II. Plantar region of the toes.— Of the toes we observe that the integuments of the under part are always soft and pliable, com pared with the rest of the integument of the sole, and possessing peculiarly the sense of touch ; that under the skin at the extremity of the toes there is a soft elastic cushion of cellular tissue, analogous to that at the tip of the fingers, and in this and in the cutis the extremity of the digital arteries and nerves is minutely ramified. The digital arteries them selves, with their accompanying nerves and veins and ahsorbents, are running along the edges of this under surface of the toes. Lastly, the tendinous them, in which the flexor tendons are lying, are situated along the under surface of the phalanges of the toes, and are particularly attached to the sharp edges of these bones (see Foot-, Jots is or). They have a smooth synovial lining which prevents the effects of friction upon the tendons, and facilitates their movements.
From the description which has now been given of the organization of the plantar region of the foot, we readily perceive, 1st, Why deep wounds of this part are both followed by considerable hmmorrhage, and why this is at the same time very difficult to stop. The arterial branches are numerous and he deep. Before we can get at them either to press upon or to tie them, we must do so through a thick integument, a dense tendinous fascia, and deep-seated layer of muscles. If we dilate the opening in all these parts we wound many more branches, while it is impossible at such a depth, and through such part, to discover the bleeding vessel, if the opening is small. We are, therefore, compelled in such a case, if pressure will not stop the haemorrhage, to tie the posterior tibial artery, either behind the ankle or at the lower third of the leg. But even this is sometimes not suflicient to stop the haemor rhage, owing to the free anastomosis of the arteria dorsalis pedis with the plantar arteries ; and we are then compelled also to tie the anterior tibial. 2d, We see why inflammation and suppuration in these parts, whose parietes as well as contents are in great measure ten dinous, are threatening both in their present symptoms and in their consequences. Not only is the ready detection of suppuration pre vented, but the efforts of nature to bring it to the surface are resisted. The inflamed parts are bound tight; if matter has formed, it is obliged to burrow laterally, in contact with nerves, arteries, tendons, &c. The inflamma tion spreading to the synovial sheaths either impairs or destroys the movements of the tendons in them, or, going still further, com municates the inflammation to the tendon, and occasions it to slough. Moreover, the tendinous structure which envelopes some of these bursal cavities is the cause of those violent and alarming symptoms of constitu tional irritation, by no means uncommon when only a very small quantity of matter has formed within then), a state sometimes almost instan taneously relieved by a judicious opening made with the lancet, and giving exit to even so small a quantity of pus. 3d, Why severe contusions or lacerations are here so often followed by bad consequences, the power of repair in tendinous struetures, which so largely enter into the composition of the parts about the foot, being small, and consequently the inflammation fre quently proving the destruction either of the structure or the functions of the parts affected.
The study of the nature and position of these joints of the foot is of great interest and im portance to the surgeon, and it will not be in appropriate in this article to offer some obser vations upon some of the operations in which they are concerned. Modern surgery, whose greatest triumphs have been in the saving of limbs, not in removing them, in discovering the least possible quantity of loss by which the disease might be eradicated, rather than the readiest method of taking off the entire limb, has taught us not to be deterred by the intrica cies of the numerous joints of the foot, but fearlessly to lead the knife through any part of them, so that we may only save a serviceable portion, which may be more convenient than a wooden substitute. The removal of the toes at their joints is comparatively easy, though it should be remembered, in amputating at the metatarso-phalangeal joint, that this articulation is situated much deeper than the corresponding one of the hand, owing to the greater length of the web and greater thickness of the member itself. The metatarsal bones may be removed separately or altogether from their junction with the tarsus, as first done by Hey of Leeds, and described in his Surgical Observations. The removal of a single bone is, except it be either the first or the fifth, more difficult and even more dangerous, in regard to the liability to after inflammation, than the removal of the whole metatarsus. In performing this last operation, the guide for entering the whole row of joints is the projecting tubercle of the fifth metatarsal bone, immediately behind which the joint may be opened, and on coming to the projection of the inner cuneiform bone, (see 167,) most surgeons recommend the cutting off its projecting part, rather than to finish by opening the joint. The tarsal bones have been extracted, both with and without the attached metatarsal bones. Of the former kind a very remarkable instance is given by Mr. Key in the second number of Guy's Hospital Reports, in which the only bones of the tarsus left were the os calcis, astragalus, scaphoid, and internal cuneiform bones as a support to the great toe. (See figs.167 and 168, in the first of which the dotted line represents the portion of the bones of the foot which was removed in fig. 168.) Should disease or accident have destroyed all, or most of the bones in the front row of the tarsus, they may all be readily removed by amputation at the astragalo-scaphoid and calca neo-cuboid joints, an operation generally known as that of Chopart, who first practised it. How far, however, such a portion of the foot pre served is preferable to the use of a short wooden leg applied to the end of the limb, amputated a little above the ankle, (a plan which we have used with perfect success,) certainly admits of a doubt. At any rate its advantages cannot be put in competition with the principle so admi rably illustrated by Mr. Key in the before mentioned case, of saving, if possible, a portion of the metatarsus and toes, though at the risk of a more painful, and perhaps more dangerous operation.