REGIONS OF THE FOOT. 



351 



Another deformity of the foot occasionally 

 met with is exactly the reverse of the prece- 

 ding; this is too great a convexity of the arch, 

 by which the foot is considerably shortened, 

 and the bearing, anteriorly, taken from the 

 under side of the heads of the metatarsal bones, 

 and thrown partly upon the bases of the first 

 phalanges and upon the metatarso-phalangeal 

 joint itself. From the tense state of the plantar 

 fascia we must suppose that this structure is 

 shortened, and indeed we have been inclined 

 to consider this contraction of the fascia as in 

 some degree a cause of the deformity, which 

 Dupuytren has proved to be the fact in the 

 parallel case of contraction of the fingers, by 

 shortening of the palmar fascia. With this 

 view, in a case of deformed foot which lately 

 came under our notice, we divided the fascia 

 plantaris, and certainly with considerable tem- 

 porary benefit. We 'have not been able to 

 ascertain why the relief was not permanent, as 

 the patient lives at a distance; but it might not 

 improbably arise from his returning to work 

 too soon, and leaving off the extension of the 

 foot which had been adopted. 



(A.T.S Dodd.J 



FOOT, REGIONS OF THE. The sur- 

 gical anatomy of the ankle having already been 

 given, (see ANKLE, REGIONS OF,) it remains 

 for us, in this article, to describe the foot pro- 

 perly so called, that is, all of the lower extremity 

 beyond the ankle. This part comprises much 

 that is practically interesting and important, 

 both in its pathology and surgery, which must 

 be evident when we consider the vast number 

 of ills which are endured in the feet. The 

 foot, considered as an entire region, is na- 

 turally and obviously subdivided into dorsal 

 and plantar regions. In the first of these 

 we observe, 1st, the dorsum, or instep, ex- 

 tending from the front of the ankle to the 

 heads of the metatarsal bones ; 2d, the toes 

 themselves. 



I. Region of the dorsum. We see the instep 

 falling, with a gentle curve, forwards from the 

 ankle, and forming the anterior portion of that 

 arch, which posteriorly runs through the ankle- 

 joint to the heel, and the crown of which, formed 

 by the astragalus, bears the weight of the whole 

 body. This most remarkable provision for 

 the safety and efficiency of the body is well 

 deserving of particular examination, and we 

 shall return to it when describing the plantar 

 region. The curve of the dorsum just men- 

 tioned is running forwards to the head of the 

 metatarsal bone of the great toe; there is 

 another arch, a lateral one, running across the 

 foot, of which the inner end is abrupt, as it 

 bends over the inner side of the ossa naviculare 

 and cuneiforme interna ; the outer end slopes 

 off more gradually to the os cuboides and 

 metatarsal bone of the little toe. The use 

 of this arch is best seen also in the sole, 

 though it presents itself to the view most 

 strikingly on the dorsum. 



The principal points which claim our atten- 

 tion in this region are : 



1. The integuments, which are here rather 



thinner and softer than in other parts of the 

 limb, but varying considerably in texture ac- 

 cording to age, sex, and habit: they are also 

 rather thinner on the outer than on the inner 

 side. 2. The subcutaneous cellular tissue. 

 This is rather loose, and freer from fat than 

 in other parts of the body, permitting free 

 movement of the superficial parts upon those 

 beneath. This laxity of the cellular tissue is 

 greatest on the middle of the instep ; and 

 accordingly we see in children and females, 

 where there is a large quantity of superficial fat, 

 and in effusions of water or other fluids, that 

 the skin of this part rises most, while across 

 the ankle and the roots of the toes there is 

 an appearance like a ligature arising from the 

 comparative closeness and shortness of this 

 cellular web. In this layer also we find 

 several large veins and some branches of 

 nerves. The dorsal veins of the foot run in 

 very irregular directions, varying in size in 

 different subjects, but mostly collected into 

 two plexuses, which form in front of the inner 

 and outer ankles, the saphena major and minor 

 veins. The course of these veins, though 

 various, is generally as follows : The saphena 

 major begins to shew itself pretty conspicuously 

 on the middle and inner side of the instep, 

 and running to the inner ankle receives in its 

 course numerous additions, and then passes 

 over the internal malleolus. The saphena 

 minor is seldom found in a notable trunk 

 on the fool ; we see only on the outer side 

 of the dorsum several small branches commu- 

 nicating with the inner plexus, and taking 

 their course towards the outer ankle ; there 

 they form sometimes one, but generally 

 two branches, which pass sometimes over, 

 generally behind the outer malleolus. It is 

 the first of these veins that is principally im- 

 portant in s'urgery, as it occasionally, and we 

 think it might with advantage be more fre- 

 quently, opened for the detraction of blood. 

 It is immediately brought into view by a 

 ligature placed above the ankle, and in opening 

 it we must bear in mind that, from its super- 

 ficial situation, from the looseness of the en- 

 veloping tissue, and from the greater distance 

 of the ligature from the point to be punctured, 

 the vein is much more liable to roll and to 

 foil our attempts than the vein at the elbow : 

 we must, therefore, take the precaution of 

 putting the fore-finger above, and the thumb 

 below the spot where the lancet is to enter, 

 which will retain with facility the vein in its 

 place. 



The varicose distention to which the trunks 

 of the saphena veins in the leg are peculiarly 

 liable, is often found extending to their minute 

 commencing branches on the dorsum of the 

 foot ; so much so that the whole of this region 

 is irregularly distended, and covered with the 

 knots and ramifications of the distended veins. 

 This morbid state is dependent upon the same 

 causes as the varicose affection of the veins 

 of the leg, and can be remedied only by the 

 same means, but with this additional disad- 

 vantage, that the mechanical means adopted 

 for their relief by pressure, owing to the more 



