Aging Bones: A Short History of Osteoporosis

Chapter Two. The Origins of a Diagnosis

24 CHAPTER TWO The Origins of a Diagnosis F F F The diagnostic category of osteoporosis did not appear until the mid-twentieth century, because of the weakness in and complexity of the knowledge base about bone physiology. Progress in illuminating the manner in which bones developed and changed over time would depend on the emergence of such specialties as endocrinology and technological innovation. Nevertheless, nineteenth-century European anatomists and physiologists interested in bones had already begun to lay the foundation for an understanding of how the human skeleton grew and developed. In 1816 John Howship (a well-known English surgeon ) first described the pitted and eroded characteristics of bone undergoing resorption, although cells had not yet been identified, so Howship could not describe the osteoclast.1 The emergence of the cell doctrine during the latter part of the nineteenth century led Swiss anatomist and physiologist Albert von Kölliker to name the osteoclast in 1873 and propose its relationship to bone resorption in a classic monograph. Several years earlier Carl Gegenbauer (a German anatomist and supporter of Darwin’s theory of evolution) described the osteoblast and its function. Others added to an understanding of bone composition, structure, and physiology. Still, nineteenth-century findings about bone and the The Origins of a Diagnosis 25 skeleton, however significant, did not explain what drove the process of bone remodeling. The focus at that time was either on a causative increase in osteoclastic activity or a causative decrease in osteoblastic activity, both of which presumably operated independently of each other. During the first quarter of the twentieth century, the causes of bone atrophy remained mysterious; speculation and eclectic but unproven theories were common. In 1929 J. Albert Key (of the Shriners Hospital and Department of Surgery at Washington University in Saint Louis) attributed bone atrophy to general causes (including senility, hunger, marasmus, biliary and pancreatic fistulas, increased metabolism, scurvy, rickets, and osteomalacia ) and localized sources (such as disuse, trauma leading to bone atrophy, inflammation, neoplasms, pressure, and neurotrophic disturbances).2 Such eclecticism, however, was already in the process of being transformed by research in specialties whose members seemingly manifested little interest in bone physiology. THE EMERGENCE OF ENDOCRINOLOGY A clearer understanding of the process that drove bone remodeling had to await the emergence of endocrinology, particularly the discovery of what later became known as hormones. In the nineteenth century there was considerable interest in the secretions of the sex glands and the parathyroid and thyroid glands. Concern with these secretions led to a redefinition of femininity, which heretofore had been characterized by the uterus. At midcentury an important shift began to take place. In 1848 young Rudolf Virchow gave a lecture in which he discussed the function of the ovary, which was the production of the ova. Virchow rejected humoralism (the doctrine that disease arose from the four bodily humors of black bile, yellow bile, phlegm, and blood) in favor of a solidistic perspective (the theory that disease arose in the solid components of the body). Menstruation was correlated with ovulation, and these periodic, rhythmic changes were governed by the nervous system. More importantly, the ovaries de- fined femininity. “The female is female,” Virchow argued, 26 Aging Bones because of her reproductive glands. All her characteristics of body and mind, of nutrition and nervous activity, the sweet delicacy and roundedness of limbs, . . . the development of the breasts and non-development of the vocal organ, the beauties of her hair and the soft down on her body, those depths of feeling , that unerring intuition, that gentleness, devotion, and loyalty —in short, all that we respect and admire as truly feminine, are dependent on the ovaries. Take the ovaries away and we get the repulsive, coarsely formed, large-boned, moustached, deepvoiced , flat-breasted, resentful, and egoistic virago [Mannweib]. Virchow, of course, was offering more than a medical statement. He was implicitly endorsing the Victorian model of femininity. This, in turn, seemed to confirm the belief that, in females, emotions prevailed over rational faculties (in contrast to the view that, in males, the intellectual propensities of the brain dominated).3 Virchow’s formulation was by no means idiosyncratic. In the eighteenth and nineteenth centuries, gender differences were increasingly explained in terms of biological determinism. Women were smaller and weaker than men, suffered more illnesses, were more emotional, and were inferior to men in reason and intellect . In the twentieth...