Landed (5 page)

Owen would soon say goodbye to this silver glade and sink into the darkness of mud. This was where he would die, and this was how, choking on sludge. He stopped struggling, but then he could feel the slime sliding, inch by inch, up over his shoulders. The boy put his lips together, arranged his tongue in his mouth and yelped the alarm note of a curlew. It sounded good. It meant, ‘Help.' He made the sound over and over again, until the mud came to his lips and he could make the sound no more, then it came over his nose, and his eyes. He knew that when he opened his mouth to breathe the mud would pour in.

Though his eyes were closed beneath the mud there came a murky vision: on a hill stood a boy, Owen himself, surely, yet he could not be certain, the boy stood with his back to him. Sound, too. Birdsong. The plaintive, haunting call of a lapwing in flight. P'weet, pee-wit, pee-wit. Could the boy see
it, the bird's tumbling aerial display? No, Owen realised: it was the boy who was making the sound.

Owen had to interrupt. He could not breathe. His lungs were on fire. Gagging, he needed to open his mouth. The mud. Instead he felt a stinging in his scalp, a terrible pain in an unexpected place, which seemed brutally unfair – he was preparing himself for the agony of choking suffocation, not for this searing of his skull – as his grandfather grabbed hold of Owen's hair, bunched it in his fist and hauled him out of the bog.

Consciousness of a Lost Limb

Ninety per cent of amputations are to lower limbs. Most are caused by peripheral vascular disease – old smokers' arteries harden, ageing diabetics lose feeling in their feet – and the legs are compromised, being the limbs furthest away from the heart.

When meningitis strikes people in their late teens their bodies, in a desperate defence against the disease, can cease sending blood to the extremities: if gangrene, or meningitic emphysema, develops, the sufferer may lose all four limbs.

About 10 per cent of amputations are to upper limbs. Most of these involve young men who've sustained trauma, usually in a traffic accident, although Owen——was thirty-five years old, and he'd been inside a car rather than on the more usual saddle of a motorbike. He came to our department in 1996 having lost his right hand. The surgeon involved had assessed the possibility of salvaging the hand, hoping to reattach it using microsurgery, but in this case nervous and circulatory function had been severely affected. In addition the hand itself, I understand, was badly damaged.

Owen——had a short transradial amputation, that is to say one between the elbow and the wrist.

Postsurgically, the limb was encased in a rigid plaster of Paris dressing: such a cast prevents the formation of oedema and so reduces postoperative pain and hastens healing of the residium, or stump. It may also serve as the foundation for a temporary prosthesis: the sooner after surgery a client uses an artificial limb, for simple grasping actions or merely from a cosmetic point of view, the more likely their acceptance of a permanent prosthesis.

Owen——spent five weeks in hospital while the wound
and other lesser injuries healed and the swelling reduced. He was given a referral letter to our centre two weeks after the accident, and came to see me on a visit from hospital. Although we don't operate strict specialisations here, I'm particularly interested in upper limb loss and rehabilitation, and so receive most such referrals.

I remember Owen well. He had home-made tattoos on the fingers of his remaining hand, but he was a gentle man, reserved. He spoke quietly, a distinct trace of his upbringing in the Welsh borders in his voice.

The first interviews with a client are of vital importance, as we try to find out their expectations, their psychological as well as physical requirements. When I first met Owen he appeared still to be in a state of shock, or rather numbness. I established that the right hand he'd lost was his dominant hand, but he showed no interest in the choice of prosthetic limbs put before him. Did he want more of a functional or a cosmetic hand? How much did he care about what others thought? At our first sessions Owen was monosyllabic and withdrawn.

The individual's psychological response to amputation is the key to their rehabilitation, and basic personality is of great significance. Self-confident individuals generally adjust better to the loss than self-conscious ones. Naturally cheerful people adjust far better than depressives, who are likely to avoid social contact following their loss, which in turn compounds their isolation and depression.

On a practical level, those whose jobs or hobbies and general independence are badly affected by the loss of a limb will have more difficulty coping than those who can adapt more easily. Men often fear impotence or sterility with the loss of a limb.

Clients usually dream of themselves as possessing all their limbs. Getting out of bed at night, those who have lost a lower limb quite often forget their loss, and fall over.

I'd been told of the circumstances of Owen's accident. It was no wonder that he was shut down, closed off. He had other issues. But it's my job to concentrate on occupational therapy: emotional or psychological therapy is between the client and counsellor. The boundaries that are in place have to be respected, otherwise things get confused and none of us are able to do our particular jobs properly. That doesn't mean that if Owen had started talking I wouldn't have listened. I would have. That's part of my job as well. But he didn't. He never said a word about the accident.

I understand Owen declined to continue seeing the counsellor after their third or fourth session.

 

Each prosthetic device is bespoke, made for the individual client. There are two types of artificial upper limb, or terminal device: the hand and the hook, either of which is secured to a plastic socket that encases the residium.

Most clients are keen to replace their lost hand with a replica, of which there are two sorts: a passive, fixed hand or an active hand with a grasping mechanism that moves the index and middle fingers, and the thumb, towards each other, while the fourth and fifth fingers remain fixed.

An active hand is commonly operated myoelectrically: the prosthetic socket has two electrodes which connect with flexor and extensor muscles in the residium. When the wearer consciously contracts the appropriate muscle, the electrode transmits the microvoltage generated by the muscle to a small motor that enables the hand mechanism to open or close the fingers. Sensors in the fingers stop them grasping objects too tightly.

Hands are laminates made from glass-reinforced plastic and acrylic resin. They are covered with a flexible ‘glove' that matches the hair colour and skin tone of the client's other, real hand. A cheap PVC glove may cost as little as £80, while a high-definition, ultrarealistic one made of silicon can cost £3,000 – 5,000 for a whole leg or an arm.

People often wear rings, wristwatches or other jewellery on their artificial hand. One of my clients has found it so difficult to come to terms with his amputation that he sleeps with his artificial arm on.

 

It was at first impossible to determine what kind of prosthesis Owen wanted. As I've said, he showed no interest in his future. But then things changed. He came to his fourth meeting with me – he was now out of hospital, back at home – and brightly asked me to show him the hooks again.

Hooks are lighter than other types of device; they're tougher and more durable. Most amputees, however, care very much what other people think. They resent and are upset by people noticing and staring at their artificial limb, their disability. A very few clients don't give a damn, and care only about the functionality of their prosthesis. I knew I should be wary of Owen's leap from depressive lack of interest to a gung-ho attitude: if this was evidence merely of denial then it would not bode well for recovery. My reservations, however, were overcome as Owen spoke of his determination to resume as active a life as possible. He worked as a self-employed gardener, and together we looked into the array of gardening tools modified for disabled people; he spoke of his young son and his wish to do everything with and for him that any father could. The only thing he didn't want to consider was motor vehicle adaptation
for disability: Owen said he had no wish ever to drive a car again.

Hooks generally operate by a steel cable attached, via metal links in a cuff running the length of the arm, to a trunk harness. The client puts tension on the cable by flexing his shoulder; the cable pulls and operates to either open or close the hook's two steel or aluminium digits. These digits can act either like a finger and oppositional thumb or like two adjacent fingers. Their grasp force is determined by rubber bands encircling the base.

Because the tips of the fingers of a hook are small, the client can see the object to be grasped more easily than with the thicker fingers of a prosthetic hand. They're also much cheaper than bespoke hands, and although our priority is to provide whatever an individual client needs, he or she may well reject an illchosen prosthesis and simply not wear it. If it was one of the most expensive types, then we've clearly wasted money. And we were already at that time working to a tightly controlled budget at the Centre.

Owen took to his hook with relish. He subjected it to all kinds of tests, challenging it and himself to do pretty well everything he could before the accident. Within a short space of time he was able to operate tools, though for other reasons was unable to return to work. He also liked gimmicky aspects of having it: holding a cigarette between the claws, or trying to juggle with soft balls. He was always making jokes.

‘Sorry to keep you waiting,' I said once, when the previous appointment had run over.

‘No problem,' Owen said. ‘Having a good chat I was with the other cybermen out there.'

A proportion of clients – particularly men – make light of their condition with such flippancy, but Owen was intelligent.
He understood, for example, that I must have heard all such cracks many times before, and he'd add an ironic touch. He once greeted me as he came into my office by raising his hook and saying, ‘Can you hear the clock ticking, Peter?'

Now I used to look younger than my age, and with my short hair I could be described as boyish. And most actors who play the role of Peter Pan are boyish women, aren't they? So Owen was making the almost obligatory such prosthesis-wearer's reference to himself as Captain Hook, but playing with it to include me. And the question itself referred not only to the clock swallowed by the crocodile, who you'll remember was after Hook, but also perhaps to time that was after me. How long would I remain a boyish, young-looking woman?

Perhaps Owen was also flirting, in a mild way.

I became aware, however, of two possibly contradictory aspects of Owen's behaviour. He made out he didn't care what people thought, making jokes at his own expense, yet one always felt that he was hiding something – which indeed he was: the loss of his hand was as nothing compared to his greater loss. I was never sure, to be honest, whether the rehabilitation with which I assisted him was also helping him come to terms with his grief, or rather offering him a peculiar form of denial.

 

Such was the speed of Owen's recovery that I stopped seeing him after three months. When he telephoned the Centre a further six months later, however, to book an appointment with me, I was not surprised. The pattern was a common one.

The persistence of sensation in and awareness of limbs after
they have been amputated has long been known. A French surgeon wrote of the phenomenon in the sixteenth century. Admiral Lord Nelson lost his right arm in 1797, and thereafter felt the fingers of his absent hand digging into his palm. Pondering this survival of the hand's spirit after its physical loss, Nelson decided it was direct evidence for the existence of the soul.

During the American Civil War thousands of wounded soldiers developed gangrene and had their infected limbs sawn off in field tents. A Philadelphian physician, Silas Weir Mitchell, later worked with many of these veterans of the war who retained the ‘sensory ghosts' of their lost arms or legs. Weir Mitchell coined the term ‘phantom limb'.

For most of the twentieth century the phenomenon remained mysterious. Explanations ranged from a patient's wish to have his or her limb back inducing the phantom in their imagination, to inflammation of nerve endings in the stump. In 1887 the eminent psychologist William James conducted the first survey of phantom limb amputees and found that ‘many patients say they can hardly tell whether they feel or fancy the limb'. He also wrote, in an article ‘The Consciousness of Lost Limbs', that phantom limb sensation tells us absolutely nothing which can practically be of use to us – except, he believed, the approach of storms.

Nowadays it's generally agreed that the causes are complex and to be found in the neurology of the brain. Parts of the body, including limbs, are mapped on to the cerebral cortex, and when a limb is lost the corresponding area of the map appears to adjust to receive signals from another part of the body, but the person feels the sensation as coming from the lost limb.