Without fever and without evident organic lesion, the heart-beats continued throughout two months of his illness at a hundred and and twenty per minute, except when modified by treatment. A tenderness, on pressure, at the emergence of the left great sciatic from the sacrum persisted after the pain had left his foot. The patient was much emaciated and very feeble when he came under our observation on the 23d of September. He had lost much of his hair and his nails were changed to a dirty brown color. The movements of the upper and lower extremities were tremulous and choreic on attempting exertion, but the toes were not paralyzed. The paroxysms of pain in the feet recurred every few minutes without exciting cause, but a touch or a draft of air or putting the feet pendant, would start the pain immediately. The pain was often in the two feet at the same time, but most frequently alternated. The most comfortable attitude the patient could assume was to flex the thigh on the abdomen and to grasp the leg below the knee with locked hands, while lying recumbent or holding his knees up in that way. Under a treatment which consisted mainly of rest, a liberal diet, judicious galvanism, quinine, belladonna, gelsemium, aconite, arsenic and the bromide and muriate of ammonia, with occasional doses of morphia and chloral, the patient became practically convalescent of the neuritis by the 7th. of October, the pain paroxysms having ceased to recur, no tarsal or plantar pain to touch, and but a little tenderness to firm pressure remains, October 12th, over the sciatic notch. The patient has increased a good deal in flesh, rests well at night without hypnotic aid, and takes a nap or two during every day, while active treatment, for the neuralgia is almost entirely withdrawn. But there remains the irritable heart, a lame step in walking, to accommodate the left side, and some incomplete rheumatic and malarial symptoms have appeared. October 24th the patient was sent home for a few days, free from pain, but still walking somewhat lame and with a pulse of a hundred and twenty per minute. On October 29th the patient returned for treatment, without pain but still with a lame step and an abnormal heart-beat, and remained under treatment till the 4th of November, when he was discharged convalescent, with a slightly lame step, no pain, and a heart-beat when sitting, of eighty-four per minute. There was no history of venereal disease in this case. A case came under my care last June not preceded by any pronounced form of fever, but by a general malaise,, irritable heart and a masked intermittent, in which there was only restless sleep and night sweats, in the person of an old lady of sixty-five years, who has had a chronic stationary left ovarian tumor for over thirty years, which Dr. Jesse Judkins, of Cincinnati, thought it not advisable to operate upon. This trouble was followed, on the first of July, with a dysentery which lasted till about the middle of September. Dr. Elsworth Smith, of this city, succeeded me in charge of the case on the 24th of July (when I took my vacation), and the patient, by our joint advice, went East, to the sea shore. After her return, in September, the foot trouble reappeared and was much like one of Wier Mitchell's typical cases of erythemomegalalgia. The skin in this case was red over a certain area of the sole of the foot and the great toe and the two adjoining lesser toes, and peeled off. The nails were not discolored, but the ball and tips of the great and adjoining toes were intensely painful. An ointment of acetate of lead and belladonna was however well borne, and this and quinine and belladonna internally, gave relief. The patient is now (November 25th) quite well for one of her age and other local infirmities, and has gained in flesh, appetite, sleep and strength. There was no persisting accelerated heart action in this case. While I regard these cases as all belonging to the same category of peripheral nerve irritability from inflammatory states of the nerves or their sheaths, or conditions approximating inflammation and due to blood states, as other forms of neural pain and nerve-sheath inflammation after fevers, they may also precede, as well as follow poison or depravity of blood, and the effect is not always, nor do I believe ever altogether spent on the peripheral nerves, though it is there usually most apparent. In the case first above described, there was pain in the sciatic on pressure near its point of emergence from the pelvis under the pyriformis muscle, and lower down between the trochantor major and the ischium. There was also some sense of constriction complained of about the waist, even after the pain had left the foot, so that what Ross says of this disease, viz., that it is sometimes progressive and in its later stages may be associated with evidences of spinal disease, such as girdle pains and partial paralysis, muscular atrophy is not a future impossibility with our patient, though we shall endeavor by judicious management of the case, if permitted, to avoid so dire a result. The efforts of pathologists have, of late, been in the direction of establishing them. as febrile sequelæ, as they most usually, but not invariably are, as MM. Pitres and Vaillard (Review de Medicine, December 10th, 1866) have lately shown in regard to post-typhoid neuritis and in regard to post-neuritis tuberculosa. They belong to the same category as those extremely sensitive states of teeth and nails and hair roots which sometimes are seen to precede, but more often to follow certain states of depravity-or poison of blood; the clinical cachæmias and toxhæmias. Neuritis plantaris, as I have observed it, is seldom displayed in the constitutionally neuralgic, like sciatica and tic-douloureux, and singularly does not suddenly migrate from one branch to another of its great nerve root, the posterior tibial, or of the popliteal bifurcations of the great sciatic, in imitation of neuralgia trifacialis and other forms of transitional neuralgia. It does not even alternately pass to and from the external and internal. plantar, which bifurcate from the posterior tibial, but is exclusively confined in all the cases I have seen to the digital branches of the internal plantar, extending no further outward than the distribution of the nerve to the inner aspect of the ball of the fourth toe, and the toes all seem to be more or less conjointly rather than alternately painful, as is usually the case in true neuralgia of central origin of the common terminal branches of a certain nerve-trunk. This gives it the character of peripheral neuritis rather than of simple neuralgia. But why neuritis plantaris should select the internal plantar nerve about the point of its bifurcation, and at its distribution in the toes is only conjectural. It may be due to the fact that it is larger than the external, has more to do in the movements of foot and toes and is more pressed upon in standing and walking than its outside neural neighbor. Ross, we think, has justly criticised the name erythemomegalalgia, given by Mitchell to these cases, "inasmuch as the vasomotor disorders are preceded and accompanied by severe paroxysms of pain," though the name given by Mitchell is certainly very descriptive of his own cases, as they all had erythema as well as intense pain and the flushing over the painful area is quite characteristic in many cases, though by no means in all. Fig. 1 shows the painful area in the first case above, the intensest pain being at the darkest spots. There was no erythema in this case, but pallor of the foot and toes. The shaded parts in, Fig. 2 shows area of flushing in second case above described, and region of pain, the chief pain being at darkest points. Fig. 3 is a diagram of the digital nerve distributions and their trunk connections with the plantars and beyond, showing how the internal aspect of the fourth toe is supplied by a branch from the plantaris internus. We must either accept the term "neuritis or neuralgia plantaris" for these cases, or apply to some of them a |