We have argued (see Chapter 2) that various societies recognised and accepted nonsurgical amputees long before surgical amputation was considered or attempted, although not all societies have undertaken amputation, as Harley indicated when studying the Mano tribe in remote Liberia:

"... surgery is limited to bone-setting, blood-letting by shallow incisions, circumcision and scarification by tribal marks on the skin ... instruments are ordinary household utensils . . ."4

Similarly in 1877, Gordon observed:

"... among the Burmese the surgeon, even in the oldest and lowest acceptance of the word, does not exist, and there is not the faintest knowledge of anatomy... They use no knife or instrument of any kind."5

We assume Gordon was recording his experience in the remoter areas of Burma and not in major cities. Whether these societies undertook ritual or punitive amputations is not stated although, as suggested earlier, some knowledge of the physical imperfections of accidental amputations must have been acquired, if only at a digital level. It may be surviving amputees were found alien to some societies and rapidly dispatched, as probably happened to crippled members of hunter-gatherer communities or nomadic tribes, when no longer able to keep up with their fellows or fulfil a positive role in a harshly competitive environment. Within historic times, we have considered evidence that weak or crippled infants were judged useless to the Spartan state and thrown into a ditch (see Chapter 1). Such attitudes doubtless applied to congenital amputees but we cannot be sure how surviving amputees after trauma or disease were viewed, especially if previously contributing positively to their tribe or family group, particularly if a community leader or chieftain. Even societies that refused amputation entirely might accept accidental loss, as Daniell discovered when visiting Old Callebar in the Bight of Biafra (now Calabar, Nigeria) in 1849:

"The people of this town manifest the most decided aversion to the performance of any surgical operation, and so strong is their abhorrence of amputation, that they would rather suffer death than any loss of an extremity. When, however, any portion of the limb has been taken off, either by alligator or ground-shark, they check the haemorrhage by applying a hot piece of iron, which has sometimes been of permanent benefit."6

It may be that peoples dependant on gruelling and continuous work to subsist knew instinctively that amputation would restrict efforts to support themselves, rendering them a serious drain on others. In 2005, the massive earthquake centred on Kashmir highlighted the position of isolated mountain people, especially in Pakistan, dependant on their own resources and hard physical labour for survival. Commenting on much delayed treatment, due to communication difficulties, of those injured with grossly infected wounds in need of amputation a newspaper report stated:

"Pakistan is a country without a safety welfare net, and in its remote northern villages physical disability is often a worse fate than death. For poor subsistence farmers scraping a living from the harsh mountains, a dependant who cannot work is seen as a huge liability." To emphasise this, a husband said of his injured wife, a candidate for amputation: "I will not permit this. I will let her die than allow cutting her arm. She would not be able to work anyway.'"

Ultimately, it is apparent amputees were accepted by many societies, possibly promoted by their survival after accidental loss, or punitive and legal severance ordered by the self-same societies, to designate community outcasts as prisoners, slaves, trespassers or criminals, or participants in tribal rituals, and also as a warning or reminder to others. In these latter cases,victims were denied choices either for or against loss of their limbs or digits, as society monopolised all decision powers impelled by punitive, ritualistic or religious convictions; moreover, those who performed the actual punishment and severance, as pseudosurgeons, also had no choice but to obey higher authority. Such profound societal convictions continue in some Islamic states where Sharia law punishes thieves and prisoners by amputations, although often these are now undertaken under anaesthesia by trained surgeons, as described in Chapter 4 when, in 1999, a prisoner of war of the Taleban underwent hand and foot amputations by a surgical team before a large crowd in a football stadium. In contrast, the same Muslim states often forbid elective surgical amputation for injury or disease, believing this renders the human frame imperfect for burial and precludes its ascent to Paradise. Even in the presence of mangled lower limbs following antipersonnel mine explosions, Coupland, working for the International Red Cross, confirmed in 1992 that Muslim religious practices to avoid surgical amputation have to be respected.8 Also in the 20th century, Hilton-Simpson noted Berber tribesmen isolated in the Atlas Mountains of Algeria frequently undertook skull trephination, yet never surgical amputation which was completely taboo; indeed, Hilton-Simpson recorded the enormous pleasure of Berber practitioners when compound limb fractures healed after many months of expectant treatment and after discharging much dead bone to leave a short, weak, barely functioning limb.9 Yet, lacking knowledge of antiseptic and aseptic surgical techniques, this was doubtless the safest course, at least for the surgeon, although else where modern amputation techniques would have provided sound working stumps and satisfactory prostheses with a more-certain return to early activity and employment.

Of the many ritual amputations recorded (see Chapter 4), most concern the fingers of females, principally in Africa, North and South America, India and New Guinea. It can be supposed adults assigned this mutilation had little choice in the matter but at least understood long-established tribal magic and custom in acquiescing to their loss, unlike the small girls of the Dugum Dani tribe of New Guinea subjected to finger amputations with a stone adze, without anaesthesia, in 1961, whose state of mind is difficult to imagine, even if told their sacrifice was to placate the ghost of a blood-related tribesman killed in battle (see Fig. 4.2). One must emphasise such guillotine amputations healed very slowly and often badly because of bone infection and necrosis leaving poor fragile scars, and yet, such sacrifices were frequently multiple over a period of time, resulting in the loss of several or even all fingers. The rationale for finger amputations included the following: to indicate a sign of mourning, to secure an eventual peaceful death, to prevent further deaths when these were numerous in a family, to avert serious illness, to indicate a widow's second marriage, to facilitate the making of fishing nets by removing the ring fingers, to celebrate the achievement of manhood, or to indicate a self-inflicted penitence towards a hierarchy such as a gangster mafia, or to participate in a religious act, a political protest or an insurance scam.

In those societies eventually accepting elective surgery, most prominently in Renaissance Europe, the debate surrounding intervention or not was essentially between patient and surgeon, although their communication involved inevitable overtones of religious, cultural and traditional attitudes, influenced by Catholic Church decrees rejecting deliberate operation and bleeding which prevented instructed priests from contributing to medical and surgical care as hitherto. And in Europe, the earliest accounts of elective amputation all expressed the need for patients or surgeons, but usually both, to pray or go to church for confession before the operation.

Thus, Von Gersdorff counselled in 1517:

"If the limb must be cut off, and nothing else will help, ... you should advise the patient above all to go to confession. and receive the Holy Sacrement on the day before you amputate. And if the surgeon hears Mass before operation, God will favor his work."10

Von Gersdorff's illustration of an amputation scene (see Fig. 1.5) shows a spectator who has a dressing on his left hand suggesting amputations of his fingers, but who is wearing the emblem of a cross at his neck, emphasising the importance of religion to Gersdorff. Ryff's illustration of about 1545 (Fig. 9.1) is even more explicit, picturing a priest, prayer book in hand administering to the patient during surgery. In 1596, Clowes reminded his surgical readers that when performing amputation:

"... through the assistance of almightie God, you shall luckily accomplish this worke, by your good industry and diligence," And their patients: "... have ministered unto them some good exhortation concerning patience in adversitie, to be made by the minister or preacher. And you shall likewise advertise the friends of the patient, that the worke which you go about is great, and not without danger of death."11

Here Clowes reminds us that operative death could be attributed by society to the surgeon, irrespective of the patient's original condition, and hence it was essential to warn the relatives. Whether legal actions or sanctions followed at this time is not clear, but at least a surgeon's reputation and capability would be suspect. No evidence indicates that surgeons faced the penalty of losing a hand for their operative failure, as noted when we discussed the Code of Laws established by Hammurabi in ancient Babylon (see Chapter 4). However, Kirk hints at a society's retribution when composing a medical report on the Kingdom of Shoa, Abyssinia, in 1843. When asked for his opinion on a boy with a grossly ulcerated tibia and an ununited compound fracture near the knee joint, he told an officer of the King's household that amputation offered the only chance of saving his life, to which the horrified official replied:

"If you succeed you will get no credit by it, people will say it was the will of God; if the boy dies, they will say you killed him and you will have much trouble."12

In the 20th and 21st centuries, surgeons found guilty of operative negligence by society (their

Fig. 9.1. Amputation scene showing patient supported by a priest, his surgeon and apprentice, by Walther Ryff, 1545. "Tourniquets" appear to be applied above and below the amputation site, and two knives, a bow saw, needle and thread, sponge and dressings are seen. (From Gurlt E. Geschichte der Chirurgie, vol 3, Berlin, Hirschwald, 1898:49")

Fig. 9.1. Amputation scene showing patient supported by a priest, his surgeon and apprentice, by Walther Ryff, 1545. "Tourniquets" appear to be applied above and below the amputation site, and two knives, a bow saw, needle and thread, sponge and dressings are seen. (From Gurlt E. Geschichte der Chirurgie, vol 3, Berlin, Hirschwald, 1898:49")

Ancient Amputation

peers and the courts) lose their status and employment but not their lives. Patients are now well protected by society and its legal systems, which enable examination of the facts through a succession of court appeals if necessary.

In addition, society also had cultural restraints associated with ancient astrological superstitions, as Woodall indicated in 1617 when speaking of amputation and the necessary instruments (Fig. 9.2).

"All these necessaries as is said made ready to the worke, in the name of the Almighty, the sharpe instruments being as neere as you can hidden from the eyes of the patient This worke of dismembering is best to be done in the morning, doe it not willingly the signe being in the place, neither the day of the full moone,.. ."n

Woodall suggested a practical note by operating in the morning during daylight, still available in the afternoon when complications might supervene. On the other hand, amputations after severe trauma required immediate action, irrespective of the quality of the light or the phase of the moon. Towards the middle of the 17th century, admonitions advising patient and surgeon to pray or confess, or to adhere to astrological directions, disappeared from European surgical texts.

Earlier discussion has noted that not all societies countenance elective amputation, including those in Saudi Arabia, parts of Nigeria and Afghanistan when under the Taleban (see Chapter 4) who are guided by Sharia law, a code for human existence, including daily prayers, fasting and donations to the poor, but also a code dictating physical punishment for crimes including flogging, stoning and amputation. Yet, the same societies forbid or disapprove of amputation for medical reasons, believing it an interference with the wholeness of the human corpus, precluding ascent to Paradise. Coincidentally, in some Islamic countries practising legal amputations, many innocent victims have been seriously injured in recent years by antipersonnel mines, designed to blow off the foot, posing difficult choices for



Amputation Instruments
Fig. 9.2. Amputation instruments from 1639; these are of relatively simple construction, including a very modern form of scissors. Woodall offers a wide range of cauteries and chisels with a mallet. (From Woodall J, The Surgeon's Mate, London: Bourne, 1639.41)

patients and relatives, especially the parents of maimed children. Even so, as Coupland stated, Sharia views must be accommodated.8

Despite a general acceptance of amputees into the community, they, as do other handicapped citizens, often met and continue to meet bias and misguided intolerance, as Thomas and Haddan reminded us in 1945:

"The amputee often experiences great anxiety as to this attitude towards his disfiguring handicap and usually dreads the ordeal of returning home and having to face family and friends. The malevolent influence of the unreasoning prejudice of society towards a physical defect is well known and must be faced realistically and with courage by the amputee ... Not pity, but a sympathetic understanding and helpfulness are what is desired.

Assistance should be rendered only when requested, the amputee being given every opportunity to be as independent as possible .. ."u

For lesser amputations of fingers and toes, toleration by the community is more evident, and indeed such amputees may lead a normal existence without apparent physical handicap, especially if only a single digit has been lost, for adaptation and reeducation of the hand may be remarkable, as a colleague's history confirms. He lost his left index finger in an accident at the age of 4 and subsequently played the piano, passing the Teacher's Certificate at the Royal Academy of Music, and later became a consultant orthopaedic surgeon performing major operations demanding bimanual skill and control until normal retirement; he has observed his left middle finger is thicker than on the right, although he is right-handed.15

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