REGIONS OF THE LEG. 



skin has full opportunity to exert itself, and 

 this it does sometimes to a degree that is re- 

 markable, acting as a sort of ligature upon the 

 back part of the leg. We have seen a case 

 where, by the cicatrization of an old and very 

 extensive ulcer, the lower part of the calf of 

 the leg, viewed in profile, had an appearance 

 as if more than half the entire leg had been cut 

 away.* The most dense and strung part of the 

 integument of the leg is over the inner side of 

 the tibia where this forms the only covering of 

 the bone, while at the upper and back part of 

 the leg the skin is exceedingly thin and deli- 

 cate, and devoid of hairs. We may here re- 

 mark, in illustration of the properties of the 

 integuments of the leg, important in relation to 

 surgery, that the contractile property of the 

 skin is usefully exemplified in amputation, 

 when, should the flap of the integument be more 

 extensive than we desire, even to a great de- 

 gree, we always find that in the progress of the 

 case it contracts so much as to exhibit no re- 

 dundance in the end ; in fact that a large 

 quantity of integument, however unsightly, is 

 far less to be dreaded than the opposite defect. 

 It is not our intention here to enter minutely 

 upon the diseases of the parts we are now de- 

 scribing, but we cannot refrain from alluding 

 to a state of disease of the integuments which 

 we have never seen but in the leg, and of which 

 we have met with no account in books. It 

 consists in a soft elastic swelling, generally 

 occupying the entire circumference of the leg, 

 for the lower third or fourth of its length, 

 though often much less. The skin over it is 

 considerably redder than natural, and of a 

 somewhat dark colour. It is not at all tender 

 to the touch, but is exceedingly painful when 

 the foot is down and in exercise ; on pressing 

 the finger firmly upon it no pit is left, but the 

 skin is very white until the capillaries fill again, 

 which they do slowly. Should the skin ulce- 

 rate, the sore is very slow in healing, and gene- 

 rally has a brownish unhealthy look, but the 

 state in question often lasts for years without 

 any ulceration occurring. The disease is very 

 indolent, neither increasing nor diminishing in 

 extent for many years. We have not been able 

 to trace it satisfactorily to any cause more than too 

 much standing. All the cases observed by us 

 have occurred in females between the ages of 

 twenty and forty, whose employment kept 

 them very much on foot. It appears to us to 

 consist in a varicose state of the capillaries of 

 the cellular tissue and inner side of the cutis. 

 No treatment that we have employed has had 

 anything more than a temporary effect. Pres- 

 sure, as long as it is continued, relieves it ; but 

 all the morbid symptoms return upon the 

 remedy being omitted. 



Immediately under the skin lies the cellular 

 tissue, which is a part of the general cellular 

 investment of the body, and is here known as 

 the superficial fascia of the leg. It is gene- 

 rally pretty thick, and is easily dissected back 

 in amputations. Placed between two solid 

 layers, the aponeurosis and skin, it easily in- 



* See article CICATRIX. 



flames and may become the seat of extensive 

 inflammation and abscess. When the inflam- 

 mation has terminated in gangrene, the slough- 

 ing process in this cellular tissue is very rapid 

 and often very uncontroulable ; and where this 

 destruction has occurred to considerable ex- 

 tent, in the after process of reparation the new 

 cellular web is so short, close, and inelastic, as 

 to materially impede the freedom of movement 

 in the limb. When pus has been formed, the 

 facility which the loose texture of the super- 

 ficial fascia offers for its spreading in all direc- 

 tions, points out the necessity for early and free 

 incisions through the integuments ; and even 

 before this stage of the inflammation, and while 

 it is in its most active state, the same bold 

 practice offers us the best means of arresting its 

 progress. This cellular layer is the seat of the 

 effusion in phlegmonous erysipelas, anasarca, 

 phlegmasia dolens, and partially so in ele- 

 phantiasis. The distension which this tissue 

 and the integument over it undergo in the dis- 

 eases just mentioned, is occasionally enormous, 

 and affords a striking contrast between the 

 elastic properties of the natural and adventitious 

 structures. W'hen anasarca distends a leg upon 

 which an old cicatrix exists, the newly formed 

 cellular web of this part is so little elastic and 

 so little admits the fluid into its cells, that a 

 considerable depression is seen here in the 

 midst of the general swelling. 



Imbedded in this superficial fascia we find 

 a number of veins which are various in size, 

 none very large in the natural state, numerous, 

 and here possessed of more surgical interest 

 and importance than in any other superficial 

 region of the body. They are principally ar- 

 ranged in two sets ; one commencing about 

 the inner ankle, and running along the inner 

 side of the calf, terminates just below the knee 

 by one trunk called the internal or major 

 saphena. The other set form the saphena 

 minor, by coining from the outer ankle, along 

 the outer and back part of the leg, and termi- 

 nating in the popliteal vein in the middle of 

 the ham. This vein is superficial only in the 

 lower two-thirds of the leg ; after this, it passes 

 through the layers of the aponeurosis, and runs 

 under it till its termination. This is the more 

 ordinary course of them, but no part of the 

 circulating system is more various than these 

 superficial veins in their divisions and arrange- 

 ment. These veins, by becoming varicose, 

 frequently occasion great suffering to the pa- 

 tient, and annoyance to the surgeon, by the 

 difficulty of their cure. The saphena major is 

 more liable to this state of disease than the 

 minor; indeed few persons whose habits are to 

 be much in the erect posture appear to attain 

 middle age without being more or less troubled 

 by it. 



The deeper seated veins, which accompany 

 the arteries, lie imbedded among the muscles, 

 and from them receive considerable passive 

 support, in sustaining the weight of the column 

 of blood above them, and still more in an active 

 sense, when, in contracting, the muscles swell 

 and press against their sides, and thus assist in 

 forcing onwards their contents. But these 



