Popular Science Monthly/Volume 22/January 1883/Bodily Deformities in Girlhood
By CHARLES ROBERTS, F. R. C. S.
HOPE the time is not distant when a careful study of the living model of the child and the adult, and the whole period of the development of the one into the other, will form a part of the student's ordinary course of anatomy and physiology, as such knowledge is essential to the surgeon engaged in removing and preventing deformities of the body. Orthopedic surgery as a specialty is a great evil both to the profession and the public. The specialist who concentrates all his attention on a narrow field of study and practice is tempted to exaggerate its importance, and to analyze and disintegrate his facts till he loses sight of their relation to and their dependence on each other; while, on the other hand, the general practitioner is disheartened and repelled by the apparent complication of the subject, and is induced to hand over to the specialist many cases which he is quite competent to treat, or, as is too often the case, to undervalue the importance or deny the existence of many deformities. How else can we explain the difference in practice between the fussy mechanical ingenuity with which many professed orthopedists treat the slightest deformities of children—which, by the way, they often tell us are only visible to their specially trained eye, and are hidden from that of the family doctor—and the sang-froid of the general practitioner who meets the difficulties by the administration of a few doses of steel and quinine and rest in the recumbent position?
No deformity of a child's body gives rise to so much alarm to parents, or is the subject of greater diversity of treatment among medical men, as lateral curvature of the spine, and this is due, I believe, to an imperfect acquaintance with its origin. Specialists are accustomed to treat lateral curvature, knock-knee, and flat-foot as distinct deformities, while in truth they are all links in the chain of one deformity. Lateral curvature may arise in different ways, but in all cases it is due to the loss of the lateral balance of the body in the upright position, and is the result of an effort of nature to maintain the center of gravity of the body and support the head and shoulders in the position which requires the least expenditure of muscular effort. The paralysis, wasting or loss of a limb, or the shortening of one of the legs by disease of joint, rickets, knock-knee, or flat-foot in growing children, will produce lateral curvature, and these are its chief if not its only causes. It is not a deformity arising from general debility, and I do not think it can be produced, as is often asserted, by an awkward sitting position, as in writing and other school occupations. The curvature of the spine which results from these causes is antero—posterior, or what is commonly called round-shoulder (non-carious). The tendency of debility, whether local or general, is to bring the body into the prone or recumbent position, and not to tilt it on one side.
Setting aside the cases of lateral curvature in children who have been affected with rickets, disease of joints, paralysis or loss of a limb in early life, and which affect both sexes and all ages equally, what may be called the idiopathic or acquired deformity is rarely found in children of either sex under the age of nine or ten years, and very rarely in boys above that age. It is, indeed, almost peculiar to girls verging on puberty, and is as often found in strong and healthy as in weak and delicately built girls, and most commonly in those who are too fat and heavy for their stature and age. It is a deformity which is less common among the laboring classes than among the rich and well-to-do, and is largely associated with a life of indolence and luxury.
A careful examination of the subject has satisfied me that this acquired lateral curvature in girls is due to the change in the position of the lower limbs, resulting from the development of the pelvis from the infantile to the female type a year or two before the accession of puberty. Any one who will examine the figures of young children below this age will find little differences between the two sexes. The legs of young girls are set on the body like those of boys, and, within the limits of their training and dress, they can run as well and as gracefully as boys; but as puberty approaches, and the pelvis alters its shape, the heads of the femora are removed farther from the center of gravity, and at the same time become rotated forward by the widening of the pelvis, and especially of the outlet of the pelvis. The effect of these changes is to bring the knees closer together, and to produce the weak-kneed condition and the awkward running gait peculiar to women. This condition of the limbs is well seen in pictures and statues of the nude figure, and it is often exaggerated by the artist or sculptor, probably to give a more distinct idea of a woman's helplessness or modesty. The knee-cap in women looks straight forward, while in men it is turned a little outward; and in women the knees touch, or even overlap each other, while in men they are quite free. In running, a woman has to move the knees round each other, and to throw the feet out in a succession of small semicircles, which accounts for the peculiarity in her gait. This gait is not found in young girls before the onset of puberty, and is useful as a diagnostic sign of pelvic evolution long before the ordinary signs appear.
Although this weak-kneed condition is quite normal, it is a fruitful source of deformity in growing girls. A little additional strain will convert it into knock-knee, and, by throwing the weight of the body on the inner ankle, it will quickly break down the arch of the foot and produce flat-foot or complete eversion of one or both feet. It is here, indeed, that nearly all the mischief lies, for according to my experience ninety per cent of the cases of lateral curvature of the spine in girls are associated with flat-foot. This deformity is exceedingly common among women, and a French savant recently quoted it as a proof of the physical inferiority of woman to man. To a slight extent flatfoot may exist in all women, as the position of the lower limbs after puberty would seem to produce it, and it may be Nature's plan to promote what anthropologists call marriage by capture; but to a large extent, and in its worst forms, flat-foot is the result of civilization. Indeed, both the highly arched instep and the everted foot are peculiar to civilized peoples, and are absent from the lower races, especially those who go barefoot, and both conditions owe their existence to the wasting of the muscles which flex the toes and foot by the constant use of tight-fitting shoes. In India, where the native workman makes use of his toes with almost the same facility as his fingers, the instep is obliterated by the fleshy bellies of the abductor of the great toe and the short flexor of the toes, which stretch across the arch from their attachment to the heel-bone. The wasting of these muscles is of little importance to us who have no need to use our toes in detail; but it is far otherwise with the deep flexors of the foot and toes which are attached to the leg-bones, and whose tendons pass under the ankle joint and arch of the foot and form their chief support. It is, indeed, from the wasting or inaction of the deep flexor muscles, coupled with the turning out of the toes which fashion has imposed upon us, that the ankle and arch of the foot give way under the changed position of the limbs in girls at puberty, which I have described; and what is remarkable, and not easily explained, the deformity generally occurs only in one foot, or is greater in one than in the other. In this way, however, the legs become of unequal length, and we have obliquity of
The diagram shows the relation of the brim of the pelvis in the child, at puberty, and in the adult female, from measurements of pelves in the museum of the Royal College of Surgeons. The want of parallelism of the two inner pelvic curves shows that in the change from the infantile to the female type evolution takes place chiefly behind, and that the legs must be rotated forward and inward. The dimensions are—Child: breadth, 83 mm.; length, 73; index, 114. Young female: breadth, 112 mm.; length, 85; index, 132. Adult female: breadth, 143 mm.; length, 108; index, 132. The indices of the young female and the adult are the same, but the bones of the former are not united together.
the pelvis, and consequently lateral curvature of the spine to correct the balance of the body, and bring the head and shoulders into the line of the center of gravity. Flat-foot also produces, or exaggerates, the natural disposition to knock-knee in girls, which, in its turn, adds to the inequality in the length of the two legs. Some observations recently made in America show that even in adults of both sexes the two legs are rarely of equal length, and there must be, therefore, slight lateral curvature in all persons, and it is probable that these natural curves become exaggerated, as in the development of round shoulder the large antero-posterior curves of the spine are exaggerated. It is to the wasting or non-development of the fleshy parts of the deep flexors of the toes or foot that Europeans owe the small ankle and the comparatively large calf of which they are so proud as distinguishing them from the lower races. It is a distinction, however, which is more than counterbalanced by the ugliness and inconvenience of flat-foot, to which it frequently gives rise. The ingenuity of an Edison could not devise a machine so favorable to the production of flat-foot as the tight-fitting, high-heeled, long-topped boot at present worn by girls. Not only does the rigidity of the front part cramp the action of the muscles, but the high heels place the foot at such an angle with the leg that the tendons are of least use in supporting the ankle-joint, and the long tops hamper the development of the muscles in the remainder of their course. The high heels, moreover, push the center of gravity forward on the arch of the foot, and by propping up the heel gives greater leverage, and a greater space for the arch to fall when once it gives way. In the majority of cases the mischief would stop when the arch reached the level of the natural heel, but the heels of boots favor a still greater fall, which ends in e version of the foot. It is difficult to understand how women submit to the discomfort of wearing high-heeled boots, or can be so cruel as to let their daughters wear them. It is true they give a fictitious height to the body, and disguise the slighter forms of flat-foot, but on the other hand they exaggerate the severer forms, and the boots are entirely wanting in proportion. Zeising's law of proportion requires that the sole and the heel should have the relative length of three to two, like that of the normal foot.
In treating the deformities of the spine and legs incident to healthy girls, it is obvious that attention must be directed, in the first instance, to correcting the deformed knees and feet. The very first signs of the giving way of the arch of the foot, which is easily detected by examination, by growing pains, and especially a change of gait, should be met by the wearing of flat-soled, well-fitting boots, with India-rubber or felt pads inside to support the arch, and special exercises favorable to the development of the deep flexor muscles. At puberty, and for two or three years before, the growth is very vigorous, and in both stature and bulk girls shoot ahead of boys of the same age, the period of rapid growth of boys coming later. From ten to fourteen years the stature of girls increases at a uniform rate of two inches per year, except at thirteen, when it is two inches and a half; but the weight increases at a much greater rate. At ten years girls add four pounds, at eleven six pounds, at twelve ten pounds, at thirteen twelve pounds, and at fourteen and fifteen eight pounds to their weight, and this sudden addition to the weight tells rapidly on ankles, feet, and knees, placed at a disadvantage by concurrent change in the position of the lower limbs by the evolution of the pelvis and the cramping of the muscles by tight boots. The arch of the foot often breaks down in the course of a few weeks, without warning or apparent cause, and in girls in perfect health, and especially those of an indolent habit. Fortunately, the remedy is as easy and complete, if applied promptly at the beginning and adhered to persistently, as it is difficult and unsatisfactory if put off till the deformity is firmly established. Support to the arch of the foot prevents the formation of knock-knee and lateral curvature of the spine. When it fails to do so, the knock-knee can be corrected by the temporary application of long splints, especially in bed at nights; but no apparatus is necessary for the curvature of the spine in its earlier stages, as it will disappear on restoring the lateral balance of the body, and all treatment will be useless until this is done. Much walking or standing should be avoided, and short but vigorous gymnastic exercises substituted, and when possible the recumbent position assumed. Sitting on the ground or on a sofa, in the cross legged, Oriental position, serves to expand the pelvis, evert the knees and invert the ankles, and counteract all the deformities; while sitting on chairs with the legs crossed one over the other directly favors them. It is probable that most children spend too much of their time on their feet, and that their power of walking is very much overrated. Running is the natural gait of all young animals, and children always run if left to play by themselves. The dire effect of standing and walking in producing flat-foot in children is shown by the following statistics, taken from my paper on "Flat-foot," in the St. George's Hospital Reports (1872-'74): Of 10,000 children, between the ages of eight and thirteen years, which were examined, about one third were schoolchildren living in country towns and agricultural districts, another third were school-children living in manufacturing towns, and the remainder were factory-children. Among the first, 17·1 cases per 1,000 of flat-foot occurred; among the second, 30·7 cases per 1,000; and among the third—i. e., the factory children, who were employed five hours daily standing, walking, and carrying weights—79 cases per 1,000 of flat-feet were found. Among the latter the deformity was found to increase rapidly with age—i. e., with the longer period of employment in factories. Thus:
At the period when these observations were made (1873) children were allowed to commence work in factories at the age of eight years, instead of ten as now, and the low rate of 15·1 per 1,000 represents the normal rate before the strain of labor has begun to tell on the children's feet.
There can be little doubt that children are made to stand and walk far too much both at home and at school. Standing at lessons, parade-exercise, and much of the military drill in schools are injurious to both boys and girls, and especially to the latter. Instead of listless standing about, or taking long walks with adults, children should be permitted and encouraged to play lively games, which they will generally do even if left to themselves, to dance, and to perform short but spirited gymnastic exercises with apparatus. Exercises which develop the muscles of the feet and ankles, such as hopping and skipping, are especially necessary for girls; and still better than these are the admirable exercises preparatory to stage-dancing taught at the National Training-School for Dancing. These exercises are directed to the development of the muscles and the free action of the joints of the lower limbs, and are far preferable to the languid movements of ordinary dancing. For the development of the muscles of the trunk and arms the excellent system of gymnastics for girls recently established by a lady in various parts of London, with the approval, after careful and repeated inspection by myself, of Dr. Richardson, Mrs. Garrett Anderson, and others, is all that can be desired. The Swedish and other exercises effected without apparatus are of little use, as idle and indolent girls who stand most in need of physical training easily comply with the form, but evade the spirit and hearty compliance which such systems demand. These systems lack motive to complete an exercise, while simple apparatus, such as balls, dumb-bells, and bars, compel it by keeping the end in view, and giving an impetus to its performance. With half the care which mothers spend on dressing and decking-out their children, often in unsuitable clothing, they might, with a little help from their medical advisers, prevent most of the deformities which mar the physical beauty, comfort, and health of their offspring; and no time seems more appropriate than the present for directing the attention of medical practitioners, and through them of parents, to the means of attaining these objects, as the short walking-dresses worn by women and girls at the present time reveal to all of us to what a great, indeed unexpected, extent the ugly deformities of the feet and ankles to which I have referred exist, especially among the well-to-do and higher classes.—Lancet.