Bunions in the Middle Ages

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Hello and welcome to Gone Medieval. I'm Dr Kat Jarman. Changes in fashion over time can be puzzling and sometimes have unexpected consequences. And today on the podcast, we're going to be talking about just that and specifically medieval feet. A new evidence that certain types of footwear worn in the Middle Ages were not just uncomfortable, but downright dangerous.

A new study from a series of medieval cemeteries in Cambridge has shown that the frequency of a condition called hallux valgus, or bunions to you and me, led to sometimes broken bones and was likely caused by a new type of shoes. And importantly, this research shows us how studying the bones of those who lived during the Middle Ages can give us insights into society and reveal customs and social differences we may never otherwise discover.

I've invited the lead researcher of that study, Dr Jenna Dittmar, to tell us more about it and why we should care about medieval podiatry. Jenna is a specialist in osteology and paleopathology, that's the study of bones and ancient disease, at the University of Aberdeen. So welcome to Gone Medieval, Jenna. Thank you very much for having me, it's a pleasure.

So just to start out then, this research project, which sounds like a bit of an odd one, can you just tell us how did that research come about? What were you actually looking to find? Certainly. So this research project was done as part of a larger research project that was explored. health in medieval Cambridge, both before and after the medieval plague pandemic, also known as the Black Death.

So we were interested in looking at the social and biological consequences of the Black Death, but also medieval society in general. Okay so you started out a bit more broadly then and started looking at feet but let's just talk about this particular condition hallux valgus or bunions. What is that and how do people get it? So hallux valgus is a condition where the big toe becomes angled

outward towards the other toes. And you get a painful lump at the base of the big toe. And this is known as a bunion. And this becomes inflamed and can be quite painful. There's a lot of clinical research that have explored the etiology and how bunions come about, and a lot of it links back to footwear. It can, of course, be congenital. You can be born with it, but it does appear that standing for...

Long periods of time or wearing shoes that are pointed, narrow, or shoes that have incredibly high heels can aggravate this condition. Okay, that gives us an idea why this might affect people then, I suppose, that this could become very painful. And, I mean, it's an interesting one because it's quite recognisable to a lot of people in our society and certainly things like heels and footwear and stuff like that. But is that easy to detect?

in skeletons, in bones? It is relatively straightforward, yes. Certainly the chronic cases are quite easy to detect. So when we're looking at the bones of the foot, you can see evidence of degenerative changes in the joints of the big... you see lipping on the head of the first metatarsal, which is what?

this bone is called. And sometimes you can see evidence of arthritis, and it shows that the bones were misaligned during the person's life. And you can also see these bony protrusions at the base of the big toe, which is the area that would have been inflamed.

interesting then to try to find out this in the medieval population and see maybe how it compares over time but let's just talk about that specific site then that you were looking at in Cambridge can you give us some context to it so tell us a little bit about medieval Cambridge

and those cemeteries that you were studying? During the 13th century, Cambridge was a medium-sized market town that had a population of about 2,500 to 4,000 people. And many were involved in agriculture. activities, farming in the surrounding fields, and this type of work. But there were also a number of general laborers, construction workers, including carpenters and tilers, thatchers, and artisans, including shoemakers and tailors.

It was quite a cosmopolitan scene, actually. Close to 50 trades would have been practiced in and around Cambridge. And they also had quite a famous fair in which people would come to trade goods. A really unique feature of medieval Cambridge is that it was home. one of only two universities in England at this time. So the university was founded in about 1208 to 1210, but it wasn't a major component of the town until the late 13th to early 14th century.

Because the university was present in Cambridge, we also had an increase in the number of ecclesiastical institutions. We had a number of friaries as well as a nunnery that all came to Cambridge as well. So as part of the After the Plague Project, we... analyzed a number of cemeteries located in and around Cambridge. For this study we analyzed four different cemeteries and all of the individuals that were part of this research were excavated because they were in danger of being damaged by

by new construction projects or various renovation works. Nothing that I'm talking about was excavated specifically for this study. So the studies that we looked at were a parish cemetery, which is the Hospital of All Saints by the Castle. So this parish was located just- north of the river. And it was founded about 940 to 1100 and stayed in use until just after the Black Death in 1365, when it was amalgamated with another parish. So these individuals represent...

the normal place of burial for the vast majority of what we would call ordinary people in Cambridge. We also had the cemetery of a hospital. So this was the hospital of St. John the Evangelist. And this was a really interesting story. It was discovered during the renovation of the old Divinity School building as part of St. John's College in Cambridge. And the site was excavated in 2010.

in 2011 in the basement of one of these buildings. Oh, so they're finding the cemetery in the basement of the college building. Yes, part of the cemetery was right in the basement of the college building. Yes. Fantastic. So the Hospital of St. John the Evangelist was an ecclesiastical institution that was built to provide pastoral and spiritual care for the poor and infirm habitants of Cambridge. It wasn't really a hospital as we would think of.

Today, they weren't providing medical care as far as we know. So this site represents the individuals that would have been inmates and they probably would have needed clothing, food and other pastoral care. So they were likely people that were impoverished. or chronically ill, possibly both. So it's a unique subset of the Cambridge social landscape.

We also had a number of individuals from an Augustinian friary. And these individuals were members of the clergy, but there were also a number of wealthy benefactors that were buried in the friary. And we can tell the difference between the...

lay people and the people that were members of the clergy because the lay people were buried in shrouds and the members of the friary actually wore these belt buckles and they had quite spectacular buckles that were found as part of the excavation. So that's how we're able to differentiate. between in addition to the location of the burials who were considered wealthy.

townspeople and then who were actually the friars. And the other site we looked at is located in Cherry Hinton and it would have been a rural parish burial ground located about six kilometers. outside of Cambridge. So this cemetery represents the individuals that would have been living and working in a rural location.

at this time. So you actually have a fantastic material here you've got all different forms of society you've got a really nice snapshot which is quite unusual I think quite often we get just one or the other but you actually you can tell that you've got these different locations which is great.

In terms of the study then, looking at these particular conditions, what results did you get? How many people had this condition roughly? So when we analysed the feet of these individuals, we found that about 18% of our sample had evidence of bunions. And we suspect this is an underestimate because we're only really seeing evidence of chronic conditions that will affect the bone. So if people had a milder case, it might not leave the same kind of

indicators. So it could be even higher than this. And was that in all cemeteries? Or was that just in one particular cemetery that you got that sort of percentage? So we found 18% of individuals in our sample size had evidence of hallux vulgus. Interestingly, we found that almost half of those buried in the friary, so 43%, had evidence of hallux vulgus. And we compared that.

to what we found at other sites, we only found 3% of individuals in the rural cemetery of Cherry Hinton that had similar changes. And in the parish cemetery, it was about 10%. So we can really see. the social differences between individuals buried in each of these locations. We also looked at temporal changes over time.

We had a number of individuals that dated from the 11th to the 13th centuries. And when we compared that group to the group of individuals that lived from the 14th to 15th centuries, we found really clear differences in evidence of longstanding hallucination. Helixfelgus. 6% of the people from the early time periods, the 11th to 13th centuries, had Helixfelgus, but 27% of those in the 14th and 15th centuries had evidence. So we can see that there is an increasing number of people that are

suffering from this condition. That's quite spectacular. That's a really big difference, isn't it? So what exactly was then the explanation for these quite extraordinary results? What was it that changed over time, do you think? So we think this change over time is directly related to the type of footwear that people were wearing. And we see this transition right in the middle of the 14th century where shoes become pointy-toed. So during the earlier part...

of the high medieval period. We see people wearing rounded toed shoes that were flat with a wide toe box. You had plenty of room to wiggle your toes. And we see this transition right during the middle of the 14th century where shoes become. pointed. So the pointy-toed shoes became known as poulaines. And this is a type of shoe that has a very long, exaggerated tip. And the toes were so long that they were often stuffed with wool or moss or something so they would keep their shape.

So this style of shoe is thought to have originated in Poland, and many think that it became popular in England when Richard II married Anne of Bohemia in the late 1300s. Okay that sounds like a really convincing explanation to me but that wasn't the only thing you found so you found obviously evidence of this condition but you were also looking more widely at the bones and you were studying injuries specifically.

And that's where you found a bit of a link. So can you tell me about those other injuries that you found in these skeletons? So we found that individuals over the age of 45 that had hallux vulgus were significantly more likely to have evidence. of a fracture that resulted from a fall compared to other individuals who didn't have hallux vulgus of the same age. And this finding is consistent with modern clinical research that shows that hallux vulgus is an independent risk factor for

falls, especially in over adults when they're walking over uneven ground. And this is because the big toe plays an important role in maintaining upper body stability. So when the big toe is laterally deviated, and this is the characteristic of a bunion. balance and stability while walking are negatively affected and it makes people much more likely to fall.

So you actually have evidence then that this footwear, that these changes over time are dangerous to people. Yes, exactly. So you also found then that there was a high proportion of those buried in the Augustinian friary with the condition. Can that tell us something about how they were made to dress and whether we think people followed the rules that they were meant to be following?

So the highest rate of Hallux Vulgus that we found was in the Augustinian friary. So we found five of the 11 individuals that were identified as friars by their belt buckles had evidence of bunions. So this suggests... that the attire rules for the Augustinian friars that included footwear that was required to be black and fastened by a thong around the ankle may not have exactly adhered to the religiously mandated.

So we can also tell by the historic records that in the 13th and 14th centuries, it was increasingly common for those in clerical orders in Britain to wear stylish clothing. And this appears to have been a cause for... concern among some of the high ranking church officials. And in 1215, the church actually forbade the clergy from wearing pointed toed shoes. And this may not have actually done much to prevent people in the clergy from actually wearing these types of shoes.

by the number of friars that we found that were clearly marked by wearing of these shoes. That's fantastic. So we're sort of getting into the sort of information here that we can't get from the records. This is the real everyday life, isn't it, of those people in the Middle Ages? catastrophic warfare bloody revolutions and violent ideological battles i'm james rogers and over on the warfare podcast we're exploring the vast history of ferocious global conflict

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I'm going to move a little bit away from feet now because I know that in this research that you did on that same material, you found other things as well. You were looking at other forms of injuries and you actually found other injuries as well that were not just considered. with falls, but other types of things. Can you tell us about some of those other injuries and factors and things that you found? Sure, absolutely. So as part of this project, I analysed skeletal trauma more generally.

And I tried to reconstruct injury risk and how this related to people's status. So the occupation, age, and gender. And this kind of research can provide really valuable insight on the lived experiences of medieval people. people because different environments and lifestyles will affect the overall prevalence rates of skeletal injuries. And were you able to see any social differences? So differences between men and women, for example?

So when we looked at fractures in the population of Cambridge, we found that 32% of the adult individuals had one or more fractures. When we compared this between our sites located specifically within Cambridge, we found that those buried at the parish of All Saints by the Castle had the highest number and the lowest number were seen in the hospital of St. John. So remember, these were the inmates that were likely poor and infirm and in need of pastoral care. We found a surprise.

a surprisingly high number of individuals in the friary had fractures. So this suggests that maybe life within the confines of an ecclesiastical institution was not quite as protected as we might have thought.

More males than females had fractures, but there were substantial differences even between the women that we studied as part of this. So the difference that we're finding between fractures for women specifically likely doesn't reflect socioeconomic differences, but whether women were actively. involved as working members of society in agricultural type of roles.

or individuals that were poor and needy and had long-term illnesses and therefore would have been present in the hospital. So that was quite a startling difference because you typically find that men and women have different roles within medieval society. But when you break it down even further to look at the differences within a town, you can see that women certainly would have had a number of different roles, even within a small community like Cambridge.

That's really interesting. So you are seeing some social differences there, although it's a little bit difficult to untangle exactly what. That's always a challenge, isn't it? With material like this, you know, you see the differences, but what's causing them. Now, we often think of the Middle Ages as a very violent... period but you're talking about sort of fractures and falls and that sort of thing mainly what about things like weapon related injuries was that something that you saw

That's actually the thing that surprised me the most about this study is that we didn't find any evidence of weapon injuries, even weapon injuries that were healed. And this is quite unusual, certainly within sample size of what we had. we studied 314 individuals as part of the study. And warfare was a very common feature of the medieval landscape and the fact that we don't have any sharp force injuries.

is very unusual. It's very atypical. So this suggests that if an individual survived a battle, they maybe did so unscathed or maybe they didn't. returned to Cambridge. But it's also very possible that the individuals with weapon-related injuries were buried elsewhere within the town. There are a number of other medieval cemeteries that are still in use in Cambridge that weren't excavated as part of this project.

Excellent. So there might be essentially battle cemeteries in other places, I suppose. Something like that. Yes, absolutely. We did have one example of a lethal accident that actually occurred on an individual from the friary. Both of his legs were broken around the mid thigh and there was no evidence of healing. So this suggests that he probably died as a result of this accident. And this type of fracture is called a butterfly fracture and they're commonly seen in the low.

extremities when the thigh or calf receives a really powerful lateral blow. So in modern times we often see this when pedestrians are struck by cars. His neck was also broken in several places which suggests that the accident in which he sustained these injuries was most likely the cause of his death. So a possible explanation for this is that these injuries may have been caused by him being struck by something like

a runaway cart. That's such a vivid image and such a natural thing that even back in the Middle Ages, you have...

possibly evidence of somebody being hit by a moving vehicle of some description. So you're looking at factors and you're just talking about somebody who died quite quickly. You've talked about a hospital where people are being cared for. Can you say something about how people treated those who had injuries, how they sort of cared for anybody with an injury from this material?

Yes, absolutely. So we had a number of individuals buried in both the Hospital of St. John as well as other locations in Cambridge that very likely received care either from family members or neighbors while they were healing. Some of these injuries were very... severe. So for example, there were two older adult females, so two older women who had hip fractures that likely received help while they were healing from these types of injuries.

So one of the women that was buried in the hospital of St. John that had this hip fracture. During the healing process, her hip actually fused at a 45 degree angle, which made it almost impossible for her to walk normally. So she would have had a very awkward gait for the rest of her life. And she was buried. in the hospital but these long-term complications from these injuries were probably the reason that she

entered into the hospital in the first place. So it's very likely that she would have needed care during her recovery, but also for an extended period of time, as she would have been immobilized and probably bedridden immediately following this type of fracture. And it would also have been very painful for her to move this leg

or to even walk short distances within her house. So it certainly suggests that someone, possibly a family member, was going to the local market to bring back food and then prepare and cook this food for her. That's an absolutely wonderful story.

To be able to get that from this material, that's really quite unique. Now, I do just want to ask you, I mean, how representative do you think these results are for England in this time period? Do you think Cambridge was quite unusual? Or do you think that these sort of patterns, both in terms of what's happening to people's feet, but also other injuries?

that care that you just talked about. Is that England in the Middle Ages? A lot of the archaeological and osteoarchaeological data does suggest that what we're seeing in Cambridge... was very common of what was happening elsewhere throughout England. Certainly the pattern and types of fractures that are observed all over England do suggest that people were involved in manual labor.

But if they were injured as a result, they kind of got on with it to whatever extent they were able to. And they were certainly relying on varied support networks to help them through the various stages of recovery. But it does appear that. people were continuing to work even with these quite severe injuries. And there is also quite a lot of evidence to suggest that if someone was injured, that there were certainly family and social support.

available through this period. There's only been one other study that's really looked at hallux vulgus and this took place in Ipswich and that paper also identified this increase in hallux vulgus over time. So it does suggest that footwear may have had a role in the development of this condition all over medieval England and certainly not just isolated to Cambridge. That's such a fantastic solution and I love the insight that it gives us into people's lives and how it relates to fashion and how

These sort of things that we deal with today were pretty much also issues in the Middle Ages. So now we know that the changing fashion for pointy shoes was quite possibly a very risky thing that you could do in your life and you could end up with fractures.

Jenna, thank you so much for joining us here on Gone Medieval today. Thank you very much for having me. It's been great. That was a really brilliant insight. So we're going to have more medieval content for you in our next episode. Please do subscribe to the podcast if you haven't already, and you can leave us a review. if you like online. This has been Gone Medieval and I'm Dr. Kat Jarman and I'll be back again next week.