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CLINICAL LECTURE 



ON 

CASES OF PAINFUL AFFECTION 
OF THE FOOT 




THOMAS G. MORTON, M.D., 

One of the Surgeons to the Pennsylvania Hospital ; also Surgeon to the Phila- 
delphia, Orthopsedic, and Jewish Hospitals ; Emeritus Surgeon to the 
Wills Ophthalmic Hospital ; Consulting Surgeon to the Woman's 
Hospital and to the Pennsylvania Institution for the Instruc- 
tion of the Blind, and to the Institution for the Deaf 
and Dumb ; one of the Commissioners of Public 
Charities of the State of Pennsylvania. 




[REPRINTED FROM THE PHILADELPHIA MEDICAL TIMES 
FOR OCTOBER 2, 1886.] 



CLINICAL LECTURE 



ON 



CASES OF PAINFUL AFFECTION OF 
THE FOOT. 




^ account of a "Peculiar and Painful 
Affection of the Fourth Metatarso-Phalan- 
geal Articulation," and reported a number 
of cases of an affection of the foot involv- 
ing the proximal joint of the fourth toe.* 
I then stated that I considered this malady 
of sufficient importance to be brought to 
the notice of the profession generally, es- 
pecially as it unquestionably had not been 
recognized before that time. 

My attention was first directed to this 
peculiar affection in 1870. After a care- 
ful study of a case which came under my 
observation at that time, I became con- 
vinced that I had an unusual condition to 
deal with. In this instance the symptoms 
were so clearly marked, and my patient, 



* American Journal of the Medical Sciences, January. 
1876. 





published an 



2 



who was an intelligent woman, gave such a 
positive account of her painful malady, that 
I was satisfied that I had to treat a condi- 
tion which had not previously been de- 
scribed by systematic writers or in the 
medical journals, at least as far as I was 
aware. Since that time I have had such a 
number of these cases coming under my 
observation, and have learned of so many 
others in the hands of medical friends, 
that I have no hesitation in saying that the 
disease is a very common one, and that 
even up to the present time it has not 
been recognized by the profession as it 
should be. 

This neglect or apparent indifference on 
the part of the profession may perhaps be 
due to the fact that the foot, to most per- 
sons, is not a very interesting portion of 
the human frame, so that, as a rule, a suf- 
ferer with any painful condition of the feet 
presenting no conspicuous abnormality is 
usually referred to the chiropodist, who is 
only able to cope with the simplest affec- 
tions of this important region. Too often 
it happens that the general practitioner 
dismisses the cases which I shall describe 
as beneath his consideration : the pain is 
looked upon as a form of gout or rheuma- 
tism, even where this is not sustained by 
the family or personal history of the pa- 
tient, and the case is sent away with direc- 
tions to get less fashionable shoes, or with 
some other trifling recommendation, no di- 
agnosis having been made. Consequently, 
the sufferer remains unrelieved, and in time 



3 



settles down to the conviction that he is 
the victim of some constitutional or in- 
curable malady; and so he goes on, suffer- 
ing periodical attacks of almost intolerable 
agony with a disease which, if properly 
understood, could be readily and perma- 
nently cured. 

This painful joint-disease, which is 
strictly local, may be of a mild or a 
severe type. Cases of the mild form of 
the affection, which are said to be bear- 
able, may develop into the severe form. 
In them occasional attacks of pain are 
followed by periods of complete immunity, 
the neuralgia coming back again from time 
to time. The cases of the severer form are 
usually so from the commencement : they 
frequently result from a sprain or twist of 
the anterior portion of the foot or from 
undue pressure of a shoe. Occasionally the 
neuralgia has appeared simultaneously in 
both feet ; in such cases it may be depend- 
ent in part upon ill-fitting shoes: indeed, 
in two cases I have seen the disease was 
undoubtedly induced by ill-fitting ready- 
made shoes, and in one case the pain came 
on at once in both feet from a similar 
cause. 

In my first account of this disease I only 
mentioned pain occurring in the metatarso- 
phalangeal joint of the fourth toe ; but I 
have since seen instances in which the cor- 
responding joint of the third toe was in- 
volved. Dr. Erskine Mason, of New York, 
has published the report of a case of meta- 
tarso-phalangeal neuralgia which he sue- 



4 



cessfully treated by excision of the joint of 
the second toe.* 

I have made some extended inquiries 
among the larger retail shoe-dealers, in 
order to find out if their attention had 
ever been called to this painful condition 
of the foot by their customers. I learned 
that this peculiar condition has not only 
been frequently recognized by them, but 
that it is also considered to be quite com- 
mon. Almost every intelligent shoe-retailer 
has seen a number of persons to whom this 
disease has been a source of frequent suffer- 
ing, and who believe their malady to be 
beyond relief by medical art. Indeed, it 
would seem that in some of the most severe 
of the cases it has been found impossible 
to obtain the serious consideration of their 
condition by their medical attendants. 

The history given by the patient will 
generally be like the following, which 
should be sufficient to lead to a correct 
idea of the trouble. One of my patients 
wrote as follows : 

" During the summer of 1868, while travel- 
ling in Switzerland, I made a pedestrian tour 
to the valley of the Faulhorn Mountain, and 
when descending a steep ravine I trod upon 
quite a large stone, which rolled from under 
my foot, causing me to slip, and throwing my 
entire weight upon the forward foot: though 
not falling, I found my right foot injured. 
The pain was intense and accompanied by 
fainting sensations. With considerable diffi- 



* American Journal of the Medical Sciences, Oct. 1877. 



5 



culty I reached the valley of the Grindelwald, 
where for hours I endured great suffering. 
After this I found it impossible to wear a shoe 
even for a few moments, the least pressure 
inducing an attack of severe pain. At no 
time did the foot or toe swell or present any 
evidence of having been injured. During 
the succeeding five years the foot was never 
entirely free from pain : often my suffering 
has been very severe, coming on in parox- 
ysms. I have been only able to wear a very 
large shoe, and only for a limited space of 
time, frequently being obliged to remove it to 
relieve the foot. Much of the time I have 
gone without any covering except a stock- 
ing, and even at night have suffered in- 
tensely : slight pressure of the finger on the 
tender spot causes the same sensation as 
wearing a shoe. During the past year or so 
I have walked but little, and consequently 
have suffered much less." 

In this case a twisting of the foot was 
followed by acute pain, which was suc- 
ceeded by permanent local sensitiveness or 
tenderness and neuralgia, brought on by 
pressure of the shoe or stocking, and some- 
times without any known cause. The pain 
was always referred to the metatarso-pha- 
langeal joint of the fourth toe, but during 
the severe paroxysms it extended up the 
limb as far as the knee and hip. On exami- 
nation there was found neither redness nor 
swelling of the foot. The head of the fourth 
metatarsal bone, with the adjoining pha- 
langeal base, was exceedingly sensitive, 
and pain was caused by the slightest press- 
ure. In this case, at my suggestion, a deep 
excavation was made in the sole of the 



6 



shoe which she wore, which was sufficiently 
broad to permit the affected joint to be as 
free as possible from pressure, and local an- 
odyne applications were made, but the pa- 
tient obtained no relief. I then considered 
the propriety of excision of the joint; but 
the patient was threatened with pulmonary 
disease and not in a condition to undergo 
any treatment that would confine her in- 
doors. In June, 1873, I a g a h"> saw this 
patient, on this occasion in consultation 
with Dr. Ellwood Wilson. There had been 
no improvement in the affected joint from 
treatment during this period. A short time 
before visiting this patient, however, in the 
same year, I had had under my care a simi- 
lar case which I had successfully treated by 
excision of the painful joint, but neither 
Dr. Wilson nor I deemed it advisable to 
perform this operation upon this patient, 
on account of her impaired physical con- 
dition. 

In the following case an operation was 
successfully performed. 

In March, 1873, I was asked to see Miss H. 
S., aged 26 years, who, while in Europe four 
years before, had injured her right foot by step- 
ping upon a small stone. She said that she had 
at once experienced intense pain, which was 
soon followed by slight swelling and redness. 
From the date of the injury localized pain in 
the foot continued, especially while wearing a 
shoe. The pain was referred to the head of 
the fourth metatarsal bone. There was con- 
stant distress in the part, often of a sicken- 
ing character. After wearing a shoe, pain 
came on with great intensity. At such times 



7 



the shoe had to be instantly removed, the 
least delay causing a paroxysm of great suf- 
fering. The boot or shoe had to be removed 
so often that a slipper was substituted. A 
marked lameness was induced by the patient's 
endeavor to spare the foot in walking. The 
pain was confined to the joint of the fourth 
metatarsal bone with the base of the associ- 
ated phalanx. Pressure in this region or roll- 
ing the fourth and fifth toes upon each other 
caused violent pain, which extended up the 
limb. It was severe when pressure was made 
upon the base of the first phalanx of the 
fourth toe, which could be prominently felt 
between the third and fifth toes. Rest, ano- 
dynes, and other applications failed to re- 
lieve this patient. Dr. William Hunt, who 
had frequently seen this case in consultation, 
agreed with me in advising excision of the 
joint. 

m On March 22, 1873, after etherization, an 
incision two inches in length was made on 
the outer edge of the extensor tendon of the 
fourth toe; the metatarso-phalangeal articu- 
lation was then opened, and a portion of the 
shaft of the metatarsal bone, with the head of 
the bone, was excised ; likewise a quarter of 
an inch of the shaft of the phalanx. The 
wound soon closed ; the toe was shortened 
half an inch by the operation. The patient 
has since visited Europe on two occasions, 
and has remained in perfect health, and has 
been able to wear any form of shoe. 

This, and the following cases, may be 
taken as types of the disease, of which I 
reported thirteen cases in my first paper, 
and have seen more than twice as many 
since, and several have been reported in the 
medical journals. 

The following cases are such typical 



s 



illustrations of the affection that I abstract 
them from a previous article upon this 
subject.* 

In April, 1872, Mr. W. K. M., of Rome, No- 
ble County, Indiana, wrote me as follows : " I 
am a carpenter, and have been a hard-labor- 
ing man all my life. In 1866 I was suddenly 
seized with pain in the joint of the fourth toe 
of my right foot ; at times was obliged to pull 
off my boot and sock, which gave me relief ; 
many times I would wear my boot without 
my sock ; at times the toe would puff up and 
become numb. In 1867 it was worse ; I wore a 
larger boot, but was often very lame. In 1870 
I had to use a cane, but kept at work until 
two years later, when I was unfit for busi- 
ness, for the pain was nearly constant. 

" The disease was called rheumatism and 
gout; rest and quiet proved the best remedy 
for the time ; the neuralgia then extended to 
the back of my heel, and was an aching, 
heavy, dead pain, so that I could not even 
bear the weight of the bedclothes." 

In December, 1876, this patient came to 
Philadelphia. An examination showed the 
usual pain on pressure ; the foot was normal 
in appearance. As there was some tender- 
ness also in the same joint of the third toe, I 
excised the joints of the third and fourth toes. 

Some months later Mr. M. wrote me, " My 
foot was tender for some time after I came 
home ; but at the present time it is well. I 
have no pain, and can safely say that it is a 
permanent cure, and feel satisfied that the 
operation has saved my life." Four years later 
this patient reported himself as perfectly well 
and no lameness, and that he had worked 
steadily since his return. 



* Surgery in the Pennsylvania Hospital, article entitled 
" Painful Affection of the Foot." Philadelphia, 1880. P. 109. 



9 



Dr. M. W. Alison, of Hagerstown, Mary- 
land, called on me in the spring of 1875, 
seeking relief from neuralgia in his right foot! 
which had existed for years and was gradu- 
ally getting worse, and stated that he was 
willing and ready to submit even to amputa- 
tion of the leg. He gave the following his- 
tory : 

"About six years ago I experienced an 
unpleasant painful sensation in my right foot, 
which possibly originated in a strain : the 
pain was first observed in the fourth meta- 
tarso-phalangeal region ; in the course of a 
fortnight it was followed by most violent pain, 
which was simply unbearable and so severe 
that it terminated in a convulsion. A painful 
condition of the parts followed, and with the 
least provocation (wearing a shoe or boot), 
sometimes without known cause, paroxysms 
of intense pain returned at various intervals, 
lasting from one to forty-eight hours. The 
pain, with one or two exceptions, has been 
confined entirely to the section of the foot in- 
dicated. My suffering has been beyond all 
comprehension : very often I have been com- 
pelled to jump from my buggy or stop while 
walking, remove my boot, which has always 
been of ample size, apply ligatures to the 
limb or foot, use hypodermic injections of 
morphia, frictions, or call upon some one to 
assist me by standing on the foot. This af- 
fliction has been the burden of my life, and 
this burden has been increased after consult- 
ing many eminent medical men, who gave 
me no satisfaction as to the nature of the dis- 
ease, nor even suggested a hope of relief. My 
health otherwise has been uniformly good. 
I am satisfied the cases you have had are 
similar to my own save in the intensity of my 
sufferings, and I shall gladly submit to the 
operation you have suggested." 



Operation. — June 15 I made an incision 
on the upper side of the fourth metatarsal, 
bone, the shaft of which was divided half an 
inch beyond the head of the bone ; the base 
of the first phalanx was also removed; the 
toe was then found to be so isolated that it 
was removed ; the adjacent soft parts were 
dissected away to insure the excision of the 
surrounding nerve. On the third day Dr. 
Alison left the city, and subsequently wrote, 
"Am happy to report all right; have not 
experienced any pain whatever, and am 
feeling better than I have for years, and feel 
assured that the operation will give me per- 
manent relief." 

Dr. Thomas, of Savannah, Georgia, wrote 
me in 1876, reporting a case which had 
come under his notice : " I think your article 
throws some light on a case which has been 
under my advice for several years, and I 
have looked in vain through some of the 
surgical authorities for guidance. The patient 
is a young lady, with every comfort around 
her. For the past three or four years she has 
suffered with a severe pain in the fourth 
metatarso-phalangeal articulation of the left 
foot, sometimes brought on by long walks, 
and at other times without any immediate 
provoking cause. She does not know that 
she has ever hurt the part, though possibly has 
sprained it, but not enough to have noticed 
it. There has never been any swelling or 
redness perceptible, but always more or less 
sensitiveness to pressure or the touch. The 
joint, when handled, appears to be too loose ; 
otherwise no abnormal indication save the 
pain. 

" I have tried many things in the way of 
treatment, but all without proper success. 
She has applied tincture of iodine, belladonna 
plaster, capsicum plaster, etc. There are 



1 1 

times when she thinks that a comfortable- 
fitting shoe feels better than a looser one. My 
impression is that this neuralgia, or whatever 
it may be called, is more common than we 
would at first think, and the profession may 
be grateful to you for the article mentioned." 

Mrs. C. H. K., of this city, a lady 50 years 
of age, gave me the following history : " ' The 
queer feeling,' I have been accustomed to 
call it, which has been in my left foot for 
thirty years, is a painful condition. The pain 
is in and about the joint of the fourth toe, 
with occasional attacks of intense suffering,' 
when the pain extends to the knee, and, if 
my shoe is not instantly removed when the 
attack comes, the pain reaches the hip. It 
does not matter whether I wear a large or a 
small shoe, as I have never worn a tight one, 
but it seems that the least pressure will pro- 
duce the same result. Often my sufferings 
have been exceedingly acute, and coming on 
without any warning. Once I was taken while 
walking in the street, and the agony was so 
great that I was compelled to rest on a stoop, 
remove my shoe, and walk some distance in 
my stocking alone, the pain running in a 
straight line to the hip-joint. I then con- 
sulted Dr. Joshua Wallace, and was asked 'if 
there was any gout in the family.' In Sep- 
tember, 1868, while at the Academy of Music, 
I had an unusually severe attack, and, not re- 
moving my shoe as quickly as I should have 
done, was obliged to walk to my carriage 
without the shoe, and suffered intensely for 
three hours. My eldest sister has been simi- 
larly affected still longer than myself, but in 
her right foot, same toe and joint. She has 
several times given up wearing shoes, but 
the attacks continued. She has not suffered 
so much during the past four years. Two of 
my friends suffer in like manner at the pres- 



12 



ent time. In one of the cases the pain is re- 
lieved by placing the foot on the ground with 
the shoe off, and thus spreading the toes. In 
neither of the cases I have known is there any 
deformity or lap of the toes." 

Mrs. R., aged 43, from New York, con- 
sulted me at the Orthopaedic Hospital, Octo- 
ber 14, 1876, and gave the following account: 
" Some ten or twelve years ago, while skating, 
I injured my left foot, was attended by Dr. 
James E. Rhoads, of Germantown, who sup- 
posed at first that a tendon had been rup- 
tured, but this opinion was not confirmed. 
My sufferings were very acute, and I was 
confined a long time to my room. After this, 
neuralgic attacks came on, sometimes at night 
without cause. I have always referred the 
pain to the joint of the fourth toe. For many 
years I have carried about me a vial of chlo- 
roform, the only application which has ever 
relieved the pain, and this is now losing its 
effect." 

Mrs. G. C., of Philadelphia, wrote me as 
follows : " When 14 years of age, while jump- 
ing on a hard floor I slipped and fell, and 
at the time felt something give way in my 
foot ; very severe pain followed, and for some 
five years afterwards I experienced in the 
foot a sensation of want of support ; pain was 
felt during all this period, and has since con- 
tinued. While walking, pain would come on 
so suddenly that I would seek the nearest store 
or step, remove my shoe, manipulate the foot, 
and gradually the pain would subside, leaving 
the foot, however, very sensitive. Pressure of 
a slipper, stocking, or even the bedclothes, at 
times has been sufficient to bring on an attack. 
There has never been any swelling or redness 
in the foot." 

The head of the fourth metatarsal bone and 
base of the associated phalanx were found to 



13 



be in a very painful condition. In all respects 
the case was similar to those already ob- 
served ; the patient otherwise enjoyed excel- 
lent health. 

The operation of excision, as previously de- 
scribed, was performed ; the wound quickly 
closed up, with the toe shortened half an 
inch. An ordinary shoe has since been worn 
with entire comfort, and there has been no 
recurrence of pain. 

Dr. T. M. Woodson, of Gallatin, Tennessee, 
wrote as follows : 

" I have read with much interest your ar- 
ticle describing a peculiar and painful affec- 
tion of the fourth metatarsal phalangeal 
articulation. Since then I have met with a 
case which in every particular coincides with 
your description. It certainly can be nothing 
else, for there is no local evidence of any 
disease. 

" The patient, a well-to-do and very intelli- 
gent farmer, aged 36, rather small in stature, 
weight one hundred and thirty pounds, has 
suffered from the pain in the locality de- 
scribed for eleven years. He does not recol- 
lect or know of any strain or injury. Suffers 
most on active exercise, so much so as to rob 
him of all rest night and day. There are oc- 
casionally times when the pain is slight, 
especially on rest and in wearing loose shoes, 
but the affection incapacitates him from at- 
tending to his farm-duties. I showed him 
your article and explained his trouble, and 
he now insists on my performing the opera- 
tion described by you. Have you any new 
suggestions to offer ? Do you still advise an 
operation in suitable cases ? Would it not be 
better to remove the toe of the fourth meta- 
tarsal ? Would this weaken the foot? 

" The gentleman mentioned is exceedingly 
anxious for relief by the operation, and, as 



14 



my information is solely obtained from your 
article, I take the liberty of addressing you 
on the subject." 

W. R., aged 46, from Ohio, consulted me 
September 29. On entering a meeting-room 
on a winter night, some twelve years since, 
he stamped violently to remove some snow 
which covered his boots ; the latter were new 
and fitted tightly. He experienced sudden 
intense pain in his left foot, and has not been 
free from it since. Even in bed, occasion- 
ally, the pressure of the clothes is sufficient 
to bring on an attack. 

Mrs. R. W., daughter of the above, aged 
22, has been suffering for six years. She at- 
tributes her malady to a pair of tight, narrow- 
toed shoes, with high heels. Always, in the 
house, wears slippers ; constantly is obliged 
to remove the shoe when walking, and gener- 
ally avoids buttoning the shoe. No redness 
or swelling has ever been noticed. 

Mrs. M. L. M., of Germantown, writes me 
that she has suffered paroxysms of intense 
suffering in the right foot. The pain, which 
has always been confined to the joint of the 
fourth toe, seems to be always brought on by 
the pressure of a new shoe, and relieved when 
this is removed. 

The following graphic description is from a 
medical friend who has himself suffered from 
the more severe form of this neuralgia : 

" Philadelphia, January i, 1877. 

" I have read with pleasure and profit your 
paper on a ' Peculiar and Painful Affection 
of the Foot.' Thinking it might be interest- 
ing to you, I send you an account of my own 
case. 

" I have suffered intensely at intervals from 
this affection for many years, and in all this 



15 



time have never found medical man or lay- 
man who understood what I meant when I 
complained of it or alluded to it. It has been- 
pronounced by surgeons who have examined 
my foot to be a subluxation or a malforma- 
tion of the articular surface of the first pha- 
lanx of the fourth toe, where it articulates 
with the fourth metatarsal bone, the con- 
cavity not being sufficiently concave. This I 
have long been convinced is an error. By 
other eminent authorities I have been conve- 
niently ' pooh-pooh-ed.' By persons out of 
the medical profession I have been in my 
agony comforted by an ' Oh, tight boots.' I 
had at last despaired of making anybody 
understand my ailment, summoned all my 
patience, and suffered in silence. 

" My own sensations have convinced me 
that the pain is caused by pressure upon a 
nerve, but what pressed upon the nerve I was 
unable to tell. The immediate necessity of 
removing the boot and the relief afforded by 
manipulating the foot in a manner learned by 
experience pointed to a dislocation ; but the 
reduction of the displacement was never suf- 
ficiently sudden and marked to confirm the 
belief that there had been a dislocation. 

" Now, after living for more than half a 
century, practised my profession for over 
thirty years, and suffered half my life with an 
affection not understood and ranked with a 
disease so trifling as a corn, I find myself en- 
lightened and the mystery cleared up by your 
valuable paper on the subject. 

"The first paroxysm occurred in my boy- 
hood, and was produced by tight lacing of 
skate-straps. On unbuckling the straps, the 
'cramp,' as I called it, was at first soon re- 
lieved and thought nothing of ; but a contin- 
uance of this system of squeezing by tight 
straps and tight boots, and riding for hours 



i6 

on horseback with the flexors of the leg and 
foot in violent action and the toes turned in, 
the attacks became more frequent, more 
painful, and the abnormal condition of the 
parts became chronic. These were in my 
case undoubtedly the causes predisposing. 
The causes determining the accession of a 
paroxysm are the wearing of a badly-fitting 
boot, especially if the sole be narrow ; a long 
and fatiguing walk, particularly on a hot 
day over a hot pavement ; a long ride on 
horseback ; a wet boot sticking to the sock ; 
a wet sock sticking to the toes ; long-contin- 
ued flexion of the knee-joint, as in a railroad- 
car, carriage, or lecture-room ; treading on 
an uneven surface, as a cobblestone pave- 
ment ; and, should the nervous system be 
depressed from any cause, these exciting 
causes will act more powerfully. 

" The symptoms of an attack in my case 
are most intense pain, ' cutting to the heart,' 
sickening, a feeling that it is unendurable, 
faintness, cold sweat, total incapacity for the 
time of directing the mind or will to any 
other subject, a horrible increase of torture 
on the use of the boot-jack ; and all this with 
no redness, no swelling, no abrasion of the 
skin, no callosity, no visible displacement of 
bones, at least after removal of the boot. 

" The suddenness of the attack is note- 
worthy. I have been obliged to drop every- 
thing and remove my boot, sometimes in 
company, sometimes in my carriage. I have 
even been obliged to sit down on the curb- 
stone and remove the boot. I have dis- 
mounted from my horse and sent home for 
slippers before I could proceed. I have tied 
my horse to a tree and lain on the ground, 
unable to ride farther. 

" I have spoken of a tight boot and of re- 
moving the boot, but I have had tight boots 



i7 



which were great favorites, because they would 
not ' let my toe out of joint.' 

" The remedies from which I have obtained 
relief are removal of the boot and then ma- 
nipulating the toes, straightening them out. 
When inconvenient to take off the boot, I 
have found that grasping the foot tightly 
round the metatarsal region will answer ; and 
I have sometimes worn a circlet of india- 
rubber band, binding the foot round the in- 
step. Putting on a dry boot and dry stocking 
is of great benefit, and the boot should be 
well sprinkled with powdered soapstone be- 
fore putting it on. Frequently an attack has 
been relieved completely without other means 
than rest and a cup of strong tea." 

My friend and colleague, Dr. John H. Pack- 
ard, sent me the following account of his own 
case : 

" For several years previous to 1864, I had 
been subject to occasional dislocations of a 
relaxed joint in the fourth toe of my right 
foot. They had always occurred in walking, 
and the symptoms were perfectly distinct ; the 
reduction, which was usually effected without 
difficulty, by simply ' working' the toe, was 
equally unmistakable. 

" In the summer of that year I was climb- 
ing a mountain, when the joint became dis- 
placed ; and, as it would speedily have slipped 
out again if reduced, I allowed it to remain 
luxated until I had finished the ascent and 
returned to the base ; when the pain was so 
great as to make it necessary for me to ride 
home. After several hours of suffering, the 
joint gradually resumed its normal state. 

" Since that time I do not remember that 
the luxation has ever taken place ; but I have 
had many attacks of neuralgic pain in the 
part, coming on generally after exercise, but 
sometimes after sitting in one position, as in 



i8 

my carriage. Often exercise does not induce 
it. Heat, as from the pavements or the sand 
in summer, is a much more frequent cause.. 
It begins gradually, and sometimes wears 
away in the same manner, but sometimes 
vanishes suddenly, as if by magic, without 
the use of any means of relief. The pressure 
of a boot always aggravates it, but it has at- 
tacked me while in bed at night. Diversion 
of the mind will often allay it, but it some- 
times comes on again afterwards with far 
greater severity. 

" In 1869, while spending most of the sum- 
mer at Atlantic City, I suffered more from this 
trouble than ever before or since. It would 
then often come on at night, after a day in 
town ; and once or twice the attacks lasted 
more than twenty-four hours. So great was 
the annoyance from it, that I proposed ampu- 
tation of the toe to a surgical friend, but he 
advised me against it. Since then it has been 
much less troublesome, though I have some- 
times had it more or less every day for a 
week. 

" Deep pressure over the metatarsophalan- 
geal joint is painful, but does not bring on an 
attack unless long continued. Cold has given 
me more effectual relief than any other rem- 
edy I have tried." 

The dislocation referred to is not a true dis- 
location, but is simply a twist of the toe, and 
a violent spasmodic condition of the muscles 
of the toe incident to the intense pain simu- 
lating a dislocation, which when the toe is 
compressed laterally and in its rolling be- 
tween the third and fifth suddenly presses 
upon and pinches the underlying plantar- 
nerve branch. 



These clinical notes of cases might be 
very greatly extended, but the above will 



*9 



suffice to show the disabling and painful 
character of this affection and the pro- 
priety of the means adopted for its relief.* 

Painful affections of the feet have long 
been known as a cause of disability among 
soldiers, but, so far as I can learn, the pecu- 
liar disorder under consideration has not 
been described as a cause of tender feet. 

In order to satisfy my mind, I addressed 
a query upon this point to Surgeon J. S. 
Billings, of the Surgeon-General's Office, 
U.S.A., Washington, who replied under 
date of September 4, 1886, as follows : "I 
do not think there are any records of the 
special conditions which you describe as 
occurring among soldiers. Cases of excuse 
from duty on account of painful feet are 
occasionally reported, but these seem to be 
mostly of a temporary character, and are 
not described with sufficient fulness to 
make it certain what part of the foot is 
affected." 

With regard to the etiology of this dis- 
ease, I think that the explanation I have 
already given in a former paper has been 
supported by subsequent observation. 

The occurrence of neuralgia may be un- 
derstood by a reference to the anatomy of 
the parts. The metatarso-phalangeal joints 
of the first, second, and third toes are 
found on almost a direct line with each 
other, while the head of the fourth meta- 



* Feeling convinced that this is a comparatively common 
affection, Dr. Morton would be obliged to his readers if they 
will send him brief clinical notes of cases coming under their 
observation. 



20 



tarsal is from one-eighth to one-fourth of 
an inch behind the head of the third, and 
the head of the fifth is from three-eighths 
to half an inch behind the head of the 
fourth: the joint of the third, therefore, 
is slightly in advance of the joint of the 
fourth, and the joint of the fifth is con- 
siderably behind the joint of the fourth. 

The fifth metatarsal joint is so much 
posterior to the fourth that the base of the 
first phalanx of the little toe is brought on 
a line with the head and neck of the fourth 
metatarsal, the head of the fifth metatarsal 
being opposed to the neck of the fourth 
(see illustration). 



21 



On account of the character of the 
peculiar tarsal articulation, there is very 
slight lateral motion in the first three meta- 
tarsal bones. The fourth has greater mo- 
bility, the fifth still more than the fourth, 
and in this respect it resembles the fifth 
metacarpal. Lateral pressure brings the 
head of the fifth metatarsal and the pha- 
lanx of the little toe into direct contact 
with the head and neck of the fourth 
metatarsal, and to some extent the ex- 
tremity of the fifth metatarsal rolls above 
and under the fourth metatarsal. 

The mechanism of the affection now 
becomes apparent when we consider the 
nerve-supply of the parts. The branches 
of the external plantar nerve are fully dis- 
tributed to the little toe and to the outer 
side of the fourth ; there are also numer- 
ous branches of this nerve deeply lodged 
in between these toes, and they are liable 
not only to be unduly compressed, but 
pinched by a sudden twist of the anterior 
part of the foot. Any foot-movement 
which suddenly may displace the toes, 
when confined in a shoe, may induce an 
attack of this neuralgia. In some cases no 
abnormality or other specific cause for the 
disease has been detected. 

Treatment. — The question of treatment 
may be dismissed in a few words. In acute 
cases of this disease, where it has evidently 
been induced by an injury, the treatment 
should be by local depletion, anodyne ap- 
plications, and rest, and, as in those less 
severe cases which do not seem to demand 



22 



operative treatment, a suitable, broad-soled 
shoe should be worn, which should lace up 
in front. 

The greatest comfort and often entire 
relief is afforded by the use of a narrow, 
fine flannel bandage, which should cover 
the anterior part of the foot moderately 
firmly, so as to give absolute steadiness to 
all the toes, and tight enough to prevent 
any rolling or movement of the joints or 
toes upon each other. In very many cases 
this simple treatment has, with a properly- 
constructed shoe, given entire relief. Even 
in the most severe cases this treatment 
should be fairly tried before an operation 
is decided upon. 

In some cases, however, no treatment 
except excision of the irritable part will 
be of any service, and the excision of the 
joint of the toe, which is readily performed 
and quickly recovered from, will insure a 
complete and permanently good result. 



1421 Chestnut Street, Philadelphia, 
Oct. 6, 18S6.