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The victims of congenital deficiencies, acute accidental limb severance and of punitive, legal and many ritual amputations have no opportunity to express their wishes in the matter, in contrast to the majority of patients faced with less concrete situations where there is opportunity to debate their future with surgeons, relatives and friends. By contrast, victims who are trapped alone and without communication or aid have to make a choice for or against amputation without advice, relying only on their knowledge and a veneer of traditions inherent to their own society. The trapped victim in extremis and desirous of survival who performs an amputation acts as both patient and surgeon. Repugnant as such actions appear to the average citizen, the instinct to survive remains powerful despite self-inflicted excruciating pain and uncertain immediate complications. Such self-amputations have been reported with some regularity in the press, proving less rare than may be imagined (see Chapter 3).

In somewhat similar frame of mind and desperation, we note injured or diseased patients who clamoured for a surgeon, demanding or indeed insisting on immediate limb amputation. In particular, from close observation of wounded comrades, many soldiers and sailors recognised no other course was possible and moreover were aware that delayed amputation was more painful. Wiseman emphasised these points, about 1658, as follows:

"... a Walloon earnestly begged me to cut off his shattered Leg: which whilst I was doing, he cried, 'Hurry up when we're back on land we'll have a drink'. Also others have urged me to dismember their shattered Lims at such a time, when the next day they have profest rather to die. ... Therefore you are to consider well the Member, and if you have no probable hope of Sanation, cut it off quickly, while the Souldier is heated and in mettle. But if there be hopes of Cure, proceed rationally to a right and methodical Healing of such Wounds: it being more for your Credit to save one Member than to cut off many."16

Another sailor's sangfroid is recorded by Ryder in 1685:

"... upon the Recoil of a Gun the Truck ran over his Foot, breaking in pieces all the Bones of the Metatarsus: perceiving his Foot very much tumefied and discoloured above the Ankle, I made deep Incisions on the Tarsus, and Metatarsus, which he felt not; I told him there was a necessity to take off his Leg, to which he readily agreed; so he hopp'd on one Leg to a Chest where sitting I took it off, (he not expressing the least sign of pain or sorrow."17

"Heated and in mettle" is a 17th-century description of the body's immediate response to injury when boosted by high adrenaline levels, bolstering a courageous acceptance of surgery but which diminished as levels returned to normal and as the wound began to swell and inflame. Earlier we noted the elated sailor who sang "Rule Britannia" during his amputation.18

For more-chronic conditions such as dry gangrene and persistent fracture non-union with chronic pain, purulent discharge, loss of weight, sleeplessness and immobility, it is apparent courage of a different kind is manifest. We have already recorded the remarkable determination of a boy, aged about 9, with severe chronic leg complications after crushing by a cartwheel a year previously. Reduced to a skeleton with 11 discharging fistulae and his health fading fast, he insisted on removal of his useless limb, saying to the surgeon:

"... he knew he should be well, if I would cut off his Thigh: and that if I would lend him a Knife, he would cut it off himself;.. ."19

He remained remarkably composed throughout a successful amputation. In drawing attention to the incredible cooperation of some children faced with major operations without anaesthesia, Stanley quoted an observation recorded in 1819. A 7-year-old boy with a diseased knee joint came under the care of Abernethy, a London surgeon, who said:

"I suppose, my little fellow that you would not mind having this knee removed, which pained you so much and made you very ill?" The boy replied, "Oh no, for mammy has told me that I ought."20

During the amputation, the boy remained quiet and displayed neither hesitation nor opposition. Here perhaps the influence and encouragement of the parent were paramount. At the other end of the age range, Sir James Lowther, aged 77 years in 1750, asked for a below-knee amputation for gout complicated by infection and bone necrosis in the foot after years of misery, which he:

"... submitted to with his own peculiar calmness and resolution without the least tendency to faint under the operation.. ."21

He lived for another 5 years and wore a below-knee prosthesis. In general terms such patients have reached the end of their tether, perhaps realising that anything would be better than the unremitting pain, persistent discharge, rotten odour, immobilisation, general fever, loss of appetite and weight, and an instinctive recognition that death approached relentlessly. In 1706, Edward Thwaites, who became Professor of Greek at Oxford, consulted Charles Bernard, surgeon in London, with a constantly painful tuberculous knee (the King's Evil), and when the surgeon demurred amputation, Thwaites said:

"I came to London on purpose to have my leg cut and off it shall go: and if you will not do it, lend me your tools and I will do it myself"

It is reported he would not suffer himself to be tied down and during the whole operation made no sound. He recovered to die 5 years later when the disease spread to his lungs.22 This is not to imagine that every patient had the courage to hazard the uncertainties of a major operation before the days of safe surgery. However, those surviving were often relieved. Also in the 18th century, Petit recounted the case of a boy who had been ill with caries of a leg and infected fistulae keeping him awake for 2 months; the night of the amputation he slept soundly and this continued till after his stump healed.23

The rapid progression of infected gangrene from the foot or hand towards the trunk was another reason for patients to demand immediate amputation. For dry or slowly established gangrene, the prospect of living with a black, func-tionless, foul-smelling limb into an uncertain future gave time for reflection, yet also proved a persuasive reason for accepting amputation. Similarly, the relentless growth of a tumour, especially if hindering mobility and work, has persuaded patients to ask for surgical excision or in extreme cases acceptance of limb sacrifice, even in the absence of pain as recounted by Peirce in 1737. A farmer's son, aged 25 years, complained of a swelling which enlarged over 8 years, ultimately preventing him working from the time "of Hay-Harvest 1735" (Fig. 9.3). It is clear the size and weight of what was probably a cartilaginous tumour near the right knee would have prevented a normal gait, or even a comfortable sitting or sleeping posture, and its continuing growth presented a frightening prospect for the patient. Peirce states the lower thigh stump healed but does not tell us whether the patient had an artificial leg or resumed work.24

A more urgent demand for amputation relates to the victim's entrapment in a dangerous envi ronment with poor resources, as applied to the rescue of a Colonel of the Gurkha Rifles trapped by his arm in a crashed helicopter leaking oil from an overheated engine, in a remote area of the Malaysian jungle in 1964. A medical officer in the helicopter was unharmed although he carried no anaesthetic or surgical equipment. The victim, suspended by his crushed arm, and the surgeon had to be supported amidst the wreckage by a colleague whilst a difficult amputation lasting an hour was undertaken using a pair of socks as a tourniquet, a clasp knife, a bayonet and a fishing line for ligatures. As another example of sangfroid in extremis, the Colonel remained conscious and silent throughout, acknowledging the powerful effect of peer pressure in stating:

"I sensed that the Gurkha soldiers of B Company were now grouped around the wreckage. Bravest of the brave, how often had I seen their courage when wounded in battle. Now I had to try to live up to their standards, to show I was worthy to be one of their officers."

A successful operation enabled him to continue his career and become a Brigadier-General.25

Sometimes patients initiate an amputation following dissatisfaction with a badly healed and painful compound fracture, or a painful and recurrently infected amputation stump, or a stump too long for an efficient prosthesis. An example of this, reported in the press in 2004, concerned a Royal Marine officer whose severe leg injury in a climbing accident eventually healed,

Pare Artificial Limb
Fig. 9.3. Engraving of massive upper tibial tumour with its bony and cartilaginous skeleton, excised in 1736 by Jeremiah Peirce; he stated the amputated specimen weighed 69 pounds.24

leaving him with poor function and a threat of retirement. He perceived a sophisticated artificial limb would improve his capacity and after surgery and rehabilitation was permitted to remain in the service fully active and, indeed, was enabled to join a polar expedition.26 In the 16th century, Paré left the following account of reamputation of an overlong stump incompatible with the prostheses then available:

"For I so knew Captain Francis Clark, when his foot was srticken off with an iron bullet, shot forth of a man of War, and afterwards recovered and healed up, he was much troubled and wearied with the heavy and unprofitable burden of the rest of his leg, wherefore, though whole and sound, he caused the rest thereof to be cut off, some five fingers bredth below his Knee; and verily he used it with much more ease and facility than before in performance of any motion."27

Cox wrote a complete monograph in 1845 concerning a woman of 23 years who asked for reamputation, after suffering for 14 years from an infected stump following an above-knee amputation for a diseased left knee joint. She submitted to amputation through the hip joint in 1844, shortly before general anaesthesia was available; Cox reported she drank half a bottle of port wine, although it is not clear whether this was before or after the operation, and subsequently survived with a well-healed stump (Fig. 9.4).28

For many patients faced with an acute injury operation was totally unacceptable, perhaps more often than we can estimate, as such case observations of refusal are rarely described. However, for most patients matters were less clear cut, as their decision for or against amputation was not heightened by the acute shock of an injury or by chronic illness and relentless bodily sapping misery, but by less precipitate symptoms, for example, the gunshot wound treated conservatively until infection gradually spread or the chronic bone ulcer which dripped with pus and interfered with normal activity but was not life threatening. In these circumstances the debate between patient, surgeon and relatives might occupy days or weeks and, before general anaesthesia, persuaded many patients to refuse amputation and to live on in hope of recovery, however slim.

Wiseman described the instantaneous reaction of a soldier who received a musket ball injury of the elbow joint at the battle of Worcester in 1651; the humerus, radius and olecranon bones were all shattered and, at that time, open joint injuries were considered a clear indication for amputation. Wiseman commented:

"Upon sight whereof I called Will. Clarke (now a Chirurgeon at Bridgnorth) and other Servants about me, to cut off the Arm, and the while I endeavoured to encourage

"Upon sight whereof I called Will. Clarke (now a Chirurgeon at Bridgnorth) and other Servants about me, to cut off the Arm, and the while I endeavoured to encourage

Fig. 9.4. Elizabeth Powis, aged 24 years, showing healed scar after hip disarticulation in 1844 for a painful unhealed stump following above-knee amputation when aged 9 years, probably for tuberculosis.28 (See Fig. 8.2)

Above Knee Amputation

Fig. 9.4. Elizabeth Powis, aged 24 years, showing healed scar after hip disarticulation in 1844 for a painful unhealed stump following above-knee amputation when aged 9 years, probably for tuberculosis.28 (See Fig. 8.2)

the Souldier to endure it. In answer thereto he only cried, Give me drink, and I will die. They did give him drink, and he made good his promise, and died soon after; yet had no other Wound than that. By which may be perceived the danger in delaying this work to the next day, when the aforesaid Accidents have kept them watching all night, and totally debilitated their Spirits."16

Duhamel highlighted the more-laboured quandary of a soldier in World War I who was struck in both knees by a grenade and required immediate amputation of one leg for massive injuries. The other less traumatised leg was treated conservatively for some weeks, but gradually chronic infection spread and his general condition deteriorated, for which a second amputation was advised. At first the soldier refused to consider this advice, despairing of a future without legs, work, marriage and children until, eventually, Duhamel convinced him independence was possible with artificial legs, and he was rescued by a second dismemberment above the knee. Both stumps healed and eventually he coped with prostheses, became a tax inspector, was married and had children.29 Before the days of anaesthetics and antibiotics, it was even more daunting for patients with an inflamed wound who underwent an amputation which proved insufficient to cure their condition and were then advised to undergo further amputations at higher levels to avert spreading infection. Wheeler recounts this experience of a nurse working in a hospital attached to his Regiment, in the War of the Spanish Peninsula, in 1814 as follows:

"... she pricked her finger with a pin left in one of the bandages, caught the infection, her finger was first amputated, then her hand, the sluff appeared again in the stump, she refused to undergo another operation, the consequence was she soon died."30

Beyond the decision to accept an amputation and its associated threats of immediate complications, the patient also had to accept, if all went well, inevitable deformity and disability, as manifest sources of future anxiety and misgivings. Even in the 21st century, as the Waterford Disability Network affirmed:

"Many people who have suffered the loss of a limb will go through a period of intense emotional turmoil and grief: they will suffer anger, depression and disbelief. Ongoing support from family, friends and medical profes sionals is vital, and rehabilitation has to include both the physical and emotional needs of the person."31

On a different note, some Muslim patients preserve their amputated limbs or limb remnants to be buried with them after death so they can go to Paradise whole. And on a related note, the preserved limb has been retained, in one instance at least, for public inspection and the victim's repeated pilgrimage, as the case of General Sickles reveals. Injured while on horseback at the battle of Gettysburg, his shin being shattered by a cannon-ball, he was evacuated with a saddle-strap tourniquet, smoking a cigar and drinking brandy. After a low-thigh amputation, the specimen was preserved and sent to the Army Medical Museum for display (Fig. 9.5). On recovery and retirement, Sickles preferred a pair of crutches to a prosthesis, and was in the habit of visiting the Museum regularly to view his loss (Fig. 9.6), often bringing

Battle Injured Bones
Fig. 9.5. Tibia and fibula of General Sickles amputated for injury by cannonball at the Battle of Gettysburg in 1863, demonstrating massive bone loss below the knee and an appropriate cannonball. (With permission of the National Museum of Health and Medicine, Washington, DC.)
General Sickles Viewing His Leg
Fig. 9.6. Engraving of General Sickles with an above-knee amputation, on crutches, examining his shattered leg on public display in the Armed Services Medical Museum.32 (With permission of the National Museum of Health and Medicine, Washington, DC.)

friends with him to admire the leg. Mark Twain, who was a neighbour, commented:

.. the General valued his lost leg away above the one that is left. I am perfectly sure that if he had to part with either of them, he would part with the one he has got."32

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