Posterior Flaps in Amputation

[Will Fiddle]

In Journal of the Royal Society of Medicine Volume 78 September 1985, Watt describes how "In 1697, James Yonge, surgeon at the naval hospital in Plymouth, devised a posterior flap technique for amputation which avoided sepsis and bone necrosis and accelerated healing (Yonge 1697, pp 108-120).

How does this differ from the "circular method"? Does this mean Yonge advocated a flap for closure as opposed to bringing the peeled back flesh to close like the end of a salami? Direction to an informative source is as welcome as a direct answer.

[Mission]

The author in JRSM seems to have gotten it all wrong. Yonge didn't invent it and he mostly advocated against it.

"I acquaint you of this for its rarity, not that I ever but once practised it, and I think it not prudent, because there is no necessity to imitate it in such stumps: for the disquamation [desquamation - shedding of outer layer, presumably of bone], which is also achieved without any great trouble; whereas should we neglect it, and find when the stumps come to be almost cicatrized [healed by the formation of scar tissue] (as once I did in designing to imitate the said Artist, and which made me resolve for ever to decline it) that there was necessity of doing it, by reason of a Caries [decay, usually of bone] then contracted, or but then

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discovering it self, it's manifest when trouble it would beget, and how greatly impede the dessication [drying up of the wound]; there are those that think they ought to scale all bones, that have though but by a recent Wound been bare: and others I have met with who on the other hand too much slight the Caries of bones, pretending they moulder off with the matter; how equally unreasonable and vain both are, I need not discourse to so competent a Judg as your self. Wherefore passing these matters, I shall now entertain you with an account of the manner of this Operation, I would recommend to you, after I have told you, that it was from a very ingenious Brother of ours, Mr. C. Lowdham of Exceter, that I had the first hints thereof." [Yonge, Currus Triumphalis, é Terebinthô, 1679, p. 109-10)

I doubt most audiences would be that interested in a description of such a thing, but FYI,

"...with your Catling [Catlin], or some long incision-Knife, to rase (suppose it the Leg) a flap of the membraneous flesh, covering the muscles of the Calf, beginning below the place where you intend to make excision, and rasing it thitherward, of length enough to cover the stump; having so done, turn it back under the hand of him that gripes [grips]: and as soon as you have severed the member, bring this flap of Cutaneous flesh over the stump, and fasten it to the edges thereof, by four or five strong stitches..." (Yonge, p. 110)

So it's just a long flap of skin designed to be folded over and sutured on the edges that are not already attached to the stump. Yonge's concern appears to be that once you do this, you can't access the bone and necrosis is stymied, which is something Paré's flap method allows for.

I think the JRSM author is confused by the (indeed confusing) statement: "Wherefore passing these matters, I shall now entertain you with an account of the manner of this Operation, I would recommend to you, after I have told you, that it was from a very ingenious Brother of ours, Mr. C. Lowdham of Exceter, that I had the first hints thereof." By this, if I have the right of it, he means that Mr. Lowdham, a man he finds to be clever, came up with it. However, when you read, "...I think it not prudent, because there is no necessity to imitate it in such stumps..." and it seems clear to me that while he finds Mr. Lowdham's ideas clever, he doesn't really recommend this procedure. At least that's my take on it.

I have been using Yonge's manuscript on Turpentine as my car reading - that is, a document that I keep in my car in case I get stuck somewhere without a book. I can't say that I recommend it as it is mostly a long discussion about the benefits of turpentine with pages and pages of offshoots into stuff that is not very revealing or interesting IMHO. I hadn't actually gotten to this part, but I read ahead for you. [Caveat: I did not read the whole thing, just to where I saw the answer to your question.]

I would like to note that I am a trifle confused over how the circumferential flap method of amputation got attributed to Ambroise Paré (a French surgeon who wrote in the mid/late 16th c.). I believe I have seen glimmerings of it mentioned much, much earlier, although I don't recall where just now. Paré does give the first full account of it that I have seen, however. I do commend Paré to you if you're determined to read far and wide on the topic. You can pick up well-edited and annotated books for a reasonable price on Amazon that may inform your surgeon impression. Paré is considered one of the great surgeons in the pantheon...plus he writes on some wacky superstitious cures in his book that can make for amusing reading.

[Will Fiddle]

Mission,

Thank you for the thoughtfulness and detail of your reply. It is fascinating that Yonge is attributed as being in favor or the posterior flap, as the evidence you present --and with which I am inclined to agree-- militates to the contrary.

As you say, he does not recommend the procedure. Rather, he recommends to his reader that he first heard of it it was from an ingenious "Brother". "I shall now entertain you with an account of the manner of this Operation, I would recommend to you, after I have told you, that it was from a very ingenious Brother of ours, Mr. C. Lowdham of Exceter, that I had the first hints thereof." Much as Pare had his puppies, Lowdham has this flap, or was aware of the flap procedure.

Dr Watt in JRSM seems eager throughout his article to demonstrate how often unsung heroes of naval medical practice championed innovations only to be ignored by lesser minds and their wisdom lost. It is much the same spirit as Moore's zealous desire to attribute hundreds of texts to Defoe, including the General History.

Thanks also for interjecting explanations for the many terms. Some of these I knew, but others I am transferring into my personal study guide.

William

[Mission]

I actually like Watt. Among other things he wrote a nice thing on burns that I have in my notes. I do tend to prefer the period stuff to the modern for the most part. I often use the Bibs in modern articles and texts to find period resources I didn't know about.

Ah, Paré and his "...boiling new whelpt puppies..." ! He even has some wackier things than that in the last chapter of his Apologie and Treatise if I remember right.

[Will Fiddle]

Watt is indeed engaging and informative, and I am digging through him for more material on medical practice and the nature of "scientific" investigations.

Both my wife and I are really wondering about the use of "new whelpt pups". Current science has shown that the use of Dragon's Blood, makes good sense. I can even understand the thought process behind packing wounds with dung; it makes sense as dung helps things to grow. But puppies?

I think you are right, I have to get my hands on some of Pare's texts. I found him online in e-text once, but that was years ago.

[Mission]

For fun medical recipes (most not quite as horrifying as that, but still bizarre), I recommend Stephen Bradvvell's Helps for suddain accidents endangering life. I've re-posted a couple of my favorites from that one on the forum.

To get all this stuff, you really need access to the Early English Books On-line and English Short Title Catalogue Databases. I explain one way of getting to them here.