The Man Who Mistook His Wife For A Hat Part 2

'Naturally.'

'h.e.l.l! You're joking-how the h.e.l.l would you do that?'

Unless he was a consummate actor, a fraud simulating an astonishment he did not feel, this was an utterly convincing demonstration that he was still in the past. His words, his feelings, his innocent wonder, his struggle to make sense of what he saw, were precisely those of an intelligent young man in the forties faced with the future, with what had not yet happened, and what was scarcely imaginable. 'This more than anything else,' I wrote in my notes, 'persuades me that his cut-off around 1945 is genuine . . . What I showed him, and told him, produced the authentic amazement which it would have done in an intelligent young man of the pre-Sputnik era.'

I found another photo in the magazine and pushed it over to him.

'That's an aircraft carrier,' he said. 'Real ultramodern design. I never saw one quite like that.'

'What's it called?' I asked.

He glanced down, looked baffled, and said, 'The Nimitzl'

'Something the matter?'

'The h.e.l.l there is!' he replied hotly. 'I know 'em all by name, and I don't know a Nimitz ... Of course there's an Admiral Nimitz, but I never heard they named a carrier after him.'

Angrily he threw the magazine down.

He was becoming fatigued, and somewhat irritable and anxious, under the continuing pressure of anomaly and contradiction, and their fearful implications, to which he could not be entirely oblivious. I had already, unthinkingly, pushed him into panic, and felt it was time to end our session. We wandered over to the window again, and looked down at the sunlit baseball diamond; as he looked his face relaxed, he forgot the Nimitz, the satellite photo, the other horrors and hints, and became absorbed in the game below. Then, as a savoury smell drifted up from the dining room, he smacked his lips, said 'Lunch!', smiled, and took his leave.

And I myself was wrung with emotion-it was heartbreaking, it was absurd, it was deeply perplexing, to think of his life lost in limbo, dissolving.

'He is, as it were,' I wrote in my notes, 'isolated in a single moment of being, with a moat or lacuna of forgetting all round him ... He is man without a past (or future), stuck in a constantly changing, meaningless moment.' And then, more prosaically, 'The remainder of the neurological examination is entirely normal. Impression: probably Korsakov's syndrome, due to alcoholic degeneration of the mammillary bodies.' My note was a strange mixture of facts and observations, carefully noted and itemised, with irrepressible meditations on what such problems might 'mean', in regard to who and what and where this poor man was-whether, indeed, one could speak of an 'existence', given so absolute a privation of memory or continuity.

I kept wondering, in this and later notes-unscientifically- about 'a lost soul', and how one might establish some continuity, some roots, for he was a man without roots, or rooted only in the remote past.

'Only connect'-but how could he connect, and how could we help him to connect? What was life without connection? 'I may venture to affirm,' Hume wrote, 'that we are nothing but a bundle or collection of different sensations, which succeed each other with an inconceivable rapidity, and are in a perpetual flux and movement.' In some sense, he had been reduced to a 'Humean' being- I could not help thinking how fascinated Hume would have been at seeing in Jimmie his own philosophical 'chimaera' incarnate, a gruesome reduction of a man to mere disconnected, incoherent flux and change.

Perhaps I could find advice or help in the medical literature- a literature which, for some reason, was largely Russian, from Korsakov's original thesis (Moscow, 1887) about such cases of memory loss, which are still called 'Korsakov's syndrome', to Lu-ria's Neuropsychology of Memory (which appeared in translation only a year after I first saw Jimmie). Korsakov wrote in 1887: Memory of recent events is disturbed almost exclusively; recent impressions apparently disappear soonest, whereas impressions of long ago are recalled properly, so that the patient's ingenuity, his sharpness of wit, and his resourcefulness remain largely unaffected.

To Korsakov's brilliant but spare observations, almost a century of further research has been added-the richest and deepest, by far, being Luria's. And in Luria's account science became poetry, and the pathos of radical lostness was evoked. 'Gross disturbances of the organization of impressions of events and their sequence in time can always be observed in such patients,' he wrote. 'In consequence, they lose their integral experience of time and begin to live in a world of isolated impressions.' Further, as Luria noted, the eradication of impressions (and their disorder) might spread backward in time-'in the most serious cases-even to relatively distant events.'

Most of Luria's patients, as described in this book, had ma.s.sive and serious cerebral tumours, which had the same effects as Korsakov's syndrome, but later spread and were often fatal. Luria included no cases of 'simple' Korsakov's syndrome, based on the self-limiting destruction that Korsakov described-neuron destruction, produced by alcohol, in the tiny but crucial mammillary bodies, the rest of the brain being perfectly preserved. And so there was no long-term follow-up of Luria's cases.

I had at first been deeply puzzled, and dubious, even suspicious, about the apparently sharp cut-off in 1945, a point, a date, which was also symbolically so sharp. I wrote in a subsequent note: There is a great blank. We do not know what happened then- or subsequently . . . We must fill in these 'missing' years- from his brother, or the navy, or hospitals he has been to . . . Could it be that he sustained some ma.s.sive trauma at this time, some ma.s.sive cerebral or emotional trauma in combat, in the war, and that this may have affected him ever since? . . . was the war his 'high point', the last time he was really alive, and existence since one long anti-climax?*

We did various tests on him (EEG, brain scans), and found no evidence of ma.s.sive brain damage, although atrophy of the tiny mammillary bodies would not show up on such tests. We received reports from the navy indicating that he had remained in the navy until 1965, and that he was perfectly competent at that time.

Then we turned up a short nasty report from Bellevue Hospital, dated 1971, saying that he was 'totally disoriented . . . with an advanced organic brain-syndrome, due to alcohol' (cirrhosis had also developed by this time). From Bellevue he was sent to a wretched dump in the Village, a so-called 'nursing home' whence he was rescued-lousy, starving-by our Home in 1975.

We located his brother, whom Jimmie always spoke of as being in accountancy school and engaged to a girl from Oregon. In fact *In his fascinating oral history The Good War (1985) Studs Terkel transcribes countless stories of men and women, especially fighting men, who felt World War II was intensely real-by far the most real and significant time of their lives-everything since as pallid in comparison. Such men tend to dwell on the war and to relive its battles, comradeship, moral certainties and intensity. But this dwelling on the past and relative hebetude towards the present-this emotional dulling of current feeling and memory-is nothing like Jimmie's organic amnesia. 1 recently had occasion to discuss the question with Terkel: 'I've met thousands of men,' he told me, 'who feel they've just been "marking time" since '45-but I never met anyone for whom time terminated, like your amnesiac Jimmie.'

he had married the girl from Oregon, had become a father and grandfather, and been a practising accountant for thirty years.

Where we had hoped for an abundance of information and feeling from his brother, we received a courteous but somewhat meagre letter. It was obvious from reading this-especially reading between the lines-that the brothers had scarcely seen each other since 1943, and gone separate ways, partly through the vicissitudes of location and profession, and partly through deep (though not estranging) differences of temperament. Jimmie, it seemed, had never 'settled down', was 'happy-go-lucky', and 'always a drinker'. The navy, his brother felt, provided a structure, a life, and the real problems started when he left it, in 1965. Without his habitual structure and anchor Jimmie had ceased to work, 'gone to pieces,' and started to drink heavily. There had been some memory impairment, of the Korsakov type, in the middle and especially the late Sixties, but not so severe that Jimmie couldn't 'cope' in his nonchalant fashion. But his drinking grew heavier in 1970.

Around Christmas of that year, his brother understood, he had suddenly 'blown his top' and become deliriously excited and confused, and it was at this point he had been taken into Bellevue. During the next month, the excitement and delirium died down, but he was left with deep and bizarre memory lapses, or 'deficits,' to use the medical jargon. His brother had visited him at this time-they had not met for twenty years-and, to his horror, Jimmie not only failed to recognise him, but said, 'Stop joking! You're old enough to be my father. My brother's a young man, just going through accountancy school.'

When I received this information, I was more perplexed still: why did Jimmie not remember his later years in the navy, why did he not recall and organise his memories until 1970? I had not heard then that such patients might have a retrograde amnesia (see Postscript). 'I wonder, increasingly,' I wrote at this time, 'whether there is not an element of hysterical or fugal amnesia-whether he is not in flight from something too awful to recall', and I suggested he be seen by our psychiatrist. Her report was searching and detailed-the examination had included a sodium amytal test, calculated to 'release' any memories which might be repressed.

She also attempted to hypnotize Jimmie, in the hope of eliciting memories repressed by hysteria-this tends to work well in cases of hysterical amnesia. But it failed because Jimmie could not be hypnotized, not because of any 'resistance,' but because of his extreme amnesia, which caused him to lose track of what the hypnotist was saying. (Dr M. h.o.m.onoff, who worked on the amnesia ward at the Boston Veterans Administration hospital, tells me of similar experiences-and of his feeling that this is absolutely characteristic of patients with Korsakov's, as opposed to patients with hysterical amnesia.) 'I have no feeling or evidence,' the psychiatrist wrote, 'of any hysterical or "put-on" deficit. He lacks both the means and the motive to make a facade. His memory deficits are organic and permanent and incorrigible, though it is puzzling they should go back so long.' Since, she felt, he was 'unconcerned . . . manifested no special anxiety . . . const.i.tuted no management problem,' there was nothing she could offer, or any therapeutic 'entrance' or 'lever' she could see.

At this point, persuaded that this was, indeed, 'pure' Korsakov's, uncomplicated by other factors, emotional or organic, I wrote to Luria and asked his opinion. He spoke in his reply of his patient Bel,* whose amnesia had retroactively eradicated ten years. He said he saw no reason why such a retrograde amnesia should not thrust backward decades, or almost a whole lifetime. 'I can only wait for the final amnesia,' Buriuel writes, 'the one that can erase an entire life.' But Jimmies amnesia, for whatever reason, had erased memory and time back to 1945-roughly-and then stopped. Occasionally, he would recall something much later, but the recall was fragmentary and dislocated in time. Once, seeing the word 'satellite' in a newspaper headline, he said offhandedly that he'd been involved in a project of satellite tracking while on the ship Chesapeake Bay, a memory fragment coming from the early or mid-Sixties. But, for all practical purposes, his cut-off point was during the mid- (or late) Forties, and anything subsequently re- *See A.R. Luria, The Neuropsychology of Memory (1976), pp. 250-2.

trieved was fragmentary, unconnected. I his was the case in 1975, and it is still the case now, nine years later.

What could we do? What should we do? There are no prescriptions,' Luria wrote, 'in a case like this. Do whatever your ingenuity and your heart suggest. There is little or no hope of any recovery in his memory. But a man does not consist of memory alone. He has feeling, will, sensibilities, moral being-matters of which neuropsychology cannot speak. And it is here, beyond the realm of an impersonal psychology, that you may find ways to touch him, and change him. And the circ.u.mstances of your work especially allow this, for you work in a Home, which is like a little world, quite different from the clinics and inst.i.tutions where I work. Neuropsychological!}', there is little or nothing you can do; but in the realm of the Individual, there may be much you can do.'

Luria mentioned his patient Kur as manifesting a rare self-awareness, in which hopelessness was mixed with an odd equanimity. 'I have no memory of the present,' Kur would say. 'I do not know what I have just done or from where I have just come ... I can recall my past very well, but I have no memory of my present.' When asked whether he had ever seen the person testing him, he said, 'I cannot say yes or no, I can neither affirm nor deny that I have seen you.' This was sometimes the case with Jimmie; and, like Kur, who stayed many months in the same hospital, Jimmie began to form 'a sense of familiarity'; he slowly learned his way around the home-the whereabouts of the dining room, his own room, the elevators, the stairs, and in some sense recognised some of the staff, although he confused them, and perhaps had to do so, with people from the past. He soon became fond of the nursing sister in the Home; he recognised her voice, her footfalls, immediately, but would always say that she had been a fellow pupil at his high school, and was greatly surprised when I addressed her as 'Sister'.

'Gee!' he exclaimed, 'the d.a.m.nedest things happen. I'd never have guessed you'd become a religious, Sister!'

Since he's been at our Home-that is, since early 1975-Jimmie has never been able to identify anyone in it consistently. The only person he truly recognises is his brother, whenever he visits from Oregon. These meetings are deeply emotional and moving to observe-the only truly emotional meetings Jimmie has. He loves his brother, he recognises him, but he cannot understand why he looks so old: 'Guess some people age fast,' he says. Actually his brother looks much younger than his age, and has the sort of face and build that change little with the years. These are true meetings, Jimmie's only connection of past and present, yet they do nothing to provide any sense of history or continuity. If anything they emphasise-at least to his brother, and to others who see them together-that Jimmie still lives, is fossilised, in the past.

All of us, at first, had high hopes of helping Jimmie-he was so personable, so likable, so quick and intelligent, it was difficult to believe that he might be beyond help. But none of us had ever encountered, even imagined, such a power of amnesia, the possibility of a pit into which everything, every experience, every event, would fathomlessly drop, a bottomless memory-hole that would engulf the whole world.

I suggested, when I first saw him, that he should keep a diary, and be encouraged to keep notes every day of his experiences, his feelings, thoughts, memories, reflections. These attempts were foiled, at first, by his continually losing the diary: it had to be attached to him-somehow. But this too failed to work: he dutifully kept a brief daily notebook but could not recognise his earlier entries in it. He does recognise his own writing, and style, and is always astounded to find that he wrote something the day before.

Astounded-and indifferent-for he was a man who, in effect, had no 'day before'. His entries remained unconnected and un-connecting and had no power to provide any sense of time or continuity. Moreover, they were trivial-'Eggs for breakfast', 'Watched ballgame on TV-and never touched the depths. But were there depths in this unmemoried man, depths of an abiding feeling and thinking, or had he been reduced to a sort of Humean drivel, a mere succession of unrelated impressions and events?

Jimmie both was and wasn't aware of this deep, tragic loss in himself, loss of himself. (If a man has lost a leg or an eye, he knows he has lost a leg or an eye; but if he has lost a self- himself-he cannot know it, because he is no longer there to know it.) Therefore I could not question him intellectually about such matters.

He had originally professed bewilderment at finding himself amid patients, when, as he said, he himself didn't feel ill. But what, we wondered, did he feel? He was strongly built and fit, he had a sort of animal strength and energy, but also a strange inertia, pa.s.sivity, and (as everyone remarked) 'unconcern'; he gave all of us an overwhelming sense of'something missing,' although this, if he realised it, was itself accepted with an odd 'unconcern.' One day I asked him not about his memory, or past, but about the simplest and most elemental feelings of all: 'How do you feel?'

'How do I feel,' he repeated, and scratched his head. 'I cannot say I feel ill. But I cannot say I feel well. I cannot say I feel anything at all.'

'Are you miserable?' I continued.

'Can't say I am.'

'Do you enjoy life?'

'I can't say I do ... '

I hesitated, fearing that I was going too far, that I might be stripping a man down to some hidden, unacknowledgeable, unbearable despair.

'You don't enjoy life,' I repeated, hesitating somewhat. 'How then do you feel about life?'

'I can't say that I feel anything at all.'

'You feel alive though?'

'Feel alive? Not really. I haven't felt alive for a very long time.'

His face wore a look of infinite sadness and resignation.

Later, having noted his apt.i.tude for, and pleasure in, quick games and puzzles, and their power to 'hold' him, at least while they lasted, and to allow, for a while, a sense of companionship and compet.i.tion-he had not complained of loneliness, but he looked so alone; he never expressed sadness, but he looked so sad- I suggested he be brought into our recreation programs at the Home. This worked better-better than the diary. He would become keenly and briefly involved in games, but soon they ceased to offer any challenge: he solved all the puzzles, and could solve them easily; and he was far better and sharper than anyone else at games. And as he found this out, he grew fretful and restless again, and wandered the corridors, uneasy and bored and with a sense of indignity-games and puzzles were for children, a diversion. Clearly, pa.s.sionately, he wanted something to do: he wanted to do, to be, to feel-and could not; he wanted sense, he wanted purpose-in Freud's words, 'Work and Love'.

Could he do 'ordinary' work? He had 'gone to pieces', his brother said, when he ceased to work in 1965. He had two striking skills- Morse code and touch-typing. We could not use Morse, unless we invented a use; but good typing we could use, if he could recover his old skills-and this would be real work, not just a game. Jimmie soon did recover his old skill and came to type very quickly-he could not do it slowly-and found in this some of the challenge and satisfaction of a job. But still this was superficial tapping and typing; it was trivial, it did not reach to the depths. And what he typed, he typed mechanically-he could not hold the thought-the short sentences following one another in a meaningless order.

One tended to speak of him, instinctively, as a spiritual casualty-a 'lost soul': was it possible that he had really been 'de-souled' by a disease? 'Do you think he has a soul?' I once asked the Sisters. They were outraged by my question, but could see why I asked it. 'Watch Jimmie in chapel,' they said, 'and judge for yourself I did, and I was moved, profoundly moved and impressed, because I saw here an intensity and steadiness of attention and concentration that I had never seen before in him or conceived him capable of. I watched him kneel and take the Sacrament on his tongue, and could not doubt the fullness and totality of Communion, the perfect alignment of his spirit with the spirit of the Ma.s.s. Fully, intensely, quietly, in the quietude of absolute concentration and attention, he entered and partook of the Holy Communion. He was wholly held, absorbed, by a feeling. There was no forgetting, no Korsakov's then, nor did it seem possible or imaginable that there should be; for he was no longer at the mercy of a faulty and fallible mechanism-that of meaningless sequences and memory traces-but was absorbed in an act, an act of his whole being, which carried feeling and meaning in an organic continuity and unity, a continuity and unity so seamless it could not permit any break.

Clearly Jimmie found himself, found continuity and reality, in the absoluteness of spiritual attention and act. The Sisters were right-he did find his soul here. And so was Luria, whose words now came back to me: 'A man does not consist of memory alone. He has feeling, will, sensibility, moral being ... It is here . . . you may touch him, and see a profound change.' Memory, mental activity, mind alone, could not hold him; but moral attention and action could hold him completely.

But perhaps 'moral' was too narrow a word-for the aesthetic and dramatic were equally involved. Seeing Jim in the chapel opened my eyes to other realms where the soul is called on, and held, and stilled, in attention and communion. The same depth of absorption and attention was to be seen in relation to music and art: he had no difficulty, I noticed, 'following' music or simple dramas, for every moment in music and art refers to, contains, other moments. He liked gardening, and had taken over some of the work in our garden. At first he greeted the garden each day as new, but for some reason this had become more familiar to him than the inside of the Home. He almost never got lost or disoriented in the garden now; he patterned it, I think, on loved and remembered gardens from his youth in Connecticut.

Jimmie, who was so lost in extensional 'spatial' time, was perfectly organised in Bergsonian 'intentional' time; what was fugitive, unsustainable, as formal structure, was perfectly stable, perfectly held, as art or will. Moreover, there was something that endured and survived. If Jimmie was briefly 'held' by a task or puzzle or game or calculation, held in the purely mental challenge of these, he would fall apart as soon as they were done, into the abyss of his nothingness, his amnesia. But if he was held in emotional and spiritual attention-in the contemplation of nature or art, in listening to music, in taking part in the Ma.s.s in chapel-the attention, its 'mood', its quietude, would persist for a while, and there would be in him a pensiveness and peace we rarely, if ever, saw during the rest of his life at the Home.

I have known Jimmie now for nine years-and neuropsychologically, he has not changed in the least. He still has the severest, most devastating Korsakov's, cannot remember isolated items for more than a few seconds, and has a dense amnesia going back to 1945. But humanly, spiritually, he is at times a different man altogether-no longer fluttering, restless, bored, and lost, but deeply attentive to the beauty and soul of the world, rich in all the Kier-kegaardian categories-and aesthetic, the moral, the religious, the dramatic. I had wondered, when I first met him, if he was not condemned to a sort of 'Humean' froth, a meaningless fluttering on the surface of life, and whether there was any way of transcending the incoherence of his Humean disease. Empirical science told me there was not-but empirical science, empiricism, takes no account of the soul, no account of what const.i.tutes and determines personal being. Perhaps there is a philosophical as well as a clinical lesson here: that in Korsakov's, or dementia, or other such catastrophes, however great the organic damage and Humean dissolution, there remains the undiminished possibility of reintegration by art, by communion, by touching the human spirit: and this can be preserved in what seems at first a hopeless state of neurological devastation.

Postscript I know now that retrograde amnesia, to some degree, is very common, if not universal, in cases of Korsakov's. The cla.s.sical Korsakov's syndrome-a profound and permanent, but 'pure', devastation of memory caused by alcoholic destruction of the mammillary bodies- is rare, even among very heavy drinkers. One may, of course, see Korsakov's syndrome with other pathologies, as in Luria's patients with tumours. A particularly fascinating case of an acute (and mercifully transient) Korsakov's syndrome has been well described only very recently in the so-called Transient Global Amnesia (TGA) which may occur with migraines, head injuries or impaired blood supply to the brain. Here, for a few minutes or hours, a severe and singular amnesia may occur, even though the patient may continue to drive a car, or, perhaps, to carry on medical or editorial duties, in a mechanical way. But under this fluency lies a profound amnesia- every sentence uttered being forgotten as soon as it is said, everything forgotten within a few minutes of being seen, though long-established memories and routines may be perfectly preserved. (Some remarkable videotapes of patients during TGAs have recently [1986] been made by Dr John Hodges, of Oxford.) Further, there may be a profound retrograde amnesia in such cases. My colleague Dr. Leon Prota.s.s tells me of a case seen by him recently, in which a highly intelligent man was unable for some hours to remember his wife or children, to remember that he had a wife or children. In effect, he lost thirty years of his life- though, fortunately, for only a few hours. Recovery from such attacks is prompt and complete-yet they are, in a sense, the most horrifying of 'little strokes' in their power absolutely to annul or obliterate decades of richly lived, richly achieving, richly memo-ried life. The horror, typically, is only felt by others-the patient, unaware, amnesiac for his amnesia, may continue what he is doing, quite unconcerned, and only discover later that he lost not only a day (as is common with ordinary alcoholic 'blackouts'), but half a lifetime, and never knew it. The fact that one can lose the greater part of a lifetime has peculiar, uncanny horror.

In adulthood, life, higher life, may be brought to a premature end by strokes, senility, brain injuries, etc., but there usually remains the consciousness of life lived, of one's past. This is usually felt as a sort of compensation: 'At least I lived fully, tasting life to the full, before I was brain-injured, stricken, etc.' This sense of 'the life lived before', which may be either a consolation or a torment, is precisely what is taken away in retrograde amnesia. The 'final amnesia, the one that can erase an entire life' that Bunuel speaks of may occur, perhaps, in a terminal dementia, but not, in my experience, suddenly, in consequence of a stroke. But there is a different, yet comparable, sort of amnesia, which can occur suddenly-different in that it is not 'global' but 'modality-specific'.

Thus, in one patient under my care, a sudden thrombosis in the posterior circulation of the brain caused the immediate death of the visual parts of the brain. Forthwith this patient became completely blind-but did not know it. He looked blind-but he made no complaints. Questioning and testing showed, beyond doubt, that not only was he centrally or 'cortically' blind, but he had lost all visual images and memories, lost them totally-yet had no sense of any loss. Indeed, he had lost the very idea of seeing-and was not only unable to describe anything visually, but bewildered when I used words such as 'seeing' and 'light.' He had become, in essence, a non-visual being. His entire lifetime of seeing, of visuality, had, in effect, been stolen. His whole visual life had, indeed, been erased-and erased permanently in the instant of his stroke. Such a visual amnesia, and (so to speak) blindness to the blindness, amnesia for the amnesia, is in effect a 'total' Korsakov's, confined to visuality.

A still more limited, but none the less total, amnesia may be displayed with regard to particular forms of perception, as in the last chapter, 'The Man Who Mistook His Wife for a Hat'. There there was an absolute 'prosopagnosia', or agnosia for faces. This patient was not only unable to recognise faces, but unable to imagine or remember any faces-he had indeed lost the very idea of a 'face', as my more afflicted patient had lost the very ideas of'seeing' or 'light.' Such syndromes were described by Anton in the 1890s. But the implication of these syndromes-Korsakov's and Anton's-what they entail and must entail for the world, the lives, the ident.i.ties of affected patients, has been scarcely touched on even to this day.

In Jimmie's case, we had sometimes wondered how he might respond if taken back to his home town-in effect, to his pre-amnesia days- but the little town in Connecticut had become a booming city with the years. Later I did have occasion to find out what might happen in such circ.u.mstances, though this was with another patient with Korsakov's, Stephen R., who had become acutely ill in 1980 and whose retrograde amnesia went back only two years or so. With this patient, who also had severe seizures, spasticity and other problems necessitating in-patient care, rare weekend visits to his home revealed a poignant situation. In hospital he could recognise n.o.body and nothing, and was in an almost ceaseless frenzy of disorientation. But when his wife took him home, to his house which was in effect a 'time-capsule' of his pre-amnesia days, he felt instantly at home. He recognised everything, tapped the barometer, checked the thermostat, took his favourite armchair, as he used to do. He spoke of neighbours, shops, the local pub, a nearby cinema, as they had been in the mid-Seventies. He was distressed and puzzled if the smallest changes were made in the house. ('You changed the curtains today!' he once expostulated to his wife. 'How come? So suddenly? They were green this morning.' But they had not been green since 1978.) He recognised most of the neighbouring houses and shops-they had changed little between 1978 and 1983-but was bewildered by the 'replacement' of the cinema ('How could they tear it down and put up a supermarket overnight?'). He recognised friends and neighbours-but found them oddly older than he expected ('Old so-and-so! He's really showing his age. Never noticed it before. How come everyone's showing their age today?'). But the real poignancy, the horror, would occur when his wife brought him back-brought him, in a fantastic and unaccountable manner (so he felt), to a strange home he had never seen, full of strangers, and then left him. 'What are you doing?' he would scream, terrified and confused. 'What in the h.e.l.l is this place? What the h.e.l.l's going on?' These scenes were almost unbearable to watch, and must have seemed like madness, or nightmare, to the patient. Mercifully perhaps he would forget them within a couple of minutes.

Such patients, fossilised in the past, can only be at home, oriented, in the past. Time, for them, has come to a stop. I hear Stephen R. screaming with terror and confusion when he returns-screaming for a past which no longer exists. But what can we do? Can we create a time-capsule, a fiction? Never have I known a patient so confronted, so tormented, by anachronism, unless it was the 'Rose R.' of Awakenings (see 'Incontinent Nostalgia', Chapter Sixteen).

Jimmie has reached a sort of calm; William (Chapter Twelve) continually confabulates; but Stephen has a gaping time-wound, an agony that will never heal.

3.

The Disembodied Lady The aspects of things that are most important for us are hidden because of their simplicity and familiarity. (One is unable to notice something because it is always before one's eyes.) The real foundations of his enquiry do not strike a man at all.

Wittgenstein What Wittgenstein writes here, of epistemology, might apply to aspects of one's physiology and psychology-especially in regard to what Sherrington once called 'our secret sense, our sixth sense'- that continuous but unconscious sensory flow from the movable parts of our body (muscles, tendons, joints), by which their position and tone and motion are continually monitored and adjusted, but in a way which is hidden from us because it is automatic and unconscious.

Our other senses-the five senses-are open and obvious; but this-our hidden sense-had to be discovered, as it was, by Sherrington, in the 1890s. He named it 'proprioception', to distinguish it from 'exteroception' and 'interoception', and, additionally, because of its indispensability for our sense of ourselves; for it is only by courtesy of proprioception, so to speak, that we feel our bodies as proper to us, as our 'property', as our own. (Sherrington 1906, 1940.) What is more important for us, at an elemental level, than the control, the owning and operation, of our own physical selves? And yet it is so automatic, so familiar, we never give it a thought.

Jonathan Miller produced a beautiful television series, The Body in Question, but the body, normally, is never in question: our bodies are beyond question, or perhaps beneath question-they are simply, unquestionably, there. This unquestionability of the body, its certainty, is, for Wittgenstein, the start and basis of all knowledge and certainty. Thus, in his last book (On Certainty), he opens by saying: 'If you do know that here is one hand, we'll grant you all the rest.' But then, in the same breath, on the same opening page: 'What we can ask is whether it can make sense to doubt it . . . '; and, a little later, 'Can I doubt it? Grounds for doubt are lacking!'

Indeed, his book might be t.i.tled On Doubt, for it is marked by doubting, no less than affirming. Specifically, he wonders-and one in turn may wonder whether these thoughts were perhaps incited by his working with patients, in a hospital, in the war- he wonders whether there might be situations or conditions which take away the certainty of the body, which do give one grounds to doubt's one body, perhaps indeed to lose one's entire body in total doubt. This thought seems to haunt his last book like a nightmare.

Christina was a strapping young woman of twenty-seven, given to hockey and riding, self-a.s.sured, robust, in body and mind. She had two young children, and worked as a computer programmer at home. She was intelligent and cultivated, fond of the ballet, and of the Lakeland poets (but not, I would think, of Wittgenstein). She had an active, full life-had scarcely known a day's illness. Somewhat to her surprise, after an attack of abdominal pain, she was found to have gallstones, and removal of the gallbladder was advised.

She was admitted to hospital three days before the operation date, and placed on an antibiotic for microbial prophylaxis. This was purely routine, a precaution, no complications of any sort being expected at all. Christina understood this, and being a sensible soul had no great anxieties.

The day before surgery Christina, not usually given to fancies or dreams, had a disturbing dream of peculiar intensity. She was swaying wildly, in her dream, very unsteady on her feet, could hardly feel the ground beneath her, could hardly feel anything in her hands, found them flailing to and fro, kept dropping whatever she picked up.

She was distressed by this dream. ('I never had one like it,' she said. 'I can't get it out of my mind.')-so distressed that we requested an opinion from the psychiatrist. 'Pre-operative anxiety,' he said. 'Quite natural, we see it all the time.'

But later that day the dream came true. Christina did find herself very unsteady on her feet, with awkward flailing movements, and dropping things from her hands.

The psychiatrist was again called-he seemed vexed at the call, hut also, momentarily, uncertain and bewildered. 'Anxiety hysteria,' he now snapped, in a dismissive tone. 'Typical conversion symptoms-you see them all the while.'

But the day of surgery Christina was still worse. Standing was impossible-unless she looked down at her feet. She could hold nothing in her hands, and they 'wandered'-unless she kept an eye on them. When she reached out for something, or tried to feed herself, her hands would miss, or overshoot wildly, as if some essential control or coordination was gone.

She could scarcely even sit up-her body 'gave way'. Her face was oddly expressionless and slack, her jaw fell open, even her vocal posture was gone.

'Something awful's happened,' she mouthed, in a ghostly flat voice. 'I can't feel my body. I feel weird-disembodied.'

This was an amazing thing to hear, confounded, confounding. 'Disembodied'-was she crazy? But what of her physical state then? The collapse of tone and muscle posture, from top to toe; the wandering of her hands, which she seemed unaware of; the flailing and overshooting, as if she were receiving no information from the periphery, as if the control loops for tone and movement had catastrophically broken down.

'It's a strange statement,' I said to the residents. 'It's almost impossible to imagine what might provoke such a statement.'

'But it's hysteria, Dr Sacks-didn't the psychiatrist say so?'

'Yes, he did. But have you ever seen a hysteria like this? Think phenomenologically-take what you see as genuine phenomenon, in which her state-of-body and state-of-mind are not fictions, but a psychophysical whole. Could anything give such a picture of undermined body and mind?

'I'm not testing you,' I added. 'I'm as bewildered as you are. I've never seen or imagined anything quite like this before . . . '

I thought, and they thought, we thought together.

'Could it be a biparietal syndrome?' one of them asked.

'It's an "as if',' I answered: 'as if the parietal lobes were not getting their usual sensory information. Let's do some sensory testing-and test parietal lobe function, too.

We did so, and a picture began to emerge. There seemed to be a very profound, almost total, proprioceptive deficit, going from the tips of her toes to her head-the parietal lobes were working, but had nothing to work with. Christina might have hysteria, but she had a great deal more, of a sort which none of us had ever seen or conceived before. We put in an emergency call now, not to the psychiatrist, but to the physical medicine specialist, the physiatrist.

He arrived promptly, responding to the urgency of the call. He opened his eyes very wide when he saw Christina, examined her swiftly and comprehensively, and then proceeded to electrical tests of nerve and muscle function. 'This is quite extraordinary,' he said. 'I have never seen or read about anything like this before. She has lost all proprioception-you're right-from top to toe. She has no muscle or tendon or joint sense whatever. There is slight loss of other sensory modalities-to light touch, temperature, and pain, and slight involvement of the motor fibres, too. But it is predominantly position-sense-proprioception-which has sustained such damage.'

'What's the cause?' we asked.

'You're the neurologists. You find out.'

By afternoon, Christina was still worse. She lay motionless and toneless; even her breathing was shallow. Her situation was grave- we thought of a respirator-as well as strange.

The picture revealed by spinal tap was one of an acute polyneuritis, but a polyneuritis of a most exceptional type: not like Guillain-Barre syndrome, with its overwhelming motor involvement, but a purely (or almost purely) sensory neuritis, affecting the sensory roots of spinal and cranial nerves throughout the neu-raxis. *

Operation was deferred; it would have been madness at this time. Much more pressing were the questions: 'Will she survive? What can we do?'

'What's the verdict?' Christina asked, with a faint voice and fainter smile, after we had checked her spinal fluid.

'You've got this inflammation, this neuritis . . . ' we began, and told her all we knew. When we forgot something, or hedged, her clear questions brought us back.

'Will it get better?' she demanded. We looked at each other, and at her: 'We have no idea.'

The sense of the body, I told her, is given by three things: vision, balance organs (the vestibular system), and proprioception-which she'd lost. Normally all of these worked together. If one failed, (he others could compensate, or subst.i.tute-to a degree. In particular, I told of my patient Mr MacGregor, who, unable to employ his balance organs, used his eyes instead (see below, Chapter Seven). And of patients with neurosyphilis, tabes dorsalis, who had similar symptoms, but confined to the legs-and how they too had to compensate by use of their eyes (see 'Positional Phantoms' in Chapter Six). And how, if one asked such a patient to move his legs, he was apt to say: 'Sure, Doc, as soon as I find them.'