The Man Who Mistook His Wife For A Hat Part 10

The original had lacked character, had looked lifeless, two-dimensional, even stuffed. Jose's fish, by contrast, tilted and poised, was richly three-dimensional, far more like a real fish than the original. It was not only verisimilitude and animation that had been added but something else, something richly expressive, though not wholly fishlike: a great, cavernous, whalelike mouth; a slightly crocodilian snout; an eye, one had to say, which was distinctly human, and with altogether a positively roguish look. It was a very funny fish-no wonder he had smiled-a sort of fish-person, a nursery character, like the frog-footman in Alice.

Now I had something to go on. The picture of the clock had startled me, stimulated my interest, but did not, in itself, allow any thoughts or conclusions. The canoe had shown that Jose had an impressive visual memory, and more. The fish showed a lively and distinctive imagination, a sense of humour, and something akin to fairy-tale art. Certainly not great art, it was 'primitive', perhaps it was child-art; but, without doubt, it was art of a sort. And imagination, playfulness, art are precisely what one does not expect in idiots, or idiots savants, or in the autistic either. Such at least is the prevailing opinion.

My friend and colleague Isabelle Rapin had actually seen Jose years before, when he was presented with 'intractable seizures' in the child neurology clinic-and she, with her great experience, did not doubt that he was 'autistic'. Of autism in general she had written: A small number of autistic children are exceedingly proficient at decoding written language and become hyperlexic or preoccupied with numbers . . . Extraordinary proficiencies of some autistic children for putting together puzzles, taking apart mechanical toys, or decoding written texts may reflect the consequences of attention and learning being inordinately focused on non-verbal visual-spatial tasks to the exclusion of, or perhaps because of, the lack of demand for learning verbal skills. (1982, pp. 146-50) Somewhat similar observations, specifically about drawing, are made by Lorna Selfe in her astonishing book Nadia (1978). All idiot savant or autistic proficiencies and performances, Dr Selfe gathered from the literature, were apparently based on calculation and memory alone, never on anything imaginative or personal. And if these children could draw-supposedly a very rare occurrence-their drawings too were merely mechanical. 'Isolated islands of proficiency' and 'splinter skills' are spoken of in the literature. No allowance is made for an individual, let alone a creative, personality.

What then was Jose, I had to ask myself. What sort of being? What went on inside him? How had he arrived at the state he was in? And what state was it-and might anything be done?

I was both a.s.sisted and bewildered by the available information-the ma.s.s of 'data' that had been gathered since the first onset of his strange illness, his 'state'. I had a lengthy chart available to me, containing early descriptions of his original illness: a very high fever at the age of eight, a.s.sociated with the onset of incessant, and subsequently continuing, seizures, and the rapid appearance of a brain-damaged or autistic condition. (There had been doubt from the start about what, exactly, was going on.) His spinal fluid had been abnormal during the acute stage of the illness. The consensus was that he had probably suffered an encephalitis of sorts. His seizures were of many different types- pet.i.t mal, grand mal, 'akinetic', and 'psych.o.m.otor', these last being seizures of an exceptionally complex type.

Psych.o.m.otor seizures can also be a.s.sociated with sudden pa.s.sion and violence, and the occurrence of peculiar behaviour-states even between seizures (the so-called psych.o.m.otor personality). They are invariably a.s.sociated with disorder in, or damage to, the temporal lobes, and severe temporal-lobe disorder, both left-sided and right-sided, had been demonstrated in Jose by innumerable EEGs.

The temporal lobes are also a.s.sociated with the auditory capacities, and, in particular, the perception and production of speech. Dr Rapin had not only considered Jose 'autistic', but had wondered whether a temporal-lobe disorder had caused a 'verbal auditory agnosia'-an inability to recognise speech sounds that interfered with his capacity to use or understand the spoken word. For what was striking, however it was to be interpreted (and both psychiatric and neurological interpretations were offered), was the loss or regression of speech, so that Jose, previously 'normal' (or so his parents avowed), became 'mute', and ceased talking to others when he became ill.

One capacity was apparently 'spared'-perhaps in a compensatory way enhanced: an unusual pa.s.sion and power to draw, which had been evident since early childhood, and seemed to some extent hereditary or familial, for his father had always been fond of sketching, and his (much) older brother was a successful artist. With the onset of his illness; with his seemingly intractable seizures (he might have twenty or thirty major convulsions a day, and uncounted 'little seizures', falls, 'blanks', or 'dreamy states'); with the loss of speech and his general intellectual and emotional 'regression', Jose found himself in a strange and tragic state. His schooling was discontinued, though a private tutor was provided for a while, and he was returned permanently to his family, as a 'fulltime' epileptic, autistic, perhaps aphasic, r.e.t.a.r.ded child. He was considered ineducable, untreatable and generally hopeless. At the age of nine, he 'dropped out'-out of school, out of society, out of almost all of what for a normal child would be 'reality'.

For fifteen years he scarcely emerged from the house, ostensibly because of'intractable seizures', his mother maintaining she dared not take him out, otherwise he would have twenty or thirty seizures in the street every day. All sorts of anticonvulsants were tried, but his epilepsy seemed 'untreatable': this, at least, was the stated opinion in his chart. There were older brothers and sisters, but Jose was much the youngest-the 'big baby' of a woman approaching fifty.

We have far too little information about these intervening years. Jose, in effect, disappeared from the world, was 'lost to follow-up', not only medically but generally, and might have been lost forever, confined and convulsing in his cellar room, had he not 'blown up' violently very recently and been taken to the hospital for the first time. He was not entirely without inner life, in the cellar. He showed a pa.s.sion for pictorial magazines, especially of natural history, of the National Geographic type, and when he was able, between seizures and scoldings, would find stumps of pencil and draw what he saw.

These drawings were perhaps his only link with the outside world, and especially the world of animals and plants, of nature, which he had so loved as a child, especially when he went out sketching with his father. This, and this only, he was permitted to retain, his one remaining link with reality.

This, then, was the tale I received, or, rather, put together from his chart or charts, doc.u.ments as remarkable for what they lacked as for what they contained-the doc.u.mentation, through default, of a fifteen-year 'gap': from a social worker who had visited the house, taken an interest in him, but could do nothing; and from his now aged and ailing parents as well. But none of this would have come to light had there not been a rage of sudden, unprecedented, and frightening violence-a fit in which objects were smashed-which brought Jose to a state hospital for the first time.

It was far from clear what had caused this rage, whether it was an eruption of epileptic violence (such as one may see, on rare occasions, with very severe temporal-lobe seizures), or whether it was, in the simplistic terms of his admission note, simply 'a psychosis', or whether it represented some final, desperate call for help, from a tortured soul who was mute and had no direct way of expressing his predicament, his needs.

What was clear was that coming to the hospital and having his seizures 'controlled' by powerful new drugs, for the first time, gave him some s.p.a.ce and freedom, a 'release', both physiological and psychological, of a sort he had not known since the age of eight.

Hospitals, state hospitals, are often seen as 'total inst.i.tutions' in Erving Goffman's sense, geared mainly to the degradation of patients. Doubtless this happens, and on a vast scale. But they may also be 'asylums' in the best sense of the word, a sense perhaps scarcely allowed by Goffman: places that provide a refuge for the tormented, storm-tossed soul, provide it with just that mixture of order and freedom of which it stands in such need. Jose had suffered from confusion and chaos-partly organic epilepsy, partly the disorder of his life-and from confinement and bondage, also both epileptic and existential. Hospital was good for Jose, perhaps lifesaving, at this point in his life, and there is no doubt that he himself felt this fully.

Suddenly too, after the moral closeness, the febrile intimacy of his house, he now found others, found a world, both 'professional' and concerned: unjudging, unmoralistic, unaccusing, detached, but at the same time with a real feeling both for him and for his problems. At this point, therefore (he had now been in hospital for four weeks), he started to have hope; to become more animated, to turn to others as he had never done before-not, at least, since the onset of autism, when he was eight.

But hope, turning to others, interaction, was 'forbidden', and no doubt frighteningly complex and 'dangerous' as well. Jose had lived for fifteen years in a guarded, closed world-in what Bruno Bettelheim in his book on autism called the 'empty fortress'. But it was not, it had never been, for him, entirely empty; there had always been his love for nature, for animals and plants. This part of him, this door, had always remained open. But now there was temptation, and pressure, to 'interact', pressure that was often too much, came too soon. And precisely at such time Jose would 'relapse', would turn again, as if for comfort and security, to the isolation, to the primitive rocking movements, he had at first shown.

The third time I saw Jose, I did not send for him in the clinic, but went up, without warning, to the admission ward. He was sitting, rocking, in the frightful day room, his face and eyes closed, a picture of regression. I had a qualm of horror when I saw him like this, for I had imagined, had indulged, the notion of 'a steady recovery'. I had to see Jose in a regressed condition (as I was to do again and again) to see that there was no simple 'awakening' for him, but a path fraught with a sense of danger, double jeopardy, terrifying as well as exciting-because he had come to love his prison bars.

As soon as I called him, he jumped up, and eagerly, hungrily, followed me to the art room. Once more I took a fine pen from my pocket, for he seemed to have an aversion to crayons, which was all they used on the ward. 'That fish you drew,' I hinted it with a gesture in the air, not knowing how much of my words he might understand, 'that fish, can you remember it, can you draw it again?' He nodded eagerly, and took the pen from my hands. It was three weeks since he had seen it. What would he draw now?

He closed his eyes for a moment-summoning an image?- and then drew. It was still a trout, rainbow-spotted, with fringy fins and a forked tail, but, this time, with egregiously human features, an odd nostril (what fish has nostrils?), and a pair of ripely human lips. I was about to take the pen, but, no, he was not finished. What had he in mind? The image was complete. The image, perhaps, but not the scene. The fish before had existed- as an icon-in isolation: now it was to become part of a world, a scene. Rapidly he sketched in a little fish, a companion, swooping into the water, gambolling, obviously in play. And then the surface of the water was sketched in, rising to a sudden, tumultuous wave. As he drew the wave, he became excited, and emitted a strange, mysterious cry.

I couldn't avoid the feeling, perhaps a facile one, that this drawing was symbolic-the little fish and the big fish, perhaps him and me? But what was so important and exciting was the spontaneous representation, the impulse, not my suggestion, entirely from himself, to introduce this new element-a living interplay in what he drew. In his drawings as in his life hitherto, interaction had always been absent. Now, if only in play, in symbol, it was allowed back. Or was it? What was that angry, avenging wave?

Best to go back to safe ground, I felt; no more free a.s.sociation. I had seen potential, but I had seen, and heard, danger too. Back to safe, Edenic, prelapsarian Mother Nature. I found a Christmas card lying on the table, a robin redbreast on a tree trunk, snow and stark twigs all around. I gestured to the bird, and gave Jose the pen. The bird was finely drawn, and he used a red pen for the breast. The feet were somewhat taloned, grasping the bark (I was struck, here and later, by his need to emphasise the grasping power of hands and feet, to make contact sure, almost gripping, obsessed). But-what was happening?-the dry winter twiglet, next to the tree trunk, had shot up in his drawing, expanded into florid open bloom. There were other things that were perhaps symbolic, although I could not be sure. But the salient and exciting and most significant transformation was this: that Jose had changed winter into spring.

Now, finally, he started to speak-though 'speak' is much too strong a term for the strange-sounding, stumbling, largely unintelligible utterances that came out, on occasion startling him as much as they startled us-for all of us, Jose included, had regarded him as wholly and incorrigibly mute, whether from incapacity, indisposition, or both (there had been the att.i.tude, as well as the fact, of not speaking). And here, too, we found it impossible to say how much was 'organic', how much was a matter of 'motivation'. We had reduced, though not annulled, his temporal-lobe disorders-his electro-encephalograms (EEGs) were never normal; they still showed in these lobes a sort of low-grade electrical muttering, occasional spikes, dysrhythmia, slow waves. But they were immensely improved compared with what they were when he came in. If he could remove their convulsiveness, he could not reverse the damage they had sustained.

We had improved, it could not be doubted, his physiological potentials for speech, though there was an impairment of his abilities to use, understand, and recognise speech, with which, doubtless, he would always have to contend, But, equally important, he now was fighting for the recovery of his understanding and speech (egged on by all of us, and guided by the speech therapist in particular), where previously he had accepted it, hopelessly or m.a.s.o.c.h.i.s.tically, and indeed had turned against virtually all communication with others, verbal and otherwise. Speech impairment and the refusal to speak had coupled before in the double malignancy of disease; now, recovery of speech and attempts to speak were being happily coupled in the double benignity of beginning to get well. Even to the most sanguine of us it was very apparent that Jose would never speak with any facility approaching normal, that speech could never, for him, be a real vehicle for self-expres- sion, could serve only to express his simpler needs. And he himself seemed to feel this too and, while he continued to fight for speech, turned more fiercely to drawing for self-expression.

One final episode. Jose had been moved off the frenzied admission ward to a calmer, quieter special ward, more homelike, less prisonlike, than the rest of the hospital: a ward with an exceptional number and quality of staff, designed especially, as Bet- telheim would say, as 'a home for the heart', for patients with autism who seem to require a kind of loving and dedicated attention that few hospitals can give. When I went up to this new ward, he waved his hand l.u.s.tily as soon as he saw me-an outgoing, open gesture. I could not imagine him having done this before. He pointed to the locked door, he wanted it open, he wanted to go outside.

He led the way downstairs, outside, into the overgrown, sunlit garden. So far as I could learn, he had not, voluntarily, gone outside since he was eight, since the very start of his illness and withdrawal. Nor did I have to offer him a pen-he took one himself. We walked around the hospital grounds, Jose sometimes gazing at the sky and trees, but more often down at his feet, at the mauve and yellow carpet of clover and dandelions beneath us. He had a very quick eye for plant forms and colours, rapidly saw and picked a rare white clover, and found a still rarer four-leaved one. He found seven different types of gra.s.s, no less, seemed to recognise, to greet, each one as a friend. He was delighted most of all by the great yellow dandelions, open, all their florets flung open to the sun. This was his plant-it was how he felt, and to show his feeling he would draw it. The need to draw, to pay graphic reverence, was immediate and strong: he knelt down, placed his clipboard on the ground, and, holding the dandelion, drew it.

This, I think, is the first drawing from real life that Jose had done since his father took him sketching as a child, before he became ill. It is a splendid drawing, accurate and alive. It shows his love for reality, for another form of life. It is, to my mind, rather similar to, and not inferior to, the fine vivid flowers one finds in medieval botanies and herbals-fastidiously, botanically exact, even though Jose has no formal knowledge of botany, and could not be taught it or understand it if he tried. His mind is not built for the abstract, the conceptual. That is not available to him as a path to truth. But he has a pa.s.sion and a real power for the particular-he loves it, he enters into it, he re-creates it. And the particular, if one is particular enough, is also a road-one might say nature's road-to reality and truth.

The abstract, the categorical, has no interest for the autistic person-the concrete, the particular, the singular, is all. Whether this is a question of capacity or disposition, it is strikingly the case. Lacking, or indisposed to, the general, the autistic seem to compose their world picture entirely of particulars. Thus they live, not in a universe, but in what William James called a 'multiverse', of innumerable, exact, and pa.s.sionately intense particulars. It is a mode of mind at the opposite extreme from the generalising, the scientific, but still 'real', equally real, in a quite different way. Such a mind has been imagined in Borges's story Tunes the Me-morious' (so like Luria's Mnemonist): He was, let us not forget, almost incapable of ideas of a general, Platonic sort ... In the teeming world of Funes, there were only details, almost immediate in their presence . . . No one . . . has felt the heat and pressure of a reality as indefatigable as that which day and night converged upon the hapless Ireneo.

As for Borges's Ireneo, so for Jose. But it is not necessarily a hapless circ.u.mstance: there may be a deep satisfaction in particulars, especially if they shine, as they may do for Jose, with an emblematic radiance.

I think Jose, an autist, a simpleton too, has such a gift for the concrete, for form, that he is, in his way, a naturalist and natural artist. He grasps the world as forms-directly and intensely felt forms-and reproduces them. He has fine literal powers, but he has figurative powers too. He can draw a flower or fish with remarkable accuracy, but he can also make one which is a personification, an emblem, a dream, or a joke. And the autistic are supposed to lack imagination, playfulness, art!

Creatures like Jose are not supposed to exist. Autistic child-artists like 'Nadia' were not supposed to exist. Are they indeed so rare, or are they overlooked? Nigel Dennis, in a brilliant essay on Nadia in the New York Review of Books (4 May 1978), wonders how many of the world's 'Nadias' may be dismissed or overlooked, their remarkable productions crumpled up and consigned to the trash can, or simply, like Jose, treated without thought, as an odd talent, isolated, irrelevant, of no interest. But the autistic artist or (to be less lofty) the autistic imagination is by no means rare. I have seen a dozen examples of it in as many years, and this without making any particular effort to find them.

The autistic, by their nature, are seldom open to influence. It is their 'fate' to be isolated, and thus original. Their 'vision', if it can be glimpsed, comes from within and appears aboriginal. They seem to me, as I see more of them, to be a strange species in our midst, odd, original, wholly inwardly directed, unlike others.

Autism was once seen as a childhood schizophrenia, but phe-nomenologically the reverse is the case. The schizophrenic's complaint is always of 'influence' from the outside: he is pa.s.sive, he is played upon, he cannot be himself. The autistic would complain-if they complained-of absence of influence, of absolute isolation.

'No man is an island, entire of itself,' wrote Donne. But this is precisely what autism is-an island, cut off from the main. In 'cla.s.sical' autism, which is manifest, and often total, by the third year of life, the cutting off is so early there may be no memory of the main. In 'secondary' autism, like Jose's, caused by brain disease at a later stage in life, there is some memory, perhaps some nostalgia, for the main. This may explain why Jose was more accessible than most, and why, at least in drawing, he may show interplay taking place.

Is being an island, being cut off, necessarily a death? It may be a death, but it is not necessarily so. For though 'horizontal' connections with others, with society and culture, are lost, yet there may be vital and intensified 'vertical' connections, direct connections with nature, with reality, uninfluenced, unmediated, untouchable, by any others. This 'vertical' contact is very striking with Jose, hence the piercing directness, the absolute clarity of his perceptions and drawings, without a hint or shade of ambiguity or indirection, a rocklike power uninfluenced by others.

This brings us to our final question: is there any 'place' in the world for a man who is like an island, who cannot be acculturated, made part of the main? Can 'the main' accommodate, make room for, the singular? There are similarities here to the social and cultural reactions to genius. (Of course I do not suggest that all autists have genius, only that they share with genius the problem of singularity.) Specifically: what does the future hold for Jose? Is there some 'place' for him in the world which will employ his autonomy, but leave it intact?

Could he, with his fine eye, and great love of plants, make ill.u.s.trations for botanical works or herbals? Be an ill.u.s.trator for zoology or anatomy texts? (See the drawing overleaf he made for me when I showed him a textbook ill.u.s.tration of the layered tissue called 'ciliated epithelium'.) Could he accompany scientific expeditions, and make drawings (he paints and makes models with equal facility) of rare species? His pure concentration on the thing before him would make him ideal in such situations.

Or, to take a strange but not illogical leap, could he, with his peculiarities, his idiosyncrasy, do drawings for fairy tales, nursery tales, Bible tales, myths? Or (since he cannot read, and sees letters only as pure and beautiful forms) could he not ill.u.s.trate, and elaborate, the gorgeous capitals of ma.n.u.script breviaries and missals? He has done beautiful altarpieces, in mosaic and stained wood, for churches. He has carved exquisite lettering on tombstones. His current 'job' is hand-printing sundry notices for the ward, which he does with the flourishes and elaborations of a latter-day Magna Carta. All this he could do, and do very well. And it would be of use and delight to others, and delight him too. He could do all of these-but, alas, he will do none, unless someone very understanding, and with opportunities and means, can guide and employ him. For, as the stars stand, he will probably do nothing, and spend a useless, fruitless life, as so many other autistic people do, overlooked, unconsidered, in the back ward of a state hospital.

Postscript After publication of this piece, I again received many offprints and letters, the most interesting being from Dr C.C. Park. It is indeed clear (as Nigel Dennis suspected) that even though 'Nadia' may Ciliated epithelium from the trachea of a kitten (magnified 255 times).

have been unique-a sort of Pica.s.so-artistic gifts of fairly high order are not uncommon among the autistic. Testing for artistic potential, as in the Goodenough 'Draw-a-Man' intelligence test, is almost useless: there must occur, as with 'Nadia', Jose and the Parks' 'Ella', a spontaneous production of striking drawings.

In an important and richly ill.u.s.trated review of'Nadia', Dr Park (1978) brings out, on the basis of experience with her own child, no less than from a perusal of the world literature, what seem to be the cardinal characteristics of such drawings. These include 'negative' characteristics, such as derivativeness and stereotypy, and 'positive' ones, such as an unusual capacity for delayed rendition, and for rendering the object as perceived (not as conceived): hence the sort of inspired naivete especially seen. She also notes a relative indifference to display of others' reactions, which might seem to render such children untrainable. And yet, manifestly, this need not be the case. Such children are not necessarily unresponsive to teaching or attention, though this may need to be of a very special type.

In addition to experience with her own child, who is now an accomplished adult artist, Dr Park cites also the fascinating and insufficiently known experiences of the j.a.panese, especially Mor-ishima and Motzugi, who have had remarkable success in bringing autists from an untutored (and seemingly unteachable) childhood giftedness to professionally accomplished adult artistry. Morishima favours special instructional techniques ('highly structured skill training'), a sort of apprenticeship in the cla.s.sical j.a.panese cultural tradition, and encouragement of drawing as a means of communication. But such formal training, though crucial, is not enough. A most intimate, empathic relationship is required. The words with which Dr Park concludes her review may properly conclude 'The World of the Simple': The secret may lie elsewhere, in the dedication that led Motzugi to live with another r.e.t.a.r.ded artist in his home, and to write: 'The secret in developing Yanamura's talent was to share his spirit. The teacher should love the beautiful, honest r.e.t.a.r.ded person, and live with a purified, r.e.t.a.r.ded world.'

Bibliography GENERAL REFERENCES.

Hughlings Jackson, Kurt Goldstein, Henry Head, A. R. Luria-these are the fathers of neurology who lived intensely, and thought intensely, about patients and problems not so dissimilar to our own. They are always present, in the neurologist's mind, and they haunt the pages of this book. There is a tendency to reduce complex figures to stereotypes, to disallow the fullness, and often the rich contradictoriness, of their thought. Thus 1 often talk about cla.s.sical "Jacksonian" neurology, but the Hughlings Jackson who wrote of "dreamy states" and "reminiscence" was very different from the Jackson who saw all thought as propositional calculus. The former was a poet, the latter a logician, and yet they are one and the same man. Henry Head the diagram-maker, with his pa.s.sion for schematics, was very different from the Head who wrote poignantly of "feeling-tone." Goldstein, who wrote so abstractly of "the Abstract," delighted in the rich concreteness of individual cases. In Luria, finally, the doubleness was conscious: he had, he felt, to write two sorts of books: formal, structural books (like Higher Cortical Functions in Man) and biographical "novels" (like The Mind of a Mnemonist). The first he called "Cla.s.sical Science," the second, "Romantic Science."

Jackson, Goldstein, Head, and Luria-they const.i.tute the essential axis of neurology, and certainly they are the axis of my own thinking and of this book. My first references must therefore be to them-ideally to everything they wrote, for what is most characteristic is always suffused through a life's work, but for the sake of practicality to certain key-works which are the most accessible to English-speaking readers.

Hughlings Jackson There are wonderful descriptions of cases before Hughlings Jackson- such as Parkinson's "Essay on the Shaking Palsy," as early as 1817-but no general vision or systemization of nervous function. Jackson is the founder of neurology as a science. One can browse through the basic volumes of Jacksoniana: Taylor, J., Selected Writings of John Hughlings Jackson. London: 1931; repr. New York: 1958. These writings are not easy reading, though often evocative and dazzlingly clear in parts. A further selection, with records of Jackson's conversations and a memoir, had been almost completed by Purdon Martin at the time of his recent death, and will, it is Jioped, be published in this sesquicentennial year of Jackson's birth.

Henry Head Head, like Weir Mitch.e.l.l (see below under Chapter 6), is a marvellous writer, and his heavy volumes, unlike Jackson's, are always a delight to read: Studies in Neurology. 2 vols. Oxford: 1920.

Aphasia and Kindred Disorders of Speech. 2 vols. Cambridge: 1926.

Kurt Goldstein Goldstein's most accessible general book is Der Aufbau des Organis-mus (The Hague: 1934), translated as The Organism: A Holistic Approach to Biology Derived from Pathological Data in Man (New York: 1939). See also Goldstein, K. and Sheerer, M., "Abstract amp; concrete behaviour," Psychol. Monogr. 53 (1941).

Goldstein's fascinating case-histories, scattered through many books and journals, await collection.

A. R. Luria The greatest neurological treasure of our time, for both thought and case description, is the works of A. R. Luria. Most of Luria's books have been translated into English. The most accessible are: The Man with a Shattered World. New York: 1972. The Mind of a Mnemonist. New York: 1968.

Speech amp; the Development of Mental Processes in the Child. London: 1959. A study of mental defect, speech, play, and twins.

Human Brain and Psychological Process. New York: 1966. Case histories of patients with frontal lobe syndromes.

The Neuropsychology of Memory. New York: 1976.

Higher Cortical Functions in Man. 2nd ed. New York: 1980. Luria's magnum opus-the greatest synthesis of neurological work and thought in our century.

The Working Brain. Harmondsworth: 1973. A condensed and highly readable version of the above. The best available introduction to neuropsychology.

CHAPTER REFERENCES.

1. The Man Who Mistook His Wife for a Hat Macrae, D. and Trolle, E. "The defect of function in visual agnosia." Brain (1956) 77: 94-110.

Kertesz, A. "Visual agnosia: the dual deficit of perception and recognition." Cortex (1979) J 5: 403-19.

Marr, D. See below under Chapter 15.

Damasio, A. R. "Disorders in Visual Processing," in M. M. Mesulam (1985), pp. 259-88. (See below under Chapter 8.) 2. The Lost Mariner Korsakov's original (1887) contribution and his later works have not been translated. A full bibliography, with translated excerpts and discussion, is given in A. R. Luria's Neuropsychology of Memory (op. cit.), which itself provides many striking examples of amnesia akin to that of "The Lost Mariner." Both here, and in the preceding case history, I refer to Anton, Potzl, and Freud. Of these only Freud's monograph-a work of great importance-has been translated into English.

Anton, G. "Uber die Selbstwarnehmung der Herderkrankungen des Gehirns durch den Kranken." Arch. Psychiat. (1899) 32.

Freud, S. Zur Auffa.s.sung der Aphasia. Leipzig: 1891. Authorized English tr., by E. Stengel, as On Aphasia: A Critical Study. New York: 1953.

Potzl, O. Die Aphasielehre vom Standpunkt der klinischen Psychiatrie: Die Optische-agnostischen Storungen. Leipzig: 1928. The syndrome Potzl describes is not merely visual, but may extend to a complete unawareness of parts, or one half, of the body. As such it is also relevant to the themes of Chapters 3, 4, and 8. It is also referred to in my book A Leg to Stand On (1984).

3. The Disembodied Lady Sherrington, C. S. The Integrative Action of the Nervous System. Cambridge: 1906. Esp. pp. 335-43.

----. Man on His Nature. Cambridge: 1940. Ch. 11, esp. pp.

328-9, has the most direct relevance to this patient's condition.

Purdon Martin, J. The Basal Ganglia and Posture. London: 1967. This important book is more extensively referred to in Chapter 7.

Weir Mitch.e.l.l, S. See below under Chapter 6.

Sterman, A. B. et al. "The acute sensory neuronopathy syndrome." Annals of Neurology (1979) 7: 354-8.

4. The Man Who Fell out of Bed Potzl, O. Op. cit.

5. Hands Leont'ev, A. N. and Zaporozhets, A. V. Rehabilitation of Hand Function. Eng. tr. Oxford: 1960.

6. Phantoms Sterman, A. B. et al. Op. cit.

Weir Mitch.e.l.l, S. Injuries of Nerves. 1872; Dover repr. 1965. This great book contains Weir Mitch.e.l.l's cla.s.sic accounts of phantom limbs, reflex paralysis, etc. from the American Civil War. It is wonderfully vivid and easy to read, for Weir Mitch.e.l.l was a novelist no less than a neurologist. Indeed, some of his most imaginative neurological writings (such as "The Case of George Dedlow") were published not in scientific journals but in the Atlantic Monthly in the 1860s and 1870s, and are therefore not very accessible now, though they enjoyed an immense readership at the time.

7. On the Level Purdon Martin, J. Op. cit. Esp. ch. 3, pp. 36-51.

8. Eyes Right!

Battersby, W. S. et al. "Unilateral 'spatial agnosia' (inattention) in patients with cerebral lesions." Brain (1956) 79: 68-93.

Mesulam, M. M. Principles of Behavioral Neurology (Philadelphia: 1985), pp. 259-88.

9. The President's Speech The best discussion of Frege on "tone" is to be found in Dummett, M., Frege: Philosophy of Language (London: 1973), esp. pp. 83-89.

Head's discussion of speech and language, in particular its "feeling-tone," is best read in his treatise on aphasia (op. cit.). Hughlings Jackson's work on speech was widely scattered, but much was brought together posthumously in "Hughlings Jackson on aphasia and kindred affections of speech, together with a complete bibliography of his publications of speech and a reprint of some of the more important papers," Brain (1915) 38: 1-190.

On the complex and confused subject of the auditory agnosias, see Hecaen, H. and Albert, M. L., Human Neuropsychology (New York: 1978), pp. 265-76.

10. Witty Ticcy Ray In 1885 Gilles de la Tourette published a two-part paper in which he described with extreme vividness (he was a playwright as well as a neurologist) the syndrome that now bears his name: "Etude sur an affection nerveuse caracterisee par l'incoordination motrice accompagnee d'echo-lalie et de coprolalie," Arch. Neurol. 9: 19-42, 158-200. The first English translation of these papers, with interesting editorial comments, is provided by: Goetz, C. G. and Klawans, H. L., Gilles de la Tourette on Tourette Syndrome (New York: 1982).

In Meige and Feidel's great Les Tics et leur traitement (1902), brilliantly translated by Kinnier Wilson in 1907, there is a wonderful opening personal memoir by a patient, "Les confidences d'un ticqueur," which is unique of its kind.

11. Cupid's Disease As with Tourette's syndrome, we must go back to the older literature to find full clinical descriptions. Kraepelin, Freud's contemporary, provides many striking vignettes of neurosyphilis. The interested reader might consult: Kraepelin, E., Lectures on Clinical Psychiatry (Eng. tr. London: 1904), in particular chs. 10 and 12 on megalomania and delirium in general paralysis.

12. A Matter of Ident.i.ty See Luria (1976).

13. Yes, Father-Sister See Luria (1966).

14. The Possessed See above under Chapter 10.

15. Reminiscence Alajouanine, T. "Dostoievski's epilepsy." Brain (1963) 86: 209-21.

Critchley, M. and Henson, R. A., eds. Music and the Brain: Studies in the Neurology of Music. London: 1977. Esp. chs. 19 and 20.

Penfield, W. and Perot, P. "The brain's record of visual and auditory experience: a final summary and discussion." Brain (1963) 86: 595-696. I regard this magnificent 100-page paper, the culmination of nearly thirty years' profound observation, experiment, and thought, as one of the most original and important in all neurology. It stunned me when it came out in 1963 and was constantly in my mind when I wrote Migraine in 1967. It is the essential reference and inspiration to the whole of this section. More readable than many novels, it has a wealth and strangeness of material which any novelist would envy.

Salaman, E. A Collection of Moments. London: 1970.

Williams, D. "The structure of emotions reflected in epileptic experiences." Brain (1956) 79: 29-67.

Hughlings Jackson was the first to address himself to "psychical seizures," to describe their almost novelistic phenomenology and to identify their anatomical loci in the brain. He wrote several papers on the subject. Most pertinent are those published in Volume 1 of his Selected Writings (1931), pp. 251ff. and 274ff., and the following (not included in that volume): Jackson, J. H. "On right- or left-sided spasm at the onset of epileptic paroxysms, and on crude sensation warnings, and elaborate mental states." Brain (1880) 3: 192-206.

----. "On a particular variety of epilepsy ('Intellectual Aura')."

Brain (1888) I J: 179-207.

Purdon Martin has provided an intriguing suggestion that Henry James met Hughlings Jackson, discussed such seizures with him, and employed this knowledge in his depiction of the uncanny apparitions in The Turn of the Screw. "Neurology in fiction: The Turn of the Screw," British Medical]. (1973)4:717-21.

Marr, D. Vision: A Computational Investigation of Visual Representation in Man. San Francisco: 1982. This is a work of extreme originality and importance, published posthumously (Marr contracted leukemia while still a young man). Penfield shows us the forms of the brain's final representations-voices, faces, tunes, scenes-the "iconic": Marr shows us what is not intuitively obvious, or ever normally experienced-the form of the brain's initial representations. Perhaps I should have given this reference in Chapter 1-it is certain that Dr. P. had some "Marr-like" deficits, difficulties in forming what Marr calls a "primal sketch" in addition to, or underlying, his physiognomonic difficulties. Probably no neurological study of imagery, or memory, can dispense with the considerations raised by Marr.