Nevertheless, Luria argued, one might well expect these negative phenomena—alienation, derealization, indifference, inattention—on a peripheral basis, because “the organism is a unitary system” and, as such, might show a system breakdown whether the original disturbance was central or peripheral. But doctors—surgeons, neurologists—might not be “hospitable” to such complaints from their patients, and it might be hard for such patients to convey their feelings: the patient might not speak, the doctor might not hear. It might therefore require an unusual patient—perhaps a patient who was a physician, and a neuropsychologist, himself—to bring out the full character of the experiential disturbance.
Luria’s letter provided crucial encouragement and support, as did the many other letters he later wrote to me, and strengthened the resolve I had made in hospital to launch an investigation into the whole question. While I was in hospital I was a patient, perplexed and afraid, struggling to come to terms with a personal predicament. Now I could become a physician and investigator. I was neurologist to many hospitals and had under my care many hundreds of neurological patients with the most varied disorders and diseases. I would make the most careful investigations of these patients—clinical investigations based on dialogue and physical examination, and physiological investigations based on an arsenal of electro-physiological techniques: studies of the electrical potentials in damaged (or otherwise inactivated) nerves and muscles, and of so-called “evoked potentials” in the spinal cord and brain, in particular of the somatosensory cortex, the “end-station” in the brain, where neural activity was organized to form the objective “body-image.”
Had it not been for my own injury and experience, I would not, I think, have launched on an investigation of this type. My previous interests had lain in quite other directions—in migraine, in Parkinsonism, in post-encephalitic syndromes, in Tourette’s syndrome. I might not have become interested in body-image disturbances had I not myself experienced such a disturbance in the most profound form. But having experienced it—and having been totally misunderstood myself—I was passionately concerned to get at the truth of the matter—to establish by clinical and physiological studies what actually occurs, and to reach, if I could, a fundamental understanding of it. Was it not, as Luria had said, “an entirely new field”?
And if my own experience served as an incentive it would also serve as a very special qualification for the task. For unlike my own doctor, and the “veterinary” profession in general (as Luria had called it), I could now open myself fully to the experiences of my patients, enter imaginatively into their experiences and be accessible and “hospitable” in these regions of dread. I would listen to my patients as never before—to their stammered half-articulate communications as they journeyed through a region I knew so well myself.
I did not know at the time whether I had any predecessors in this area—and it was only years later that I discovered them. I described this odd situation in an article published in the London Review of Books:
I did not become aware of any accounts similar to mine until more than three years after my accident. Then, in rapid succession, I found three such accounts: Weir Mitchell’s, based on his experiences in the American Civil War; Babinski’s—an entire book—written during the First World War; and Leont’ev and Zaporozhets’, based on their experiences with 200 soldiers in the Second World War….Although all these authors were of the utmost eminence and their publications of the utmost importance, I have never met anyone who has heard of these works, let alone read them—and this strange forgetting extends to the authors themselves. Weir Mitchell “forgot” his “negative phantom,” Babinski “forgot” his “syndrome physiopathique,”* and Luria “forgot” the work of Leont’ev—even though it was inspired by, and actually dedicated to, him.
Weir Mitchell’s is a particularly interesting case. As a young neurologist working with amputees in the Civil War, he published a “clinical fiction,” entitled The Case of George Dedlow. This was an imaginary, and wonderfully imaginative, case-history of a physician who had suffered amputation of all his limbs. His fictitious physician-patient, George Dedlow, writes:
I found to my horror that at times I was less conscious of myself, of my own existence, than used to be the case. The sensation was so novel that it quite bewildered me….Well aware of how absurd I might seem, I refrained from speaking of my case, and strove more keenly to analyze my feelings….It was, as well as I can describe it, a deficiency in the egoistic sentiment of individuality.
Dedlow goes on to ascribe these feelings, profound and specific defects of what we now call body-image and body-ego, to the “eternal silence…of the great ganglia subserving the limbs.” It is interesting that Weir Mitchell published this as a “clinical fiction” before venturing on his famous medical delineations of phantoms. Perhaps he felt that the public, imaginative readers, might consider matters that would be rejected as fanciful by his colleagues.
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Over the years I studied some four hundred patients, complementing the clinical dialogue and examination, where possible, by videotaping the patients, and by electrophysiological studies. One patient, typical of many, was an old lady with a flaccid and paralyzed left leg. At first glance I thought she had had a stroke; but, as it turned out, she had had a complex hip fracture, which had required not only surgery but long immobilization in a cast. She had not regained any use or feeling of the leg, though it was three years since the operation. There was no anatomical nerve-injury, and there were normal conduction-velocities in the nerves; but the muscles were entirely atonic and showed a complete “electrical silence”—an absence of any functional or postural innervation. She herself felt that the leg was “missing.” Evoked-potential studies of the sensory cortex, in correspondence, were a blank, which indicated an absence of objective neural information from the leg—an objective hiatus in body-image. Though no deliberate movements were possible, there had sometimes been a spontaneous or involuntary movement, the foot tapping in time to music. This suggested the possibility of music therapy—ordinary physiotherapy had been of no use. Using support (a walker, etc.), we were able gradually to get her to dance, and we finally achieved a virtually complete recovery of the leg, even though it had been defunct for three years.
I studied nearly fifty patients with severe peripheral neuropathies—severe sensory (and sometimes motor) impairment in hands and feet, usually on the basis of diabetes. All these patients felt that their hands and feet were missing or alien objects stuck on to arm and leg stumps. Here again evoked-potential studies showed severe impairment or absence of perceptual information and representation in the corresponding areas of the sensory cortex, and objectively demonstrable loss of hand and foot image.
Two hundred patients had spinal cord injuries, disease or anesthesia. Many of these patients, encouraged to speak freely—which is often not done, in ordinary neurological practice—volunteered bizarre descriptions of their states. Some with broken necks—like a patient described by Henry Head (Studies in Neurology, p. 529)—felt that they consisted of “a head and shoulders only.” Such catastrophic losses of body-image were easily confirmed by evoked-potential studies.
I examined scores of patients with amputations of one or more limbs, who presented with positive phantoms, negative phantoms, or both. Here again the disorders or defects of body-image, some of which were bizarre and terrifying, found objective correlation in disturbances of the receiving and representing cortex.
These many observations and investigations over the years provided a decisive answer to the first of my questions: do severe disturbances of body-image and body-ego occur as a result of peripheral injury, disease or disorder? The answer was a resounding “Yes.” Such disturbances were indeed, as Luria thought, quite common: common, and indeed almost inevitable, perhaps universal, if there were a sufficient disruption of peripheral sensation or action
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Furthermore they suggested an answer to the other half of the question: if such disturbances are indeed common, why are they not more commonly described? Allowing my patients to speak fully and freely, unconfined by any neurological catechism, I received, again and again, descriptions of an emotional and existential intensity never, or rarely, to be found in the neurological literature. Every patient with a severe disturbance of body-image had an equally severe disturbance of body-ego. Every such patient, it became increasingly clear, goes through a profound ontological experience, with dissolutions or annihilations of being, in the affected parts, associated with an elemental derealization and alienation, and an equally elemental anxiety and horror. This is followed, if they are fortunate enough to recover, by an equally elemental sense of “re-realization” and joy. Every such experience is, to use the medieval term, an experimentum suitatis (an experiment with the self)—an elemental alteration of identity or “self-hood,” with a perfectly clear-cut, organic, neurological basis. How equipped was neurology, an empirical discipline, to take account of such radical changes in reality or identity? To what extent could it allow such experiences to come through?
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Classical neurology is based on the concept of function—sensory function, motor function, intellectual function and so on. Its most illustrious exponent in England was Sir Henry Head (1861–1940). Among Head’s many interests was an abiding concern with the nature of sensation, in which he was an audacious pioneer. Some of his earliest observations came from experiments on himself. There he described in great detail the effects of cutting a sensory nerve in his own arm. His culminating concept, from his studies of sensation, was the notion of a schema, or body-image, in the brain, by which the body might “know” and control its own movements. His observations, over some twenty years, were brought together in his great Studies in Neurology (1920). But let us see how Head describes profound sensory disturbance:
The patient was entirely unable to recognise the position into which his lower limbs had been placed passively. Extensive movements could be made to the ankles, knees and hips without his knowledge. If his eyes were closed, the legs could be moved from the extended position in any direction, and the knees flexed to forty degrees, and he still imagined they lay stretched before him on the bed. When he was allowed to open his eyes, his expression of surprise amply testified to the greatness of his error.
This is a beautiful description. For me it recalls precisely what happened when I asked Nurse Sulu to move my own leg. It is absolutely right—but is it enough?
I had a patient myself with exactly the same pathology: the metastasis of a malignancy to involve several sensory spinal nerves, associated also with the collapse of some vertebrae. But her experience was much stranger, and more startling and shocking. “My thigh disappeared!” she said. “Just like that.” The terms which Head uses, which are the terms of classical neurology, are perfectly adequate to describe a profound loss of function, but they cannot describe a “disappearance” like this, for it is not just a loss of function. It may follow a loss of function, but in itself it is much more.
As long as Head confines himself to the testing of function, and to speaking in such terms, something vital, something extraordinary, eludes his descriptions. But let him forget his neurological language for a moment and simply give us the actual words of his patients. At such times (they are few) something infinitely more startling emerges. Thus we read (p. 412) of the patient who complained that his “right leg felt exactly as if it were a cork leg,” or of Lieutenant W. (p. 529) who crashed in a plane and realized he had injured his spine because “he felt he had a head and shoulders only.” We cannot say that Head showed no personal interest in his patients. My father, who was his houseman sixty-five years ago, tells me that he was “full of curiosity and sympathy” and fascinated by the strange experiences his patients would describe to him. But, as a neurologist, he deletes such experiences, and only lets them through very rarely and by accident. They are never given a central emphasis or importance. And this seems to be the case with classical neurology in general—that, in striving to establish a rigorous science of function, it must exclude any observations beyond the realm of function. When it forgets itself, so to speak, it may let such observations through, and be faithful and transparent to the experiences of patients; but as soon as it reasserts its empirical rigor, it becomes opaque.
Paradoxically it was only in its pre-scientific dawn, before it was too enclosed by its own concepts, that neurology was open to the full singularities of experience. Thus, in the American Civil War in the 1860s, Weir Mitchell was receptive to the idea of phantom limbs and to the existential dissolutions so vividly described by “George Dedlow.” Weir Mitchell reports these symptoms in hundreds of patients. But by the turn of the century, such descriptions had become extremely rare. Neurology had no room for anything existential.
While classical neurology retained, as it still retains, all its uses and was indispensable for the study of “lower” functions, it became clear, by degrees, that a new approach, a new science, was needed. This need became a crisis in the Second World War. The new science of neuropsychology, foreshadowed in the thirties, came of age in Soviet Russia, and was especially the creation of the Lurias (R.A. and A.R., father and son) and of Leont’ev, Bernstein and others. Little could be done, or was done, in the First World War for the rehabilitation of patients with neurological injuries. They were given physiotherapy, in the hope that time, and nature, would help. It was the demand for a rational “neurotherapy” in the Second World War that brought neuropsychology into being, and gave birth to concepts which transcended function. Patients who were brain-injured and neurologically injured in other ways were seen to experience peculiar difficulties in action. Neuropsychology aimed to be a science of doing, and its central concept was not function but “functional system” and “performance.”
Classical neurology was essentially static: its model was a model of fixed centers and functions. Neuropsychology, on the other hand, is essentially dynamic: it sees countless systems in continual interaction and interplay. “The organism is a unitary system,” wrote Luria, and this is the credo of neuropsychology. The picture which emerges is one of a magnificent, self-regulating, dynamic machine, and its greatest theorist, Bernstein, was the true founder of cybernetics, fifteen years before Norbert Wiener.
In this great machine, there are “programs,” “engrams,” “inner images,” “schemata”—ways of doing things, procedures, which are analyzable, and, to some extent, manipulable. Where classical neurology, rather helplessly, sees “reduced function,” neuropsychology, more constructively, identifies the affected system, or interaction of systems, and tries to rehabilitate by developing a new system, or system of systems, made possible by the “freedom,” or plasticity, of the nervous system. The theoretical and practical powers, thus introduced, are immense. And yet, incredibly, this is scarcely realized in the West.
A revolutionary book, which I have briefly referred to, is The Rehabilitation of the Hand by Leont’ev and Zaporozhets. I have never met a colleague who has read it, though it was published in an English translation in 1948. It describes a syndrome, analogous to my own, in two hundred soldiers with injured and surgically repaired hands. Despite anatomical and neural integrity, at least in terms of classical neurology, there was in every case profound distress and incapacity. The repaired hands were useless, and felt “alien” to their possessors, like objects or “counterfeit hands” stuck on to the wrists. Leont’ev and Zaporozhets speak here of “internal amputation,” referable to a “dissociation of gnostic systems” normally controlling and affirming the hands, in consequence of their inactivation through injury and surgery. The aim of therapy, therefore, is to effect a reintegration of the “split-off” gnostic systems. How is this done? By using the hands. But this cannot be done directly or deliberately. (If it coul
d, the dissociation would not have developed in the first place.) Commands to move the hands are meaningless, they fail to work. What is required is a sort of trick—for example, getting the subject to engage in some complex activity, in which, inadvertently, the hand is involved. The alienated part, so to speak, is deceived into action, by being made a part of, participating in, some complex activity. The moment this occurs—and typically this is sudden—the sense of unrealness and alienation vanishes, and the hand suddenly feels alive and real, no longer an appendage but a part of the self.
All this is getting very close to what happened with me, what I observe in my patients and what I try to effect. The essential truth contained in such neuropsychological procedures is shown by the fact that they work so well. And yet one must wonder whether the concepts are adequate, and whether the procedures may not work because they transcend the concepts.
As Head occasionally forgets himself and transcribes without comment the experiences of some patients—that their legs feel like cork, or that they consist of a head and shoulders only—so the most vivid portions of Leont’ev and Zaporozhets’ book are also transcriptions of actual experiences—of hands which feel “alien,” “dead,” “unreal,” “stuck-on.” The analyses, the formulations, are far less convincing. There is a peculiar doubleness, disparity, in the book: for the formulations are mechanical, analytic, cybernetic and are couched entirely in terms of “systems,” whereas the described experiences, and actions, of the patients are in terms of an ego, a self. If a hand is “alien,” it is alien to you; if something is done, it is you who are doing it. But the “you,” or the “I” which is everywhere implicit is formally, explicitly, denied or disallowed. Hence the peculiar double-think of the book, the peculiar double-think of neuropsychology in general.
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