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Vitamin D deficiency, pregnancy, and childbirth in early medieval Milan

October 2024
Journal of Archaeological Science 170:106054

DOI:10.1016/j.jas.2024.106054

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Lucie Biehler-Gomez

University of Milan

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Vitamin D deciency, pregnancy, and childbirth in early medieval Milan

Lucie Biehler-Gomez

a,*

, Elisa Pera

, Valentina Lucchetti

, Laura Sisto

, Beatrice del Bo

Mirko Mattia

, Lucrezia Rodella

a,c

, Giorgio Manzi

c,d

, Anna Maria Fedeli

, Alessandro Porro

f,g

Cristina Cattaneo

LABANOF, Laboratorio Di Antropologia E Odontologia Forense, Sezione Di Medicina Legale, Dipartimento Di Scienze Biomediche per La Salute, Universit`

a Degli Studi

Di Milano, Milan, Italy

Dipartimento di Studi Storici, Universit`

a degli Studi di Milano, Milan, Italy

Dipartimento di Scienze dell’Antichit`

a, Sapienza Universit`

a di Roma, Rome, Italy

Dipartimento di Biologia Animale e dell’Uomo, Universit`

a“La Sapienza”, Rome, Italy

Soprintendenza Archeologia, Belle Arti e Paesaggio per la Citt`

a Metropolitana di Milano, Milan, Italy

Dipartimento di Scienze Cliniche e di Comunit`

a, Universit`

a degli Studi di Milano, Milan, Italy

Centro di Salute Ambientale, Universit`

a degli Studi di Milano, Milan, Italy

ARTICLE INFO

Keywords:

Osteomalacia

Vitamin D deciency

Paleopathology

Pregnancy

Childbirth

Rickets

Early Middle Ages

ABSTRACT

This paper explores the burden of osteomalacia on pregnancy and childbirth through two cases from early

medieval urban Milan. Two skeletons of female individuals with skeletal deformities and associated with 25–36

gestational weeks fetuses, excavated from the Ad Martyres and San Vittore al Corpo urban cemeteries and dated to

the Early Middle Ages, were examined. Paleopathological and historical analyses were performed in a biocultural

approach to investigate the impact of clinical complications and skeletal deformities on their daily life, the course

of their pregnancy, and childbirth. The women showed severe skeletal deformities attributable to osteomalacia

including scoliosis, reduced rib-neck angle, coxa vara, severe bending of the pelvic bones, protrusio acetabuli, and

narrowed pelvic outlet. The condition and its biomechanical complications impacted the health of both mothers

and fetuses, the quality of life of the women (i.e., gait alteration, difcult and limited mobility, compression of

internal organs), as well as pregnancy outcomes. It is possible that both the mothers and fetuses died due to

childbirth complications. Bioarchaeological cases of osteomalacia, pregnancy, and death during childbirth are

excessively rare. This paper also provides insight into how maternal experiences and biocultural environments in

early medieval Milan impacted childbirth outcome. The study of the Ad Martyres and San Vittore al Corpo

necropolises is still ongoing and could provide further insight. Isotopic and paleogenomic analyses may shed

more light into the factors that led to vitamin D deciency in these women.

1. Introduction

Vitamin D is a hormone precursor that holds a key role in various

functions of the organism including metabolic regulation of calcium and

phosphorus, bone mineralization and health, innate immunity, cell

growth and differentiation, and neuromuscular and cardiovascular

health (Brickley and Ives, 2010; Holick, 2006). Vitamin D is primarily

acquired by cutaneous exposure to sunlight, specically solar ultraviolet

B irradiation at 280–315 nm (with peak synthesis at wavelengths be-

tween 295 and 297 nm), and dietary sources, although amounts in food

are low (Holick, 2006; Jablonski and Chaplin, 2018). In fact, as

Jablonski and Chaplin (2018, p. 56) explain “Outside of the tropics, the

challenge is getting enough vitamin D throughout the year, when one

accounts for the fact that stored serum vitamin D can be exhausted after

2–3 UVB [ultraviolet B]-free months and is insufcient to satisfy phys-

iological needs through the months of the year when active production

in the skin is not possible”. Its synthesis in the skin from sun exposure

earned it the moniker “sunshine vitamin” (Uday and H¨

ogler, 2020). The

main function of vitamin D is to regulate intestinal absorption of cal-

cium. Thus, vitamin D insufciency leads to poor intestinal calcium

absorption and impaired calcium and phosphorus homeostasis. Low

serum calcium levels stimulate the increase of production and release of

* Corresponding author. Laboratorio di Antropologia e Odontologia Forense, Sezione di Medicina Legale, Dipartimento di Scienze Biomediche per la Salute,

Universit`

a degli Studi di Milano, Via Mangiagalli 37, 20133 Milan, Italy.

E-mail address: lucie.biehler@unimi.it (L. Biehler-Gomez).

Contents lists available at ScienceDirect

Journal of Archaeological Science

journal homepage: www.elsevier.com/locate/jas

https://doi.org/10.1016/j.jas.2024.106054

Received 8 May 2024; Received in revised form 11 July 2024; Accepted 12 August 2024

Journal of Archaeological Science 170 (2024 ) 106054

parathyroid hormone which restores calcium levels but triggers sec-

ondary hyperparathyroidism which acts on osteoclasts by increasing

bone turnover and causing progressive bone loss (Holick, 2006; Uday

and H¨

ogler, 2020).

There are many factors that may limit vitamin D synthesis. Biological

factors include skin pigmentation (as melanin levels in increased skin

pigments may reduce by up to 99.9% ultraviolet B-mediated production

of vitamin D), use of specic medication (e.g., anticonvulsants, corti-

costeroids), body fat content, malabsorption disorders that can alter

calcium uptake from the intestines (e.g., celiac disease, cystic brosis,

Crohn’s disease), genetic diseases linked to rickets, and advanced age.

Physical factors consist in natural variables such as latitude, altitude,

cloud cover, and local climatic conditions that can restrict sunlight.

Cultural and environmental factors include concealing clothing, sun

avoidance in hot climates, high indoor lifestyle, high air pollution

limiting penetration of ultraviolet rays, night or low sunlight work shifts,

heavy and concealing make-up, vegetarian diets, and diets with a high

content of phytates (that bind and sequester calcium) (Bhan et al., 2010;

Brickley et al., 2014; Holick, 2006; Snoddy et al., 2016; Uday and

H¨

ogler, 2019, 2020). Overall, sunlight exposure necessary to maintain

vitamin D levels are low and correspond to about 5–10 min, 2 to 3 times

a week with limited skin exposure (Brickley et al., 2014). Dietary

sources of vitamin D are limited and consist of oily sh (e.g., tuna,

salmon, eel, mackerel, sardines, trout), some shy oils (cod liver oil),

mushrooms (including shiitake mushrooms), and egg yolk.

Phosphorous-lacking diets may lead to metabolic diseases, but the

mineral can be found in all natural foods and as such deciency is

excessively rare. Calcium absorption by the intestines is about 25% of its

dietary intake and varies with age and pregnancy. Food sources rich in

calcium include oily sh, egg yolk, and milk products (Brickley et al.,

2014; Cardwell et al., 2018; Holick, 2006). Regardless of the source,

irregular intake of vitamin D can lead to chronic vitamin D insufciency.

Classically, vitamin D deciency is referred to as “rickets” in infants,

children, and adolescents and “osteomalacia” in the grown skeleton

(Mays and Brickley, 2018). While sharing the same etiology, the con-

ditions differ in terms of process: rickets affects endochondral bone

growth, and in particular refers to a defective mineralization of the

growth plates, whereas osteomalacia interests cell turnover in the

maintenance of the bone tissue, corresponding to a defective minerali-

zation of the preformed osteoid (Snoddy et al., 2016; Uday and H¨

ogler,

2020). The term “osteomalacia” etymologically derives from two Greek

words: ὀ

στ

έο

(bone) and

μα

κό

(soft), referring a general softening of

the bones.

Written sources suggest that vitamin D deciency, and in particular

rickets, has been known and recognized since Ancient Rome. Indeed,

since the 2nd century AD, physicians remarked upon the frequency of

young children with bowed and knock-kneed legs in Rome (Mays, 2018;

Watts and Valme, 2018). Texts in reference to the condition were also

found dating back to 8th century AD in China (Mays, 2018). Clear

clinical descriptions of the symptoms of rickets can be found by the

English medical community from the mid-17th century with authors

including Daniel Whistler, Arnoldus Boot, Francis Glisson, and John

Mayow (Mays, 2018; Veselka et al., 2021). The history of osteomalacia

appears much less ancient. In fact, no clear mention of osteomalacia or

description of its skeletal deformities could be found in the texts

attributed to Trota/Trotula de Ruggiero (ca. second half of 11th century)

(Green, 2013); Soranus of Ephesus’ "Gynaeciorum liber" from the 2nd

century AD (based on Muscio’s translation from Greek to Latin in the 5th

century AD, making it more accessible to midwives) (Temkin, 1991);

Hildegard of Bingen’s (1098–1179) "Liber causae et curae" dealing with

pregnancy, childbirth and menstruation (Pereira, 1980); Mattioli’s work

on medicinal plants for therapeutic use (Mattioli, 1555); "De secretis

mulierum" (13th-14th century AD) attributed to Albertus Magnus (late

12th/early 13th century-1280), but actually written by his disciples

(Lemay, 1992); or in Ricci’s reference work on the history of gynecology

and obstetrics from 2000 BCE to 1800 AD (Ricci, 1950). The book

“Observations sur la grossesse et l’accouchement des femmes et sur leurs

maladies, et celles des enfants nouveau-n´

es” by delivery surgeon François

Mauriceau is a casuistry in which he presented 700 cases from 1668 to

1693 of unnatural childbirth, difcult pregnancies, and post-partum

complications. Among these, only one may potentially be related to

osteomalacia: case n◦190 of February 7, 1677, describes a woman with

“les os du passage si serr´

ees et le croupion recourb´

e en dedans” (“the passage

bones so tight and the rump curved inwards”) (Mauriceau, 1695).

However, this description is not unequivocal and may not refer to

osteomalacia-related skeletal deformities. Several mentions are made in

gynecology works of difcult labor because of the baby’s head being too

big or the pelvic canal being too narrow, but they are generally blamed

on the women being too small, too tall, or even too fat (Green, 2013;

Ricci, 1950; Temkin, 1991). We know that osteomalacia has been known

since the 17th century, but it was not studied until the second half of the

18th century (Loudon, 1992).

Vitamin D deciency is clinically associated with a wide range of

negative health outcomes. Osteomalacia may manifest with indenite

clinical symptoms such as bone pain, muscle weakness, and fatigue.

Because of its importance in enabling proper osteoid mineralization,

vitamin D deciency results in delays in bone mineralization, bowing

deformities (i.e., bone bending, kyphosis, coxa vara, pigeon breast,

protrusio acetabuli, triradiate pelvis with narrow pelvic arch), osteopenia

and osteoporosis, increased risk of fractures, and pseudofractures (Bhan

et al., 2010; Brickley and Ives, 2010; Morgan et al., 2020), leading to

clinical complications such difculties in rising from a seated position,

waddling gait, and falls (Uday and H¨

ogler, 2020). The onset of skeletal

defects associated with vitamin D deciency is marked by a decrease in

the serum levels of 25(OH)D (calcifediol), which persists below the

physiological threshold of 25 nmol/L for a prolonged period (Snoddy

et al., 2016). In addition, vitamin D deciency is clinically associated

with an increased risk of multiple cancers, autoimmune diseases,

opportunistic infections (regarding susceptibility and ability to combat

infections), cardiovascular diseases, and type 1 diabetes mellitus, having

an overall impact on quality of life and increased risk of mortality

(Brickley et al., 2014; Lockau and Atkinson, 2018; Snoddy et al., 2016).

While clinical symptoms and pseudofractures may be resolved if treated,

bone deformities and cortical thinning are irreversible and accompanied

by an increased lifetime fracture risk (Bhan et al., 2018; Uday and

H¨

ogler, 2019).

Osteomalacia is clinically diagnosed based on large amounts of

accumulated osteoid. In bioarchaeological cases, the diagnosis is more

challenging as some of its features are not specic to the condition (i.e.,

skeletal deformations) and pseudofractures, considered virtually

pathognomonic, can be elusive (Jennings et al., 2018; van der Merwe

et al., 2018). However, histomorphometric techniques have proven to be

a reliable tool for the identication of characteristic features of osteo-

malacia, including areas of incomplete mineralization, defective

mineralization adjacent to cement lines, resorptive bays (Howship

lacunae), bearded/halo lacunae, and enlarged osteocyte lacunae (Bhan

et al., 2018; van der Merwe et al., 2018; Welsh et al., 2020).

Pregnancy constitutes in itself a state of high physiological demand

of vitamin D. During pregnancy, the physiological requirements of the

fetus are fullled in priority, even at the expense of the mother (Ortner,

2003, p. 393). Adaptations to maternal calcium homeostasis are

implemented during pregnancy. Indeed, the rate or efciency of intes-

tinal is doubled early in pregnancy to meet the calcium needs of the fetus

(Kovacs, 2008). Additionally, clinical literature on vitamin D meta-

bolism during pregnancy and fetal development suggested that while 1,

25(OH)

D (calcitriol) concentrations in fetuses are inferior to maternal

levels (from low parathormone and high phosphorus levels), 25(OH)D

(calcifediol) is likely to cross the hemochorial placenta, which may lead

to reduced maternal concentrations, especially if the mother suffers

from vitamin D deciency (Kovacs, 2008). As such, vitamin D deciency

in a woman will only be exacerbated during pregnancy. Among the

demographic groups most affected by vitamin D deciency are pregnant

L. Biehler-Gomez et al.

Journal of Archaeological Science 170 (2024 ) 106054

and breastfeeding women, who should receive up to 2000 IU (Interna-

tional Units) of vitamin D daily to maintain the infant’s calcifediol levels

and sustain their own metabolism (Brickley and Ives, 2010, p. 84). In

fact, despite the prevalent usage of supplements in pregnancy, research

has shown that they continue to experience vitamin D deciency even

12 months postpartum (Kramer et al., 2016). Circulating concentrations

of 1,25(OH)

D (calcitriol) are multiplied by 2–3 to support placental

calcium transfer for fetal bone mineral growth from fourth weeks of

gestation; as such, from this stage on, the fetus becomes dependent upon

the vitamin D status of the mother. Maternal vitamin D status is a major

factor in placental development and fetal programming, which may lead

to poor bone health outcomes across the lifespan of the future child

(Lockau and Atkinson, 2018). Pregnancy has also been linked with an

increase in bone remodeling, due to temporary bone loss related to

increased serum calcium concentration required for fetal development.

Then, bone loss can be further exacerbated by the eventual onset of

secondary hyperparathyroidism (Brickley and Ives, 2010, p. 75).

Few bioarchaeological cases of osteomalacia have been published in

the literature (Brickley et al., 2007, 2005, 2018; Brickley and Ives, 2010,

pp. 147–150; Ives and Brickley, 2014; Khudaverdyan et al., 2020; Mays

and Brickley, 2018; Morgan et al., 2020; Welsh et al., 2020). This may be

explained by its challenging diagnosis with subtle and

non-pathognomonic lesions (Jennings et al., 2018; van der Merwe et al.,

2018; Veselka et al., 2018) and the low bone density that characterizes

bones with the metabolic condition which are more likely to be affected

by diagenetic changes, resulting in skeletons that are more prone to poor

preservation and fragmentation because of substantial bone loss and

fragility (Khudaverdyan et al., 2020; Welsh et al., 2020).

In this paper, we explore the interplay between osteomalacia and

pregnancy in the past through two cases from urban necropolises of

Milan, dated to the Early Middle Ages. The two skeletons belonged to

women with pathological signs attributable to osteomalacia who were

found associated with 25–36 gestation weeks fetuses. Paleopathological,

clinical, and historical analyses were undertaken to investigate the

impact of the skeletal deformities on daily life, the inuence of vitamin

D deciency on the course of pregnancy and childbirth, as well as the

care and assistance available to these women at this time in Milan. The

present study is based on a biocultural approach, which brings an

important perspective to archaeological studies, bridging the gap be-

tween past individuals and their living environment, and breaking down

the separation between human biology and social, cultural, and physical

factors in understanding past ways of life (Dufour, 2006). Considering

these aspects as fundamentally linked provides a more complete picture

of past societies, allowing researchers to explore how the social, his-

torical and cultural environment impacted health in the past, and how

past individuals and populations interacted and adapted to changes in

their environment (Grauer, 2012).

2. Materials and methods

This study is part of an ongoing project on the reconstruction of the

life of the Milanese throughout history (Biehler-Gomez et al., 2021,

2022a, 2022b, 2023a, 2023c; Giordano et al., 2023; Mattia et al., 2021).

The skeletal remains in the present paper are part of the CAL (Collezione

Antropologica LABANOF – Anthropological Collection of the LABANOF),

currently under study at the Laboratory of Forensic Anthropology and

Odontology (LABANOF) and housed at the University of Milan

(Cattaneo et al., 2018). The skeletons originate from two urban

necropolises of the city of Milan: the Ad Martyres cemetery at the Basilica

of Saint Ambrose and the necropolis of San Vittore al Corpo associated

with the eponym basilica.

The Ad Martyres necropolis of Sant’Ambrogio is located at the

entrance to the basilica and extends over 270 m

. Started in 2018, an

emergency excavation, initiated for the construction of the new urban

metropolitan line, has brought to light 319 tombs with an occupation

period ranging from the Roman era (1st-5th century AD) to the Late

Middle Ages (11th-15th century AD). Tomb 230, subject of this paper,

was recovered in the stratigraphic units dated to the early medieval

phase (6th

10th century AD). The depositions of this phase were

commonly deposited in earthen pits, with variable orientations and a

chaotic arrangement (Cooperativa Archeologia, 2018a). Based on the

available archaeological evidence, and in particular the modesty of the

burials and associated grave goods, this necropolis appears to have been

populated by individuals of a common low to middle socioeconomic

background (Biehler-Gomez et al., 2023b; Cooperativa Archeologia,

2018a).

The emergency excavations of 2018 also uncovered another ne-

cropolis underneath the square that faces the Basilica of San Vittore al

Corpo. Like the Ad Martyres necropolis, this area is located in the south-

western suburb of Milan and is part of a major urbanistic complex,

where the imperial authority built the Imperial Mausoleum by the end of

the 4th century AD. (Baratto and Massara, 2014, p. 41). The archaeo-

logical excavations shed light on a specic area of the major complex,

used as a necropolis, related to the Basilica of San Vittore al Corpo. The

stratigraphic evidence showed a multilayered context, dated from the

1st-2nd centuries AD to the 16th century AD. (Cooperativa Archeologia,

2018b). Tomb 31 – focus of the present paper – could be dated to the

beginning of the early medieval period. Its stratigraphic unit belongs to a

phase of usage of the necropolis dated between the 3rd and 6th century

AD, with depositions homogeneously structured as earthen pits and

brick-box tombs. According to archaeological data, a considerable

number of burials show a lack of associated grave goods, except for a

limited number of high-quality funerary objects. In particular, tomb 31

was a brick-box deposition covered with tiles and no associated grave

goods. Based on the evidence just mentioned, and the relevance of the

context related to the Basilica of San Vittore al Corpo, it has been sug-

gested that the individuals deposited belonged to both upper and lower

social segments (Cooperativa Archeologia, 2018b).

Anthropological analyses included estimation of biological sex based

on morphological aspects of the pelvis (Klales et al., 2012; Phenice,

1969) and post-cranial measurements (Spradley and Jantz, 2011);

age-at-death from epiphyseal bone fusion (Scheuer and Black, 2004),

dental eruption (AlQahtani et al., 2010) and degenerative changes at the

pubic symphysis (Brooks and Suchey, 1990), auricular surface, acetab-

ulum (Roug´

e-Maillart et al., 2009), and sternal end of the fourth rib

(Iscan and Loth, 1986); stature based on the regression formulae elab-

orated by Trotter (1970); and pathological analysis according to

paleopathological standards and manuals (Biehler-Gomez and Cattaneo,

2021; Buikstra, 2019; Ortner, 2003). Description of bone lesions and

diagnosis of osteomalacia was based on Brickley’s extensive literature

on the subject (Brickley et al., 2005, 2007, 2010; Brickley and Ives,

2010; Ives and Brickley, 2014; Mays and Brickley, 2018). Conventional

radiographic imaging was performed trou using a Poskom PXM-40BT

and an X-DR L WiFi with the following technical parameters: 50 kV

and 4 mAs and then acquired using Examion® software. 3D acquisition

of the skeletal human remains was performed using the Artec Space

Spider scanning device (Artec 3D, Luxembourg), a high-resolution,

hand-held 3D scanner based on blue light technology (structured light

scanner). The acquired data were processed with its software (Artec

Studio Professional 17) to obtain the 3D models of the original bones,

allowing for copies of both the shape and the supercial texture of the

specimens to be produced and digitally stored. To visualize the original

anatomical structure, the 3D models were imported into Blender Soft-

ware (Blender Foundation), an open-source 3D modeling and animation

software. A 2D illustration of the superior view of a healthy female

pelvic girdle was produced, imported in Blender software, and super-

imposed to the pelvic bones of each individual (skeletons of Tomb 230

US 840 of the Ad Martyres necropolis and Tomb 31 US 231 of the San

Vittore al Corpo necropolis) to visualize the extent of the obstruction of

the pelvic canal. Transparency of the image was set to 25%, in order to

see the underlying 3D model.

L. Biehler-Gomez et al.

Journal of Archaeological Science 170 (2024 ) 106054

3. Results

Bioarchaeological investigations of the Ad Martyres necropolis are

still underway and have evidenced one individual from the early me-

dieval phase with vitamin D deciency (frequencies calculated as n

present/n observable * 100): Tomb 230, subject of the present study

(1.6% of the early medieval sample). Similarly, in the San Vittore al

Corpo necropolis, bioarchaeological analysis is still ongoing and so far,

have revealed two early medieval individuals (5.7%) with signs of

vitamin D deciency: one adult male with residual rickets (diagnosed

based on the criteria by Brickley and Ives (2010)) and one adult female

(Tomb 31, focus of the present paper) (see Fig. 1). To date, no clear case

of vitamin D deciency in juveniles were found.

3.1. Tomb 230 US 840 of the Ad Martyres necropolis

Tomb 230 was found in the ninth excavation level, in stratigraphic

units 839, 840 and 841. The woman was buried within an earthen pit

oriented according to a NW-SE axis and was in a supine position -.

The study of the individual belonging to tomb 230 revealed a female

of about 21–30 years old. The skeleton was unfortunately largely

incomplete (less than 25% of the skeleton was preserved), and the bones

were very fragmented and fragile. Hence, estimates regarding popula-

tion afnity and stature could not be performed. In situ, within the pelvic

girdle, were found the skeletal remains of a fetus of about eight lunar

months. The fetal remains were incomplete, very fragile, and frag-

mented, and did not show any pathological sign through naked eye

observation (Fig. 2).

The adult skeleton was immediately striking because of the great

deformity of its bones, particularly at the level of the pelvic girdle, lower

limbs, ribs, and spinal column. The vertebral column, once assembled,

showed signs of scoliosis with its characteristic lateral bending; that is,

an alteration of the curves with vertebral bodies slightly rotated on the

axial plane. In fact, two such curvatures were found: one on the high

thoracic segment with a Cobb’s angle of 48◦, the other on the thoracic-

lumbar segment with a Cobb’s angle of 40◦(Fig. 3).

In addition to the vertebral column, all bones present showed signs of

skeletal deformities. At the level of the thoracic cage, the rib evidenced

reduction of the rib-neck angle (Fig. 4). The femora, present only in their

proximal half, showed a closure of the femoral neck angle or coxa vara (i.

e., angle <120◦; here, 111◦on the right, and 107◦on the left) as well as

medio-lateral subtrochanteric widening (Fig. 4). The most pronounced

deformities can be observed in the pelvic girdle (Figs. 4 and 5): the

fourth and fth lumbar vertebrae descend and protrude into the pelvic

canal, the iliac crests are forcibly bent inward, folding over into the body

of the ilium, the pubic rami are bent, meet parallelly and project ante-

riorly with the pubic symphyses projecting forward, the acetabuli are

pushed dorsally into the pelvic cavity (protrusio acetabuli) and face

anteriorly, and the sacrum is bent and projects ventrally; all these de-

formities lead to a signicant narrowing of the pelvic canal, causing it to

take on a triangular shape.

Despite the extensive bending of the bones, radiographic imaging

shows no clear evidence of antemortem trauma. No pseudofractures

were found macroscopically or on radiographs. Consequent to the bone

fragility caused by the pathology are the compressions of the thoracic

vertebral bodies as well as those of L3-L4 and S1-S2. There is also a

partial fusion of the 5th lumbar vertebra to the sacrum.

3.2. Tomb 31 US 231 of the San Vittore al Corpo necropolis

Tomb 31 was uncovered in the second level of the third phase of the

San Vittore al Corpo necropolis. This multiple burial was structured as a

brick-box tomb with a S-N orientation axis and refers to the stratigraphic

units 230, 231, 237 and 238.

Based on anthropological analyses, a minimum number of seven

individuals was uncovered in Tomb 31, the material was mainly

constituted of commingled remains with the exception of two in-

dividuals identied by their bones in anatomical connection. Both in-

dividuals were buried in supine position: one was a middle-aged male

and the other, of interest to the present paper, was a female of about

31–45 years (Fig. 6). Because of the state of incompleteness (50–74% of

the skeleton was preserved) and fragmentation of the skeleton, analysis

Fig. 1. Map of Milan showing the location of the Ad Martyres and San Vittore al Corpo necropolises and city walls in the Early Middle Ages.

L. Biehler-Gomez et al.

Journal of Archaeological Science 170 (2024 ) 106054

of population afnity could not be performed. Yet, stature could be

estimated at approximately 152 cm, by measuring both right humeral

and tibial maximum lengths. Initially unnoticed by the archaeologists,

the skeletal remains of a fetus of about 8 lunar months were recovered

within the soil found inside Tomb 31 and associated with the in-

dividuals. Consequently, in situ position was lost during excavation, and

it is no longer possible to trace the exact position of the fetus in the tomb.

Given their association in the grave, it is possible that the fetal remains

and the adult female skeleton were related. Nonetheless, paleogenomic

analyses would be required to conrm kinship. The fetal bones were

largely incomplete, fragile, and did not show gross pathological signs.

The adult skeletal remains showed signicant deformities, in

particular at the level of the pelvic girdle, the upper and lower limbs, and

the spinal column. Both humeri show abnormal inferior bending of the

head (Fig. 7). Similarly, the coracoid process of the left scapula is bent

inferiorly (the contralateral coracoid process was not recovered).

The femora presented a decreased angle of the femoral neck or coxa

vara (102◦on the right and 93◦on the left). Femorotibial angle was

calculated on the right side by measuring the angle formed by the

intersection of the anatomical axes of the femur (from the center of the

femoral head to the center of the knee, or the mechanical axis of the

femur) and tibia (from the center of the knee to that of the ankle), and

showed of degree of deformity of 12◦, evidence of genum valgum or

knock-knee deformity (Fig. 8). The vertebral column was assembled and

did not manifest any sign of spinal bending; however, all vertebral

bodies of the thoracic segment showed biconcave compressions on the

superior and inferior surfaces, more marked inferiorly (Fig. 7). The

anterior surface of the vertebral bodies, partially damaged by tapho-

nomic processes, allowed the observation of a coarsening of the verte-

bral trabeculae and a loss of the horizontal trabeculae (Brickley and Ives,

2010, p. 126). These compressions are associated with acute and chronic

pains (Leidig et al., 1990; Razi and Hershman, 2020). The bones of the

pelvic girdle showed the most noticeable deformities (Fig. 9). The

sacrum was very fragmented and was only represented by the left side of

the rst sacral vertebra and a fragment of the fourth and fth sacral

crests. Both ilia showed marked anterior bending and folding over of the

iliac crest into the body of the ilium, projecting into the pelvic canal. The

pubic rami are bent anteriorly, resulting in the pubic bones meeting

parallelly instead of opposingly. The symphyseal surfaces project ante-

riorly and are buckled to maintain contact. The acetabulae are also

oriented anteriorly, instead of laterally. Despite the extensive bending of

the bones, radiographic imaging shows no clear evidence of antemortem

Fig. 2. Skeleton TB 230 US 840. Left: photograph of the skeletal remains of the adult female; top right: photograph of the tomb; bottom right: photograph of the fetal

skeletal remains.

L. Biehler-Gomez et al.

Journal of Archaeological Science 170 (2024 ) 106054

trauma. No pseudofractures were found macroscopically or on radio-

graphs. The deformities caused a signicant narrowing of the pelvic

canal which took on a triangular shape.

4. Discussion

a Differential diagnosis

Fig. 3. Vertebral column of the skeleton of TB 230 US 840 of the Ad Martyres necropolis.

Fig. 4. Skeletal deformities of skeleton of TB 230 US 840 of the Ad Martyres necropolis. Left: radiograph of the femora showing coxa vara and subtrochanteric

widening (D: destra =right; S: sinistra =left); top right: superior view of a rib showing reduced rib-neck angle; bottom right: anterior and lateral views of the sacrum.

L. Biehler-Gomez et al.

Journal of Archaeological Science 170 (2024 ) 106054

Individually, several conditions may be responsible for the lesions

observed. Indeed, the extreme ventral angulation of the sacrum of Tomb

230 US 840 could be caused by traumatic lesions or congenital defects,

and the biconcave compression on the superior and inferior surfaces of

all thoracic vertebral bodies seen in Tomb 31 US 231 may be found in

osteoporosis, although usually in a single site (Brickley and Ives, 2010).

Vitamin D status is related to bone mineral density, and its deciency

can cause or exacerbate osteoporosis (Lips and Van Schoor, 2011). Both

conditions may coexist and further analyses (e.g., bone densitometry

techniques) would be required to quantify bone mineral density in these

cases. Scoliosis may also result from infections to the spine (e.g.,

tuberculosis), though no signs of infectious diseases were found on the

skeleton and the vertebral column did not present the body cavitations

or Pott’s disease deformity typically associated with tuberculosis

(Ortner, 2003). Blount’s disease is a rare growth disorder affecting

children that causes bowlegs due to excessive compressive forces on the

proximal medial metaphysis of the tibia; yet the condition is a genu varus

deformity, contrasting with the genu valgum angulation of Tomb 31 US

231 (Brickley and Ives, 2010). Anterior folding of iliac crest may be

found in Paget’s disease, a skeletal growth disorder, but no other lesion

suggestive of the disorder (such as thickened bones of the cranial vault,

unilateral involvement of the pelvis, wedged or V-shaped areas of

Fig. 5. Pelvic deformities of the skeleton of TB 230 US 840 of the Ad Martyres necropolis. Left: medial, anterior, and lateral views of the right innominate bone; right:

radiograph of the pelvic bones.

Fig. 6. Skeleton TB 31 US 231. Left: photograph of the skeletal remains of the adult female; top right: photograph of the tomb; bottom right: photograph of the fetal

skeletal remains.

L. Biehler-Gomez et al.

Journal of Archaeological Science 170 (2024 ) 106054

radiolucency, enlargement and thickening of vertebral bodies plates)

could be found on either of the skeletons under study (Roches et al.,

2002; Whyte, 2006). The deformation of the pubic rami, appearing

adjacent instead of opposing, the dislocation of the pubic symphysis, and

the obstruction of the pelvic inlet are strongly diagnostic features of

osteomalacia (Brickley and Ives, 2010; Ortner, 2003, pp. 399–400).

Other diagnostic features found on the skeletons presented here include

the biconcave compression of the vertebral bodies of Tomb 31 US 231,

the reduced rib-neck angles of Tomb 230 US 840, the narrowing of the

pelvis, curving of the ilia, folding of the iliac crest and protrusio acetabuli

of both pelvic girdles, the coxa vara deformities in both women, and the

“knock-knees” with genu varum angulation of Tomb 31 US 231. The

anterior curvature of the sacrum projecting in the pelvic inlet and

scoliosis of Tomb 230 US 840 are general but non diagnostic features of

osteomalacia (Brickley and Ives, 2010). Nonetheless, recent research has

shown a correlation between the angulation of the sacrum and the

metabolic condition (Lamer et al., 2023). Specically, the authors sug-

gest that anterior sacral angulation may be the result of vitamin D

deciency developed during the critical phases of adolescent growth.

Overall, the pathological signs observed on the skeleton are typical of

osteomalacia (Appleby et al., 2015). However, residual rickets may also

be responsible for the aforementioned features observed in the ribs,

sacrum, and femoral neck (Brickley and Ives, 2010). The two conditions

are not mutually exclusive and the onset of osteomalacia may be

explained in a life course perspective by chronic or recurrent vitamin D

deciency since childhood.

Consequently, based on pathological signs observed on the skeletons

presented in this paper and in accordance with clinical and paleo-

pathological literature, the two women were suffering from vitamin D

deciency. Additionally, both skeletons showed changes consistent with

those described by Brickley et al. (2005) in severe osteomalacic de-

formities, informing on the severity of the cases presented here. Indeed,

severe folding over of the iliac crests into the body of the ilium was seen,

reducing the size of the pelvic inlet. Obstruction of the pelvic inlet and

reduction of the pelvic canal was worsened by the abnormal anterior

angulation of the sacrum and anterior protrusion of L4 and L5 in skel-

eton TB 230 US 840 (not observable in skeleton TB 31 US 231). The

pubic rami were forcibly bent, projecting anteriorly, further deforming

and narrowing the pelvic inlet. The pubic symphyses buckled attempting

to maintain contact between the symphyseal surfaces, and the aceta-

bulae were oriented anteriorly instead of more laterally.

b. Causes of vitamin D deciency

As previously mentioned, causes of vitamin D deciency can be

classied into biological, physical, and cultural factors. Given the lack of

bones of the cranium and their fragmentation, population afnity could

not be performed; we therefore cannot provide information regarding

the skin pigmentation of these two women, which could give important

information about the uptake of vitamin D. Indeed, melanin-rich skin is

less sensitive to the action of ultraviolet rays leading to a lower synthesis

of vitamin D (Libon et al., 2013). Advanced age does not appear as a

valid factor given their young age-at-death, and the time period pre-

cludes any possible use of specic medication such as anticonvulsants

and corticosteroids. Genetic diseases and malabsorption disorders

remain possible biological contributing factors. On average, people were

more covered by clothing in medieval times than they are today. Women

in particular were covered because it was not acceptable to display

certain parts of the body, such as the d´

ecollet´

e, shoulders, legs, and arms,

due to religious and cultural reasons (Muzzarelli, 1996, pp. 23–33).

However, people, especially from low socioeconomic status, also spent

more time outdoors, working in elds, vineyards, and gardens, and

travelling by foot, carts, donkeys, and horses. Indeed, written documents

describe how the early medieval city was partly occupied by "horti"

(gardens), vineyards, cultivated lands, "sedimi" (plots) consisting of

buildings, sometimes in ruins, and "terra" (land) (Augenti, 2006; Bal-

zaretti, 2021, p. 8; Brogiolo and Gelichi, 1998; Rao, 2015, pp. 52–57;

Violante, 1981, pp. 140–141, 281, 284–285). Documentation about

make-up among the poor population in the Early Middle Ages does not

exist, and it is reasonable to expect that early medieval Milanese women

of low socio-economic did not use make-up, as it was not tolerated by the

Church.

The diet of the Milanese varied according to social status. For the

lower segments of society, it consisted in a preponderance of low-cost

Fig. 7. Skeletal deformities of skeleton of TB 31 US 231 of the San Vittore al Corpo necropolis. Left: anterior view of the left proximal humerus and scapula showing

inferior bending of the humeral head and coracoid process; right: anterior view of ve thoracic vertebrae showing biconcave compressions of the vertebral bodies and

coarsening of the vertical trabeculae.

L. Biehler-Gomez et al.

Journal of Archaeological Science 170 (2024 ) 106054

cereal-based foods (pastries, pies lled with vegetables, eggs, cheese,

and meat or sh depending on their availability), such as rye, barley,

and millet (1979). Diet also included legumes, such as beans, chickpeas,

peas, and broad beans; vegetables, including turnips, squash, zucchini,

leeks, onions, and cabbage; and fruits. Gardens and trees were wide-

spread within the city’s many undeveloped spaces, where apple, pear,

g, cherry, black cherry, peach, hazelnut, and plum trees grew. Food

products of animal origin came from sheep, wild animals, rabbits, and

poultry. The drink par excellence was wine, while milk was consumed in

the form of cheeses, especially lightly aged. Freshwater sh was

consumed, such as craysh, trout, carp, barbel, tench, and eels, of which

the many streams owing through the city and surrounding countryside

at the time were rich. This type of sh was also raised in the many shing

ponds and city wells. Seafood, due to the difculties of preservation and

the consequent costs, was reserved for the upper strata of the popula-

tion, although it cannot be ruled out that anchovies and sardines were

also consumed by the less afuent (1979). Therefore, the main sources

of vitamin D in early medieval Milan for this segment of the population

were eggs, cheese, and sh (e.g., trout). In contrast to Late Antiquity, the

Middle Ages saw an improvement in the diet of all societal levels,

including the lower classes, with increased variety and accessibility of

food. This is particularly true for the Early Middle Ages, as barbarian

invasions brought marked changes in diet, compared to the Roman age.

In fact, meat became more present on the tables of all social segments of

the population, due to the contribution of a new food culture that

arrived with the Goths and Lombard populations. Gradually, bread and

wine also came to dominate thanks to the Catholic religion that made

them central to the liturgy and thus familiar and widespread (1979).

One hypothesis that may be advanced is the possibility of celiac

disease. As grains were an indispensable and preponderant component

of diet (especially for the lower strata of the population), it may be

hypothesized that the two women suffered from celiac disease, an

autoimmune disorder affecting the digestive system and caused by

intolerance to gluten. The gastrointestinal disorder is associated with

vitamin D deciency, with about 25% of celiac patients developing

osteomalacia (Javorsky et al., 2006). Moreover, celiac disease in preg-

nant women is associated with poor health outcomes, including

miscarriage (nine times more frequent than in non-celiac women),

premature births, intrauterine growth restriction, and poor fetal nutri-

tional intake (Butler et al., 2011). Yet, possible pathological signs on

bones are not specic to the condition and ancient DNA analyses can

only reveal genetic predisposition and not attest that the individual had

the disease, which is why bioarchaeological cases are excessively rare

(Simpson, 2017).

c Contextualization

In the early medieval phases of the necropolises considered in the

present paper, three individuals with signs of vitamin D deciency were

present (3%), including two with osteomalacia (i.e., the two women

subject of this paper) (representing 2% of the early medieval phases) and

one with residual rickets. These frequencies are lower than in most

bioarchaeological studies. Lockau et al. (2019) found 6.4% of their

Imperial sample from Isola Sacra with vitamin D deciency, including

1.4% (of the adult population) with osteomalacia. In adult Greco-Roman

mummies, frequencies of 7.4% have been proposed (El-Banna et al.,

2014). In their medieval English sample, Ortner and Mays (1998) found

1.2% of children with rickets, but the active condition was not present in

our sample. Many post-medieval population studies, especially in the UK

and Netherlands, have examined vitamin D deciencies, reporting

values ranging from 12.5% to 26.9%, with higher frequencies in urban

settings (Ives, 2018; Veselka et al., 2015, 2018, 2021; Watts and Valme,

2018). The lack of active lesions among the juveniles of the Ad Martyres

and San Vittore al Corpo necropolises suggests that while they may have

suffered from vitamin D deciency during childhood, as evidenced by

the presence of residual rickets, they survived with the condition and

Fig. 8. Right femorotibial angle of skeleton of TB 31 US 231 of the San Vittore

al Corpo necropolis.

L. Biehler-Gomez et al.

Journal of Archaeological Science 170 (2024 ) 106054

enough intake resumed for lesions to heal. The low frequencies observed

in our two sites may be the result of the good availability of dietary

sources of vitamin D in early medieval Milan, even for individuals from

the middle/low socioeconomic strata of society.

d. Impacts on lived experience

By examining the skeletal deformities, we investigated how the

condition and its biomechanical complications impacted the lived

experience (Agarwal, 2016; Schrader and Torres-Rouff, 2020; Tilley,

2015; Tilley and Schrenk, 2017) of the two women presented in this

study, specically their daily lives and mobility, and in a second step,

how it may have affected the course of their pregnancy and childbirth.

As mentioned earlier, vitamin D deciency is associated with poor

health outcomes affecting innate immunity, susceptibility to autoim-

mune diseases, cancers, and cardiovascular diseases, and all-risk mor-

tality (Brickley et al., 2014; Lockau and Atkinson, 2018; Snoddy et al.,

2016). Classical clinical symptoms of osteomalacia described in the

literature include pain, fatigue, muscle weakness, increased fracture risk

and overall limited mobility (Bhan et al., 2010; Snoddy et al., 2016;

Uday and H¨

ogler, 2019), of which these women probably suffered.

Additionally, both of these women showed biomechanical complica-

tions to osteomalacia that directly impacted their quality of life and their

mortality risk. One (Tomb 230 US 840) showed two moderate scoliotic

curvatures of the spine and reduced rib-neck angle, causing abnormal

compression of the internal organs. Indeed, the Cobb’s angle measured

make this scoliosis fell within the forms considered "moderate" (between

30◦and 50◦). While the lumbar curve may have favored the onset of

chronic low back pain, the curvature at the thoracic level may have

caused more debilitating complications. It is documented that a curve

with a Cobb’s angle of 20◦starts to put pressure on the heart and lungs,

and contributes to muscle, lung, heart, and general fatigue, thus

affecting breathing patterns (Koumbourlis, 2006). The young woman

may therefore have experienced fatigue, breathing difculty and

shortness of breath, in addition to low back pain, from her scoliotic

curvatures. Tomb 31 US 231 did not present spinal bending but bicon-

cave compressions of the thoracic vertebral bodies resulting from the

metabolic disturbance. This type of compression is associated with acute

and chronic pain which may interfere with daily activities, including

walking, sitting for prolonged periods, and lifting weights (Leidig et al.,

1990; Razi and Hershman, 2020). Even to this day, the only solution –

besides medication – to lessen the pain exacerbated by these activities

appears to be bed rest. A greater number of compression fractures causes

an increased reduction of overall stature, which results in a reduced

thoracic capacity and subsequent impaired lung function, pressure on

internal organs, as well as a feeling of premature satiety and subsequent

weight loss (Razi and Hershman, 2020, p. 97). In an effort to counter-

balance the loss of height, back muscles may be subjected to continuous

strain, and body weight may be abnormally distributed on the pelvis and

lower limbs (Alexandru and So, 2012). Moreover, chronic pain has been

clinically associated with insomnia, depression, and anxiety, leading to

further negative outcomes in their quality of life (Razi and Hershman,

2020, p. 97). Although, we could not reliably evaluate the stature of the

woman, Stokes’ (2008) formula suggested that the curvatures of Tomb

230 US 840 may have reduced her height by about 20.22 mm. The

scoliosis thus minimally affected the woman’s height, though it must

have impacted body asymmetry, in particular in view of the different

femoral neck angles reported. Tomb 31 US 231 also showed right genu

valgum. Both skeletons also showed coxa vara, protrusio acetabuli,

asymmetry, and severe deformities of the pelvic bones. These likely

affected the women’s gait, which, especially in the last months of

pregnancy with the weight of the baby bump, could have appeared more

awkward and unstable. As documented in clinical literature, these

skeletal complications likely led to difculties in rising from a seated

position, waddling gait, limited mobility, and falls (Uday and H¨

ogler,

2020).

e. Osteomalacia and pregnancy

Osteomalacia has been described as rare in rst pregnancies unless

the woman suffered from rickets during childhood and persistent

vitamin D deciency during puberty (Konje and Ladipo, 2000). Ac-

cording to clinical literature, the condition can develop after several

pregnancies, in particular in rural and low economic areas where

lactation is prolonged and the interval between pregnancies is not

temporally distant enough to permit a replenishment of calcium stores

(Konje and Ladipo, 2000). In the Middle Ages, the number of pregnan-

cies was often very high and could therefore affect women’s health,

leading to a prolonged and frequent lowering of vitamin D. It is

important to remember that at the time, a woman’s duty was to get

married and beget children, and only then could her social function be

considered fullled. Entry into the monastery, which was also a plau-

sible option, was limited to women of the aristocracy, hence not for the

two women analyzed here. Women of the lower strata of society married

at a more advanced age than aristocratic women. In early medieval

sources, the ideal age for a rst marriage was noted as 20 years (Herlihy,

Fig. 9. Pelvic deformities of the skeleton of TB 31 US 231 of the San Vittore al Corpo necropolis. Lateral views of the right (left image) and left (right image)

innominate bones, note the bending of the iliac bones and pubic rami.

L. Biehler-Gomez et al.

Journal of Archaeological Science 170 (2024 ) 106054

1994, p. 97), and it is stated that the spouses should be of the same age

(Herlihy, 1994, p. 98), usually between the ages of 25 and 30 (Herlihy,

1994, p. 100). From that point on, women had recurrent pregnancies,

while breastfeeding their children and/or fullling the function of

nannies of infants from families of higher social levels (Herlihy, 1994).

Little is known about breastfeeding practices during the Early Middle

Ages (Muzzarelli, 2013, pp. 9–11), it can be assumed that breastfeeding

lasted from 18 to 24 months, with variations based on gender and social

status (Muzzarelli, 2013, pp. 14–15). Thus, a woman could – but this

does not mean that it always happened – carry out as many as ten to

twelve pregnancies during her fertile period (Herlihy, 1994). Conse-

quently, the older woman (Tomb 31 US 231) (though this may also

apply to the younger woman – Tomb 230 US 840), may have faced

numerous pregnancies. In the Early Middle Ages, an estimated 30%–

45% of infants died by the age of ve (Rouche, 1987), due to natural

infant mortality, accentuated by the family’s economic conditions,

continuous pregnancies that adversely affected breast milk production,

and the incidence of diseases, such as malarial, typhoid, and dysentery

fevers (Urso, 2002). While we cannot ascertain the number of preg-

nancies the women presented in this paper went through and given the

extent of the deformity of the pelvis compromising normal childbirth,

chronic or recurrent episodes of vitamin D deciency may have been a

signicant contributor to the development of osteomalacia in the case of

Tomb 31 US 231 if this was a rst pregnancy.

f. Impacts on pregnancy and childbirth

The mother-infant nexus concept considers that the mother and child

are not two separate entities but interrelated (Gowland, 2015). In fact,

the maternal ability to provide her child with substances required for

development, such as calcium, vitamin D or iron, via the placenta and

through lactation, is crucial since the fetal, perinatal, and infant life

stages are intrinsically fragile and related to the mother’s well-being

(Goodman and Armelagos, 1989). Therefore, under the mother-infant

nexus framework, previous and existing maternal life course experi-

ences must have impacted upon the health of the growing fetus

(Gowland and Halcrow, 2020). Here, both the vitamin D deciency –

potentially recurrent in the life course of the women and aggravated by

the current pregnancies – and the biomechanical complications

observed would have been associated with poor pregnancy outcomes

impacting not only the health and survival of the child but also that of

the mother. Indeed, in clinical literature, osteomalacia in the mother is

associated with intra-uterine growth retardation, pre-term birth, and

vitamin D deciency passed from the mother in the form of congenital

rickets (Jablonski and Chaplin, 2018; Konje and Ladipo, 2000; Lockau

and Atkinson, 2018; Uday and H¨

ogler, 2020). Though no pathological

signs were visible macroscopically on the fetal bones, the condition

would have undeniably been responsible for harmful effects on the

health of the fetus. Histological analyses of mineralization defects in

teeth (i.e., interglobular dentin) have proven a useful tool for the

recognition of the condition and estimation of the age of occurrence of

the deciency (Brickley et al., 2020; D’Ortenzio et al., 2016). Unfortu-

nately, such analyses could not be undertaken in our case as no dentition

was preserved among the fetal skeletal remains. Similarly, histological

mineralization defects such as wider osteoid seams and increased

mineralization lag time could be used to investigate whether osteoma-

lacia was still active at the time of death (Brickley et al., 2007; Mon-

ier-Faugere et al., 1998, p. 259). However, this represents destructive

analyses leading to the loss of precious material, which is why it was not

undertaken at present, but may be considered in future studies. In the

pregnant mother, osteomalacia can cause deleterious effects by affecting

blood pressure and the ability to carry to term, leading a wide range of

signicant complications, including pre-eclampsia, maternal gestational

diabetes mellitus, pre-term labor, maternal hypertension, difculties

during labor, and even obstructed labor (i.e., related to

osteomalacia-related deformities, in particular at the level of the pelvis)

which is a major cause of maternal mortality as well as infant morbidity

and mortality (Jablonski and Chaplin, 2018; Konje and Ladipo, 2000;

Lockau and Atkinson, 2018; Uday and H¨

ogler, 2020). Both women of the

present study show severe deformities of the pelvic girdle, with bending

and even folding of the ilia, pubic rami, and sacrum causing a signicant

narrowing of the pelvic canal which assumed a triangular shape

(Fig. 10). These deformities undeniably caused abnormal pressure on

the internal organs and uterus, compromising the health of the fetus and

the ability of the woman to carry to term. In fact, the extensive nar-

rowing of the pelvic canal would have rendered vaginal birth virtually

impossible (Brickley and Ives, 2010, p. 85), potentially causing the

death of both mothers and fetuses during childbirth.

In Milan, one of the fundamental works on osteomalacia was written

by Gaetano Casati (1838–1897), entitled “Sulla Osteomalacia osservata

alla Maternit`

a di Milano e sulle alterazioni apportate alla pelvi studiate

specialmente sotto il rapporto ostetrico per le indicazioni che presentano in

gravidanza ed all’atto del parto”, and published in 1871. The monograph

stems from his experience as a physician at the Maternity of Milan, and

in particular based on the 62 cases of osteomalacia he examined among

the 8062 women admitted to the hospital between 1852 and 1870. The

affected women came from peripheral territories; hence, it appears that

prevalence of osteomalacia in women living in Milan was marginal. In

his book, the author explained that in the 19th century, osteomalacia

was considered a fairly rare affection and its denition was used to

indicate “a special disease of the bones, that when fully matured became

spongy, friable, porous, soft, and altered even in their form” (Casati,

1871, p. 9). Despite numerous contemporary scholars disagreeing about

a relationship between rickets and osteomalacia (such as Plangue,

Conradi, Monteggia, Fleischmann, Cartoni, Lobstein, Proesk, and Colli-

neau), Casati (like Duverney, Frank, Eckmann, Richerant, Boyer,

Trousseau, Lesegue, Beylard, and Giordano) assumed that both condi-

tions had an intimate connection, dening osteomalacia as “adult

rickets” (Casati, 1871, p. 9). The author acknowledged the condition

affected both men and women, with a prevalence in the latter, and was

caused by “a special inammatory process of the bones” affecting the

whole skeleton, but most particularly the pelvis, creating an angular

shape, and the spinal column (Casati, 1871, p. 11). Fractures were

commonly observed, especially in the typology dened by scholars as

friabilis or fracuturosa, while a higher frequency of “deviations, bending

and contortions” were noticed in the osteomalacia cerea (Casati, 1871, p.

13). The clavicles were considered the site most prone to fractures,

followed by the ribs, the lower limbs, and the pubis. Casati also inves-

tigated the etiology of the condition, researching the habits of the

women affected, their occupation, and dietary customs, noting that a

majority lived in poorly ventilated accommodations and were factory

workers, especially weavers, required to work in humid conditions to

keep the yarn soft. The author suggested that women affected by “pu-

erperal” osteomalacia should treat their “general constitution” by

avoiding cold and damp environments, rain and, most of all, repeated

pregnancies, and long-term breastfeeding (Casati, 1871, pp. 13–14).

Casati emphasized that women with rickets should avoid pregnancies

because of the increased mortality risk, but often women were diag-

nosed with osteomalacia only once pregnant. In this case, miscarriage

could halt the course of the disease. When deformities were too severe,

compromising delivery and risking the survival of the mother, abortion

was induced or pre-term delivery surgery were performed, such as

symphysiotomy, although such an intervention commonly led to the

death of the mother. In fact, written sources indicate that abortion was

recommended when pregnancy and labor lead to maternal danger and

mortality since Soranus in the 2nd century AD (Ricci, 1950, p. 118). A

signicant difference in approach was indicated by Emilio Aleri

(1874–1949) in his summarized lessons collected in the work “Le

viziature pelviche”, published in 1939. As director of the Obstetrics and

Gynecology clinic of the University of Milan since 1927, the author

discussed the main characteristics of the pelvic alterations he observed

during his career (Franchini et al., 2015). Aleri believed that the

L. Biehler-Gomez et al.

Journal of Archaeological Science 170 (2024 ) 106054

condition was not to be attributed to environmental causes nor to in-

fectious conditions, but instead had an endocrine etiology. Like Casati,

he observed a worsening of the condition during pregnancy. Whenever

skeletal deformities compromised a natural birth, Aleri argued against

abortion or pre-term deliveries, and instead recommended the practice

of a cesarean section (Aleri, 1939, p. 44). Since the rst successful

procedure by Edoardo Porro in 1876, this intervention became more

commonly practiced, as it permitted to save both mother and fetus

(Aleri, 1939, p. 54).

Pregnancy and childbirth represent pivotal moments in a woman’s

life, bearing signicant risks for both the mother and the child carried.

Although no quantication is possible, the risk of death was extremely

high for both mother and child in pre-industrial times, as medical in-

terventions were limited, and cesarean deliveries were only practiced

postmortem (earliest record in the 13th century) (Urso, 2012). Cultural

and religious norms dictated that women were solely responsible for the

care of expectant mothers as well as the puerpera, and for assisting

during childbirth (Foscati, 2023). In cases where the mother’s life was in

jeopardy, the fetus faced similar risks (Urso, 2012). If the child was alive

after birth, infancy (in particular the rst ve years of life) also repre-

sented a formidable challenge due to high mortality rates (Duby and

Perrot, 1994; Filippini, 2017). Childbirth typically occurred at home,

with the assistance of female relatives and a midwife (“levatrice”), who

possessed expertise in medicinal practices, and/or an obstetrician

(“ostetrica”), based on knowledge from attending the “doctae mulieres”.

Monasteries were places pregnant women and those in labor could turn

to, as Benedictine nuns and monks attended to the sick and needy as part

of their duties. Being literate, nuns had access to medical texts (including

the few gynecological texts in circulation), enhancing their ability to

provide care (Duby and Perrot, 1994; Filippini, 2017). As mentioned

earlier, the severe biomechanical abnormalities displayed in the skele-

tons of these women would have rendered vaginal birth virtually

impossible. Given the limited medical interventions of the time, the lack

of knowledge regarding osteomalacia-related complications, and the

advanced development of both fetuses, it is therefore possible that both

the mothers and fetuses presented here died due to childbirth

complications.

5. Conclusion

The vertical excavation conducted at the Ad Martyres and San Vittore

al Corpo necropolis, initiated in 2018, brought to light numerous tombs.

Among these, two women, central to this study, exhibited pathological

signs consistent with osteomalacia.

The individuals were associated with fetuses of about 25–36 weeks of

gestation, but presented distinctive burial contexts: the rst woman (TB

230 US 840) was interred in a basic earthen pit of the Ad Martyres ne-

cropolis with the fetal remains still in situ in the pelvic girdle; in contrast,

the second (TB 31 US 231 – San Vittore al Corpo necropolis) was part of a

multiple burial within a brick box grave, with the fetal remains found a

posteriori in the soil of the tomb.

The impact of the vitamin D deciency and its subsequent biome-

chanical complications on the health of both women (and their fetuses)

was profound. Pregnancy worsened the health challenges faced by these

women and considerably increased the physiological demand for

vitamin D. The condition is associated with adverse health outcomes for

both mother and child, including intra-uterine growth retardation, pre-

term birth, and complications during labor. In fact, the severe pelvic

deformities observed in both women would have obstructed labor and

given the advanced stage of development of the fetuses (at/nearing full

term), it is likely that the women experienced complications during

delivery, which may have ultimately led to their death.

Through a multidisciplinary approach combining paleopathological,

clinical, and historical analyses, this paper explored the repercussions of

these physical deformities, and the effects of vitamin D deciency on the

pregnancies and daily lives of these women. Ultimately, this investiga-

tion not only improves our understanding of the living experience of

these two individuals, examining the interplay and intersection between

the metabolic condition, maternal health, medical knowledge, and so-

cial and cultural processes in the Early Middle Ages in Milan, but also

highlights the importance of interdisciplinary research in reconstructing

the broader socio-medical context of the past.

CRediT authorship contribution statement

Lucie Biehler-Gomez: Writing – review & editing, Writing – original

draft, Methodology, Investigation, Formal analysis, Conceptualization.

Elisa Pera: Writing – original draft, Investigation, Formal analysis.

Valentina Lucchetti: Writing – original draft, Investigation, Formal

analysis. Laura Sisto: Investigation, Formal analysis. Beatrice del Bo:

Writing – original draft, Investigation. Mirko Mattia: Resources.

Lucrezia Rodella: Software, Investigation. Giorgio Manzi: Supervi-

sion. Anna Maria Fedeli: Resources. Alessandro Porro: Resources.

Cristina Cattaneo: Supervision.

Declaration of competing interest

The authors declare that they have no known competing nancial

interests or personal relationships that could have appeared to inuence

the work reported in this paper.

Acknowledgements

We would like to thank and acknowledge the Sopraintendenza

Archeologica Lombardia. The authors acknowledge the support of the

FAITH (Fighting Against Injustice Through Humanities) project of the

Fig. 10. Superior view of the pelvic girdles of skeletons TB 230 US 840 of the Ad Martyres necropolis and TB 31 US 231 of the San Vittore al Corpo necropolis, showing

the deformation and narrowing of the pelvic canal. 3D models of the original bones (in white) and superimposition with a 2D illustration of a healthy female pelvic

girdle in 25% transparency.

L. Biehler-Gomez et al.

Journal of Archaeological Science 170 (2024 ) 106054

University of Milan. L.B.G. was awarded a L’Or´

eal-UNESCO grant ‘For

Women in Science’ Italian edition.

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Papaver somniferum in seventeenth century (Italy): archaeotoxicological study on brain and bone samples in patients from a hospital in Milan

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Full-text available

Feb 2023

In this paper, we present the results of toxicological analyses of preserved brain tissue and bone samples from the remains of the seventeenth century patients of the Ospedale Maggiore, the main hospital in Milan and one of the most innovative hospitals in Europe from the Renaissance period. Beneath it, the crypt functioned as the burial place for the deceased of the hospital. In this multidisciplinary study of the remains, toxicological analyses in particular were performed with HPLC–MS/MS on different biological samples from nine individuals. Anthropological, paleopathological, histological, radiological examinations and radiocarbon dating were also carried out. As a result, archeotoxicological analyses revealed the presence of codeine, morphine, noscapine and papaverine, derived from Papaver somniferum, a plant present in the hospital pharmacopeia used as a narcotic, analgesic, astringent, coagulant, and antitussive agent. Such analyses have shed light on the pharmacological therapies administered to the patients near the time of death and have implemented our knowledge of medical treatment and drug administration in the 1600’s.

The diachronic trend of female and male stature in Milan over 2000 years

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Full-text available

Feb 2023

Stature is a biological trait directly determined by the interaction of genetic and environmental components. As such, it is often evaluated as an indicator for the reconstruction of skeletal biological profiles, past health, and social dynamics of human populations. Based on the analysis of 549 skeletons from the CAL (Collezione Antropologica LABANOF), a study of the diachronic trend of male and female adult stature in Milan (Italy) is being proposed here, covering a time span of about 2000 years, ranging from the Roman era to present-days. The skeletons, from necropolises dedicated to the less wealthy classes of Milanese society, were assigned to one of following five historical periods: Roman Era (first–fifth centuries AD), Early Middle Ages (sixth–tenth centuries AD), Late Middle Ages (eleventh–fifteenth centuries AD), Modern Era (sixteenth–eighteenth centuries AD) and Contemporary Era (nineteenth–twentieth centuries AD), and their stature was estimated according to the regression formulae of Trotter (1970). The collected data were then subjected to statistical analyses with ANOVA using R software. Although stature values showed an ample standard deviation in all periods, statistical analyses showed that stature did not significantly vary across historical periods in Milan for both sexes. This is one of the rare studies showing no diachronic changes in the trend of stature in Europe.

Physical disability in Late Antiquity Milan: slipped capital femoral epiphysis with severe secondary joint disease in the Basilica of San Dionigi

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Oct 2022

The paper presents the skeletal remains of an adult male of 30-40 years with bone lesions and deformity on the left hip, recovered during the archaeological excavation below the former Basilica of San Dionigi, dated to Late Antiquity (3rd - 5th century AD) Milan. Biological profile and paleopathological analysis were performed following standard references and the bones underwent radiological examination. Differential diagnosis included congenital anomaly, active rickets, infectious diseases, femoral neck trauma, Legg-Carvé-Perthes disease, Slipped Capital Femoral Epiphysis (SFCE), osteogenesis imperfecta and osteoporosis. While the lesions were highly consistent with Legg-Calvé-Perthes disease, they were typical of SFCE, complicated by an avascular necrosis and secondary osteoarthrosis. The alteration of the femoral head led to a 7.8% leg-length discrepancy, causing gait alteration with partial compensation though increased muscular activity on the right leg, reduced mobility of the joint and potentially hip pain, difficulty in walking and running and even limping. This paper explores a case of physical disability from the Roman era found near a Christian place of worship and represents a rare case of SFCE in the paleopathological record.

Differential skeletal preservation between sexes: a diachronic study in Milan over 2000 years

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Full-text available

Aug 2022

A recurring observation in the literature is that females tend to be less represented than males in osteological collections. How can we explain such observations? Do female skeletons preserve less well than their male counterparts? In this study, 200 skeletons from the Collezione Antropologica LABANOF (CAL), equally divided between sexes, were selected from four archaeological sites of Milan, representing a continuum of about 2000 years. The state of preservation was analyzed according to three criteria: quantity, quality, and integrity. Linear model and ANOVA statistical analyses were performed using R software. As a result, females tend to be less complete than males, regardless of age-at-death or post-mortem interval (PMI). Preservation also showed lower values as PMI increased, except for the medieval sample, which may be explained by soil taphonomy and/or general poor bone health. This is one of the few studies to demonstrate a differential skeletal preservation between sexes, supporting bone mineral density as a major factor of bone survival. Further studies may strengthen our results and confirm the trends observed in this paper.

Mercury poisoning in two patients with tertiary syphilis from the Ca’ Granda hospital (17th century Milan)

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Sep 2021

Syphilis was a widespread infectious disease in the 17th century Italy, commonly treated with mercury‐based ointments and fumigations. Few reports exist on the analysis of abnormally high mercury levels in bone as a result of exposure to mercury‐containing anti‐syphilitic medicine. In this research, two crania recovered among the 2.9 million commingled bones resting under the crypt of the former hospital of the poor of Milan were submitted to pathological, radiological and toxicological analysis. The crania showed gummatous lesions characteristic of tertiary syphilis and ICP‐MS analysis revealed over the double values of mercury in bone relative to that of the control sample. Archival documentation confirms the presence and use of mercury‐based treatments in the pharmacy of the hospitals of Milan. Consequently, the individuals probably came into contact with mercury as a treatment for syphilis, confirming its medical use in the 17th century Milan and strengthening our knowledge of the history of medicine.

Nutritional rickets & osteomalacia: A practical approach to management

Article

Full-text available

Oct 2020
INDIAN J MED RES

Defective mineralization of the growth plate and preformed osteoid result in rickets and osteomalacia, respectively. The leading cause of rickets worldwide is solar vitamin D deficiency and/or dietary calcium deficiency collectively termed as nutritional rickets. Vitamin D deficiency predominates in high-latitude countries in at-risk groups (dark skin, reduced sun exposure, infants and pregnant and lactating women) but is emerging in some tropical countries due to sun avoidance behaviour. Calcium deficiency predominates in tropical countries, especially in the malnourished population. Nutritional rickets can have devastating health consequences beyond bony deformities (swollen wrist and ankle joints, rachitic rosary, soft skull, stunting and bowing) and include life-threatening hypocalcaemic complications of seizures and, in infancy, heart failure due to dilated cardiomyopathy. In children, diagnosis of rickets (always associated with osteomalacia) is confirmed on radiographs (cupping and flaring of metaphyses) and should be suspected in high risk individuals with the above clinical manifestations in the presence of abnormal blood biochemistry (high alkaline phosphatase and parathyroid hormone, low 25-hydroxyvitamin D and calcium and/or low phosphate). In adults or adolescents with closed growth plates, osteomalacia presents with non-specific symptoms (fatigue, malaise and muscle weakness) and abnormal blood biochemistry, but only in extreme cases, it is associated with radiographic findings of Looser's zone fractures. Bone biopsies could confirm osteomalacia at earlier disease stages, for definitive diagnosis. Treatment includes high-dose cholecalciferol or ergocalciferol daily for a minimum of 12 wk or stoss therapy in exceptional circumstances, each followed by lifelong maintenance supplementation. In addition, adequate calcium intake through diet or supplementation should be ensured. Preventative approaches should be tailored to the population needs and incorporate multiple strategies including targeted vitamin D supplementation of at-risk groups and food fortification with vitamin D and/or calcium. Economically, food fortification is certainly the most cost-effective way forward.

Multiple injuries and injury recidivism in Milan over 2,000 years

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Jun 2023
JASR

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

Article

Dec 2022

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.

“Man is what he eats”. Plant residues from dental calculus in the ancient population of Milano from Roman times to modern age

Article

Oct 2021
JASR

The study of plant residues extracted from dental calculus is a potent tool for reconstructing the past. In this study, three archaeological sites of the city of Milano (Italy) from two time periods (Roman and Modern Ages) were considered. An anthropological study (biological profile and pathologies) was performed for the 150 skeletons of the study sample and when present, residues trapped in the dental calculus were extracted. Through the observation of 883 identified starch granules, the possible changes in diet over the centuries in Milano were analysed and compared with the presence of specific signs of stress markers on the skeletons. The study showed that major cereals were a constant finding in the varied diet of the Milanese area, and that over time, legumes partially substituted the consumption of minor cereals. Interestingly, no severe nutritional deficiencies nor signs of poor diet were found in the sample. This research sheds light on the food habits of the ancient inhabitants of the city of Milano through a diachronic botanical examination of dental calculus.

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

Article

Mar 2021

Objective : By applying a joint medico-historical and paleopathological perspective, this paper aims to improve our understanding of factors influencing past vitamin D deficiency in ten Dutch 17th to 19th-century communities of varying socioeconomic status and settlement type. Materials : Vitamin D deficiency is evaluated in 733 individuals of both sexes and all age groups: Silvolde (n = 16), Rotterdam (n = 23), Rhenen (n = 24), Noordwijkerhout (n = 27), Gouda1and 2 (n = 40; n = 59), Roosendaal (n = 51), Den Haag (n = 93), Hattem (n = 113), and Beemster (n = 287). Methods : Rickets and residual rickets are macroscopically assessed using established criteria. Hypotheses formulated based on medico-historical texts are investigated via multivariate statistical analysis of vitamin D deficiency prevalence. Results : Vitamin D deficiency prevalence ranges from 13.7 % (7/51) in Roosendaal to 48.1 % (13/27) in Noordwijkerhout, with an onset of < 4 years, and higher rates in cities, conforming to medico-historical texts. Patterns of child labor are likely key. In contrast, socioeconomic status did not statistically significantly influence vitamin D deficiency prevalence rates. Conclusion : Systematically collected paleopathological data enabled evaluation of medico-historical texts and provided insights into the role that socioeconomic status and settlement type played on the prevalence of vitamin D deficiency. Significance : Combining medico-historical texts and large-scale paleopathological data enables disease patterning to be embedded in a comprehensive biocultural perspective. Limitations : Comparisons may be limited by the small sample size of high socioeconomic status nonadults and some of the collections. Suggestions for future research : Analysis of more individuals and sites would improve our understanding of disease patterns.

Vitamin D deficiency, pregnancy, and childbirth in early medieval Milan

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