Hallucinations

Other hallucinations are only sensations or perceptions, albeit of a very special sort, whereas a phantom limb is capable of phantom action. Given a suitable prosthesis, the phantom limb will slip into the prosthesis (“like a hand into a glove,” as many patients say) — slip into it and animate it, so that the artificial limb can be used like a real one. Indeed, this must happen if one is to use a prosthesis effectively. The artificial limb becomes part of one’s body, of one’s body image, as a cane in a blind man’s hand becomes an extension of himself. One may say that an artificial leg, for instance, “clothes” the phantom, allows it to be effective, gives it an objective sensory and motor existence, so that it can often “feel” and respond to minute irregularities in the ground almost as well as the original leg.

⁵ (Thus the great climber Geoffrey Winthrop Young, who lost a leg during World War I, was able to climb the Matterhorn using a prosthetic limb of his own design.)⁶

One might go further and say that a phantom is a portion of body image which is lost or dissociated from its natural, embodying home (the body) — and, as such, as something extraneous, it may be intrusive or deceptive (thus the danger of walking off a curb with a phantom leg). The lost phantom (if one can speak figuratively) longs for a new home, and it will find this in a suitable prosthesis. I have had many patients tell me how they may be disturbed by their phantom at night but relieved in the morning, for the phantom disappears the moment they put on their prosthesis — disappears, that is, into the prosthesis, merging so seamlessly with it that phantom and prosthesis become one.

Knowledge of what one is doing with one’s phantom — even without a prosthesis — can be exquisitely refined. As a young student, Erna Otten, a distinguished pianist, was a pupil of the great Paul Wittgenstein, who lost his right arm in the First World War but continued to play with his left hand (and commissioned a number of composers to write music for the left hand). Yet he continued to teach, in a sense, with both hands. In a letter to the New York Review of Books, responding to an article I had written, Otten wrote:

I had many occasions to see how involved his right stump was whenever we went over the fingering for a new composition. He told me many times that I should trust his choice of fingering because he felt every finger of his right hand. At times I had to sit very quietly while he would close his eyes and his stump would move constantly in an agitated manner. This was many years after the loss of his arm.

Unfortunately, not all phantoms are as well formed, as painless, or as mobile as Wittgenstein’s. Many show a tendency to shrink or “telescope” with time — a phantom arm may be reduced to a hand seemingly sprouting from the shoulder. This tendency to shrink is minimized by embedding the phantom in a prosthesis and using it as much as possible. A phantom may also become paralyzed or contorted in painful positions, with its “muscles” in spasm. Thus Admiral Lord Nelson, after losing his right arm in battle, developed a phantom limb with the hand permanently clenched, the fingers digging excruciatingly into the palm.⁷

Such disorders of body image have long seemed inexplicable and untreatable. But over the last few decades, it has become clear that the body image is not as fixed as we once thought; indeed, it is remarkably plastic, and extensive reorganization or remapping can occur with phantom limbs.

If there is interruption of nerve function from injury or disease in the spinal cord or peripheral nerves, cutting off or reducing normal sensory input to the brain, this may cause major disturbance of body image, with strange phantom images superimposed on the real but insentient body parts. This was very striking with a colleague of mine, Jeannette W., who broke her neck in a car accident and became quadriplegic, with a complete absence of sensation below the level of the fracture. She had, in a sense, been “amputated” from the neck down and had little sense of her body below this. But in its place, she had a phantom body, which was unstable and prone to distortions and deformations. She could reverse these, for a while, by seeing that her body still had a normal shape and conformation, and she arranged for mirrors to be set up in her office and in the hospital corridors, so that she could glance up and (in her words) take “visual sips” from them as she bowled past in her wheelchair.