A modern case study of a foot and ankle from the mid-Victorian era

By David Holland, BSc, CSci, FFPM-RCPS(Glasg). Chartered Scientist and Podiatry Expert Witness

On page 178 of the first edition of Gray’s Anatomy (Henry Gray, 1858), human ankle articulations are described. The illustration - on the same page - shows a medial (inside) view of a right-sided foot and ankle dissection. The ligaments are notable for their robustness.

Ligaments are strong, flexible structures which connect bone to bone. They are composed of inorganic matter, fibroblasts, and an extracellular matrix (D Amiel, 1984). They allow minimal movement of bone whilst having the ability to resist applied forces so that joint congruency remains intact (Angela Lis et al - 2012). Under muscular control the foot - shod or unshod - is able to conform to most types of supporting surface. The ligaments ensure that the articulating surfaces forming the joints stay in close proximity, enabling the foot to convert from a flexible structure on landing to a stiff structure for push-off during walking or running (James et al, 1978).

A written account of Carters’ illustrations for the 1st edition of Gray’s confirms that in the main they were an accurate representation of the specimens in front of him. “In the majority of cases, they (the illustrations) have been copied from, or corrected by, recent dissections, made jointly by the author (Gray) and Dr Carter” (H. Gray,1858).

Other anatomical texts of the time also show ankle ligaments. This next is from Quain’s, by Jones Quain and Erasmus Wilson (1842). It is impossible to do a direct comparison with Gray’s. The Quain’s illustration is drawn in a very different style, and the foot is slightly adducted on the long tibial axis, whereas in the Gray’s illustration the observer looks directly at the medial ankle in the sagittal plane.

Gray and Carter only collaborated on the first (1858) edition of Gray’s (Ruth Richardson, 2008). The second edition was published in 1860 - Gray died suddenly in 1861. The meticulous editorial control exerted by the author - which included the illustrations by Carter, and which characterised the first edition, was thereby lost from the second edition onwards.

London. Longmans, Green: 1918.

The previous illustration is from the twentieth (1918) edition of Gray’s. The same illustration is found on page 455 of the twenty-fourth (1930) edition of Gray’s - both published by Longmans, Green of London. A direct comparison between the first edition (1858) illustration in Gray’s, and this later (1918/1930) illustration is possible because they are both sagittal plane views of a right foot and ankle, drawn in a similar style. The ligaments in the later illustration are less robust. It is also interesting to note that although the illustrations were drawn by different artists, both show a clear medial longitudinal arch, formed by bony architecture and held in place by ligaments. The first edition makes no mention of foot arches at all.

A sagittal plane view of the medial ligaments of the left foot and ankle - in which the ligaments are even more attenuated compared with the 1918/1930 illustration - can be found in more recent editions of Gray’s (2008).

This case-study concerns the cadaver subject of the 1858 illustration by Dr H.V. Carter MD. Whilst it is impossible not to introduce some conjecture in a case study dependent on an accurate drawing of a specimen which is over a hundred and sixty years old, the author has been careful to explain his opinions and reasoning, and given references wherever possible. It is important for the reader to note that it is highly likely that this (1858) illustration was drawn directly from a cadaver dissection, and not copied from a previous illustration. In England in the 1850’s the only legal sources of cadavers for anatomical dissection were paupers and prisoners whose families could not pay for a burial, unclaimed bodies, and the deceased inmates of Workhouses (Anatomy Act of 1832). The cadaver may have been sourced illegally of course - from the euphemistically-named “resurrection men” (they resurrected the newly-buried dead). The dissection is suggestive of a fresh specimen - the cadaver was therefore relatively recently deceased at the time the illustration was made, there being no effective long-term cadaver storage facilities available to Gray or Carter. The foot and ankle are those of an adult male or female, in good health at the time of death (i.e. with no obvious signs of systemic disease or decline). That points to the source of the cadaver as suicide or grave robbery, rather than the workhouse. The presence of physiological ageing, disease, and/or malnutrition are suggestive of poverty and perhaps the workhouse or prison. There are no signs which would indicate anything other than a healthy body on the specimen. Robust ligaments suggest well-developed musculature - to be expected in a manual worker used to heavy work. In mid-Victorian London manual-labour workers were usually male rather than female.

Robust ligamentous development then, in an ankle and foot in which there is no obvious disease, wasting of the tissues, physiological ageing of the ankle and foot, signs of malnutrition, or putrefaction, strongly suggest that Carter’s illustration is of the foot and ankle of a male cadaver - either a recently-buried and recently “resurrected” accident victim in which the ankle and foot were undamaged (too many coincidences?), or a suicide, or an unclaimed body from prison or hospital. There is also an outside possibility that the foot and ankle could be from a limb amputation. It is such a good specimen that it is hard to imagine that Anatomists of the time would have allowed it to be destroyed.

If the subject has been identified, as far as is possible to do so, what else can be gleaned from the 1858 illustration by Carter?

Archaic terminology - extant in 1858 - has been used - Os-Calcis for Calcaneum, Astragalus for Talus, and Scaphoid for Navicular, Internal-lateral rather than Medial (pertaining to the Deltoid ligament).

The bony and ligamentous architecture is clear, and anatomically correct. The specimen exhibits robustness of the ligaments in comparison to cadaver specimens today - one explanation for this may be our (largely) modern sedentary living habits compared to our Victorian forebears. Normal growth in bones, ligaments, and muscle is directly affected by use and disuse. Increased use will result in increased tissue mass, decreased use will result in decreased tissue mass.

There is a clear medial longitudinal arch in the 1858 illustration, yet Gray did not think to describe, or make any comment about it.

In general, foot arches gained medical attention only after the first edition of Gray’s had been published. Coincidentally, Darwin’s On the Origin of Species was published in 1859. The possibility raised - of evolutionary development over divine creation - caused a huge furore (M. R. Rose, 1998). The Church were particularly vehement in their support of orthodox Christian teaching. Man being created in God’s image was a main tenet of Christian teaching at the time. Did Gray try to ensure that his cadaver specimen reflected this by showing a developed foot arch which is only present in humans? The question is almost redundant before it is asked. The 1st edition of Gray’s pre-dated Darwin, and even if Gray had been anti-Darwinian, he died in 1861. He had no involvement with any edition of his book past the second (1861) edition.

As Gray and Carter showed (unwittingly) back in 1858, the shape of the medial longitudinal arch depends - not on muscle - but upon the bony and ligamentous architecture of the foot and ankle (McMinn et al, 1996). Muscular activity affects arch-shape when the subject supports and ambulates. Arch-shape is also dependent upon the supporting surface - a mildly flat foot will appear normal, and function normally on an undulating and/or soft, supporting surface.

A scientific method of analysing the weight-bearing footprint during gait, by means of an inked mat, was initially formally described by Ernest Onimus (1876). The inked mat became an objective tool with which physicians could pronounce whether feet, and gait, was normal or abnormal. Arch-height - too much or too little - became an anomaly (mild cases) or a medical condition (severe cases). The inked mat depended on the subject standing or walking on the mat which was placed on a hard, flat surface in order to capture a satisfactory print. A medical convention - still in widespread use today - was thus established for examining foot arches, and gait - on hard, flat surfaces only.

This evaluation (and the biomechanical evaluation which follows it) is based upon the drawn evidence of a dissection of the right foot and ankle by Dr H.V. Carter (1958), together with what is already known about normal foot function. The author of this article has assumed that the foot and ankle in question were drawn directly from a cadaver specimen. He has further assumed that the contralateral (left) limb was the same as the right (i.e. not deformed or malfunctioning in any way). It is likely that the original owner of the 1858 first edition cadaver ankle and foot was male, and that he was a manual worker, in good health at the time of his demise. The sagittal plane view of the dissection exhibits a healthy right foot and ankle.

The robust Deltoid ligament so clearly seen on Carter’s illustration provides a strong tie between the distal end of the tibia and the calcaneus, the anterior and posterior portions of the talus, and the navicular. It ensured that the foot was able to move easily around the long axis of the tibia via the subtalar and mid-tarsal joints, without the arch collapsing. There was no excessive internal rotation of the tibia which is often found in conjunction with a flattened arch (B. Hinterman, 1994). The tibia was therefore able to remain vertical in the frontal plane (i.e. viewed from the front or back) when the subject supported and ambulated. Vertical tibiae facilitate good posture. This geometry allows simultaneous tri-plane motion (inversion/eversion, adduction/abduction, dorsiflexion/plantarflexion) at the ankle-joint-complex, which comprises the subtalar and tala-crural joints. The tibiae are able to remain vertical in the frontal plane whilst the tai-plane motion occurs (Hagins and Pappas, 2012). The subject could therefore ambulate comfortably - which is to say efficiently and with no effort - on a mix of supporting surfaces. That is important - Victorian London (and surrounding areas) was not wellpaved, apart from a few areas, and certainly not paved and concreted like present-day London.

The adult male subject had normal foot arches, good posture, and good balance. He was probably healthy at the time of death, physiologically well-built, and strong. Stridelength was normal for a man of his height. When standing, his feet were not overly abducted. The feet were capable of the normal sagittal plane components of gait - heel-strike, mid-stance, and toe-off - when walking on flat surfaces. On surfaces which were undulating and/or soft, the feet could conform to the supporting surface comfortably, whilst allowing the trunk to remain erect and balanced.

The Quain’s of 1842 was not a lightweight text - it took two library staff to manoeuvre it onto the photocopier in order to obtain the image for this article! Gray’s Anatomy was miniature, and pocketable compared to Quain’s, which would explain, at least in part, the instant popularity of the early editions of Gray’s with medical students.

I’m very grateful to the Librarian and staff at the Royal College of Physicians and Surgeons of Glasgow for their time and help in sourcing original material for this article, suggesting alternative material when specific, early volumes were not immediately available, and for the use of their photocopying facilities.

Anatomy Act - An Act for regulating Schools of Anatomy. The National Archives. (1832). Amiel D, Frank C, Harwood F, et al.Tendons and ligaments: A morphological and biochemical comparison. J Orthop Res, 1, 257. Gray Henry. Gray’s Anatomy, Descriptive and Surgical. Pub: John W Parker and Son. 1858. Gray H, Gray’s Anatomy - preface to first ed (1858). Ibid. Pub: Longmans, Green, London (1918). Ibid (1930). Ibid Pub: Churchill Livingstone Elsevier (2008). Hagins M, Pappas E. Biomechanics of the Foot and Ankle, in Basic Biomechanics of the Musculoskeletal System, 4th (international) ed. Pub: Wolters Kluwer, Lippincott, Williams and Wilkins, pp 228. (2012). James SL, Bates BT, Osterning L R. Injuries to runners. Am J of Sp Med. 6, 2, 40-49 (1978). Lis A, Castro C D, Nordin M. Biomechanics of Tendons and Ligaments, in Basic Biomechanics of the Musculoskeletal System, 4th (international) ed. Pub: Wolters Kluwer, Lippincott, Williams and Wilkins 2012 - pp 109/110. McMinn, RMH, Hutchings RT, Logan BM. Colour Atlas of Foot and Ankle Anatomy, 2nd ed, Pub: Mosby-Wolfe, pp 84 (1996). Onimus E. “Des deformations de la plante des pieds, spécialement chez les enfants, dans les affections atrophiées et paralytiques de la jambe: Memoire lu a L’Association française pour l’avancement des sciences, dans la seance du 19 aout 1876.” Gazette hebdomadaire de médecine et de chirurgie 34, pp 531-33 (1876). Quain Jones, Wilson Erasmus. The bones and ligaments of the human body: in a series of plates, with references and physiological comments. Pub: London, Taylor and Walton (1842). Richardson, R. The Making of Mr Gray’s Anatomy. Pub: Oxford University Press (2008) pp 229. Rose M J. Darwins Spectre. Evolutionary Biology in the Modern World. Pub: Princeton University Press, pp 31 (1998).