by Oliver Sacks
Barely twenty years elapsed before these considerations were put to the test—when, in 1728, William Cheselden, an English surgeon, removed the cataracts from the eyes of a thirteen-year-old boy born blind. Despite his high intelligence and youth, the boy encountered profound difficulties with the simplest visual perceptions. He had no idea of distance. He had no idea of space or size. And he was bizarrely confused by drawings and paintings, by the idea of a two-dimensional representation of reality. As Berkeley had anticipated, he was able to make sense of what he saw only gradually and insofar as he was able to connect visual experiences with tactile ones. It had been similar with many other patients in the two hundred and fifty years since Cheselden’s operation: nearly all had experienced the most profound, Lockean confusion and bewilderment. 67
67. The removal (or, as was first done, the dislocation or “couching” of the cataracted lens) leaves an eye strongly farsighted and in need of an artificial lens; and the thick lenses used in the eighteenth and nineteenth centuries, and indeed until quite recently, markedly reduced peripheral vision. Thus all patients operated upon for cataract before the present era of contact and implanted lenses had significant optical difficulties to contend with. But it was only those blind from birth or early childhood who had the special Lockean difficulty of not being able to make sense of what they saw.
And yet, I was informed, as soon as the bandages were removed from Virgil’s eye, he saw his doctor and his fiancée, and laughed. Doubtless he saw something—but what did he see? What did “seeing” for this previously not-seeing man mean? What sort of world had he been launched into?
Virgil was born on a small farm in Kentucky soon after the outbreak of the Second World War. He seemed normal enough as a baby, but (his mother thought) had poor eyesight even as a toddler, sometimes bumped into things, seemed not to see them. At the age of three, he became gravely ill with a triple illness—a meningitis or meningoencephalitis (inflammation of the brain and its membranes), polio, and cat-scratch fever. During this acute illness, he had convulsions, became virtually blind, paralyzed in the legs, partly paralyzed in his breathing, and, after ten days, fell into a coma. He remained in a coma for two weeks. When he emerged from it, he seemed, according to his mother, “a different person”; he showed a curious indolence, nonchalance, passivity, seemed nothing at all like the spunky, mischievous boy he had been.
The strength in his legs came back over the next year, and his chest grew stronger, though never entirely normal. His vision also recovered significantly—but his retinas were now gravely damaged. Whether the retinal damage was caused wholly by his acute illness or perhaps partly by a congenital retinal degeneration was never clear.
In Virgil’s sixth year, cataracts began to develop in both eyes, and it was evident that he was again becoming functionally blind. That same year, he was sent to a school for the blind, and there he eventually learned to read Braille and to become adept with the use of a cane. But he was not a star pupil; he was not as adventurous or aggressively independent as some blind people are. There was a striking passivity all through his time at school—as, indeed, there had been since his illness.
Yet Virgil graduated from the school and, when he was twenty, decided to leave Kentucky, to seek training, work, and a life of his own in a city in Oklahoma. He trained as a massage therapist and soon found employment at a YMCA. He was obviously good at his job, and highly esteemed, and the Y was happy to keep him on its permanent staff and to provide a small house for him across the road, where he lived with a friend, also employed at the Y. Virgil had many clients—it is fascinating to hear the tactile detail with which he can describe them—and seemed to take a real pleasure and pride in his job. Thus, in his modest way, Virgil made a life: had a steady job and an identity, was self-supporting, had friends, read Braille papers and books though less, with the years, as Talking Books came in. He had a passion for sports, especially baseball, and loved to listen to games on the radio. He had an encyclopedic knowledge of baseball games, players, scores, statistics. On a couple of occasions, he became involved with girlfriends and would cross the city on public transport to meet them. He maintained a close tie with home, and particularly with his mother—he would get hampers of food regularly from the farm and send hampers of laundry back and forth. Life was limited, but stable in its way.
Then, in 1991, he met Amy—or, rather, they met again, for they had known each other well twenty or more years before. Amy’s background was different from Virgil’s: she came from a cultivated middle–class family, had gone to college in New Hampshire, and had a degree in botany. She had worked at another Y in town, as a swimming coach, and had met Virgil at a cat show in 1968. They dated a bit—she was in her early twenties, he was a few years older—but then Amy decided to go back to graduate school in Arkansas, where she met her first husband, and she and Virgil fell out of contact. She ran her own plant nursery for a while, specializing in orchids, but had to give this up when she developed severe asthma. She and her first husband divorced after a few years, and she returned to Oklahoma. In 1988, out of the blue, Virgil called her, and, after three years of long phone calls between them, they finally met again, in 1991. “All of a sudden it was like twenty years were never there”, Amy said.
Meeting again, at this point in their lives, both felt a certain desire for companionship. With Amy, perhaps, this took a more active form. She saw Virgil stuck (as she perceived it) in a vegetative, dull life: going over to the Y, doing his massages; going back home, where, increasingly, he listened to ball games on the radio; going out and meeting people less and less each year. Restoring his sight, she must have felt, would, like marriage, stir him from his indolent bachelor existence and provide them both with a new life.
Virgil was passive here as in so much else. He had been sent to half a dozen specialists over the years, and they had been unanimous in declining to operate, feeling that in all probability he had no useful retinal function; and Virgil seemed to accept this with equanimity. But Amy disagreed. With Virgil being blind already, she said, there was nothing to lose, and there was a real possibility, remote but almost too exciting to contemplate, that he might actually get reasonable sight back and, after nearly forty-five years, see again. And so Amy pushed for the surgery. Virgil’s mother, fearing disturbance, was strongly against it. (“He is fine as he is”, she said.) Virgil himself showed no preference in the matter; he seemed happy to go along with whatever they decided.
Finally, in mid-September, the day of surgery came. Virgil’s right eye had its cataract removed, and a new lens implant was inserted; then the eye was bandaged, as is customary, for twenty-four hours of recovery. The following day, the bandage was removed, and Virgil’s eye was finally exposed, without cover, to the world. The moment of truth had finally come.
Or had it? The truth of the matter (as I pieced it together later), if less “miraculous” than Amy’s journal suggested, was infinitely stranger. The dramatic moment stayed vacant, grew longer, sagged. No cry (“I can see!”) burst from Virgil’s lips. He seemed to be staring blankly, bewildered, without focusing, at the surgeon, who stood before him, still holding the bandages. Only when the surgeon spoke—saying “Well?”—did a look of recognition cross Virgil’s face.
Virgil told me later that in this first moment he had no idea what he was seeing. There was light, there was movement, there was color, all mixed up, all meaningless, a blur. Then out of the blur came a voice that said, “Well?” Then, and only then, he said, did he finally realize that this chaos of light and shadow was a face—and, indeed, the face of his surgeon.
His experience was virtually identical to that of Gregory’s patient S.B., who was accidentally blinded in infancy, and received a corneal transplant in his fifties:
When the bandages were removed—he heard a voice coming from in front of him and to one side: he turned to the source of the sound, and saw a “blur.” He realized that this must be a face—He seemed to think that he would not ha
ve known that this was a face if he had not previously heard the voice and known that voices came from faces.
The rest of us, born sighted, can scarcely imagine such confusion. For we, born with a full complement of senses, and correlating these, one with the other, create a sight world from the start, a world of visual objects and concepts and meanings. When we open our eyes each morning, it is upon a world we have spent a lifetime learning to see. We are not given the world: we make our world through incessant experience, categorization, memory, reconnection. But when Virgil opened his eye, after being blind for forty-five years—having had little more than an infant’s visual experience, and this long forgotten—there were no visual memories to support a perception; there was no world of experience and meaning awaiting him. He saw, but what he saw had no coherence. His retina and optic nerve were active, transmitting impulses, but his brain could make no sense of them; he was, as neurologists say, agnosic.
Everyone, Virgil included, expected something much simpler. A man opens his eyes, light enters and falls on the retina: he sees. It is as simple as that, we imagine. And the surgeon’s own experience, like that of most ophthalmologists, had been with the removal of cataracts from patients who had almost always lost their sight late in life—and such patients do indeed, if the surgery is successful, have a virtually immediate recovery of normal vision, for they have in no sense lost their ability to see. And so, though there had been a careful surgical discussion of the operation and of possible postsurgical complications, there was little discussion or preparation for the neurological and psychological difficulties that Virgil might encounter.
With the cataract out, Virgil was able to see colors and movements, to see (but not identify) large objects and shapes, and, astonishingly, to read some letters on the third line of the standard Snellen eye chart—the line corresponding to a visual acuity of about 20⁄100 or a little better. But though his best vision was a respectable 20⁄80, he lacked a coherent visual field, because his central vision was poor, and it was almost impossible for the eye to fixate on targets; it kept losing them, making random searching movements, finding them, then losing them again. It was evident that the central, or macular, part of the retina, which is specialized for high acuity and fixation, was scarcely functioning, and that it was only the surrounding paramacular area that was making possible such vision as he had. The retina itself presented a moth-eaten or piebald appearance, with areas of increased and decreased pigmentation-islets of intact or relatively intact retina alternating with areas of atrophy. The macula was degenerated and pale, and the blood vessels of the entire retina appeared narrowed. Examination, I was told, suggested the scars or residues of old disease but no current or active disease process; and, this being so, Virgil’s vision, such as it was, could be stable for the rest of his life. It could be hoped, moreover (since the worse eye had been operated on first), that the left eye, which was to be operated upon in a few weeks’ time, might have considerably more functional retina than the right.
I had not been able to go to Oklahoma straightaway—my impulse was to take the next plane after that initial phone call—but had kept myself informed of Virgil’s progress over the ensuing weeks by speaking with Amy, with Virgil’s mother, and, of course, with Virgil himself. I also spoke at length with Dr. Hamlin and with Richard Gregory, in England, to discuss what sort of test materials I should bring, for I myself had never seen such a case, nor did I know anyone (apart from Gregory) who had. I gathered together some materials—solid objects, pictures, cartoons, illusions, videotapes, and special perceptual tests designed by a physiologist colleague, Ralph Siegel; I phoned an ophthalmologist friend, Robert Wasserman (we had previously worked together on the case of the colorblind painter), and we started to plan a visit. It was important, we felt, not just to test Virgil but to see how he managed in real life, inside his house, outside, in natural settings and social situations; crucial, too, that we see him as a person, bringing his own life history—his particular dispositions and needs and expectations—to this critical passage; that we meet his fiancée, who had so urged the operation, and with whom his life was now so intimately mingled; that we look not merely at his eyes and perceptual powers but at the whole tenor and pattern of his life.
Virgil and Amy—now newlyweds—greeted us at the exit barrier in the airport. Virgil was of medium height, but exceedingly fat; he moved slowly and tended to cough and puff with the slightest exertion. He was not, it was evident, an entirely well man. His eyes roved to and fro, in searching movements, and when Amy introduced Bob and me he did not seem to see us straightaway—he looked toward us but not quite at us. I had the impression, momentary but strong, that he did not really look at our faces, though he smiled and laughed and listened minutely.
I was reminded of what Gregory had observed of his patient S.B.—that “he did not look at a speaker’s face, and made nothing of facial expressions.” Virgil’s behavior was certainly not that of a sighted man, but it was not that of a blind man, either. It was, rather, the behavior of one mentally blind, or agnosicable to see but not to decipher what he was seeing. He reminded me of an agnosic patient of mine, Dr. P. (the man who mistook his wife for a hat), who, instead of looking at me, taking me in, in the normal way, made sudden strange fixations—on my nose, on my right ear, down to my chin, up to my right eye—not seeing, not “getting”, my face as a whole.
We walked out through the crowded airport, Amy holding Virgil’s arm, guiding him, and out to the lot where they had parked their car. Virgil was fond of cars, and one of his first pleasures after surgery (as with S.B.) had been to watch them through the window of his house, to enjoy their motions, and spot their colors and shapes—their colors, especially. He was sometimes bewildered by shapes. “What cars do you see?” I asked him as we walked through the lot. He pointed to all the cars we passed. “That’s a blue one, that’s red—wow, that’s a big one!” Some of the shapes he found very surprising. “Look at that one!” he exclaimed once. “I have to look down!” And, bending, he felt it—it was a slinky, streamlined V-12 Jaguar—and confirmed its low profile. But it was only the colors and general profiles he was getting; he would have walked past their own car had Amy not been with him. And Bob and I were struck by the fact that Virgil would look, would attend visually, only if one asked him to or pointed something out—not spontaneously. His sight might be largely restored, but using his eyes, looking, it was clear, was far from natural to him; he still had many of the habits, the behaviors, of a blind man. 68
68. One does not see, or sense, or perceive, in isolation—perception is always linked to behavior and movement, to reaching out and exploring the world. It is insufficient to see; one must look as well. Though we have spoken, with Virgil, of a perceptual incapacity, or agnosia, there was, equally, a lack of capacity or impulse to look, to act seeing—a lack of visual behavior. Von Senden mentions the case of two children whose eyes had been bandaged from an early age, and who, when the bandages were removed at the age of five, showed no reaction to this, showed no looking, and seemed blind. One has the sense that these children, who had built up their worlds with other senses and behaviors, did not know how to use their eyes.
Looking—as an orientation, as a behavior—may even vanish in those who become blind late in life, despite the fact that they have been “lookers” all their lives. Many startling examples of this are given by John Hull in his autobiographical book, Touching the Rock. Hull had lived as a sighted man until his midforties, but within five years of becoming totally blind, he had lost the very idea of “facing” people, of “looking” at his interlocutors.
The drive from the airport to their house was a long one; it took us through the heart of town, and it gave us an opportunity to talk to Virgil and Amy and to observe Virgil’s reactions to his new vision. He clearly enjoyed movement, watching the ever-changing spectacle through the car windows and the movement of other cars on the road. He spotted a speeder coming up very fast behind us and identi
fied cars, buses (he especially loved the bright-yellow school buses), eighteen-wheelers, and, once, on a side road, a slow, noisy tractor. He seemed very sensitive to, and intrigued by, large neon signs and advertisements and liked picking out their letters as we passed. He had difficulty reading entire words, though he often guessed them correctly from one or two letters or from the style of the signs. Other signs he saw but could not read. He was able to see and identify the changing colors of the traffic lights as we got into town.
He and Amy told us of other things he had seen since his operation and of some of the unexpected confusions that could occur. He had seen the moon; it was larger than he expected. 69
69. Gregory’s patient, too, was startled by the moon: he had expected a quarter moon would be wedge-shaped, like a piece of cake, and was astonished and amused to find it a crescent instead.
On one occasion, he was puzzled by seeing “a fat airplane” in the sky—“stuck, not moving.” It turned out to be a blimp. Occasionally, he had seen birds; they made him jump, sometimes, if they came too close. (Of course, they did not come that close, Amy explained. Virgil simply had no idea of distance.)