“The organism is a unitary system,” but what is a system to a real living self? Neuropsychology speaks of “inner images,” “schemata,” “programs,” etc.; but patients speak of “experiencing,” “feeling,” “willing” and “acting.” Neuropsychology is dynamic, but it is still schematic; whereas living creatures, first and last, have selves—and are free. This is not to deny that systems are involved, but to say that systems are embedded in, and transcended by, selves.
Neuropsychology, like classical neurology, aims to be entirely objective, and its great power, its advances, come from just this. But a living creature, and especially a human being, is first and last active—a subject, not an object. It is precisely the subject, the living “I,” which is being excluded. Neuropsychology is admirable, but it excludes the psyche—it excludes the experiencing, active, living “I.” There is no doubt that Luria himself felt this—intensely—and it is evident throughout his work, but particularly in his later years. He felt compelled, as he once wrote me, to write two sorts of books—“systematic” books (like Higher Cortical Functions in Man), and what he liked to call neurological biographies or novels, centered upon the suffering, acting “I” (The Man with a Shattered World, The Mind of a Mnemonist). His earlier work is entirely objective, but in his last years, without any sacrifice of objectivity or accuracy, he introduced the subject more and more—at the center. And he felt that this was absolutely essential, that one must enter fully into the actual experience of the patient, and go beyond the purely “veterinary” approach.
We have seen that experiences such as I myself had are common, even universal, given a critical degree of perceptual disorder or of “afferent field.” We have seen, moreover, that the objective and empirical character of neurology precludes any consideration of the subject, the “I.” Something must happen, something quite radical, if this contradiction, this impasse, is to be avoided. Moreover the time is ripe for this next step to be made. Classical neurology has established itself—it was established by the 1920s—and will always be of enduring importance. Neuropsychology has established itself—it was established by the 1950s—and will always be of enduring importance. What we need now, and need for the future, is a neurology of self, of identity.
There are countless indications that the time has now come. A crisis has developed in cerebral neurology, especially during the last fifteen years. Luria’s Higher Cortical Functions in Man, originally published in 1960, deals comprehensively with the functional systems of the left hemisphere of the brain, and scarcely at all with the right. The method of higher cortical functions does not work with the right hemisphere. There are a thousand papers on the left hemisphere for every one on the right, and yet disturbances and disorders occur equally in both. But the syndromes of the right hemisphere, like Pötzl’s, are exceedingly strange, and characteristically take the form of alterations of identity. Such alterations are not analyzable as disturbances of function or system—they have to be seen as disturbance of self. More and more there is the awareness of our limitation and need.
This crisis of the 1980s is oddly reminiscent of another crisis which occurred two hundred years ago. Empirical philosophy, on which our empirical science is modelled, reached its apogee with Hume. For Hume, in pressing it to its limit, forced it, and himself, to a profound contradiction.
I venture to affirm…that [we] are nothing but a bundle or collection of different perceptions, succeeding one another with inconceivable rapidity, and in a perpetual flux and movement.
In consequence Hume was driven to conclude that “personal identity” is a fiction. But his conclusion was at odds with all his deepest feelings: he called it a “chimaera,” and it drove him to “philosophical despair.”
This despair, this impasse, was resolved in 1781, when Kant published his Critique of Pure Reason. And my own despair, my own impasse, was resolved when I read the Critique. I had had an experience of “self” I could not deny, but neuropsychology disallowed, had no room for, a self. This crisis drove me to Kant. Here I found what analysis could not give me—the concept of synthetic a priori intuitions which allowed, organized and made sense of, experience: the a priori intuitions of space and time, which could structure experience and support an experiencing ego or self. These formulations afforded me, or so I believe, the basis of what I came to call a “clinical ontology” or “existential neurology”—a neurology of the self, in dissolution and creation.
The key passage for me in the Critique was:
Time is nothing but the inner form of sense, that is, of the intuition of ourselves and of our inner states. It cannot be a determination of outer appearances; it has to do with neither shape nor position, but the relation of…our inner states….Space, as the pure form of all outer intuition, serves only as the a priori condition of outer appearance….Time is the immediate condition of inner appearances (of our souls), and thereby the mediate condition of outer appearances.
Normal experience, in Kantian terms, conjoins outer appearance and inner states, conjoins outer and inner intuitions, conjoins space and time. But what I was especially concerned with, from my own experience and observations, was the possibility of a radically defective experience, which might be lacking in inner states, outer appearances, or both. It was precisely such radical underminings of experience, it seemed to me, which constituted the essence of my own experience, and of the disordered experiences all my patients had described. Such experiences, or elemental breakdowns in experience, were unintelligible until illuminated by Kant’s formulations.
Scotoma, in Kantian terms, was an ultimate neuro-ontological extinction (or “Akantia”). Physically, physiologically, there was an absence of nerve-impulse, image and field; but metaphysically, or ontologically, an absence of reason, and of its constructs, space and time. “Flutter”—such as the delirium of disconnected leg-images I had had, or the cinematic “detemporalised” incoherence of a migraine aura—seemed a sort of intermediate state, either in the making or the unmaking of reality, and, as such, to consist of disconnected outer appearances devoid of any inwardness or articulation in time. Music, by contrast, while having nothing to do with outer appearances, was the very prototype of inwardness, inner being, soul.
And it was here in music—the seamless flow of inner states, of indivisible, interpenetrating, “Bergsonian” inner time—that the mysterious nature of doing was illumined. One might say, paradoxically, that proceeding could not be reduced to “procedures,” or doing to any sequence or series of “operations.” Proceeding or doing was essentially a stream, an articulate stream, an art-stream, which must be likened to melody. Without this living stream, this kinetic melody and utterance, without the being who streamed and uttered himself forth, there could be no doing, no walking, at all. This was the “answer” to solvitur ambulando.
The radical and living nature of acting and doing, of even the simplest, most “animal” motions, found its correspondence and confirmation in what occurred if it was taken away: the radical extinction, the nothingness, the “deadness,” of scotoma. And yet these two—Being and Nothing—seemed singularly, even comically, difficult to grasp, at least in a down-to-earth “medical” dialogue. Hence the strange impasse between the surgeons and myself, when I spoke of the matter: “That’s not our business.” “Then whose business is it?” Whose indeed—and what sort of business was it, this business of action, being, and nothingness? One had to go through from the inside, in one’s own person—the radical collapse of action, the radical collapse of experience, the radical collapse of their categories, elemental space and time—to see what manner of business it was. It was, quite simply, a Kantian business.
The radical extinction, de-creation, which scotoma involved; the radical re-creation of space and time which recovery involved; the radical, transcendental, nature of both—could not be comprehended by anything less than a Kantian formulation. They could not be grasped by c
lassical neurology or neuropsychology, because these were pre-Kantian, empirical sciences. The science one needed, if one was ever to explore the full range of experiences patients might go through, had to be a transcendental, Kantian science.
This was the point I had arrived at, and at which I concluded, my last book, Awakenings, in its 1983 edition. And although the field, the phenomena, were so different, this was, this is, the end I reach here.
Yet all this which seems, in a way, so paradoxical and so difficult to grasp, is the simplest and most obvious thing in the world. It is neither more nor less than discovering, rediscovering, where one actually stands, the actual ground of one’s experience. Kant writes: “…the synthetic a priori has the peculiar character that it makes possible the very experience which is its own ground of proof, and in this experience it must always itself be presupposed.” So, in this sense, coming to Kant, and a Kantian science, had, for me, a quality of nostalgia, recollection, returning to what one had, somehow, always felt and known. Thus, at last, the mind found its repose and home.
And so I have the sense of an immense journey traversed and completed. Standing on Parliament Hill, on the final day of my recovery, I had a feeling, an intimation, of strange vistas. They reached forward to the unimaginable future, and at the same time seemed to reach back to my earliest thoughts and feelings. So my journey has led both forwards and backwards—but this seems to be the nature of thought, that it leads to its own starting point, the timeless home of the mind.
And the end of all our exploring
Will be to arrive where we started
And know the place for the first time.
—T. S. ELIOT
* Babinski spoke here of “a third realm”—neither hysterical, nor “organic” in the classical (neuroanatomical) sense—but due to shock and spreading inhibition of spinal and peripheral mechanisms, a profound post-traumatic physiological disturbance. My own “physiopathy” was apparently in this “third realm.”
Afterword (1993)
In January of 1984—I had just completed the long-incubated manuscript of A Leg to Stand On—I had another fall: this time, rather unromantically, in an icy Bronx gutter, and not, as in ’74, fleeing from a bull in the mountains. This time I ruptured my right quadriceps tendon, as well as sustaining a dislocation of my right shoulder. This time there was no long waiting for death on a mountain, no long journey over land and sea; but prompt emergency surgery within two hours of the accident.
I had asked, back in ’74, for the operation to be done under spinal anesthesia; I asked again now, and this time my wish was granted. As the spinal took effect, I lost all sensation in my legs, in the lower half of the body; I lost all sense that my legs and hips, which I could observe in a mirror over the operating table, were in any sense “mine.” Now, in some fundamental sense, I terminated in the middle, and what lay on the table, reflected in the mirror, these “legs” and “hips,” so-called, were not mine. My lower half, so to speak, had been wholly amputated, was no longer present to my perceptions, to my sense of self. This was not to say that it was felt as missing. Quite the contrary: I had no sense of there being anything “missing,” but a sense of completeness, of seamless completeness, just as I was. It was as if I had never had any legs or hips or buttocks or lower half, as if all this part of me was congenitally absent.
I was fascinated rather than frightened by this experience, for it was identical with the alienation I had experienced years before, with my other leg; and I knew too that things would return to normal when the anesthetic wore off. And yet this anticipation was strangely thin and theoretical, for in this state, one cannot imagine having one’s lower half back, one cannot remember what it is like to be “whole.” And the alienated part of one’s body makes no sense at all. Spinal anesthesia places one in this unimaginable state—a proper state, I could not help thinking, for readers of A Leg to Stand On: let them all have spinals, and under spinal read the book; then they would know exactly what I was talking about!
Most adults, surely, have experienced alienations at various times. Many have slept on an arm, compressing the nerves or their blood supply; and turning, been awakened by the nerveless arm getting flung, by the movement of the trunk, into the face—an arm which, horrifyingly, seems no longer one’s own, no longer anything, merely a disgusting lump of meat.*1 Most adults know what it is like to be injected with local anesthetic at the dentist’s, to feel part of the mouth or tongue disappear, or, conversely, appear swollen and deformed. And, of course, countless women have given birth under spinal anesthesia—the milder epidural form is usually used now, but in former days a full spinal was given, and this could cause the most drastic alterations in body-image, the sense that one terminated around the umbilicus, and that everything below was stony or waxy, unreal, unalive, in no sense part of one’s own living body.
Back in the Casting Room, years before, when my alienated left leg was first removed from its cast, I saw it as “exquisite, lifeless, like a fine wax model from an anatomy museum,” and this was how both of my legs looked now, reflected in the mirror above the operating table. I observed the surgery with a sort of aesthetic pleasure, and a sense of complete disengagement and detachment; it was not my leg that was being operated on, but a sort of duplicate which had nothing to do with me.
With the right leg, there was not the huge contusion and edema there had been with the first injury; there was no sign of any gross injury to the femoral nerve. Surgery was altogether easier and more straightforward, and no more than two hours elapsed between the first and last stitch. Further, I was given a walking cast, and instructed to stand and walk on the leg, the very next day. This was in marked contrast to the fifteen days I had been immobilized after the original surgery, the fifteen-day limbo spent in wheelchair or bed.
The next day I did stand, and clutching a walker, took a few steps, the whole stress of my weight being borne by the cast. Half a dozen feeble steps, that was enough—but enough to show me that the frightful situation of ten years earlier had not recurred. I was terribly weak, but I knew how to walk; the leg felt part of me, there was no hint of alienation. It was easy now, back in bed, to work on the leg, to tense the quadriceps, to build back the muscle; easy, standing on my good leg, to swing the operated one at the hip, swinging it this way and that, keeping all the muscles in good tone. The physiotherapist encouraged me, and delighted in my progress: “You’re one of the good ones,” she said. “You haven’t had any problems.”
“What sort of problems?” I inquired. “What are the ‘bad’ ones?”
“Oh, you’d never believe it,” she replied, “the things that go on….Some of the quads say they can’t feel their leg, that it doesn’t belong to them, that they can’t move it, that they’ve forgotten how to use it. You’d never believe it!” she repeated with great emphasis.
“Oh, yes,” I said, “oh, yes, I believe it,” and then told her the story of my earlier experience.
Back in London, the first time, I found the words “uneventful recovery” written in my chart—when my course had been, in reality, one of almost unimaginable vicissitudes and resolutions, qualitative (and almost existential) changes which could not be anticipated, which had to be gone through, one at a time. None of this happened the second time: nothing was lost, was put out of action; nothing was forgotten, or needed to be relearned.*2 Recovery, this second time, was uneventful—it had none of the phenomena which distinguished the first one. The mystery this time was this: why were there no changes in perception and inner image of my leg? Why was there no erosion, no forgetting, of its identity or “will”? What made the first quad a “bad” one, and this a “good” one?*3
There was another event which intrigued me at this time—a different body-image disturbance, an unexpected one, differently produced, but shedding light on the great plasticity of body-image. I had sustained, along with the quadriceps
rupture, a dislocation of the right shoulder, and this was treated not by casting, but by tight bandaging. But being strongly right-handed, and with an intense need to write (and finding myself able only to write excruciatingly slowly, in a large childish script, with my left hand), I gradually loosened the bandage in my furious attempts to write with the right arm. Observing this, the surgeon determined to immobilize the arm absolutely, and had the shoulder put in a cast. Within a few hours of this being put on, I developed the strangest sense of shoulderless deformity, of having lost my shoulder and a large part of my arm. But oddly, I could not remember my shoulder and upper arm—I felt I had never had them, as though I had been born without them. When I complained of this, the surgeon had the cast removed, and went back to the original bandage, with the strictest injunction to use only my left hand for writing. Within an hour or two, my shoulder “returned.”
It was as if body-image could change, could adapt itself, within hours, depending on the mobility, the use, the experience, of body parts. That it was not some fixed representation in the brain, as one might think from seeing the classical figures of the sensory or motor homunculus, so-called. Might it be possible indeed, given the amputation or inactivation or deafferentation of a limb, for a part of it to be erased, the rest of the body-image expanding to take its place?
These thoughts, and kindred ones, filled my head during my hospital stay, in the days after surgery, pressing urgently for articulation. Forbidden to write with my right hand, I wrote with my left; maddened by the slowness of this, I attempted to dictate. I phoned up my publisher and told him of my accident. “Ah, Oliver,” he said in exasperation, “you’d do anything for a footnote!”*4
But I could not put the experience out of my mind, though I relegated it to a back region where it could simmer away unconsciously. There had been a nagging “why?” for ten years in my mind, a “why” never wholly answered, or resolved, in the book. I was never clear as to what had “happened” in 1974, and none of the explanations I read, or which I was given, satisfied me. I had had some damage to the femoral nerve, but this might, at most, cause some local weakness and numbness, not a total motor and sensory outage, an amnesia, an ideational extinction of the entire leg. The whole business had been terrifying and traumatic, had become a subject of intense concern and rumination; and yet did not resemble a defensive dissociation, a hysteria, either. If it was neither neurological in the classic (anatomic) sense, nor psychiatric in the classic (dynamic) sense; if it was neither one nor the other—then what was it?
A Leg to Stand On Page 19