136 
upon the stump 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 — 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 the tibialis 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 unfre- 
guently cost the patient a limb, which by a 
more correct knowledge of the disease might 
have been saved.t 
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, &e., 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 fiom 
the general similarity of the symptoms to mus- 
cular rheumatism; the extreme tenderness of 
* Sec Dictionnaire des Sciences Médicales, Art. 
Jambe. 
+ See also some excellent practical observations 
on the subject in Liston’s Elements of Practical 
Surgery, p. 95. 
REGIONS OF THE LEG. 
the periosteal inflammation, much me 
than that of rheumatism, and the more cireut 
scribed nature of this tenderness, are sigt 
which will facilitate the diagnosis, a subjec 
however, upon which it is not here the p 
to dilate. a 
In the foetus, the tibia presents me 
slight curve anteriorly, which appears 
augmented in the adult by the weight of 
body. The posterior muscles, stronger 
more numerous, acting on the flexible 
concur to the same end. Thus, in f 
rticularly from indirect causes, the al 
ormed by the fragments of the tibia is alm 
always in front, and the limb bends in 
situation of the fracture. a 
Experience proves that the two bones 0 
leg are more frequently broken togeti 
singly, a fact ascribed by Boyer to th n 
of the knee and ankle-joints. The directio 
an oblique fracture of the tibia is g 
from below upwards and from withi 
wards, a circumstance due to the form of 
bone. The end of the upper fragment 
presents itself under the skin, at the front : 
main part of the leg. The most frequent 
tion of fracture of either of the bones of | 
leg is at the lower third; this, in the tibia 
readily accounted for by its being here m 
exposed to injury and being smaller and we 
than elsewhere ; in the fibula, on the cont 
this part is not weaker, but is here placed n 
superticial, the upper part being complet 
covered and much defended by a cushior 
muscle. Fractures of the tibia at its a 
part are less liable to displacement thar 
down on account of the greater thi 
the bone, but the vicinity to the knee- 
here increases the danger of a fracture e¢ 
derably. In consequence of the thickne 
the bone at this point, fractures here are 01 
narily transverse, while the abundance 
spongy tissue causes them to unite quickh 
easily. The tibia is more frequentl 
by itself than the fibula because it 2 
tains the whole weight of the body, 
fibula has nothing to support. In fae 
fibula is generally broken at the same tf 
with the tibia, the injury to the fibula is 
subsequent to the other, and takes place 
cause this slender bone is not capable ¢ 
ing the weight of the body, the impulse 
ternal violence, or even the action of the 
cles, after the tibia has given way.* " 
There is rarely much displacement, ¢ 
gards the length of the bones, at what 
point their fractures may have oc 1, ut 
the cause has continued to act after thes 
tion of continuity. This appears to 1 
from the muscles being inserted over the w 
of the bony surfaces. -¥ 
When the fibula alone has been bro 
there is very little deformity resulting, ai 
principal support of the limb still rem 
particularly if the injury has resulted 
external violence. When however the ¢a 
v 
J 
CK! 
‘ 
* See Cooper's Surgical Dictionary, article Ft 
ture, a 
