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amputation.” 4 Given that a lot of these procedures were performed
in fields or stables, it comes as no surprise to find gangrene, sepsis,
hemorrhage, and tetanus as constantly dreaded complications
associated with these operations. 4,5
Postamputation pain
Along with the lack of pain control during the amputation,
the phenomenon of postamputation pain has been recognized
for many centuries. Admiral Lord Nelson lost his right arm at an
attack on Santa Cruz de Tenerife. 6 Not only was the amputation
in itself quite challenging, but imagine the difficulty of performing
this under a most compromised situation, namely, on a moving
battleship, with little space, in the semi-darkness of the ship’s
interior. Admiral Nelson, who barely survived hypothermia and
considerable blood loss, found himself in tremendous pain after he
survived the amputation of his arm—in the amputated arm! He
found the emergence of painful phantom sensations to be proof of
the existence of the soul, given that an extremity that was no longer
there could hurt so much. Fortunately, a second operation, which
likely relieved an inadvertently placed suture on the median nerve,
relieved most of his pain and restored him to function. However,
through the ages, a significant percentage of amputees could not
be delivered from their torturous pain. 7,8
S. Weir Mitchell, who is considered the Father of American
Neurology, wrote a short story, “The Case of George Dedlow,”
in 1886. 9 The central character, George Dedlow, progressively
loses all 4 extremities and is befallen by phantom limb pain: “I
was suddenly aware of a sharp cramp in my leg. I tried to get at it
to rub it with my single arm, but finding myself too weak, hailed
an attendant: ‘Just rub my left calf,’ said I, ‘if you please.’ ‘Calf?’
said he. ‘You ain’t none, pardner. It’s took off.’ ‘I know better,’ said
I. ‘I have pain in both legs.’ ‘Wall, I never!’ said he. ‘You ain’t got
nary leg.’” In this story, George Dedlow becomes the symbol for
the cost of the Civil War, which left 500 000 soldiers disfigured,
disabled, and in chronic pain. 10
Erich Maria Remarque described in his classic novel All Quiet on
the Western Front the sufferings endured by the generation involved
in the atrocities of trench warfare in World War I. 11 Standing at
the bedside of his severely injured friend, Franz Kemmerich,
Albert Kropp asks, “How goes it Franz?” “Not so bad…but I have
such a damned pain in my foot.” The leg has been amputated.
With more than one meaning, Kropp commends, “Now you will
soon be going home.” During the next visit, Franz is dying from
complications of the amputation. He gives his “good army boots”
to his friend Müller, also giving hope to go on fighting not only a
war, but also the adversities in life.
Ambroise Paré (1510-1590) described phantom pain in
a surprisingly comprehensive fashion. 12 He differentiated
preamputation pain from postamputation symptoms, and stump
pain from phantom sensations and phantom limb pain. Paré
recognized a psychological component in pain perception, as well
as pain-alleviating and pain-modulating modalities.
Paré’s tract was geared toward his surgical colleagues who were
familiar with the challenges of treating postamputation pain.
Paré rejected the use of multiple limb-shortening procedures for
persistent pain and advocated for early amputation of necrotic
limbs and nonsurgical treatment of phantom pain as a combination
hiStoriCAL noteS on AMputAtion And phAntoM LiMb pAin
figure 2. Ambroise Paré (1510-1590), French barber surgeon
credited with the first detailed description of phantom limb pain.
Courtesy of the National Library of Medicine.
of massage therapy for the stump and neck and the use of an
antispasmodic ointment. Paré used 2 neurological models to
explain phantom sensation/pain: (1) A peripheral model focused
on contractures of muscles, nerves, and tendons; contractures
postinjury were commonplace in his era and, therefore, widely
recognized; and (2) A central nervous system model that identified
“pain memory” as the cause of pain without contractures.
Silas Weir Mitchell, a 19th-century neurologist, is credited
with coining the term phantom limb and the first concise description
of the phantom pain phenomena, 13-15 though Charles Bell, a
British physician, had also described phantom limb sensations in
1830 in his monograph The Nervous System of the Human Body. 16,17
Guéniot 18 described in an 1861 tract About Hallucination of
Feeling in Certain Amputees, the phenomenon of regressive
deformation, also known as telescoping. Telescoping refers to
the process of shrinking of the phantom sensation as the digits
become approximated to the stump, a phenomenon that seems
more likely to occur in the arm than in the leg. It is a gradual
process that occurs in 25% to 75% of amputees and is usually
complete after the first year. Pain, recurrent trauma, and other
similar events can reverse this process.
Since these original descriptions, phantom limb phenomena
have also been described with multiple other organ extirpations,
such as the tongue, penis, testicle, breast, bladder, gallbladder, and
teeth, as well as with spinal cord and nerve avulsion injuries. Bors
described in 1951 phantom pain associated with spinal cord injury
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