Cerebral congestion, in middle life, occasionally causes spastic contractions; it is then premonitory of further organic disease.

In parturition, pressure of the head of the foetus, or subsequent inflammatory action, may occasion retraction of the ham-string muscles, and ultimately distortion of the foot. This muscular retraction has been thought to be occasioned by the improper use of the forceps. I am inclined to believe that it might often be prevented by their timely application. I have lately seen two instances of this form of distortion.

The first case was a lady who had given birth to seven children in India, and who, on her husband's retirement from the military service, was confined of her eighth child in this country. In India, the forceps were used on each occasion; but on the birth of the eighth child they were thought to be unnecessary, and the period of labour was greatly prolonged. Whilst it was proceeding, very painful cramp was experienced in the affected limb. On the second day after parturition, pain had rather increased than diminished; but from this time it gradually abated, and ceased on the fifth or sixth day; the ham-string muscles remained contracted, and the toes only could be brought to rest on the ground.

The second instance occurred in a poor woman, who had previously given birth to two children. Inflammation of the iliac and crural veins commenced two days after parturition, and muscular retraction (of the ham-string muscles) succeeded about the tenth day, and increased until the foot was so much raised that the toes could not touch the ground.

It is scarcely necessary to state that, when the hands and feet are spasmodically affected, the acts of prehension and walking are rendered impossible.

In cases of severe spasmodic distortion, with cerebral disturbance, the prognosis must always be unfavorable, especially after puberty. Occasionally, severe cases, with

a tolerably clear intellect, defy the powers of medicine. Some of these have their origin in abuses contracted in youth and continued in manhood; and it may be impossible to eradicate long continued habits of vicious indulgence, and, consequently, to remove spinal irritation, which has been set up.

But by far the largest number of these spasmodic cases, whether in the child or in the adult, are amenable to treatment: distortion may be entirely removed and will probably not recur. On removal of the cause spastic contractions cease: distortions can then be overcome, and the limb be subsequently retained in a normal position until its free use is obtained.

The influence of sleep on these patients is worthy of close observation. They are usually restless in sleep and disturbed; but in some instances, the contracted limbs are loosed, and the hands which were clenched will move freely, as an infant's in sleep. The muscles only wait, however, for the moment of waking to resume their rigidity. And the same may be occasionally witnessed in congenital distortions. I have noticed it in affections both of the hand and foot. Also the exhibition of chloroform is, in these cases, occasionally attended with similar results.

INFLAMMATION.

Inflammation of muscle occasionally gives rise to the distortions in question. Adhesion of the muscle to its sheath takes place; the free motions of the muscle are in consequence prevented; atrophy succeeds, and structural shortening; and distortion is proportioned to the previous inflammation.

A more common form of inflammation, and which gives rise more frequently to distortion, is of the skin and sub

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cutaneous cellular tissue. A chilblain or an ulcer in healing may occasion adhesions to form between the muscle, or its sheath, and the superjacent skin and these subsequently restrict motion, and occasion distortion. Perhaps, the muscles of the calf of the leg are more frequently affected than others in this manner. Scrofulous abscesses in the course of the muscles are also an occasional cause of distortion. Also, strumous deposits within muscles give rise to muscular retraction. I have observed them in the deltoid, in the biceps cubiti, in the rectus femoris, and in the calf of the leg.

Burns, also, are occasionally productive of talipes. I have lately seen two very severe forms which were induced by burns one on the dorsum of the foot and anterior surface of the leg, occasioning calcaneus: the other, on the inner side of the foot and leg, had given rise to varus.

Traumatic inflammation may in like manner occasion distortions of a similar character. There is in the hospital at the present time, under the charge of Mr. Tamplin, a child with a very severe form of traumatic varus, which was Fig. 19.

occasioned by a lacerated wound, caused by the wheel of a heavy waggon. (See fig. 19.) Incised and punctured wounds, also, and gun-shot wounds, are occasionally productive of these forms of distortion.

Rheumatic inflammation, especially of the structures in the sole of the foot, is a much more common cause of distortion than those last mentioned. The plantar fascia and ligaments frequently are attacked, and occasion great suffering.

Inflammation of muscle may terminate in exudation; the muscular fibre becomes pale red, or fawn coloured; induration results, and the transverse striæ are lost. The muscle is rendered immovable, atrophy results, and distortion is adapted to the amount of structural shortening.

The ligamentous structures becoming inflamed are thickened and softened, and they lose their elasticity and peculiar lustre. Or, through repeated attacks of inflammation, they become indurated and thickened, and acquire a dense, firm, cartilaginous character; they become contracted, and impair the motions of the joint.

Inflammation of and about joints is a common cause of distortion. The knee-joint is perhaps more prone to be attacked than any other joint, if it be not the hip; but the ankle-joint is also frequently, similarly affected. The muscles contract to hold the joint at rest whilst it is in a painful condition; or they become contracted in consequence of a continued flexed, or extended position; and, subsequently, in consequence of structural change in the interior of the joint, the tension of tendons becomes permanent. Occasionally, both flexor and extensor tendons are found in this rigid, tense condition; more frequently, however, theextensors of the foot only. And, even when destruction of the joint

is complete, or apparently so, tension of the tendons around may still continue. When muscular tension is present, mobility of the joint, as a rule, still exists. Yet, it is occasionally a nice point for the surgeon to determine, whether anchylosis is complete or partial. Voluntary motion may be apparently lost; and even an appreciable amount of motion, on making forcible attempts to move the joint, may be wanting, and yet the tendons passing over the joint may perhaps be rendered tense by these attempts at motion. Under such circumstances, the diagnosis will be favorable to partial anchylosis. This is not, however, an infallible argument whereon to base a strictly accurate diagnosis; and it may be necessary to have recourse to anæsthetic agents to determine between synostosis and anchylosis. When tendons are rendered tense by attempted motion, anæsthesia should always be obtained, before the case is pronounced hopeless through anchylosis.

VOLUNTARY POSITION.

Distortion may be occasioned by an assumed position to avoid pain. I have known, especially, equinus and valgus to have been thus occasioned. A corn on the heel, or on the ball of the little toe, will occasion the heel to be raised, or the outer edge of the foot. (See fig. 20.) In time, shortening of the muscles of the calf results, so that either the heel cannot be placed on the ground, or the foot cannot be flexed beyond a right angle; or the superincumbent weight being thrown entirely on to the inner side of the foot, the plantar ligaments yield, and the arch of the foot sinks. Thus, voluntary position occasions talipes with healthy muscles; but it is a rare occasion of distortion.