136 



REGIONS OF THE LEG. 



upon the slump itself, but it is divided between 

 this and some part of the anterior surface of 

 the leg, generally falling most powerfully 

 about the tubercle of the tibia. The bearing 

 on the anterior part of the leg is so strong, 

 that unless the precaution is taken of well 

 padding that part of the wooden box, the 

 pain occasioned by the pressure entirely pre- 

 vents the use of the wooden leg ; but by the 

 use of this precaution all inconvenience is ob- 

 viated, and by this support to the weight of 

 the body a valuable help is found for the pre- 

 vention of injury to the cicatrix of the stump. 



The French surgeons used to recommend 

 this mode of applying the artificial leg, but 

 only in cases of conical stump, or at least 

 where the integuments were from excess of 

 inflammation after the amputation closely ad- 

 herent to the bones.* But we have found it 

 applicable to every case of amputation below 

 the knee. The superiority which this wooden 

 leg gives to amputations below the knee over 

 all those at the ankle and through the joints 

 of the foot is obvious. Besides saving the 

 extra pain and risk of inflammation, it affords 

 a much better point of support than the muti- 

 lated foot can form. 



The anterior surface of the tibia being sub- 

 cutaneous, and not covered by any artery of 

 importance, indicates the region which should 

 be chosen for exposing, when we would re- 

 move a portion, trephine, extract sequestra, 

 balls, &c. Superiorly, as its external region is 

 only covered by the origin of thetibialis anticus 

 muscle, it is favourable to the same operation. 

 This consideration is the more important since 

 the publication of the very valuable observa- 

 tions of Sir B. Brodie on abscess in the can- 

 cellated structure of the tibia, a disease which 

 till then was little understood and scarcely at 

 all described, and which, from our own expe- 

 rience, we are inclined to think has not un fre- 

 quently cost the patient a limb, which by a 

 more correct knowledge of the disease might 

 have been saved.-f 



The periosteum of this anterior surface is the 

 subject of troublesome inflammation more fre- 

 quently than that of the other parts of the bone, 

 in consequence of its greater exposure. Com- 

 mon inflammation of it is often productive of 

 abscess, necrosis, &c., or in a scrofulous dia- 

 thesis, of caries ; while syphilitic inflammation 

 is here showing itself in the form of nodes, 

 occasioning great trouble to the surgeon and 

 suffering to the patient, and generally leaving 

 some permanent thickening. These nodes, 

 which, as we have said, generally occur on the 

 anterior surface of the bone, are sometimes 

 thrown out upon the external and posterior 

 parts, and when they do thus occur are 

 doubly embarrassing to the surgeon from their 

 deep situation among the muscles, and from 

 the general similarity of the symptoms to mus- 

 cular rheumatism ; the extreme tenderness of 



* See Dictionnairc des Sciences Medicales, Art. 

 Jambe. 



t See also some excellent practical observations 

 on tbe subject in Liston's Elements of Practical 

 Surgery, p. 95. 



the periosteal inflammation, much more acute 

 than that of rheumatism, and the more circum- 

 scribed nature of this tenderness, are signs 

 which will facilitate the diagnosis, a subject, 

 however, upon which it is not here the place 

 to dilate. 



In the foetus, the tibia presents merely a 

 slight curve anteriorly, which appears to be 

 augmented in the adult by the weight of the 

 body. The posterior muscles, stronger and 

 more numerous, acting on the flexible bones, 

 concur to the same end. Thus, in fractures, 

 particularly from indirect causes, the angle 

 formed by the fragments of the tibia is almost 

 always in front, and the limb bends in the 

 situation of the fracture. 



Experience proves that the two bones of the 

 leg are more frequently broken together than 

 singly, a fact ascribed by Boyer to the strength 

 of the knee and ankle-joints. The direction of 

 an oblique fracture of the tibia is generally 

 from below upwards and from within out- 

 wards, a circumstance due to the form of the 

 bone. The end of the upper fragment then 

 presents itself under the skin, at the front and 

 main part of the leg. The most frequent situa- 

 tion of fracture of either of the bones of the 

 leg is at the lower third; this, in the tibia, is 

 readily accounted for by its being here more 

 exposed to injury and being smaller and weaker 

 than elsewhere ; in the fibula, on the contrary, 

 this part is not weaker, but is here placed more 

 superficial, the upper part being completely 

 covered and much defended by a cushion of 

 muscle. Fractures of the tibia at its upper 

 part are less liable to displacement than lower 

 down on account of the greater thickness of 

 the bone, but the vicinity to the knee-joint 

 here increases the danger of a fracture consi- 

 derably. In consequence of the thickness of 

 the bone at this point, fractures here are ordi- 

 narily transverse, while the abundance of 

 spongy tissue causes them to unite quickly and 

 easily. The tibia is more frequently ^broken 

 by itself than the fibula because it alone sus- 

 tains the whole weight of the body, while the 

 fibula has nothing to support. In fact if the 

 fibula is generally broken at the same time 

 with the tibia, the injury to the fibula is but 

 subsequent to the other, and takes place be- 

 cause this slender bone is not capable of bear- 

 ing the weight of the body, the impulse of ex- 

 ternal violence, or even the action of the mus- 

 cles, after the tibia has given way.* 



There is rarely much displacement, as re- 

 gards the length of the bones, at whatever 

 point their fractures may have occurred, unless 

 the cause has continued to act after the solu- 

 tion of continuity. This appears to result 

 from the muscles being inserted over the whole 

 of the bony surfaces. 



When the fibula alone has been broken, 

 there is very little deformity resulting, as the 

 principal support of the limb still remains, 

 particularly if the injury has resulted from 

 external violence. When however the cause 



* See Cooper's Surgical Dictionary, article Frac- 

 ture. 



