METATARSALGIA (MORTON’S PAINFUL AFFECTION OF 
THE FOOT), WITH AN ACCOUNT OF SIX CASES 
CURED BY OPERATION. 
BY 
THOMAS S. K. MORTON, M.D., 
PROFESSOR OF SURGERY IN THE PHIL'JttJtffiWffr POLYCLINIC, ETC. 
Reprinted, from the Transactions of the Philadelphia Academy of Surgery. 
Meeting of March 6th, iSgj. 
PHILADELPHIA: 
1893. \_Read before the Philadelphia Academy of Surgery, March 6, 
METATARSALGIA (MORTON’S PAINFUL AFFEC- 
TION OF THE FOOT), WITH AN ACCOUNT 
OF SIX CASES CURED BY OPERATION. 
By THOMAS S. K. MORTON, M.D., 
Professor of Surgery in the Philadetfkia Polyclinic, etc. 
The affection that has come to be best known as “ Morton’s 
Painful Affection of the Foot,” or “ Morton’s Toe,” was first 
described and a method of certain cure presented by Dr. 
Thomas G. Morton, of Philadelphia, in 1876, under title of “ A 
Peculiar Painful Affection of the Fourth Metatarso-phalangeal 
Articulation.”1 In subsequent publications2 he has confirmed 
his views relative to cause and treatment, and reported large 
numbers of cases. 
The disease under consideration may be described as a pain- 
ful affection of the plantar digital nerves, directly caused by 
pressure upon or pinching of them by certain portions of the 
metatarso-phalangeal articulations—especially the fourth. 
The reason for the fourth toe being the almost invariable 
seat of origin of the train of painful and neurotic symptoms to 
be described is ascribed to anatomical causes by Morton in the 
following language: 
“ The occurrence of neuralgia may be understood by a refer- 
ence 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- 
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 considerably behind the joint of the 
fourth. 
“ The fifth metatarsal joint is so much posterior to the fourth 
that the base of first phalanx of the little toe is brought on a 
1 American Journal Medical Sciences, January, 182&*.. . 
2 Surgery in the Pennsylvania Hospital, i88o<lKrtiifrj£? Philadelphia Medical Times, 
October 2, 1886. *• OKS, 2 
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.) 
“ On account of the character of the peculiar tarsal articulation, 
there is very slight lateral motion in the first three metatarsal 
bones. The fourth has greater mobility, the fifth still more 
than the fourth, and in this respect it resembles the fifth meta- 
carpal. Lateral pressure brings the head of the fifth metatarsal 
and the phalanx of the little toe into direct contact with the 
head and neck of the fourth metatarsal, and to some extent the 
extremity 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 distributed to the little toe 
and to the outer side 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 may suddenly 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 dis- 
ease has been detected.” 
This explanation undoubtedly will account for the great ma- 
jority of cases, and perhaps all could be ascribed to pinching of 
the nerves between the metacarpo-phalangeal articulation. Yet 
there have been reported a few cases where the transverse meta- 
tarsal ligament has appeared to be lax or ruptured, thus permit- 
ting the metatarsal heads to descend upon the nerves. Auguste 
Poullosson, of Lyons, in 1889,1 after reporting a typical case, 
says that “ the cause of the affection is evidently a certain laxity 
of the transverse metatarsal ligament, which permits partial 
infraction of the arch formed by the heads of the five metatarsal 
1 Lancet, March 2, 1889, p. 346. 3 
bones, one of the middle ones, probably the third, becoming 
dislocated downward and compressing the nerves running along 
each side of it against the heads of the neighboring bones.” 
L. G. Guthrie,1 in writing of metatarsal neuralgia, states his 
belief that “ under the influence of prolonged standing or walk- 
ing in tight boots, the ligaments of one or more joints, meta- 
tarso-phalangeal or phalangeal only, become strained, slight 
sublaxation takes place, the nerves are stretched and pressed 
upon by the partially dislocated bones, and the characteristic 
pain is produced.” 
In reference to the supposed dislocations above mentioned, 
Morton says : 
“ The dislocation referred to is not a true dislocation, but is 
simply a twist of the toe, and a violent spasmodic condition of 
the muscles of the toe incident to the intense pain, simulating a 
dislocation, which, when the toe is compressed laterally and in 
its rolling between the third and fifth suddenly, presses upon and 
pinches the underlying plantar-nerve branch.” 
Edward F. Grim,2 himself a sufferer from the affection, be- 
lieves that the pain results from descent of the tarsal arch, 
which is accompanied by lengthening of the foot and spreading 
to the outer side, so that “ where the weight comes on the 
member the foot spreads inordinately; the boot is not con- 
structed to allow for so much spreading, and a frightful cramp- 
ing pain is the result, causing the patient to remove the boot 
without regard to place or circumstances—often the most 
inconvenient.” 
E. H. Bradford 3 states that the results of treatment in these 
cases, as well as the symptoms and localization of the point of 
severest pain, make him agree with Morton, in believing the 
affection to be originated by pinching of the metatarsal nerve, 
rather than to flattening of the tarsal arch, as suggested by 
Poullosson. In none of his thirteen cases was any degree of 
flat-foot present. 
In a large number of cases seen by me, in addition to those 
herein reported, it has not been possible to demonstrate any 
laxity of the metatarsal ligaments, and, while in a few the pain 
was referred to other of the metatarso-phalangeal joints than 
the fourth, yet upon careful manipulation it was always found 
that the pain was reflected from the fourth to the other joints. 
It must be conceded, of course, that laxity or rupture of the 
transverse ligament would predispose to injury of the nerves at 
1 “ On a Form of Painful Toe,” Lancet, 1892, vol. i. p. 628. 
2 Lancet, April 6, 1889, p. 707. 
3 “Metatarsal Neuralgia, or Morton’s Affection of the Foot.” Boston Med. and 
Surg. Journal, 1891, vol. ii. p. 52. 4 
the fourth joint by permitting greater motion of the overlap- 
ping bony points in that situation. However, while the exact 
etiology of the affection is of great scientific interest, clinically 
it is of small account, as excision of the fourth metatarso- 
phalangeal articulation, as originally proposed by Morton, or 
amputation of the fourth toe, including the corresponding meta- 
tarsal head, invariably has secured an absolute and permanent 
cure. No dissections of the diseased regions have yet been 
possible, nor have the nerves been in any case excised so that 
microscopical examination could be made. I have carefully 
examined a number of the joints that have been removed for the 
cure of the affection, and have in no instance been able to prove 
any anomaly or disease. 
Metatarsalgia is, in its lesser degrees, a very common disease. 
Almost every one has suffered more or less, at times, from neu- 
ralgic twinges radiating from the joint in question. These mild 
cases occasionally develop into the more severe forms. In them 
occasional attacks of pain are often followed by periods of com- 
plete immunity. 
Morton made extended inquiries among retail shoe dealers 
and found “that this peculiar condition had not only been fre- 
quently recognized by them, but that it is also considered to be 
quite common. Almost every intelligent shoe retailer has seen a 
number of persons to whom this disease has been a source of 
frequent suffering, 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.” 
So recently as 1891 Bradford1 has written : 
“ It is somewhat singular that an affection that is not infre- 
quent in these days of thorough investigation of all ailments, 
should have attracted but little attention, either in the researches 
of surgeons or of neurologists. The cases are so usually classed 
among the ill-defined hysterical or nervous affections, and not 
thoroughly investigated; or they are deemed to be gouty, as, in 
the minds of many practitioners, are frequently all affections of 
the toes.” 
The disease has not been observed before adolescence. 
Women are certainly more predisposed than are men, and its 
occurrence in the former sex I should judge to be almost twice 
as frequent as in the latter. One foot is most usually involved, 
especially in those cases apparently taking origin from an injury. 
But very frequently one foot is affected to an almost unbearable 
1 Loc. cit. 5 
degree, while its fellow is but slightly involved. Neither right 
nor left foot appears to be most liable to involvement unless one 
or the other is constantly subjected to a motion, as in running 
certain sewing machines, looms, lathes, etc., while the other is 
not employed. In this case, as in one of my own, the pain 
developed in the foot so employed. When both feet become 
simultaneously affected the cause will often be found in ill- 
fitting or tight shoes. Middle life is the period at which the 
disease is most apt to develop or to become severe. The aged 
are by no means exempt, although in them more purely gouty 
or neuralgic forms are prone to occur, and persons at any age, so 
predisposed, appear to be much more liable to the affection— 
idiopathic or traumatic—than are others. 
The influence of heredity is very marked. I know of several 
families in which a number of persons, mainly confined to the 
female sex, are similarly affected. It is interesting to note that 
in these instances some cases have arisen from twists or sprains 
of the foot, and others apparently idiopathically. 
The exciting or immediate cause of metatarsalgia is usually 
excessive or unusual exercise of the feet while confined in new, 
tight, or ill-fitting shoes, as in walking over rough surfaces 
(mountain-climbing), dancing, playing lawn tennis, etc , or in 
changing from a firm-soled shoe to one that permits great motion 
of the metatarsal arch. When the heads of the metatarsal bones 
are rigidly held in contact by a tight shoe it is reasonable to 
believe that a very slight twist or wrench of the foot would bring 
great pressure to bear upon the sensitive branches of the digital 
nerves distributed upon and about them, and, particularly in 
those predisposed thereto, bring about a neuralgic and even 
neuritic condition. This once set up, and the nerves having 
become sensitive, swollen, or inflamed, ever so slight repetitions 
of the pressure or bruising are capable of originating the most 
agonizing suffering. Later, continuous or frequently recurring 
attacks of this pain, or actual ascent of neuritis, commence 
reflex contractions and other neurotic complications, perhaps 
of the gravest type, as witness in Case I. of my series, where 
the patient had become bed-ridden and severely neurasthenic. 
So far as relates to symptomatology, I shall depend upon 
quoting a few more or less typical cases from the literature of 
the subject and upon the histories of my own operative cases, 
but may here mention that I regard the imperative necessity of 
removing the shoe, regardless of surroundings, when a paroxysm 
comes on, as a pathognomonic symptom of the disease. It may 
also be said that no evidence of the disease can usually be felt 
or seen, except that the parts are often of a bluish tint and cold, 
from venous stasis, and have a tendency to profuse perspiration. 6 
Case I.—Miss I. F. S., aged thirty-one years, teacher, was 
brought to me by her physician, Dr. George L. Romine, of Lam- 
bertville, N. J., in June, 1892. 
The following history was elicited : Family history excellent; 
she had always enjoyed the best of health and strength until the 
present trouble commenced. In July, 1890, she played lawn 
tennis for the greater portion of a day, coming down heavily on 
the balls of the feet many times, after which she walked a short 
distance to her home, and felt greatly fatigued. After resting 
two hours she attempted to walk, and experienced a “ queer 
sensation” along the outside of the left foot, a feeling “ as if 
something had given way about half-way between the toes and 
heel.” 
“ In the evening I walked down town, but could scarcely re- 
turn, for it was so hard to make my foot go. I felt as if retarded 
in some mysterious way. By the time I reached home a line of 
pain extended from the place above mentioned all the way to my 
hip Thinking I had sprained my foot, I applied the usual 
remedies. The next morning my foot felt rested, but during a 
short walk on the street the pain in my foot and limb returned. 
“ By this time the foot began to swell, particularly along the 
outside, and in a few days had a reddish appearance. After a 
night’s rest the swelling disappeared, and I was able to use my 
foot, with intervals of rest, in ordinary walking about the house. 
Each day it gave out after less use, so at the end of five days I 
called in our family physician, Dr. Romine, of Lambertville.” 
It was presumed that a ligament or tendon had been ruptured, 
and fixation by bandages resorted to. On August 7 these 
dressings were removed. 
“ The foot and limb were helpless, and the whole side of the 
foot felt so indescribably bad that it made me faint. A starched 
dressing was then put on the foot and limb to the knee. For 
four or five days following I held my foot on a chair, but after 
that, during part of the day, on a pillow on the floor. Toward 
evening I had almost unbearable tingling in the foot, but this 
passed away on retiring. I never could rest my foot on the 
outside from the time of the accident without having that un- 
bearable feeling in the foot, and at times the line of pain in the 
limb. 
“At the end of four weeks the Doctor told me to stand with 
my feet even. Never shall I forget what I suffered that day. 
The limb had shortened so that the heel was about two inches 
from the floor, and in trying to stretch it down the bottom of 
the foot pained and tingled dreadfully. I was completely ex- 
hausted and deathly sick. 7 
“Crutches were then ordered, and I commenced my hard 
work of learning to walk. 
“ My foot was so bad on the side, and a line of dreadful pain 
extended from about two inches from the fourth toe along the 
side of the foot and to the knee. After a time the pain in the 
limb seemed better, but the whole side of the foot felt unspeak- 
ably bad. The uncomfortable sensation did not seem confined 
to any particular place on the side, as it did at first. 
“The 1st of October the physician advised my going to 
school in order to overcome my nervousness, and take my mind 
from the foot. I wore a worsted slipper. 
“ The last of October the Doctor commenced the use of a 
battery every night—the interrupted current being used. The 
sponge was applied under and over the toes five minutes, five 
on each side of the heel, and five under the knee. The toes 
twitched a great deal, and I always dreaded when the sponge 
neared the fourth and fifth toes, for I felt the sting and jerk 
along the injured side, and it made me sick. I could bear only 
a light pressure there. When applied under the knee I felt the 
line of pain down the outside of the limb, and often the toes 
would jump. When the current passed down the inside of the 
limb it felt agreeable. 
“ My foot always felt badly on removing the shoe at night, 
and the limb above was very much swollen and glossy in ap- 
pearance. 
“The last of July, 1891, I took a short walk, without support, 
along the piazza. That night my foot pained up to the knee, 
and I was unable to touch it to the floor for more than a week. 
I was careful to take only a few steps at a time after that. At 
the end of a year this was all I could do. 
“ If I rubbed the foot, or put it down otherwise than just flat 
when I stepped, I was unable to use it afterward. 
“I used crutches all the time at school, so as not to overtire 
my foot again; but, in spite of all my care, I had that dreadful 
feeling on the side, and many days the line of pain up the limb. 
“ Often the foot had fits of shaking, which I could not con- 
trol.” 
She continued thus helpless, using crutches for locomotion, 
and became thoroughly neurasthenic, until June, 1892, when I 
saw her in consultation with Dr. Romine. We agreed that the 
diagnosis was clearly the peculiar painful affection of the fourth 
metatarso-phalangeal articulation, and that the other symptoms 
were probably but those of reflex neuroses; also that excision 
of the joint offered the only means of relief. However, it was 
determined first to try the effect of an ointment composed of 
ichthyol and lanolin, together with fly blisters in the course of 8 
the affected nerves. These measures proving of no avail, in 
July I removed the joint. At the same time it was thought best 
to divide the tendo Achillis, as the heel had become much drawn 
up by contraction of the calf muscles, and did not relax even 
under anaesthesia. 
From the moment of operation she never again experienced 
the old pain, and immediately began to gain flesh and strength 
under massage, hyper-nutrition, and rest in bed for three weeks. 
At the expiration of this period she was walking about unaided, 
and soon was as well and strong as ever. Union by first inten- 
tion was secured, no weakness of the calf resulted, and the 
amount of retraction of the, toe is about one-quarter of an inch. 
She now wears an ordinary shoe, and can make almost any 
exertion without discomfort. 
Case II.—N. C., aged thirty-two years, female, servant, native 
of Ireland. Family history negative. Had always enjoyed 
good health until October, 1889, when she tripped in going 
down stairs, and brought her left foot down violently in saving 
herself. Instantly she experienced an intense cutting pain in 
the region of the base of the fourth toe. The dorsum of the 
foot became black and blue, while the whole limb was affected 
with a dull burning pain. For several days she wore a slipper ; 
then the discoloration gradually disappeared and pain became 
more endurable. But she had to cut every shoe that was worn, 
to prevent pressure upon the painful area. This painful sensa- 
tion gradually extended from the original location up the front 
of the tibia, and became very severe in that situation. This 
misled a prominent surgeon to diagnose periostitis of the tibia, 
and cut down upon and scrape the bone. She remained in the 
hospital eight weeks, and was discharged unimproved. In Feb- 
ruary, 1891, another hospital surgeon cut down upon and 
chiseled away a portion of the tibia. Again no improvement 
followed. 
Early in 1892 the patient entered the Polyclinic Hospital, 
willing to submit to anything to obtain relief. At this time she 
was almost helpless, exceedingly neurasthenic, and had lost 
much flesh. The scars of the previous operations were very 
evident. The entire leg was blue and cold and somewhat 
atrophied, but beyond this nothing was evident except that the 
fourth metatarso-phalangeal joint and its surroundings were 
exquisitely sensitive to motion or pressure. From this point 
the pain was reflected up through the entire sciatic distribution. 
She was put to bed, and upon a milk diet for four weeks, while 
local counter-irritants and absorbents were applied, all to but 
little effect; the old pains and her general nervous condition 
persisted. I then excised the affected joint, and was amazed at 9 
her rapid progress to subsequent cure. Primary union was 
secured, and in three weeks she was walking about and entirely 
free from pain. Since then she has entirely recovered her 
former health and strength. 
Case III.—Mrs. E., aged thirty-five years, well-to-do farmer’s 
wife, seen in consultation with Dr. George L. Romine. Family 
history good. She is of a neurotic temperament, and faints easily. 
During last ten years she has been subject to attacks of neural- 
gia, affecting the left forearm. Three years ago she was seized 
with neuralgia, affecting the second and third fingers of the left 
hand. There was tenderness in the metacarpal region, whence 
pains were reflected up the forearm and arm, producing com- 
plete disability of the member. The parts were very painful to 
the touch, and slightly swollen. This condition persisted for 
four months, and then gradually disappeared. From this time 
until June, 1892, she remained well, when a marked attack of 
metatarsal neuralgia, affecting the fourth toe, supervened. This 
apparently did not follow an injury. The pain became continu- 
ous, and resisted all efforts for its relief, except when she laid 
down, when it would diminish or entirely disappeared. When 
I saw her, at the end of October, she had become bed-ridden, 
almost helpless, and exceedingly nervous, but nothing of disease 
was evident in the foot except the violent, unbearable pain that 
was invariably produced at the fourth metatarso-phalangeal 
articulation, upon the slightest pressing together or rolling 
upon each other of the outer metatarsal bones. At this time, 
even the weight of a stocking could not be tolerated upon the 
foot. The pain extended into the peroneal and sciatic nerves. 
She had lost fifty pounds in four months. The calf on affected 
side measured one and a half inches less than its fellow. 
The affected joint was excised, primary union secured, and 
she steadily regained her usual health. Pain has disappeared, 
and she can walk with comfort. 
A maternal aunt of Mrs. E. injured her foot eight years ago, 
and suffered in much the same manner as did the niece. She 
has never been able to secure relief, and to-day is scarce able to 
walk across a room without bringing on a severe attack of the 
pain. 
A sister of the patient injured her foot ten years ago, and was 
then confined to her room for twelve months, because pain de- 
veloped whenever the member was placed upon the ground. 
For five years she was unable to walk upon the street, while at 
the present time she cannot walk far without originating an 
attack of metatarsalgia, and has to be extremely cautious in 
walking over uneven surfaces. 10 
Case IV.—Mrs. S. C., aged forty-five years, a missionary 
residing in Japan. She writes : 
“When out walking in the city of Tokio, Japan, in the sum- 
mer of 1888, and wearing a new pair of high-heeled shoes, I felt 
first a slight pain, which soon increased to severity, in my right 
foot in the region of the fourth metatarso-phalangeal articula- 
tion. The pain became so intense that I could walk no further. 
These paroxysms of pain continued to return with the slightest 
aggravating cause, the disease gradually becoming worse, so 
that for two years past, when at home, I have seldom had a 
shoe on my foot, and was not able to bear the loosest shoe 
while riding in a carriage, being almost always compelled to 
remove it after entering. When suffering the most intense pain 
it was accompanied with a general nervousness of my whole 
system. Upon removing my shoe all pain and nervousness 
soon ceased.” 
I removed the affected joint in May, 1892. In three weeks 
the patient was able to walk about with great freedom in ordi- 
nary shoes, and has since remained free of pain. 
Case V.—Mrs. R. T., aged thirty-two years; Canadian; house- 
keeper. Has suffered for five years from well-marked metatarso- 
phalangeal neuralgia, involving fourth toe of left foot. No 
assignable cause. Attacks have been growing more frequent 
and severe progressively until she became almost invalided. 
Was compelled to remove shoe regardless of surroundings in- 
stantly upon supervention of the attack. 
In December, 1892, I amputated the fourth toe together with 
the corresponding metatarsal head. In three weeks she was 
walking about as well as ever and has been entirely relieved of 
all discomfort. 
Case VI.—Lizzie T., a Russian; single, aged twenty-two 
years; mill hand. This woman works the treadle of a machine 
with right foot. Two years ago began having pain radiating 
from fourth toe. The frequency and severity of these attacks— 
necessitating removal of shoe—have increased steadily until she 
was entirely unable to work and had difficulty in walking. 
In January, 1893, she entered the Polyclinic Hospital, and 
my resident, Dr. M. W. White, excised the affected joint under 
my supervision. Primary union occurred, and the cure has been 
complete. 
Morton1 gives the following graphic description of a case of 
metatarsalgia, written by a medical friend who had been a suf- 
ferer from the more severe form of the disease: 
“ I have suffered intensely at intervals from this affection for 
1 Loc cit. 11 
many years, and in all this time have never found medical man 
or layman 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 malformation 
of the articular surface of the first phalanx 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. 
“ 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 remov- 
ing 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 sufficiently sudden 
and marked to confirm the belief that there had been a disloca- 
tion. 
“ 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 enlightened and the mystery cleared up 
by your valuable paper on the subject. 
“ The first paroxysm occurred in my boyhood, and was pro- 
duced by tight lacing of skate-straps. On unbuckling the 
straps, the 4 cramp,’ as I called it, was at first soon relieved and 
thought nothing of; but a continuance of this system of squeez- 
ing by tight straps and tight boots, and riding for hours 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 pre- 
disposing. 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- 
continued flexion of the knee-joint, as in a railroad-car, car- 
riage, or lecture-room; treading on an uneven surface, as a 
cobblestone pavement; 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 
paiq, 4 cutting to the heart,’ sickening, a feeling that it is unen- 
durable, faintness, cold sweat, total incapacity for the time of 
directing the mind or will to any other subject, a horrible in- 
crease of torture on the use of the boot-jack; and all this with 
no redness, no swelling, no abrasion of the skin, no callosity, 12 
no visible displacement of bones, at least after removal of the 
boot. 
“ The suddenness of the attack is noteworthy. I have been 
obliged to drop everything and remove my boot, sometimes in 
company, sometimes in my carriage. I have even been obliged 
to sit down on the curbstone 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 removing the boot, 
but I have had tight boots 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 manipulating 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, bind- 
ing the foot round the instep. Putting on a dry boot and dry 
stocking is of great benefit, and the boot should be well sprinkled 
with powdered soapstone before putting it on. Frequently an 
attack has been relieved completely without other means than 
rest and a cup of strong tea.” 
Morton also reports the following from another medical 
friend: 
“ 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 symp- 
toms 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 climbing a mountain, 
when the joint became displaced; 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 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 13 
of relief. The pressure of a boot always aggravates it; but it 
has attacked me while in bed at night. Diversion of the mind 
will often allay it, but it sometimes comes on again afterward 
with far greater severity. 
“In 1869, while spending most of the summer 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 amputation 
of the toe to a surgical friend, but he advised me against it. 
Since then it has been much less troublesome, though I have 
sometimes had it more or less every day for a week. 
“ Deep pressure over the metatarso-phalangeal joint is pain- 
ful, but does not bring on an attack unless long continued. 
Cold has given me more effectual relief than any other remedy 
I have tried.” 
The three following cases are quoted from the same source: 
“ In March, 1873,1 was asked to see Miss H. S., aged twenty- 
six years, who, while in Europe four years before, had injured 
her right foot by stepping upon a small stone. She said that 
she had at once experienced intense pain, which was soon fol- 
lowed 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 constant distress in the part, often 
of a sickening character. After wearing a shoe, pain came on 
with great intensity. At such times the shoe had to be instantly 
removed, the least delay causing a paroxysm of great suffering. 
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 
associated phalanx. Pressure in this region, or rolling the fourth 
and fifth toes upon each other, caused violent pain, which ex- 
tended 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.” 
“ Dr. M. W. Alison, of Hagerstown, Maryland, called on me 
in the spring of 1875, seeking relief from neuralgia in his right 
foot, which had existed for years, and was gradually getting 
worse, and stated that he was willing and ready to submit even 
to amputation of the leg. He gave the following history: 
“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 metatarso-phalangeal 14 
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 con- 
fined entirely to the section of the foot indicated. 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 morphine, fric- 
tions, or call upon some one to assist me by standing on the 
foot. This affliction has been the burden of my life, and this 
burden has been increased after consulting many eminent medi- 
cal men, who gave me no satisfaction as to the nature of the 
disease, nor even suggested a hope of relief. My health other- 
wise has been uniformly good. I am satisfied the cases you 
have had are similar to my own, save in the intensity of my suf- 
ferings, and I shall gladly submit to the operation you have 
suggested.” 
Mrs. C. H. K., of this city, a lady fifty years of age, gave me 
the following history : “ ‘ The queer feeling,’ I have been accus- 
tomed 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 produce the same result. Often my sufferings have been 
exceedingly acute, and come 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. In September, 1868, while 
at the Academy of Music, I had an unusually severe attack, 
and, not removing 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 similarly 
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.” 
Charles K. Mills,1 in a lecture upon “ Pain in the Feet,” relates 
1 Journal Nervous and Mental Diseases, vol. xv. p. 4. 15 
the history of a typical case that was entirely relieved by the 
operation of Morton. A woman, in jumping upon rocks twisted 
her foot. The foot apparently was not injured, and she was soon 
about as usual. During the next two years, at intervals of from 
two to eight weeks, a peculiar pain in the foot wo'uld develop 
that would last two or three days. Two years later she injured 
the foot again in the same manner. After this the pain was 
seldom absent more than a few days, and each recurring attack 
was of increased violence. Again, two years later, the pain be- 
came almost constant. The pain was a dull, heavy, sickening 
ache, from the foot to the hip, and with a sharp pain through 
the foot. At times the ache would be limited to the foot, but 
the sharp pain was there constantly. Arising in the morning, 
the patient could not put her weight upon the foot until she had 
taken hold of it suddenly from the top and pressed it hard 
together, and held it in' both hands with all her strength for 
some minutes. After exhausting every known local and general 
remedy, the fourth metatarso-phalangeal articulation was ex- 
cised. The patient subsequently slowly became free of every 
vestige of the former pain, and was entirely restored to health. 
Poullosson1 describes an instance where a medical man, 
twenty-nine years of age, had suffered from this affection for 
some years. It gave no trouble when the foot was at rest and 
without a shoe, but was usually brought on by wearing boots 
and walking a good deal. It was much more likely to occur 
when going down than in going up hill. The pain came on 
suddenly, a feeling of something having given way in the feet 
accompanying the onset, together with a kind of grating sensa- 
tion. After this the patient walked lame, for all pressure of the 
anterior portion of the sole of the foot to the ground was pain- 
ful. If walking was persisted in the pain increased, till in a 
few moments it attained its maximum, rendering all further 
attempts at locomotion impossible. 
Edmund Roughton2 has reported the following case: 
“ A medical man, aged thirty-three years, complained that for 
eighteen months he had suffered from attacks of burning pain in 
the forepart of the sole of the left foot. The pain occurred 
several times a week, and was usually brought on by prolonged 
standing or by walking any considerable distance, and was so 
severe as sometimes to cause him to remove his boot and grasp 
the sole of his foot with his hand. On examining the foot, I 
found that the transverse arch formed by the heads of the meta- 
tarsal bones had sunk, so that a distinct convexity replaced the 
concavity normally found in this situation. 
1 Loc. cit. 
2 London Lancet, March 16, 1889, p. 553. 16 
“In this case the patient had increased considerably in weight 
during the period of development of the symptoms, and his 
transverse metatarsal ligament had presumably been unequal to 
the increased strain.” 
E. H. Bradford1 has reported a series of thirteen cases, none 
of which, however, were severe enough to demand operation. 
In these the symptoms were not in a single instance the result 
of traumatism, nor was any evidence of dislocation or other 
local change observable. These patients were all in enjoyment 
of excellent health, and in none were there evidences of gout or 
rheumatism. 
Treatment.—The less severe forms of metatarsalgia may 
often be prevented from running into the more serious types by 
proper shoe construction or by wearing a narrow flannel ban- 
dage about the ball of the foot. Morton, whose suggestion the 
latter is, directs that the bandage be two inches wide, and long 
enough to wrap neatly and firmly about the metatarsus some 
five or six times. The end is pinned, and the stocking drawn 
over. This has given marked relief in a number of cases. 
The shoes for persons suffering from this disease should be 
firm-soled, make no lateral pressure upon the metatarsus, yet 
have the instep tight enough to prevent the foot slipping for- 
ward. The great object of the shoemaker should be to prevent 
pressure, either lateral or antero-posterior, upon the metatarsal 
arch, and also to prevent any rolling motion of the outer meta- 
tarsal heads upon their fellows. A broad, rigid sole would 
appear to best fulfil this last indication. Bradford proposes the 
use of digitated stockings in these cases, with a view of keeping 
the toes further apart. As the foot spreads when the weight of 
the body is thrown upon the member, it is apparent that the 
individual should be standing when the measurements for shoes 
are made, as has been advised by Grim. 
The use of various pads in the shoe and about the toes, also 
such measures as the hollowing out of cavities in the sole oppo- 
site one or more of the metatarsal heads have been tried, but 
invariably found unsatisfactory. A variety of the affection call- 
ing for so much attention to secure comfort would clearly 
demand the certain cure to be afforded by operation. 
In persons where rheumatic or gouty diathesis may be sus- 
pected appropriate remedies for those disorders should be given 
a thorough trial before operative measures are resorted to. But 
when the condition is entirely of local mechanical origin the 
employment of general or local medicinal agents is useless. On 
1 Loc. cit. 17 
the other hand prolonged rest in bed will benefit all cases more 
or less, and occasionally secure relief for long periods, or even 
permanently cure the milder phases of the disorder. 
Operative treatment should be limited to excision of the 
metatarso-phalangeal articulation from which the neuralgia 
radiates, or, perhaps, to amputation of the corresponding toe 
above the joint, as have been recommended by Morton and 
endorsed by other writers. These procedures are among the 
safest and simplest in surgery. Of amputation of the toe, together 
with its metatarsal head, nothing more need be said than that 
by this measure the possibility of subsequent trouble arising 
from a tendency of the toe to retract and ride above or below 
its fellows is excluded. However, this heretofore occasionally 
troublesome sequel can be avoided by dividing the extensor 
and flexor tendons while excising the joint, as I have done in 
five cases with most satisfactory results. 
Operation.—Primary union should be aimed at. To secure 
this the foot must be scrupulously cleansed. The nails should 
be trimmed short. Then soap, water, and nail-brush should be 
liberally applied. Following this the member should be soaked 
in 2\ per cent, carbolic acid solution, and finally dressed in a 
moist carbolic dressing of the same strength until the surgeon 
is about to operate. Where the foot is especially foul it is my 
my custom to finally dip it into a saturated solution of perman- 
ganate of potash until colored to a dark mahogany hue, and 
then transfer it to a saturated solution of oxalic acid until 
decolorized, before applying the temporary dressing. When 
the surgeon is about to operate the temporary dressing is re- 
moved and the parts given a final douche with i : 1000 subli- 
mate solution. 
A vertical incision from one and a half to two inches long is 
made, beginning over the proximal inter-phalangeal joint and 
extending upward in the centre line of the toe.1 The extensor 
tendon now comes into view, and is divided. Another stroke of 
the knife carries the incision through its entire length down to 
the bone. The handle of the knife or other moderately blunt 
implement is then employed to separate the tissues from the 
upper and lateral portions of the joint. Next the blades of a 
powerful sharp-pointed, narrow-bladed cutting pliers are pushed 
down on either side of the phalanx immediately below its base 
(hollow of the blades always toward the articulation), and this 
bone divided. The metatarsal bone is then similarly divided 
just above its head. The separated joint is now seized by bone 
1 This joint has also been excised through an incision in the sole, but the method is 
objectionable on many grounds. 18 
forceps and dissected away from any remaining attachments. 
This done, the flexor tendons will be seen lying in the bottom 
of the wound, and should be picked up by forceps and divided 
with scissors. If hemorrhage is severe and not controllable by 
moderate compression of the parts, ligatures should be applied. 
I have never had occasion to apply a ligature in this operation, 
as the pressure of the dressing has always sufficed to control 
any oozing that might continue after the sutures had been 
applied. The wounded edges are next to be approximated—no 
drainage being required if asepsis has been maintained—by 
continuous or interrupted suture, as may be preferred. A gauze 
and cotton dressing is finally applied and bound firmly on with 
a wet gauze roller, care being observed to place little pads of 
the gauze in such positions as will hold the toe in its proper 
position during healing. 
The foot should be kept considerably elevated for the first 
two days, after which it may be brought to the level of the bed. 
I prefer my cases to remain in bed or on a couch until the 
fourth or fifth day, when they may be permitted to sit up with 
the foot resting on a chair. At the end of a week the sutures 
are removed ; two or three days after which the patient is per- 
mitted to move cautiously around, while at the termination of 
three weeks all restraint may be removed and a firmly healed 
wound and permanent cure confidently expected. No special 
form of shoe or particular care of the foot is afterward required. 
In case suppuration should arise in the wound, the sutures 
should be at once removed, the wound cavity washed out with 
full strength peroxide of hydrogen solution, then with cor' 
rosive sublimate solution, and gently stuffed with iodoform 
gauze. All of which should be repeated every one or two days 
until the wound closes by granulation. 
In addition to the references given in the text the following 
may be mentioned to complete the bibliography of the subject: 
Gross : System of Surgery. 
Agrew’s Surgery. 
Erskine Mason: Am. fount. Med. Sci., Oct., 1877. 
Editorial, N. Y. Med. fotirn., Oct. 8, 1892, “Morton’s Pain- 
ful Affection of the Foot.” 
Roswell Park ; Med. News., 1892, vol, ii, p. 406, “Morton’s 
Affection of the Foot.” 
Meade C. Kemper: Virginia Med. Monthly, vol. viii, p. 522, 
“ Case of Metatarsal Neuralgia.” 
1506 Locust Street.