This inability to retain the foot in a bent position by the action of the anterior muscles of the leg, was caused by their previous elongation during the many years the deformity had existed.

Nov. 5. Apparatus is laid aside, and the patient now walks with a common shoe; the gait resembles that of a person who has recently recovered from a sprained ankle or broken leg, the foot being cautiously placed on the ground, and the toes turned outwards, to avoid motion of the yet tender ligaments of the joint. She only complains of the sensation that her leg is much shorter than it was previously to the operation, or than the other leg is at present. It was stated at the commencement of this report, that the tibia and fibula were nearly an inch shorter than those of the opposite extremity; but her impression is, that when walking, the operated limb is at least three or four inches shorter than the other. This impression arises from a false sensation, depending upon its former greatly elongated state. The spinal column and pelvis, with the vertebral and pelvic muscles, had accommodated themselves to the unnatural length of the deformed limb; and the ankle-joint being now restored to its proper action, and the limb shortened to the extent of the former elevation of the heel (five inches), it is not surprising that the change should appear to the patient so remarkable. It may be observed, notwithstanding that the foot is restored, and that for three weeks she has been walking on the whole of the sole, the shoulder of the affected side continues higher than the other; so slowly is the proper relation of the pelvis and vertebral column restored, after having, during so many years, assumed an unnatural position. This defect will shortly cease, and the only remaining trace of lameness will depend upon the difference between the actual length of the tibiæ.

Nov. 19. The stiffness and awkwardness of the gait have much decreased. A perceptible difference exists in the length of the two extremities, although the exaggerated sensation of shortening has ceased. The shoulder which had previously been elevated has gradually descended, and is somewhat lower than the other. She is able to stand or walk within doors for a considerable part of the day, without experiencing uneasiness, with the exception of a slight pain over the front of the articulation when the whole weight of the body is thrown upon the toes in ascending the stairs. I have this day carefully examined the state of the muscles of the leg: the

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situation where the tendon was divided is not indicated by depression or enlargement; she can voluntarily contract the gastrocnemii, and, assisted by the other posterior muscles, elevate the heel; the action of the peronei in drawing the toes outwards is perfect; and she can also, by means of the tibialis anticus and other anterior muscles, bend the ankle-joint perfectly.

Jan. 1, 1838. At the present time she is able to walk or dance as if the limb had never been ankylosed.

May 1843. The cure is permanent; Mr. Herring has repeatedly informed me that the lady does not retain a trace of lameness even after considerable exertion.

Remarks.-The indications of cure in this case were, to divide the tendo achillis, and to obtain, by gradual stretching with the appropriate apparatus, the full natural extent of motion of the ankle-joint. A difficulty presented itself, arising from the lowest cicatrix-uniting the skin, bones, and tendo achillis-approaching closely to the insertion of the latter into the os calcis; and also from the distance between the anterior surface of the tendon and the back of the anklejoint (occupied in a healthy limb by yielding cellular tissue) appearing, from thickening and induration around the tendon, to be filled up by a dense mass of organised lymph, which denoted the former situation of an abscess. It was necessary to avoid injuring the bursa at the insertion of the tendo achillis, and appeared objectionable to traverse the old cicatrices in the course of the operation. But being convinced that the greater portion of the obstacles to bending the joint would be overcome by division of the large and inelastic tendo achillis, with as much of the subjacent indurated cellular tissue as might be reached with safety to the tibial nerve and vessels (unless that left undivided were completely fibro-cartilaginous), I did not hesitate to undertake the treatment of this case on the same principles I have recommended in the treatment of club-foot.

The prompt recovery in this case of the power of volition

in the tibialis anticus is highly instructive in the study of the ætiology of congenital and acquired deformities in general.

In the commencement of my investigations into the causes of these diseases, I supposed that the debility of the anterior muscles of the leg invariably resulted solely from the longcontinued over-action of the powerful antagonist muscles, producing mechanical extension, and physically altering the muscular fibres. That the latter takes place to a certain extent is proved by this case, as the patient was for more than a month after the removal of the deformity unable to bend the ankle; but although the anterior tibial muscle had been held mechanically elongated to the utmost extent for nearly twenty years, a few weeks sufficed for the complete recovery of its power, on the restoration of the ankle-joint to its proper motion; whereas, in some distortions of paralytic origin, where the same muscle was primarily involved, and which I have watched for seven years after cure by division of the tendo achillis, I have not perceived that the paralysed muscle recovered its natural power, although this defect may have only caused a trifling impediment in walking.

CASE XXIV.

FALSE ANKYLOSIS OF ANKLE IN EXTENDED POSITION.

I was consulted by Mr. Wood, of Rochdale, in the case of a gentleman very similar to the above, in which, after section of the tendo achillis, the heel could not be depressed. I recommended division of the peroneus longus and brevis, and redivision of T. achillis. But even these means were not successful. On subsequent examination a band similar to that described Case XXIII. was discovered, connecting the extremity of the fibula to the posterior and external surface of the os calcis, which was divided. With the additional relaxation of the ankle thus effected, we succeeded, though slowly, in depressing

the heel so that the entire sole was applied to the ground; but flexion of ankle beyond 90° could not be obtained. It then became obvious that the remaining resistance depended on the changes in form of the articular surfaces. I was strengthened in this opinion by the history of the case furnished me by Mr. Wood, and by the evidence of previous disease of the tibia and fibula, the former of these bones being, in its whole length, in a sequestered condition. The patient's state being so greatly ameliorated that he could walk with comfort and almost entirely free from lameness, it was undesirable to risk disturbance of the reparatory processes going on in the limb by longer continuance of mechanical extension. I was, notwithstanding, disappointed in having been unable to restore complete flexion.

CASE XXV.

FALSE ANKYLOSIS OF THE ANKLE IN THE EXTENDED POSITION.

JULY 27, 1837. Miss ***, ætat. 24, the daughter of a medical friend, informs me that a disease attacked her right leg nearly nine years since, which at first was supposed to arise from rheumatic inflammation. It continued for four years, during which period numerous abscesses were formed in different parts of the back and outer side of the leg, from several of which large pieces of bone were 'emoved. When the wounds had entirely healed, and she had regained strength, she found herself unable to touch the ground with more than the front part of the foot (see fig. 32), the heel having been drawn up to the extent of two inches and a half. The action of walking was consequently very difficult. This has throughout continued, great fatigue and profuse perspiration resulting from trifling exercise. Her medical attendant had placed her under the care of a mechanist of repute, who undertook, by means of appropriate apparatus, to overcome the contraction of the calf, and gradually to force the toes upwards and the heel downwards. This plan had been perseveringly continued to the present time by the almost daily attendance of the mechanist, without the production of further benefit than the prevention of any aggravation of the contraction.

The patient does not touch the ground equally with the ball of the great and little toes, but chiefly treads on the latter, from the

toes having been thrust inwards. The drawing exhibits a degree of external convexity and internal concavity of the tarsus, shortening of the distance from the posterior extremity of the heel to the metatarsal articulation of the great toe, and a projection (see a, fig. 32)

False ankylosis of ankle (spurious Talipes equino-varus), Case XXIV.-The perpendicular line d b, passing through the axis of the leg, shews the inward inclination of the anterior part of the foot, the little toe being alone situated on the outside of that line. The patient, therefore, chiefly walked on the ball of the little toe.

occasioned by the outline of the abductor pollicis muscle, all characteristic of the similar grade of club-foot.

Aug. 1. Divided the tendo achillis, assisted by my friend Mr. Kingdon.