The Man Who Mistook His Wife for a Hat: "Phantoms"

A ‘phantom’, in the sense that neurologists use, is a persistent image or memory of part of the body, usually a limb, for months or years after its loss. Known in antiquity, phantoms were described and explored in great detail by the great American neurologist Silas Weir Mitchell, during and following the Civil War.

Weir Mitchell described several sorts of phantom—some strangely ghost-like and unreal (these were the ones he called ‘sensory ghosts’); some compellingly, even dangerously, life-like and real; some intensely painful, others (most) quite painless; some photographically exact, like replicas or facsimiles of the lost limb, others grotesquely foreshortened or distorted...as well as ‘negative phantoms’, or ‘phantoms of absence’.

Weir Mitchell described several sorts of phantom—some strangely ghost-like and unreal (these were the ones he called ‘sensory ghosts’); some compellingly, even dangerously, life-like and real; some intensely painful, others (most) quite painless; some photographically exact, like replicas or facsimiles of the lost limb, others grotesquely foreshortened or distorted...as well as ‘negative phantoms’, or ‘phantoms of absence’.

He also indicated, clearly, that such ‘body-image’ disorders—the term was only introduced (by Henry Head) fifty years later—might be influenced by either central factors (stimulation or damage to the sensory cortex, especially that of the parietal lobes), or peripheral ones (the condition of the nerve-stump, or neuromas; nerve-damage, nerve-block or nerve-stimulation; disturbances in the spinal nerve-roots or sensory tracts in the cord).

The following pieces, extremely short, almost anecdotal, come from the ‘Clinical Curio’ section of the British Medical Journal.

A sailor accidentally cut off his right index finger. For forty years afterwards he was plagued by an intrusive phantom of the finger rigidly extended, as it was when cut off.

It is well known that a central pathological disorder, such as a sensory stroke, can ‘cure' a phantom. How often does a peripheral pathological disorder have the same effect?

One such patient, under my care, describes how he must ‘wake up’ his phantom in the mornings: first he flexes the thigh-stump towards him, and then he slaps it sharply—‘like a baby's bottom'—several times. On the fifth or sixth slap the phantom suddenly shoots forth, rekindled, fulgurated, by the peripheral stimulus.

Only then can he put on his prosthesis and walk.

A patient, Charles D., was referred to us for stumbling, falls and vertigo—there had been unfounded suspicions of labyrinthine disorder.

A patient, Charles D., was referred to us for stumbling, falls and vertigo—there had been unfounded suspicions of labyrinthine disorder.

It was evident on closer questioning that what he experienced was not vertigo at all, but a flutter of ever-changing positional illusions—suddenly the floor seemed further, then suddenly nearer, it pitched, it jerked, it tilted—in his own words 'like a ship in heavy seas’.

In consequence he found himself lurching and pitching, unless he looked down at his feet.

We soon ascertained that he was suffering from the acute onset of tabes—and (in consequence of dorsal root involvement) from a sort of sensory delirium of rapidly fluctuating ‘proprioceptive illusions’.

Have readers encountered this intermediate stage—of positional phantoms or illusions—due to an acute (and reversible) tabetic delirium?

The source was my leg—or, rather, that thing, that featureless cylinder of chalk which served as my leg—that chalky-white abstraction of a leg.

It was constantly changing in size and shape, in position and angle, the changes occurring four or five times a second. The extent of transformation and change was immense—there could be a thousandfold switch between successive ‘frames’...

With this patient, with all patients, is not use all-important, in dispelling a 'bad' (or passive, or pathological) phantom, if it exists; and in keeping the 'good' phantom—that is, the persisting personal limb-memory or limb-image—alive, active, and well, as they need?

I have—since the original publication of this book—received many fascinating letters from patients about this: one such patient speaks of the discomfort of an ingrown toenail, which had not been ‘taken care of' before amputation, persisting for years after the amputation; but also of an entirely different pain—an excruciating root-pain or ‘sciatica’ in the phantom—following an acute ‘slipped disc’, and disappearing with removal of the disc and spinal fusion.

Thus, Dr Jonathan Cole, a former student of mine and now a spinal neurophysiologist, describes how in a woman with persistent phantom leg pain, anaesthesia of the spinous ligament with Lignocaine caused the phantom to be anaesthetized (indeed to disappear) briefly...