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

OBJECTIVE

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

MATERIALS

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

METHODS

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

RESULTS

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

CONCLUSIONS

Adolescent rickets may be associated with anterior sacral angulation.

SIGNIFICANCE

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

LIMITATIONS

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

SUGGESTIONS FOR FURTHER RESEARCH

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

Differential diagnosis of metabolic disease in a commingled sample from 19th century Hisban, Jordan

OBJECTIVE

This research attempts a differential diagnosis of skeletal lesions in a commingled sample from Hisban, Jordan, focusing on non-adults in the assemblage.

MATERIALS

2,883 well-preserved skeletal elements and 9 relatively complete skulls representing an MNI of 32 non-adults (<18 years old).

METHODS

All skeletal elements were observed macroscopically and pathophysiological processes underlying any lesions or other anomalies were assessed, followed by a comparative approach to rule out potential diagnoses.

RESULTS

The skeletal lesions observed were caused by inflammation due to chronic hemorrhaging, marrow hyperplasia due to an increase in hemopoiesis, rapid bone growth, and the impact of biomechanical strain on poorly mineralized elements. Rickets, scurvy, and acquired anemias best fit this pattern of lesions, although inflammation from other sources such as trauma or infection could not be definitively ruled out.

CONCLUSIONS

The in utero and postnatal environments at Hisban were conducive to the development of vitamin C and D deficiencies from birth until 2 years of age. The analysis of commingled remains requires an ontological shift in the importance of the individual to the population in paleopathology.

SIGNIFICANCE

This investigation demonstrates the efficacy of a combined biological and comparative approach in differential diagnosis in complicated commingled collections. In addition, it emphasizes the importance of the mother-infant dyad in understanding metabolic disease.

LIMITATIONS

Histological and radiographic analyses were not included in this diagnostic study due to COVID-19 travel restrictions.

SUGGESTIONS FOR FURTHER RESEARCH

Isotopic analysis to investigate childhood diet and histological and radiographic analyses to assess survival of deficiencies.

Nutritional rickets: Historic overview and plan for worldwide eradication

Rickets was first described in great detail in the mid 17th century and was affecting a great number of children in major European cities. The disease, however, existed already in the Roman times. The etiology of this disease remained enigmatic until the 1920s when two different mechanisms, lack of exposure to sunlight and lack of a dietary factor were finally solved by the discovery of vitamin D and its dual origin. Soon thereafter, the implementation of vitamin D supplementation for all infants and small children largely eliminated nutritional rickets in Europe and North America. It took nearly a century to elucidate the complex chemistry, metabolism, mode and spectrum of activity of the vitamin D endocrine system. Nutritional rickets, whether due to simple vitamin D or calcium deficiency or both, remains widely ravaging many infants and children around the world. Asian countries and the Middle East are mainly confronted with vitamin D deficiency whereas many African and some Asian countries face calcium deficiency rickets. Immigrants and refugees or in general people with a darker skin living in moderate climate zone are also confronted with this disease. There is great consensus how this disease could be prevented or cured. In collaboration with most international professional societies, we prepare a memorandum, in line with the successful battle against iodine deficiency disorders, to convince the World Health Organization and its member states to start an implementation program to eradicate nutritional rickets by 2030.

The epidemiology of rickets in the 17th-19th centuries: Some contributions from documentary sources and their value to palaeopathologists

This article considers the nature of written sources on the epidemiology of rickets in the post-Mediaeval period, and examines the value of these sources for palaeopathologists. There is a progression from 17th-18th century sources, which generally make ex cathedra, qualitative statements on rickets frequency to, in the 19th century, semi-quantitative geographical surveys of its occurrence, through to reports of percentage prevalence in various groups. Of course, even these latter cannot be directly compared with prevalences calculated from excavated skeletal remains, but there are also considerable difficulties in comparing them with one another, and this effectively precludes synthesis to provide reliable information on geographic and temporal trends at anything more than a very broad-brush level. Their problematic nature mandates a cautious approach when using written sources to shed light on the epidemiology of rickets. For palaeopathologists, a useful way of incorporating these sources into a biocultural approach may be to use them in order to formulate hypotheses that can then be evaluated using skeletal evidence.

Analysis of patterning in the occurrence of skeletal lesions used as indicators of vitamin D deficiency in subadult and adult skeletal remains

Paleopathological investigations of conditions linked to vitamin D deficiency have increased in the last twenty years, and a suite of skeletal lesions has been established to aid in the diagnosis of vitamin D deficiency disease in subadults and adults. This paper analyzes the occurrence of these lesions in a large skeletal series comprising 3541 Roman period individuals (1st-6th century AD). Sixteen lesions reported in rickets in subadults, and 13 associated with residual rickets and osteomalacia in adults, were analyzed. Among subadults, there were clear associations among post-cranial lesions. Porotic cranial changes were associated with each other, but not with post-cranial lesions. A range of conditions could have produced the cranial lesions. There was a general paucity of correlations between indicators found in adults, and the difficulty in recording bending deformities was clear. Pseudofractures appear to provide a useful means of investigating osteomalacia in adults. In general, a simple algorithmic approach using presence or absence of lesions is unlikely to provide an adequate means of diagnosing vitamin D deficiency in paleopathology. Knowledge and consideration of the underlying physiological mechanisms involved in lesion formation, combined with individual judgement, will be required to differentially diagnose cases.

Rare paleopathological insights into vitamin D deficiency rickets, co-occurring illnesses, and documented cause of death in mid-19th century London, UK

Growing evidence suggests that vitamin D supports immune responses to infections, autoimmune conditions and cancers, although evidence from large-scale studies is limited. There is scope to better understand how vitamin D deficiency interacted with other diseases to affect health in past groups. This study investigated paleopathological evidence and documentary records of individual cause of death to examine disease co-occurrence in a group of mid-19th century child burials from London, UK. Twenty-one percent of children had vitamin D deficiency rickets (138/642) and 36 children with rickets had an identified cause of death. Cyclical episodes of metabolic and nutritional deficiencies (rickets and scurvy) had occurred during childhood. Active rickets co-occurred with respiratory and gastrointestinal infections in a small number of children, likely reflecting vitamin D's role in supporting immune function. Consideration of the stage of the vitamin D deficiency showed that the majority of children were affected by chronic disease loads indicative of multiple episodes of illness. Reconstructions of the wider health consequences of vitamin D deficiency in past groups are dependent on recognising whether the deficiency was active or healed. The variability of diseases identified illustrates the high disease burden that affected children in this socially disadvantaged group.

Osteological evidence for juvenile vitamin D deficiency in a 19th century suburban population from Surrey, England

Vitamin D deficiency rickets was considered endemic in the industrialized cities of 19th century England, but was rarely reported in more rural and suburban areas. The commercial excavation of St. John's Church, Redhill, Surrey, UK provided an opportunity to examine to what extent suburban children were affected by rickets and the factors responsible for its development. Seventy-nine non-adults (0-17 years) from St. John's Church were subjected to macroscopic and radiographic analysis to identify skeletal manifestations of vitamin D deficiency. Rachitic lesions were identified in 14/79 individuals (17.7%) aged from six months to six years. Active cases occurred from six months to two years of age with healed cases observed from three to six years. One seven month old infant also displayed healed lesions. The age-specific pattern of active and healed rickets suggests the population was vulnerable to the seasonal restriction of sunlight hours, with the considerably low vitamin D content of the infant diet unable to provide sufficient amounts to maintain metabolic functions. This research demonstrates that rickets was not simply a disease of industrialization but that a variety of factors contributed to its development in groups previously considered to be low risk.

"English Disease": Historical Notes on Rickets, the Bone-Lung Link and Child Neglect Issues

Nutritional or classical rickets (here labeled as "rickets") is a worldwide disease involving mostly infants and young children having inadequate sunlight exposure, often associated with a low dietary intake of Vitamin D. Rickets targets all layers of society independently of economic status with historical information spanning more than two millennia. Vitamin D is critical for the absorption of calcium and prevention of rickets in children as well as osteomalacia in adults. The initial and misleading paradigm of the 19th and 20th centuries that rickets may have been the consequence of infection has been, indeed, reversed following the identification of the Vitamin D molecule's important role in the function of the immune system. Although traditionally considered limited to osteopathology, Vitamin D deficiency is now known to be linked to infection, inflammation, and carcinogenesis. In this review, we consider the key historical (Whistler, pre-Whistler and post-Whistler descriptors) and social facts around rickets; highlight the osteo-pathological features of rickets and the pathology of the upper and lower respiratory tract, stressing the fact that lungs remain the main secondary organ affected by Vitamin D deficiency; and emphasize the public health role in identifying the cases of child neglect or abuse based on the evaluation of the costochondral region.

Ideology and disease identity: the politics of rickets, 1929-1982

How can we assess the reciprocal impacts of politics and medicine in the contemporary period? Using the example of rickets in twentieth century Britain, I will explore the ways in which a preventable, curable non-infectious disease came to have enormous political significance, first as a symbol of socioeconomic inequality, then as evidence of racial and ethnic health disparities. Between the 1920s and 1980s, clinicians, researchers, health workers, members of Parliament and later Britain's growing South Asian ethnic communities repeatedly confronted the British state with evidence of persistent nutritional deficiency among the British poor and British Asians. Drawing on bitter memories of the 'Hungry Thirties', postwar rickets-so often described as a 'Victorian' disease-became a high-profile sign of what was variously constructed as a failure of the Welfare State; or of the political parties charged with its protection; or of ethnically Asian migrants and their descendants to adapt to British life and norms. Here I will argue that rickets prompted such consternation not because of its severity, the cost of its treatment, or even its prevalence; but because of the ease with which it was politicised. I will explore the ways in which this condition was envisioned, defined and addressed as Britain moved from the postwar consensus to Thatcherism, and as Britain's diverse South Asian communities developed from migrant enclaves to settled multigenerational ethnic communities.

RICKETS AT THE MEDICI COURT OF FLORENCE: THE CASE OF DON FILIPPINO (1577-1582)

Among the children found in the crypt of the Grand Duke Giangastone in S. Lorenzo Basilica (Florence), the skeletal remains of a 5-year-old child still wearing his fine high social status clothing were recovered. This child of the Medici family was identified as Don Filippino (1577-1582), son of the Grand Duke Francesco I (1541-1587) and Giovanna from Austria (1547 - 1578). The prince showed several pathological deformities of the cranial and post-cranial skeleton, including enlargement of the cranium, thinning of the cranial vault bones (craniotabes), platybasia and marked bending of femora, tibiae and fibulae. Differential diagnosis suggests that Don Filippino was affected by rickets. The occurrence of this metabolic disease related to vitamin D deficiency in a Renaissance high social class individual can be explained by the practice of very prolonged breast-feeding, up until two years of age. Maternal milk contains insufficient vitamin D ratios and retarded weaning severely exposes children to a higher risk of developing rickets, especially if dietary habits are combined with inadequate exposure to sunlight. Historical sources describe Don Filippino as frail and sickly, with frequent illnesses and persistent slight fevers, and it can be supposed that the child was frequently confined indoors, especially in the cold season. Integration of osteoarchaeological evidence with historical documentation suggests that bone lesions observed in the skeletal remains of Don Filippino are compatible with a diagnosis of rickets, caused by the custom of prolonged breast-feeding associated with inadequate sunlight exposure to sunlight. Historical sources describe Don Filippino as frail and sickly, with frequent illnesses and persistent slight fevers, and it can be supposed that the child was frequently confined indoors, especially in the cold season. Integration of osteoarchaeological evidence with historical documentation suggests that bone lesions observed in the skeletal remains of Don Filippino are compatible with a diagnosis of rickets, caused by the custom of prolonged breast-feeding associated with inadequate sunlight exposure.

Kinderheilkunde and continental connections in child health: the "Glasgow school revisited"--again

The last two hundred years or so have seen the transformation of medical practice from a clinical art to the application of science to the diagnosis and treatment of disease. There has been a historical debate about how the use of technology and discoveries of the laboratory have become integrated within medical practice. In trying to understand the evolution of "scientific medicine," this has generally focused on the tensions between the differing cultures, persons, and professions of the "laboratory" and "clinic" and sought to explain how they were resolved within specific institutions. This paper looks again at the "Glasgow School" (the subject of a number of seminal papers on this subject) and the forces that shaped it, by exploring the career of Leonard Findlay, whose training in Glasgow, and in Berlin (where he worked in a department in which science and medicine were integrated), defined a style of clinical medicine that formed the model for a new sort of university department of medicine in which clinicians and scientists worked side by side, albeit under the leadership of the former. As a clinician exposed in Berlin to the emerging new sciences of nutrition, microbiology, and immunology, which were particularly relevant to the care of sick children, Findlay created in Glasgow a department of medical pediatrics, which owed less to local factors, figures, and forces and more to his experience in Germany.

The medicalization of sunlight in the early twentieth century

This paper traces the emergence of the therapeutic use of sunlight in medicine during the first half of the twentieth century. This was a period of considerable flux in medicine with various strands of practice and theory competing. Drawing on two case studies of sunlight therapy, both artificial (actinotherapy) and natural (heliotherapy), in the treatment of rickets and tuberculosis this paper will explore how medicine was constituted within these regimes. The paper will argue that therapeutic and clinical applications of sunlight helped establish an association between sunlight and health but also defined a particular and specific performance of medicine.

Theobald palm and his remarkable observation: how the sunshine vitamin came to be recognized

The seminal discovery that sunlight was important in the prevention of nutritional rickets was made in 1890 by Theobald A. Palm, a medical missionary who contrasted the prevalence of rickets in northern European urban areas with similar areas in Japan and other tropical countries. He surmised that exposure to sunlight prevented rickets. Over the next 40 years his observation led to an understanding of ultraviolet irradiation and its role in vitamin D synthesis. This opened a new era of appreciation for the curative powers of the sun and "the sunshine vitamin". While Palm's observations were in some ways obscure, they had a potent effect on the development of photobiology.

[Laboratories "Produits Scientia" and mineral waters from Pougues and Carabana]

In the end of XIXth century, the french "Compagnie des eaux minérales de Pougues-les-Eaux" begins to exploit the spanish natural purgativ water of Carabaña. In the same way, Edouard Jéramec, director of the french compagny, decides to associate to his firm the best medicine to fight against rickets and tuberculosis. He joins the new medical theory wich recommends to give more calcium to tubercular patients, called "méthode de recalcification du Dr Ferrier". Then, with the chemist Emile Perraudin, he creates the pharmaceutical laboratory named "Produits Scientia". One of their famous patents medicines will be the "Tricalcine".

[Radiated drugs, the way of health]

During the inter-war years, the word "radiated" did not only suggest radioactivity, but it was also used to indicate exposure to others radiations, such as ultraviolets. The actinotherapy, a new therapy in vogue, was applied to many pathologies and tried on many substances. "Radiated drugs" result of those experimentations. Their therapeutical characteristics were found during searches on rickets. Our study relates the story of fight against rickets in France, from the use of cod liver oil to the synthesis of Vitamine D.

Sir Edward Mellanby (1884-1955) GBE KCB FRCP FRS: nutrition scientist and medical research mandarin

Edward Mellanby used the experimental method to investigate medical problems. In 1918, working at King's College for Women, London, he provided conclusive evidence that rickets is a dietary deficiency disease due to lack of a fat-soluble vitamin [D]. In Sheffield he demonstrated that cereals, in an unbalanced diet, produced rickets due to the phytic acid content reducing the availability of calcium. Mellanby became Secretary of the Medical Research Council (1933-49) but continued his research by working at weekends. In the 1930s he campaigned for the results of nutritional research to be used for the benefit of public health. During World War II he acted as a scientific adviser to the War Cabinet and had a strong influence on the food policy which maintained successfully the nutrition of the population during the shipping blockade. Mellanby was a formidable person but with sagacity he promoted new research and guided the expansion of the organization.

Does inadequate diet during childhood explain the higher high fracture rates in the Southern United States?

SUMMARY

Southern states have the highest age-adjusted hip fracture rates among older adults in the United States. Regional hip fracture rates in the United States in 1986-1993 correlate with death rates from rickets in the 1940s. Historical patterns of bone nutrition early in life might explain contemporary geographic patterns in bone fragility.

INTRODUCTION

State of residence early in life is a better predictor of the risk of hip fracture after age 65 than state of current residence. Therefore, the geography of rickets mortality in the United States before 1950 was compared with the geography of hip fracture rates among older adults in the United States during 1986-1993.

METHODS

Vital statistics data for the US white population for 1942-1948 allowed calculation of the ratio of deaths from rickets to live births for each geographic division of the USA. These ratios were correlated with previously published, standardized hip fracture rates among whites 65-89 years old during 1986-1993 by census division.

RESULTS

During 1942-1948, the rickets mortality ratio among whites was 3.11 in the South, 1.91 in the Northeast, 1.75 in the Midwest, and 1.04 in the West. The correlation of mortality with risk of hip fracture was 0.71 (p = 0.03) for both sexes combined and 0.86 (p = 0.01) for women.

CONCLUSIONS

Inadequate nutrition during skeletal formation early in life might explain the higher incidence of hip fracture among older adults in the South.

The chemistry of light: the life and work of Theobald Adrian Palm (1848-1928)

The chemistry of light examines the work of Dr Theobald Palm. After his graduation from Edinburgh University, Palm joined the Edinburgh medical mission and was sent to Niigata in Japan where he remained for 10 years. During this time he noted the absence of rickets (a disease rife in Britain) in Japanese children and instituted a survey from which he deduced that sunlight deficiency was implicated in the aetiology of rickets. Unfortunately, he was largely ignored by the medical world. This paper seeks to contextualize his work. By placing Palm's study within a historical and social framework, its reception can be explained more easily.

Scientific knowledge and clinical authority in dentistry: James Sim Wallace and dental caries

Once the germ theory had become generally accepted within medicine, the importance of experimental science to the improvement of medical practice could no longer be reasonably doubted. However, clinicians still sought to retain control of how knowledge that had originated in the laboratory was interpreted and applied within practical diagnostics and therapeutics. Thus how practitioners incorporated new scientific knowledge into their medical discourse and practice is a matter for careful empirical inquiry. James Sim Wallace, born in Renfrewshire in 1869 and a graduate in medicine from the University of Glasgow, was a leading figure in British dentistry throughout the first half of the twentieth century. Through an examination of his voluminous writings, we explore how the new 'chemico-parasitical' theory of dental caries was accommodated within dentists' understanding of oral hygiene. The paper also looks at the controversies that surrounded the application of the vitamin theory to the problems of rickets and dental caries, focusing on the contentious interaction between Sim Wallace and his colleagues, on the one hand, and the eminent physiologists May and Edward Mellanby, on the other.

SOLAR ultraviolet radiation and vitamin D: a historical perspective

Rickets, the state of vitamin D deficiency, has reemerged as a potential problem in the United States. At the dawn of the 20th century, rickets was pervasive among infants residing in the polluted cities of Europe and the northeastern United States. Important milestones in the history of rickets were the understanding that photosynthesized vitamin D and dietary vitamin D were similar, the discernment of the antirachitic potency of artificial and natural ultraviolet rays, and the discovery that ultraviolet irradiation could render various foods antirachitic. Clinical guidelines were instituted to promote sensible exposure to sunlight and artificial ultraviolet radiation. In addition, irradiated ergosterol from yeast became the major vitamin D source for food fortification and the treatment of rickets, leading to a public health campaign to eradicate rickets by the 1930s. We review the sequence and turn of events pertaining to the discovery of vitamin D and the strategies for the eradication of the reemerging rickets problem.

[Brief history of rickets and of the discovery of vitamin D]

Almost eighteen centuries mediated between the first cases of rickets, reported by Soranus and Galeno, and the clarification of the disease aetiology. Due to the outbreak of rickets verified in the 17th century in England, the situation was known as the 'English disease', being its first detailed description presented by Francis Glisson. The growing incidence of rickets with the Industrial Revolution raised speculations about its origin and treatment. The characterization of solar light and luminous spectrum led to the identification of the biological effects of ultraviolet radiation, and to the discovery of phototherapy as an alternative therapeutic process to the solar irradiation. The experimental rickets achieved by Mellanby and McCollum gave support to the concept that this situation could have an origin in a dietary defect. It was also referred an inverse relationship between sun exposure and the incidence of rickets. The identification of the chemical nature of an essential dietary factor with anti-rickets effect (ergocalciferol or vitamin D2), together with another factor with identical properties, but more potent, produced in the skin exposed to sunlight (cholecalciferol or vitamin D3), was essential to the elucidation, prevention and therapy of the disease. The present revision summarizes the history of rickets, the characterization and anti-rickets properties of the light and dietary supplements of lipid nature, and the identification of the major biological forms of vitamin D.

Morbidity, rickets and long-bone growth in post-medieval Britain--a cross-population analysis

BACKGROUND

Vitamin D deficiency rickets is associated with skeletal deformities including swollen rib junctions, bowing of the legs, and the flaring and fraying of the wrist and long-bone metaphyses. There is, however, scarce information on the direct effect of rickets on skeletal growth in either present or past populations.

AIM

The study investigated the effect of vitamin D deficiency rickets on long-bone growth in two post-medieval skeletal populations from East London (Broadgate and Christ Church Spitalfields). Subsequently, inter-population growth variations in relation to non-specific environmental stress (dental enamel defects), industrialization, urbanization and socio-economic status during infancy (birth to 3 years) and early childhood (3-7 years) were examined.

SUBJECTS AND METHODS

Data on long-bone diaphyseal length dimensions and stress indicators of 234 subadults from Anglo-Saxon, late medieval and post-medieval archaeological skeletal samples were analysed using both linear and non-linear growth models.

RESULTS

Rickets had no effect on the growth curves for any of the long bones studied. However, pronounced variations in growth between the four populations were noted, mainly during infancy. The diaphyseal length of long bones of Broadgate were significantly smaller-per-age than those of Spitalfields and the other samples up to the age of 4 years, and were associated with a high prevalence of enamel defects during early infancy.

CONCLUSION

Socio-economic status, rather than urbanization, industrialization or rickets, was the central factor behind the observed differences in growth among the post-medieval populations. The observed inter-population growth variations were only significant during infancy.

"The English disease" or "Asian rickets"? Medical responses to postcolonial immigration

Do the former colonizing powers, like their former colonies, have "postcolonial medicine," and if so, where does it take place, who practices it, and upon whom? How has British medicine in particular responded to the huge cultural shifts represented by the rise of the New Commonwealth and associated postcolonial immigration? I address these questions through a case study of the medical and political responses to vitamin D deficiency among Britain's South Asian communities since the 1960s. My research suggests that in these contexts, diet frequently became a proxy or shorthand for culture (and religion, and race), while disease justified pressure to assimilate.

Rickets in the 17th century

Rickets was first documented as a cause of death in the Bills of Mortality for The City of London in 1634, but detailed descriptions were only published between 1645 and 1668. It was thought at the time that this was a new disease in England, but there was no indication as to the cause of the condition. However, air pollution from smoke produced by burning coal caused serious problems at that time, and so it can be suggested that vitamin D deficiency was responsible.

Skeletal manifestations of rickets in infants and young children in a historic population from England

Gross and radiographic changes characteristic of inadequate bone mineralization due to rickets are described in 21 immature skeletons from a 19th century urban population from Birmingham, England. The aims of the study are as follows: to evaluate and if possible augment existing dry-bone criteria for the recognition of rickets in immature skeletal remains; to investigate the value of radiography for the paleopathological diagnosis of rickets; and to compare and contrast the expression of rickets in this group with that previously documented for a rural agrarian population from Wharram Percy, England. Some gross skeletal signs of rickets which were not previously well-documented in paleopathological studies are noted. The worth of radiography for evaluating structural changes to both cortical and trabecular bone in the disease is demonstrated, and features useful for the interpretation of vitamin D deficiency are discussed. The pattern of skeletal elements affected and the severity of changes differs in the Birmingham group from that seen in the comparative rural population. It is emphasized that a variety of factors may influence the expression of rickets in paleopathological material, including rate of skeletal growth, age cohort affected, and intensity of vitamin D deficiency. Nevertheless, careful analysis, not only of the frequency of rickets but also of the degree of severity of lesions and the patterning with respect to skeletal elements affected, may enable more nuanced understanding of the biocultural context of the disease in earlier populations.

Sir Robert Hutchison (1871-1960) of London and the causes and treatment of rickets

A general physician with a special interest in nutrition and in children, Sir Robert Hutchison became a leader in medicine and paediatrics in the United Kingdom during the early decades of the 20th century. His wisdom and wit educated and amused successive generations of students and doctors.

Reemerging nutritional rickets: a historical perspective

Recent case reports highlight the resurgence of rickets in certain groups of breastfed infants. Infants residing in the North, irrespective of skin color, and dark-skinned African American infants residing anywhere in the United States are most vulnerable to nutritional rickets if they are exclusively breastfed past age 6 months without vitamin D supplementation. At the turn of the 20th century, rickets was nearly universal among African American infants living in the North. The discovery of vitamin D, the initiation of public health campaigns to fortify infant foods with vitamin D, and the supplementation of vitamin D to breastfed infants were responsible for overcoming the rickets scourge. We review a classic nutritional study by Alfred F. Hess, one of the greatest clinical nutritional researchers of the early 20th century, in the context of the resurgence of rickets, especially among dark-skinned infants. The Columbus Hill district, a black community of New York, NY, served as the setting for the study. Sixty-five infants (aged 1-17 months) entered a 6-month open-label trial of daily cod liver oil therapy. Participants were assessed for signs of rickets at recruitment and at 2, 4, and 6 months. Cod liver oil prevented the development of rickets in 34 (92%) of 37 infants treated for 6 months and in 7 (58%) of 12 treated for 4 months. Of the 16 infants who did not take the prescribed treatment, rickets progressed unremittingly in 15. Hess translated his success into a public health campaign leading to the development of the first rickets clinic in 1917. This was the first step in the conquest of the rickets epidemic of the early 20th century.

Vitamin D, cod-liver oil, sunlight, and rickets: a historical perspective

Rickets, a disease of vitamin D deficiency, is rarely confronted by the practicing pediatrician in the United States today. At the turn of the 20th century, rickets was rampant among the poor children living in the industrialized and polluted northern cities of the United States. With the discovery of vitamin D and the delineation of the anti-rachitic properties of cod-liver oil by the 1930s, it became possible to not only treat but also eradicate rickets in the United States. Rickets was a common disease in 17th century England. Frances Glisson's treatise on rickets published in 1650, a glorious contribution to English medicine, described the clinical and anatomic features of rickets in great detail. The exact etiology of rickets had been elusive until the 1920s. During the Glissonian era, rickets was a mysterious disease. By the late 19th and early 20th century, faulty diet or faulty environment (poor hygiene, lack of fresh air and sunshine) or lack of exercise was implicated in its etiology. Animal experiments, appreciation of folklore advocating the benefits of cod-liver oil, and the geographical association of rickets to lack of sunshine were all relevant factors in the advancement of knowledge in the conquest of this malady. In this article, the history of rickets pertaining to the discovery of vitamin D, cod-liver oil, and sunlight is reviewed.

[Rachitic knock knees in children]

Knee malpositions, for example valgus or varus deformations or flexion contractures, were often cited in the historical literature. In earlier times, clinical pictures such as rickets were often the reason for this kind of deformity. A causal therapy did not exist until the twentieth century. In most cases of rickets, genu valgum was reported as the typical knee deformation. The differential diagnosis for genu valgum caused by rickets was genu valgum traumaticum, paralyticum, and inflammatorium. The most important reports on the pathogenesis of valgus deformation can be found in publications by Hueter and von Mikulicz. The causal therapy of rickets was introduced at the beginning of the twentieth century.Vitamin therapy and UV phototherapy were developed during this period. Using these therapies, rickets decreased dramatically. Kurt Huldschinsky, a pediatrician from Berlin,was one of the main inventors of UV phototherapy in Germany. At the end of the nineteenth century, the operative correction of knee deformities increased while conservative treatment continued to be applied. Plaster casts,orthoses, and osteoclast therapy were the main noninvasive therapeutic possibilities. Positive aspects of the conservative techniques were mostly the good results and easy, timesaving technique compared with the operative treatment. The operative therapy increased with the knowledge of antisepsis and asepsis as well as advances in anesthetic procedures. Operative treatment modalities, for example tibial and femoral osteotomies, were more precise, but connected with multiple complications and greater time expenditure. Sufficient vitamin prophylaxis rendered knee deformations caused by rickets a rarity.

An ill child among mid-Holocene foragers of Southern Africa

The skeletal remains of an infant from a southwest South African rock shelter at Byneskranskop show pervasive abnormalities that are consistent with the effects of hypertrophic (hyperplastic) rickets. Diagnostic features include beading of the costochondral junctions of the ribs, flaring and tilting of the metaphyses, and cupping of the distal ulna, as well as general skeletal hypertrophy. With an uncalibrated accelerator mass spectrometry (AMS) radiocarbon date of 4820 +/- 90 BP (TO-9531), this is a very early instance of the condition, among foragers whose environment and diet make dietary shortages of active vitamin D or dietary calcium improbable. Carbon and nitrogen stable isotope ratios indicate a mixed diet, including marine as well as terrestrial protein. Solicitous care maintained the sick infant to an estimated age of 3.5-5 months; it was buried in a manner like that of other deceased group members. This case suggests that if infanticide was practiced, it was an option only during the immediate perinatal period, when this infant would have appeared normal. This is consistent with documentation of infanticide practices among historic foragers from southern Africa.