I DESIRE to call attention to a class of cases which, as a rule, are much neglected. These cases are the children who walk awkwardly, with toes turned in and knees knocking together, but not to a degree sufficient to induce the parents to seek surgical advice.
This awkward, shuffling gait is generally attributed to laziness or carelessness on the part of the child, who may be constantly lectured on the subject and told to turn out his toes, which he may do for a short time in a constrained manner, with hands spread out as though he was trying to walk and balance himself on the edge of a board. Frequently, under the watchful eye of the parent or nurse, the child may with difficulty maintain a correct position, but the moment his attention is diverted the had position is resumed, or, if very much wearied by a long walk or other exercise, the deformity (for such it becomes then) will be greatly exaggerated.
The toeing-in is not the only form of the trouble, but it is frequently, if not generally, combined with a partially flexed knee. Sometimes the toes, instead of turning in, turn out, and the arch of the foot is depressed.
The general belief is that the child will outgrow the trouble, and to a great extent, as he grows older and becomes more self-conscious, he does manage to conceal it,. but neither the cause nor the difficulty itself becomes entirely removed. As the child grows older, he becomes ashamed of his crooked legs and awkward gait, and makes an effort to correct them, but he does it at the expense of unusual fatigue and a strain upon weakened muscles.
The cause of the difficulty under consideration is that there is an unequal balance of muscular power on the opposite sides of the limbs. Either through some prenatal influence or some condition developing subsequent to birth, the muscles of one of more groups become partially enervated; in other words, partially paralyzed. This term is perhaps too strong to apply to this condition; probably the term weakened muscles is better. At any rate, whichever term is applied, the fact remains that the weakened muscles fail to do their whole duty, and the consequence is the bad position and awkward gait before mentioned.
Under the stimulus of the will, the position may be corrected and remain so as long as this stimulus is acting or until over-fatigued, when the muscles give up in despair and become more relaxed than ever. I have seen a child who had a moderate degree of toeing-in under ordinary condition become absolutely deformed on returning weary from a picnic, and the feet so badly turned in that in walking he raised one foot over the other to avoid hitting them together.
The study of the reflexes and causes of nervous and muscular strains are now being actively pursued by the profession, and why not pay some attention to the condition here presented. The nervous irritation induced by unequal muscular balance of the ocular muscles, and the reflex irritation of spasmodic contraction of sphincter muscles, will doubtless be considered at this meeting, but we must remember that the human system is a confederation of parts, and a weakness in one part weakens the whole, and that anything which acts as a drug or which causes an unhealthy weariness during the formative period of life, must leave a more or less lasting effect if allowed to remain uncorrected.
I do not wish to exaggerate the importance of the subject; the children thus afflicted may not give evidence of any special reflex irritation. As a rule, if a child does not suffer actual pain he does not complain; the only indication perhaps is the awkward hobbeldehoy gait and weariness.
The muscles usually most affected are the peronei in the leg and the quadriceps extensor in the thigh. The other muscles may be affected, but weakness of these in particular is most likely to cause the condition of toeing in an flexed knee. If combined with laxity of the internal lateral ligaments of the knee-joint, we also have the condition of “in-knee” or “knock-knee.”.
As the whole trouble consists in the lack of muscular balance, the indications for treatment are plain. The strength of the affected muscles should be brought up to the normal a after a careful comparative test of the strength of the opposing groups. This should be done by one skilled in finding the motor paints on the surface of the limb with the galvanic current.
The comparative tests should be made of the excitability of the opposing sets of muscles, and the results, as shown by the milliampere-meter carefully noted, due allowance being made of course for the varying resistance on account of the varying distances of the nerves from the surface, etc. Then the treatment of the affected muscles by galvanism should be carried on systematically, the applications being made from two to six times a week, as the case may require. In addition to this, massage to the affected muscles should be given regularly, and if my constitutional condition seems to indicate their use, internal remedies should be employed.
In some cases mechanical treatment may be necessary as an adjunct to the electricity and massage. For this purpose a light bar, fastened to the shoe and running up the outside of the leg to a pelvic band, should be employed. There should be joints in the bar corresponding to the ankle, knee, and hip-joints, and the amount of eversion of the foot may be regulated by z set screw between the knee and hip. This brace may be made very light, and only strong enough to produce the effect desired.
It is necessary to have the pelvic band with the brace extending from it to the shoe, as it is impossible otherwise to get sufficient leverage to evert the foot.
In very severe cases it may even be necessary to employ a more powerful apparatus, like Doyle’s spring rotator, but cases of such severity hardly come within the range of this paper.
SARAH J. MILLSOP, M.D.: Bowing Green, Ky.: It is with hesitancy that I comply with Dr. Pardee’s request to discuss this paper, for the reason that I belong to that large and formerly very useful army, the general practitioner, now being relegated to the top shelf as back numbers.
We have been told here women have not been asked to take a more active part in those deliberations for the reason that they were not specialists.
But, as all women are specialists in diseases of children, I may venture to say a few words on this most important subject, a subject to which not enough attention is paid, as the awkward gait of children means, when not corrected, the awkward gait to men and women.
In the South, where I live, I have found it positively painful to watch the crowds of country-people who flock to our city on what is called “show day.” So many have not only an awkward, shuffling gait, but they are round-shouldered, slouching, knock-kneed and club-footed.
This I think, in great measures, is the fault of mothers, who, not realizing the importance of forming correct early habits, or being burdened with domestic cares, have their children to “grow” like Topsy, or, to come up, hap-hazard, like the young of the lower animals, but without their natural grace of motion.
In my opinion, a judicious course of calisthenics in the school or at the home would do much, not only to prevent but to contract the bad conditions the doctor refers to.
Where the muscles are at fault from a weakened condition, no better measure can be recommended than the use of massage, with the inunction of some nutrient oil. Where constitutional dyscrasia underlies those bad conditions, our materia medica will give us most effectual aid. We have, doubtless, all found a most potent ally in ear Calcareas, especially in Cal. phos. in overcoming deformities in children. One dietetic measure I should recommend above all others is the use in some form of the entire wheat.
Chemists tell us that the kernel of wheat contains, not only must of the elements needed in the system, but just in the proportion in which they are needed, even to the constituents of teeth, nails and hair. That our children are fed don the least nutritious portion of this cereal, which forms our “staff of life,” while the most nutritious portion is given our lower animals, may account for the greater physical superiority of the latter.
The whole wheat is not only a builder-up of the young, but there is nothing to equal it is a repairer of waste tissue in the adult. Its constant use will keep brain and body young and active long past the allotted three score and ten.
W.D. GENTRY, M.D.: I want, in this connection, to earnestly suggest to the physicians of this country the importance of looking after this very serious matter of phymosis, and if time allowed me, I would like to speak at more length on this subject.
GERTRUDE G. WELLINGTON, M.D., Chicago, Ill.: I would like to add, that in cities like New YOrk, we find a great deal more of that complaint than in Chicago, I believe, largely from the fact that the children are confined to pavements which are very hard on their little bones. The remedy for that is putting then where their feet can have access to the soil, that when the little foot is put on the ground the heel sinks.