A CASE OF MORTON'S 
METATARSALGIA. 
Neuritis; Exsection of Joint; Cure. 
BY 
0. T. OSBORNE, M. D., 
Professor of Therapeutics at Yale, New Haven, Conn. 
REPRINTED FROM THE 
Nete ¥orft JBeUtcal journal 
for August 31, 1895. Reprinted from the New York Medica l Journal 
for August 31, 1895. 
A CASE OF MORTON'S METATARSALGIA. 
NEURITIS; EXSECTION OF JOINT; CURE. 
By O. T. OSBORNE, M. D., 
PROFESSOR OF THERAPEUTICS AT YALE, NEW HAVEN, CONN. 
In November, 1893, a young woman, about twenty-five 
years of age, came under my care, complaining of pain in the 
right foot, with a feeling of numbness in, and often a cramp- 
ing of, the fourth toe. The pain was increased by walking 
and going down stairs, and, when sitting still, often the shoe 
must be removed to relieve it. The pain was of a sickening, 
boring character, often shooting around the ankle and up the 
leg. 
The history of the patient was as follows : In December, 
1892, she had slipped on a piece of coal, turned her ankle, 
and fallen on her right hip with the foot twisted under her. 
For a week she walked with difficulty, due to the strain and 
soreness of the whole leg. About one month afterward- 
viz., in January, 1893-she had a cerebro-spinal meningitis, 
during which both ankles became stiff and the leg muscles 
contracted, so that the feet were turned in and down, greatly 
out of shape. On recovery, after remaining in bed nearly 
two months, she was hardly able to walk, owing to the stiff- 
ened ankle joints, and to the contractures of the muscles of 
the legs. 
In June, 1893, she was first able to walk well, but typhoid 
fever again put her to bed in the latter part of July, and kept 
Copyright, 1895. by D. Appleton and Company. 2 
MORTON'S METATARSALGIA. 
her there until she first went out in October. At this time 
the right foot began to pain her badly, was numb, and caused 
her trouble in walking. 
In November, when she first came to me, as above stated, 
I found almost total anaesthesia of the fourth and fifth toes 
of the right foot, and slight anaesthesia of the skin along the 
course of the external plantar nerve. There were also ten- 
der points along the course of the sciatic nerve and in the 
popliteal space. 
The diagnosis of neuritis in a subacute stage was made. 
Electrical treatment was started, and quickly, by the con- 
stant current, the anesthesia disappeared; as for the pain, 
the interrupted current always caused a diminution of it, 
but the periods of absence of pain were always irregular and 
evanescent. 
The pain was always increased by walking or going up 
and down stairs. All medicinal treatment utterly failed, and 
at times there was a great deal of sciatic pain, even to the 
hip, and often in the knee. 
Every resource was tried to cure the patient, but the only 
relief, or rather the only treatment that seemed to preven} 
the pain from being unbearable, was the constant current, to 
reddening of the skin, over the painful points of the sciatic 
nerve, and the interrupted current to the foot and toes. This 
treatment was continued at short intervals until October, 
1894, during all of which period walking was always more or 
less painful and the shoe must be loosened or actually re- 
moved, at almost any place, be it church or theatre, if she 
had sat quietly for a time. Morton maintains that this com- 
pelled removal of the shoe is a diagnostic sign of this meta- 
tarsalgia. 
In October, 1894, after some unusual amount of going up 
and down stairs, and after several previous aborted attacks, a 
violent ascending neuritis of the sciatic nerve started up. 
This was the most violent and intensely painful sciatic neu- 
ritis that I have ever seen. 
The fixation splint from the heel to the axilla was con- 
stantly kept in place, with occasional removals for the relief of MORTON'S METATARSALGIA. 
3 
pressure points and for the reapplication of cotton and flannel 
for dry warmth. Hot sand bags were constantly used about 
the leg, as dry heat diminished the amount of the pain. 
During the paroxysms of pain always, and constantly for 
four weeks, hypodermics of morphine in enormous dosage 
were given. Nothing else was of any avail. 
For five weeks these paroxysms occurred almost daily, and 
at these times individual muscles or groups of muscles of 
this (right) leg would be thrown into contractions, both 
clonic and even tonic in character. Often these contractions 
would affect the back and abdominal muscles on the right 
side, and even opisthotonus often occurred. These convul- 
sions of the leg and hip muscles caused excruciating pain, as 
every twist or pull would injure the inflamed sciatic nerve, so 
that the patient begged for the attendants to hold the leg 
still, as even in the splint the joints were slightly moved by 
the muscular spasm. 
At any time if the splint was momentarily removed the 
toes and foot flexed spasmodically toward the plantar surface, 
always causing agonizing pain. 
Nothing stopped these spasmodic, convulsive paroxysms 
but inhalations of chloroform to partial anaesthesia and kept 
up for half an hour at least. Then relaxation enough would 
occur for the powerful hypodermics of morphine to take 
hold. Enough morphine, without endangering the life of the 
patient, could not be given to prevent these paroxysms, al- 
though three grains were often given in a night, and fre- 
quently one grain and three fourths at one dose, and that to 
a patient who had never taken morphine up to the time of 
this acute neuritis. All of the surface of the foot and leg 
receiving nervous filaments from the external plantar and 
posterior tibial nerves was anaesthetic, but any movement or 
any pressure that would affect any part of the sciatic nerve 
would cause intense pain and perhaps precipitate a paroxysm. 
During this attack of neuritis the most painful region, and 
the point that could not bear even the touch of a finger, was 
on the sole of the foot at the joint of the metatarsal bone 
and proximal phalanx of the fourth toe. 4 
MORTON'S METATARSALGIA. 
As here was the point of most intense pain, and as injury 
to this part by walking and going down stairs could be the 
cause of the traumatic ascending neuritis which I decided 
that she had, I concluded thtft there was either a neuroma at 
this point or that she had Morton's metatarsalgia as the cause 
of the whole trouble, and that only surgical interference could 
ultimately cure the patient. I at this time stated my opin- 
ion to the family, and the subsequent operation proved the 
condition to be that described by Morton. 
In seven weeks the acute stage had passed and the patient 
was about on crutches, as the muscles supplied by the poste- 
rior tibial nerve were paralyzed as well as the fourth and 
fifth toes. The skin supplied by the posterior tibial and the 
external plantar nerves was anaesthetic, while movement of 
the ankle joint was very painful. 
With massage and electricity the sensation became nor- 
mal, and the paralyzed muscles of the leg returned to normal 
action by about January 15, 1895. 
But now again we had the same old plantar neuralgia, 
and the same aching toes and leg, and the same inability to 
walk. 
As, soon, a threatening sciatic pain after a little extra use 
of the foot compelled me to send her to bed for three or 
four days, I called in Dr. William H. Oarmalt as consultant, 
as I desired surgical interference. Dr. Carmalt agreed with 
me as to the trouble being Morton's neuralgia, and exsection 
of the joint was decided upon. 
The operation was performed by Dr. Carmalt in March, 
1895, and was perfectly successful. 
From that date up to the present time there has been en- 
tire and complete absence of pain from the toes, foot, leg, and 
thigh. 
There has been no pain on walking or going down stairs, 
and no cause to remove the shoe. 
The atrophy of the leg, which had in considerable meas- 
ure persisted since the attack of neuritis, has entirely dis- 
appeared. The New York Medical Journal. 
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