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. [Illustration: FIG. 16. Rheumatoid arthritis. Retracted hallux with arthritic hammer toes. A. Before operation; B. After operation. The dotted outline in A indicates the position of the flap made to expose the diseased joint. From casts at St. Thomas’s Hospital.] 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.