A flap bears weight badly when the muscles have retracted around the bone, over which there is then nothing but skin. It is the same when the flap is stretched tightly across the end of the bone, the soft parts must remain soft and free.
Among the hundreds of cases of amputation of the leg or thigh that have passed before us in being fitted at the Fédération des Mutilés, there were many in which the presence of a terminal scar rendered the fitting of an apparatus difficult; we have never found this the case with a lateral scar; we have never seen the latter ulcerate rapidly as the result of pressure or friction in a properly made wooden bucket. So that it cannot be admitted that the proper covering of a stump is ever a matter of secondary importance.
Consequently we should consider, as a matter of principle, the circular method of amputating only as a last resort, and we ought to arrange the section of the soft parts so as to cover the end of bone as adequately as possible, and to bring the scars to one side.
We realise that in practice war surgery often necessitates deviations from the ideal. We often find ourselves in a dilemma—either the stump must be good but too short; or, being long, must be poor or even bad.
In the special case of the thigh, circular amputation in the lower third when it is carried out through healthy tissue and has not suppurated can be trimmed and sutured in such a way as to give an excellent scar, which is transverse and slightly posterior. In this situation after these routine amputations, a linear scar which is supple and has healed by first intention, separated from the bone by a good cushion of muscular and fibrous tissue, causes little embarrassment, whatever its position; at the end of a few months it stands pressure and friction without harm. But we are considering war surgery and consequently we are often called upon to fit stumps in which the cicatrix is large, hard, and more or less irregular, in which the bone has suppurated and in which the neighbouring soft parts are indurated and scarred. These stumps are not, however, the results of the work of the worst surgeon.
Amputating through infected parts, resigning himself to healing by granulation and subsequent trimming by operation, he must take time and trouble to attain in the end a result which is good functionally, although at first sight unsightly. But it is this surgeon who is on the right road, rather than he who sends us good stumps which have not suppurated, because he has amputated through the thigh for a wound of the middle of the leg, or through the leg for a wound of the foot or even of the front of the foot.
It is clear, that for the stump effectually to play its part of a lever in its bucket, a certain definite length is necessary; and we ought to do everything possible to secure a length of at least 15 to 20 centimetres in a thigh stump, or 10 to 12 centimetres in a leg stump. But when this length is secured, there is no great functional difference between, for example, an amputation of the leg in the lower third or in the lower quarter, particularly if the fitter understands how to utilise direct end bearing. The knowledge of this is of capital importance to the surgeon called upon to carry out secondary operations upon imperfect stumps, in determining whether it is possible to put an immediate stop to suppuration by drastic shortening, or whether he must preserve length and lose time by curretting the foci of inflammation in the bone.