knee (genu-valgum), next the hip (certain waddling gait,!
when not caused by rickety change in the neck of femur),
lastly, the spinal column (scoliosis).
As an instance of imperfect gait from want of tone of
parts, we may cite the hobbledehoy movement of a fast-
growing adolescent boy, one who has "outgrown his
strength," the power of co-ordinating his muscles (apart
from a possible touch of chorea) has been outdone by the
over-rapid elongation of the bones of the lower extremities
proper to this period of life. We have occasionally been
consulted as to adolescent girls in whom, as in the above
class of boys, we could discover no distinct disease, yet the
* Consult Louis F. Stromeyer : Platt-fuss ' Beitrage zur Operativen
Orthopaedik,' Hanover, 1838. Ernst Stromeyer : ' Ueber Atonie
fibroser Gewebe,' Wurzburg, 1840.
16
IN-KNEB DISTORTION.
gait was extremelywanting in steadiness and firmness, some-
times amounting in the minds of the attendants to lame-
ness of hip. It is a question in some such cases of want of
tone in the hgaments and muscles attached to the rapidly
enlarging pelvis, analogous to the hobbledehoy gait caused by
rapid elongation of the bones of the boy's lower extremities.
We have elsewhere stated that we have known even a girl
grow six inches in a year, just before pubert3^ The case
was one of incipient scoliosis. We had periodically measured
her during the year, as an aid in determining the pro-
bability of cure.
Hitherto it has not been sufficiently noted that there are
two periods in the age of man at which growth is extra-
ordinarily rapid. The first period is from birth until the
age of nine months ; the second period is at the approach
of, or during, puberty or adolescence, say from the tenth or
twelfth to the fourteenth or sixteenth year, more or less.
We are indebted to Burdach * and Schwartz for precise
details on this interesting head. Schwartz watched a child
which grew in the
First week
H
in.
,, month
2
3 lines.!
Second ,,
1
1 line.
Third „
7 lines.
Fourth „
11 „
Fifth „
6 „
Sixth „
7 „
Seventh ,,
1
Eighth and n
mth month
H
â– â– ' Carl F. Burdacli : 1880, ' Die Physiologie als Erfaliruugswissen-
schaft,' 3 Band, p. 236.
•j- We were led to enquire into this subject through having repeat-
edly observed how very often in the treatment of congenital varus in
infants during "the month" it became necessary to exchange the
splints used for longer ones.
GBOWTH DURING INFANCY AND ADOLESCENCE.
17
.
3 in.
.
2 „
.
2 „
.
2 „
.
1 „
.
1 „
If in
the first seven
22 inches, it will in-
so that its length increased in nine months about one-
third, say 8^ German inches.*
The average rate of growth in the infant is estimated to
be 6 to 8 German inches during the first nine months, or
from 18 or 20 inches to 24 or 26 inches. Burdach says that
growth is during the
Second year
Third
Fourth
Fifth
Sixth
Seventh
at which period there is often a stop,
years the length has increased 20 or
crease in the second seven years only 10 or 12 inches, and
attains in the male 5|- feet. The weight which at seven
years is 37 lbs. German, increases at the age of fourteen
22 or 25 lbs.
Adolescence extends from puberty to completion of
growth, i.e., until sixteenth to twenty-third year in the male,;
and fourteenth to twentieth in the female. Growth at the
beginning of this period proceeds rapidly, and, especially ini
cases where it had not greatly advanced, makes a fresh start.
During adolescence the growth is from 10 to 12 inches. W^
believe that in the male growth may not stop until the age
of twenty-five. It is known that ossification is not com-
pleted before thirty. It was stated at the meeting, in 1881,
of the British Association for the Advancement of Science,
that growth continues until the age of forty ; probably in
width only.
These two periods of most rapid growth are, we venture
to say, predetermined physiologically : the first to hasten
* n . , 128
* German inch = vtt?
loo
1-098 English.
•9519 EngUsh. German pound
56
51
18 IN-KNEE DISTORTION.
the infant's fitness for independent locomotion and self-help
to food, when the mother's poAver of lactation may in the
normal com'se he expected to cease, and the infant's ahso-
lutc dependence on the mother for hoth locomotion and food
shall terminate ; the second period is, we consider, allied to
sexual development, and the [ipparent necessity of then more
rapidly completing the frame of the individual of either sex
to fit it for propagation of the race, for a life of lahour, and
its defence against dangers.
Volkmann (oj). cit.) applies the term idiopathic to denote
what we have termed the atonic form of genu-valgum, and
remarks that it occurs almost without exception only be-
tween the second and fourth and between the fourteenth
and seventeenth years. He appears to attribute it to abso-
lute overloading, whilst we attribute it in infancy and early
childhood, as a rule, to relative overloading of the joint
which is relaxed from atonic causes. In adolescents it is
probable that the carrying of heavy weights, fatigue, and
long hours of work, have the principal share in its pro-
duction, favoured in fast-growing lads by insufficient diet,
and consequent weakness of tissue. Volkmann is the only
observer who, besides ourselves, as far as we have ascer-
tained, recognises the fact of atonic genu-valgum taking
place mainly at two epochs of life. We have never seen a
rachitic in-knee produced after the age of five years. Pre-
vious observers and statistical* enumerators speak of cases
of rickets originating during adolescence, and even adult
age. They have often, doubtless, included under the head
of rickets, as originating during adolescence, cases which
had commenced in early childhood, and cases of the simjAe
loeak in-knee of early infancy and adolescence, all of which
are liable to become aggravated through statical influences
during rapid growth. Simple in-knee without unequivocal
â– â– ' See the "Discussion ou Eickets" at the Pathological Societj',
December, 1880, in the medical journals of the period.
INFLUENCE OF GROWTH. 19
signs of rickets may originate at any period between birth
and the completion of growth, but occm-s by far the most
frequently in early infancy and during the progress of
puberty and adolescence, corresponding, in fact, with the
two rapid periods of growth to which we have alluded.
Simple or weak in-knee occurs independently of the pre-
sence of signs of rickets. Eickety in-knee is accompanied
with constitutional and local signs of rickets elsewhere ;
rachitic bone curvatures, for example, rickety teeth, rickety
face and skull, restricted growth. (See rickety in-knee.)
Simple in-knee from weakness attacks tall children, and
does not lead to shortening of their stature. Rickety genu-!
valgum is met with only in individuals stunted from rickets,
i. e., shortened more or less according to the intensity of
that disease.*
As regards the proximate causes of genu-valgum and
their anatomical results, the opinions which have had more
or less temporary currency during the last forty years may
be summarised by saying that some observers, through not
having taken a comprehensive view of knock-knee, or from
not having had sufficient opportunities of studying the dis-
tortion in all its forms and stages, have singled out one fact,
often not a constant one, in the history of the complaint, to
which alone they have attributed its origin. Thus one writer
has attributed it to elongation of the internal lateral liga-
ment of the knee joint ; another to shortening of the external
lateral ligament ; another to contraction of the outer ham-
string, muscle and tendon ("retraction musculaire"), — a
great number of writers have put down enlargement of the
internal condyle of the femur as the immediate cause.
Gradually deficiency of the external condyle has obtained a
share of the etiologist's attention. Finally, it is acknow-
ledged that when the distortion has long existed, deficiency
* See also paper by the author in tlie ' Transactions of tlie Inter-
national Medical Congress,' London, 1881.
20
IN-KNEE DISTORTION.
of the external condj^le and. enlargement of the internal
condyle co-exist. In our opinion these several conditions
grow up jxiri j^assu, or successively, and appear as factors
of the deformity. The time has arrived when it may be said
that the majority of the above conditions are but conse-
quences of a common cause, — a weakening of the j&brous
structures and bones affecting the knee joint, which becomes
statically disturbed by gravity, by passive muscular action,
and may even be influenced by the will of the patient in his
efforts to eflect locomotion in the least uneasy manner when
the distortion has reached the highest stage ; and through
inability of the patient to take any exercise the members
may become surrendered to the passive adaptive shortening
of muscles, and get more or less rigidly fixed in the deformed
state.
One of our ablest surgeons, author of a ' Monograph on
Genu- valgum,' Macewen, attributes it exclusively to rickets,
and in particular to curvature of the
lower end of the femur and hyper-
trophy of the internal condyle and
adjacent part of the shaft. It may
here be remarked that curvature of
the tibia is sometimes a more promi-
nent fact in rickety genu-valgum (see
fig. 7) than femoral curvature, or
inward inclination of the knee joint
itself.
We refer knock-knee in all its
forms primarily to relative or abso-
lute weakness and relaxation of the
structures composing and surround-
ing the knee joint, the ordinary state
of perpendicularity of the whole limb being disturbed
through the weight of the head, upper extremities and
trunk being too great to be properly borne by the enfeebled
Fig. 7.
Racliitic (lemi-vahjuiit and
curvature confined to one
le<i, from flayer.
PATHOLOGICAL CHANGES. 21
and strained knee structures. It follows that the resulting
distortion of the articular surfaces in genu-valgum, whether
preceded by the weakness of over-growth, by rickets, by
paralysis, or by articular disease, should present more or
less similar mechanical altered relations in all cases.
The minute pathological conditions, when fully known,
will probably be found to differ as much as the constitutional
conditions of the system at large differ in the several
causatory disorders above named. C. Hueter and Mikulicz
have ably demonstrated the minute changes of the articular
ends of the bones, as shown by microscopical examination
in genu-valgum caused by the action of rachitis. We are
at present ignorant of the minute changes in the bones and
fibrous structures of children fed on too watery a diet, and
in paralysis and other causes of the distortion.
In confirmation of this view, that however different may
have been the primary constitutional condition, and what-
ever the secondary or determining causes, either in infancy
or adolescence, such as over-much standing or walking in
the former, or the pursuit of particular occupations neces-
sitating much standing and carrying heavy weights in the
latter, the mechanical conditions are the same, we may
quote C. Hueter's {op. cit., p. 263) emphatic assertion. We
premise that Hueter appears only to have met with three
forms of genu-valgum : the rachitic, beginning in young
children ; the statical, as he erroneously says, arising only in
growing youths without obvious rickets ; and the traumatic.
He says : " When I reflect upon the number of cases of both
kinds which I have watched, I believe them to be essentially
different, not, it is true, in relation to their clinical symp-
toms and pathologico-anatomical results, — for these are in
both forms identical, — as they are also in their chronolo-
gical, etiological, and therapeutical relations." We consider
Hueter to be quite mistaken in attributing identical clinical
symptoms and anatomico-pathological results to rachitic
22 IN-KNEE DISTORTION.
in-knee which begins in childhood, and the statical which he
believes originates onl}' in adolescence. Pathologically, as
well as clinically, rachitic genu- valgum is in the early stages
distinguishable from all other forms by its being complicated
with curvatures of the shafts of the thigh and leg bones, as
well as by rachitic affection of other parts. See further on
as to co-existence of two forms of disease.
In studying the subject of the influence which the natural
form and relations of parts concerned in the knee joint may
exercise upon the production of genu-valgum, it becomes
necessary to review some of the opinions of surgeons upon
it. This is especially needed, as many believe that the dis-
tortion is due to the naturally greater length of the internal
condyle. Some, speaking of the normal femur, have attri-
buted too great an excess to the normal internal condyle.
Holden,* for example, attributes to the internal condyle
an excess of half an inch. When handling the bone, or
suspending it, it may be looked at in an unnatural position.
Naturally, the femur is attached to the trunk in such
manner that its lower portion inclines towards the median
line of the body sufficiently to bring the two condyles on
nearly the same plane, so as to correspond with the two
usually nearly level articular surfaces of the tibia. This
fact disposes of the notion that the internal condyle, being
naturally half an inch longer than the external one, acts as
a direct cause of genu-valgum.
In the annexed fig. 8 are represented two femurs, taken
at random from amongst others. The first {a) is a well-
formed bone of a tall, probably slender individual, in which
the length and breadth of the internal condyle are, accord-
ing to the norm, greater than of the external condyle. When
placed as nearly upright as possible against a wall it is seen
that the prominence in a of the internal condyle below is
very small, and is only sufficient to occasion the slight
* Holcleu : ' Humau Osteology.'
LENGTH OF INTERNAL CONDYLE.
23
natural obliquity or adduction of the shaft. The other bone
(h) is shorter, heavier, possibly from rachitis, more bulky in
Fig. 8.
Fig. 9.
Fig. 8.~ -Front viexo of hvo femora: (a) norvml hone; (b) believed to be
taken from a rickety subject. They were jihotographed, the loicer ends resting
on a horizontal table, and the upper ends resting against an upright xoall.
Fig. 9. — Copy of photograph of the front vieiv of the same two femurs : (rf)
has the longer internal condyle, but on contrasting (b) and (d) it will be observed
that the placing three bronze pennies beneath the external condyle suffices to
produce in this plwtograph the same inward inclination of the shaft of the
thigh as (a) and (c) exhibit.
all respects, except as to length ; all the processes and the
caput much more pronounced, and the neck more hori-
zontal ; probably the bone of a stouter individual, and one
accustomed to carry heavy burdens. This second femur,
when similarly placed resting upon the table and against
the wall, as nearly upright as possible, exhibits a greater
obliquity or adducted position of the shaft. At d (fig. 9) it
is seen that three penny bronze pieces (= 0*18 inch, or
24
IN-KNEE DISTORTION.
4*57 millimetres), placed beneath the external condyle, are
all that is required to give this second bone the appearance
of possessing the smaller degree of obliquity or adduction of
the shaft, as in the neighbouring bone (c). We next direct
attention to e and/ (fig. 10), which represent the back view
Fig, 10.
Copy of photographic hack views of the tihice (/) and (c), corresponding to the
above femurs : (e) the bach view of tibia, which corresponds to the femur [b] and
(d) ; (/) is the back view of the tibia, corresponding to the femur («) and (c).
of the two tibiae corresponding to these femora, and note
that the femur b and d (in figs. 8 and 9), which has the
longer condyle, has the deeper articular cavity for its re-
ception, as seen at (*), compared with the articular cavity
at (+). Assuming that these femurs represent comparatively
small development of internal condyle, we consider that
they show that the relative normal superiority in length of
the internal condyle has been much exaggerated.
In like manner it may be inferred that the abnormal
enlargement of the internal condyle of the femur in genu-
ATONIC IN-KNEB.
25
Fig. 11.
valgum has been unintentionally exaggerated from observers
having in their estimate compared it to the external condyle,
the development of which has been reduced below the norm
by absorption through undue friction and bearing upon it.
A clinical examination of the form and relation of the
bones in the very young, affected with non-rachitic gonu-
valgum from weakness, shows that
enlargement of the internal condyle
does not at that period exist. See
fig. 11. There is prominence of the
knee on the internal aspect (" in-
knee"), but not increase of bulk,
either of that condyle or of the
neighbouring internal part of the
tibia. In the very young this pro-
minence immediately disappears,
when in the gentlest manner the
limb is straightened with the hand.
Gradually, however, during the per-
sistence of the distortion, and the
constant strain and stretching in
walking and standing, which is ex-
perienced by all the structures on
the inner aspect of the knee joint,
when the distortion is not arrested
in early childhood, some thicken-
ing and deposit in the structures,
bone, periosteum and ligament, take
place. These changes may be the
result of altered nutrition and growth of bone through pro-
longed afflux of blood to the part under influence of strain.
In 1842-3 (Lectures in 'Lancet') the author said,
" Besides curvature of leg bones the internal condyle of the
femur becomes (with the progress of the distortion) very pro-
minent, and sometimes disproportionately enlarged, whilst
Moderate amount of atonic {non-
rachitic) gemt-valpum in a
very young child, seen from
behind; reduced from a natu-
ral sized actual tracing from
the limbs, to shoiv prominence
of the internal condyle, but
no enlargement of it in tltis
stage.
26
IN-KNEK DISTORTION.
Fio. 12.
the development of the external condyle is impeded." These
changes are in some cases denoted hy the aching pain and
sense of weakness complained of at the part as age ad-
vances, and as the demands upon the powers of locomotion,
especial^ amongst the i)oor, increase.
Fig. 12 is a fairly typical example of a child who could
stand and walk alone, affected with atonic genu-valgum of
both limljs. Compare with the
above a case of moderate knock-
knee of ricket}^ origin, in which
loss of symmetry is very marked
(fig. 3, p. 6), not owing alone to
the distortion, but also from the
marked swelling of the ends and
smaller swelling of the shafts.
The annexed diagram a (p. 27), of
left knock-knee, will afford an idea
of the mechanical relation of the
femur and tibia before and after
restoration of form. The outline
{a, c) is supposed to represent the
left femur of fig. 3, and c, h is
supposed to represent the leg or
the tibia before recovery ; the
dotted outline, ending below at
d, is intended to represent the
leg brought into a straight line
with the trunk, as it immediatel}'
becomes in a successfully handled
or instrumentally treated case of well-marked knock-knee
of a very young child. When an atonic case, and occa-
sionally a half-cured rickety one, is gently handled and
straightened by applying the palm of one hand against the
inside of the knee, at c in the diagram a, and the other
hand against the outer malleolus, at }i in the same diagram,
Slifilit alonic douhh' hi-hnee.
GAP BETWEEN FEMUR AND TIBIA.
27
Diagram a.
there results — as shown by the dotted outhne ending below
at d — a triangular gap (e) between the supposed arti-
cular surface of the femur and the opposing surface of
the tibia.
The surgeon, when examining in the same manner the
child's living limb, may feel this triangular gap, into which,
but for the integuments, fascia, and liga-
ments, he might almost introduce the tip
of his finger. This gap represents a space
equal to the amount of the existing defi-
ciency in length of the external condyle,
and the corresponding articular facet of
the tibia, augmented at this early stage of
the distortion by the laxity of ligaments.*
The surgeon, by the most gentle hand-
ling, has removed all prominence of the
internal part of the knee and of the in-
ternal condyle, and therefore all deformity a
has at once disappeared. The limb has Diagram of left hwck-
recovered its natural symmetry. He is kneejmm Little, on
cognizant of an unusual space between the
external articular surfaces of the femur
and tibia, due to deficiency of the external
condyle and to relaxation of ligament from
the fact of feeling the gap between it and
the outer part of the articular surface of
the tibia, and because when holding the
thigh immovable with one hand he can
with the other, by moving the leg to and
fro in the horizontal plane, recognise an
unnatural "play" in the knee joint, "wob-
bling" ("Schlottern"), and is able at will to produce genu-
valgum, or the normal position and symmetry. This normal
position is temporarily produced by him, for with his hands
-'• Little : ' Deformities of tlie Human Frame,' 1853, j). 220.
'Deformities,^ 1853,
p. 218 : (a) femur ;
{&) tibia; (c) the pro-
jecting knee joint
of genu -valgum;
{d) dotted lines re-
presenting the tibia
placed in its natu-
ral relation ; (e)gap
left on outside of
the joint, when tem-
porary replacement
is effected.
^8 IN-KNEE DISTORTION.
he holds the joint straight, in the same manner as he could
effect straightening in an anatomical specimen hj placing a
wedge between the external condyle and the opposite part
of the tibia. It is possible that the sm-geon, if he impro-
per 1}^ applied adequate force, might convert the in-knee into
the opposite distortion (genu-extrorsum) ; but if he uses no
more than the gentle pressure we have spoken of, he will
merely straighten the limb, and will be unable to intro-
duce the tip of the finger between the internal condyle
and tibia, as he was able to do on the external side of
the joint.
With increasing age and recovery of tone the looseness
of the joint in the extended position ceases, but the deformity
produced during the atonic stage continues (if unattended
to), and afterwards increases through statical influence. The
gap also ceases to exist, but from clinical observation and
post-mortem anatomical sources of information, derived,
as will be shown, from the labours of Sandifort, Mayer, and
Mikulicz, we have evidence of the pre-existence of the gap
during the early stage (atonic), in the fact of the observed
wide space interposed between the external condyle and
opposite surface of the tibia when the femur and tibia are
straightened, as regards one another, and placed in their
normal relation. See figs. 13 and 14. We may affirm, also,
from our therapeutic experience from instrumental treat-
ment, by means of which we assist Nature to deposit new
bone where the gap from deficiency existed (pp. 29, 30),
and from the effects of supra-condylar osteotomy (Macewen),
which gives length to the limb on its outer aspect, whereby
the genu-valgum is cured, that a wedge-like portion of
bone has been substituted, supplying in the shaft of the
femur the deficiency previously existing at the outer
condyle.
This gap (fig. 20) is a measure of the amount of bony
deposit which, during curative treatment by use of mecha-
DIMINUTION OF EXTERNAL CONDYLE. 29
nical splints or other appliances, the orthopaedic surgeon
attracts to the external condyle and opposite surface of the
tibia, i. e., renders deposit of bone possible during the pro-
gress of growth by relieving the outer condyle and tibia from
the pressure it undergoes when walking is permitted, so long
as the limb has the form of knock-knee, and thus brings
about a lengthening of the external condyle and heighten-
ing of the external part of the articular surface of the tibia,
and, together with recovered tone in the fibrous tissues,
effects a cure. This cure consists of no temporary replace-
ment of parts, but is an instance of the true art of medicine,