PRIMARY CRURAL ASYMMETRY. BY HENRY LING TAYLOR, M.D., NEW YORK. Reprinted from The MEDICAL RECORD, April 26, 1884. NEW YORK: TROW’S PRINTING AND BOOKBINDING CO., 201-213 East Twelfth Street. 1884. PRIMARY CRURAL ASYMMETRY. BY HENRY LING TAYLOR, M.D., NEW YORK. Reprinted from The Medical Record, April 26, 1884. NEW YORK: TROW’S PRINTING AND BOOKBINDING CO., 201-213 East Twelfth Street. 1884. PRIMARY CRURAL ASYMMETRY. There is a natural equilibrium between the two great and opposing biological forces, namely, the centripetal one of heredity, tending to preserve the type, and the centrifugal one of variation, tending to modify it. In studying the evolution of the human form we find that civilization and refinement come in as disturbing factors, favoring variation. It has long been known that the human form is not strictly bilaterally symmetrical. We are right- or left- handed, /.T!lT;lTllTl|rrJ,T;-<'hr!rr;iT; OJ • ' W+.1-I Age. Short leg. • i^iHcetaf->ifc|co Inches short- ening. UUU NNNUKMNHNUhhh M r-l Ovo 00 ~4 OlUl 04 N w O O 00 No. Sex. 04 i-i Os m m mwih mi-im 0004 O U O W 00 CO OOOn Ln CwO m w 4^ Age. ►—1 v—i h—i (—i j—1j—i t [—• t-11-11 t-11--1 tr-1 tr^ Short leg. W M M MM • Inches short- ening. [Since compiling the above table, ‘wo months ago, I have seen two cases of primary crural asymmetry in fe- males of sixteen and twenty-five years of age. The left leg was half an inch shorter in the former and an inch and a quarter in the latter.] Another striking result is the large size of the differ- ence found in most cases. It is not a question of eighths or fourths of an inch; in sixteen cases the difference is over half an inch, and in six it is an inch or more.1 Crural asymmetry does not seem to depend on the rate of bodily growth. Some of the patients tabulated had grown rapidly, others slowly, while many had devel- 1 Out of 637 cases reported by Drs. Cox, Wight, and Morton, there was asym- metry in 370 cases, but this amounted to more than half an inch in only twenty- eight cases. 8 oped at about the average rate. No. 21, a young man of sixteen, whose left leg is an inch shorter than its mate, rather more than less, is only fifty-eight inches tall. The majority of these children compare well with others of their age and circumstances, in respect to general health and development. Many of them, however, have im- perfect and asymmetrical chests, partly due, in many cases, to changes secondary to pelvic lateral obliquity. Out of a few measurements made, I have found a differ- ence in the length of the arms, measured from the tip of the acromion process to the end of the middle fin- ger, in two cases. In Case 12, the left arm was f inch shorter than the right, and the mother had noticed that in fitting dresses for her daughter she had always been obliged to shorten the left sleeve. In Case 13, the right arm was found to be § inch shorter than its mate, though the left leg was the shorter. Accurate measurements of the length of the arms are even more difficult than those of the legs, which is the less to be regretted, as moderate inequality in the lengths of the upper extremities is of no practical importance. I have noticed that in a few of these cases there seemed to be a general ill-development. The chest and loins were asymmetrical and the former flat or narrow (I am not now speaking of the effect of secondary lateral curvature), the whole form devoid of grace of line and movement, and the circulation poor, as shown by cold feet and hands, bluish skin, and “ goose-flesh.” These were apt to have particularly intellectual parents. How do these cases come under the notice of the prac- tical physician ? What do they come for ? In most in- stances the parents’ attention is attracted by some of the evidences of a lateral spinal bending, due to the pelvic obliquity. It is a drooping or bulging shoulder, a peculiar attitude of the body or head, or an abnormally curved spinal column that leads the patient’s friends to seek a physician’s advice. In other cases it is a peculiar or awkward gait, or an 9 undue tendency to stand on one leg. In Case 30, a single lady of thirty, the simple question was, “ Why do I tire so easily in walking ? ” The if inch difference in the lengths of the lower extremities found answered the question. It is not easy to walk constantly along a side hill. In spite of this considerable difference this lady had no lateral curvature. Fig. 1. Fig. 3. This brings us to the practical core of the matter. Crural asymmetry is chiefly important from the pelvic obliquity which it necessitates, giving as it does a strong bias in the growing period, when there is increased flexi- bility of the spinal column, toward a lateral curvature. I say a “bias,” because if the spinal column and muscles . be exceptionally strong this tendency will be resisted, 10 and the patient once tided over the vulnerable period —pubescence—the danger is over. The preceding figures (i, 2) show how a lateral curvature must ensue with an oblique pelvis, from the instinctive tendency to carry the head over the centre of gravity. Now, whether this slight bending shall go on increasing, necessitating rotation and a permanent curvature, will depend on the individual susceptibility to such a bias. As a matter of fact, in nearly one half of the cases there was no per- manent curvature. In a few cases the pelvic slant is diminished by carrying the pelvis toward the long side (Fig. 3), which, as it necessitates the carrying of the head and shoulders toward the opposite side, to preserve the equilibrium, enables the patient to stand and walk with a straight back. The following case walked and stood in the manner described : No. 31, aged forty-three, the father of a little patient under Dr. C. Fayette Tay- lor’s care for hip disease. While Dr. Taylor was ex- amining the little girl one day, she suddenly exclaimed to her father, a large, well-developed man, “ Why, papa, you are not straight either ! ” On looking at the gentle- man Dr. Taylor detected pelvic obliquity, and on ex- amination discovered an inch difference, yet there was no lateral curvature and the gentleman had been entirely unaware of his abnormality. Pelvic obliquity, however, in the vulnerable period is a threat against the symmetry of the spinal column, and is to be diligently guarded against. The simple remedy is to place sufficient extra sole under the shoe of the short side to level the pelvis. In cases taken early, before there is any permanent curvature, i.e., when the spine can be as easily bent and rotated in one direction as the other, levelling the pelvis until growth is attained is often sufficient to prevent deformity, though not always so, as children with horizontal pelves may acquire lateral curvature. When a permanent curvature is al- ready present, levelling the pelvis should be only acces- sory to mechanical means, and is never in itself sufficient. 11 After the patient has attained her growth, the danger of lateral curvature is passed and the high sole may be discarded, unless, from excessive difference in the length of the limbs or from a susceptible nervous system, the unnatural walking be too great a tax on the strength. There is a common and ignorant prejudice, that the wearing of a high sole will tend to make the leg still shorter. It is hardly necessary to observe that the leg cannot be driven into the body like a pin into a potato, and it is hardly reasonable to suppose that a procedure which, by restoring pelvic horizontalism, puts the muscles into their proper relations and permits of the leg being used to the greatest advantage, would involve a retarda- tion of growth. But what is more to the purpose, I can adduce an instance of the contrary effect. Case 3 came at twelve, with a difference of over three-fourths inch. She wore the high sole for a con- siderable time. At seventeen years of age the difference had so diminished as to be barely perceptible. Similar instances have been observed. Secondary crural asym- metry due to joint or bone disease, or paralytic retarda- tion of growth, of course, involves pelvic obliquity and its accompanying dangers. Many of the points made above apply with equal force in these cases. In concluding, I must urge the importance of deter- mining the presence or absence of pelvic obliquity as a necessary preliminary to the treatment of every case of lateral curvature of the spine. There is an almost uninterrupted procession of these cases coming to our office, who are wearing or have wern plaster jackets or mechanical appliances to straighten the spine, when the attempt was about as hopeful as that of the traditional individual who tried to lift himself over a stone wall by pulling at the straps of his boots, unless the sloping pelvis was first made level. I also wish to call attention to the light which these cases throw on the etiology of lateral curvature, though 12 I have no time to develop this subject here. Dr. C. Fayette Taylor estimates that half the cases of lateral curvature, as met with in his practice, occur with a slop- ing pelvis. In these cases, certainly, the primary curve is in the lumbar region, and he believes this to be equally true of all ordinary cases. Does not the large preponderance, in the table, of in- stances where the slope is to the left, explain, partially at least, the long-recognized fact that in the majority of cases of lateral curvature the convexity of the dorsal curve is to the right, the lumbar to the left?