Journal of the Royal Society of Medicine Volume 87 December 1994 729 Rickets and the crippled child: an historical perspective Denis Gibbs DM FRCP 21 Albion Square, London E8 4ES, UK Keywords: English disease; rickets; smog; sunshine; orthopaedics Francis Glisson (1597-1677) was born in the village of Rampisham in Dorset and brought up in that Nicholas Andry (1658-1742), who gave orthopaedics county. Daniel Whistler (1619-1684), who wrote the both its name and the symbol ofthe crooked tree, was first detailed description ofthe disease 5 years before a physician. In his 40s he wrote a physicianly treatise, Glisson, was schooled in Thame, educated at Oxford An Account Of the Breeding of Worms in Human and Leiden, and practised successfully as a physician Bodies1: L'Orthopedie2 (Orthopaedia3 in the English in London. When he was a student of 25 he defended edition), his most influential work, was published his disputation for the Leiden MD on the subject De when he had reached the mature age of 83. The art morbo puerili anglorum, quem patrio idiomate of correcting and preventing deformities forms the indigenae vocant the Rickets. (Concerning the disease subtitle, more appropriately given in the reverse order of English children, which in native speech they in the original French edition. In many northern call the rickets). His thesis was published in 1645 in countries of Europe, notably in England, childhood Leiden, but was probably not much read in his rickets was the most common of all causes of lifetime. It was re-published in 1684, the year of his deformities. Doubtless Andry would have been death, when he had become President of the College impressed by present day prevention of this disease, of Physicians. but he would have had to live another two centuries In addition to his excellent clinical description, he to witness the elucidation of the intricate aetiology proposed an alternative name for the disease, of rickets. 'Paedosplanchnosteocaces'6. No doubt he thought this name would convey the gravity ofthe disease and The English disease also the gravitas ofthe doctors. It is no surprise that It was the prerogative ofEnglish physicians to publish the polysyllabic name did not catch on. If it had the first descriptions ofrickets, about a century before survived it would have emphasized that severe rickets Andry's Orthopaedia appeared. On the Continent the is more than a disease of bones, and may include condition soon became known as the English disease. serious systemic manifestations contributing to mortality in childhood. Both Whistler and Glisson There is a disease ofinfants ... having scarcely as yet gotten fully recognized these non-skeletal and life- a proper name in Latin, called the rickets; wherein the head threatening aspects. waxeth too great, whilst the legs and lower parts wane too Daniel Whistler's account of rickets was little.4 overshadowed by that of Francis Glisson, published in 1650 in a book which immediately became popular This was a comment by Thomas Fuller (1608-1661), and widely read7. An English translation of the a divine living in Exeter, which he made in a pious Latin appeared after only a year. Attention was given work Good Thoughts in Worse Times. The author to the anatomical and clinical features ofthe disease, went on to invite his readers to ponder a spiritual as well as some consideration to the morbid anatomy. analogy of rickets. Though Glisson got the credit, he was in fact a co- author, together with George Bate, a 'vicar of Bray' Have not many nowadays the same sickness of their souls, among physicians in his affiliations, and with their heads swelling to a vast proportion and they Dr Assuerus Regimorter, who was born in London of wonderfully enabled with knowledge to discourse? But, alas, Dutch parentage. The work can be regarded as the how little their legs, poor their practice, and lazy their first report on a disease by a working party from the walking in a godly conversation4. College of Physicians. It also reflected something of His readers would have been sufficiently familiar a new approach to clinical medicine, trusting more with rickets to appreciate the analogy. on physical evidence and enquiry than on theoretical Inthe mid seventeenth centuryrickets was rife, most speculation. notably in the West Country, where it occurred in Why did rickets quite suddenly become the English disease Revolution with a epidemic and florid form, making such an impact that ofpre-Industrial England, both Whistler and Glisson, each ofwhom later became special prevalence and severity in the counties in the have been President ofthe College ofPhysicians, thought it was south-west? Social and economic historians silent on the and medical historians a completely new disease. Glisson wrote in 1650: mainly subject, have placed too much emphasis on possible dietary deficiencies to This disease became first known as near as we could gather provide acceptable explanations. from the relation of others, after sedulous inquiry, about Environmental factors were almost certainly thirty years since, in the counties of Dorset and Somerset contributory. As in the smog-enveloped cities . since which time the observation ofit hath been derived of Victorian England, so too in seventeenth cen- unto all the southern and western parts of the Kingdom5. tury Wessex, rickets was almost certainly more a 730 Journal of the Royal Society of Medicine Volume 87 December 1994 consequence of lack of exposure of the skin to As rickets is the direct result of malnutrition produced by ultraviolet light than due to deficiency of vitamin D the anti-hygienic conditions in which the child has been in food. Ifso, why were there so many children living living, our first care must be to alter these conditions. We in the shadows rather than the sunlight? must see that the living rooms are thoroughly ventilated; The stage may have been set by adverse weather that the child is taken out regularly into the open air; ... and that his skin is kept perfectly clean by the abundant conditions in the first halfofthe seventeenth century; use of soap and water. We must next select a diet for the winters tended to be exceptionally cold and summers patient which is at once sufficiently digestible and unduly wet. The Thames froze in London in five of nutritious14. 50 successive winters. Such conditions may have contributed, but the true answers are likely to lie in William Macewan working in Glasgow had the special economic circumstances that prevailed in unrivalled experience ofrickets, which he had gained some regions more than others, and in the social from his treatment of leg deformities by osteotomy. practices of the time. Based on observations made on hundreds ofchildren There is little doubt that it was the children in the with ricketty deformities he concluded that high and middle ranks of society who were being environmental factors, including deprivation of affected or, as a writer of the time put it, 'especially sunlight, outweighed faulty nutrition as the cause of those that were rich and opulent, and put their the condition. He referred to children reared in some children out to nurse'8. The children of the poorest parts of a city like Glasgow being families, mainly those still attached to the land, were almost certainly protected by getting out of doors shut out from the light partly by the height of the houses rather than by differences in diet. A particularly (and) partly from the fact that even the sun's rays which do susceptible part of the population would have been manage to struggle through the canopy of smoke which that part involved in the home-based textile industry envelops them, are so diluted that they are ofcomparatively which had developed following England's monopoly little value. of the wool trade, and which, by 1600, provided the dominant export commodity. Whole families worked Even so, while clearly recognizing the importance of from before dawn until after dusk in their homes and, sunshine, his focus of attention was more on 'bad air'. whether the children were too young to work or old enough to assist in home production, they would have That bad air is even more potent than scant food, may be lived their lives predominantly indoors9. adduced from the fact that there are many people living in the West Highlands ofScotland on very poor diet, poorer than Such socio-economic considerations in relation to what most of the poor classes in our towns have, and yet access of children to sunlight, rather than precise there seems to be little rickets among them. Although from analyses ofwhat they were fed on and when they were most quarters in Scotland cases of distorted limbs have weaned, are likely to explain why 'in the time ofKing presented themselves for treatment, there has not been one Charles I it (rickets) was almost epidemical, few from the West Highlands. The fresh air and the sea breezes families escaping it'8. appear to compensate for the lack of sufficient food"5. Rickets was, of course, not confined to the West Country and it remained widespread in the pre- At this time, as one of a variety of therapies, the Industrial England of the early 18th century. From administration of cod liver oil was often advocated. his experience in the Midlands, Sir John Floyer wrote Cod liver oil, traditionally used as a folk remedy in in 1706 that 'no distemper is more frequent in infants some northern communities, and first recommended than the rickets'"O. As for many other disorders, cold medically by Thomas Percival in Manchester in the bathing was his therapeutic recommendation and he eighteenth century, underwent many vicissitudes.