by Oliver Sacks
44. Though the medical literature of frontal lobe syndromes starts with the case of Phineas Gage, there are earlier descriptions of altered mental states not identifiable at the time—which we can now, in retrospect, see as frontal lobe syndromes. One such account is related by Lytton Strachey in “The Life, Illness, and Death of Dr. North.” Dr. North, a master of Trinity College, Cambridge, in the eighteenth century, was a man with severe anxieties and tormenting obsessional traits, who was hated and dreaded by the fellows of the college for his punctiliousness, his moralizing, and his merciless severity. Until one day, in college, he suffered a stroke:
His recovery was not complete; his body was paralyzed on the left side; but it was in his mind that the most remarkable change occurred. His fears had left him. His scrupulosity, his diffidence, his seriousness, even his morality—all had vanished. He lay on his bed, in reckless levity, pouring forth a stream of flippant observations, and naughty stories, and improper jokes. While his friends hardly knew which way to look, he laughed consumedly, his paralyzed features drawn up in a curiously distorted grin—Attacked by epileptic seizures, he declared that the only mitigation of his sufferings lay in the continued consumption of wine. He, who had been so noted for his austerity, now tossed off, with wild exhilaration, glass after glass of the strongest sherry.
Strachey gives us here a precise and beautifully described picture of a frontal lobe stroke altering the personality in a major and, so to speak, “therapeutic” way.
In a March 1979 note about Greg, I reported that “games, songs, verses, converse, etc. hold him together completely—because they have an organic rhythm and stream, a flowing of being, which carries and holds him.” I was strongly reminded here of what I had seen with my amnesiac patient Jimmie, how he seemed held together when he attended Mass, by his relationship to and participation in an act of meaning, an organic unity, which overrode or bypassed the disconnections of his amnesia. 45
45. The nature of the “organic unity”, at once dynamic and semantic, which is central to music, incantation, recitation, and all metrical structures, has been most profoundly analyzed by Victor Zuckerkandl in his remarkable book Sound and Symbol. It is typical of such flowing dynamic-semantic structures that each part leads on to the next, that every part has reference to the rest. Such structures cannot usually be perceived, or remembered, in part—they are perceived and remembered, if at all, as wholes.
And what I had observed with a patient in England, a musicologist with profound amnesia from a temporal lobe encephalitis, unable to remember events or facts for more than a few seconds, but able to remember, and indeed to learn, elaborate musical pieces, to conduct them, to perform them, and even to improvise at the organ. 46
46. This patient is the subject of a remarkable BBC film made by Jonathan Miller, Prisoner of Consciousness (November 1988).
It was similar with Greg as well: he not only had an excellent memory for songs of the sixties, but was able to learn new songs easily, despite his difficulty in retaining any “facts.” It seemed as if wholly different kinds—and mechanisms—of memory might be involved. Greg was also able to pick up limericks and jingles with ease (and had indeed picked up hundreds of these from the radio and television that were always on in the ward). Soon after his admission, I tested him with the following limerick:
Hush-a-bye baby,
Hush quite a lot,
Bad babies get rabies
And have to be shot.
Greg immediately repeated this, without error, laughed at it, asked if I’d made it up, and compared it with “something gruesome, like Edgar Allan Poe.” But two minutes later he could not recall it, until I reminded him of the underlying rhythm. With a few more repetitions, he learned it without cueing and thereafter recited it whenever he met me.
Was this facility for learning jingles and songs a mere procedural or performative one, or could it provide emotional depth or generalizability of a sort that Greg did not normally have access to? There seemed no doubt that some music could move him profoundly, could be a door to depths of feeling and meaning to which he normally had no access, and one felt Greg was a different person at these times. He no longer seemed to have a frontal lobe syndrome, but was (so to speak) temporarily “cured” by the music. Even his EEG, so slow and incoherent most of the time, became calm and rhythmical with music. 47
47. Another patient in Williamsbridge, Harry S.—a gifted man, a former engineer—suffered a huge cerebral hemorrhage from a burst aneurysm, with gross destruction of both frontal lobes. Emerging from a coma, he started to recover and eventually recovered most of his former intellectual powers, but remains, like Greg, severely impaired—bland, flat, indifferent emotionally. But all this changes, suddenly, when he sings. He has a fine tenor voice and loves Irish songs. When he sings, he does so with a fullness of feeling, a tenderness, a lyricism, that are astounding—the more so because one sees no hint of this at any other time and might well think his emotional capacity entirely destroyed. He shows every emotion appropriate to what he sings—the frivolous, the jovial, the tragic, the sublime—and seems to be transformed while he sings.
It is easy to show that simple information can be embedded in songs; thus we can give Greg the date every day in the form of a jingle, and he can readily isolate this and say it when asked, without the jingle. But what does it mean to say, “This is July 9, 1995”, when one is sunk in the profoundest amnesia, when one has lost a sense of time and history, when one is existing from moment to moment in a sequenceless limbo? Knowing the date means nothing in these circumstances. Could one, however, through the evocativeness and power of music, perhaps using songs with specially written lyrics—songs that relate something valuable about himself or the current world—accomplish something more lasting, deeper? Give Greg not only the “facts”, but a sense of time and history, of the relatedness of events, an entire (if artificial) framework for thinking and feeling?
It seemed natural, at this time, given Greg’s blindness and the revelation of his potential for learning, that he should be given an opportunity to learn Braille. Arrangements were made with the Jewish Institute for the Blind for him to enter intensive training, four times a week. It should not have been a disappointment, nor indeed a surprise, that Greg was unwilling to learn any Braille—that he was startled and bewildered at finding this imposed on him, and cried out, “What’s going on? Do you think I’m blind? Why am I here, with blind people all around me?” Attempts were made to explain things to him, and he responded, with impeccable logic, “If I were blind, I would be the first person to know it.” The institute said they had never had such a difficult patient, and the project was quietly allowed to drop. And indeed, with the failure of the Braille program, a sort of hopelessness gripped us, and perhaps Greg, too. We could do nothing, we felt; he had no potential for change.
Greg by this time had had several psychological and neuropsychological evaluations, and these, besides commenting on his memory and attentional problems, had all spoken of him as being “shallow”, “infantile”, “insightless”, “euphoric.” It was easy to see why these words had been used; Greg was like this for much of the time. But was there a deeper Greg beneath his illness, beneath the shallowing effect of his frontal lobe loss and amnesia? Early in 1979, when I questioned him, he said he was “miserable—at least in the corporeal part”, and added, “It’s not much of a life.” At such times, it was clear that he was not just frivolous and euphoric, but capable of deep, and indeed melancholic, reactions to his plight. The comatose Karen Ann Quinlan was then very much in the news, and each time her name and fate were mentioned, Greg became distressed and silent. He could never tell me, explicitly, why this so interested him—but it had to be, I felt, because of some sort of identification of her tragedy with his own. Or was this just his incontinent sympathy, his falling at once into the mood of any stimulus or news, falling almost helplessly, mimetically, into its mood?
This was not a question I could decide at fir
st, and perhaps, too, I was prejudiced against finding any depths in Greg, because the neuropsychological studies I knew of seemed to disallow this possibility. But these studies were based on brief evaluations, not on long-continued observation and relationship of a sort that is, perhaps, only possible in a hospital for chronic patients, or in situations where a whole world, a whole life, are shared with the patient.
Greg’s “frontal lobe” characteristics—his lightness, his quick-fire associations—were fun, but beyond this there shone through a basic decency and sensitivity and kindness. One felt that Greg, though damaged, still had a personality, an identity, a soul. 48
48. Mr. Thompson (“A Matter of Identity”), who also had both amnesia and a frontal lobe syndrome, by contrast often seemed “desouled.” In him the wisecracking was manic, ferocious, frenetic, and relentless; it rushed on like a torrent, oblivious to tact, to decency, to propriety, to everything, including the feelings of everyone around him. Whether Greg’s (at least partial) preservation of ego and identity was due to the lesser severity of his syndrome, or to underlying personality differences, is not wholly clear. Mr. Thompson’s premorbid personality was that of a New York cabbie, and in some sense his frontal lobe syndrome merely intensified this. Greg’s personality was gentler, more childlike, from the start—and this, it seemed to me, even colored his frontal lobe syndrome.
When he came to Williamsbridge we all responded to his intelligence, his high spirits, his wit. All sorts of therapeutic programs and enterprises were started at this time, but all of them—like the learning of Braille—ended in failure. The sense of Greg’s incorrigibility gradually grew on us, and with this we started to do less, to hope less. Increasingly, he was left to his own devices. He slowly ceased to be a center of attention, the focus of eager therapeutic activities—more and more he was left to himself, left out of programs, not taken anywhere, quietly ignored.
It is easy, even if one is not an amnesiac, to lose touch with current reality in the back wards of hospitals for the chronically ill. There is a simple round that has not changed in twenty, or fifty, years. One is wakened, fed, taken to the toilet, and left to sit in a hallway; one has lunch, one is taken to bingo, one has dinner and goes to bed. The television may indeed be left on, blaring, in the television room—but most patients pay no attention to it. Greg, it is true, enjoyed his favorite soap operas and westerns and learned an enormous number of advertising jingles by heart. But the news, for the most part, he found boring and, increasingly, unintelligible. Years can pass, in a sort of timeless limbo, with few, and certainly no memorable, markers of the passage of time.
As ten years or so went by, Greg showed a complete absence of development, his talk seemed increasingly dated and repertorial, for nothing new was being added to it, or him. The tragedy of his amnesia seemed to become greater with the years, although his amnesia itself, his neurological syndrome, remained much the same.
In 1988 Greg had a seizure—he had never had one before (although he had been on anticonvulsants, as a precaution, since the time of his surgery)—and in the seizure broke a leg. He did not complain of this, he did not even mention it; it was only discovered when he tried to stand up the following day. He had, apparently, forgotten it as soon as the pain eased and as soon as he had found a comfortable position. His not knowing that he had broken a leg seemed to me to have similarities to his not knowing he was blind, his inability, with his amnesia, to hold in mind an absence. When the leg caused pain, briefly, he knew something had happened, he knew it was there; as soon as the pain ceased, it went from his mind. Had he had visual hallucinations or phantoms (as the blind sometimes do, at least in the first months and years after losing their sight), he could have spoken of them, said, “Look!” or “Wow!” But in the absence of actual visual input, he could hold nothing in mind about seeing, or not-seeing, or the loss of a visual world. In his person, and in his world, now, Greg knew only presence, not absence. He seemed incapable of registering any loss—loss of function in himself, or of an object, or a person.
In June of 1990, Greg’s father, who had come every morning before work to see Greg and would joke and chat with him for an hour, suddenly died. I was away at the time (mourning my own father), and hearing the news of Greg’s bereavement on my return, I hastened to see him. He had been given the news, of course, when it happened. And yet I was not quite sure what to say—had he been able to absorb this new fact? “I guess you must be missing your father”, I ventured.
“What do you mean?” Greg answered. “He comes every day. I see him every day.”
“No”, I said, “he’s no longer coming—He has not come for some time. He died last month.”
Greg flinched, turned ashen, became silent. I had the impression he was shocked, doubly shocked, at the sudden, appalling news of his father’s death, and at the fact that he himself did not know, had not registered, did not remember. “I guess he must have been around fifty”, he said.
“No, Greg”, I answered, “he was well up in his seventies.”
Greg grew pale again as I said this. I left the room briefly; I felt he needed to be alone with all this. But when I returned a few minutes later, Greg had no memory of the conversation we had had, of the news I had given him, no idea that his father had died.
Very clearly, at least, Greg showed a capacity for love and grief. If I had ever doubted Greg’s capacity for deeper feeling, I no longer doubted it now. He was clearly devastated by his father’s death—he showed nothing “flip”, no levity, at this time. 49
49. This is in distinction to Mr. Thompson, who with his more severe frontal lobe syndrome had been reduced to a sort of nonstop, wisecracking, talking machine, and when told of his brother’s death quipped “He’s always the joker! ” and rushed on to other, irrelevant things.
But would he have the ability to mourn? Mourning requires that one hold the sense of loss in one’s mind, and it was far from clear to me that Greg could do this. One might indeed tell him that his father had died, again and again. And every time it would come as something shocking and new and cause immeasurable distress. But then, in a few minutes, he would forget and be cheerful again, and was so prevented from going through the work of grief, the mourning. 50
50. The amnesiac musicologist in the BBC film Prisoner of Consciousness showed something both similar and different. Every time his wife went out of the room, he had a sense of calamitous, permanent loss. When she came back, five minutes later, he sobbed with relief, saying, “I thought you were dead.”
I made a point of seeing Greg frequently in the following months, but I did not again bring up the subject of his father’s death. It was not up to me, I thought, to confront him with this—indeed it would be pointless and cruel to do so; life itself, surely, would do so, for Greg would discover his father’s absence.
I made the following note on November 26, 1990: “Greg shows no conscious knowing that his father has died—when asked where his father is, he may say, ‘Oh, he went down to the patio’ or ‘He couldn’t make it today’ or something else plausible. But he no longer wants to go home, on weekends, on Thanksgiving, as he so loved to—he must find something sad or repugnant in the fatherless house now, even though he cannot (consciously) remember or articulate this. Clearly he has established an association of sadness.”
Toward the end of the year Greg, normally a sound sleeper, started to sleep poorly, to get up in the middle of the night and wander gropingly for hours around his room. “I’ve lost something, I’m looking for something”, he would say when asked—but what he had lost, what he was looking for, he could never explain. One could not avoid the feeling that Greg was looking for his father, even though he could give no account of what he was doing and had no explicit knowledge of what he had lost. But, it seemed to me, there was perhaps now an implicit knowledge and perhaps, too, a symbolic (though not a conceptual) knowing.
Greg had seemed so sad since his father’s death that I felt he deserved a special celebrati
on—and when I heard, in August of 1991, that his beloved group, the Grateful Dead, would be playing at Madison Square Garden in a few weeks, this seemed just the thing. Indeed, I had met one of the drummers in the band, Mickey Hart, earlier in the summer, when we had both testified before the Senate about the therapeutic powers of music, and he made it possible for us to obtain tickets at the last minute, to bring Greg, wheelchair and all, into the concert, where a special place would be saved for him near the soundboard, where acoustics were best.
We made these arrangements at the last minute, and I had given Greg no warning, not wanting to disappoint him if we failed to get seats. But when I picked him up at the hospital and told him where we were going, he showed great excitement. We got him dressed swiftly and bundled him into the car. As we got into midtown, I opened the car windows, and the sounds and smells of New York came in. As we cruised down Thirty-third Street, the smell of hot pretzels suddenly struck him; he inhaled deeply and laughed. “That’s the most New York smell in the world.”
There was an enormous crowd converging on Madison Square Garden, most in tie-dyed T–shirts—I had hardly seen a tie-dyed T–shirt in twenty years, and I myself began to think we were back in the sixties, or perhaps that we had never left them. I was sorry that Greg could not see this crowd; he would have felt himself one of them, at home. Stimulated by the atmosphere, Greg started to talk spontaneously—very unusual for him—and to reminisce about the sixties:
Yeah, there were the be-ins in Central Park. They haven’t had one for a long time—over a year, maybe, can’t remember exactly—Concerts, music, acid, grass, everything—First time I was there was Flower-Power Day—Good times—lots of things started in the sixties-acid rock, the be-ins, the love-ins, smoking—Don’t see it much these days—Allen Ginsberg—he’s down in the Village a lot, or in Central Park. I haven’t seen him for a long time. It’s over a year since I last saw him—