Ambroise Paré: His Contribution to the Future Advancement of Neurosurgery and the Hardships of His Times Affecting His Life and Brilliant Career.

Ambroise Paré was celebrated surgeon of the 16th century whose practical accomplishments, books, and ideas transformed surgery and was a precursor for the later development of neurosurgery. He developed many surgical innovations related to wound management, arterial ligation for the prevention of hemorrhage during limb amputations, and the treatment of war-related head and spine injuries. He maintained that a surgeon should operate gently to reduce pain and improve outcome, and he dedicated his career to the wounded, sick, and poor. He also served 4 consecutive French monarchs-Henri II and his 3 sons François II, Charles IX, and Henri III. As a Huguenot (a Reformed Protestant) by faith, he lived in an environment dominated by Catholicism. Hence, his practice and life were sometimes hindered by political circumstances and religious prejudice. In this historical vignette, we will discuss the professional accomplishments of Ambroise Paré that influenced the future development of neurosurgery, including his descriptions of phantom-limb pain and peripheral nerve injury, his innovations in neurotraumatology, and the saws he invented for use in skull surgery. We will also highlight Paré's broad neurosurgical contributions to the field. Finally, we will discuss his personal life during the difficult and dangerous political circumstances of 16th century France.

Édouard Manet's Tabes Dorsalis: From Painful Ataxia to Phantom Limb.

Édouard Manet (1832-1883) is considered the "father" of impressionism and even of twentieth century modern art. Manet's genius involved getting away from the classical narrative or historical topics and replacing them by the banality of daily life. Technically, he erased volumes into flat two-dimensional coloured planes, and distorted conventional perspective with often gross brushstrokes intentionally giving an "unfinished" aspect to the work. It is little known that Manet had a very painful second part of his life, due to excruciating limb and chest pains, which developed in parallel with proprioceptive ataxia and gait imbalance. Manet always remained discreet about his private life, and we mainly know that his future wife was his family piano teacher, with whom he had a liaison at the age of 17 years. Later, the great but platonic passion of his life was the painter Berthe Morisot (1841-1895), who married Manet's brother Eugène. In fact, we do not know whether he had a mistress at all, although he had several elegant "flirts" in the mundane and artistic milieu. Thus, while Manet's progressive painful ataxia from the age 40 years yields little doubt on its tabetic origin, how he contracted syphilis at least 15-20 years before will probably remain a mystery. It is fascinating that Manet's daily struggle against pain and poor coordination may have led his art to become one of the most significant of modern times, opening the way to twentieth century avant-gardes, along with another victim of syphilis, Paul Gauguin (1848-1903). Manet never showed any sign of general paresis, and like his contemporary, the writer Alphonse Daudet, his clinical picture remained dominated by paroxysmal pain and walking impairment. Difficult hand co-ordination made him quit watercolour painting, and during the last 2 years of his life he had to focus on small format oil works, the subject of which was nearly limited to modest bunches of fresh flowers, now often considered to be his maturity masterpieces. Having become bedridden, he had to be amputated of one leg, which was developing gangrene, probably associated with ergot overuse. While he died shortly thereafter, we have some witness anecdotes suggesting that he experienced a phantom limb: when Claude Monet (1840-1926) visited him and sat down on his bed, Manet violently shouted that he was sitting on his (absent) leg, which provoked terrible pains. With its facts and mysteries, the subtle interaction between Manet's illness and his work output remains one of the most intriguing stories in the neurology of art.

Arthur Rimbaud: "The Man with Wind Soles" - Riders' Osteosarcoma with Postamputation Stump Pain.

The famous poet Arthur Rimbaud (1854-1891) stopped writing poetry at 21 years and subsequently had a rather adventurous life mainly in the Arabic peninsula and Ethiopia. He died at 37 years, only a few months after the amputation of his right lower limb due to a developing tumor in the knee, which probably was an osteosarcoma in the lower third of the femur. His letters to his sister Isabelle suggest that he suffered from severe stump pain rather than phantom limb, but since he lived only shortly after surgery (he developed extensive carcinomatosis), one does not know whether a full phantom would have developed and how this would have affected his subsequent life.

Édouard Manet's Tabes Dorsalis: From Painful Ataxia to Phantom Limb.

Édouard Manet (1832-1883) is considered the 'father' of Impressionism and even of XXth century modern art. Manet's genius involved getting away from the classical narrative or historical topics and replacing them by the banality of daily life. Technically, he erased volumes into flat two-dimensional coloured planes, and distorted conventional perspective with often gross brushstrokes intentionally giving an 'unfinished' aspect to the work. It is little known that Manet had a very painful second part of his life, due to excruciating limb and chest pains, which developed in parallel with proprioceptive ataxia and gait imbalance. Manet always remained discreet about his private life, and we mainly know that his future wife was his family piano teacher, with whom he had a liaison already at age 17. Later, the great but platonic passion of his life was the painter Berthe Morisot (1841-1895), who got married to Manet's brother Eugène. In fact, we do not know whether he had any mistress at all, although he had several elegant 'flirts' in the mundane and artistic milieu. Thus, while Manet's progressive painful ataxia from age 40 yields little doubt on its tabetic origin, how he contracted syphilis at least 15-20 years before will probably remain a mystery. It is fascinating that Manet's daily struggle against pain and poor coordination may have led his art to become one of the most significant of modern times, opening the way to XXth century avant-gardes, along with another victim of syphilis, Paul Gauguin (1848-1903). Manet never showed any sign of General Paresis, and like his contemporary the writer Alphonse Daudet, his clinical picture remained dominated by paroxysmal pain and walking impairment. Difficult hand coordination made him quit watercolor painting, and during the last 2 years of his life, he had to focus on small format oil works, whose subject was nearly limited to modest bunches of fresh flowers, now often considered to be his maturity masterpieces. Having become bedridden, he had to be amputated of one leg, which was developing gangrene probably associated with ergot overuse. While he died shortly thereafter, we have some witness anecdotes suggesting that he experienced a phantom limb: when Claude Monet (1840-1926) visited him and sat down on his bed, Manet violently shouted at him that he was just sitting on his (absent) leg, which provoked terrible pains. With its facts and mysteries, the subtle interaction between Manet's illness and his work output remains one of the most intriguing stories in neurology of art.

'It's All Done With Mirrors': V.S. Ramachandran and the Material Culture of Phantom Limb Research.

This article examines the material culture of neuroscientist Vilayanur S. Ramachandran's research into phantom limbs. In the 1990s Ramachandran used a 'mirror box' to 'resurrect' phantom limbs and thus to treat the pain that often accompanied them. The experimental success of his mirror therapy led Ramachandran to see mirrors as a useful model of brain function, a tendency that explains his attraction to work on 'mirror neurons'. I argue that Ramachandran's fascination with and repeated appeal to the mirror can be explained by the way it allowed him to confront a perennial problem in the mind and brain sciences, that of the relationship between a supposedly immaterial mind and a material brain. By producing what Ramachandran called a 'virtual reality', relating in varied and complex ways to the material world, the mirror reproduced a form of psycho-physical parallelism and dualistic ontology, while conforming to the materialist norms of neuroscience today.

Voices from the past: Mental and physical outcomes described by American Civil War amputees.

Studies of trauma commonly concentrate on the psychological and physiological effects of recent violent events. Although today connections are becoming more explicitly drawn, early studies of the aftermath of amputation serve to shed light on modern understanding of the interaction of the physical and emotional. The study of combat amputation, dissociation, and related posttraumatic stress largely began with the work of 19th-century Philadelphia physician Silas Weir Mitchell, who brought attention to the phenomenon of phantom limb pain. Less known, however, are the data he and his son, John K. Mitchell, also collected on the mental outcomes of trauma. Using an archived collection of original surveys of double-amputee patients dating largely from 1893 housed at the Historical Medical Library at the College of Physicians of Philadelphia, an interdisciplinary team explored the historical, anthropological, and psychological background of the study of combat trauma. Almost 30 years following the end of hostilities, the majority of the sample of U.S. Civil War veterans indicated that their general disposition, general health, and sleeping or eating patterns had changed following limb amputation. More telling, possibly, are the written comments on the surveys and letters that indicate frustration with the continuous suffering and the knowledge of their mental and physical changes. These data illustrate the value of historical archives in documenting the development of the study of trauma and modern concepts of combat experiences.

The Torments of Spring: Jake Barnes's Phantom Limb in The Sun Also Rises.

While critics recently have found The Sun Also Rises a fruitful text for reexamining issues of gender and sexuality in Hemingway's work, a significant aspect of Jake Barnes's genital wounding has been overlooked. At least from the time of the American Civil War, a diverse body of medical literature has documented the psychosomatic reality of phantom genitalia in traumatically injured men. Revisiting the novel from this perspective-imagining that Jake Barnes is haunted by a penile ghost-allows us to see this character as something more than a victim of disability. Instead, we might think of Jake's material self as figuratively masculine but accidentally transgendered: a body that others can desire and that still can choose, or not, to reciprocate sexual feeling.

Paul Wittgenstein's right arm and his phantom: the saga of a famous concert pianist and his amputation.

Reports of postamputation pain and problems linked to phantom limbs have increased in recent years, particularly in relation to war-related amputations. These problems are still poorly understood and are considered rather mysterious, and they are difficult to treat. In addition, they may shed light on brain physiology and neuropsychology. Functional neuroimaging techniques now enable us to better understand their pathophysiology and to consider new rehabilitation techniques. Several artists have suffered from postamputation complications and this has influenced not only their personal life but also their artistic work. Paul Wittgenstein (1887-1961), a pianist whose right arm was amputated during the First World War, became a famous left-handed concert performer. His case provides insight into Post-World War I musical and political history. More specifically, the impact on the artistic life of this pianist illustrates various postamputation complications, such as phantom limb, stump pain, and especially moving phantom. The phantom movements of his right hand helped him develop the dexterity of his left hand. Wittgenstein played piano works that were written especially for him (the most famous being Ravel's Concerto for the Left Hand) and composed some of his own. Additionally, several famous composers had previously written for the left hand.

"Doomed to go in company with miserable pain": surgical recognition and treatment of amputation-related pain on the Western Front during World War 1.

The principal feature of injuries from World War 1 was musculoskeletal trauma and injury to peripheral nerves as a result of damage to the upper and lower limbs caused by gunshot wounds and fragments of artillery munitions. Amputation was used as a treatment in field hospitals to save lives; limb conservation was a secondary consideration. A century later, the principal feature of injuries to soldiers in today's wars in Iraq and Afghanistan is also musculoskeletal trauma and injury to the peripheral nerves caused by improvised explosive devices. Common to both types of injury is postamputation pain. We searched The Lancet's archives in this Series paper to show the efforts of surgeons in World War 1 to understand and treat postamputation pain in its own right both during and immediately after the war. Despite unprecedented patient numbers and levels of civilian medical expertise, little progress was made in providing relief from this type of pain, a grave concern to the surgeons treating these soldiers. Today postamputation pain is understood beyond a surgical context but remains a complex and poorly understood condition with few effective treatments.

Phantoms in artists: the lost limbs of Blaise Cendrars,Arthur Rimbaud, and Paul Wittgenstein.

There have been an increasing number of reports of postamputation pain and problems linked to phantom limbs over recent years, particularly in relation to war-related amputations. These problems, which are often poorly understood and considered rather mysterious, are still relevant because they are difficult to treat medically. Functional neuroimaging techniques now enable us to better understand their pathophysiology and to consider new rehabilitation techniques. Phantom limbs have often been a source of inspiration to writers, particularly in the period following the First World War, which was responsible for thousands of amputees. Some artists have suffered from postamputation complications themselves and have expressed them through their artistic works. Blaise Cendrars (1887-1961), one of the greatest authors of the twentieth century, suffered from stump pain and phantom limb phenomena for almost half a century following the amputation of his right arm during the First World War. He suffered from these phenomena until the end of his life and his literary work and personal correspondence are peppered with references to them. Arthur Rimbaud (1854-1891), one of the most famous poets in world literature, developed severe stump pain after his right leg was amputated due to a tumor. He survived for only six months after the procedure but left behind an account of the pain he experienced in correspondence to his family. The famous pianist Paul Wittgenstein (1887-1961), whose right arm was amputated during the First World War, became a famous left-handed concert pianist. The phantom movements of his right hand helped him to develop the dexterity of his left hand. The impact on the artistic life of these three men provides an original illustration of the various postamputation complications, specifically phantom limbs, stump pain, and moving phantom.

Mirror therapy for facial paralysis in traditional South Asian Islamic medicine.

Mirror therapy has stimulated a dynamic clinical and research agenda for the treatment of poststroke hemiparesis and phantom pain. The origins of mirror therapy are thought to lie with the end of the twentieth century. This article translates key sections on the use of mirror therapy for facial paralysis from Muhammad Akbar Arzani, an influential practitioner of South Asian Islamic medicine. Given that his text appeared over a quarter millennium before Western accounts of mirror therapy, this article calls for an amendment to the historical record so that Arzani is recognized.

The phantom and the supernumerary phantom limb: historical review and new case.

The way we experience the world is determined by the way our brain works. The phantom limb phenomenon, which is a delusional belief of the presence of a non-existent limb, has a particular fascination in neurology. This positive phenomenon of the phantom limb raises theoretical questions about its nature. After a stroke, some patients experience the perception of an extra limb in addition to the regular set of two arms and two legs. This complex cognitive and perceptual distortion is called supernumerary phantom limb. Here, we review the pathogenesis and historical aspects, and report a new case.

Chapter 32: sensory and perceptual disorders.

Disorders of perception can be examined appropriately only after the normal operations of the senses have been appreciated. There was a long descriptive history of perceptual phenomena before theories were formed and experiments were performed. The phases through which phenomena pass in progressing from description to dissection are charted. The first stage is a description of phenomena, followed by attempts to incorporate them into the body of extant theory. Finally, the phenomena are accepted and utilized to gain more insights into the functioning of the senses and of the brain. In many cases, the phenomena have been described in the distant past, and no clear origin can be determined. In others, there is an obvious break with the past and a phenomenon is described and investigated for the first time. For most of the history of the senses, interest was usually restricted to illusions or oddities of experience: the commonplace characteristics of constant perception were ignored. These factors are taken into consideration with regard to the classification of the senses, phantom limbs, vertigo, and developmental disorders. Imposing some order on the senses was a long but necessary precursor to examining their disorders. Once order was established then a range of fascinating phenomena came to light (particularly in vision). Others that had long been known became open to more detailed scrutiny.

From pleasure to pain: The role of the MPQ in the language of phantom limb pain.

In opposition to the argument that pain is private, personal and unsharable, I propose that the intersubjectivity of pain is fundamental to it. Using the case of phantom limb, I show how a specific language of pain emerged and became concretized in the US circa 1975 with the advent of the McGill Pain Questionnaire (MPQ). Through widespread use of the MPQ, a language of pain materialized, one that was commonly used to describe the qualitative dimensions of phantom limb. After 1975, the terminology used within the medical literature was overwhelmingly consonant with the set of descriptors advanced by the MPQ. The utilization of a pain questionnaire to assess the qualitative dimensions of phantom limb effectively accentuated pain, and by 1980, what was once considered relatively rare became a common sequela of phantom manifestation.