AMERICAN JOURNAL OF PHYSICAL ANTHROPOLOGY 156:90101 (2015)

Evidence of Skeletal Treponematosis from the Medieval

Burial Ground of St. Mary Spital, London, and
Implications for the Origins of the Disease in Europe
Don Walker,1* Natasha Powers,1 Brian Connell,1 and Rebecca Redfern2
1
2

Museum of London Archaeology, London, N1 7ED, UK

Museum of London, Center for Human Bioarchaeology, London, EC2Y 5HN
KEY WORDS

Caries sicca; gummatous lesions; paleopathology; syphilis

ABSTRACT
Treponematosis is a syndrome of chronic
infectious diseases. There has been much debate on its
origins and spread, particularly with regard to venereal
syphilis, an unsightly and debilitating disease in preantibiotic populations. The osteological analysis of 5,387
individuals excavated by Museum of London Archaeology from the medieval burial ground of St. Mary Spital
in London (dated c 11201539) provided an unprecedented opportunity to investigate the nature and prevalence of disease over a period of time. Twenty-five
individuals were found with suspected treponematosis,
originating from all but the earliest period of the burial

ground. Descriptions of affected individuals from each

period, together with supporting images, are provided.
In this work, particular emphasis was given to the distribution of lesions on the skeleton and the variation in
patterns by sex and over time. Little change was
observed in the distribution of bony change between
individuals dated to pre- and post-Columbian periods.
However, a dramatic rise in the prevalence of the disease in the final period (c 14001539) may reflect documentary reports of a European epidemic from the late
15th century. Am J Phys Anthropol 156:90101,
2015. VC 2014 Wiley Periodicals, Inc.

Treponematosis is a chronic or subacute bacterial

infectious disease, caused by spirochetes (microorganisms) of the genus Treponema. There are four syndromes
of the disease, classified according to clinical manifestation and geographical spread: pinta (T. carateum) occurs
only in tropical America, yaws (T. pallidum subspecies
pertenue) in humid areas such as the tropics and subtropics, bejel or endemic syphilis (T. pallidum subspecies
endemicum) in nonhumid temperate and subtropical
rural regions, and venereal or acquired syphilis (T. pallidum subspecies pallidum), the most widespread of the
diseases, found chiefly in urbanised populations. All
except pinta can cause pathological changes in human
bone (Hackett, 1975, 229; Hunnius, et al., 2006, 559).
There has been much debate on the origins and epidemiology of treponematosis, particularly with regard to
the sexually transmitted form, venereal syphilis, an
unsightly, and debilitating disease in preantibiotic populations (Ortner, 2003, 273). One theory, known as the
Columbian hypothesis, asserts that venereal syphilis
was absent from Europe until Columbus and his men
brought it back from the Americas in 1493. There is also
a pre-Columbian hypothesis, where syphilis was present
in Europe prior to the voyages of Columbus, but was not
clinically identified, perhaps due to confusion with
another infectious disease, such as leprosy. However, a
reinvestigation of the paleopathological and dating evidence for each published case of Old World treponemal
disease reported an absence of skeletal evidence for the
disease from pre-1493 contexts, together with unreliable
dating evidence (Harper et al., 2011). A further theory,
the unitarian hypothesis, suggests that treponemal diseases were present in both the Old and New World, and
evolved separately in response to social and ecological factors (Mays et al., 2003, 133; Powell and Cook, 2005, 31
7). It is possible that the disease arrived relatively late in

Europe, perhaps spreading from the Middle East through

pilgrimage to the Holy Land or as campaigners returned
from the Crusades (Mays et al., 2003, 141; Mitchell, 2003,
122). The discovery of a possible case of treponemal disease from a sixth century AD Anglo-Saxon cemetery at
Apple Down in England suggests it was could have been
present long before (Cole and Waldron, 2011).
In order to investigate these theories, it is necessary
to look at the impact of the disease on a population of
known date. Such evidence has been recovered from the
excavation of the burial ground at the Augustinian Priory and Hospital of St. Mary without Bishopsgate, later
known as St. Mary Spital, one of about two hundred
hospitals founded in 12th century England. St. Mary
Spital became one of the largest and most significant
hospitals in the country in the medieval period, providing shelter not only for the sick, but also for the poor,
elderly, and homeless of the City. Its location on a road
beyond the City walls helped the priory serve the needs
of passing migrants and pilgrims (Thomas et al., 1997,
2, 889). It is presently the most thoroughly investigated
of the hospitals of medieval England.

2014 WILEY PERIODICALS, INC.

Grant sponsor: The City of London Archaeological Trust with

London Archaeologist Magazine.
*Correspondence to: Don Walker; Museum of London Archaeology, Mortimer Wheeler House, London N1 7ED, UK. E-mail:
dwalker@mola.org.uk
Received 2 May 2014; revised 17 September 2014; accepted 20
September 2014
DOI: 10.1002/ajpa.22630
Published online 6 October 2014 in Wiley Online Library
(wileyonlinelibrary.com).

SKELETAL TREPONEMATOSIS FROM ST. MARY SPITAL

The osteological recording of a sample of 5,387 individuals from the medieval burial ground at St. Mary Spital
revealed 25 individuals with skeletal changes characteristic of treponematosis. The sample allowed us to investigate the presence of this disease in medieval London,
not simply on the basis of a single diagnosis, but with
the aid of multiple examples, where the distribution of
lesions could be mapped and analysed. This study concentrates on such distributions in order to investigate
the disease at a population level, and to examine any
variation in its skeletal expression over time. Specific
lesions, when found in certain locations and in certain
combinations on the skeletal remains of individuals,
may indicate the presence of particular syndromes of
treponematosis.

THE DIAGNOSIS OF TREPONEMATOSIS

Infection with venereal syphilis can lead to progression through three clinical stages. A primary chancre is
followed by a second stage where dissemination around
the body, through the regional lymph nodes and blood
stream, leads to more general rashes on the skin and
mucous membranes. The tertiary stage of the disease
appears most frequently 210 years following infection,
and can affect the bone, viscera, skin, and central nervous and cardiovascular systems (Resnick, 2002, 2552;
Ortner, 2003, 279).
Diagnosis of specific infectious diseases in archaeological samples is highly dependent on the preservation of
skeletal remains. Frequently it is only in the complete
or near complete individuals where sufficient evidence of
the type and distribution of lesions exists to offer a
secure diagnosis. However, there can also be a variety of
expression in many chronic systemic diseases due to variations in immune response between individuals (Roberts, 2000, 145, 149). Thus, even well-preserved
skeletons which exhibit a number of lesions may lack
pathognomonic bone changes, and diseases such as venereal syphilis may produce lesions reminiscent of many
different disorders (Hackett, 1975, 230). Clinical data
has established that approximately 2050% of untreated
cases of venereal syphilis progress to the tertiary stage
(Aufderheide and Rodrguez-Martn, 1998, 1578). In
addition, only 1012% of individuals with syphilis
exhibit bone changes (Roberts and Manchester, 1995,
152). As well as the frequency with which an infectious
disease affects the skeleton, paleopathological investigations must take into account the osteological paradox.
Those individuals in good health with strong immune
systems are more able to survive infections for a sufficient period to allow bone changes to develop. This contrasts with the more infirm who may die after the initial
infection prior to the appearance of lesions on the skeleton (Wood et al., 1992). In such cases, a low prevalence
of lesions within a skeletal sample may not always
reflect a healthy population, thus creating the paradox.
Although transient cranial periostitis may appear during the secondary stage of syphilis, the majority of bone
changes occur in the tertiary stage (Ortner, 2003, 280).
The lesion considered to be most characteristic of treponematosis is caries sicca, a gummatous osteoperiosteal
lesion which presents as focal destruction and remodelling of the outer table and diploe of the skull. It is particularly associated with venereal syphilis and is most
commonly reported in the frontal bone, but can also
affect the parietal and facial bones, and can lead to

91

severe bone and soft tissue destruction (Hackett, 1975,

2326; Ortner, 2003, 280). The facial bones usually
become involved when the nasal mucosa is infected (Ortner, 2003, 283). In his substantial study of treponematosis in medical museum specimens, Hackett (1975, 230,
2325, 238) considered caries sicca diagnostic of the syndrome, particularly when found in conjunction with long
bone gumma. von Hunnius et al. (2006, 564) argued that
the presence of caries sicca and both proliferative and
destructive lesions in the postcranial skeleton, were
more indicative of venereal syphilis than other treponemal diseases.
Gummas contain caseous necrotic material. They are
created by the action of the toxic products of spirochete
degeneration on the bone (Resnick, 2002, 25578). They
destroy both bone and organs, and in skeletal remains
can be found in the skull and long bones, both as periosteal and medullary lesions (Ortner, 2003, 280).
Certain forms of nongummatous lesions may feature
in cases of treponematosis, also occurring in the skull
and long bones. New bone forms at the metaphyses following periosteal inflammation, and this can spread to
cause severe and diffuse plaque-like bone growth.
Lesions can also occur in the cortex leading to osteitis,
and narrowing and even obliteration of the medullary
cavity by sclerotic trabeculae (Ortner, 2003, 2856). In
individuals where the long bones remain intact it is not
always possible to differentiate between periostitis and
osteitis without radiographs. Care must be taken to map
the distribution of lesions in the skeleton if a specific disease process is to be identified, as periosteal new bone
formation can result from a wide range of disorders
[metabolic, neoplastic, infectious, traumatic, joint, dysplastic, circulatory, and hematological (Weston, 2008,
50)]. The most commonly affected skeletal element in
cases of venereal syphilis is the tibia, followed by the
frontal and parietal bones, the nasalpalatal region, the
sternum, clavicle, vertebrae, and long bones (Aufderheide and Rodrguez-Martn 1998, 158). Clinical symptoms include boring pain in the bones affected by
proliferative periostitis, fever, tenderness, and soft tissue
swelling (Resnick, 2002, 2555).
In the case of endemic syphilis and yaws, approximately 15% of cases develop skeletal lesions (Aufderheide and Rodrguez-Martn, 1998, 1567). However, it
is possible that the expression of some or all of the treponemal diseases has changed since the medieval period.
Yaws, endemic syphilis, and venereal syphilis can all
produce similar bone changes and are difficult to distinguish (Hackett, 1975, 238; Buckley and Dias, 2002, 179).
Differences in skeletal involvement between the diseases
are to a certain extent quantitative; with the cranial
vault rarely involved in endemic syphilis and yaws
(Baker and Armelagos, 1988). Ortner (2003, 280) identified calvarial lesions as the most diagnostic for venereal
syphilis.
An important aspect of the study of treponematosis is
the placement of examples of disease within their historical, geographical and environmental contexts. Aufderheide and Rodrguez-Martn (1998, 171) stated that the
pattern of treponemal infection discerned in entire skeletal series, viewed in conjunction with social and climatological factors, may permit epidemiological inferences.
Hackett (1975, 238) suggested that the only way to
determine which disease was present was to take
account of the dating and provenance of cases, together
with the living environment of the affected population
American Journal of Physical Anthropology

92

D. WALKER ET AL.

(humid or arid, urban or rural). Mays et al. (2003, 139

40) observed that the microorganism that causes Yaws
(Treponema pertenue) is adapted to humid tropical environments and it would be unusual to find cases in northwest Europe. It is conceivable that endemic syphilis was
present in medieval London, or that individuals from climatically different areas had migrated there whilst suffering from the disease, though no archaeological
evidence of such exists. Endemic syphilis is usually contracted prior to adulthood and only rarely affects the
cranial vault when compared to the venereal form (ibid
141).
This report examines the type and range of bone
lesions in individuals suspected of suffering from treponematosis, together with the distribution of pathological
changes on the skeleton. It also explores the variations
in expression of the disease between the sexes and over
time. Specifically it tests the hypothesis that the distribution of lesions associated with treponematosis at St.
Mary Spital is the same in skeletons from preColumbian contexts as it is in post-Columbian contexts.
This would suggest that the same disease was responsible and would have implications for the debate on the
presence of treponematosis in London, and the Old
World in general, prior to the voyages of Columbus.

MATERIALS AND METHODS

The Priory and Hospital of St. Mary Spital was
founded in around 1197. It was originally served by a
small burial ground, but on its refoundation in 1235 on
a much larger plot of land, an adjacent pre-existing burial ground, believed to have dated from c. 1120, was
incorporated into the priory precinct (Thomas et al.,
1997, 1923, 3740). Excavations by Museum of London
Archaeology between 1999 and 2002, prior to the redevelopment of Spitalfields Market, recovered c. 10,500
individuals from an area covering 5.2 hectares. The burial ground was divided into four phases, initially based
on the stratigraphy and study of the plans (Table 1). A
detailed program of radiocarbon dating and Bayesian
modelling then allowed the formulation of a model providing interpretive estimates for the chronology of the
burial ground. Isotopic analysis of the dated skeletons
revealed diets relatively low in fish, to some extent countering the marine reservoir effect (Sidell et al., 2007).
Three models were then run to test the data. The final
estimate of accuracy of the phasing of the skeletons was
84% (Harward et al., in prep). The success of this work
has allowed us to study the burial ground over time.
Period 14 includes the original foundation of the priory, when it retained its own burial ground, separate to
the one under study, which appears to have pre-dated
St. Mary Spital. For the next 50 years, during period 15,
the priory maintained its own funerary area, separate
from the main burial ground. Period 16 spanned 150
years, during which the size of the priory expanded and
the hospital began to bury inmates within the main burial ground. The final phase of burial up to the priorys
closure at the Dissolution is covered by period 17.
The burials were further divided into two groups: single burials, together with bodies arranged in single horizontal layers and single vertical stacks, were considered
to represent normal (attritional) mortality, whilst pits
containing multiple layers of burials were regarded as
reflecting catastrophic episodes. The latter were probably associated with periods of unusually high mortality
American Journal of Physical Anthropology

TABLE 1. St. Mary Spital medieval burial ground periods

Period
14
15
16
17

Dates
c. 11201200
c. 12001250
c. 12501400
c. 14001539

when emergency measures permitted the opening of new

areas of the burial ground, to allow rapid burial of Londons dead in mass pits.
Osteological data were retrieved from the Museum
Group inter-relational Oracle database and utilised for
this study. Paper based recording forms provided in
depth information on pathological changes which supplemented the basic data. Adult age at death estimates
employed a combination of pubic symphysis degeneration (Brooks and Suchey, 1990; Buikstra and Ubelaker,
1994, 2432), auricular surface degeneration (ibid; Lovejoy et al., 1985) and sternal rib end morphology (Iscan
et al., 1984, 1985), in addition to dental attrition (Brothwell, 1981, 72).
Individuals aged below 18 years of age were classed as
subadults. Their age was estimated using a combination of long bone diaphyseal growth, stage of epiphyseal
fusion and tooth development and eruption (Moorees
et al., 1963a, b; Maresh, 1970; Gustafson and Koch,
1974; Scheuer and Black, 2000).
Biological sex was only attempted on adult individuals
and was based on a suite of morphological characteristics in the skull and pelvis. The following areas of the
skull were assessed: supraorbital ridges, inion protuberance, nuchal crest, mandibular gonions (Brothwell,
1981), mastoid processes, slope of forehead (Bass, 1987,
82), and zygoma root (Ferembach et al., 1980). The pelvis was evaluated using the following: ventral arc,
medial portion of pubis (Phenice, 1969), greater sciatic
notch, preauricular sulcus, subpubic angle, subpubic
concavity and median ischiopubic ridge (Bass, 1987,
2035).
Macroscopic methods alone were employed for the
study of pathological lesions. The bone changes considered diagnostic of tertiary treponemal disease were
caries sicca (Jaffe, 1972, 9303; Aufderheide and
Rodrguez-Martn, 1998, 1612; Ortner, 2003, 2803),
gummatous foci (Jaffe, 1972, 93041; Aufderheide and
Rodrguez-Martn, 1998, 160; Buckley and Dias, 2002,
180), and certain distributions of gummatous and nongummatous lesions (Steinbock, 1976; Aufderheide and
Rodrguez-Martn, 1998, 159; Buckley and Dias, 2002)
where characteristic infectious changes were observed in
a number of the following bones: clavicles, sternum,
acromia, tibiae, distal humeri, and proximal radii and
ulnae. Consideration was also given to reduction of the
medullary cavity of long bones through cortical thickening, destructive facial changes (Jaffe, 1972, 934), and
expanded long bones with superficial cavitations, pits,
and striae (Hackett, 1975, 237).
Details of the age, sex, period, and burial type of each
affected individual were entered into Excel spreadsheets
following the methods of Powers (in prep) in her forthcoming work on venereal syphilis in postmedieval London. Distributions of bone changes were mapped on to
skeletal diagrams and displayed in Excel tables and
graphs. In the skeletal diagrams, affected long bones
and clavicles were divided into proximal, mid, and distal

SKELETAL TREPONEMATOSIS FROM ST. MARY SPITAL

93

shafts. Demographic details of all individuals with treponematosis were analyzed by age, sex, and period.
The statistical significance of results was established
through v2 tests, employing Yates correction for small
samples, with the chosen significance level being 0.05.

RESULTS
Descriptions of Selected Individuals
Details of the pathological changes of all 25 skeletons
believed to be affected by treponematosis are located in
the project archive. Descriptions of a representative
selection of individuals are included below, together with
supporting images.
Period 15 (c. 12001250). Context [22251], 2635
years of age at death. The skull of this individual was
not preserved due to truncation of the burial, but there
were extensive pathological changes to the appendicular
skeleton. There was a thick layer of periosteal new bone
on the posterior surface of the right acromion. The
medial part of the right clavicle was covered circumferentially in a fine layer of woven periosteal new bone,
while the inferior and posterior aspects of the midshaft
and the superior aspect of the lateral part were similarly
affected. The anterior surface of the medial part exhibited a lytic lesion (longitudinal axis length 30.6 mm)
with ragged margins, which extended through the cortex
to the anterior margin of the proximal facet. In the left
clavicle, the diaphysis was swollen with a surface of
porotic periosteal new bone punctured by two lytic
lesions with irregular margins, one on the medial part
(length 14.9 mm, width 15 mm), and one on the midshaft (length 35.7 mm, width 17.9 mm). Woven periosteal new bone surrounded these lesions as well as the
anterior and posterior surfaces of the manubrium.
The distal third of the diaphyses of the humeri were
covered in periosteal new bone and the proximal third
shaft of the left bone had a deep lytic lesion (length
26.6 mm, width 12 mm) penetrating the cortex (Fig. 1).
The proximal end of the left ulna, including the articular
surface of the olecranon, was swollen and covered in a
thick layer of periosteal new bone. There was a deep
lytic lesion below the trochlear notch. The diaphyses of
the second to fourth right metacarpals were also covered
in periosteal new bone.
In the lower limb bones, the right femur displayed
fusiform enlargement of the distal third of the shaft.
Both this and the left tibial diaphysis were covered by
thick layers of woven periosteal new bone formation.
The left tibial diaphysis also had four large lytic lesions,
the largest being 53.4 mm long and 34.7 mm wide.
There was periosteal new bone on the shaft of the left
fibula, and on the diaphyses of the second and third
right metatarsals. Although the skull of this individual
was not present, the combination of diffuse gross deposits of periosteal new bone and gummatous lesions were
characteristic of treponemal infection (Hackett, 1975,
238).
Period 16 (c. 12501400). Context [10566], Male 2635
years of age at death. This individual exhibited a number of bone changes in the axial and appendicular skeleton. In addition to dense supraorbital micro-porosity,
there was an erosive lesion adjacent to the supra-orbital

Fig. 1. Anterior view of long bones of SRP98 [22251]. [Color

figure can be viewed in the online issue, which is available at
wileyonlinelibrary.com.]

foramen on the right frontal bone (Fig. 2). A number of

stellate osteolytic lesions lay within an oval zone located
on the frontal and parietal bones, near bregma. These
lesions had irregular margins and floors of dense remodelling trabecular bone. There were several further discrete lesions on both parietal bones. The anterior
surfaces of the zygomatic bones and the atlas vertebra
were dense, porotic and striated, while the anterior surface of the axis vertebra body was covered in spicules of
lamellar bone. The posterior surfaces of the manubrium
and sternal body had dense remodelling layers of lamellar bone. The changes in the cranium may have been
the result of healed and remodelled caries sicca (Ortner,
2003, 280).
Multiple layers of porotic lamellar bone were evident
on all aspects of the distal third shafts of the humeri.
In the right humerus, the mid-third was also affected
and the lateral margin of the distal shaft contained
three oval lytic lesions (4.53.2 mm in diameter). In the
right ulna, the diaphysis was affected by superficial
lytic lesions and endosteal bone formation in the medullary cavity. The carpals of the right hand were ankylosed and covered by dense lamellar bone. The proximal
ends of the second to fourth metacarpals were also
fused to their respective carpals. The diaphyses of the
right second and left third metacarpal bones were covered in porotic lamellar bone. The lower limb bones,
American Journal of Physical Anthropology

94

D. WALKER ET AL.

Fig. 2. Superior view of cranium of SRP98 [10566]. [Color

figure can be viewed in the online issue, which is available at
wileyonlinelibrary.com.]

including the nonarticular surfaces of the tarsals and

metatarsal diaphyses were covered in dense lamellar
bone, with patches of woven bone on the tibial
diaphyses.
The evidence of tertiary stage gummatous and nongummatous lesions to both the axial and appendicular
skeleton suggests that this individual was suffering from
treponemal disease, possibly the acquired (venereal)
form.
Period 17 (c. 14001539). Context [13715], Subadult c
17 years of age at death. This adolescent exhibited
bone changes to both the cranial and postcranial skeleton. In the area of the glabella, there were coalesced
lytic lesions which had exposed the internal structure of
the frontal sinuses (Fig. 3). Lateral to these lesions were
smooth scooped out areas with irregular zones of lamellar bone. Similar new bone was evident in the orbital
roofs. The nasal spine and the majority of the anterior
maxillary mid-line, together with the margins of the
nasal cavity, had evidence of osteolytic action. Most of
the nasal bones and palatine process were destroyed. In
addition, the anterior aspects of the maxillae contained
both new woven bone and sequestrum.
The mandibular rami, distal third of the right clavicle,
distal third of the right radius, proximal thirds of the
ulnae, and distal thirds of the humeri were covered in a
mix of woven and lamellar bone. In the humeri both
cortical expansion and endosteal narrowing were apparent, while the unfused right radial distal epiphysis
exhibited a smooth-walled lytic lesion with a trabecular
base.
Woven and lamellar bone formation affected the right
femoral mid third (causing circumferential enlargement)
as well as the left tibia and fibula. The tibial shaft had
three well defined, large oval erosive lesions which peneAmerican Journal of Physical Anthropology

Fig. 3. Anterior view of cranium of SRP98 [13715]. [Color

figure can be viewed in the online issue, which is available at
wileyonlinelibrary.com.]

trated the periosteal new bone, some of which was

formed into dense remodelled plaques. In the fibula, the
changes were similar, but of greater severity, with lytic
lesions penetrating the new bone, the cortex and the
medullary cavity.
The bone changes in the glabella were typical of cranial gummatous lesions (caries sicca) which coalesced to
cause extensive and unsightly bone (and soft tissue)
destruction in the mid-face. Although the lesions in the
lower limbs were unilateral, the bone changes in this
adolescent, including nasal destruction, caries sicca, diffuse periostitis, mixed reparative lesions and gummas,
were pathognomonic of treponematosis (Aufderheide and
Rodrguez-Martn, 1998, 171).
Context [6974], Subadult c 11 years of age at death. This
subadult exhibited severe multifocal osseous changes to
the skull and appendicular skeleton (Fig. 4). The frontal
bones had areas of remodelled dense nodular bone formation as well as deep lytic lesions and channels leading
to inner table disruption. The left parietal bone and left
angle of the mandible also revealed lytic activity.
In addition to erosion of the margins of the nasal aperture and exposure of the sinuses by medial maxillary
lytic lesions, the mid-lines of the palatine and alveolar
processes suffered bone loss.
There was a combination of severe circumferential
expansion and lytic lesions in the left arm bones, and a
further solitary lytic lesion in the right humerus. The
right tibia had massive fusiform expansion with multiple
lytic lesions, some of which penetrated the medullary
cavity, on the anterior and lateral aspects of the
diaphysis.

95

SKELETAL TREPONEMATOSIS FROM ST. MARY SPITAL

TABLE 2. Crude prevalence (per individual) of treponematosis

at St. Mary Spital

Total
Adults
Females
Males
Intermediate sex
Undetermined sex
Subadults

Affected

(%)

5387
4360
1883
2237
205
35
1027

25
22
8
11
0
3
3

0.5
0.5
0.4
0.5
8.6
0.3

TABLE 3. Crude prevalence of aged and sexed adults from St.

Mary Spital with treponematosis
Female

1825 years
2635 years
3645 years
46 years

Male

Affected

(%)

Affected

(%)

428
716
467
211

2
4
2
0

0.5
0.6
0.4
0

481
752
700
222

2
6
3
0

0.4
0.8
0.4
0

TABLE 4. Crude prevalence of treponematosis by subadult age

at St. Mary Spital
Fig. 4. Anterior view of skull of SRP98 [6974]. [Color figure
can be viewed in the online issue, which is available at wileyonlinelibrary.com.]

This individual had osseous changes in the cranial

vault (caries sicca), facial bones (rhinomaxillary resorption) and long bones, which appeared to be the result of
a particularly severe expression of treponematosis. However, there was no evidence of the dental anomalies
[Hutchinsons incisors and Moons (mulberry) molars]
observed in 3050% of cases of modern clinical congenital syphilis (Aufderheide and Rodrguez-Martn, 1998,
165; Ortner, 2003, 296).
Although the bone changes, in the absence of specific dental anomalies, were not pathognomonic of
congenital syphilis, the age of this individual suggests
that they may have been suffering from the late form
of the disease. In approximately 50% of cases, such
individuals survive beyond infancy (Ortner, 2003,
289).

TREPONEMATOSIS AT ST. MARY SPITAL:

EPIDEMIOLOGY
Twenty-five individuals from the recorded sample
(0.5%) were identified with bone changes which appeared
to be the result of treponemal infection (Table 2).

Age and Sex

There was no significant difference in crude prevalence (by individual) of males (0.5%) and females (0.4%)
with treponematosis. They were similarly affected in all
adult age categories, with a slightly higher male prevalence in the 2635 year age group (Table 3).
Three subadults were affected, one aged c. 11 years
and two aged c. 17 years at death (Table 4).
The crude prevalence rate of treponematosis peaked in
the 2635 year age range (Fig. 5). No evidence of the disease was identified in the older adult age category (46
years) which comprised 8.2% (442/5387) of the total
sample.

611 years
1217 years

Affected

(%)

348
544

1
2

0.3
0.4

Burial Type and Period

When analyzed by burial type, all affected individuals
were from the attritional burial ground. There were
none in the mass pits, even though the sample size of
the mass burials was approximately equal in number to
that of the attritional burials.
As only attritional burials were affected, individuals
from the mass pits were excluded from further statistical
calculations. The evidence suggests that levels of disease
(0.4%) were broadly similar from c. 1200 to c. 1400. This
was followed by a statistically significant rise in prevalence to 3.4% (v2 5 37.71, df 5 1, P < 0.0001) in period 17
(c. 14001539) (Table 5).
Whilst male crude prevalence of treponemal disease
was higher than female rates in periods 15 and 16, the
opposite was true of period 17 (Table 6). However, neither difference was statistically significant.

Distribution of Skeletal Lesions

The distribution of lesions on a skeleton is an important indicator in specific infectious disease. Of those
individuals diagnosed with treponematosis, the most
commonly affected bones were the tibia and ulna
(Fig. 6).
In order to investigate variations in the expression of
treponemal disease by sex, the distributions of lesions in
males and females were mapped on to skeletal diagrams
(Figs. 7, 8). These revealed a preponderance of bilateral
lesions and a low involvement of ribs, vertebrae, and
nonacromial areas of the scapulae. There was little evidence of variation between the sexes in the distribution
of lesions within the skeleton apart from in the femora,
where 54% (27/50) of male shaft segments (16 proximal
shafts, 17 midshafts, and 17 distal shafts) were affected,
American Journal of Physical Anthropology

96

D. WALKER ET AL.
TABLE 6. Crude prevalence of treponematosis in the attritional
burial ground by sex and period
Female

15
16
17

Fig. 5. Percentage of individuals from St. Mary Spital with

treponematosis in each age category.

TABLE 5. Crude prevalence of treponematosis in the attritional

burial ground
Period
15
16
17

Affected

(%)

510
1392
526

2
5
18

0.4
0.4
3.4

compared to none of the female shaft segments (0/46).

Overall, the distribution of lesions in males was more
diffuse and demonstrated a greater degree of repetition
than that of females.
For the purposes of studying any variation in the
expression of the disease over time, the relatively small
samples from periods 15 and 16 were combined (c. 1200
1400). This provided a larger single dataset (n 5 7) of
securely pre-Columbian individuals for comparison with
period 17 (c. 14001539). All individuals, both subadult
and adult, were included. There was little evidence of variation in the distribution of lesions between the two periods
(Figs. 9, 10). The most notable change was a reduction in
the involvement of the distal third of the femur. Although
the frontal and maxillary bones were more frequently
affected in period 17, the percentages for periods 15 and
16 (right frontal bone 40% (2/5), left frontal bone 40%
(2/5), right maxillary bone 40% (2/5), left maxillary bone
20% (1/5)) were on average only about 20% lower. Overall,
the results show continuity in the distribution of lesions
associated with treponematosis between pre-Columbian
and post-Columbian contexts at St. Mary Spital.

DISCUSSION
The aim of this work was to investigate the evidence
for pre-Columbian treponematosis in London and
explore the possibility that venereal syphilis may have
been present prior to the 15th century. We also examined evidence for changes in the expression of the disease over time and between the sexes.
Documentary evidence from Europe in the first half of
the 16th century reports a rapidly spreading, highly virAmerican Journal of Physical Anthropology

Male

Affected

(%)

Affected

(%)

167
474
164

0
1
7

0.0
0.2
4.3

219
628
239

1
4
6

0.5
0.6
2.5

ulent disease. One possible explanation for this, which is

to some extent consistent with the Columbian hypothesis, is that the disease evolved rapidly following contact
with previously unexposed populations in the Old World.
Variation in the mode of transmission, from skin contact
to venereal, may have contributed to the rapidity of the
transformation (Knell, 2004). However, increasing evidence from Europe of possible examples of venereal
syphilis in skeletal remains predating the voyages of
Columbus suggests it may have been present in both the
Old and New Worlds prior to 1493. The steep rise in
identified examples of skeletal treponematosis in period
17 at St. Mary Spital may reflect the appearance of
numerous references to venereal syphilis in European
documentary records from the end of the 15th century
(Baker and Armelagos, 1988, 7078). However, as period
17 began nearly a century before the voyages of Columbus it is possible that some of the affected individuals
died prior to 1493.
At St. Mary Spital, there was no significant difference
in the crude prevalence of treponematosis by biological
sex. This compares to a high male (3.1%) to female
(1.8%) frequency of syphilis in five postmedieval burial
grounds in London (Powers in prep) and a modern ratio
of 23 males: 1 female (Aufderheide and RodrguezMartn, 1998, 158). This variation over time in the proportions of male and female individuals identified with
treponematosis may result from numerous different cultural and biological factors, including evolutionary
changes to the disease in Britain.
The peak of individuals with treponematosis in the
2635 year age range is consistent with elevated numbers of modern clinical cases between the ages of 15 and
30 years, if one allows time for the tertiary lesions to
develop in the archaeological sample (c. 210 years following infection) (Ortner, 2003, 279). The steep decline
in prevalence with increasing age suggests that those
with skeletal changes were unlikely to survive into old
age.
The absence of individuals with evidence of treponematosis from the mass burial pits is a significant finding, as it suggests variations in health between the
samples. It seems improbable that, during a period of
catastrophic mortality, individuals with the outward
signs of certain chronic diseases would be deliberately
separated from the mass of bodies and placed in separate graves. Instead it may be that a number of chronic
sufferers were hospital inmates and were more likely to
be interred in the attritional priory burial ground. It is
also possible that the mid-13th century date of the
majority of mass pit burials coincided with a dip in the
treponemal cycle, a period of time when the infection
rates were very low. Modern studies in the United
States have identified endogenous (biological as opposed
to environmental) oscillations in disease incidence,
attributable to partially protective immunity, creating

SKELETAL TREPONEMATOSIS FROM ST. MARY SPITAL

97

Fig. 6. Percentage distribution of affected bones (n 5 201) in individuals with treponematosis from St. Mary Spital (skeletons
with paired bones where both right and left sides were affected were counted only once).

cyclical outbreaks of syphilis every 811 years (Grassly

et al., 2005). Archaeological evidence and radiocarbon
dating from St. Mary Spital suggests that the majority
of the mass burial pits were dug during short bursts of
activity in response to rapid and short-term increases in
mortality. The catastrophic episode(s) which led to the
clustering of mass burials around the mid-13th century
could in theory have coincided with a period of low treponemal disease incidence.
A further possibility is that many of those in the mass
burials were migrants from rural areas who had previously been less exposed to urban diseases. Population
movements often coincide with periods of hardship, with
rural-to-urban migrants suffering higher rates of disease, partially due to their lack of immunity to infections
associated with increased population density (Bogin,
2001, 192219). The economic circumstances of such
migrants and their crowded living conditions would have
added to such risks, potentially increasing risk of death
prior to the development of bone lesions observable in
the archaeological record.
The range of lesions exhibited in the skeletal remains
of those individuals suffering from treponematosis at the
site of St. Mary Spital included caries sicca, postcranial
gummatous and nongummatous lesions, and osteitis.
There is clear evidence, supported by C14 dating, that
some of these individuals lived and died before the 15th
century. This is consistent with the discovery by other
researchers of Old World skeletons exhibiting signs of
the disease (e.g., Stirland, 1991; Roberts, 1994; Mays
et al., 2003; Mitchell, 2003; von Hunnius et al., 2006).
The difficulty in distinguishing the different types of treponemal disease from skeletal remains hampers studies
of its origins and evolution. While some argue that the
venereal syphilis form of treponemal disease was present
in pre-Columbian Europe, others believe that it resulted
from the mutation of yaws in the New World, and that
many of the medieval treponemal cases from the Old
World were suffering from yaws (Rothschild and Rothschild, 1996, 55960). However, as yaws is normally associated with humid tropical and subtropical climates, the
individuals at St. Mary Spital are more likely to have
been suffering from endemic or venereal syphilis. The
bone changes in these diseases are very similar but the
relatively high frequency of calvarial involvement

together with the combination of proliferative and

destructive lesions supports the evidence for the presence of venereal syphilis at the site prior to the 15th
century (Ortner, 2003, 280; Roberts, 2006, 564). One possible explanation for an early spread of treponematosis
to Britain would be an eastwest dissemination by those
returning from the Crusades; elsewhere multiple lesions
of the cranial vault of the type compatible with the disease have been identified in skeletal remains radiocarbon dated to between 1290 and 1420 (Mays et al., 2003,
141; Mitchell, 2003, 117, 122).
Although in modern clinical cases males are more
likely to develop venereal syphilis, at St. Mary Spital (in
period 17) it was females who were most affected by the
disease. The peak number of affected individuals
occurred in the 2635 year age range, appearing to
reflect modern patterns (Aufderheide and RodrguezMartn, 1998, 158). At least two of the three subadults
with skeletal changes, which include caries sicca, may
have been suffering from the late form of congenital
syphilis. From at least the mid 14th century, continuing
into the 15th century, St. Mary Spital was one of the few
London hospitals which admitted pregnant women
(Orme and Webster, 1995, 110). It also took in the children of any mothers who died, caring for them up to the
age of 7 (Thomas et al., 1997, 104).
The recurring model of distribution of skeletal changes
thought to result from treponemal infection was typified
by a bilateral and symmetrical distribution of lesions.
The only anomaly occurred in the absence of femoral
lesions in female individuals, an unexpected finding
which requires further research. While not identical,
there was no evidence of significant variation in the
forms or the distribution of skeletal changes in those
affected by treponematosis from period 15 to period 17 (c
12001539).
The presence of individuals at St. Mary Spital from
pre-Columbian phases with similar bone lesions to those
diagnosed with treponematosis from period 17, suggests
that there was little change in expression, at least as far
as skeletal involvement was concerned. However, the
increase in prevalence in period 17 could be interpreted
as supporting a change to a more chronic expression,
perhaps as the population developed greater resistance
to the disease, acting over a greater period of time with
American Journal of Physical Anthropology

98

D. WALKER ET AL.

Fig. 7. Distribution of lesions in males with treponematosis

(n 5 11) (gray infill < 50% of the bones or bone segments have
lesions, black infill 50% or more of the bones, or bone segments
have lesions).

an increased likelihood that bone changes would occur.

Alternatively, this may simply reflect the spread of venereal syphilis over time in an increasingly urban
environment.
Further work is required to establish the distribution
of treponemal diseases in past populations. von Hunnius
et al. (2006, 55960) recommend a multiple methodological approach, involving both macro- and microscopic
work, in future studies of venereal syphilis in human
skeletal remains, but acknowledge the importance of
American Journal of Physical Anthropology

Fig. 8. Distribution of lesions in females with treponematosis (n 5 8) (gray infill < 50% of the bones or bone segments have
lesions, black infill 50% or more of the bones or bone segments
have lesions).

keeping to a minimum any destructive sampling of such

a limited resource. In addition, radiographic analysis
can identify medullary gummas and osteitis, and can aid
measurement of the true extent of periosteal lesions
which may be underestimated in macroscopic studies
(Weston, 2008, 56). Fundamental problems hinder
the microbiological study of treponematoses, although
advances in DNA techniques may in the future allow its
identification in archaeological bone (von Hunnius et al.,
2007).

SKELETAL TREPONEMATOSIS FROM ST. MARY SPITAL

Fig. 9. Distribution of lesions in individuals with treponematosis from periods 15 and 16 (c. 12001400) (n 5 7) (gray
infill < 50% of the bones or bone segments have lesions, black
infill 50% or more of the bones or bone segments have lesions).

The paleoepidemiological study of treponemal disease

will be advanced by the identification and refinement of
diagnostic indicators in skeletal remains. An important
element in such is the analysis of the distribution of
lesions in affected individuals from well dated burial
grounds, such as St. Mary Spital. The excavation of this
large medieval hospital produced an important sample
of individuals with treponemal disease which will contribute to the debate on the origins and evolution of the

99

Fig. 10. Distribution of lesions in individuals with treponematosis from period 17 (c. 14001539) (n 5 18) (gray infill < 50%
of the bones or bone segments have lesions, black infill 50% or
more of the bones or bone segments have lesions).

disease. The discovery of two affected individuals from

period 15 (c. 12001250) suggests that the disease was
present in London more than two centuries before
Columbus sailed. Recent work has identified another
case of possible treponemal disease from Huntingdon,
England, probably dating to the 1112th century AD
(Mays et al., 2012).
Proposed pre-Columbian cases of treponematosis from
Old World sites have attracted criticism for a lack of
diagnostic rigour and/or unreliable dating. The detailed
American Journal of Physical Anthropology

100

D. WALKER ET AL.

dating programme applied to the burials at St. Mary

Spital, together with the unprecedented size of the skeletal sample, provides a significant contribution to the
ongoing dispute over the origins of treponematosis, and
specifically venereal syphilis. As with the increasing
number of proposed Old World cases, the evidence from
St. Mary Spital points to a pre-Columbian origin.

ACKNOWLEDGMENTS
We wish to thank City of London Archaeological Trust,
together with London Archaeologist magazine, for providing a grant for this work. The Spitalfields Project was
funded principally by the Spitalfields Development Group
(a subsidiary of Hammerson Plc.). A large number of present and past employees of Museum of London Archaeology
were involved in aspects of the excavation and postexcavation work. Chris Thomas was in overall charge of the project, and we must acknowledge his work together with
numerous field archaeologists involved in the excavations
at Spitalfields Market. The skeletal remains from St. Mary
Spital were analyzed by Brian Connell, Amy Gray Jones
(University of Chester), Rebecca Redfern, and Don Walker.
David Bowsher provided assistance in the production of
the original grant application. Judit Peresztegi designed
the graphs and skeletal diagrams and Andy Chopping produced the photographic images. Finally, the authors would
like to acknowledge the advice and encouragement provided by the late Don Ortner.

LITERATURE CITED
Aufderheide AC, Rodrguez-Martn C. 1998. The Cambridge
encyclopedia of human paleopathology. Cambridge: University
Press.
Baker BJ, Armelagos GJ. 1988. The origin and antiquity of
syphilis: palaeopathological diagnosis and interpretation.
Curr Anthropol 29:703737.
Bass WM. 1987. Human osteology: a laboratory and field manual, 3rd ed. Columbia: Missouri Archaeol Soc Spec Pap 2.
Bogin B. 2001. The growth of humanity. New York: Wiley-Liss.
Brooks ST, Suchey JM. 1990. Skeletal age determination based
on the os pubis: a comparison of the Ascadi-Nemeskeri and
Suchey-Brooks methods. J Hum Evol 5:227238.
Brothwell D. 1981. Digging up bones: the excavation, treatment
and study of human skeletal remains. London: British
Museum.
Buckley HR, Dias GJ. 2002. The distribution of skeletal lesions
in treponemal disease: is the lymphatic system responsible?
Int J Osteoarchaeol 12:178188.
Buikstra JE, Ubelaker DH, editors. 1994. Standards for data
collection from human skeletal remains. Proceedings of a
seminar at the Field Museum of Natural History, Arkansas
Archaeol Survey Res Ser 44, Indianapolis.
Cole G, Waldron T. 2011. Apple Down 152: a putative case of
syphilis from 6th century AD Anglo-Saxon England. Am J
Phys Anthropol 144:7279.
Ferembach D, Schwidetzky I, Stloukal M. 1980. Recommendations for age and sex diagnosis of skeletons. J Hum Evol 9:
51749.
Grassly NC, Fraser C, Garnett GP. 2005. Host immunity and
synchronized epidemics of syphilis across the United States.
Nature 433:417421.
Gustafson G, Koch G. 1974. Age estimation up to 16 years of
age based on dental development. Odontol Revy 25:297306.
Hackett CJ. 1975. An introduction to diagnostic criteria of syphilis, treponarid and yaws (treponematoses) in dry bones, and
some implications. Virchows Archiv 368:229241.
Hackett C. 1976. Diagnostic criteria of syphilis, yaws and treponarid (treponematoses) and of some other diseases in dry
bones (for use in osteo-archaeology). Berlin: Springer.

American Journal of Physical Anthropology

Harper KN, Zuckerman MK, Harper ML, Kingston JD,

Armelagos GJ. 2011 The origin and antiquity of Old World
pre-Columbian evidence for treponemal infection. Yearb Phys
Anthropol 54:99133.
Harward C, Holder N, McKenzie M, Pitt K, Thomas C, Aitken
R, Bowsher D. in prep. Medieval Spitalfields: the priory and
hospital of St. Mary Spital and the Bishopsgate suburb,
Archaeological excavations at Spitalfields Market 19912007,
MOLA Monogr Ser, London.
Iscan MY, Loth SR, Wright RK. 1984. Age estimation from the
rib by phase analysis: white males. J Forensic Sci 29:1094
1104.
Iscan MY, Loth SR, Wright RK. 1985. Age estimation from the
rib by phase analysis: white females. J Forensic Sci 30:853
863.
Jaffe HL. 1972 Metabolic, degenerative and inflammatory disease of bones and joints. Philadelphia: Lea and Febirger.
Lovejoy C, Meindl R, Pryzbeck T, Mensforth R. 1985. Chronological metamorphosis of the auricular surface of the ilium: a
new method for the determination of age at death. Am J
Phys Anthropol 68:4756.
Knell RJ. 2004. Syphilis in Renaissance Europe: rapid evolution
of an introduced sexually transmitted disease. Proc Roy Soc
Lond B (Suppl) 271:S174S176.
Maresh MM. 1970. Measurements from roentgenograms. In:
McCammon RW, editor. Human growth and development.
Springfield, IL: Charles C. Thomas. p 157200.
Mays S, Crane-Kramer G, Bayliss A. 2003. Two probable cases
of treponemal disease of medieval date from England. Am J
Phys Anthropol 120:133143.
Mays S, Vincent S, Meadows J. 2012. A possible case of treponemal disease from England dating to the 11th12th century
AD. Int J Osteoarchaeol 22:366372.
Mitchell PD. 2003. Pre-Columbian treponemal disease from 14th
century AD Safed, Israel, and implications for the medieval
Eastern Mediterranean. Am J Phys Anthropol 121:117124.
Moorrees CFA, Fanning EA, Hunt EE Jr. 1963a. Formation and
resorption of three deciduous teeth in children. Am J Phys
Anthropol 21:205213.
Moorrees CFA, Fanning EA, Hunt EE Jr. 1963b. Age variation
of formation stages for ten permanent teeth. J Dent Res 42:
14901502.
Orme N, Webster M. 1995. The English hospital 10701570.
London: Yale University Press.
Ortner DJ. 2003. Identification of pathological conditions in
human skeletal remains. London: Academic Press.
Phenice TW. 1969. A newly developed visual method of sexing
the os pubis. Am J Phys Anthropol 30:297302.
Powell ML, Cook DC. 2005. Treponematosis: inquiries into the
nature of a protean disease. In: Powell ML, Cook DC, editors.
The myth of syphilis: the natural history of treponematosis in
North America. Gainesville, FL: University Press of Florida.
p 962.
Powers N. in prep. Venereal syphilis in post-medieval London.
Unpublished CoLAT funded report.
Resnick D. 2002. Diagnosis of bone and joint disorders. Philadelphia: WB Saunders.
Roberts C. 1994. Treponematosis in Gloucester, England: a theoretical and practical approach to the pre-Columbian theory.
In: Dutour O, P
alfi G, B
erato J, Brun J-P, editors. The origin
of syphilis in Europe: before or after 1493? Toulon: Centre
Archeologique du Var. p 6367.
Roberts CA, Manchester K. 1995. The archaeology of disease.
New York: Cornell University Press.
Roberts C. 2000. Infectious disease in biocultural perspective:
past present and future work in Britain. In Cox M, Mays S,
editors. Human osteology in archaeology and forensic science.
London: Greenwich Medical Media. p 145162.
Rothschild BM, Rothschild C. 1996. Treponemal disease in the
New World. Curr Anthropol 378:555561.
Scheuer L, Black S. 2000. Developmental juvenile osteology.
London: Academic Press.

SKELETAL TREPONEMATOSIS FROM ST. MARY SPITAL

Sidell J, Thomas C, Bayliss A. 2007. Validating and improving
archaeological phasing at St. Mary Spital, London. Radiocarbon 49:593610.
Steinbock R. 1976. Paleopathological diagnosis and interpretation. Springfield, IL: CC Thomas.
Stirland A. 1991. Pre-Columbian treponematosis in medieval
Britain. Int J Osteoarchaeol 1:3947.
Thomas C, Sloane B, Phillpotts C. 1997. Excavations at the Priory and Hospital of St. Mary Spital. MoLAS Monograph 1,
London: Museum of London Archaeology Service.

101

von Hunnius TE, Roberts CA, Boylston A, Saunders SR. 2006.

Histological identification of syphilis in pre-Columbian England. Am J Phys Anthropol 129:559566.
von Hunnius TE, Yang D, Eng B, Waye JS, Saunders SR. 2007.
Digging deeper into the limits of ancient DNA research on
syphilis. J Archaeol Sci 34:20912100.
Weston DA. 2008. Investigating the specificity of periosteal
reactions in pathology museum specimens. Am J Phys
Anthropol 137:4859.
Wood JW, Milner GR, Harpending HC, Weiss KM. 1992. The
osteological paradox: problems of inferring prehistoric health
from skeletal samples. Curr Anthropol 33:343370.

American Journal of Physical Anthropology