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Connecticut Training School for Nurses, Graduating Exercises, 31. 131, 338
Consumption, Rational Treatment of. Geo. L. Beardsley, A.M., M.D.
Consumptives, Aid for

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Contagious Disease Hospital for Yale University

Contagious Diseases, Limitations of, Especially Scarlet Fever and Diph-
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Editorials

Electricity, Effect of, on Bacteria
Epilepsy, A Suggestive Case of, Following Trauma-Operation.
W. W. Hawkes, M.D.

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Natural Toxine Immunity

Neoplasms, Treatment of, with Toxine of Erysipelas
Nucleins. W. H. Porter, M.D.
Nutmegs, Poisoning by

Piano Playing and Neuroses .
Pneumonia, Strychnine in

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Rhythmical Traction upon Tongue in Cases of Apparent Death.

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Tuberculin in Bovine Tuberculosis

Tuberculosis, Treatment of. N. E. Wordin, M.D.
Tumor of Brain, Three Cases of. S. P. Goodhart, M.D.

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Vol. II

MEDICAL JOURNAL

YALE

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NOVEMBER, 1895

ORIGINAL COMMUNICATIONS.

A CASE OF MORTON'S METATARSALGIA-— NEU-
RITIS EXSECTION OF JOINT-CURE.

No. I

By O. T. OSBORNE, M.D.

OPERATION BY Wм. H. CARMALT, M.D.
NEW HAVEN, CONN.

This affection was first described by Thomas G. Morton, of Philadelphia, in 1876, and since that time cases of this condition have occasionally been reported, notably by Thomas S. K. Morton. Up to the present time, however, this condition does not seem to have received proper attention by neurologists or surgeons, and the text-books pass over it with but brief notice, if it is mentioned at all.

This is a condition, which, I believe, in its less severe forms is of frequent occurrence, and is overlooked or passed lightly over by physicians, and the unfortunate sufferer is left to believe that the pain in his foot is incurable. This affection is a neuralgia of one of the metatarso-phalangeal nerves, viz.: that going to the fourth toe on the outer side. It is a traumatic neuralgia, i.e., a nerve-pain due to constant or intermittent injury. The cause of this nerve-injury, as pointed out by Morton, is the anatomical formation of the foot plus an injury. Reference to any plate of the bones of the foot will show that the head of the fifth metatarsal bone and the head of the proximal phalanx of the fifth toe come in close contact with the head and neck of the fourth metatarsal bone. Along the neck of this fourth metatarsal bone runs the fourth phalangeal nerve. Normally the bones are so united as to prevent the bones of the fifth toe from pressing upon the nerve of the fourth. Prolonged use of tight shoes, however, can so roll the heads of the fifth metatarsal and phalangeal bones

around the head and neck of the fourth metatarsal bone as to cause pressure on the nerves, and pain results. Also any injury to the foot, as twisting it, especially if the foot was encased in a tight-fitting shoe, as noted by Morton, would tend to drive these. bones together and injure the nerve. The relaxation of the ligaments thus caused renders ever after the pressure of the shoe a constant source of renewed traumatism.

As in all neuralgias, or, perhaps, dependent upon the exact position of the foot in the shoe, this metatarsalgia occurs in paroxysms, and in mild cases is probably absent for considerable intervals. A great amount of walking, or of going up and down stairs certainly tends to cause a recurrence.

Morton says the "imperative necessity of removing the shoe, regardless of surroundings, when a paroxysm occurs is a pathognomonic symptom." In severe cases of this affliction traumatic neuritis may occur, affecting the local nerve, or, as in the case which follows, may ascend even to the sacral notch, giving the severest form of sciatic neuritis. If this affection is severe life becomes well-nigh unbearable, the patient being compelled to change from shoe to shoe several times a day, being utterly unable to walk any distance, or in fact, to enjoy life at all. The very time when relief from the pain is most desired, as at social gatherings, at the theater, or at church, is the time when a paroxysm will develop.

Cramps in the irritated toes may develop and add their discomfort. The patient tries every kind of shoe that can be bought or made, and finds relief only in soft slippers or moccasins. In severe cases the patient may not be able to use the foot at all, and may be compelled to use crutches.

As to treatment: The neuralgia in severe or long-continued cases can, I believe, never be cured by any treatment other than surgical. Faradic electricity is one of the few sedatives of any benefit. Rest in bed will generally stop the pain. Broad-soled, soft, flexible shoes will give some relief, and, if at first preceded by absolute rest, may cure mild acute cases. If neuritis occurs, it can by proper care be cured, but will probably recur, unless the cause of the injury is removed.

The only, but absolutely successful, treatment of severe cases is by the removal of the fourth toe, or better, by an exsection of the metatarso-phalangeal joint of the fourth toe.

The following case shows a severe type of this affection:

In November, 1893, a young woman, about twenty-five years of age, came under my care, complaining of pain in the right

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