Early History of Rickets
Conditions with bony deformities have been described in ancient medical writings from the 1st and 2nd centuries.6 Soranus, a Roman physician in the 1st and 2nd century AD, had noted bony deformities more frequently among infants residing in Rome than Greece, and attributed such a variation to lack of nurture and hygiene by Roman mothers.7 Galen, also of the same era, had described the classic bony deformities noted in rickets.6 Although such descriptions can be interpreted as evidence for existence of rickets, it was not until mid-17th century that clear description of rickets emerged.6–8 In the mid-17th century England, rickets was endemic in the Southwest counties of Dorset and Somerset.6–8
Daniel Whistler, an English physician, is credited with the earliest description of rickets.6,8 In 1645, while a medical student at Leyden, Whistler published a monograph titled “Inaugural medical disputation on the disease of English children which is popularly termed the rickets.”6 Whistler provided a succinct description of the signs and symptoms of rickets in his thesis and used an alternate term called “Paedosteocaces” to describe the clinical symptoms of rickets.8 Medical historians have questioned the originality of Whistler’s report.8 It’s probable that Whistler’s report is based on hearsay rather than personal experience, as he was a medical student and only 26 years of age at the time of its publication.
In 1650, Francis Glisson, a Cambridge physician published in Latin a treatise on rickets titled “De Rachitide.”7,8 Glisson’s work remains a classic among medical texts. Unlike Whistler, Glisson’s sound and elegant observation of rickets is based on clinical and postmortem experience. Glisson’s writing reflects the transitional phase in medical thinking.6 Glisson’s treatise addresses the clinical features of rickets in a scientific tone, but lapses into medieval mysticism while discussing the etiology of rickets. Glisson ascribed the etiology of rickets to “cold distemper, that is moist and consisting of penury or paucity of and stupefaction of sprits.”6 Despite his affirmation of mysticism in the cause of rickets, Glisson was convinced that rickets was neither contagious nor heritable.9 His conclusions regarding the relationship of age to onset of rickets has stood the test of times: “We affirm therefore, that this disease doth rarely invade children presently at birth, or before they are six months old; (yea, perhaps before the ninth moneth) but after that time it beginneth by little and little daily to rage more and more to the period of eighteen moneths, then it attaineth its pitch and exaltation, and as it were resteth in it, till the child be two years and six month old: so that the time of the thickest invasion is that whole year, which bears date from the eighteenth month, two years and half being expired, the disease falleth into its declination, and seldom invadeth the child, for the reasons already alledged.”7,9
Glisson’s suggested treatments for rickets included: cautery, incisions to draw out bad humors, blistering, and ligature of soft wool around the limb to retard the return of blood.7 For correction of bony deformities, Glisson proposed splinting and artificial suspension of the affected infant: “The artificial suspension of the body is performed by the help of an instrument cunningly made with swathing bands, first crossing the brest and coming under the armpits, then about the head and under the chin, then receiving the hands by two handles, so that it is a pleasure to see the child hanging pendulous in the air, and moved to and fro by the spectators. This kind of exercise is thought to be many waies conducible in this affect, for it helpeth to restore the crooked bones, to erect the bended joynts, and to lengthen the short stature of the body.”7
There were no new advances in the study of rickets for nearly 2 centuries after the Glissonian era. At the turn of the 20th century, rickets was rampant among the underprivileged infants residing in industrialized cities of North in the United States and several polluted cities in Europe. In 1909, among infants 18 months or less who had died, Schmorl found histopathological evidence of rickets in 96% (214 of 221) at autopsy, highlighting the pervasive nature of rickets during that era.10 Despite its common occurrence, the exact etiology of rickets remained elusive. Deficient diet, faulty environment (poor hygiene, lack of fresh air and sunshine), and lack of exercise were all implicated in its etiology. Dietary animal experiments, appreciation of folklore advocating the anti-rachitic properties of cod-liver oil, and epidemiologic understanding of the geographical association of rickets to lack of sunshine were all relevant in resolving the “rickets” puzzle. The late 19th century and early 20th century witnessed a phenomenal expansion in the knowledge of rickets. Understanding the histopathology of rickets, advances in biochemical and radiologic testing, clarification of the anti-rachitic features of cod-liver oil and ultraviolet light were all responsible for the conquest of rickets as a malady.6 Alfred Hess referred to this era as “the second great chapter” and the “renaissance” in the history of rickets.3