Clinical Orthopaedics and Related Research®
Clin Orthop Relat Res DOI 10.1007/s11999-014-3480-6
A Publication of The Association of Bone and Joint Surgeons®
SYMPOSIUM: RECENT ADVANCES IN AMPUTATION SURGERY AND REHABILITATION
Punitive Limb Amputation Anna Mavroforou MSc, LLM-LAMB, MBA, Konstantinos Malizos MD, Theofilos Karachalios MD, Konstantinos Chatzitheofilou MD, Athanasios D. Giannoukas MSc, MD, PhD, FEBVS
Ó The Association of Bone and Joint Surgeons1 2014
The authors certify that they, nor any members of their immediate families, have funding or commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research1 editors and board members are on file with the publication and can be viewed on request. The opinions expressed are those of the writers, and do not reflect the opinion or policy of CORR1 or the Association of Bone and Joint Surgeons1.
Results Evidence for punitive amputation is available as early as the court of the Babylonian Code of King Hammurabi (circa 1750 Before the Common Era [BCE]), which imposed punitive limb amputations on slaves who used force against free citizens. Other reports provided evidence that punitive amputation was used as early as the 4th century BCE in ancient Peru. Limb amputation restored law and order during the Roman and Byzantine periods. Amputation as a punitive instrument prevailed in Europe throughout the 17th century. During the Enlightenment, the intellectual movement in Europe approached criminal law from a humanistic perspective, incorporated it into societal practice, and promoted its preventive dimensions. Punitive limb amputation still exists in several Arab and African countries. Conclusion Amputation as a punitive or correctional method has its roots in old civilizations. It has been used through the ages in various parts of the world. While it has been abandoned in modern western societies, punitive amputation is still used in several third-world countries.
A. Mavroforou Department of Medical Deontology and Ethics, School of Health Sciences, Faculty of Medicine, University of Thessalia, Larissa, Greece
Introduction
Abstract Background Limb amputation has been carried out through the ages as a punitive method in various parts of the world. This article highlights the historical and societal background associated with the use of punitive limb amputation. Methods We performed an extensive electronic search of the pertinent literature augmented with a hand-search of additional sources.
K. Malizos (&), T. Karachalios Department of Orthopaedics & Musculoskeletal Trauma, School of Health Sciences, Faculty of Medicine, University of Thessalia, 13 Ath. Agorogianni St., 41335 Larissa, Greece e-mail: [email protected] K. Chatzitheofilou Department of General Surgery, School of Health Sciences, Faculty of Medicine, University of Thessalia, Larissa, Greece A. D. Giannoukas Department of Vascular Surgery, School of Health Sciences, Faculty of Medicine, University of Thessalia, Larissa, Greece
Limb amputation is often performed to save human life at the expense of the limb, and is the treatment of choice for a number of conditions, including ischemic gangrene, intractable soft tissue sepsis alone or in combination with osteomyelitis, malignancy, and various civilian and war injuries. However, in some parts of the world, both in the past as well as today, limb amputation has been utilized as a punishment. This review highlights the historical uses and social perceptions of the punitive limb amputation. Particular
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Mavroforou et al.
Clinical Orthopaedics and Related Research1
effort was made to retrieve as much information as possible regarding medical details related to the conditions applied for punitive limb amputation.
Methods We performed a literature search of English-language articles from PubMed. Terms used for such search were: ‘‘Limb’’, ‘‘Amputation’’, ‘‘Mutilation’’, ‘‘Punitive’’, ‘‘Punishment’’, ‘‘Penalty’’, ‘‘Correctional’’, and ‘‘Legal’’. We then hand-searched the retrieved references to identify additional sources. We augmented the search with review of relevant books, theses, and historical literature reports written in Greek. Finally, we performed an electronic search of websites related to the subject.
Results Historical Evidence from the Ancient Period The Babylonian Code of King Hammurabi (circa 1750 BCE) [7], considered the first known collection of laws, described amputation as a method of punishment. The basic principle of the Code was equal retaliation. The penalty of amputation was imposed on slaves who used force on free citizens or on physicians of that time whose operations blinded or killed nobles. Other ancient reports on the use of amputation as a method of correction come from Peru, where the theocratic regime was based on three laws only, which prohibited false witness, theft, and laziness. Amputation was among the punishments applied for law violations. From 300 BCE onwards, punishment depended not only on the crime that took place, but also on the social class of the offender, as perpetrators belonging to higher social classes were deemed more accountable for their actions [9]. Lastres [14] found that the ancient pottery of Peru displays amputations of the lips, nose, and legs. Based on depictions of the amputations shown in many ceramic pieces, namely amputations of the lower left leg, Lastres concluded that amputation was imposed as punishment for various unlawful acts [14, 24]. Velez Lopez, a Peruvian physician, wrote in 1912 that such amputations were imposed because of the significant damage sustained by the victim of the crime [24]. Pardal [19] noted variation in the two categories of ceramics. The first category included the largest number of exhibits, and illustrates amputation of the nose and lips, made with clear cuts that could only be achieved with use of surgical instruments. Evidently, telling a lie resulted in amputation of the lips, stealing resulted in amputation of
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Fig. 1 This photo shows Moche ceramics indicating amputation of the nose and lips. Photograph provided courtesy of the San Diego Museum of Man.
Fig. 2 This photo shows Moche ceramics indicating an individual with missing feet. Photograph provided courtesy of the San Diego Museum of Man.
the hand (Fig. 1), and laziness during work resulted in amputation of the foot (Fig. 2). The second category of ceramics displayed amputations performed to treat pathological conditions [9, 19].
Punitive Limb Amputation
Pardal identified written records describing amputations of the nose and lips of the Indians of Peru who served in the temples of the Virgins of the Sun [19]. In a sample of 99 Moche ceramic vessels, Verano et al. [25] identified a missing single foot in 26 cases, both feet in 55 cases, a single arm in two cases, both arms in six cases, a forearm and a hand in six cases, both forearms in five cases, both hands in two cases, and both hands and both feet in one case. These patterns would be difficult to explain as part of any medical treatment, suggesting that these amputations were indeed punitive. In the Museo Arqueolo´gico Rafael Larco Herrera (The Larco Museum) in Lima, Peru, thousands of ceramics are displayed in a unique collection representing various medical activities and therapeutic effects. Anthropomorphic figures with amputated arms and legs are displayed there [6]. Some potteries show the amputation of both upper extremity limbs above the elbow or through it, which renders the amputee completely inept [9]. Packard [18] and Lawson [15] argued that the Iroquois and Seneca Indians used partial amputation of lower limbs as punishment around the 15th century or earlier.
Roman and Byzantine Period Christian historiography claims that emperor Constantius Flavius Valerius Aurelius (272–337 CE) implemented new legislation that introduced amputation as punishment. Slaves caught trying to escape imprisonment either were killed, sentenced to hard labor in the mines, or subjected to the amputation of a leg [8]. The exact dates of these abuses are not known. Additionally, it is believed that the first punitive amputation of this era within the Byzantine territory took place during the reign of Isaurian, who made crucial reforms to the criminal provisions of Roman law, in order to replace the death penalty. Leo III revised the previous laws, introducing amputation as a substitute for the death penalty [5]. Despite implementing alternatives to the death penalty, executions continued to occur. Executions sometimes mutated into sadistic rituals, where representatives of the judiciary tortured the criminal, severing limbs and using knives of various shapes until the criminal died. Phocas, the Byzantine Emperor, introduced and applied particularly cruel methods of torture and punishment including forced blindness and amputation [20]. Even the Agricultural Law of the 7th and 8th centuries condoned amputation for merely stealing grapes or fruits from foreign ownership [2].
Medieval Period With the collapse of the Byzantine Empire, amputations decreased in number, frequency, and violence [8].
However, in the Middle Ages, various forms of punishment once again centered on the torture of the body through amputation; through this, revenge on the body of the offender was achieved, which was seen as proper justice. During the Renaissance and the Enlightenment, a radical change in this perception occurred, in that punitive amputation fell from favor [13].
Modern Day A radical shift took place once again at the time of European colonization of Africa (1884–1904), as many slaves were punished with amputation. In 1885, the Berlin Conference donated the Congo Free State to King Leopold of Belgium as personal property. In a rush to extract profits from his new colony, King Leopold needed abundant, inexpensive labor. His agents treated the local population with great cruelty. In this 20-year period, as European powers competed to exploit the wealth of Africa, 5 to 8 million Africans died from colonial violence, including systematic amputation and torture [10]. Although most modern societies do not consider amputation as a correctional method, many third-world nations have adopted punitive amputations. Judicial amputation is still used in Iran, Yemen, Sudan, Afghanistan, and the Islamic regions of Nigeria. In July 2009, Al Shabaab of Somalia, and the Islamic Sharia (strict Islamic law) court sentenced four teenagers to amputation of their right foot and left hand as punishment for stealing mobile phones and other goods [23]. The Deputy Chief Justice of Sudan recently revealed that 16 people were subjected to amputations since 2001 [3]. Adam alMuthna, 30, was the first reported case of forced amputation in Sudan. Three doctors amputated the right hand and left foot of al-Muthna on February 14, 2013 in a hospital in Khartoum. This event attracted a public outcry, particularly by the Sudanese Doctors’ Union. The union complained that the doctors were horrified to break the Hippocratic Oath by harming their patient instead of protecting him [3]. The common judicial punishment for theft in Saudi Arabia is the amputation of the right hand [17]. But for highway robbery, the punishment is cross amputation —amputation of the right hand and left foot. Although such cases have been unusual in Saudi Arabia, Amnesty International reported four cases in 1986. In 1990, fewer than ten hand amputations reportedly occurred, at least five of which were administered to foreigners [21]. More recently, a court in Saudi Arabia sentenced six men to cross amputations for highway robbery. In October 2011, a court of appeal upheld this cross amputation sentence [1, 26].
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Discussion The Babylonian Code of King Hammurabi, which introduced as basic principle the concept of equal retaliation, provides the first evidence of punitive amputation for correction [7]. In ancient Peru, potteries and ceramics provided artistic evidence of punitive limb amputations [9, 14, 19, 24]. During the Roman and Byzantine empires, punitive limb amputations continued. Such penalties were particularly effective for restoring law and order, and remained so until the end of the empire [12, 22]. The introduction of numerous laws, which set out strict penalties for offenders, was considered necessary at the time. These penalties (beheading, stoning, enslavement, burning, hanging, shearing, pillory, crushing of the joints, cutting of the tendons of the leg with a knife, being exiled to the mines, and slavery), were considered a natural extension of the sentences of the Roman law. During the Byzantine time, theological arguments and references to the sacred texts were used to justify these punishments. They did not hesitate to use the teaching of Christ for their purposes, including the gospel proverbs, ‘‘Cut your hand or your foot if it scandalizes you,’’ and ‘‘better being lame or crippled rather than able-bodied and damned’’ [16]. The barbaric custom of amputation has been attributed to the Arabic tradition of retribution, but that view is inconsistent with the fact that amputations were performed long before the appearance of Arab populations in the Mediterranean Sea [11]. Punishment likely has its roots in the popular perception that the perpetrator should be punished by losing the limb with which he or she committed the crime. Amputation acted as a special precautionary measure as an obvious and continuing stigma of punishment of the guilty party, and as an example to others [22]. With the collapse of the Byzantine Empire as a superpower of the era, amputations decreased in number and frequency [5]. However, later in the Middle Ages, European countries adopted various forms of punishment, including torture of the body — often presented in public places. The main concern was to demonstrate the power of the absolute ruler. This explains why the citizens of the medieval period were familiar with the essence of pain and death. During the Renaissance and the Enlightenment, the intellectual movement in Europe brought about significant changes on both criminal sanctions and criminal policy issues. The Enlightenment approached criminal law from a humanistic aspect, incorporated it into the societal practice, and promoted its protective aspects. During this time, individuals recognized criminals as human [13]. It was unthinkable to use torture and amputation as punishment. Crime was an act punishable only by law, and the purpose of punishment was to correct criminals. In 1764, Beccaria emphasized that the purpose of punishment should not be to
123
take revenge on the offender, but to achieve their correction in order for them not to repeat the same offense in future [4]. Various societies have applied punitive amputation as a punishment based on a strong belief that crime can be curbed by spreading fear. However, through the societal evolution in modern western civilizations, these perceptions no longer exist. Yes, the death penalty still exists in some western countries, including the United States, though death by lethal injection is often debated, seriously criticized, and scarcely employed. Although modern societies no longer consider amputation an appropriate correctional method, some third-world nations continue to employ punitive amputations. Acknowledgements The authors thank Ms. Elena Chatzinikou (official English translator) for her help in the linguistic review of the manuscript.
References 1. A Big Message. Saudi Arabia — Cross amputation of limbs. Available at: http://www.abigmessage.com/saudi-arabia-crossamputation-of-limbs.html. Accessed December 3, 2013. 2. Ashburner W. The farmer’s law. J Hell Stud.1912;32:87–95. 3. Belay N. Opinion: Sudan must end ‘cruel’ amputation punishment. Available at: http://edition.cnn.com/2013/03/16/opinion/opinionamnesty-international-sudan-amputations. Accessed December 3, 2013. 4. Beccaria C. On Crimes and Punishments. Korai A, trans. Athens, Greece: Publication Law Library;1998:1–116. 5. Belogiannis B. Violence during Byzantine times. Brief overview of the phenomenon of amputations in the Byzantine Empire [in Greek]. Available at: http://www.scribd.com/doc/26447172/% CE%97-%CE%B2%CE%AF%CE%B1-%CE%BA%CE%B1%CF %84%CE%AC-%CF%84%CE%B1-%CE%B2%CF%85%CE%B6 %CE%B1%CE%BD%CF%84%CE%B9%CE%BD%CE%AC-% CF%87%CF%81%CE%BF%CE%BD%CE%B9%CE%BA%CE %AC. Accessed Jan. 2, 2014. 6. Checa A. Evidences of rheumatic disorders and orthopedic practices in Moche art Rheumatol Int. 2010;30:419–421. 7. Code of Hammurabi. Available at: http://www.commonlaw.com/ Hammurabi.html. Accessed December 3, 2013. 8. Frangopoulos S. Slavery — a brief historical review [in Greek]. Available at: http://www.scribd.com/doc/15628605/%CE%97-% CE%B4%CE%BF%CF%85%CE%BB%CE%B5%CE%AF%CE% B1-%CE%B9%CF%83%CF%84%CE%BF%CF%81%CE%B9% CE%BA%CE%AE-%CE%B1%CE%BD%CE%B1%CE%B4%CF %81%CE%BF%CE%BC%CE%AE-%CE%A3%CF%84-%CE% A6%CF%81%CE%B1%CE%B3%CE%BA%CF%8C%CF%80 %CE%BF%CF%85%CE%BB%CE%BF%CF%82. Accessed January 7, 2014. 9. Friedmann LW. Amputations and prostheses in primitive cultures. Bull Prosthet Res. 1972;105–138. 10. Gioulafi N, Fardella P, Chrysovitsanou C. The perception of African immigrants in Greece to treat their indigenous [in Greek]. Available at: http://nefeli.lib.teicrete.gr/browse2/seyp/ker/2007/ GioulafiNikoleta,PhardeliPinelopi,ChrisovitsanouGeorgia/attacheddocument/Gioylafi.2007.pdf. Accessed January 2, 2014. 11. Guillou A. La Civilisation Byzantine. Odorico P, Tsochantaridou S, trans. Athens, 1996.
Punitive Limb Amputation 12. Kalogeropoulos K. Crime and punishment in Byzantium. Available at: http://www.pneuma.gr/byzcrime.htm. Accessed December 3, 2013. 13. Kioupis D. The Impact of enlightenment in criminal law. Criminal Chronicles. 2001;583. 14. Lastres JB. [Peruvian Aboriginal Medicine] [in Spanish]. Lima, Peru: Revista del Museo Nacional;1943:61–80. 15. Lawson J. Lawson’s History of North Carolina. Richmond, VA: Garrett and Massie; 1937:210. 16. Matthew 5:29–30. 17. Naija thief’s hand amputated in Mecca. Available at: http:// ragy1030.wordpress.com/2012/11/22/naija-thiefs-hand-amputatedin-mecca/. Accessed December 3, 2013. 18. Packard FR. History of Medicine in the United States, Vol. 1. Hafner, New York;1963:40. 19. Pardal R. [American Aboriginal Medicine] [in Spanish]. Buenos Aires, Argentina: Editorial Renaissance;1998:1-377. 20. Phocas. Available at: http://en.wikipedia.org/wiki/Phocas. Accessed December 3, 2013.
21. Saudi Arabia Crime and Punishment. Available at: http://www. photius.com/countries/saudi_arabia/national_security/saudi_arabia_ national_security_crime_and_punishment.html. Accessed December 3, 2013. 22. Troiannos S. Penalties in Byzantine Law. In: Crime and Punishment in Byzantium [in Greek] Athens, Greece:Goulandris Foundation Horn;2001:17. 23. The 13 most brutal and inhumane judicial punishments still used today. Available at: http://brainz.org/13-most-brutal-and-inhum ane-judicial-punishments-still-used-today/. Accessed December 3, 2013. 24. Velez LL. [Mutilation in Anthropomorphic Vases of Ancient Peru] [in Spanish]. In C.I.A. London, UK;1912:267-275. 25. Verano JW, Anderson LS, Franco R. Foot amputation by the Moche of ancient Peru: Osteological evidence and archaeological context. Int J Osteoarchaeol. 2000;10;77-88. 26. Wilcke C. Letter to Saudi rights body on amputation case. Available at: http://www.hrw.org/news/2011/12/16/letter-saudirights-body-amputation-case-0. Accessed December 3, 2013.
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Clin Orthop Relat Res DOI 10.1007/s11999-014-3480-6
A Publication of The Association of Bone and Joint Surgeons®
SYMPOSIUM: RECENT ADVANCES IN AMPUTATION SURGERY AND REHABILITATION
Punitive Limb Amputation Anna Mavroforou MSc, LLM-LAMB, MBA, Konstantinos Malizos MD, Theofilos Karachalios MD, Konstantinos Chatzitheofilou MD, Athanasios D. Giannoukas MSc, MD, PhD, FEBVS
Ó The Association of Bone and Joint Surgeons1 2014
The authors certify that they, nor any members of their immediate families, have funding or commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research1 editors and board members are on file with the publication and can be viewed on request. The opinions expressed are those of the writers, and do not reflect the opinion or policy of CORR1 or the Association of Bone and Joint Surgeons1.
Results Evidence for punitive amputation is available as early as the court of the Babylonian Code of King Hammurabi (circa 1750 Before the Common Era [BCE]), which imposed punitive limb amputations on slaves who used force against free citizens. Other reports provided evidence that punitive amputation was used as early as the 4th century BCE in ancient Peru. Limb amputation restored law and order during the Roman and Byzantine periods. Amputation as a punitive instrument prevailed in Europe throughout the 17th century. During the Enlightenment, the intellectual movement in Europe approached criminal law from a humanistic perspective, incorporated it into societal practice, and promoted its preventive dimensions. Punitive limb amputation still exists in several Arab and African countries. Conclusion Amputation as a punitive or correctional method has its roots in old civilizations. It has been used through the ages in various parts of the world. While it has been abandoned in modern western societies, punitive amputation is still used in several third-world countries.
A. Mavroforou Department of Medical Deontology and Ethics, School of Health Sciences, Faculty of Medicine, University of Thessalia, Larissa, Greece
Introduction
Abstract Background Limb amputation has been carried out through the ages as a punitive method in various parts of the world. This article highlights the historical and societal background associated with the use of punitive limb amputation. Methods We performed an extensive electronic search of the pertinent literature augmented with a hand-search of additional sources.
K. Malizos (&), T. Karachalios Department of Orthopaedics & Musculoskeletal Trauma, School of Health Sciences, Faculty of Medicine, University of Thessalia, 13 Ath. Agorogianni St., 41335 Larissa, Greece e-mail: [email protected] K. Chatzitheofilou Department of General Surgery, School of Health Sciences, Faculty of Medicine, University of Thessalia, Larissa, Greece A. D. Giannoukas Department of Vascular Surgery, School of Health Sciences, Faculty of Medicine, University of Thessalia, Larissa, Greece
Limb amputation is often performed to save human life at the expense of the limb, and is the treatment of choice for a number of conditions, including ischemic gangrene, intractable soft tissue sepsis alone or in combination with osteomyelitis, malignancy, and various civilian and war injuries. However, in some parts of the world, both in the past as well as today, limb amputation has been utilized as a punishment. This review highlights the historical uses and social perceptions of the punitive limb amputation. Particular
123
Mavroforou et al.
Clinical Orthopaedics and Related Research1
effort was made to retrieve as much information as possible regarding medical details related to the conditions applied for punitive limb amputation.
Methods We performed a literature search of English-language articles from PubMed. Terms used for such search were: ‘‘Limb’’, ‘‘Amputation’’, ‘‘Mutilation’’, ‘‘Punitive’’, ‘‘Punishment’’, ‘‘Penalty’’, ‘‘Correctional’’, and ‘‘Legal’’. We then hand-searched the retrieved references to identify additional sources. We augmented the search with review of relevant books, theses, and historical literature reports written in Greek. Finally, we performed an electronic search of websites related to the subject.
Results Historical Evidence from the Ancient Period The Babylonian Code of King Hammurabi (circa 1750 BCE) [7], considered the first known collection of laws, described amputation as a method of punishment. The basic principle of the Code was equal retaliation. The penalty of amputation was imposed on slaves who used force on free citizens or on physicians of that time whose operations blinded or killed nobles. Other ancient reports on the use of amputation as a method of correction come from Peru, where the theocratic regime was based on three laws only, which prohibited false witness, theft, and laziness. Amputation was among the punishments applied for law violations. From 300 BCE onwards, punishment depended not only on the crime that took place, but also on the social class of the offender, as perpetrators belonging to higher social classes were deemed more accountable for their actions [9]. Lastres [14] found that the ancient pottery of Peru displays amputations of the lips, nose, and legs. Based on depictions of the amputations shown in many ceramic pieces, namely amputations of the lower left leg, Lastres concluded that amputation was imposed as punishment for various unlawful acts [14, 24]. Velez Lopez, a Peruvian physician, wrote in 1912 that such amputations were imposed because of the significant damage sustained by the victim of the crime [24]. Pardal [19] noted variation in the two categories of ceramics. The first category included the largest number of exhibits, and illustrates amputation of the nose and lips, made with clear cuts that could only be achieved with use of surgical instruments. Evidently, telling a lie resulted in amputation of the lips, stealing resulted in amputation of
123
Fig. 1 This photo shows Moche ceramics indicating amputation of the nose and lips. Photograph provided courtesy of the San Diego Museum of Man.
Fig. 2 This photo shows Moche ceramics indicating an individual with missing feet. Photograph provided courtesy of the San Diego Museum of Man.
the hand (Fig. 1), and laziness during work resulted in amputation of the foot (Fig. 2). The second category of ceramics displayed amputations performed to treat pathological conditions [9, 19].
Punitive Limb Amputation
Pardal identified written records describing amputations of the nose and lips of the Indians of Peru who served in the temples of the Virgins of the Sun [19]. In a sample of 99 Moche ceramic vessels, Verano et al. [25] identified a missing single foot in 26 cases, both feet in 55 cases, a single arm in two cases, both arms in six cases, a forearm and a hand in six cases, both forearms in five cases, both hands in two cases, and both hands and both feet in one case. These patterns would be difficult to explain as part of any medical treatment, suggesting that these amputations were indeed punitive. In the Museo Arqueolo´gico Rafael Larco Herrera (The Larco Museum) in Lima, Peru, thousands of ceramics are displayed in a unique collection representing various medical activities and therapeutic effects. Anthropomorphic figures with amputated arms and legs are displayed there [6]. Some potteries show the amputation of both upper extremity limbs above the elbow or through it, which renders the amputee completely inept [9]. Packard [18] and Lawson [15] argued that the Iroquois and Seneca Indians used partial amputation of lower limbs as punishment around the 15th century or earlier.
Roman and Byzantine Period Christian historiography claims that emperor Constantius Flavius Valerius Aurelius (272–337 CE) implemented new legislation that introduced amputation as punishment. Slaves caught trying to escape imprisonment either were killed, sentenced to hard labor in the mines, or subjected to the amputation of a leg [8]. The exact dates of these abuses are not known. Additionally, it is believed that the first punitive amputation of this era within the Byzantine territory took place during the reign of Isaurian, who made crucial reforms to the criminal provisions of Roman law, in order to replace the death penalty. Leo III revised the previous laws, introducing amputation as a substitute for the death penalty [5]. Despite implementing alternatives to the death penalty, executions continued to occur. Executions sometimes mutated into sadistic rituals, where representatives of the judiciary tortured the criminal, severing limbs and using knives of various shapes until the criminal died. Phocas, the Byzantine Emperor, introduced and applied particularly cruel methods of torture and punishment including forced blindness and amputation [20]. Even the Agricultural Law of the 7th and 8th centuries condoned amputation for merely stealing grapes or fruits from foreign ownership [2].
Medieval Period With the collapse of the Byzantine Empire, amputations decreased in number, frequency, and violence [8].
However, in the Middle Ages, various forms of punishment once again centered on the torture of the body through amputation; through this, revenge on the body of the offender was achieved, which was seen as proper justice. During the Renaissance and the Enlightenment, a radical change in this perception occurred, in that punitive amputation fell from favor [13].
Modern Day A radical shift took place once again at the time of European colonization of Africa (1884–1904), as many slaves were punished with amputation. In 1885, the Berlin Conference donated the Congo Free State to King Leopold of Belgium as personal property. In a rush to extract profits from his new colony, King Leopold needed abundant, inexpensive labor. His agents treated the local population with great cruelty. In this 20-year period, as European powers competed to exploit the wealth of Africa, 5 to 8 million Africans died from colonial violence, including systematic amputation and torture [10]. Although most modern societies do not consider amputation as a correctional method, many third-world nations have adopted punitive amputations. Judicial amputation is still used in Iran, Yemen, Sudan, Afghanistan, and the Islamic regions of Nigeria. In July 2009, Al Shabaab of Somalia, and the Islamic Sharia (strict Islamic law) court sentenced four teenagers to amputation of their right foot and left hand as punishment for stealing mobile phones and other goods [23]. The Deputy Chief Justice of Sudan recently revealed that 16 people were subjected to amputations since 2001 [3]. Adam alMuthna, 30, was the first reported case of forced amputation in Sudan. Three doctors amputated the right hand and left foot of al-Muthna on February 14, 2013 in a hospital in Khartoum. This event attracted a public outcry, particularly by the Sudanese Doctors’ Union. The union complained that the doctors were horrified to break the Hippocratic Oath by harming their patient instead of protecting him [3]. The common judicial punishment for theft in Saudi Arabia is the amputation of the right hand [17]. But for highway robbery, the punishment is cross amputation —amputation of the right hand and left foot. Although such cases have been unusual in Saudi Arabia, Amnesty International reported four cases in 1986. In 1990, fewer than ten hand amputations reportedly occurred, at least five of which were administered to foreigners [21]. More recently, a court in Saudi Arabia sentenced six men to cross amputations for highway robbery. In October 2011, a court of appeal upheld this cross amputation sentence [1, 26].
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Discussion The Babylonian Code of King Hammurabi, which introduced as basic principle the concept of equal retaliation, provides the first evidence of punitive amputation for correction [7]. In ancient Peru, potteries and ceramics provided artistic evidence of punitive limb amputations [9, 14, 19, 24]. During the Roman and Byzantine empires, punitive limb amputations continued. Such penalties were particularly effective for restoring law and order, and remained so until the end of the empire [12, 22]. The introduction of numerous laws, which set out strict penalties for offenders, was considered necessary at the time. These penalties (beheading, stoning, enslavement, burning, hanging, shearing, pillory, crushing of the joints, cutting of the tendons of the leg with a knife, being exiled to the mines, and slavery), were considered a natural extension of the sentences of the Roman law. During the Byzantine time, theological arguments and references to the sacred texts were used to justify these punishments. They did not hesitate to use the teaching of Christ for their purposes, including the gospel proverbs, ‘‘Cut your hand or your foot if it scandalizes you,’’ and ‘‘better being lame or crippled rather than able-bodied and damned’’ [16]. The barbaric custom of amputation has been attributed to the Arabic tradition of retribution, but that view is inconsistent with the fact that amputations were performed long before the appearance of Arab populations in the Mediterranean Sea [11]. Punishment likely has its roots in the popular perception that the perpetrator should be punished by losing the limb with which he or she committed the crime. Amputation acted as a special precautionary measure as an obvious and continuing stigma of punishment of the guilty party, and as an example to others [22]. With the collapse of the Byzantine Empire as a superpower of the era, amputations decreased in number and frequency [5]. However, later in the Middle Ages, European countries adopted various forms of punishment, including torture of the body — often presented in public places. The main concern was to demonstrate the power of the absolute ruler. This explains why the citizens of the medieval period were familiar with the essence of pain and death. During the Renaissance and the Enlightenment, the intellectual movement in Europe brought about significant changes on both criminal sanctions and criminal policy issues. The Enlightenment approached criminal law from a humanistic aspect, incorporated it into the societal practice, and promoted its protective aspects. During this time, individuals recognized criminals as human [13]. It was unthinkable to use torture and amputation as punishment. Crime was an act punishable only by law, and the purpose of punishment was to correct criminals. In 1764, Beccaria emphasized that the purpose of punishment should not be to
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take revenge on the offender, but to achieve their correction in order for them not to repeat the same offense in future [4]. Various societies have applied punitive amputation as a punishment based on a strong belief that crime can be curbed by spreading fear. However, through the societal evolution in modern western civilizations, these perceptions no longer exist. Yes, the death penalty still exists in some western countries, including the United States, though death by lethal injection is often debated, seriously criticized, and scarcely employed. Although modern societies no longer consider amputation an appropriate correctional method, some third-world nations continue to employ punitive amputations. Acknowledgements The authors thank Ms. Elena Chatzinikou (official English translator) for her help in the linguistic review of the manuscript.
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