REGIONS OF THE LEG. 



135 



flap in amputation. In the circular operation 

 the section of the flesh, which can only be 

 effected by passing the point of the knife 

 transversely over the bottom of the interosseous 

 fossae, is equally difficult in the flap method, 

 in making the anterior flap, in consequence of 

 the depth of the space in which the muscles 

 are lodged. The difference of size of the two 

 bones and the posterior relative situation of the 

 fibula renders some precaution necessary in 

 dividing them with the saw. The foot must 

 be turned in, so as to bring the fibula a little 

 forward, and care must be taken to commence 

 the section upon the tibia as being the longest 

 and strongest, but to finish the section of the 

 fibula first, since it is too thin and mobile to 

 support the movements of the saw without 

 breaking at the termination. In amputation 

 above the tubercle of the tibia, it has been held 

 advisable to remove the head of the fibula 

 from its joint, since this small portion of the 

 bone is of no advantage to the stump and by 

 its mobility may be some hindrance in the 

 after treatment. (See KNEE-JOINT.) 



The small size and moveable nature of the 

 fibula constitutes some difficulty in the treat- 

 ment of fractures of the leg, since the appli- 

 cation of the ordinary bandages, &c., would 

 have a tendency to press the bone inwards 

 against the tibia, and we not unfrequently see, 

 in old united fractures of these bones, this 

 deformity to have been produced, in all proba- 

 bility, from want of due precaution in the ap- 

 plication of bandages. The defect may be 

 obviated by proper care, that neither the splints 

 nor the cushions should take any bearing upon 

 the fibula itself except at its two extremities, 

 and great assistance may be derived from 

 proper pressure, before and behind, upon the 

 muscles, gently forcing them against the inter- 

 osseous ligament and bearing outwards the 

 bone attached to it. 



After amputation of the leg, the tibia pre- 

 sents a triangular surface, having the apex for- 

 wards. As the skin covering it is hereby in- 

 vested with the subcutaneous layer, it may, by 

 pressure against this projection, ulcerate, or 

 slough, and thus expose the bone. The great 

 means for obviating this accident is to have a 

 good supply of integument in the flap, so that, 

 in bringing the parts together afterwards, they 

 may not be drawn too tight over the bone. 

 While this rule is attended to all will go on 

 well, whereas when the integument is left scanty, 

 nothing can prevent unpleasant consequences. 

 ]t may often, however, be advisable to remove 

 with the saw the projecting angle of bone, and 

 as a matter of precaution we generally do this, 

 though not attaching much importance to it.* 



In amputating above the tuberosity of the 

 tibia, we run the risk of opening into the knee- 

 joint, as the synovial membrane is sometimes 

 prolonged thus far. According to M. Lenoir 

 the synovial cavity of the knee is continuous 

 with that of the superior tibio-fibular articu- 

 lation, once in four times. f There are always 



* See Bell's Operative Surgery, vol. ii. p. 2'2. 

 t Sec Velpcau's Anatomy of Regions, p. 484. 



three principal vessels to be tied in this ope- 

 ration : first, the anterior tibial, which is found, 

 with its collateral nerve, close upon the inter- 

 osseous ligament; secondly, the posterior ti- 

 bial, in contact with the deep layer of the 

 aponeurosis, and having its nerve to its outer 

 side ; and, thirdly, the peroneal, which is 

 found imbedded in the flexor longus pollicis 

 muscle, and may be readily tied without fear 

 of injuring any nerve. These three arteries 

 sometimes retract so far into the flesh after 

 amputation, that to secure the anterior tibial 

 it is necessary to cut through the interosseous 

 ligament to the extent of some lines. This 

 probably arises principally from the attachment 

 of the muscles to the whole parietes of the 

 interosseous fossa, while the vessels, enveloped 

 by elastic cellular tissue, retract considerably. 



It must be borne in mind, that in whatever 

 situation the amputation may be performed, if 

 it be the flap operation the arteries of the flap 

 are much more difficult to be found and se- 

 cured, owing to the oblique nature of the sec- 

 tion, than where, as in the circular operation, 

 the muscles and vessels are cut transversely 

 through. 



When the amputation is just below the tu- 

 berosity of the tibia, the nutritious artery has 

 here sometimes a volume sufficient to require 

 a ligature. With the exception of this last, 

 the arteries to be tied will be nearly tiie same, 

 in whatever part of the length of the leg the 

 amputation is performed. The muscular 

 branches seldom occasion much inconvenience 

 from haemorrhage. 



It may not be out of place here to remark 

 on the subject of amputations of the leg, that 

 the division of the bones high up may often 

 save the knee, and thus give a good bearing 

 for a wooden leg, but that we are too often apt 

 to act upon the principle that, in amputations 

 below the knee, this joint must necessarily be 

 the bearing point ; whereas we are convinced 

 that a much more useful stump is gained by 

 saving as much as possible of the leg, at least 

 as far as half of its length, with the view of 

 applying the wooden leg to the stump itself, 

 and so preserving entirely the use of the knee- 

 joint. We have now adopted this plan, with 

 the most perfect success, in several instances, 

 and always to the great comfort and satisfaction 

 of the patient. Indeed, the loss of the limb, 

 which is thus remedied, is really little felt, 

 when compared with the great inconvenience 

 of making the knee the bearing point, and thus 

 taking away all the benefit of it as a joint. 

 The reason why this mode of operating has 

 not been more generally adopted, appears to 

 us to consist in the fear that the cicatrix of the 

 stump is ill able to bear the weight of the body 

 in walking, when pressed between the ends of 

 the two bones and the artificial leg. But be- 

 sides that by the flap amputation in the middle 

 of the leg, (the best possible situation for this 

 operation; when practicable,) a soft cushion of 

 muscle can be added to the integumental 

 covering to obviate the effects of pressure, the 

 fact is that in the application of the artificial 

 leg to this stump, the bearing is not entirely 



