Volume 49 1949 pp. 26-30

The Journal of the National Association of Chiropodists



SURVEY IN CHINA AND INDIA OF FEET THAT HAVE NEVER WORN SHOES

While serving in the Army of the United States during the recently concluded war, the author spent more than a year in various parts of China and India. Most of the people there both male and female, particularly the many poor people and those in rural communities were noted to go barefoot at all times. Because many of these barefoot individuals labored long hours on their feet and carried very heavy burdens for long distances, it became interesting to note the orthopedic condition of those feet in order to compare them with the average of those of us who wear shoes almost all our lives.

The survey was begun in Kunming, China, and its vicinity over a period of eight months and concluded in and around Calcutta, India, for an additional two month period. My knowledge of the Mandarin Chinese and Hindustani languages being meagre, and efficient interpreter was employed whenever possible. Crude by accurate instruments were constructed to measure the angles of foot motion. All persons surveyed said they had never worn shoes of any kind though a light, flat and very pliable sandal was sometimes worn. These were made of thin bamboo or felt, attached to the feet with no more than two thin straps around the ankle and between the first and second toes. None of these sandals had any arch-supporting features, their use being as a partial protection against cuts and bruises of sharp stones and broken glass . . . but they were not used most of the time. No socks were worn.

Persons with any obvious generalized disease or deformity, acquired or congenital, were not considered as falling within the scope of the survey and so were not included. This ruled out talipes,1 leprosy, elephantiasis affecting the lower limbs, rickets and tuberculosis. Two cases of macrodactylism2 and twenty-one cases of polydactylism3 were included, however. No functional or painful debility marked any of these congenital abnormalities.

In China, 3,906 persons were interrogated and examined, their ages ranging from four years to eighty-seven years as near as could be determined. 1,222 persons were similarly surveyed in India with almost the same range of ages. All feet were examined both at rest and when bearing weight. The results were very surprising when compared with foot conditions as we know it among those who wear shoes in our country.

4,017 persons or 78.46% were male and the rest female. Because of customs and social habits it was very difficult and often impossible to have women surveyed without arousing animosity. Even the native interpreters had a difficult task finding suitable female subjects for the survey. No appreciable difference was noted between the male and female survey results so both were combined. The age ranges were similar. In Western China a large number of women were seen with bound feet in the old Chinese tradition, but these were not included in the survey, of course. It may be of interest to note that this custom is now rare in Eastern China, which is more modern in every way. And the custom is dying out rapidly in Western China, too. Indian women do not have their feet bound. One old Chinese lady with bound feet was seen in Calcutta.

Table I

Number of Persons ExaminedChina 3906India 1222Total 5128 Condition China India Total % of Total Weakfoot 91 29 120 2.34% Pes Planus4 (Congenital) 44 12 56 1.09% Eczemas of All Types 41 11 52 1.01% Epidermophytosis5 30 9 39 .75% Arthritic Complaints 21 6 27 .53% Polydactylism3 16 5 21 .41% Tylomata6 and Depressed A.M.A. 13 5 18 .35% Sebaceous Cyst 14 4 18 .35% Tibiale Externum22 13 4 17 .33% Verruca7 (Plantar) 11 4 15 .29% Varicosities 11 3 14 .27% Pigmented Nevi8 10 3 13 .25% Flattened Foot 6 4 10 .19% Congenital Overlapping Toes 6 3 9 .18% Fibroma 5 2 7 .14% Lacerations and Abrasions 3 2 5 .10% Mycetoma9 0 4 4 .08% Onychauxis10 3 1 4 .08% Burns 2 0 2 .04% Onychogryphosis11 1 1 2 .04% Macrodactylism2 2 0 2 .04% Hallux12 Rigidus 1 1 2 .04% Os Vesalianum13 1 1 2 .04% Sprained Ankle 0 1 1 .02% Lipoma14 0 1 1 .02% Ulcer 1 0 1 .02% Total 346 116 462 9.01%

The measurements of the angles of voluntary motion were limited to inversion, eversion, flexion and extension of the feet with the knee held straight. Those with lacerations and abrasions, mycetoma, burns and sprained ankles were not included in this part of the survey, it being considered that their foot motions were limited by ailments not dependent upon their actual ability to move their feet as far as their musculature and joint structures were concerned. Some secondary motions at the mid-tarsal joint were noted, but none of these motions were excessive. No shortened calf muscles were found.

Table II

Number of Persons Measured5,116 From To Average Inversion 7' 24' 16' Eversion 2' 13' 8' Flexion 11' 27' 17' Extension 21' 55' 34'

The voluntary motions of toes were not measured, but it was noted that remarkable ranges of motion were performed in most cases, particularly abduction of the great toe. In a few cases some voluntary individual motions of lesser toes were noticed resembling to some extent the common motions of the hand.

The average height of the longitudinal arches was quite a bit lower than we usually consider average in the United States. But the height of the arch, per se, had no significance when compared with orthopedic malfunction. The lower the arch, the less distance it can fall, the less possible strain upon it and the less possible bony mal-alignment and pain it can cause.

Of special interest is the fact that not a single person with weakfoot, and there were ninety-one of them, complained of pain of any kind.

The one ulcer was found on the right great toe of a thirty-two years old Chinese farmer. It looked and felt like a typical primary leutic ulcer or chancre. It had been present approximately one week and was painless, the man said. There were, unfortunately, no laboratory facilities for a dark-field or Kahn test. No other part of his body revealed any leutic manifestations. The man had no idea why he had gotten the ulcer nor did he understand my questions and suggestions about it. He was unmarried.

The low incidence of dermatomycotic infection here noted might be attributed to the fact that most foot fungi require dark, warm and damp interdigital spaces for growth such as that provided by shoes and stockings on a foot that has no free outlet for its persperation. In addition, these bare feet get the beneficial fungicidal effects of the sun's ultra-violet rays. My experience leads me to believe, though statistics are not available, that the Chinese and Indians who wear shoes have a foot-fungi infection rate at least as high as is found in the United States.

Only eighteen pairs of feet had depressed anterior metatarsal arches when not bearing weight and those were the only ones with plantar tylomata. All the others, however, did have a marked thickening of the plantar epidermis as nature's aid against injury. The thickened skin around the heels often showed some shallow fissures that did not extend below the corium but these were painless and did not interfere with normal walking in any way.

None of those interviewed complained of symptoms that had no objective significance.

The fact that not a single heloma15 of any type was found shows rather conclusively that ill-fitting footgear is always responsible for causing that painful lesion to form.

Upon questioning, about one-seventh of the Chinese and one-third of the Indians gave past or present histories of Uncinariasis. The actual incidence of that hookworm disease was probably higher. Beyond questioning, no further inquiries or diagnostic attempts were made regarding Uncinariasis.

The four cases of mycetoma9 were not confirmed by laboratory tests. It is felt that the disease has far greater prevalence in India than the percentage noted because those suffering from mycetoma are not apt to walk around or be found where they could have been included in this survey.

No instances among the barefoot feet were found of: Onychocryptosis,16 Hyperidrosis,17 Bromidrosis,18 Hallux Valgus,19 Hallux Varus,20 Bursitis at the first or fifth metatarso phalangeal articulations.

Without footgear that interferes with nail growth, and because these people allowed their toenails to grow long and did not have the habit of digging into the corners of their nails when cutting them, onychocryptosis16 did not form even when nails were malformed. The resulting complete absence of onychocryptosis should serve to prove that proper nail care plus nonrestrictive footgear are all that is necessary to prevent the condition even in the presence of congenital nail malformations that are considered predisposing factors.

It has long been contended by many that there is a predisposition to hallux valgus19 among various families that show prevalent cases through a number of generations. Presence of a so-called "metatarso-cuneiform wedge" is also cited as a predisposing cause. Such may be the case. But this survey shows rather conclusively that hallux valgus will not develop if footgear are not worn and it is reasonable to expect that regardless of predisposing factors, hallux valgus will not develop when well-fitted footgear are worn.

Almost everyone surveyed showed a marked spacing between the first and second toes such as that found on young babies. The great toe was either pointing straight ahead or slightly abducted to provide a greater weight-bearing base or, possibly, to compensate for a shortened first metatarsal segment.

Seventeen persons had prominent scaphoids21 which were considered as supernumary secondary scaphoids. Six cases of flattened foot and nine of weakfoot were found among them, showing that the tibiale externum or enlarged scaphoid very often causes foot pathology even in the absence of shoe irritation against the bony prominences. Two cases of enlargement at the base of the fifth metatarsal were suspected of being the os vesalianum.13 No orthopedic pathology was associated. It was impossible without Roentgen-ray examination to further determine the incidence or extent of sumernumary and sasamoid bone23 occurrence.

One hundred and eighteen of those interviewed were rickshaw coolies. Because these men spend very long hours each day on cobblestone or other hard roads pulling their passengers at a run it was of particular interest to survey them. If anything, their feet were more perfect than the others. All of them, however, gave a history of much pain and swelling of the foot and ankle during the first few days of work as a rickshaw puller. But after a rest of two days or a week's more work on their feet, the pain and swelling passed away and never returned again. There is no occupation more strenuous for the feet than trotting a rickshaw on hard pavement for many hours each day yet these men do it without pain or pathology.

These figures prove that restrictive footgear, particularly ill-fitting footgear, cause most of the ailments of the human foot. We need only to compare these figures with those from people who wear restrictive footgear. It is not intended that this paper is advocating that everyone should go barefoot through all climates and over every sort of terrain. But it is strongly urged that all children go barefoot from birth until they walk outside of their own homes. Baby shoes cause great harm to growing, formative feet. The so-called "sentimental" value of baby's shoes might well be dispensed with. When necessary, large loose socks will provide all the warmth needed during winter months in the home, even on cold linoleum floors. Strong, sturdy feet need to be developed naturally through the uninhibited normal exercises of crawling, playing and the first months of walking. Neither should the child be encouraged or aided to begin walking by supporting him by his arms or by wheeled baby-walkers. The child will walk when it is physically able, there being no standard age at which it should begin. Overzealous parents should be cautioned in this respect. Remember, a kitten learning to walk is unaided and very clumsy but soon develops into a sure-footed, graceful animal. Remember, too, that a child who had developed a strong, well-formed pair of feet by going barefoot the first few years of its life will not thereafter tolerate shoes that fit badly. When shoes are finally necessary they should be pliable and have ample toe room. Only feet that are weak need supportive rigid shanks.

Conclusion

People who have never worn shoes acquire very few foot defects, most of which are painless and non-debilitating. The range of their foot motions are remarkably great, allowing for full foot activity. Shoes are not necessary for healthy feet and are the cause of most foot troubles. Children should not be encouraged to walk prematurely and should not wear any footgear until absolutely necessary. Footgear is the greatest enemy of the human foot.

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