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Midlands Rehabilitation Centre 17 November 2000
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    Dear Sue,
    I think I told you that I agreed to give a talk at the conference next month: to tell the story of phantom limb pain, and the introduction of the mirror box. If you’ve got a minute I could really do with some feedback.
    As the audience is going to consist of health professionals across the board, I’ve interwoven a case history as a way of personalising the subject.
    I’m not used to writing at such length. Remember how much detail we put into case histories when we were training. Then you qualify and of course there’s no time, everything’s abbreviated. Anyway, it’d be great if you have any ideas for improvement.
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    Andrea
    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