THE CO-OCCURRENCE OF SCURVY AND RICKETS IN 16TH TO 18TH CENTURY SKELETAL MATERIAL FROM DOUAI, FRANCE. THE CO-OCCURRENCE OF SCURVY AND RICKETS IN 16TH TO 18TH CENTURY SKELETAL MATERIAL FROM DOUAI, FRANCE. By: ANNABELLE F. SCHATTMANN, B.A. Hon. A Thesis Submitted to the School of Graduate Studies in Partial Fulfillment of the Requirements for the Degree Master of Arts McMaster University © Copyright by Annabelle Schattmann, November 2014 MASTER OF ARTS (2014) McMaster University (Anthropology) Hamilton, Ontario TITLE: The Co-Occurrence of Scurvy and Rickets in 16th to 18th Century Skeletal Material from Douai, France. AUTHOR: Annabelle Schattmann, B.A., Hon. (Trent University) SUPERVISOR: Dr. M. B. Brickley NUMBER OF PAGES: xiii, 212 ii Abstract Disease is not a unique or singular phenomenon. The medical literature contains multiple reports discussing disease interactions and co-occurrence which remains an important issue. Despite this, there has been no systematic investigation of disease co-occurrence in paleopathology. This thesis will begin to fill the gap by producing a detailed analysis of the pathological indicators for scurvy, rickets, and their co-occurrence, focussing on features of co-occurrence and their identification. The Collégiale Saint-Amé collection from 16th to 18th century Douai, France includes 48 individuals ranging from fetal to five years of age. Previous research indicated a large number of potential cases of scurvy and rickets in the juveniles (Devriendt et al. 2010). The current study identified 12 cases of possible co-occurrence based on macroscopic, radiographic, and microscopic techniques; biocultural and historical data supported disease presence. Macroscopic results indicate that lesions associated with scurvy are identifiable and the vascular system is not known to be directly affected by rickets. Rickets features are present but changes are subtle and reduced in prevalence. Radiographs demonstrate features of both diseases but the presence or absence of the line of Fraenkel, a scurvy feature, was useful in identifying the likely dominant disease process. Diagenetic change significantly impacted microscopic investigations but the technique provided some supporting evidence for the presence of rickets. The results clearly demonstrate that cases of co-occurrence of scurvy and rickets are present and identifiable in the archaeological record. Important factors for recognition include the sequence in which conditions develop and duration of illness. Presently only cases with moderately or better developed features of both scurvy and rickets can be identified. Use of multiple techniques was critical to observe subtle changes and build a case for disease presence. Further research on co-occurrence of any diseases is encouraged to create a fuller understanding of past disease. iii Acknowledgements I would like to thank Dr. Megan Brickley for helping me discover the interesting and fascinating topic of disease co-occurrence, for her assistance in the development of the project, and providing invaluable mentorship. Additional thanks are owed for inviting me to participate on other ongoing vitamin D deficiency projects which furthered my understanding of rickets and allowed me to visit interesting cities across Europe. I would also like to thank my committee member Dr. Hendrik Poinar for his contribution to the development of the research project and investigation into collagen use for diagnosing scurvy. I cannot express the thanks I owe the members of the CAD, including Pierre Demolon, Benoît Bertrand, William Devriendt and Sophie Vatteoni, who graciously allowed me access to their collection and their facilities, as well as use of their data for the current research project. Many thanks to Dr. Snezana Popovic who assisted with the interpretation of the histology thin sections. I am grateful for the support from Bonnie Kahlon and Leila Watamaniuk who patiently taught me and assisted me in all my lab work. I would like to acknowledge the funding I received from the Social Sciences and Humanities Research Council, the Edith M. Whitman Travel Scholarship and the Schmid Family Travel Fund which made the current research possible. Last but not least, thank you to my friends, cohort and department at McMaster University for the support you have provided. I am eternally grateful to my parents, sister and family for all their continued support and encouragement and to Derek for all his love and support these past years. iv TABLE OF CONTENTS Abstract ............................................................................................................................. iii Acknowledgements ........................................................................................................... iv Tables of Contents.............................................................................................................. v List of Tables .................................................................................................................. viii List of Figures .................................................................................................................... xi Declaration of Academic Achievement .......................................................................... xii Chapter 1: Introduction .................................................................................................... 1 Chapter 2: Background - Infantile Scurvy ...................................................................... 4 2.1. Introduction ............................................................................................................... 4 2.2. Scurvy........................................................................................................................ 4 2.3. Vitamin C: Biochemical Role ................................................................................... 6 2.4. Previous Paleopathological Research on Infantile Scurvy ........................................ 7 2.5. Clinical and Macroscopic Descriptions..................................................................... 7 2.6. Radiographic Features ............................................................................................. 17 2.7. Microscopic Features .............................................................................................. 20 2.8. Conclusion ............................................................................................................... 21 Chapter 3: Background – Rickets .................................................................................. 22 3.1. Introduction ............................................................................................................. 22 3.2. Rickets ..................................................................................................................... 22 3.3. Vitamin D and Bone ................................................................................................ 23 3.4. Clinical and Macroscopic Descriptions................................................................... 24 3.5. Radiographic Features ............................................................................................. 30 3.6. Microscopic Features .............................................................................................. 33 3.7. Conclusion ............................................................................................................... 39 Chapter 4: Background – The Co-Occurrence of Scurvy and Rickets....................... 40 4.1. Introduction ............................................................................................................. 40 4.2. Frameworks and Past Examinations of Co-Occurrence in Paleopathology ............ 40 4.3. Medical Research on the Co-Occurrence of Scurvy and Rickets ........................... 41 4.4. Clinical Presentation ............................................................................................... 41 4.4.1. Physical Findings .............................................................................................. 46 4.4.2. Radiographic Presentation ................................................................................ 48 4.4.3. Microscopic Presentation ................................................................................. 50 4.5. Co-Occurrence of Scurvy and Rickets in Paleopathology ...................................... 52 4.6. Conclusion ............................................................................................................... 55 Chapter 5: Materials and Methods ................................................................................ 56 5.1. Introduction ............................................................................................................. 56 5.2. Materials .................................................................................................................. 56 5.2.1. Saint-Amé ......................................................................................................... 57 5.2.2. The Skeletal Collection .................................................................................... 59 v 5.2.3. Previous Scurvy and Rickets Research on the Infants and Children of the Collection.................................................................................................................... 59 5.3. Methods ..................................................................................................................