384 ON AMPUTATION 



where he intended to divide them, and cutting downwards formed a muscular 

 flap, which he afterwards supported by an apparatus devised for the purpose 

 of pressing the cut surfaces together so as to check bleeding without the use of 

 either cautery or ligature.^ This machine being complicated and unsatisfactory 

 was rejected in 1750 by M. Garangeot,^ who, substituting the ligature for it, 

 but retaining in other respects the method of Verduin, brought amputation of 

 the leg to the form in which it is still often practised at the present day. 



The same principle was applied to the thigh, in 1739, by Ravaton, of Landau ; 

 but instead of one long flap he made two short ones. Having divided all the 

 soft parts circularly, he thrust a knife down to the bone on the anterior aspect 

 of the limb, a hand-breadth higher up, and cut down to the circular wound ; 

 and, having made a similar longitudinal incision behind, dissected up the square 

 lateral flaps thus formed, and sawed the bone where it was exposed at their 

 angle of union, and brought them together after tying the vessels.^ 



Vermale, surgeon to the Elector Palatine, soon afterwards formed the flaps 

 more easily, and of a shape better adapted for union, by introducing a knife 

 at the front of the limb and pushing it round the bone at one side, so as to make 

 it emerge at the opposite point behind, and then cutting a flap of rounded form 

 by carrying the knife in a curved manner downwards and outwards, the same 

 process being repeated on the other side.^ 



The flap operation, performed either by cutting from without inwards or 

 by transfixion, was occasionally employed by various surgeons in the latter 

 half of last century ; but found its most strenuous advocate in the late Mr. 

 Liston, and at one time seemed likely to supersede the circular method altogether. 

 Its great merit in those days of painful surgery was its facility and speed ; for 

 the flaps were cut with great rapidity, and when they were drawn up by the assis- 

 tant, the bone was exposed with the utmost readiness at the part where it was 

 desirable to divide it ; whereas, in the circular operation, to dissect up the ring 

 of integuments was a somewhat troublesome and tedious process, especially 

 in a limb increasing in thickness upwards like the thigh, and the use of a retractor 

 was often necessary, in order that the saw might be applied at a sufliciently high 

 level. 



As regards the immediate results of the two methods, the principal difference 

 between them was that the flaps, when formed by transfixion, contained a large 

 amount of muscle, while the circular mode furnished a covering chiefly from the 

 integument. In this respect the flap operation was at first supposed to have 



^ Me'moires de I'Academie de Chirurgie, vol. ii, p. 244. ^ Ibid., p. 261. 



* Ravaton's Traits' d' Armes a feu, p. 405 ; also Me'moires de I'Academie, vol. ii, p. 251. 



* Le Dran's Surgery, Gataker's translation, p. 431. 



