The following is a curious example of this rare condition, in association with macrodactyly. The patient, a boy aged eleven, was admitted into St. Thomas’s Hospital in March 1887, with a deformity of the right great toe, dating from infancy. The member was somewhat imperfectly developed, and projected inwards almost at right angles with the metatarsal bone. (See Fig. 15, A.) A slightly prominent integumental fold was present on the inner side of the metatarso-phalangeal joint, and the ligamentous and other fibrous tissues beneath this resisted the replacement of the digit in its normal line. The toe could be moved feebly by an effort of the will, but the abnormal direction of the member prevented the muscles from exercising any useful function. The smaller toes were distinctly hypertrophied, but were otherwise well formed. The boy was unable to wear a boot, and was completely crippled. The toe was apparently useless, but it was judged advisable to restore it to its natural position rather than to amputate. This was effected by subcutaneous division of the internal lateral ligament and the application of a small plaster apparatus. Fifteen days later the child left the hospital with a light metal splint fixed to the inner side of the foot and toe. Three years afterwards he presented himself for examination, and it was found that the good result was more than maintained, as the toe was not only straight, but had acquired its normal size and considerable power of movement. The boy said he was able to walk seven or eight miles without fatigue. The relative hypertrophy of the lesser toes was still obvious.

LATERAL DEVIATION OF THE LESSER TOES.

This is frequent in childhood. It was found in twenty-five children, twelve males and thirteen females, out of 800, the ages of the subjects ranging between five and fourteen. The version is usually at the first inter-phalangeal joint, but may also be present in the distal joint, and the toe much more frequently diverges towards the tibial than towards the fibular side (six to one). It may lie over or under its neighbour. The fourth toe is affected in about two-thirds of the cases, while the second, third, and fifth toes take an almost equal share in making up the remaining third. It is symmetrical in nearly two-thirds of the examples (sixteen out of twenty-five). In the early stage the joint may be straightened by passive force; but in the later, reposition is opposed by ligamentous tension, and perhaps by some alteration in the form of the bone. Like hammer toe, it occurs only during the developmental period, and there is no reason to connect it with any special defect in the shape of the shoe. In none of the examples under my own observation was it associated with hallux valgus; but a double hammer toe (third) was present in one case, and version of the fingers in three others. The children appeared to be in good health. The deformity may usually be relieved by the use of a splint, like that recommended for hammer toe; but in some cases a partial resection might be advisable.

Inversion of the little toe at the metatarso-phalangeal joint is occasionally met with. It appears always to arise during the period of active growth and is associated with shortening of the extensor tendon. Subcutaneous section of the tendon allows complete reposition, and the cure may be made permanent by temporary fixation in plaster, and subsequent attention to the feet. The origin of the condition is obscure.

ARTHRITIC DEFORMITIES OF THE TOES.

Arthritic hammer toe may be due to rheumatoid arthritis, gout, rheumatism, or traumatic inflammation. The variety dependent upon rheumatoid arthritis is the most common of these, and the most likely to be brought under the eye of the surgeon. Its characteristics are as follows: 1. It is not limited to the developmental period, and may occur at any age in association with the causative disease, but it is most frequently met with after middle life. 2. The deformity is usually present in many or all of the toes and in both feet, and may be associated with lateral (fibular) displacement of the digits, and with bony outgrowths at the margin of the affected articulations. The movements of the joints are much more impaired than in true hammer toe, owing to changes in the cartilage; and fibrous ankylosis is often present. 3. Manifestations of the causative disease may be found in other parts of the body.

In the great toe the direction of the distortion appears to depend upon the size and position of the osteophytic developments at the margin of the affected articulation. Most commonly the position simulated is that of hallux valgus, more rarely that of hallux flexus, and we may also find a condition in which the distal phalanx is bent upwards, so that the nail approaches or even touches the dorsal surface of the first phalanx. (See Fig. 16, A.) This is a painful deformity and calls for treatment. I have not yet seen an arthritic hallux varus. It is probably rare, because the form of the boot opposes the divergence of the toe in the inward direction.

It is unnecessary here to say anything as to the nature and course of the general disease. As a rule the case falls into the hands of the physician, and the surgeon is rarely asked to intervene. It must be pointed out, however, that the contractions may cause severe inconvenience, and that despite the intractable nature of the complaint the reaction of the patient to surgical operation is favourable, recovery being nearly as speedy as in true hammer toe. I have on two occasions operated with the result of considerable relief to suffering, and without any surgical casualty. In one instance eight toes underwent operation at a single sitting, and the wounds all healed by immediate union.

In gouty contractions of the toes the history of the sudden and painful inflammatory attacks preceding the deformity, the almost constant implication of the first metatarso-phalangeal joint, and the presence of other indications of gout leave no question as to the nature of the disease. In this affection the surgeon can rarely be called upon to interfere. The distortions of the great toe are generally associated with eversion—a valgus—and complete ankylosis may supervene. Contractions in association with acute rheumatism or acute rheumatoid arthritis are comparatively rare. Lastly, certain arthritic affections of neuropathic origin may produce ankylosis of the joints, sometimes in association with rapid atrophy of the muscular and integumentary structures, as in a case shown by the author at the Medical Society in 1893 (Trans., vol. xvii. p. 104).

PARALYTIC CONTRACTIONS OF THE TOES.

Deformities of this kind may be met with in association with various diseases of the nervous system. The most common condition is a hammer deformity of the lesser toes, with retraction at the metatarso-phalangeal joint, and an exaggeration of the plantar arch (paralytic cavus). This is probably due to paralysis of the interossei in nearly all cases. Occasionally a single toe is affected. In the great toe it may arise from paralysis either of the short flexors or of the tibialis anticus (as pointed out by Mr. Davies-Colley), and is associated with retraction of the first phalanx and flexion of the second. In the smaller toes the digits assume a position like that of the clawed finger in ulnar paralysis, with extension of the proximal and flexion of the middle and distal phalanges, but, unlike in true hammer toe, there is distinct evidence of paralysis, and the capacity of the flexed joints for passive extension is usually retained for long periods. In these cases where the unopposed extensor leads to very inconvenient retraction of the first phalanx the tendon may be divided, and Mr. Davies-Colley suggests that the proximal cut end should be fixed to the metatarsal bone in order to preserve its utility as a dorsal flexor of the ankle. The return of the deformity must be prevented by the subsequent use of splints and manipulation.