What could we do? What should we do? “There are no prescriptions in a case like this,” Luria wrote.
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 circumstances of your work especially allow this, for you work in a Home, which is like a little world, quite different from the clinics and institutions where I work. Neuropsychologically, 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 recognized 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 recognized 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 damnedest 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—Jim has never been able to identify anyone in it consistently. The only person he truly recognizes is his brother, whenever he visits from California. These meetings are deeply emotional and moving to observe—the only truly emotional meetings Jim has. He loves his brother, he recognizes 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 then are true meetings, Jim’s only connection of past and present, yet they do nothing to provide any sense of history or continuity. If anything, they emphasize—at least to his brother, and to others who see them together—that Jim still lives, is fossilized, in the past.
All of us, at first, had high hopes of helping Jim—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 recognize his earlier entries in it. He does recognize 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 unconnecting, 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, passivity, and (as everyone remarked) “unconcern”; he gave all of us an overwhelming sense of “something missing,” although this, if he realized 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 aptitude 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 competition—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, passionately, 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. Jim soon did recover his old skills 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 touch 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 pray, I watched him at Mass, 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 t
he Mass. 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, Jim 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 likes gardening, and has taken over some of the work in our garden. At first, he greeted the garden each day as new, but for some reason this has become more familiar to him than the inside of the Home. He almost never gets lost or disoriented in the garden now; he patterns it, I think, on loved and remembered gardens from his youth in Pennsylvania.
Jim, who was so lost in extensional “spatial” time, was perfectly organized 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 Jim 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 were held in emotional and spiritual attention—in the contemplation of nature or art, in listening to music, in taking part in the Mass 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 Jim 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 Kierkegaardian categories—the aesthetic, the moral, the religious, the dramatic. I had wondered, when I first met him, if he were 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 constitutes 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.
Notes
1. My ignorance. I know now that retrograde amnesia, to some degree, is very common, if not universal, in cases of Korsakov’s. The classical 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 tumors. 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 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.
Further, there may be a profound retrograde amnesia in such cases. My colleague Dr. Leon Protass tells me of such a case seen by him recently, in which the patient, 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 memoried life. The horror, typically, is felt only 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.
There could be only one thing worse—and that would be to lose one’s entire lifetime. My friend Dr. Isabelle Rapin, author of Children with Brain Dysfunction: Neurology, Cognition, Language, and Behavior, tells me that very rarely, in consequence of certain brain tumors or degenerative diseases, children may develop a severe Korsakov’s syndrome. If this happens, it has been thought, they risk losing their childhood and even their infancy from a retrograde amnesia which may extend back to birth. Such children may not only become as helpless as newborns but may also become deeply “autistic” as they lose and forget all human relationships, even the most elemental—the memory of mother love.
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 Buñuel 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 nonvisual 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, co
nfined to visuality.
A still more limited, but nonetheless total, amnesia may be displayed with regard to particular forms of perception. Thus, in one patient whose history I have already described (“The Man Who Mistook His Wife for a Hat,” London Review of Books, May 1983), there was an absolute “prosopagnosia,” or agnosia for faces. This patient was not only unable to recognize 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 idea 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 identities, of affected patients, has been scarcely touched on even to this day.
2. See A. R. Luria, The Neuropsychology of Memory (New York: Halsted Press, 1976).
The Learning Curve
ATUL GAWANDE
The patient needed a central line. “Here’s your chance,” S., the chief resident, said. I had never done one before. “Get set up and then page me when you’re ready to start.”
It was my fourth week in surgical training. The pockets of my short white coat bulged with patient printouts, laminated cards with instructions for doing CPR and reading EKGs and using the dictation system, two surgical handbooks, a stethoscope, wound-dressing supplies, meal tickets, a penlight, scissors, and about a dollar in loose change. As I headed up the stairs to the patient’s floor, I rattled.
This will be good, I tried to tell myself: my first real procedure. The patient—fiftyish, stout, taciturn—was recovering from abdominal surgery he’d had about a week earlier. His bowel function hadn’t yet returned, and he was unable to eat. I explained to him that he needed intravenous nutrition and that this required a “special line” that would go into his chest. I said that I would put the line in him while he was in his bed, and that it would involve my numbing a spot on his chest with a local anesthetic, and then threading the line in. I did not say that the line was eight inches long and would go into his vena cava, the main blood vessel to his heart. Nor did I say how tricky the procedure could be. There were “slight risks” involved, I said, such as bleeding and lung collapse; in experienced hands, complications of this sort occur in fewer than one case in a hundred.
Writer, M.D. Page 12