by David Page
• An abusive husband thrusts a freshly sharpened no. 2 pencil into his wife's ear canal.
To assemble a tale of woe, you must let your imagination soar in order to discover what sort of unique injury might serve your purpose. These examples of impalement injuries will get you thinking about sharp objects and soft body parts. The rest is merely a matter of assembly, beginning at the end.
Cross-sectional anatomy of the limbs, trunk and neck helps you to determine what injuries will occur with a particular impalement. Imagine what structures a sharp object could traverse without actually killing your victim. Here are a few more examples.
There is a famous case of a man who was tamping in a dynamite charge with a metal rod when the charge went off. He was struck somewhere in the forehead and the rod went into his skull and (presumably) through part of his frontal lobes and the connecting fibers between the two cerebral hemispheres. The man survived to live for years with no ill effects other than a major personality change.
If your story takes place on a farm, an obvious implement that may be invoked in an impalement injury is a pitchfork. A fall from the hayloft onto a piece of farm equipment is another tragic working injury.
There is a photograph somewhere of a young man hanging from the top of a tall wrought iron fence. The arrowhead-shaped spike had penetrated the fellow's cheek from the outside and was protruding from his open mouth. Did the youngster attempt to scale the fence, slip and impale himself as he plummeted toward the ground?
Underwater stories flirt with the idea of someone getting impaled by a spear gun. Tales of adventure where bows and arrows flourish beg a scene with someone pinned to a tree by a poisonous arrow. Or in the belly. Or leg. Or neck. A knife driven through a hand into a wooden table might get your character's attention.
Mutilation and Torture
The idea behind mutilation is presumably twofold: first, to play out one's unmanageable rage and inflict revenge; second, to leave a message for those who discover the body. Death and disfigurement each possess a separate horror. But the message is always the same: This could happen to you.
Knit tightly into the psychology of mutilation is the sister terror of torture. Both stimulate the most profound sense of dread, panic and disgust. Only people who possess a bestial level of perception and appreciation would inflict suffering and unimaginable pain. Or writers.
So if you're telling a dreadful tale populated by lots of bad guys, you may need to have them torture or disfigure someone. Like it or not, you've got to know how it's done. As before, we'll begin with the information you'll need to build your intimidating scene. But first, ask yourself: What is it about mutilation and torture that we react to? The answer is twofold:
• We abhor disfigurement of those body parts we view as uniquely human.
• We are repulsed when viewing painful injuries with which we can easily relate, those injuries that we have experienced or that are similar to our past injuries or close to the kinds of pain we have felt.
What parts of our bodies are unique?
It isn't the sensual aspects of the human form, not the curves, not the tapered legs or the rippling shoulders or thick thighs. These defining anatomic features are sexy. We all respond to an attractive figure according to our sexual orientation. But hormonal intrigue isn't what defines us as special.
It's the human face, hands and feet.
OK, maybe you'll quibble with me about feet. But we're not searching for hallmarks of human beauty in this discussion. I'm attempting to pursue the idea of a defining structure that makes us so undeniably human in the first place.
Remember Dr. Hanibal Lecter in Thomas Harris's The Silence of the Lambs? Officers Pembry and Boyle are feeding the killer in his prison cage in Memphis. Concealing a piece of metal from which he created a handcuff key, Lecter attacks Pembry as he clears Lecter's supper tray and handcuffs him to the table. Then,
Lecter grabbed the long end of the baton and lifted. With the leverage twisting Pembry's belt tight around him, he hit Pembry in the
throat with his elbow and sank his teeth in Pembry's face. Pembry
trying to claw at Lecter, his nose and upper lip caught between the
tearing teeth. Lecter shook his head like a rat-killing dog. . .
It's a disgusting scene because it is subhuman. Lecter could have clubbed him to death without the mutilation, but instead he killed Boyle and then left Pembry with a bleeding open face, a reminder to all of Hanibal Lecter's unpredictability. Genius and insanity, separated by an angel's hair.
Consider the intern who evaluates a trauma victim in the ER for the first time or a medical student who begins the study of anatomy and views the cadaver on that memorable first day. Why are they distressed? Is it because the trauma victim is in shock? Is it because the cadaver is dead?
How do you react to a road kill?
If you'll stop laughing for a moment, it's not such a foolish question. Routinely, we drive past dead raccoons, birds, deer and other carrion and usually don't stop to mourn the passing of one of nature's family. When does the dead animal make you cringe? It's when you see the face—especially the eyes—or you view loops of intestine or something else from "inside," some ugly viscera foreign to your daily experience.
The intern looks at the motorcycle victim on the stretcher and sees his brother. The medical student views the cadaver and sees her grandmother. Both individuals focus on something familiar; they are reminded of something or someone emotionally close to them. Common to both experiences are views of those anatomic parts that we associate with being uniquely human. We are staggered by the dead face, the lifeless hands, the toe tag.
There's more.
Next you're going to learn why these very human structures are involved in both mutilation and torture. It goes beyond the obvious delight crazed maniacs derive from disfiguring their victims, debasing that which is human, that which is defining about an individual. It is tied to the hard-wiring of the human nervous system.
First, consider how body parts are represented on the cerebral (conscious) cortex. One strip of the cortex (sensory cortex) provides sensation while the adjacent strip (motor cortex) provides conscious control of muscles. Pathways, or bundles, of nerves travel from the motor cortex to the muscles and permit you to move your body any way you elect. Other neural highways course up the spinal cord to the brain— specifically to the sensory cortex—from various body parts, returning a kaleidoscope of sensations.
Not all body parts are equally represented on the sensory cortex. Stab someone in the back with an ice pick and he may not know what happened. The impact seems to the victim a mere thump on the shoulder. But push a toothpick under the same person's fingernail and the pain will be unbearable. Why? Because the area on the sensory cortex devoted to the hand is larger. Now you know why it hurts.
All that neural power is supposed to provide you with the ability to feel small objects, improve touch, appreciate pressure changes and refine and modulate hand and finger movements. It's possible because of the rich pattern of sensory signals the brain receives from the hand. This geographic generosity of the human sensory cortex has produced the Sistine Chapel, Mozart's minuets, concertos and symphonies and a wealth of literature, sports heroes and villains. We are unique among mammals because we have an opposable thumb and a supercharged brain to guide it.
The feet are well represented on the sensory cortex as well. So are the genitals.
Imagine that. Thugs with no education, no understanding of neuroanatomy actually create anguish true to the nature of the brain.
They know which sensory buttons to push.
Thus, the human nervous system is designed to process a variety of exquisite sensory bulletins, integrating various signals from touching, stroking and prodding to pinching, poking and stabbing. From pianists to keyboard-crazy adolescents, from artists to inner-city graffiti gurus, humans take for granted the remarkable biological gift provided by their marvelous brains. Receiving signals,
sending out motor messages coupled with imagination, humankind has created a culture enriched with a host of expressions of intellect.
But every complex system possesses a potential glitch. Wired for maximum efficiency, the brain also may be overloaded and break down. The sheer volume of sensations received by some people is too much for them to cope with and they decompensate. It's the price humans pay for being smart.
Warthogs don't become depressed.
Sadly, the villains and degenerates of the world also understand the inherent flaws in the wiring of the mind. Both mental and physical torture are possible because of the defenseless nature of our bodies. Few people can distract themselves to the extent that they can completely block out noxious, disagreeable sensations. And although the villain doesn't know his cortex from his elbow, he does know how to take advantage of the sensitive skin envelope.
Now, so do you.
Mutilation doesn't always result in death. The best advertisement for a subversive individual or group is a walking, talking human signpost with disfiguring scars. Once again, the most effective mutilation is designed to distort those things we hold most precious. An example: How often have you not recognized a friend because she was wearing dark glasses? We are defined by our physical features, and our eyes are truly the windows to our uniqueness. But more to the point, if the eyes are involved in mutilation, the impact is twofold:
• The injured person carries a visible scar (or eye patch).
• The injured person loses a precious gift (sight).
The villain sends a clear message. We will hurt you, and we may change your life permanently without actually killing you. Reminders. That's what the bad guys want as they wander about out there among the common folk. A scarlet letter sends a message. A missing ear sends a more virulent message. Fingers may be amputated in the name of torture as well as to leave a visible message.
Scars speak of the horrors experienced when wounds are inflicted.
My springer spaniel galloped across the train trestle a few feet ahead of the charging locomotive, making no attempt to clear the track as he galloped past the bridge abutment. I yelled at the roaring train. Blackie kept running, losing the race with the train by inches with each labored leap, and now his tongue flapped out and soon his tail was within a foot of the huge black machine. As my shouts became lost in the roar of the locomotive, my heart squeezed and Blackie's lean body disappeared beneath the screeching steel wheels. The furry black ball rolled under the locomotive, tumbled for an indeterminable moment, somersaulted beneath the wheels and bounced off of the wooden ties until at last, a small black mass shot off to the opposite side of the tracks hidden from me by the train roaring past, and a larger chunk of dog rolled across the snow until it stopped less than twenty feet from where I stood.
I was twelve years old when I saw my first traumatic amputation. Blackie was my first dog, and I buried his severed head and his body together beneath the crusted surface of a lonely stretch of Quebec's wilderness not far from my home.
There is something more chilling than it is final about the complete severance of a body part, even when death is not part of the trauma scenario. A head cannot be reattached to the body. But other parts can be and routinely are replanted.
The majority of traumatic amputations are not lethal, and thanks to microscopic surgery, often the severed part may be replaced with the use of special surgical techniques.
The first limb replacement—replantation as doctors call it—of a severed body part didn't occur in a human until 1962, even though surgeons in the U.S. were cutting off and sewing back dogs' limbs in the 1920s. It wasn't until a twelve-year-old boy was rushed to Massachusetts General Hospital in 1962 that successful replantation was accomplished. The unfortunate youngster had been playing beside railroad tracks when a train ran him down, trapping his arm between the train and a bridge support. The arm was completely severed. Dr. Ronald Malt, a surgical resident at MGH, made medical history when the boy's arm was successfully reattached.
Now the procedure is common all over the world.
First, we need to complete a small housekeeping chore. Replantation refers to the reattachment of a completely severed body part. But the whole process is based on the discipline of microsurgery, which requires the use of delicate instruments, intense surgeon training and a special operating microscope. The major focus is on revascularization— the correction of cut blood vessels—sewing back together both arteries and veins with delicate sutures. Because of its wide application, microsurgery cuts across all specialty lines, and surgeons have used this technique to transfer tissue as well as reattach amputated limbs and digits.
To limit the topic, we'll focus on the upper extremity in our discussion. Before we do, it is important to remember that all of the following (and undoubtedly other) tissues have been replanted:
• The lower extremity
• Ear
• Lip
• Lip and chin
• Penis and scrotum
• Scalp
In the scheme of things, when a multiply injured patient arrives in the emergency room, there is little worry that the upper limb injury will threaten the victim's life unless a major hemorrhage occurs. On the other hand, the final disability for the victim if she survives will be lost work ability and changes in daily living caused by loss of the severed part. Thus, it is important to consider replantation as an integral part of overall care.
Sharply created traumatic wounds have a better rate of successful replantation than those accompanied by a mangling agent, such as those seen with industrial machines and farm equipment. Machetes, meat cleavers and knives make reattachment an easier surgical tour de force.
Why does an operation for replantation fail?
It fails most often because of excessive total time the amputated part has gone without an adequate blood supply. This period of time is referred to as warm ischemia time. It means vital cells in the amputated part have no nourishment, and without cold protection to slow down metabolism, they will begin to die. Experimental studies suggest that the limb ought to be replanted within six to eight hours for optimum function. Cold protection of the amputated part (packing the part in ice) will prolong this time frame; for example, cooled amputated dog legs have been successfully reattached after as long as twenty-five hours.
Though our discussion of replantation issues will focus on the upper extremity, we'll cover the basic principles used in the replantation of other tissues. Any of the following traumatic upper extremity amputations should be considered for replantation:
• Thumb
• Hand
• One or more fingers
• Arm
• Any ischemic or amputated extremity of a child
There are some trauma victims who should not be evaluated for replantation. And all candidates who are considered must be fully informed about the arduous and prolonged rehabilitation process, loss of work time, discomfort and possibility of failure. It's possible that some folks just don't think missing a chunk of a finger is a big deal. Prior illness and the severity of the injury itself may exclude otherwise motivated patients from becoming microsurgery candidates.
Who gets rejected during the crucial initial evaluation in the emergency room after the traumatic event? Remember, the first thirty minutes of assessment and resuscitation is when saving the victim's life outweighs saving the limb. At least until the smoke clears.
The following are reasons not to consider a trauma victim a candidate for replantation:
• The amputated part is severely crushed.
• The amputated part is extremely contaminated with road dirt, etc., so that it cannot be adequately cleaned.
• The victim has one or more life-threatening injuries that require extensive emergency care including surgery.
• The victim has one or more severe chronic illnesses that are debilitating, such as severe heart disease, poorly controlled diabetes or extensive crippling arthritis.
Every amputated part should be taken to the hospital with the victim. Only a microsurgeon can determine if the severed part is viable and can be reattached to the victim's body. Even if it can't, some of it, e.g., the skin, blood vessels and nerves, may be used to repair other injured body areas. If reattachment is to succeed, your characters must know how to handle the severed part out in the field. Here are the steps that must be followed in packaging the amputated part:
• Wrap in moistened sterile gauze. Don't attempt to clean the part as vital structures may be damaged.
• Place wet gauze containing the part into a sealed plastic bag or bottle.
• Place the bag/bottle in a basin of water and ice. Don't let the part come in direct contact with the ice.
• Give the package to the ER personnel on arrival.
How a Finger Is Replanted
To demonstrate the steps involved in any type of replantation, we'll examine the replacement of an amputated finger. In a critically injured victim, the severed part may be worked on by a microsurgeon while the patient is being resuscitated and treated for other injuries by the trauma team. The surgical preparation of the part includes:
• Keeping the part as cold as possible
• Shortening the bone to allow repair of nerves and vessels without tension
• Debriding dead tissue
• Labeling nerves and blood vessels
• Flushing out blood vessels with heparin
• Placing rigid wires in injured bones to fix them to the remaining bones in the hand
A second team performs the same procedures on the amputated stump. When both ends are prepared according to the above protocol, the replantation occurs. Each cut structure of the finger is reattached by sutures in a specific order (this varies somewhat from hospital to hospital):
1. Fix bones for stability.
2. Fix extensor tendons. (Flexors are repaired after the extensors because the task is more complicated.)
