134 
operation, before having recourse to so severe 
and hazardous a measure as that of tying the 
femoral or popliteal artery. 
The operation of tying the posterior tibial 
artery in the middle of the leg will be found 
much more difficult than either of the other 
situations mentioned, as this vessel here 
lies at such a depth from the surface, and is 
covered by the gastrocnemius and internal 
head of the soleus, which in this situation is 
attached to the tibia. To expose the arte 
here, the leg should be bent, the foot extended, 
and both laid on the outer side. The incision 
must be of considerable length, not less than 
four inches, along the inner edge of the tibia. 
The integuments and fascia being divided, 
(care being at the same time taken to avoid the 
saphena vein,) the edge of the gastrocnemius 
muscle will be exposed; this will be easily 
raised and drawn to one side. The soleus 
must next be divided from its attachment to 
the tibia, and at the bottom of this incision 
will be discovered some dense aponeurotic 
fibres, which are part of the deep fascia of the 
leg. The muscular fibres in the incision must 
now be held wide apart, and carefully sepa- 
rated from this deep fascia preparatory to its 
division, and immediately underneath this 
fascia lies the artery, with its accompanying 
veins, one on each side, with the nerve on its 
inner or tibial side, and here situated about an 
inch from the edge of the tibia. 
On the dead subject this operation is not 
attended with much difficulty; in the living, 
however, the case is very different; the mus- 
cles are then rigid and unyielding, and when 
the fascia which covers them is divided, they 
leave their natural situation, and become much 
elevated, so as to make the situation of the 
artery appear as a deep cavity, at the bottom of 
which the vessel is placed. The contraction of 
the muscles has been found in some cases so 
great an impediment to the operation, as to 
require the transverse division of part of the 
muscle. The operation of cutting directly 
from behind, through the fibres of the gas- 
trocnemius, is obviously still more objection- 
able, from the cause just mentioned. 
The second terminating branch of the pop- 
liteal artery is the peroneal. This is situated 
deeply, along the posterior part of the leg, 
taking the direction of the fibula ; hence it is 
sometimes called fibular. It commences about 
an inch or two below the lower border of the 
popliteus muscle, after perforating the tibialis 
posticus at the commencement of its course, 
and descends, almost perpendicularly, towards 
the outer ankle. In this course, it lies close 
upon the fibula, between the flexor proprius 
pollicis and flexor digitorum communis. On 
reaching the lower extremity of the interos- 
seous ligament, it divides into two branches, 
the anterior and posterior peroneal, the first of 
which passes through the aperture at this part 
of the interosseous ligament, and both of these 
run to the outer side of the foot. This artery 
is so small and so deeply seated, that its 
wounds are rare and unimportant. Hence 
but little has been said of its ligature, which 
REGIONS OF THE LEG. 
would be very difficult, and could be pe 
formed at the middle of the external side of 
leg. We should then divide the same parts 
for the tibial, but on the opposite side, a 
it is enveloped in the fibres of the flexor lor 
pollicis, we must also detach this muscle 
the fibula. - 
Each of these arteries of the posterior re 
is accompanied by two veins, which 
uently overlap the artery so as to conce 
rom view, in the operation of ‘inj 
they are also so adherent to its coats as to © 
sion some difficulty in separating dy | 
to avoid including them in the ligature, 
cularly where the artery, as in the f 
stance, is deep-seated. best 
accomplishing this is to insinuate the 
rismal needle first on one side, and t nA 
the other, not attempting to bring it outs 
opposite side of the artery, till, by this 
the lateral attachments are se .. 
The deep nerve which accompa 
posterior tibial artery is the tibial, 
considerable size, being the continu: 
the trunk of the popliteal. It is sit 
first, to the outer side of the 5 
down it runs nearly behind it, and so clo: 
it, that without care it may be injured, inelu 
in the same ligature, or even tied 
vessel. J 
It may not be amiss here to observe of 
distinctive marks by which the nerve m 
recognized, when passing the ligature 
the artery, that besides the most essentia 
absence of pulsation, which may occur 
the artery itself from accidental cau 
inexperienced operator will find conside 
assistance from the following, viz. the 
round, cord-like feel of the nerve, while 
artery has a flattened yielding feel 1 
pressed between the finger and thumb, 
the whitish, somewhat glistening, and pr 
nent round appearance of the nerve, thea 
haying a scammed reddish colour, 
tened, thick, and riband-like appearance, 
is raised upon the aneurism needle. 
the cut extremities of the two are sé 
ther, after an amputation, of course the 
open mouth of the one, and the pr 
stump of the other, like a tight p 
thread cut across, are readily recogniz: 
The lymphatics of these deep parts ac 
the bloodvessels, and pass to the gl 
of the ham; hence diseases occurring ™ 
parts beneath the aponeurosis of the 
their influence on the glands of the f 
space. a 
The two bones of the leg united bj 
interosseous ligament form an elongated 
in front which is closed in by the aponewt 
and is larger at the union of its two suf 
thirds than at its extremities. The 
being imbedded here are difficult 
circular amputations, at the same time th 
depth prevents the formation of a goot 
Posteriorly, they form a gutter, or fossa, la 
than the preceding, but also much more 
low, excepting at the lower part. enc 
deep muscles are easily comprehended it 
7 
