (2012), which found a strong correlation between short stature and elevated disease mortality. Though the authors were not able to conclusively draw a direct connection between short stature and increased mortality due to their use of a control, attritional burial population, it is possible to apply anthropological theory to support the claim made in DeWitte and Hughes-Morey (2012).
Though biological stress varies in both etiology and embodiment in the human skeleton, it poses the same general outcome in respect to disease mortality. As previously stated, the DOHaD hypothesis can be applied to victims of the Black Death. DeWitte and Wood (2008) and DeWitte and Hughes-Morey (2012) have both revealed the relationship between indicators of poor health and increased mortality in respect to the epidemic. Application of the DOHaD hypothesis to the results of these two studies leads to the conclusion that elevated levels of stress early in life did in fact have an impact on disease mortality in the face of the Black Death. Thus, shorter average stature can be correlated with higher incidences of physiological stress.
Watts (2015) also supplies supporting evidence for the application of the DOHaD hypothesis in respect to victims of the Black Death. The author applied it to compare stress between burial populations from several sites both before and after the onset of the plague and found one underlying correlation – “individuals with evidence of growth disruption had an increased risk of adult mortality” (576). Though typically the hypothesis is applied in respect to infancy and young childhood, the author identified stress in late childhood as the major determining factor for an increased risk of adult mortality (Watts, 2015).
The health of Londoners declined during the century preceding the onset of the Black Death. The Great Famine of 1315-1317, among other factors secondary to Plantagenet rule, exerted physiological stress on the population which decreased survivorship of the general populace in respect to a catastrophic event such as the plague. The health of the population would not recover until the rulers of the Tudor dynasty, who collectively restored order and stability to the country.
The Tudors (1485-1603)
In 1485, Henry Tudor sailed from exile in France across the English Channel borne on capturing the throne from Richard of Gloucester, ruling as the now-infamous Richard III. On August 22, 1485, Henry engaged the forces of Richard, the King of England and the last of the Plantagenet dynasty, outside of a small village named Market Bosworth. Richard was decisively defeated and subsequently slain, terminating the Plantagenet dynasty. The Tudor’s triumph ended the Wars of the Roses and resulted in Henry Tudor’s ascension to the throne as Henry VII (Bindoff, 1950).
Through his rule, Henry VII was able to establish the foundation of a dynasty that expanded the power and wealth of England to transform the country into a much healthier state. In fact Henry Tudor is credited for the impetus of modern England. For example, he sought sweeping changes in the realm of public health, establishing regulations on slaughterhouse practices and expanding the already-existing Commission on Sewers (Larkey, 1934). Henry also invigorated the economy as prices of crops plummeted, promoting growth and trade (Oldland 2010). As a further testament to his willingness to provide for his citizens, Henry VII instructed in his will that a hospital be founded, with a specific function of caring for the poor (Rexroth, 2007).
Upon his father’s death in 1509, Henry VIII continued to rule the nation in a manner reflective of his namesake; this decision to continue his father’s legacy ultimately resulted in the continued fortune of English subjects. Despite the popularly-held beliefs about this magnanimous ruler, Henry initiated several policy objectives to improve the well-being of his subjects. He established the Royal College of Physicians on September 23, 1518 and the Barber-Surgeons Company in 1540, to standardize the practices of physicians and surgeons (Davenport, 2001; Larkey, 1934). He also ‘re-founded’ the Royal Hospital of St. Bartholomew in 1546, perhaps to perpetuate the actions of his father (Walter, 1878). Queen Elizabeth, daughter of Henry VIII, continued this legacy through her regal efforts to improve the quality of food by establishing emergency stores of grain; “The Virgin Queen” passed legislation to combat the increasingly-overcrowded nature of the capital city (Larkey, 1934). Tudor rulers served to improve the health of citizens in London and minimize physiological stress.
In short, “England was economically healthier, more expansive, and more optimistic under the Tudors than at any time since the Roman occupation of Britain” (Guy, 1988, p. 50). Furthermore, the improvements in health, quality of life, fertility, and life expectancy resulted in constant population growth in England, booming from 2.26 million in 1525 to 4.10 million by 1601 (Guy, 1988). It is important to note that population estimates before the onset of Black Plague placed the population of the country between four and five million, indicating a rapid diminution during the epidemic (Prestwich, 2005). Rapid population growth under Tudor rule stimulated the economy, reinvigorated trade, and promoted the growth of both London and England (Guy, 1988). The Tudor dynasty exerted a significant positive influence on population dynamics.
In a manner similar to the declining health under the rule of House Plantagenet, bioarchaeological data supports the claim that the Tudors significantly improved the health, and therefore the population growth, of the inhabitants of London. In a comparison of pre- and post- Black Death populations, Sharon DeWitte found a higher frequency of periosteal lesions in the latter (DeWitte, 2014a). Though this may initially signal a poorer quality of health in the post-Black Death period, the opposite is true in reality; one must consider the relationship between periosteal lesions and age. Grauer (1993) shows that the incidence of periosteal lesions increases with age and that older individuals accumulate lesions over time that reflect nonlethal conditions. The higher presence of periosteal lesions in the post-Black Death population indicates that individuals in post-Black Death burials more often survived periods of physiological stress compared to those of pre-Black Death burial samples, who experienced increased mortality rates. The conclusion of “improvements in longevity” found by DeWitte (2014a) signify a noteworthy improvement in population health in the period following the Black Death (p. 265). Enhanced survival results in an increased proportion of individuals who live to an older age (DeWitte, 2014a). Improvements in life expectancy, a greater incidence of nonlethal skeletal lesions, and declines in disease mortality collectively indicate a much better quality of health for the subjects of the crown.
Though birth rates declined slightly after the onset of Black Death, there is no indication that the general population experienced a decline in health (DeWitte, 2014b). In fact, crude birth rates tend to decline for as long as fifty years following an event that induces mortality on a catastrophic scale (Paine 2000). The aforementioned study, DeWitte (2014b), found that health continued to improve following the plague, citing improvements in survival and significant decreases in mortality risk. Similarly, DeWitte (2018) revealed increased survivorship in the period following the plague, with mean survival time increases from 31.65 to 39.58 years. This trend could initially be the result of a more resilient survivor population, and not an actual improvement in health, as those in poorer health were more likely to succumb to the disease, appearing to increase the average health of the general population after the plague. Londoners experienced a much longer life expectancy in the period following the plague, likely due to the previously-emphasized reduced levels of physiological stress events under Tudor rule.
Despite the fact that trends in health showed improvement during the reign of the Plantagenets, it was not until the rulers of the Tudor dynasty that significant developments were made in regards to health. These initial improvements can more strongly be attributed to the resilience of the survivor population, and not to efforts made by Plantagenet rulers to assuage the levels of physiological stress of Londoners during and after the Black Death. Furthermore, the data suggests that improved health resulted from a combination of increased survival following the Black Death as well as the restoration of stability in England by the Tudor dynasty.
Decreased levels of disease mortality certainly has a significant effect on population growth and dynamics. Guy (1988) cites population levels that burgeoned under Tudor rule. Though it is not possible to conclusively attribute this population growth to the efforts made by the Tudors, it is certainly sufficient to draw the conclusion that their efforts did enact a significant influence in the restoration of stability to the country and improvements in the health of its citizens.
The Plantagenet rulers (1154-1485), through direct acts or calamitous events beyond the control of the rulers, incurred significant physiological stress on the citizens of London. These stress events are captured in the skeletal record through osteological lesions, which increase frailty and disease mortality, especially in respect to virulence of the Black Death. This conclusion is achieved through a direct application of the DOHaD, which provides physiological evidence for a correlation between stress during developmental years, an increase in disease mortality, and the inferential conclusion about health. In the years immediately following the end of the plague outbreak, there were slight improvements in the health of Londoners, though these marginal improvements can be attributed to a healthier survivor population and not a healthier population as a whole, as indicated by the osteological record. Henry VII and the other Tudor rulers (1485-1603) implemented changes that positively impacted the health of their subjects. Application of the DOHaD allows for the conclusion that the decline of evidence of physiological stress indicated an improvement in health experienced by Londoners in the period following the Black Death can be attributed to the restored stability under the Tudor dynasty.
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Acknowledgments: Thank you to Dr. Laurie Reitsema and Samm Holder for making this paper possible.
Citation style: AJPA
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