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The Legacy of Phantom Limbs


Notes: A Neurobiological diagnosis with aesthetic, cultural and philosophical implications.
Part 1: The Body Fantastic: Neuroscientific Explanations

Abstract
Evidence of loss of limbs, through disease, accident, warfare, or ritual has been commented upon since records began. With this legacy, it is remarkable that reports of phantom limbs entered so late into medical records. The experience of sensations in lost limbs provides an example of the ways in which novel phenomena can be interpreted. The first phase is a description of the phenomenon. Ambroise Paré (1510-1590) initiated medical interest in this intriguing aspect of perception, partly because more of his patients survived the trauma of surgery. This is followed by attempts to incorporate it into the body of extant theory. René Descartes (1596-1650) integrated sensations in amputated limbs into his dualist theory of mind, and used the phenomenon to support the unity of the mind in comparison to the fragmented nature of the body. Finally, the phenomenon is accepted and utilized to gain more insights into the functioning of the senses. This was achieved in the eighteenth century by many physicians, but particularly by William Porterfield (ca. 1696-1771), who described and interpreted the feelings in his own missing leg; he considered that sensations projected to the missing leg were no more remarkable that colours projected to external objects. Thus, the principal features of phantom limbs were well known before Silas Weir Mitchell (1829-1914) gave them that name. Despite the puzzles they still pose, these phantoms have provided perception with some potent concepts.

Introduction

Phantoms are sometimes called illusions because they have the characteristic of defying belief. However, there are some more immediate phantoms that afflict those who have had a limb amputated. There are compelling sensations that come from the severed part, and these have been a concern of students of perception since they were clearly described in the seventeenth century. They are generally referred to as phantom limbs because the full knowledge of the missing part has little influence on the experiences deriving from the nonexistent member.

The term ‘phantom limb’ was coined by Silas Weir Mitchell (1829-1914). He treated injuries received by soldiers during the American Civil War, and set up a ‘Stump Hospital’ in Philadelphia for the many amputees. In 1866, he wrote an anonymous and fictitious account of one George Dedlow, who had lost both arms and both legs. It created such a stir that donations sent to him. Consequently, Mitchell (1871) wrote a serious account in which he described the sensations that amputees experienced in their lost limbs, and called the condition phantom limb. Many such cases have since been reported, and phantom limbs pose some perplexing problems for theories of perception. Damage or loss of other senses results in the absence of experiences formerly associated with their function. Blindness and deafness are particularly clear examples. But the sense organs for seeing and hearing – the eyes and ears – are localized in the head, and specialized receptors for light and sound are not found in other regions of the body. The skin senses are necessarily diffuse, and the consequences of loss are quite unlike those for the localized senses.

Although Mitchell gave the phenomenon its name, reports of phantom limbs were made long before the American Civil War. Reporting experiences from amputated parts has a much longer history, but it remains remarkably short considering the incidence of the condition. The experience of sensations in lost limbs also provides an example of the ways in which novel phenomena can be interpreted. In this instance, the first phase is a description of the phenomenon. This is followed by attempts to incorporate it into the body of extant theory. Finally, the phenomenon is accepted and utilized to gain more insights into the functioning of the senses (table 1). In many cases, the phenomena have been described in antiquity, and no clear origin can be determined. An example is the double vision that follows pressing one eye with the finger, and the single vision that normally occurs (see Wade, 1998). In others, there is an obvious break with the past and a phenomenon is described and investigated for the first time. A clear instance of this is stereoscopic vision based on slight disparities in the images projected to each eye: Wheatstone (1838) described this, named it stereoscopic vision, and interpreted it within empiricist theory of vision. Many phenomena are named after the first person considered to have described the phenomenon. The Purkinje shift is such a phenomenon, even though Purkinje (1825) was not the first to describe it. The clarity of a succinct label frequently blurs the detailed natural history of phenomena, and such is certainly the case for phantom limbs.

The phenomena, once described, are typically placed within some theoretical framework. This often involves its classification as illusory or not. For most of the history of perceptual phenomena, interest was usually restricted to illusions or oddities of experience: the commonplace characteristics of constant perception were ignored (see Wade, 2005a). Phantom experiences were of interest to Ambroise Paré (1510-1590; figure 1, left) because they were considered to be illusory. They had the additional aspect of theoretical intrigue because they could not be associated with stimulation with the region in which the experience was located. Thus, the issue of the locus of sensation moved to centre stage. When the brain was implicated in the experience, then the relationship between sensation and nervous action was deliberated upon. With acceptance of both the phenomenon and its possible neural basis, its characteristics can be used to support particular theories of brain function.

Table 1. A natural history of sensory phenomena indicating the phases through which their investigation can pass.

Data:
Description Phenomenology
Confirmation Refining phenomenology
Naming Often eponymous
Theory:
Interpretation Location of Sensation – peripheral or central?
Illusion or Reality?
Integration Within extant knowledge of nervous function
Exploitation Phenomena used to support particular theoretical ideas

Phase 1 – Data

The first phase of understanding any phenomenon is an adequate description of it. In this sense, Paré (1551) initiated medical interest in this intriguing phenomenon. Evidence of loss of limbs, through disease, accident, warfare, or ritual has been commented upon since records began. With this legacy, it is remarkable that reports of phantom limbs entered so late into medical records. Perhaps this was because few of those who had limbs amputated survived to describe their experiences. Paré made great strides in the surgical treatment for amputation; he applied ligatures to the large vessels in the limbs to staunch the bleeding following amputation and he applied tourniquets above the site of severance.

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Figure 1. Left, a portrait of Ambroise Paré (1510-1590); right, some intricate prosthetic legs. Both images from Paré (1649).

As a consequence of his improved surgical techniques, more of Paré’s amputees survived. He described many such operations and the procedures that can be adopted in order to increase the likelihood of post-operative survival. Indeed, Paré (1575, 1649) described and illustrated a wide range of prostheses that could be used after amputation (figure 1, right). These included mechanical hands, arms, and legs, all with moveable parts. He not only performed the operations, but followed the progress of patients following amputation. To Paré’s great surprise, some of his patients reported sensations in the lost limb. In his Apology (Paré, 1951) he devoted a chapter to amputations, indicating the signs necessitating it, and the procedures for conducting the operation. The most common cause for the operation was gangrene. Paré noted that the gangrenous extremity was bereft of sensitivity, and yet might still respond to pricking. He realized that this could indicate a false sensitivity in the affected part, and might retard operation. He then related the feelings to those of phantom limbs:

“You should certainly know that a Grangreene is turned into a Sphacell, or mortification, and that the part is wholly and thoroughly dead, if it looke of a blacke colour, and bee colder than stone to your touch, the cause of which coldnesse is not occasioned by the frigiditie of the aire; if there bee a great softnesse of the part, so that if you presse it with your finger it rises not againe, but retaines the print of the impression. If the skinne come from the flesh lying under it; if so great and strong a smell exhale (especially in the ulcerated Sphacell) that the standers by cannot endure or suffer it; if a sanious moisture, viscide, greene or blackish flow from thence; if it bee quite destitute of sense and motion, whether it be pulled, beaten, crushed, pricked, burnt or cut off. Here I admonish the young Chirurgion, that hee be not deceived concerning the losse or privation of the sense of the part. For I know very many deceived as thus; the patients pricked on that part would say they felt much paine there. But the feeling is oft deceiptfull, as that which proceeds rather from the strong apprehension of great paine which formerly reigned in the part, than from any facultie of feeling as yet remaining. A most cleare and manifest argument of this false and deceiptful sense appears after the amputation of a member; for a long while after they will complaine of the part which is cut away. Verily it is a thing wondrous strange and prodigious, and which will scarce be credited, unlesse by such as have seen with their eyes, and heard with their ears the Patients who have many months after the cutting away of the Leg, grievously complained that they yet felt exceeding great pain of that leg so cut off.” (Paré, 1649, p. 338)

Paré speculated that the lingering sensations from the lost limb were a consequence of stimulating the nerves in the severed stump. Much more was known about the peripheral nervous system than about the brain, as was evident from Paré’s diagrams (figure 2, left). It was still the belief that the animal spirit flowed through the hollow nerves from the senses to the ventricles in the brain. Paré also described cases in which individuals had no arms (figure 2, right). It is not clear from his brief descriptions whether they were armless from birth, but he did describe the remarkable feats they could achieve despite the loss of their arms. Unfortunately, Paré did not remark on any sensations they reported in the absent members, which would have been of particular interest in the light of a recent case of a paerson who was born without complete arms or legs but retained sensations from the missing extremities (Brugger, et al, 2000). Paré’s (1573) accounts were printed in his book On monsters and marvels:

“Some while ago one could see in Paris a man without any arms, forty years old, or thereabouts, strong and robust, who performed almost all the actions that another might do with his hands; to wit, with his stump of a shoulder and his head he would strike a hatchet against a piece of wood as firmly as another man might have been able to do with his arms. Similarly, he could make a carter’s whip snap, and he performed several other actions; and with his feet he ate, drank, and played cards and dice, which is shown to you in this picture. In the end, he was a robber, thief, and murderer and was executed in Guelders, that is [to say], hanged and then fastened to a wheel. Similarly, of recent memory, an armless woman was seen in Paris who could cut cloth and sewed and performed several other actions.” (Paré, 1982, pp. 36-37)

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Figure 2. Left, the diagram of the nervous system (from Paré, 1649). Right, Paré’s (1573) depiction of an armless with an indication of the tasks he could perform.

There is no explicit indication in Paré’s description whether the losses had been present since birth, but this seems likely because they were not discussed in his books on surgery and his accounts of amputation. Moreover, the many other ‘marvels and monsters’ mentioned by him in the same chapter are of anomalies of birth.
Paré’s books were widely read and they were translated into several languages. By the time René Descartes (1596-1650; figure 3, left) was writing about the phenomenon it appears to have been common medical knowledge. Nonetheless, it did not have a specific name and that was not designated until Mitchell (1871) selected ‘phantom limb’ from a range of possibilities he entertained. As is the case for many phenomena, their discovery is associated with the process of naming rather than with that of their initial description.

Phase 2 – Theory

Once attention had been drawn to the phenomenon then its phenomenology was examined in more detail; it can also be integrated into prevailing theories. This second phase is found in the speculations of Descartes. In his book on optics, Descartes (1637/1902) argued that all sensation is located in the brain. Objections to this view were expressed by some of Descartes’ correspondents, and he responded by commenting on reports of sensations in amputated limbs; they were used as evidence that all sensations take place in the brain. In subsequent letters concerning such sensations, Descartes attributed them to activity in the brain normally associated with the missing limb. He stated that this was a condition familiar to doctors and surgeons of the day:

“for they know that those whose limbs have recently been amputated often think they still feel pain in the parts they no longer possess. I once knew a girl who had a serious wound in her hands and had her whole arm amputated because of creeping gangrene. Whenever the surgeon approached her they blindfolded her eyes so that she would be more tractable, and the place where her arm had been was so covered with bandages that for some weeks she did not know that she had lost it. Meanwhile she complained of feeling various pains in her fingers, wrist and forearm; and this was obviously due to the condition of the nerves in her arm which had formerly led from her brain to those parts of her body. This would certainly not have happened if the feeling or, as he says, sensation of pain occurred outside the brain.” (Descartes, 1991, p. 64)

In addition, Descartes considered that the phenomenon indicated the unreliability of the senses. In his sixth meditation on the existence of material things, and the real distinction between mind and body he wished to “see whether the things which are perceived by that mode of thinking which I call ‘sensory perception’ provide me with any sure argument for the existence of corporeal things” (1984, p. 51). The first aspect he considered was the perception of his own body parts, but doubt was cast upon this from examples of sensations in amputated limbs: “And yet I had heard that those who had a leg or an arm amputated sometimes still seemed to feel pain intermittently in the missing part of the body” (p. 53). Finally, Descartes also used the phenomenon to support the unity of the mind in comparison to the fragmented nature of the body: “Although the whole mind seems to be united to the whole body, I recognize that if a foot or arm or any other part of the body is cut off, nothing has thereby been taken away from the mind” (1984, p. 59).

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Figure 3. Left, René Descartes (1596-1650) after a portrait in Lavater (1799). Right, the title page of Porterfield’s Treatise.

Early reports of phantom limbs were second-hand (so to speak); they relied on the amputees relating their experiences to physicians or surgeons. Other writers used the distilled medical descriptions as the sources of their own analyses. Most of the amputees had little prior medical experience, and the accuracy of their account was often dependent upon the literary skill of the surgeon (see Finger, 1994; Finger and Hustwit, 2003; Price and Twombly, 1972; Wade, 2003; Wade and Finger, 2003). This was not the case for William Porterfield (ca. 1696-1771), who was able to give a first-hand account of his own phantom leg. Porterfield was a Scottish physician of some prominence and an authority on the senses. In his Treatise on the Eye, the Manner and Phænomena of Vision, published in 1759, he described his experiences following amputation of his own leg. In the context of early reports, the account given by both an amputee and an eighteenth century student of the senses is worthy of note.

Porterfield is best known for his two-volume Treatise (figure 3, right). The first volume (Porterfield, 1759a) contains accounts of the gross anatomy of the eye and its attendant structures, the properties of light and image formation, theories of accommodation, and his own experiments with the optometer. Volume 2 (Porterfield, 1759b) is on vision: it commences with further reflections on accommodation and progresses to myopia and presbyopia, variations of pupil size, and eye movements; it ends with the phenomena of vision – binocular single vision, colour, size, distance and shape perception, and motion. The two volumes are numbered separately. The Treatise presented a survey of the then contemporary knowledge of vision and the eye, and placed them in a comparative and historical context.

The Treatise is based in part on two long essays Porterfield wrote on motions of the eyes (Porterfield 1737, 1738). The first essay addresses the action of the external muscles; it starts with a detailed account of the structure of the eye and its muscles, often drawing on comparative anatomy. Eye movements were considered important because of the function they served in vision, and his essay involves many digressions into areas of perception. Following an account of the four straight muscles (recti) he speculated on the torsional function of the oblique muscles, then on to the location of the optic disc, scanning eye movements, convergence and distance perception, binocular single vision, visual direction, colour vision, strabismus, and vision and touch. In short, Porterfield’s principal aim was philosophical; he inveighed against the empiricist theory of vision of George Berkeley (1685-1753; 1709) by proposing that visual location is innate.

In addition to Porterfield’s nativist attack on empiricist theory, he was critical of Berkeley’s proposal regarding perceptual learning. Porterfield argued that touch is as arbitrary in its representation of space as is vision, and therefore cannot teach vision external dimensions. He restated his position succinctly in the Treatise: “But if, by the Touch alone, we can judge thus of the Situation and Distance of external Things, I see not why the same Power should be denied to the Sight…. for the tangible Ideas are as much present with the Mind as the visible Ideas, and, on that Account, must be equally incapable of introducing the Idea of any Thing external” (1759b, pp. 301 and 307).

Porterfield’s (1738) second essay was about the internal motions of the eye, principally those involved in accommodation. Indeed, the term ‘accommodation’ was coined by him in this context. Porterfield devised and named an instrument called an optometer for determining the near and far points of vision, and he established that the lens was involved in accommodation by recourse to sight following their removal. He examined such an aphakic individual who was unable to accommodate at all without the aid of a convex lens, the power of which required to be modified for objects at different distances. Porterfield concluded that since elongation of the eye was still possible for such a person, as was variation in corneal curvature, the crystalline lens must be involved in accommodation.

In the period between writing his essays and his treatise he had a leg amputated; in the Treatise he used his experiences of a phantom limb to support the projective features of perception generally. He was attacking the theory that a pictorial image existed on the retina, and that this was perceived by the mind. He described his own experiences of a phantom limb in this same general context:

“Tho’ there was a Picture in the Retina in that vulgar gross Sense that so many imagine, yet it is impossible that the Mind could perceive it there; because all the Sensations or Perceptions of the Mind are present within it and in the Sensorium: I appeal to every one’s Experience, if he ever sees or observes any Pictures or any Thing else in the Retina. And to say we see, observe or perceive Pictures there, without being sensible or conscious of it is absurd and ridiculous. The Mind or sentient Principle does not at all perceive in the Retina, but in the Sensorium where it is present; for when, thro’ any Defect or Paralysis of the Nerve, the Motions or Vibrations impressed on the Retina by the Rays forming the Picture are not propogated to the Sensorium, or that the place in the Brain in which the Mind resides, the Mind perceives nothing; nor is it indeed possible it can perceive any thing; for whether the Mind be thought active or passive in its Perceptions, it is certain, that it can perceive nothing but what is present with it; for it can no more perceive where it is not, than when it is not; and it may as well be or exist where it is not, as act, suffer, or perceive where it is not. All Things perceived must therefore be present with the Mind and in the Sensorium, where the Mind resides; and that not only virtually, but substantially…

It is therefore evident, that, did the Mind perceive Pictures in the Retina, it behoved to be there present: And for the same Reason, did it perceive in the other Organs of Sense, it behoved also to be present to all the Parts of the Body; because the Sense of Feeling is diffused thro’ all the Body: Nay, in some Cases it behoved to be extended beyond the Body itself, as in the Case of Amputations, where the Person, after Loss of his Limb, has the same Perception of Pain, Itching, &c. as before, and feels them as if they were in some Part of his Limb, tho’ it has long been amputated, and removed from the Place where the Mind places the Sensation. Having had this Misfortune myself, I can the better vouch the Truth of this Fact from my own Experience; for I sometimes still feel Pains and Itchings, as if in my Toes, Heel or Ancle, &c. tho’ it be several Years since my Leg was taken off. Nay, these Itchings have sometimes been so strong and lively, that, in spite of all my Reason and Philosophy, I could scarce forbear attempting to scratch the Part, tho’ I well knew there was nothing there in the Place where I felt the Itching. And however strange this may appear to some, it is nevertheless no way miraculous or extraordinary, but very agreeable to the usual Course and Tenor of Nature; for, tho’ all our Sensations are Passions or Perceptions produced in the Mind itself, yet the Mind never considers them as such, but, by an irresistible Law of our Nature, it is always made to refer them to something external, and at a Distance from the Mind; for it always considers them as belonging either to the Object, the Organs, or both, but never as belonging to the Mind itself, in which they truely are; and therefore, when the nervous Fibres in the Stump are affected in the same Manner as they used to be by Objects acting on their Extremities in the Toes, Heel or Ancle, the same Notice or Information must be carried to the Mind, and the Mind must have the same Sensation, and form the same Judgment concerning it, viz, that it is at a Distance from it, as if in the Toes, Heel or Ancle, tho’ these have long ago been taken off and removed from that Place where the Mind places the Sensation.

If this should prove hard to be conceived, it may be illustrated by what happens in the Sensation of Colours; for tho’ the Colours we perceive are present with the Mind, and in the Sensorium, yet we judge them at a Distance from us, and in the Objects we look at; and it is not more difficult to conceive how Pain may be felt at a Distance from us, than how Colours are seen at a Distance from us.” (1759a, pp. 362-365)

Porterfield displays considerable sophistication in the analysis of his phantom limb, by associating the projective features of the experience with other aspects of perception. He was well-versed in Newtonian colour theory, and cited Newton many times. Indeed, he gave a quotation from Newton’s (1704) Opticks on the title page of his Treatise. The reference to colour relates to Newton’s statement that the rays are not coloured, but that the experience of colour is subjective (see Wade, 1998). Porterfield was extending this subjectivity of sensation to phantom limbs, and incorporating the sensations into the body of perceptual theory. A similar relationship is drawn for the visual perception of direction, as aspect of spatial vision that exercised Porterfield considerably (see Wade, 2000). He wrote:

“Now, as Objects seen by Reflection or Refraction appear and are seen, not in their true Place, but in some other Place from which they are absent, and that because the Rays fall upon the Eyes, and make a Picture on their Bottom, in the very same Manner as if they had come from the Object really placed there, without the Interposition of the Glass; so, when the Impression made upon the nervous Fibres of the Stump is the same as if it had come from the Object acting ontheir Extremities, the Sensation must also be the same, and the Mind, by forming the same Judgment concerning it, must feel it as in the Toes, Heel or Ancle &c. in which those nervous Fibres terminated before the Leg was taken off.” (Porterfield, 1759a, pp. 366-367)

Porterfield does not regard the experiences of the lost limb as phantoms, but as a natural consequence of stimulating the brain in a manner similar to that which existed prior to amputation. He integrated the phantom limb experiences with a general theory of perception.

This position was generally accepted by physicians in the eighteenth century. Rather than provide a comprehensive survey of such studies, concentration will be directed to the developments that occurred in London, mostly as a consequence of the Scotch doctors who dominated the medical scene in the city. For example, George Fordyce (1736-1802; figure 4, left) was an Aberdonian who had founded a number of medical societies in London. In his text on medicine he related phantom sensations to the normal functioning of the nervous system:

“The sensibility depends entirely on a part’s being connected with the brain by the nerves; for, If the nerves be going to any part be cut through, the sensibility is lost. If the nerves going to any part be moderately comprest, the sensibility is diminished. If the nerves be comprest strongly, the sensibility is lost. If the pressure be soon removed, the sensibility recurs. If the pressure be continued for a long time before it is removed, the sensibility returns more slowly, or not at all. Pressure on the brain, diminishes the sensibility of the whole body. If a small branch of nerve be cut through, so as to take off the sensibility of a part of the skin, it may be restored in time. The sensibility may be impaired, or lost, without any sensible pressure on the nerve, or alteration of its structure. When there is no wound in the body, the sensations appear to be in the place where the application exciting them is made. If an extremity be cut off, an application made to the stump, may produce sensations which appear to be in the part amputated.” (1771, pp. 93-95)

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Figure 4. Left, George Fordyce (1732-1802) after a portrait in Howell (1928). Right, John Hunter (1728-1793) after a frontispiece portrait in Hunter (1861).

A similar sentiment, voiced again with primary reference to the nerves and their pathways, was written in the next decade by John Hunter (1728-1793), one of the most prominent Scotch doctors in London. In his book Observations on certain parts of the animal oeconomy he described two cases of phantom sensations in the missing penis:

“I knew a gentleman who had the nerves which go to the glans penis completely destroyed by mortification, almost as high as the union of the penis with the pubes; and at the edge of the old skin, at the root of the penis, where the nerves terminated, was the peculiar sensation of the glans penis; and the sensation of the glans itself was now only common sensation; therefore the glans has, probably, different nerves, and those for common sensation may come through the body of the penis to the glans. A serjeant of marines who had lost the glans, and the greater body of the penis, upon being asked, if he ever felt those sensations which are peculiar to the glans, declared, that upon rubbing the end of the stump, it gave him exactly the sensation which friction upon the glans produced, and was followed by an emission of the semen.” (Hunter, 1786, pp. 216-217)

These examples were of particular significance as both Fordyce and Hunter considered that all senses responded to touch and pain, in addition to their specific sensations. In his papers, which were not published during his lifetime, Hunter (1861) expressed it thus: “Touch is probably the only sense that is cognizable by anothersense besides the immediate sensation” (p. 7). That is, if touch alone was experienced as a phantom sensation, then it might reflect the central operation of common sensitivity. If the specific sensations associated with a particular body part could be experienced after amputation then that was stronger evidence for the localization of sensation in the brain.

Others were able to corroborate the reports gathered by Hunter. His adversary, Andrew Marshal (1742-1813; figure 5, left), a doctor from Fife, also noted the effects of loss of the penis, and related it to the other senses:

“When we compare the different senses together, two or three observations occur to us; one is, that the first four senses take place only when certain due degrees of impression are made on the extremities of the nerves distributed to that organ: if the impression is too slight, no peculiar sensation arises; if it exceeds in measure, instead of the sense of seeing, hearing, &c. there is merely a sense of pain. Thus the first four senses, when their organs are injured, agree with the sense of feeling. Another observation is, that as the sense of feeling arises from impressions made in those parts of the body, so it is more difficult to destroy than the other senses. When the extremities of the nerves of the other senses are destroyed, peculiar sensations connected with them also cease, as was mentioned above: but the remaining body of nerves retains a sense of feeling; and the extremities of the nerves appropriated to feeling only, being destroyed, the extremities of the portion left resume the peculiar susceptibility of the original extremities. In the case of W. Scott, whose penis was carried off by a gun-shot, the stump of it, which was even with the skin of the pubis, resumed the peculiar sensibility of the glans penis; also the cicatrix of sores in other parts of the body is susceptible to impressions of touch.” (Marshal, 1815, pp. 222-223)

Marshal was a contemporary of Hunter and a fellow Scot who also practiced medicine and taught in London. Marshal had a bitter dispute with Hunter concerning the functions of the brain (see Wade, 2005b), and this might have added to his reluctance to publish his work. He kept copious notes of his dissections and discoveries, and these were assembled after his death by his erstwhile assistant Solomon Sawrey (1765-1825). It was in this collection that the case above was reported.

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Figure 5. Left, Andrew Marshal (1742-1813) after a frontispiece silhouette in Marshall (1815). Right, Erasmus Darwin (1731-1802) after a portrait in Pearson (1930).

An alternative theoretical approach was taken by Erasmus Darwin (1731-1802; figure 5, right); although he was born in Nottinghamshire, he received his medical training in Edinburgh. His theory of perception was greatly influenced by Berkeley (1709), and he expounded on matters perceptual in his Zoonomia. It was here that he speculated about sensations in a lost limb and he involved the motor as well as the sensory system in accounting for them:

“After the amputation of a foot or a finger, it has frequently happened, that an injury being offered to the stump of the amputated limb, whether from cold air, too great pressure, or other accidents, the patient has complained of a sensation of pain in the foot or finger, that has been cut off. Does this not evince that all our ideas are excited in the brain, and not in the organs of sense? This objection is answered, by observing that our ideas of shape, place, and solidity of our limbs, are acquired by our organs of touch and of sight, which are situated in our fingers and eyes, and not by any sensations in the limb itself. In this case the pain or sensation, which formerly has arisen in the foot or toes, and been propagated along the nerves to the central part of the sensorium, was at the same time accompanied with a visible idea of the shape and place, and with a tangible idea of the solidity of the affected limb: now when these nerves are afterwards affected by any injury done to the remaining stump with a similar degree or kind of pain, the ideas of the shape, place, or solidity of the lost limb, return by association; as these ideas belong to the organs of sight and touch, on which they were first excited.” (Darwin, 1794, p. 28)

Yet further fuel for this philosophical fire was provided a few decades later by Charles Bell (1774-1842; figure 6, left) who referred to sensations in a lost penis obliquely in his Idea of a new anatomy of the brain (Bell 1811/2000). Bell made recourse to phantom limb sensation to support his view that the seat of sensation is in the brain; however, his sensibilities led him to express the report of sensations in the missing penis in Latin:

“It may be said, that there is here no proof of the sensation being in the brain more than in the external organ of sense. But when the nerve of a stump is touched, the pain is as if in the amputated extremity. If it be still said that this is no proper example of a peculiar sense existing without its external organ, I offer the following example: Quùando penis glandem exedat uùlcuùs, et nihil nisi granulatio maneat, ad extremam tamen nervi pudicæ partem ubi terminatuùr sensus supersunt, et exquisitissima sensuùs gratificatio.” (Bell 1811/2000, pp. 11-12)

The Latin text translates as “When an ulcer consumes the glans penis so that nothing remains but granulation, the most exquisite sensory gratification still survives at the end of the pudic nerve where the sensation terminates.”

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Figure 6. Left, Charles Bell (1774-1842) after a frontispiece engraving in G. Bell (1870). Right, Johannes Müller (1801-1858) after a portrait in Hirsch (1929).

Both Bell and Johannes Müller (1801-1858; figure 6, right) employed phantom limb phenomena as supports for the doctrine of specific nerve energies. Müller (1837, 2003) provided descriptions of thirteen cases of sensations following amputation. His summary of the effects of amputation is astute:

“When a limb has been removed by amputation, the remaining portion of the nerve which ramified in it may still be the seat of sensations, which are referred to the lost part. – This is a fact known to all surgeons, and is subject to no exception. It is usually said that the illusion continues for some time, namely, as long as the patient is under the care of the surgeon; but the truth is, that in most cases it persists throughout life: of this it is easy to convince oneself by questioning a person whose limb has been amputated, at any period after the operation. The sensations are most vivid while the surface of the stump and the divided nerves are the seat of inflammation, and the patient complains of severe pains felt, as if in the whole limb which has been removed. When the stump is healed, the sensations which we are accustomed to have in a sound limb are still felt; and frequently throughout life tingling, often pains, are felt, which are referred to the parts that are lost. These sensations are not of an undefined character; the pains and tingling are distinctly referred to single toes, to the sole of the foot, to the dorsum of the foot, to the skin, &c. These important phenomena have been absurdly attributed to the action of the imagination, &c. They have been treated merely as a curiosity; but I have convinced myself of their constancy, and of their continuance throughout life, – although patients become so accustomed to the sensations that they cease to remark them. The feeling of tingling or creeping of ants in the hand foot, or whole extremity, with the same distinctness as when the limb is still present, may be excited much more vividly by applying a ligature or tourniquet to the stump, or by exerting pressure on its nerves; hence patients have the feeling of their lost limb most distinctly, when from any cause the application of the tourniquet is again necessary. If the patient have suffered before amputation from a local painful affection of the limb, the whole limb will still be felt as if in pain after its removal; and pain will be felt as if in the whole limb, at the moment when the nerve is divided, and during inflammation of the stump.” (Müller 2003, pp. 745-746, original italics)

Müller’s claim that the experience of phantom limb sensations in amputees is universal has been supported, although Mitchell (1872) found that eighty-six of ninety cases he examined reported sensations in the missing limb. These features make the absence of reports before Paré even more surprising. Limbs have been amputated because of damage or disease for millenia, and some must have survived the trauma of amputation to experience these enigmatic feelings. Moreover, the common feature of all reports is the existence of localised pain in the severed part; other sensations associated with the skin and muscles (like being touched, temperature sensitivity or movement) have not been so commonly reported.
There were many reports of phantom sensations in amputated limbs before Mitchell (1871) than have been reported above, but Mitchell himself did not draw upon them.

Conclusion

The phenomena associated with phantom limbs continue to intrigue and excite us, as is evident from this conference (see also Ramachandran and Blakeslee, 1998). There remain many ways of interpreting the phenomenon, which is clearly concerned with memory: a current pattern of stimulation in the brain is associated with ones from the past, and similarities are experienced. In his treatise on monsters and marvels, Paré described a case of a man who was born without arms, and could perform remarkable feats; nonetheless, Paré did not comment on any aspect of phantom sensations reported by the man.
The history of phantom limb research can be examined in much the same way as can that for other sensory phenomena (table 2). It is evident that, despite the puzzles they still pose, the phantoms have provided perception with some potent concepts and have assisted in understanding the relationship between perception and brain processes. These features will be extended further in the future.

Table 2. A natural history of phantom limb research and the directions in which contemporary concerns are likely to proceed.

History
Description Paré (16th Century)
Confirmation Many 17th and 18th Century Surgeons
Naming Mitchell (1871)
Theoretical interpretation Descartes (1637)
Theoretical integration Porterfield (1759); Hunter (1786)
Theoretical exploitation Bell (1811); Müller (1837)

Modern Concerns

  • Examination Panoply of methods of modern neuroscience
  • Extension Concerns with consciousness
  • Exploration Phantoms as metaphors. The art of absence

References
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2. Bell, G. J. (1870). The letters of Sir Charles Bell, selected from his correspondence with his brother George Joseph Bell. London: Murray. 13
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Nicholas Wade is Professor of Visual Psychology at the University of Dundee. He received a B.Sc. in psychology from the University of Edinburgh, and a Ph.D. from Monash University, Melbourne, Australia. After postdoctoral research at the Max-Planck-Institut für Verhaltensphysiologie, Seewiesen, Germany he moved to Dundee University where he has remained. His research covers three main topics: (1) The representation of space and motion in human vision. This has the aim of developing a model of space and motion perception in terms of nested frames of reference defined by the articulations of the body. (2) The history of research in visual science, with the aim of providing an account the development of experimental methods in vision, particularly those concerned with stereoscopic vision. (3) The relationship between visual science and visual art. This has the aim of fostering a closer association between the graphical language of art (particularly geometrical abstraction) and the interpretative language of science. He has exhibited art work internationally, and has written several books including The Art and Science of Visual Illusions (1982), Visual Allusions: Pictures of Perception (1990), Psychologists in Word and Image (1995), A Natural History of Vision (1998), Purkinje’s Vision. The Dawning of Neuroscience, (with J. Bro_ek, 2001), Visual Perception: An Introduction (with M. T. Swanston, 2001), Destined for Distinguished Oblivion: The Scientific Vision of William Charles Wells (1757-1817) (2003) and Perception and Illusion. Historical Perspectives (2005).
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