A joint medico-historical and paleopathological perspective on vitamin D deficiency prevalence in post-Medieval Netherlands

The palaeopathology of industry, a perspective from Britain

OBJECTIVES

This article considers the position of palaeopathology of ca. 1750AD onward within the subdiscipline of Industrial Archaeology, and reflects upon the relationship between skeletal palaeopathology and textual sources on disease prevalences.

METHODS

It draws upon the author's experience in engaging with threat-led archaeology. It synthesises key elements of palaeopathological literature, emphasising contributions to the IJPP VSI 'Changes in Health with the Rise of Industry', and also the broader literature regarding Industrial Archaeology.

RESULTS

Industrial Archaeology has seen a recent refocus to include not only a concentration upon technological aspects of industry but also increased emphasis the social context of industrialisation. This movement toward a placement of people as well as machines centre stage has resulted in an environment conducive for paleopathology to make a greater impact upon studies of the period.

CONCLUSIONS

Palaeopathologists need to ensure that their biocultural work is orientated toward research goals of broader relevance if the impact of their work is to be maximised. We cannot directly align prevalence data generated from skeletal and and written sources; roles played by these two sources of evidence will depend, inter alia, upon the problems being investigated.

SIGNIFICANCE

The success of 'Industrial Palaeopathology' will be measured by the extent to which human remains studies move toward centre stage within the broader discipline of Industrial Archaeology.

LIMITATIONS

Multiple perspectives on disciplinary development are possible. Academic traditions, relationships between university- and threat led-sectors, and the opportunities and challenges engendered by working with human remains, differ in different countries.

Precarious adolescence: Adolescent rickets and anterior sacral angulation in two Dutch skeletal collections from the 18th-19th centuries

OBJECTIVE

This project aims to provide an objective approach to suggesting cases of adolescent rickets using the presence of anterior sacral angulation and interglobular dentine.

MATERIALS

Sacra from 49 individuals from Hattem and 150 individuals from Middenbeemster, and second and third molars from five individuals from Hattem were analyzed. Both sites date to the 17th to 19th centuries.

METHODS

The sacra were visually assessed for sacral angulation and measured to quantify anterior sacral angulation. The sampled molars were thin sectioned to look for the presence of interglobular dentine.

RESULTS

Metric analysis determined that seven individuals had significantly anteriorly angled sacra. Three of the five individuals with sampled molars had interglobular dentine formed during adolescence.

CONCLUSIONS

Adolescent rickets may be associated with anterior sacral angulation.

SIGNIFICANCE

Anterior sacral angulation may help identify possible cases of adolescent rickets in archaeological human remains.

LIMITATIONS

The small sample size for the molars prevented the identification of more individuals with interglobular dentine present during adolescence. Several individuals with visibly angled sacra were unmeasurable due to post-mortem damage and lacked molars.

SUGGESTIONS FOR FURTHER RESEARCH

Research on a larger sample would allow us to understand better the association between anterior sacral angulation and adolescent rickets.

The role of dietary calcium in the etiology of childhood rickets in the past and the present

For more than two centuries, lack of sunlight has been understood to cause vitamin D deficiency and documented as a primary cause of rickets. As such, evidence of rickets in the archeological record has been used as a proxy for vitamin D status in past individuals and populations. In the last decade, a clinical global consensus has emerged wherein it is recognized that dietary calcium deficiency also plays a role in the manifestation of rickets and classic skeletal deformities may not form if dietary calcium is normal even if vitamin D is deficient. This disease is now clinically called "nutritional rickets" to reflect the fact that rickets can take calcium deficiency-predominant or vitamin D deficiency-predominant forms. However, there are currently no paleopathological studies wherein dietary calcium deficiency is critically considered a primary etiology of the disease. We review here the interplay of calcium, vitamin D, and phosphorous in bone homeostasis, examine the role of dietary calcium in human health, and critically explore the clinical literature on calcium deficiency-predominant rickets. Finally, we report a case of rickets from the late Formative Period (~2500-1500 years ago) of the Atacama Desert and argue the disease in this infant is likely an example of calcium deficiency-predominant rickets. We conclude that most archeological cases of rickets are the result of multiple micronutrient deficiencies that compound to manifest in macroscopic skeletal lesions. For clinicians, these factors are important for implementing best treatment practice, and for paleopathologists they are necessary for appropriate interpretation of health in past communities.

Compounding vulnerabilities: Syndemics and the social determinants of disease in the past

OBJECTIVE

This article explores the theory and utility of a syndemic approach for the study of disease in the past. Syndemic principles are examined alongside other theoretical developments within bioarchaeology. Two case studies are provided to illustrate the efficacy of this approach: Tuberculosis and vitamin D deficiency in 18th and 19th century England, and malaria and helminth infections in Early Medieval England.

MATERIALS

Public health studies of present syndemics, in addition to published bioarchaeological, clinical and social information relating to the chosen case studies.

METHODS

The data from these two historical examples are revisited within a syndemic framework to draw deeper conclusions about disease clustering and heterogeneity in the past.

RESULTS

A syndemic framework can be applied to past contexts using clinical studies of diseases in a modern context and relevant paleopathological, archaeological, and historical data.

CONCLUSIONS

This approach provides a means for providing a deeper, contextualised understanding ancient diseases, and integrates well with extant theoretical tools in bioarchaeology SIGNIFICANCE: Syndemics provides scholars a deep-time perspective on diseases that still impact modern populations.

LIMITATIONS

Many of the variables essential for a truly syndemic approach cannot be obtained from current archaeological, bioarchaeological, or historical methods.

SUGGESTIONS FOR FURTHER RESEARCH

More detailed and in-depth analysis of specific disease clusters within the past and the present, which draws on a comprehensive analysis of the social determinants of health.

Adipositas and metabolic bone disorder in a 16th century Upper Austrian infant crypt mummy—An interdisciplinary palaeopathological insight into historical aristocratic life

We describe here the results of a multidisciplinary study on an infant mummy from 16th century Upper Austria buried in the crypt of the family of the Counts of Starhemberg. The macroscopic-anthropological, radiological (whole-body CT scan), histological (skin tissue), and radiocarbon isotope investigations suggested a male infant of 10–18 months' age, most likely dying between 1550 and 1635 CE (probably Reichard Wilhelm, 1625–1626 CE), that presented with evidence of metabolic bone disease with significant bilateral flaring of costochondral joints resembling “rachitic rosary” of the ribs, along with straight long bones and lack of fractures or subperiosteal bleeding residues. Although incompletely developed, the osteopathology points toward rickets, without upper or lower extremities long bone deformation. The differential diagnosis is vitamin C deficiency (scurvy) (also with an incomplete presentation, although overlap between both disorders may be present). As additional pathology, there was significantly enlarged subcutaneous fat tissue (thickness more than 1 cm at the navel and thighs and longitudinal creases of the skin) along with a histologically enlarged subcutaneous fat layer consistent with infantile adipositas as a coincident disorder. Finally, remnants of lung tissue with pleural adhesion of the right lung indicate possibly lethal pneumonia, a disease with an increased prevalence in vitamin D deficient infants. Ultimately, the skull presented with extensive destruction of the bones of the base and dislocation of the bones of the skull squama. These changes, however, are most likely post-mortal pseudopathology, the result of a burial in a flat, narrow coffin because there were no bone fractures or residues of bleeding/tissue reaction that would have occurred whilst the patient was alive.

Is dietary deficiency of calcium a factor in rickets? Use of current evidence for our understanding of the disease in the past

OBJECTIVE

Rickets is considered an indicator of vitamin D deficiency in palaeopathology, but a strand of biomedical thought maintains that dietary calcium deficiency may sometimes play a part in its causation. Our aim is to evaluate the extent to which low calcium intake should be considered as a factor in biocultural interpretations of rickets.

METHODS

We assess published modern epidemiological studies that provide primary data to support claims for a role for dietary calcium deficiency in rickets. We also consider how we might identify, via indicators of calcium intake, populations at risk of calcium deficiency in the past.

RESULTS

Support for dietary calcium deficiency as a cause of rickets is equivocal. Direct measurement of dietary calcium in the past is not possible, but exposure to risk factors for low calcium intake can to some extent be identified.

CONCLUSION

Whilst there is little evidence to alter the view that rickets is essentially an indicator of a population's vitamin D status, occasionally, in very low calcium intake groups, dietary calcium deficiency may play a synergistic role by accentuating the need for vitamin D.

SIGNIFICANCE

The notion that dietary calcium deficiency may be a cause of rickets appears to be gaining currency in bioarchaeological studies. This paper shows that it is unusual for this to be the case, and even then the role of vitamin D remains crucial.

LIMITATIONS

This paper attempts to summarise the current state of biomedical study in an area that is subject to continuing investigation.

Interglobular dentine attributed to vitamin D deficiency visible in cremated human teeth

Vitamin D deficiency has hugely impacted the health of past societies. Its identification in skeletal remains provides insights into the daily activities, cultural habits, and the disease load of past populations. However, up till now, this approach remained impossible in cremated bones, because temperatures reached during cremations destroyed all macroscopic evidence of vitamin D deficiency. This precluded the analyses of a large fraction of the archaeological record, as cremation was an important burial ritual from the Late Neolithic until the Early Medieval period in Europe. Here, the identification of interglobular dentine (IGD), a dental mineralisation defect attributed to vitamin D deficiency, in experimentally burnt teeth, demonstrates this deficiency to be observable in human teeth burned to temperatures as high as 900 °C. In most cases, it becomes even possible to assess the ages-of-occurrence as well as the severity of the IGD and possibly vitamin D deficiency intensity. This study represents a major step forward in the fields of biological anthropology, archaeology, and palaeopathology by opening up a variety of new possibilities for the study of health and activities related to sunlight exposure of numerous past populations that practiced cremation as their funerary ritual.

Can the palaeoepidemiology of rickets during the industrialisation period in France be studied through bioarchaeological grey literature and French medico-historical literature of the 18th-early 20th centuries? Preliminary examination of a complex topic

OBJECTIVE

This study explores whether data relating to rickets from the French medico-historical literature (FMHL) and bioarchaeological grey literature are useful in evaluating its epidemiology during the industrialisation of France. Unlike other European countries such as England, industrialisation in France was a slow and continuous process with two phases: the first in 1830-1870 and the second in 1870-1914.

MATERIALS AND METHODS

A bibliographical analysis of 2800 FMHL sources from the 18th to the early 20th centuries and 50 archaeological excavation reports from the last 21 years was undertaken.

RESULTS

The FMHL data is very heterogeneous and predominantly dates to the second phase of industrialisation. The bioarchaeological data is very incomplete and predominantly relates to the period before industrialisation. At the same time, knowledge improvement and institutional changes to protect children could explain more systematic registration of cases of rickets.

CONCLUSIONS

No solid conclusions can be made regarding the prevalence of rickets at present, however these data hold great potential.

SIGNIFICANCE

In comparison to England, no systematic investigation of rickets prevalence during the period of industrialisation in France has been undertaken to date.

LIMITATIONS

The lack of archaeological excavations from this period and the limited paleopathological analysis of the sites excavated have contributed to our current lack of understanding regarding the impact of industrialization on the prevalence of rickets on the French population.

SUGGESTIONS FOR FURTHER WORK

The FMHL data needs to be homogenized and osteoarchaeological collections need to be restudied with a common protocol focusing on signs of vitamin D deficiency.