SOME OBSERVATIONS 
ON 
Bow-Leg and In-Knee 
WITH ESPECIAL REFERENCE TO THE QUESTION 
OF OUTGROWTH OF THESE DEFORMITIES 
BY c 
ROYAL WHITMAN, MJ? - 
ORTHOPEDIC SURGEON TO THE BOSTON DISPENSARY 
Reprinted from The Medical Record, July 30, 1887 
NEW YORK 
TROW'S PRINTING AND BOOKBINDING CO., 
201-213 East Twelfth Street 
1887 Boston, October /, 1887. 
DR. ROYAL WHITMAN 
HAS REMOVED TO 
142 HUNTINGTON A 3T 33 3NC V 33, 
(OPPOSITE the mechanics fair building.) 
OFFICE HOURS 1 TO 3 P. M. SOME OBSERVATIONS 
ON 
BOW-LEG AND IN-KNEE, 
With Especial Reference to the Question of Outgrowth 
of these Deformities. 
By ROYAL WHITMAN, M.D., 
ORTHOPEDIC SURGEON TO THE BOSTON DISPENSARY. 
Reprinted, from The Medical Record, July 30, 1887. 
A large proportion of the cases seen at an orthopedic 
clinic are deformities of the lower extremity (bow-legs 
and in-knees). Any radical treatment in such cases is 
especially difficult, because of the firmly held belief among 
parents that these deformities are outgrown, and even the 
application of apparatus is objected to or delayed until 
such treatment is ineffectual. Family physicians usually 
advise delay, and that authorities differ may be seen by 
the following brief extracts from three of the many 
writers on this subject : 
" When rachitis has disappeared such amount of cur- 
vature may remain as to require treatment. In the great 
majority of cases this is unnecessary, since, as has already 
been stated, the curvatures spontaneously disappear with 
the growth of the skeleton. Only in the leg, curvatures 
sometimes remain so that the foot is distorted and only 2 
the inner or outer border can be placed on the floor. 
If this remain for years at the same point an attempt 
may be made to straighten it." 1 
" The curvatures of rachitis often become less marked 
during growth, but many of them are so severe that they 
remain for life. These might have been benefited by 
timely interference." 2 
" Most of our best surgeons are of the opinion that the 
so-called vis medicatrix naturae. is sufficient to correct 
the deformed leg if sufficient time be allowed for it to re- 
gain the necessary strength, hardness, and ability to bear 
the weight placed upon it. This is a most dangerous 
error. No time, no natural process, is sufficient to 
bring a bent bone which, by a diminished quantity of 
lime-salts, has once lost its original elasticity back to its 
normal position." 3 
It is evident that the only way this question of out- 
growth could be conclusively settled would be by a series 
of observations on children suffering from these de- 
formities, extending over the entire period of growth. 
Such observations have never, to my knowledge, been 
made, and how the authorities who believe in such out- 
growth arrive at their conclusions is not stated. Mean- 
while, is one justified in allowing the comparatively short 
time, during which these bent bones can be easily re- 
placed, to go by ? I think not, as I shall endeavor to 
show. 
In considering this subject, as to the advisability of 
treatment, I concluded to make some observations on 
the prevalence of bow-leg and in-knee among adults, 
thinking that by comparing such results with the sup- 
posed prevalence of such deformities in children, some 
general conclusions might be arrived at. Aggregations 
of adults on whom observations might be made, being 
presumably of a better or worse grade, it was finally de- 
1 Billroth : Surg. Path. Tenth edition. 
2 O. Lannelongue: Nouv. Diet, de Med. et de Chir., art. Rachitisme. 
8 John Bishop, F.R.S., etc. : Unters. fib. d. Wesen u. d. Behandlung d. De- 
formitaten d. Menschl. Korpers. 3 
cided that the opportunity which presented itself in the 
streets of Boston would be most satisfactory. This, of 
course, limited me to adult males, but as the deformi- 
ties under consideration were more of cosmetic than of 
medical importance, this did not seem an objection. 
These results are as follows : 
Number of observations. 
Number 
adults 
served. 
of 
ob- 
Bow-legs. 
In-knee. 
I. 
25 
6 
2 
25 
4 
I 
3- 
30 
6 
I 
4. 
13 
1 
2 
5 
6S 
9 
2 
6. 
27 
5 
7- 
37 
9 
• • 
8. 
23 
5 
• • 
y. 
27 
6 
io . 
68 
12 
2 
11. 
34 
6 
12. 
52 
8 
2 
13- 
21 
3 
I 
14. 
28 
6 
• • 
IS. 
20 
4 
16. 
SI 
8 
17. 
58 
13 
I 
24 
3 
I 
19. 
14 
4 
• 
20. 
92 
19 
2 
9 
I 
22. 
57 
II 
23 • 
92 
13 
2 
24. 
57 
20 
I 
25. 
94 
l8 
• 
26. 
78 
21 
• • 
27. 
48 
8 
I 
28. 
/ 45 
8 
2 
29. 
150 
30 
I 
30. 
70 
17 
31. 
65 
II 
I 
32. 
143 
28 
2 
33- 
87 
25 
I 
34. 
136 
2 
35- 
47 
16 
36- 
37 
7 
I 
■ ■ 
- 
Totals 
2,000 
400 
32 4 
Thus, according to these observations, the legs of one 
adult male in five, or twenty per cent., are curved to a 
greater or less degree, while only one in sixty-two, or .or 6 
per cent., are affected with in-knee. 
As to the relative frequency of these deformities in 
children, no very satisfactory statistics can be obtained. 
Most observations have been on the prevalence of rachi- 
tis, without regard to deformities, among children pre- 
sented at hospitals for various diseases or injuries. 
McNamara states it to be as high as thirty per cent, 
at hospitals, and believes it to be as frequent among 
children of the better classes, induced by the cold, damp 
climate of England. 
Parry found twenty-eight per cent, of children at Phil- 
adelphia hospitals affected with rachitis. 
Gee, thirty per cent, at London hospitals. 
Ritter von Rittershain, thirty-one at the Prague Poli- 
klinick. 
Smith, among the children at the various institutions 
in New York over which he had supervision, found less 
than ten per cent, affected by rachitis. 
I have no data from which to estimate the prevalence 
of rachitis and its resulting deformities in children, other 
than by general observation of children in the poorer 
quarters of the city and at the primary schools, but I am 
convinced that the proportion of these deformities among 
children will not exceed, even if it equals, it in adults. 
It seems reasonable to suppose that in certain cases 
bow-leg may be an inherited peculiarity, and not the re- 
sult of disease. Again, a certain proportion of these de- 
formities are developed during adolescence, as shown by 
the well-known prevalence of in-knee among the bakers 
of Vienna, induced by the peculiar strain to which their 
knees are subjected, and very probably bow-legs may 
also result from certain laborious occupations. 
In considering this question of outgrowth of rachitic de- 
formities, it must be remembered that the upper and lower 
extremities stand in completely different relations. In the 5 
arms, their weight alone tends to rectify it, and the strains 
to which they are subjected also tend in the same direc- 
tion, but the legs, already weakened by disease, have a 
constantly increasing weight to bear. It is very possible 
that the bones may so gain in strength that the deformity 
may not increase, and as the leg grows longer it becomes 
less marked. Still it must be remembered that the ma- 
jority of children one is called upon to treat for such de- 
formities are already from thirty to thirty-six inches in 
height, and that the curve in a well-marked case of bow- 
leg, even if lessened one-half, would still remain in the 
adult a noticeable deformity. 
Thus, taking into consideration all possibilities and 
probabilities, the following will, I think, be considered 
fair propositions : 
1. A bow-legged boy is more likely to become a bow- 
legged man than a boy with straight legs. 
2. If such a proportion of bow-legs exists among 
adults as would appear by these observations, it would 
seem more reasonable to treat such cases in children, 
rather than to trust to nature for their rectification. 
3. If these deformities are to be treated, the sooner 
treatment is applied the better. 
At an orthopedic clinic children are rarely seen during 
the acute stage of rachitis. In my experience, those ap- 
plying may be divided into three classes- 
First, those who have evidently suffered from a severe 
form of the diseases, with various irregular curvatures of 
the bones, which are thickened and deformed, usually 
with marked inequality, between the upper and lower ex- 
tremities, stunting of the growth, etc. 
Second, children with no well-defined history of rachitis, 
tardy in development, showing slight general enlargement 
of the epiphyses, with curvatures principally in the lower 
extremities. 
Third, large, active children with curvatures of the 
lower leg, with no history of rachitis, and, in many cases, 
no signs of the disease excepting the deformity. 6 
The proportion of cases in these two latter classes is 
much greater than in the former, from which I infer that 
the children of Boston are subject to a milder form of the 
disease than often occurs elsewhere. The worst cases 
that I have seen have been among Italian and colored 
children, especially the latter. I have also noticed a 
greater proportion of deformities of the leg among adult 
negroes, though my observations have been too limited 
to be of any particular value. 
In-knee, a much less frequent deformity, I have only 
considered incidentally. Why rachitis should in one 
child cause bow-legs and in another in-knee has never 
been satisfactorily explained. Possibly, in some cases, 
a weak child in attempting to stand aids itself by press- 
ing the knees together, the feet being widely separated 
for a larger base of support. This position, combined 
with lax internal lateral ligaments, with possibly an ex- 
aggerated outward bending of the femur, might induce 
this deformity. It is a much more serious deformity than 
bow-leg, as interfering more with locomotion, and as 
tending to produce laxity of the ligaments at the ankle, 
with flat-foot, a condition often accompanied by more or 
less pain. 
As to treatment, of course the general condition is of 
the first importance, but, as has already been stated, 
these cases are rarely seen until they have nearly or quite 
recovered from the original disease. 
If a patient is seen early enough mild forms of the de- 
formity may be remedied by massage with daily bending 
of the bones, with possibly the application of splints at 
night, the child being restrained as much as possible 
from walking. In more advanced cases suitable appa- 
ratus may be applied. In moderately stiff bones I pre- 
fer the gradual forcible reposition under ether, with re- 
tention by plaster bandages. Often the bones crack 
during the operation, green-stick fractures being appar- 
ently produced. Apparatus, which may be applied at 
the end of a few weeks, is then simply retentive. 7 
In stiff bones, where the external or anterior curves are 
low down, apparatus is in most cases useless, and osteo- 
clasis or osteotomy should be performed, osteoclasis be- 
ing safer when children are to be treated at their homes. 
In-knee can usually be remedied by apparatus; in more 
severe cases, where it is not considered advisable to per- 
form osteotomy, the epiphyses of the femur may be par- 
tially separated and plaster bandages applied, to be re- 
placed by suitable braces at the end of a few weeks.