flap in amputation. In the circular operation 
he section of the flesh, which can only be 
effected by passing the point of the knife 
transversely over the bottom of the interosseous 
ones and the posterior relative situation of the 
jula renders some precaution necessary in 
dividing them with the saw. The foot must 
be turned in, so as to bring the fibula a little 
mward, and care must be taken to commence 
@ section upon the tibia as being the longest 
“and strongest, but to finish the section of the 
bula first, since it is too thin and mobile to 
UP ort the movements of the saw without 
weaking at the termination. In amputation 
ve the tubercle of the tibia, it has been held 
able to remove the head of the fibula 
its joit, 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 Knes-Jornr-) 
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, 
n old united fractures of these bones, this 
deformity to have been produced, in all proba- 
bility, from want of due precaution in the ap- 
lication of bandages. The defect may be 
obviated by proper care, that neither the splints 
1or the cushions should take any bearing upon 
the fibula itself except at its two extremities, 
nd great assistance may be derived from 
proper pressure, before and behind, upon the 
nuscles, gently forcing them against the inter- 
ysseous ligament and bearing outwards the 
Jone attached to it. 
After amputation of the leg, the tibia pre- 
sents a triangular surface, having the apex for- 
yards. As the skin covering it is hereby in- 
vested with the subcutaneous layer, it may, by 
ressure against this projection, ulcerate, or 
ough, and thus expose the bone. The great 
heans for obviating this accident is to have a 
300d supply of integument in the flap, so that, 
bringing the parts together afterwards, they 
hay not be drawn too tight over the bone. 
While this rule is attended to all will go on 
ell, whereas when the integument is left scanty, 
hothing can prevent unpleasant consequences. 
may often, however, be advisable to remove 
ith the saw the projecting angle of bone, and 
$a matter of precaution we generally do this, 
hough not attaching much importance to it.* 
In amputating above the tuberosity of the 
ibia, we run the risk of opening into the knee- 
‘Joint, as the synovial membrane is sometimes 
prolonged thus far. According to M. Lenoir 
@ synovial cavity of the knee is continuous 
with that of the superior tibio-fibular articu- 
ation, once in four times.t There are always 
< ™ See Bell’s Operative Surgery, vol. ii. p. 22. 
_ +t See Velpeau’s Anatomy of Regions, p. 484. 
Ke 
REGIONS OF THE LEG. 
135 
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 tisswes 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 the same, 
in whatever part of the length of the leg the 
amputation is performed. The muscular 
branches seldom occasion much inconvenience 
from hemorrhage. 
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 
