Wednesday, December 26, 2007
The most curious history of orthopaedic shoes
Footwear throughout history has supplied a social ritual, the knowledge of which indicated, breeding and status. The wealthy classes of the Middle Ages indulged their superiority by wearing sumptuous clothing and shoes. These became symbols, serving to indicate standards of conduct as well as emotional states. The author explores the sumptuary social convention of mens’ footwear of the medieval period and draws interesting conclusions on contemporary safe sex practice of our ancestors as well as the design of orthopaedic shoes. From antiquity to the present day foot ulcers and their treatments have always presented problems to healers. The question I pose in this presentation is, over the last millennium how far have we come in shoe design for the compromised limb. Zeitgeist means a sign of the times and shoe fashions are not determined by chance but the times and technology we live in. Disease and how we cope, is arguably the most fundamental human characteristic of all our traits and I propose to demonstrate this by comparing today’s “orthopaedic footwear” with that of the Middle Ages, and by doing so make reference to that other human frailty, sex. For the purpose of comparison I have taken Charcot neuropathy to represent a common denominator between the 15th century and the 21st century.
Charcot foot was first described in people with tertiary syphilis but now is seen more usually in severe diabetes mellitus (Caputo et al 1998). The condition describes a progressive deterioration of weight-bearing joints which are usually in the foot or ankle. Charcot foot is also found in people suffering from alcoholic neuropathy, sensory loss caused by cerebral palsy or leprosy, and congenital insensitivity to pain. First described in 1868, the condition is recognised by an unusual pattern of bone destruction found in patients with tabes dorsalis. Much later in 1936, the same neuro-arthropathy was described in diabetics. The discovery of antibiotics markedly reduced the incidence of syphilis in the general population in the 20th century whilst almost at the same time as diabetes mellitus became more prevalent. In the Middle Ages the life expectancy of an insulin dependant diabetic was short however people living with tertiary syphilis were far more likely to survive to the later stages of neurosyphilis with attended destructive infection of the brain and or spinal cord giving rise to severe symptoms fifteen or twenty years after the initial syphilis infection. Today, it is estimated almost 50% of people with severe neuropathy have associated plantar ulcerations and the author can only postulate the same incidence was found in the Middle Ages, and probably higher.
Syphilis was long been thought to be a disease introduced to Europe in the 15th century (carried by Christopher Columbus’s crew). Syphilis is caused by the bacterium Treponema palladium and most medical authorities now accept treponmeal disease existed in Europe prior to this time but the new strain was more virulent and was spread by sexual contact. In the century that followed, Europe was devastated as syphilis spread to Russia, China, India and Africa causing possibly the world‘s first STD epidemic. Initially physicians were left helpless and refused to treat the suffering leaving them to barbers, bath attendants and quacks (many of which were corn cutters). The presence of the pox and the knowledge of its transmission gave reason to influence sexual practises. Two types of neurosyphilis were common tabes dorsalis was characterised by a progressive locomotor ataxia (due loss of proprioception), lightning pains and urinary incontinence. Sensory ataxia caused people to stoop forward and walk with a wide based, "high-stepping" gait. General paresis the other complication of neurosyphilis caused brain damage which presented as impaired mental function with personality disorders including grandiose delusions.
After the Crusades promiscuous sex among the privileged classes in Europe was prevalent but modern scholars acknowledge the Influence of Islam formed the basis for European Chivalry and Courtly Love. The conventions of courtly love taught young men to sublimate their desires and channel their energies into socially useful behaviour. To do otherwise might have threatened social stability especially at a time when feudal lords and knights were engaged in the Crusades. For people to break these taboos only reinforced the strength and drive for sexual pleasure which transcended any moral precept. European courtly love flourished in the early 12th century and the high minded ideals of true romance spread when troubadours sang openly of love’s joys and heartbreaks in daringly personalised terms, extolling the ennobling effects of the lover’s’ selfless devotion. The relationship was always illicit i.e. the woman was the wife of another, often a lord or patron and its consummation was virtually impossible.
Troubadour’s songs promoted a love yearned for, and at times rewarded by, the solace of every delight of the beloved except physical possession by sexual intercourse. However two "intimate ceremonies" of courtship were common. Domnei or woman worship was where the would-be suitor gazed on the partly or fully undressed lady; and Donnoi when a couple lay naked together sometimes separated only by a pillow. Kissing and embrace were encouraged but the lovers proved their depth of love by avoiding sexual intercourse. These behaviours were highly sensual and carnal and under the circumstances and with no stretch of the imagination a 24" long extension on the end of the foot, (the long toed shoe) could be put to very practical use. At a time in history when married couples were parted or marriage was delayed, masturbation provided the perfect solution. By the same token heavy petting would provide a practical form of birth control especially at a time when religious or civil authorities rarely interfered with women’s business. In Occidental Society mens’ long toed shoes may have provided the ideal means of birth control and later provide protection from sexually transmitted disease.
From the 11th century the length of men’s shoes in Europe got longer and longer until they were 24 inches longer than the foot. Despite papal laws to prevent the lower classes from wearing long poulaines, the fashion continued unabated for four hundred years. Men’s shoes were stuffed with moss and grass and small hawk bells were sewn on the end of the shoe to indicate the wearer was interested in sexual frolics. Poulaines caused men to adopt a wide based, high stepping gait and this became the norm for fashionable courtiers. The same clinical pattern is seen in people with advanced tabes dorsalis.
About the same time European courts were introduced to the Court Jester or professional fool. As Willeford wrote:
"When the king was a syphilitic semi-imbecile, a jester even more grotesque may have served as a useful stage prop, disarming criticism by making the king look more nearly normal by comparison and thus making the make-believe of kingship possible."
Medievil fashions took many years to change in part due to the absence of a mass media, unlike today. However something happened at the end of the 15th century and the fashion for long toed shoes became passé, very quickly. Absence of written documentation means the reasons for this are unclear. From contemporary paintings, the only evidence available, the style was quickly replaced by shoes which were so broad across the ball if the foot as to boast of individual compartments for each toe. The podiatrist’s delight was called Bears Paws. The same principle is caught in the design of today’s post-surgical moon boots used to support and protect injured tissue. One other clinical outcome of neurosyphilis is Charcot foot where trophic ulceration decimates the sole of the foot. Decreased sensation and the ability to feel temperature, pain or trauma, which follows mean feet with a total lack of feeling, need complete protection. In days of old those who could afford it would heavily bandage the foot and encase the Bears Paw shoes. Today the availability of new polymer chemistry allows compromised feet to be protected by total contact casts and orthotic walking braces.
What I have just recounted is conjecture, and in the absence of written evidence, must remain so. Whether shoes became sex toys by necessity and sexualisation of the foot, a focus for safe sex, will never be clear. However something strange did happened in the 11th century and the presence of a global epidemic of sexually transmitted disease did correspond to a curious preoccupation with feet (Oriental Society) and footwear (Occidental Society). Although these phenomenons are well documented, the socio-anthropological reasoning for their existence remains unexplained.
This was presented as a lecture at the FIP Conference in Copenhagen, May 2007.
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