by Oliver Sacks
The catastrophe, when it came, was very sudden. On February 8, I had a phone call from Amy: Virgil had collapsed, had been taken, grey and stuporous, to the hospital. He had a lobar pneumonia, a massive consolidation of one lung, and was in the intensive-care unit, on oxygen and intravenous antibiotics.
The first antibiotics used did not work: he grew worse; he grew critical; and for some days he hovered between life and death. Then, after three weeks, the infection was finally mastered, and the lung started to re-expand. But Virgil himself remained gravely ill, for, though the pneumonia itself was clearing, it had tipped him into respiratory failure—a near-paralysis of the respiratory center in the brain, which made it unable to respond properly to levels of oxygen and carbon dioxide in the blood. The oxygen levels in his blood started to fall—fell to less than half of normal. And the level of carbon dioxide started to rise—rose to nearly three times normal. He needed oxygen constantly, but only a little could be given, lest his failing respiratory center be further depressed. With his brain deprived of oxygen and poisoned by carbon dioxide, Virgil’s consciousness fluctuated and faded, and on bad days (when the oxygen in his blood was lowest and the carbon dioxide highest) he could see nothing: he was totally blind.
Much contributed to this continuing respiratory crisis: Virgil’s lungs themselves were thickened and fibrotic; there was advanced bronchitis and emphysema; there was no movement of the diaphragm on one side, a consequence of his childhood polio; and, on top of all this, he was enormously obese—obese enough to cause a Pickwick syndrome (named after the somnolent fat boy, Joe, in The Pickwick Papers). In Pickwick syndrome, there is a grave depression of breathing, and failure to oxygenate the blood fully, associated with a depression of the respiratory center in the brain.
Virgil had probably been getting ill for some years; he had gradually been increasing in weight since 1985. But between his wedding and Christmas he had put on a further forty pounds—had shot up, in a few weeks, to two hundred and eighty pounds—partly from fluid retention caused by heart failure, and partly from nonstop eating, a habit of his under stress.
He now had to spend three weeks in the hospital, his blood oxygen still plummeting to dangerously low levels, despite his being given oxygen—and each time the level grew really low he became lethargic and totally blind. Amy would know the moment she opened his door what sort of day he was having—where the blood oxygen was—depending on whether he used his eyes, looked around, or fumbled and touched, “acted blind.” (We wondered, in retrospect, whether the strange fluctuations his vision had shown from almost the day of surgery might also have been caused, at least in part, by fluctuations in his blood oxygen, with consequent retinal or cerebral anoxia. Virgil had probably had a mild Pickwick syndrome for years, and could have been close to respiratory failure and anoxia even before his acute illness.)
There was another, intermediate state, which Amy found very puzzling; at such times, he would say that he saw nothing whatever, but would reach for objects, avoid obstacles, and behave as if seeing. Amy could make nothing of this singular state, in which he manifestly responded to objects, could locate them, was seeing, and yet denied any consciousness of seeing. This condition—called implicit sight, unconscious sight, or blindsight—occurs if the visual parts of the cerebral cortex are knocked out (as they may be by a lack of oxygen, for instance), but the visual centers in the subcortex remain intact. Visual signals are perceived and are responded to appropriately, but nothing of this perception reaches consciousness at all.
At last, Virgil was able to leave the hospital and return home, but to return a respiratory cripple. He was tethered to an oxygen cylinder and could not even stir from his chair without it. It seemed unlikely at this stage that he would ever recover sufficiently to go out and work again, and the Y now felt that it had to terminate his job. A few months later, he was forced to leave the house where he had lived as an employee of the Y for more than twenty years. This was the situation that summer: Virgil had lost not only his health but his job and his house as well.
By October, however, he was feeling better and was able to go without oxygen for an hour or two at a time. It had not been wholly clear to me, from speaking to Virgil and Amy, what had finally happened to his vision after all these months. Amy said that it had “almost gone” but that now she felt it was coming back as he got better. When I phoned the visual-rehabilitation center where Virgil had been evaluated, I was given a different story. Virgil, I was told, seemed to have lost all the sight restored the previous year, with only a few bits remaining. Kathy, his therapist, thought he saw colors but little else—and sometimes colors without objects: thus he might see a haze or halo of pink around a Pepto-Bismol bottle without clearly seeing the bottle itself. 82
82. Semir Zeki has observed in some cases of cerebral anoxia that the color-constructing areas of the visual cortex may be relatively spared, so that the patient may see color and nothing else—no form, no boundaries, no sense of objects whatsoever.
This color perception, she said was the only seeing that was constant; for the rest he appeared almost blind, missed objects, groped, seemed visually lost. He was showing his old, blind random movements of the eyes. And yet sometimes, spontaneously, out of the blue, he would get sudden, startling moments of vision, in which he would see objects, quite small ones. But these percepts would then vanish as suddenly as they came, and he was usually unable to retrieve them. For all practical purposes, she said, Virgil was now blind.
I was shocked and puzzled when Kathy told me this. These were phenomena radically different from anything he had shown before: What was happening now with his eyes and his brain? From a distance, I could not sort out what was happening, especially since Amy, for her part, maintained that Virgil’s vision was now improving. Indeed, she got furious when she heard anyone say that Virgil was blind, and she maintained that the visual-rehab center was actually “teaching him to be blind.” So in February of 1993, a year after the onset of his devastating illness, we brought Virgil and Amy to New York to see us again and to get some specialized physiological tests of retinal and brain function.
As soon as I met Virgil at the arrival gate at LaGuardia Airport, I could see for myself that everything had gone quite terribly wrong. He was now almost fifty pounds heavier than when I had met him in Oklahoma. He was carrying a cylinder of oxygen strung over one shoulder. He groped; his eyes wandered; he looked totally blind. Amy guided him, her hand under his elbow, everywhere they went. And yet sometimes as we drove over the Fifty-ninth Street Bridge into the city, he would pick up something—a light on the bridge—not guessing but seeing it quite accurately. But he could never hold it or retrieve it, and so remained visually lost.
When we came to test him in my office—first using large colored targets, then large movements and flashlights—he missed everything. He seemed totally blind—blinder than he had been before his operations, because then, at least, even through his cataracts he could consistently detect light, its direction, and the shadow of a hand moving before him. Now he could detect nothing whatever, no longer seemed to have any light-sensitive receptors: it was as if his retinas had gone. Yet not totally gone—that was the odd thing. For once in a while he would see something accurately: once, he saw, described, grasped, a banana; on two occasions, he was able to follow a randomly moving light bar with his hands on a computer screen; and sometimes he would reach for objects, or “guess” them correctly, even though he said he saw “nothing” at such times—the blindsight that had first been observed in the hospital.
We were dismayed at his near-uniform failure, and he was sinking into a demoralized, defeated state—it was time to stop testing and take a break for lunch. As we passed him a bowl of fruit, and he felt the fruit with swift, sensitive, skillful fingers, his face lighted up, and he regained his animation. He gave us, as he handled the fruit, remarkable tactile descriptions, speaking of the waxy, slick quality of the plum skin, the soft fuzz of peaches and smoothness o
f nectarines (“like a baby’s cheeks”), and the rough, dimpled skin of oranges. He weighed the fruits in his hand, spoke of their weight and consistency, their pips and stones; and then, lifting them to his nose, their different smells. His tactile (and olfactory) appreciation seemed far finer than our own. We included an exceedingly clever wax pear among the real fruit; with its realistic shape and coloring, it had deceived sighted people completely. Virgil was not taken in for a moment: he burst out laughing as soon as he touched it. “It’s a candle”, he said immediately, somewhat puzzled. “Shaped like a bell or a pear.” While he may indeed have been, in von Senden’s words, “an exile from spatial reality”, he was deeply at home in the world of touch, in time.
But if his sense of touch was perfectly preserved, there were, it was evident, just sparks from his retinas—rare, momentary sparks, from retinas that now seemed to be 99 percent dead. Bob Wasserman, too, who had not seen Virgil since our visit to Oklahoma, was appalled at the degradation of vision and wanted to re-examine the retinas. When he did so, they looked exactly as before—piebald, with areas of increased and decreased pigmentation. There was no evidence of any new disease. Yet the functioning of even the preserved areas of retina had fallen to almost zero. Electroretinograms, designed to record the retina’s electrical activity when stimulated by light, were completely flat, and visual evoked potentials, designed to show activity in the visual parts of the brain, were absent, too—there was no longer anything, electrically, going on in either the retinas or the brain that could be recorded. (There may have been rare, momentary sparks of activity, but if so, we failed to catch these in our recordings.) This inactivity could not be attributed to the original disease, retinitis, which had long been inactive. Something else had emerged in the past year and had, in effect, extinguished his remaining retinal function.
We remembered how Virgil had constantly complained of glare, even on relatively dull, overcast days—how glare seemed to blind him sometimes, so that he needed the darkest glasses. Was it possible (as my friend Kevin Halligan suggested) that with the removal of his cataracts—cataracts that had perhaps shielded his fragile retinas for decades—the ordinary light of day had proved lethal, burnt out his retinas? It is said that patients with other retinal problems, like macular degeneration, may be exceedingly intolerant of light—not merely ultraviolet but light of all wavelengths—and that light may hasten the degeneration of their retinas. Was this what had happened with Virgil? It was one possibility. Should we have foreseen it and rationed Virgil’s sight, or the ambient light, in some way?
Another possibility—a likelier one—related to Virgil’s continuing hypoxia, the fact that he had not had properly oxygenated blood for a year. We had clear accounts of his vision waxing and waning in the hospital as his blood gases went up and down. Could the repeated, or continuing, oxygen-starving of his retinas (and perhaps also of the visual areas of his cortex) have been the factor that did them in? It was wondered, at this point, whether raising blood oxygenation to 100 percent (which would have required sustained artificial respiration with pure oxygen) might restore some retinal or cerebral function. But it was decided that this procedure would be too risky, since it might cause long-term or permanent depression of the brain’s respiratory center.
This, then, is Virgil’s story, the story of a “miraculous” restoration of sight to a blind man, a story basically similar to that of Cheselden’s young patient in 1728, and of a handful of others over the past three centuries—but with a bizarre and ironic twist at the end. Gregory’s patient, so well adapted to blindness before his operation, was first delighted with seeing, but soon encountered intolerable stresses and difficulties, found the “gift” transformed to a curse, became deeply depressed, and soon after died. Almost all the earlier patients, indeed, after their initial euphoria, were overwhelmed by the enormous difficulties of adapting to a new sense, though a very few, as Valvo stresses, have adapted and done well. Could Virgil have surmounted these difficulties and adapted to seeing where so many others had foundered on the way?
We shall never know, for the business of adaptation—and, indeed, of life as he knew it—was suddenly cut across by a gratuitous blow of fate: an illness that, at a single stroke, deprived him of job, house, health, and independence, leaving him a gravely sick man, unable to fend for himself. For Amy, who incited the surgery in the first place, and who was so passionately invested in Virgil’s seeing, it was a miracle that misfired, a calamity. Virgil, for his part, maintains philosophically, “These things happen.” But he has been shattered by this blow, has given vent to outbursts of rage: rage at his helplessness and sickness; rage at the smashing of a promise and a dream; and beneath this, most fundamental of all, a rage that had been smoldering in him almost from the beginning—rage at being thrust into a battle he could neither renounce nor win. At the beginning, there was certainly amazement, wonder, and sometimes joy. There was also, of course, great courage. It was an adventure, an excursion into a new world, the like of which is given to few. But then came the problems, the conflicts, of seeing but not seeing, not being able to make a visual world, and at the same time being forced to give up his own. He found himself between two worlds, at home in neither—a torment from which no escape seemed possible. But then, paradoxically, a release was given, in the form of a second and now final blindness—a blindness he received as a gift. Now, at last, Virgil is allowed to not see, allowed to escape from the glaring, confusing world of sight and space, and to return to his own true being, the intimate, concentrated world of the other senses that had been his home for almost fifty years.
5. The Landscape of His Dreams
I first met Franco Magnani in the summer of 1988, when the Exploratorium in San Francisco held a symposium and an exhibit on memory. The exhibit included fifty paintings and drawings by him—all of Pontito, the little Tuscan hill town where he was born but had not seen for more than thirty years. Next to them, in astounding apposition, were photographs of Pontito taken by the Exploratorium’s photographer, Susan Schwartzenberg, from exactly the same viewpoints as Magnani’s, wherever possible. (This was not always possible, because Magnani sometimes visualized and painted Pontito from an imaginary aerial viewpoint fifty or five hundred feet above the ground; Schwartzenberg sometimes had to hoist her camera aloft on a pole and at one point thought of hiring a helicopter or a balloon.) Magnani was billed as “A Memory Artist”, and one had only to glance at the exhibit to see that he indeed possessed a prodigious memory—a memory that could seemingly reproduce with almost photographic accuracy every building, every street, every stone of Pontito, far away, close up, from any possible angle. It was as if Magnani held in his head an infinitely detailed three-dimensional model of his village, which he could turn around and examine, or explore mentally, and then reproduce on canvas with total fidelity.
My first thought when I saw the resemblance between the paintings and the photographs was that here was that rare phenomenon, an eidetic artist: an artist able to hold in memory, for hours or days (perhaps for years), an entire scene that has been glimpsed in a flash; the commander (or slave) of a prodigious native power of imagery and memory. But an eidetic artist would scarcely confine himself to a single theme or subject; on the contrary, he would exploit his memory, or display it, in a huge range of subjects, to show that nothing lay beyond its grasp—whereas Magnani seemingly wanted to concentrate it exclusively upon Pontito. This, then, was an exhibit not of “pure” memory but of memory harnessed to a single, overwhelming motive: the recollection of his childhood village. And, I now realized, it was not just an exercise in memory; it was, equally, an exercise in nostalgia—and not just an exercise but a compulsion, and an art.
A few days later, I spoke to Franco and arranged to meet him at his house. He lives in a small community a few miles outside San Francisco. Once I had found his street, I did not need to look for his house number, because his house stood out immediately from its neighbors. In the small front yard was a lo
w stone wall, resembling those in his paintings of Pontito; his car, an aging sedan with vanity plates (“Pontito”), was parked in the street; the garage had been converted into a studio, and its door was wide open, revealing the artist himself, intently at work.
Franco was tall and slim, with enormous horn-rimmed glasses that magnified his eyes. He had thick brown hair, carefully parted on one side; a springy stride; and an air of great exuberance and vitality—he was fifty-four but seemed much younger. He invited me in and showed me around his home. Every room had paintings on every wall, and every drawer and closet seemed stacked full of paintings—it was less like a house than a museum or archive, totally devoted to the recollection, the reproduction, of Pontito.
As we walked through the house, each painting arrested his attention, aroused a flood of reminiscence: what happened here, what there, and how so-and-so stood there once. “Look at this wall here—that’s where the priest, he caught me climbing into the garden behind the church. He chase me all the way down the street. Oh, he always chase all the kids away from there.” Each reminiscence triggered others, and these still others, so that within minutes we were engulfed in a flood, without any clear direction or center, but all relating to his early life—to Pontito as he had experienced it as a child. He leapt from one story to another, without any connection that I could discern. This sort of rambling—single-minded and intense but incoherent and unfocused—seemed characteristic of Franco: it showed the quality of his obsession, the fact that he thought of Pontito day and night, to the exclusion of all else.
As Franco talked, I had the impression that his reminiscences were taking him over, that these upsurging memories drove him, dominated him, exerted a huge, irresistible force. He would gesture; he would mime; he would breathe heavily; he would glare—he seemed to be completely transported. Then, with a start, he would come back, smile a little embarrassedly, and say, “That’s how it was.”