128 
skin has full opportumity 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 halt the entire leg ha en cut 
away.* The most dense and strong 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 
uantity of integument, however unsightly, is 
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,. 
REGIONS OF THE LEG. 
flames and may become the seat of ex 
inflammation and abscess. When the in 
mation has terminated in gangrene, the slot 
ing process in this cellular tissue is r 
and often very uncontroulable ; and ¥ 
destruction has occurred to conside 
tent, in the after process of reparation 
cellular web is so short, close, and in 
to materially impede the freedom of mover 
in the limb. When pus has. been form 
facility which the loose texture of the s 
ficial fascia offers for its spreading in all ¢ 
tions, points out the necessity for early an 
incisions through the integuments; and 
before this stage of the inflammation, and ' 
it is in its most active state, the same 
practice offers us the best means of arresti 
progress. This cellular layer is the seat« 
effusion in phlegmonous_ erysipelas, ¢ 
phlegmasia dolens, and partially so 
phantiasis. The distension which th 
and the integument over it undergo in the) 
eases just mentioned, is occasionally e 
and affords a striking contrast between 
elastic properties of the natural and adventit 
structures. When anasarca distends a leg u 
which an old cicatrix exists, the newly for 
cellular web of this part is so little elastic 
so little admits the fluid into its cells 
considerable depression is seen here in 
midst of the general swelling. a 
Imbedded in this superficial fascia we 
a number of veins which are various in} 
none very large in the natural state, nun 
and here possessed of more surgical 
and importance than in any other superf 
region of the body. They are principal 
ranged in two sets; one commencing @ 
the inner ankle, and running along the i 
side of the calf, terminates just below the 
by one trunk called the internal or 
saphena. The other set form the sap 
minor, by coming from the outer ankle, ak 
the outer and back part of the leg, and tert 
nating in the popliteal vein in the midd 
the ham. This vein is superficial only im 
lower two-thirds of the leg ; after this, it; 
through the layers of the aponeurosis, and 
under it till its termination. This is the m 
ordinary course of them, but no part of 
circulating system is more various than t 
superficial veins in their divisions and arr 
ment. These veins, by becoming yari¢ 
frequently occasion great suffering to the 
tient, and annoyance to the surgeon, by 
difficulty of their cure. The saphena ma 
more liable to this state of disease than 
minor; indeed few persons whose habits a 
be much in the erect posture appear to a 
ag age without being more or less trot 
y it. 4 
The deeper seated veins, which accom 
the arteries, lie imbedded among the mu 
and from them receive considerable p 
support, in sustaining the weight of the coh 
of blood above them, and still more in ana 
sense, when, in contracting, the muscles: 
and press against their sides, and thus 
forcing onwards their contents. & 
« 
ae 
Pa eee ee ee ee er eee 
