352 



REGIONS OF THE FOOT. 



conical form of the foot, can with greater 

 difficulty be retained. 



Besides the veins, we find imbedded in this 

 same layer of cellular tissue a number of 

 nervous filaments, which should be remem- 

 bered as occasionally interfering with operations 

 on this part. The last portion of the saphenus 

 or long cutaneous nerve runs so near to the 

 saphena major vein that some of its twigs 

 pass in front of and some behind it, and 

 have been occasionally punctured in opening 

 this vein ; but this should form no stronger 

 an objection to this operation than a similar 

 arrangement of the nerves, and a similar 

 accident in bleeding, which occasionally hap- 

 pens, should be allowed as an objection to 

 venesection at the bend of the arm. 



3. The next layer brought into view by 

 dissection is a thin expansion of fascia, con- 

 tinuous with the anterior annular ligament of 

 the ankle, and formed of fibres running in 

 various directions, principally transverse and 

 spreading over the whole of the dorsal region, 

 but principally at the upper part. The ob- 

 servations which have been made on this same 

 fascia when covering the ankle may be applied 

 also to the part just described, (see ANKLE- 

 JOINT, REGION OF,) with this exception, that 

 as the dorsal fascia is much thinner and more 

 incomplete than that over the ankle, matter 

 would here not be so tightly bound down, nor 

 would it present so strong an obstacle to the 

 pointing of it outward. 



4. On removing the layer of aponeurosis 

 a muscular and tendinous stratum is exposed, 

 comprehending the entire muscle of the ex- 

 tensor brevis digitorum and the tendons of 

 several of the long muscles situated on the 

 leg. The first of these has a thick fleshy 

 belly, and occupies the outer part of the 

 dorsum of the foot, sending its tendons down, 

 like so many rays, to the bases of the toes. 

 The tendons are spread over the foot in the 

 following order : on the inner side the tibialis 

 anticus passing to be inserted, by a broad 

 attachment, into the internal cuneiform bone 

 and base of the first metatarsal bone ; next 

 the extensor proprius pollicis runs forwards 

 and inwards, along the fibular edge of the 

 first metatarsal bone; then the tendons of the 

 extensor longus digitorum run diverging to- 

 wards the bases of the four outer toes, crossing 

 over the tendons of the extensor brevis ; and 

 lastly, the tendon of the peroneus tertius, 

 diverging from the extensor longus, sends its 

 small flat tendon to the base of the fifth me- 

 tatarsal bone. Each of these tendons runs 

 in its own synovial sheath, and these are, 

 from their superficial situation and from their 

 proximity to the bones over which they pass, 

 peculiarly liable to be affected by pressure, 

 as from tight boots. The consequence of this 

 is not unfrequently seen in a small round 

 swelling, situated generally over the tarsal 

 bones, and upon one of the tendons of the 

 extensor digitorum longus. It is first dis- 

 covered generally by its tenderness, and when 

 this is relieved by taking off the pressure 

 which was its first cause, the swelling itself 



still remains, soft and elastic to the touch, 

 and having all the characters of an enlarged 

 bursa, and which has received the name of 

 ganglion. The cure may generally be accom- 

 plished easily and expeditiously : a smart blow 

 with some hard body, as the back of a book, 

 while the swelling is rendered tense by the 

 forcible extension of the foot, will be all that 

 is necessary; the cyst is thus burst, and its 

 synovial contents, when extravasated among 

 the adjacent cellular tissue, soon become ab- 

 sorbed, while the empty cyst itself shrinks 

 and contracts to its natural size. Should, 

 however, this plan not be approved, or, which 

 may happen, not succeed, the introduction of 

 a cataract needle in an oblique direction under 

 the skin, and the puncture of the cyst, will 

 evacuate the fluid into the surrounding cellular 

 tissue, and thus effect a cure.* 



A tumour is sometimes formed upon the 

 instep, which is also the result of pressure, 

 and which bears a near relation to a corn. 

 It is met with in young men who wear tight 

 boots, and the usual situation of it is over 

 the articulation between the internal cuneiform 

 bone and the metatarsal bone of the great toe. 

 The tumour is under the skin, hard and im- 

 movable ; so that it seems to a superficial 

 observer to be an enlargement of the bone 

 itself. The skin over it is in a natural state, 

 except in cases of long standing, in which 

 the cuticle becomes thickened. This swelling 

 is described by Sir B. Brodie in a clinical 

 lecture in the Medical Gazette, vol. xvii. 

 He is uncertain in what precise situation this 

 tumour exists, whether in the ligaments of the 

 joint, or periosteum, or in the ultimate fibres 

 of the tendon of the tibialis anticus muscle, 

 not having had an opportunity of dissecting it. 



In this view also are exposed the course and 

 situation of the dorsal artery of the foot. This, 

 which is merely the continuation of the anterior 

 tibial artery, commences its course from the 

 anterior annular ligament of the ankle, a little 

 to the inner side of the middle of the foot; 

 from thence it runs obliquely towards the 

 first interosseal space of the metatarsal bones, 

 at the commencement of which it dips into 

 the sole of the foot, leaving only a branch to 

 continue its course to the great toe. In the 

 course just mentioned this artery rests upon 

 the bones of the tarsus, separated from them 

 and their ligaments only by a small quantity 

 of cellular tissue. It is accompanied by its 

 vein and a branch of a nerve, and will readily 

 be found running along the outer or fibular 

 edge of the tendon of the extensor proprius 

 pollicis, which partly overlaps it. Notwith- 

 standing the superficial situation of this artery, 

 its close connexion with the above-mentioned 

 tendon renders it peculiarly ineligible for the 

 application of a ligature, and fortunately it is 

 very rarely that we are called upon to perform 

 an operation upon it; but its course and 

 situation are important to the surgeon, as afford- 

 ing a valuable diagnostic mark, negative at 



* See a paper on Ganglion by C. A. Key, Esq. 

 in the 1st vol. of Guy's Hospital Reports. 



