history

Would this Kill Me in the 1800s: Club Foot

Club foot is a relatively common birth defect, impacting up to 4 births in 1,000. It’s a type of joint contracture that causes one or both feet to turn in and down, leading to difficulty walking if untreated.

This isn’t actually a lethal disease on it’s own; it typically doesn’t have any comorbidities, and isn’t associated with a weakened immune system or any other illnesses or weaknesses. In about 20% of cases, it might be related to other joint contractions (such as in the arms or another part of the body), and in some rare cases it’s linked with a severe form of spina bifida called myelomeningocele.

While this is one of the oldest birth defects we have records of, we still don’t know the cause. Genetics seem to play a big factor, as it’s more common in some ethnic group and less common in others, and is more common in male children. However, about 80% of cases today occur in developing nations, which indicates that environment also plays a large factor. If the mother is a smoker, it seems to increase the risk, but other risks haven’t been narrowed down.

Whatever the cause, the result is muscles, bones, and joints that are not properly formed at birth. Connective tissue might also be impacted, leading to extremely thick, fibrous tissue. There are four different types of club foot, each indicated where exactly the contraction point is and what direction the foot is pointing in. For the purposes of this blog post, I won’t be focusing on any particular type, and just giving a rough overview of the condition in general.

Our first records of club foot date back to Egyptian tomb paintings. Hippocrates described it, and in India treatments were written down as early as 1,000 BCE.

Hippocrates described manipulating and massaging the foot to not only bring it back to the proper position, but to overcorrect the problem slightly in order to prevent a relapse. His descriptions are remarkably similar to the same treatments used today, which involves using as series of casts on infants to slowly adjust the position of the leg and foot. These treatments have to be started as soon after birth as possible, while the child’s bones are still soft and malleable.

Over the centuries, a variety of devices and aides have been used to stretch and secure the feet, but the work of Hippocrates and other ancients who successfully treated the disorder were somehow forgotten by the middle ages. Treatments often started later or not at all. This might have been due to the belief that it was “gods will” for the child to be deformed, or that the parents or child deserved it due to their sins or other bad behavior.

Obviously, I’m speaking of Europe here. I have not been able to find any free resources that describe treatment in other parts of the world, though I did come across several papers behind paywalls that probably do describe treatments in China, India, and other parts of the world, and how successful (or not) they were.

By the 1600s, the European interest in ancient Greece and Rome recovered the work of Hippocrates, and several new treatments were developed. Unfortunately, some doctors thought that rather than a firm but gentle movement, the foot should be forced into a new position. Scarpa’s shoe and the Thomas wrench were two devices that fall into this category, and caused far more pain and suffering to the patient than anything else.

Finally, in the 1800s, these forced corrections were abandoned, and doctors returned to gentle, repeated manipulations of the foot and leg using casts and massage. A paper on the subject was published in 1806 by Timothy Sheldrake, but was largely ignored, potentially because poverty is such an important factor in the development of club foot. While the 1800s was dominated by scientific discovery and technological development, on the other side of the aisle there was a return to religious thinking, and the idea of the “deserving” poor, and that things like birth defects were due to moral failings on the part of the parents. Poor parents who are struggling to survive can’t pay for things like weekly casts on their children’s legs, regular specialized massages, and surgical treatments, which at the time would have been incredibly dangerous due to the risk of infection.

But let’s talk about those surgeries for a moment. By the 1800s, it was recognized that while external manipulation of the effected foot was helpful and provided a great deal of improvement, it wasn’t always 100% successful.

The first attempt was made in 1823, but both patients died of sepsis, and that put off any repeat attempts until 1831. In the intervening years, Georg Stromeyer, a German surgeon, practiced a technique for splitting the Achilles tendon (likely on animal carcasses or human cadavers), before attempting it on several living patients. One of them, Dr. W.J. Little was an English physician. It was successful enough that Little stayed with Stromeyer to learn the technique before taking it back to England to teach to other doctors there.

Unfortunately, the hunger for science meant that this became a first line treatment. It took about 30 years for another doctor, William Adams, pointed out that it was more effective if performed later.

By the 1930s manual manipulation was once again back in favor. The two most common, the “French” method and Kite method are the two most common. The main difference is that the French method is more intensive physiotherapy, requiring daily exercises performed by a professional. The Kite method also uses these manipulations, but relies more heavily on casting, immobilization, and bracing later on. While these are effective, about 90% of patients do need at least some level of surgical correction at some point to release tension in the muscles, tendons, and other tissues surrounding the joints involved.

The current common treatment for most cases was finally developed in the 1960s at the University of Iowa. Dr. Ignacio Ponseti. It takes elements of both of these non-invasive methods to return the foot to a forward-facing position, and then surgical correction to restore the flexibility and up-down angle of the foot. Afterward, the child has to wear leg braces daily, and then eventually only at night.

Once treated, it is possible for the condition to recur, usually because the patient hasn’t kept up with their bracing or at-home exercises (or their parents haven’t encouraged it).

One thing that was missing in my research was a treatment timeline. It’s implied that most patients have full functionality of their limb within a few years, but one paper I read also pointed out that there haven’t been any long-term studies done, checking in on children as adults to see how well the treatment has held up. The research was also heavily focused on Western Europe and North America, so there’s definitely some missing information here. By and large, because the condition is not life threatening and is easily corrected in infancy now, it seems that not much has been dedicated to the details later on, or how it has been treated in other countries.

Further Reading:
Wiki
Spina Bifida Wiki
Treatment of Idiopathic Clubfoot
History of Clubfoot Management
Clubfoot from Ancient Times up to Now


Like what you see? Check out Would This Kill Me in the 1800s: Yellow Fever.