Oliver Sacks
THE MIND’S EYE
PICADOR
for David Abramson
CONTENTS
Preface
Sight Reading
Recalled to Life
A Man of Letters
Face-Blind
Stereo Sue
Persistence of Vision: A Journal
The Mind’s Eye
Bibliography
Index
PREFACE
I grew up in a household full of doctors and medical talk—my father and older brothers were general practitioners, and my mother was a surgeon. A lot of the dinner-table conversation was inevitably about medicine, but the talk was never just about “cases.” A patient might present as a case of this or that, but in my parents’ conversation, cases became biographies, stories of people’s lives as they responded to illness or injury, stress or misfortune. Perhaps it was inevitable that I myself became both a physician and a storyteller.
When The Man Who Mistook His Wife for a Hat was published in 1985, it was given a very pleasant review by an eminent academic neurologist. The cases, he wrote, were fascinating, but he had one reservation: he thought I was being disingenuous in presenting patients as if I had come to them with no preconceptions, with little background knowledge of their conditions. Did I really read up on the scientific literature only after seeing a patient with a particular condition? Surely, he thought, I had started with a neurological theme in mind and simply sought out patients who exemplified it.
But I am not an academic neurologist, and the truth is that most practicing physicians have, apart from their broad medical education, little in-depth knowledge of many conditions, especially those which are considered rare, and thus not worthy of much time in medical school. When a patient presents himself with such a condition, we must do some research and, especially, go back to original descriptions. Typically, then, my case histories start with an encounter, a letter, a knock on the door—it is the patients’ description of their experience that stimulates the more general exploration.
As a general neurologist working mostly in old-age homes, I have seen thousands of patients over the past decades. All of them have taught me something, and I enjoy seeing them—in some cases, we have been seeing each other regularly, as doctor and patient, for twenty years or more. In my clinical notes, I do my best to record what is happening with them and to reflect on their experiences. Occasionally, with the patient’s permission, my notes evolve into essays.
After I began publishing case histories, starting with Migraine in 1970, I began receiving letters from people seeking to understand or comment on their own neurological experiences, and such correspondence has become, in a way, an extension of my practice. Thus some of the people I describe in this book are patients; others are people who have written to me after reading one of my case histories. I am grateful to all of them for agreeing to share their experiences, for such experiences enlarge the imagination and show us what is often concealed in health: the complex workings of the brain and its astounding ability to adapt and overcome disability—to say nothing of the courage and strength that individuals can show, and the inner resources they can bring to bear, in the face of neurological challenges that are almost impossible for the rest of us to imagine.
Many of my colleagues, past and present, have generously shared their time and expertise to discuss the ideas in this book or to comment on its various drafts. To all of them (and the many whom I have omitted here) I am most grateful, especially to Paul Bach-y-Rita, Jerome Bruner, Liam Burke, John Cisne, Jennifer and John Clay, Bevil Conway, Antonio and Hanna Damasio, Orrin Devinsky, Dominic ffytche, Elkhonon Goldberg, Jane Goodall, Temple Grandin, Richard Gregory, Charles Gross, Bill Hayes, Simon Hayhoe, David Hubel, Ellen Isler at the Jewish Braille Institute, Narinder Kapur, Christof Koch, Margaret Livingstone, Ved Mehta, Ken Nakayama, Görel Kristina Näslund, Alvaro Pascual-Leone, Dale Purves, V. S. Ramachandran, Paul Romano, Israel Rosenfield, Theresa Ruggiero, Leonard Shengold, Shinsuke Shimojo, Ralph Siegel, Connie Tomaino, Bob Wasserman, and Jeannette Wilkens.
I could not have completed this book without the moral and financial support of a number of institutions and individuals, and I am enormously indebted to them, above all to Susie and David Sainsbury, Columbia University, The New York Review of Books, The New Yorker, the Wylie Agency, the MacDowell Colony, Blue Mountain Center, and the Alfred P. Sloan Foundation. I am grateful, too, to the many people at Alfred A. Knopf, Picador UK, Vintage Books, and my other publishers around the world.
Several correspondents have contributed ideas or descriptions to this book, including Joseph Bennish, Joan C., Larry Eickstaedt, Anne F., Stephen Fox, J. T. Fraser, and Alexandra Lynch.
I am grateful to John Bennet at The New Yorker and Dan Frank at Knopf, superb editors who have improved this book in many ways; and to Allen Furbeck for his help with the illustrations. Hailey Wojcik typed many of the drafts and contributed research and virtually every other type of assistance, to say nothing of deciphering and transcribing the almost 90,000 words of my “melanoma journals.” Kate Edgar has, for the past twenty-five years, filled a unique role as collaborator, friend, editor, organizer, and much else. She has incited me, as always, to think and write, to see from different perspectives, but always to return to the center.
Above all, I am indebted to my subjects or patients and their families: Lari Abraham, Sue Barry, Lester C., Howard Engel, Claude and Pamela Frank, Arlene Gordon, Patricia and Dana Hodkin, John Hull, Lilian Kallir, Charles Scribner, Jr., Dennis Shulman, Sabriye Tenberken, and Zoltan Torey. They have not only allowed me to write about their experiences and quote their descriptions; they have commented on drafts, introduced me to other people and resources, and, in many cases, become good friends.
Finally, I must express my deepest gratitude to my physician, David Abramson; to him I dedicate this book.
O.W.S.
New York
June 2010
Sight Reading
IN JANUARY OF 1999, I received the following letter:
Dear Dr. Sacks,
My (very unusual) problem, in one sentence, and in non-medical terms, is: I can’t read. I can’t read music, or anything else. In the ophthalmologist’s office, I can read the individual letters on the eye chart down to the last line. But I cannot read words, and music gives me the same problem. I have struggled with this for years, have been to the best doctors, and no one has been able to help. I would be ever so happy and grateful if you could find the time to see me.
Sincerely yours,
Lilian Kallir
I phoned Mrs. Kallir—this seemed to be the thing to do, although I normally would have written back—because although she apparently had no difficulty writing a letter, she had said that she could not read at all. I spoke to her and arranged to see her at the neurology clinic where I worked.
Mrs. Kallir came to the clinic soon afterward—a cultivated, vivacious sixty-seven-year-old woman with a strong Prague accent—and related her story to me in much more detail. She was a pianist, she said; indeed, I knew her by name, as a brilliant interpreter of Chopin and Mozart (she had given her first public concert at the age of four, and Gary Graffman, the celebrated pianist, called her “one of the most naturally musical people I’ve ever known”).
The first intimation of anything wrong, she said, had come during a concert in 1991. She was performing Mozart piano concertos, and there was a last-minute change in the program, from the Nineteenth Piano Concerto to the Twenty-first. But when she flipped open the score of the Twenty-first, she found it, to her bewilderment, completely unintelligible. Although she saw the staves, the lines, the individual notes sharp and clear, none of it seemed to hang together, to make sense. She thought the difficulty must have something to do with her eyes. But she went on to perform the concerto flawlessly from memory, and dismissed the strange incident as “one of those things.”
Several months later, the problem recurred, and her ability to read musical scores began to fluctuate. If she was tired or ill, she could hardly read them at all, though when she was fresh, her sight-reading was as swift and easy as ever. But in general the problem worsened, and though she continued to teach, to record, and to give concerts around the world, she depended increasingly on her musical memory and her extensive repertoire, since it was now becoming impossible for her to learn new music by sight. “I used to be a fantastic sight reader,” she said, “easily able to play a Mozart concerto by sight, and now I can’t.”
Occasionally at concerts she experienced lapses of memory, though Lilian (as she asked me to call her) was adept at improvising and could usually cover these. When she was at ease, with friends or students, her playing seemed as good as ever. So, through inertia, or fear, or a sort of adjustment, it was possible for her to overlook her peculiar problems in reading music, for she had no other visual problems, and her memory and ingenuity still allowed her a full musical life.
In 1994, three years or so after she had first noticed problems reading music, Lilian started to have problems with reading words. Here again, there were good days and bad, and even times when her ability to read seemed to change from moment to moment: a sentence would look strange, unintelligible at first; then suddenly it would look fine, and she would have no difficulty reading it. Her ability to write, however, was quite unaffected, and she continued to maintain a large correspondence with former students and colleagues scattered throughout the world, though she depended increasingly on her husband to read the letters she received, and even to reread her own.
Pure alexia, unaccompanied by any difficulty in writing (“alexia sine agraphia”) is not that uncommon, although it usually comes on suddenly, following a stroke or other brain injury. Less often, alexia develops gradually, as a consequence of a degenerative disease such as Alzheimer’s. But Lilian was the first person I had encountered whose alexia manifested first with musical notation, a musical alexia.
By 1995 Lilian was beginning to develop additional visual problems. She noticed that she tended to “miss” objects to the right, and, after some minor mishaps, she decided that she had best give up driving.
She had sometimes wondered whether her strange problem with reading might be neurological rather than ophthalmological in origin. “How can I recognize individual letters, even the tiny ones on the bottom line of the eye doctor’s chart, and yet be unable to read?” she wondered. Then, in 1996, she started to make occasional embarrassing mistakes, such as failing to recognize old friends, and she found herself thinking of a case history of mine she had read years before, entitled “The Man Who Mistook His Wife for a Hat,” about a man who could see everything clearly but recognize nothing. She had chuckled when she had first read it, but now she started to wonder whether her own difficulties might be eerily similar in nature.
Finally, five years or more after her original symptoms, she was referred to a university neurology department for a full workup. Given a battery of neuropsychological tests—tests of visual perception, of memory, of verbal fluency, etc.—Lilian did particularly badly in the recognition of drawings: she called a violin a banjo, a glove a statue, a razor a pen, and pliers a banana. (Asked to write a sentence, she wrote, “This is ridiculous.”) She had a fluctuating lack of awareness, or “inattention,” to the right, and very poor facial recognition (measured by recognition of photographs of famous public figures). She could read, but only slowly, letter by letter. She would read a “C,” an “A,” a “T,” and then, laboriously, “cat,” without recognizing the word as a whole. Yet if she was shown words too quickly to decipher in this way, she could sometimes correctly sort them into general categories, such as “living” or “nonliving,” even though she had no conscious idea of their meaning.
In contrast to these severe visual problems, her speech comprehension, repetition, and verbal fluency were all normal. An MRI of her brain was also normal, but when a PET scan was performed—this can detect slight changes in the metabolism of different brain areas, even when they appear anatomically normal—Lilian was found to have diminished metabolic activity in the posterior part of the brain, the visual cortex. This was more marked on the left side. Noting the gradual spread of difficulties in visual recognition—first of music, then of words, then of faces and objects—her neurologists felt she must have a degenerative condition, at present confined to the posterior parts of the brain. This would probably continue to worsen, though very slowly.
The underlying disease was not treatable in any radical sense, but her neurologists suggested that she might benefit from certain strategies: “guessing” words, for example, even when she could not read them in the ordinary way (for it was clear that she still possessed some mechanism that allowed unconscious or preconscious recognition of words). And they suggested that she might also use a deliberate, hyperconscious inspection of objects and faces, making particular note of their distinctive features, so that these could be identified in future encounters, even if her normal “automatic” powers of recognition were impaired.
In the three years or so that had elapsed between this neurological exam and her first visit to me, Lilian told me, she had continued to perform, though not as well, and not as frequently. She found her repertoire diminishing, because she could no longer check even familiar scores by vision. “My memory was no longer fed,” she remarked. Fed visually, she meant—for she felt that her auditory memory, her auditory orientation, had increased, so that she could now, to a much larger degree than before, learn and reproduce a piece by ear. She could not only play a piece in this way (sometimes after only a single hearing); she could rearrange it in her mind. Nonetheless, there was, on balance, a shrinkage of her repertoire, and she began to avoid giving public concerts. She continued to play in more informal settings and to teach master classes at the music school.
Handing me the neurological report from 1996, she commented, “The doctors all say, ‘Posterior cortical atrophy of the left hemisphere, very atypical,’ and then they smile apologetically—but there’s nothing they can do.”
When I examined Lilian, I found that she had no problem matching colors or shapes, or recognizing movement or depth. But she showed gross problems in other areas. She was unable now to recognize individual letters or numerals (even though she still had no difficulty writing complete sentences). She had, too, a more general visual agnosia, and when I presented her with pictures to identify, it was difficult for her even to recognize pictures as pictures—she would sometimes look at a column of print or a white margin, thinking it was the picture I was quizzing her about. Of one such picture, she said, “I see a V, very elegant—two little dots here, then an oval, with little white dots in between. I don’t know what it’s supposed to be.” When I told her it was a helicopter, she laughed, embarrassed. (The V was a sling; the helicopter was unloading food supplies for refugees. The two little dots were wheels, the oval the helicopter’s body.) Thus she was now seeing only individual features of an object or picture, failing to synthesize them, to see them as a whole, much less to interpret them correctly. Shown a photograph of a face, she could perceive that the person was wearing glasses, nothing else. When I asked if she could see clearly, she said, “It’s not a blur, it’s a mush”—a mush consisting of clear, fine, sharp but unintelligible shapes and details.
Looking at the drawings in a standard neurological test booklet, she said of a pencil, “Could be so many things. Could be a violin . . . a pen.” A house, however, she immediately recognized. Regarding a whistle, she said, “I have no idea.” Shown a drawing of scissors, she looked steadfastly at the wrong place, at the white paper below the drawing. Was Lilian’s difficulty in recognizing drawings due simply to their “sketchiness,” their two-dimensionality, their poverty of information? Or did it reflect a higher-order difficulty with the perception of representation as such? Would she do better with real objects?
When I asked Lilian how she felt about herself and her situation, she said, “I think I am dealing with it very well, most of the time . . . knowing it is not getting better, but only slowly worse. I’ve stopped seeing neurologists. I always hear the same thing. . . . But I am a very resilient person. I don’t tell my friends. I don’t want to burden them, and my little story is not very promising. A dead end. . . . I have a good sense of humor. And that’s it, in a nutshell. It is depressing, when I think of it—frustrations daily. But I have many good days and years ahead.”
After Lilian left, I was unable to find my medical bag—a black bag with some similarities (I now remembered) to one of the several bags she had brought. Going home in the taxi, she realized that she had taken the wrong bag when she saw a red-tipped object sticking out of it (my long, red-tipped reflex hammer). It had attracted her attention, by its color and shape, when she saw it on my desk, and now she realized her mistake. Returning, breathless and apologetic, to the clinic, she said, “I am the woman who mistook the doctor’s bag for her handbag.”
Lilian had done so badly on the formal tests of visual recognition that I had difficulty imagining how she managed in daily life. How did she recognize a taxi, for example? How could she recognize her own home? How could she shop, as she told me she did, or recognize foods and serve them on a table? All this and much more—an active social life, traveling, going to concerts, and teaching—she did by herself when her husband, who was also a musician, went to Europe for weeks at a time. I could get no idea of how she accomplished this from seeing her dismal performance in the artificial, impoverished atmosphere of a neurology clinic. I had to see her in her own familiar surroundings.
The following month, I visited Lilian at home, home being a pleasant apartment in upper Manhattan where she and her husband had lived for more than forty years. Claude was a charming, genial man about the same age as his wife. They had met as music students at Tanglewood nearly fifty years earlier and had pursued their musical careers in tandem, often performing onstage together. The apartment had a friendly, cultured atmosphere, with a grand piano, a great many books, photographs of their daughter and of friends and family, abstract modernist paintings on the wall, and mementos of their trips on every available surface. It was crowded—rich in personal history and significance, I imagined, but a nightmare, a complete chaos, for someone with visual agnosia. This, at least, was my first thought as I entered, negotiating my way between tables full of knickknacks. But Lilian had no difficulty with the clutter and threaded her way confidently through the obstacles.
Since she had had such difficulty on the drawing-recognition test, I had brought a number of solid objects with me, wondering if she would do better with these. I started with some fruit and vegetables I had just bought, and here Lilian did surprisingly well. She instantly identified “a beautiful red pepper,” recognizing it from across the room; a banana, too. She was momentarily uncertain whether the third object was an apple or a tomato, though she soon decided, correctly, on the former. When I showed her a small plastic model of a wolf (I keep a variety of such objects, for perceptual testing, in my medical bag), she exclaimed, “A marvelous animal! A baby elephant, perhaps?” When I asked her to look more closely, she decided it was “a kind of dog.”
Lilian’s relative success in naming solid objects, as opposed to drawings of them, again made me wonder whether she had a specific agnosia for representations. The recognition of representations may require a sort of learning, the grasping of a code or convention, beyond that needed for the recognition of objects. Thus, it is said, people from primitive cultures who have never been exposed to photographs may fail to recognize that they are representations of something else. If a complex system for the recognition of visual representations must be specially constructed by the brain, this ability might be lost through damage to that system by a stroke or disease, just as the learned understanding of writing, say, or any other acquired ability may be lost.
I followed Lilian into the kitchen, where she set about taking the kettle off the stove and pouring boiling water into the teapot. She seemed to navigate her crowded kitchen well, knowing, for instance, that all the skillets and pots were hung on hooks on one wall, various supplies kept in their regular places. When we opened the refrigerator and I quizzed her on the contents, she said, “O.J., milk, butter on the top shelf—and a nice sausage, if you’re interested, one of those Austrian things . . . cheeses.” She recognized the eggs in the fridge door and, when I asked her, counted them correctly, moving her finger from egg to egg as she did so. I could see at a glance that there were eight—two rows of four—but Lilian, I suspect, could not perceive the eightness, the gestalt, easily and had to enumerate the eggs one by one. And the spices, she said, were “a disaster.” They all came in identical red-topped bottles, and, of course, she could not read the labels. So: “I smell them! . . . And I call for help some of the time.” With the microwave oven, which she used often, she said, “I don’t see the numbers. I do it by feel—cook, try, see if it needs a bit more.”
Though Lilian could scarcely recognize anything in the kitchen visually, she had organized it in such a way that mistakes rarely, if ever, occurred, utilizing a sort of informal classification system instead of a direct perceptual gnosis. Things were categorized not by meaning but by color, by size and shape, by position, by context, by association, somewhat as an illiterate person might arrange the books in a library. Everything had its place, and she had memorized this.
Seeing how Lilian inferred the character of the objects around her in this way, using color, above all, as a marker, I wondered how she would do with objects of similar appearance, like the fish knives and the steak knives, which looked almost the same. This was a problem, she confessed, and she often confused them. Perhaps, I suggested, she could use an artificial marker, a little green dot for the fish knives, a red one for the steak knives, so that she could see the difference at a glance. Lilian said she had already thought about this but was not sure she wanted to “flaunt” her problem to others. What would her guests think of color-coded cutlery and dishes, or a color-coded apartment? (“Like a psychological experiment,” she said, “or an office.”) The “unnaturalness” of such an idea disturbed her, but if the agnosia got worse, she agreed, she might need it.
In some cases where Lilian’s categorization system did not work, such as using the microwave, she could operate by trial and error. But if objects were not in their place, major difficulties could appear. This showed itself startlingly at the end of my visit. The three of us—Lilian, Claude, and I—had sat down at the dining room table. Lilian had laid the table, put out biscotti and cakes, and now brought in a steaming pot of tea. She chatted as we ate, but retained a certain watchfulness, monitoring the position and movement of every dish, tracking everything (I later realized), so that it did not get “lost.” She got up to take the empty dishes into the kitchen, leaving only the biscotti, which she saw that I especially liked. Claude and I chatted for a few minutes—our first talk alone—pushing the plate of biscotti between us.
When Lilian came back, and I packed my bag and prepared to go, she said, “You must take the rest of the biscotti with you”—but now, bizarrely, she could not find them, and became upset, almost frantic, at this. They were right on the table in their dish, but since the dish had been moved she no longer knew where they were, or even where to look. She seemed to have no strategy for looking. She was, however, quite startled to see my umbrella on the table. She failed to recognize it as an umbrella, noticing only that something curved and twisted had appeared—and wondered, for a half-serious moment, if it was a snake.
Before I left, I asked Lilian to go to the piano, asked if she would play something for me. She hesitated. It was clear that she had lost a good deal of her confidence. She started beautifully, on a Bach fugue, but broke off, apologetically, after a few bars. Seeing a volume of Chopin mazurkas on the piano, I asked about those, and, encouraged, she closed her eyes and played two of the Opus 50 mazurkas without faltering, and with great brio and feeling.
She told me afterward that the printed music was just “lying around,” saying, “It throws me off to see the score, people turning pages, my hands, or the keyboard,” and that, in such circumstances, she might make mistakes, especially with her right hand. She had to close her eyes and perform nonvisually, using only her “muscle memory,” and her fine ear.
What could I say about the nature and progress of Lilian’s strange disease? It had clearly advanced somewhat since her neurological examination three years before, and there were hints—though no more than hints—that her problems might no longer be purely visual. In particular, she occasionally had difficulty naming objects even when she recognized them, and would speak of a “thingmy” when she could not get the word.
I had ordered a new MRI to compare with her earlier one, and it showed that there was now some shrinkage of the visual areas on both sides of the brain. Was there any sign of real damage elsewhere? It was difficult to tell, although I suspected that there might have been some shrinkage in the hippocampi, too—parts of the brain crucial for the registration of new memories. But the damage was still largely confined to the occipital and occipitotemporal cortex, and it was clear that the rate of advance was very slow.
When I discussed these MRI findings with Claude, he stressed that in speaking with Lilian I should avoid certain terms, above all the frightening label of Alzheimer’s disease. “It’s not Alzheimer’s disease, is it?” he said. Clearly, this had been much on their minds.
“I’m not sure,” I said. “Not in the ordinary sense. One should see it as something rarer—and more benign.”
Posterior cortical atrophy, PCA, was first formally described by Frank Benson and his colleagues in 1988, although it has undoubtedly existed, unrecognized, for much longer. But Benson et al.’s paper provoked a rush of recognition, and dozens of cases have now been described.
People with PCA preserve elementary aspects of visual perception, such as acuity or the ability to detect movement or color. But they tend to experience complex visual disturbances—difficulties reading or recognizing faces and objects, occasionally even hallucinations. Their visual disorientation may become profound: some patients get lost in their own neighborhoods or even in their own homes; Benson called this “environmental agnosia.” Other difficulties commonly follow: left-right confusion, difficulty in writing and calculation, even an agnosia for one’s own fingers, a tetrad of problems sometimes called Gerstmann’s syndrome. Sometimes patients with PCA may be able to recognize and match colors but unable to name them, a so-called color anomia. More rarely, there can be a difficulty in visual targeting and tracking movements.
In contrast to these difficulties, memory, intelligence, insight, and personality tend to be preserved until late in the course of the disease. Every patient described by Benson, he writes, “could present his or her own history, was aware of current events, and showed considerable insight into his or her predicament.”
Although PCA is clearly a degenerative brain disease, it seems quite different in character from the commoner forms of Alzheimer’s, where gross changes in memory and thinking, in the comprehension and use of language, and often in behavior and personality tend to occur, and insight into what is happening (perhaps mercifully) is generally lost early on.
In Lilian’s case, the course of the disease seemed to have been relatively benign, for even nine years after her first symptoms, she did not get lost in her own home or neighborhood.
I could not help making a comparison, as Lilian herself had, with my patient Dr. P., “the man who mistook his wife for a hat.” Both of them were highly gifted professional musicians; both developed severe visual agnosias, while remaining remarkably intact in many other ways; and both had discovered or developed ingenious ways around their problems, so that it was possible for them to keep teaching at the highest level in music colleges, despite what might appear to be quite devastating disabilities.
The actual ways in which Lilian and Dr. P. coped with their illnesses were very different, though—a reflection in part of the severity of their symptoms, and in part of differences in temperament and training. Dr. P. was already in grave trouble when I saw him, barely three years after his initial symptoms. He had not only visual difficulties but tactile ones, too—he grasped his wife’s head and mistook it for a hat. He showed a sort of levity or indifference, and little insight into the fact that he was ill, and he often confabulated to make up for the fact that he could not identify what he was seeing. This was in strong contrast to Lilian, who, nine years after her first symptoms, had no substantial problems outside her visual ones, was still able to travel and teach, and showed acute insight into her own condition.
Lilian could still identify objects by inference, using her intact perception of color, shape, texture, and movement, along with her memory and intelligence. Dr. P. could not. He could not, for instance, identify a glove by sight or by feel (despite being able to describe it in almost absurdly abstract terms, as “a continuous surface infolded on itself [with] five outpouchings, if this is the word . . . a container of some sort?”)—until, by accident, he got it onto his hand. He was, in general, almost wholly dependent on doing things, on action, on flow. And singing, which for him was the most natural, irrepressible activity in the world, allowed him to bypass his agnosia to some extent. He had all sorts of songs that he would hum or sing: dressing songs, shaving songs, action songs. Music, he had found, could organize his activities, his daily life.1 This was not the case with Lilian. Her great musicality was also preserved, but it did not play a comparable role in her daily life; it was not, for her, a strategy for dealing with agnosia.
A few months later, in June of 1999, I again visited Lilian and Claude in their apartment—Claude was just back from his weeks in Europe, and Lilian, I gathered, had been moving freely within a four-block radius of their apartment, going to her favorite restaurant, shopping, doing errands. When I arrived, I saw that Lilian had been sending cards to her friends all over the world—there were envelopes addressed to Korea, to Germany, to Australia, to Brazil, scattered all over the table. Her alexia, clearly, had not diminished her correspondence, though the names and addresses sometimes straggled over the envelope. She seemed to be managing well in her own apartment, but how did she deal with shopping and the challenges of a busy New York neighborhood, even her own?
“Let’s go out, let’s wander,” I said. Lilian immediately started singing “Der Wanderer”—she loves Schubert—and then the elaboration of this in the Wanderer Fantasy.
In the elevator, she was greeted by some neighbors. It was not clear to me whether she recognized them visually or by their voices. She instantly recognized voices, sounds of all sorts; indeed, she seemed hyperattentive here, as she was to colors and shapes. They had assumed a special importance as cues.
She had no difficulty crossing the street. She could not read the “Walk” and “Don’t Walk” signs, but she knew their relative position and color; knew, too, that she could walk when the sign was blinking. She pointed out a synagogue on the corner opposite; other shops she identified by shapes or colors, as with her favorite diner, which had alternating black and white tiles.
We went into a supermarket and got a cart—she headed instantly to the alcove where these were. She had no difficulty in finding the fruit and vegetable section, or in identifying apples, pears, carrots, yellow peppers, and asparagus. She could not at first name a leek but said, “Is it a cousin of an onion?” and then got the missing word, “leek.” She was puzzled by a kiwifruit, until I let her handle it. (She thought it “delightfully furry, like a little mouse.”) I reached up for an object hanging above the fruit. “What is this?” I asked. Lilian squinted, hesitated. “Is it edible? Paper?” When I let her touch it, she burst into somewhat embarrassed laughter. “It’s an oven glove, a pot holder,” she said. “How could I be so silly?”
When we moved to the next section, Lilian called out, “Salad dressings on the left, oils on the right,” in the manner of a department-store elevator operator. She had obviously mapped the entire supermarket in her head. Wanting a particular tomato sauce, one of a dozen different brands, she picked it out because it had “a deep-blue rectangle and below that a yellow circle” on its label. “Color is of the essence,” she emphasized again. This is her most immediately visible cue, recognizable when nothing else is. (For that reason, fearing we might be separated, I had dressed entirely in red for our visit, knowing that it would allow her to spot me instantly if we did.)
But color was not always enough. If confronted with a plastic container, she might have no idea whether it contained peanut butter or cantaloupe. Often, she found that the simplest strategy was to bring in a used can or carton and ask someone for help in matching it.
As we left the market, she accidentally crashed the shopping cart into a pile of shopping baskets to her right. Such accidents, when they happen, are always to the right, because of her impaired visual awareness to this side.
Some months later, I arranged to see Lilian in my own office rather than at the clinic, where she had come before. She arrived promptly, having made her way to Greenwich Village from Penn Station. She had been in New Haven the night before, where her husband had given a concert, and he had seen her onto a train that morning. “I know Penn Station like the back of my hand,” she said, so she did not have problems there. But outside, in the melee of people and traffic, she noted, “there were many moments when I had to ask.” When I inquired about how she had been doing, she said her agnosia was getting worse. “When you and I went to the market together, there were many things I could recognize easily. Now, if I want to buy the same things, I have to ask people.” In general, she had to ask others to identify objects for her, or to help her if there were awkward steps, sudden changes of level, or irregularities in the ground. She depended more on touch and on hearing (to make sure, for instance, that she was facing the right way). And she depended increasingly on her memory, her thinking, her logic and common sense to help negotiate what would otherwise be—visually—an unintelligible world.
Yet, in my office, she immediately recognized a picture of herself on a CD cover, playing Chopin. “It looks slightly familiar,” she said with a smile.
I asked her what she saw on a certain wall of my office. First, she turned her chair not to the wall but to the window, and said, “I see buildings.” Then I rotated her chair for her until she faced the wall. I had to take her through it bit by bit. “Do you see lights?” Yes, there, and there. It took a little while to establish that she was looking at a sofa beneath the lights, though its color was commented on at once. She observed something green lying on the sofa, and astonished me by saying, correctly, that it was a stretch cord. She said she had been given such a cord by her physiotherapist. Asked what she saw above the couch (a painting with abstract geometric forms), she said, “I see yellow . . . and black.” What is it? I asked. Something to do with the ceiling, Lilian hazarded. Or a fan. A clock. Then she added, “I haven’t really found out whether it is one item or many.” It was in fact a painting done by another patient, a colorblind painter. But clearly Lilian had no idea that it was a painting, was not even sure that it was a single object, and thought that it might be part of the structure of the room.
I found all this puzzling. How was it that she could not clearly distinguish a striking painting from the wall itself, yet could instantly recognize a small photograph of herself on a CD? How could she identify a slender green stretch cord while failing to see, or recognize, the sofa it was on? And there had been innumerable such inconsistencies before.
I wondered how she could read the time, since she was wearing a wristwatch. She could not read the numbers, she said, but could judge the position of the hands. I then showed her, mischievously, a strange clock I have, in which the numbers are replaced by the symbols of elements (H, He, Li, Be, etc.). She did not perceive anything the matter with this, since for her the chemical abbreviations were no more or less unintelligible than numerals would have been.
We went out for a walk, I in a bright-colored hat for recognition. Lilian was bewildered by the objects in one shop window—but so was I. This was a Tibetan-handicrafts shop, but they could have been Martian handicrafts, given the exotic unfamiliarity of everything. The shop next to this one, curiously, she recognized at once, and mentioned having passed it on her way to my office. It was a clock shop, with dozens of clocks of different sizes and shapes. She told me later that her father had had a passion for clocks.
A padlock on the door of another store was a total puzzle, though Lilian thought it might be something “to open up . . . like a hydrant.” The moment she touched it, though, she knew what it was.
We stopped briefly for coffee; then I took her to my apartment, on the next block. I wanted her to try my grand piano, an 1894 Bechstein. Entering my apartment, she immediately identified the grandfather clock in the hall. (Dr. P., by contrast, had tried to shake hands with a grandfather clock.)
She sat at the piano and played a piece—a piece that I found puzzling, for it seemed familiar to me in a way, yet unfamiliar, too. Lilian explained that it was a Haydn quartet she had heard on the radio and been enchanted by a couple of years before and which she had longed to play herself. So she had arranged it for the piano, and had done so entirely in her head, overnight. She had occasionally arranged pieces for the piano before her alexia, using manuscript paper and the original score, but when this became impossible, she found that she could do it wholly by ear. She felt that her musical memory, her musical imagery, had become stronger, more tenacious, but also more flexible, so that she could hold the most complex music in her mind, then rearrange it and replay it mentally, in a way that would have been impossible before. Her continually strengthening powers of musical memory and imagery had become crucial to her, kept her going since the onset of her visual difficulties, nine years earlier.2
Lilian’s obvious confusion about what was what in my office, and in the little streets and shops around it, brought home to me how dependent she was on the familiar, the memorized; how anchored she was to her own apartment and her own neighborhood. In time, perhaps, if she were to visit a place frequently, she would gradually become more familiar with it, but this would be a hugely complex enterprise, demanding great patience and resourcefulness, a whole new system of categorization and memorization. It was clear to me, after this one visit of Lilian’s to my office, that in the future I should stick to house calls, visiting her in her own apartment, where she felt organized, in control, at home. Going out, for her, was becoming an increasingly surreal visual challenge, full of fantastic and sometimes frightening misperceptions.
Lilian wrote to me again in August of 2001, expressing growing concern. She said she hoped I might be able to come soon for a visit, and I suggested the following weekend.
She stood by her door to welcome me, knowing, as she did, my own (lifelong) defects of visual and topographic recognition, my confusion of left and right, and my inability to find my way around inside buildings. She welcomed me with great warmth, but also a touch of anxiety, which seemed to hover throughout the visit.
“Life is difficult,” she began, after she had seated me and given me a glass of seltzer. She had trouble finding the seltzer in her refrigerator, and, not seeing the bottle, which was “hidden” behind a jug of orange juice, she had taken to exploring the refrigerator by hand, groping for a bottle of the right shape. “It is not getting better. . . . The eyes are very bad.” (She knows, of course, that her eyes are fine, and that it is the visual parts of the brain that are declining—indeed, she realized this before anyone else—but she finds it easier, more natural, to refer to her “bad eyes.”) When I had gone shopping with her two years before, she had seemed to recognize almost everything she saw, or at least had it coded by shape and color and location, so that she hardly ever needed help. At that time, too, she moved infallibly about her kitchen, never losing anything, working efficiently. Today, she “lost” both the seltzer and the schmaltz herrings—a losing that entailed not only forgetting where she had put them but not recognizing them when she saw them. I observed that the kitchen was less organized than it had been before—and organization is crucial in her situation.
Lilian’s anomia, her problems with finding words, had increased, too. When I showed her some kitchen matches, she recognized them at once, visually, but could not say the word “match,” saying, instead, “That is to make fire.” The Sweet’n Low, similarly, she could not name, but identified as “Better Than Sugar.” She was well aware of these difficulties, and of her strategies for dealing with them. “When I can’t say something,” she explained, “I circumscribe.”
She said that although she had recently traveled to Ontario, to Colorado, and to Connecticut with her husband, she would not have been able to do this by herself, as she had only a few years before. She felt that she remained quite capable of looking after herself at home when Claude was away. Still, she said, “When I am alone, it is lousy. I’m not complaining—I’m describing.”
While Lilian was in the kitchen at one point, I asked Claude how he felt about these problems. He expressed sympathy and understanding, but added, “My impatience is provoked sometimes when I think that some of her weaknesses may be exaggerated. I’ll give you an example. I get puzzled, annoyed sometimes, because Lilian’s ‘blindness’ is sometimes ‘selective.’ Last Friday, she noticed that a painting was hung lopsidedly by a few millimeters. And sometimes she comments on people’s facial expressions in tiny photographs. She will touch a spoon and ask, ‘What is this?’ and then five minutes later look at a vase and say, ‘We have a similar one.’ I have found no pattern, only inconsistency. What should my attitude be when she grabs a cup and says, ‘What’s this?’ I sometimes don’t tell her. But this may be wrong, and the effect disastrous. What should I say?”
This was, indeed, a very delicate matter. How much should he intervene when she was faced with perceptual bewilderment? How much should we prompt a friend or a patient when he has forgotten someone’s name? How much do I myself—with no sense of direction—wish to be saved from blundering off in the wrong direction or left to battle out the right way by myself? How much do any of us like to be “told” anything? The question was especially vexing with Lilian, for, while she needed to work things out, fend for herself, her visual difficulties were becoming more severe all the time, and they sometimes threatened, as Claude observed, to throw her into a panic of disorientation. I could suggest no rule, I said to Claude, except that of tact: each situation would call for its own solution.
But I, too, was puzzled by the extraordinary variations in Lilian’s visual function. Some of them, it seemed, went with the reduced and unstable function of her damaged visual cortex—just as, ten years earlier, when the first problems appeared, her ability to read music would come and go. Some of the variations, I thought, might reflect fluctuations in blood flow. But some of the variations seemed to go with a decreasing ability, for whatever reason, to compensate in her usual way. Her ability to make use of her memory and her intellectual powers in place of direct visual recognition, I now felt, might also be diminishing at this point. Thus it was more important than ever for Lilian to “code” things, to provide easily used sensory clues—above all, color, to which she remained intensely sensitive.
What intrigued me especially was Claude’s mention of Lilian’s sudden abilities—her ability, for example, to perceive facial expressions on a tiny photograph, even though most of the time she had difficulty recognizing people at all. I could not help wondering whether this was an example of the preconscious abilities she had shown on earlier testing—as when she could categorize words, even though she could not recognize the objects they represented, as “living” or “nonliving.” Such unconscious recognition might be possible to some extent despite her agnosia, despite her cortical damage, because it made use of other, still intact mechanisms in the visual system.
An extraordinary firsthand account of “musical alexia with recovery” was published by Ian McDonald in 2006. It was the first such personal account to be published, and was doubly remarkable because McDonald himself was both a neurologist and a fine amateur musician. His musical alexia (along with other problems, including difficulties with calculation, face-blindness, and topographic disorientation) was caused by an embolic stroke, and he was to make a complete recovery.3 He stressed that, even though there was gradual improvement in his ability to read music, especially associated with practice, his musical alexia fluctuated considerably from day to day.
Lilian’s physicians initially thought that she, too, had had a stroke and that the variations in her abilities might go with this. But such fluctuations are typical of any neural system that has sustained damage, irrespective of the cause. Patients with sciatica from nerve-root compression have good and bad days, as do patients with impairments of sight or hearing. There is less reserve, less redundancy, when a system is damaged, and it is more easily thrown off by adventitious factors such as fatigue, stress, medications, or infections. Such damaged systems are also prone to spontaneous fluctuations, as my Awakenings patients experienced constantly.
Lilian had been ingenious and resilient in the eleven or twelve years since her illness started. She had brought inner resources of every kind to her own aid: visual, musical, emotional, intellectual. Her family, her friends, her husband and daughter, above all, but also her students and colleagues, helpful people in the supermarket or on the street—everyone had helped her cope. Her adaptations to the agnosia were extraordinary—a lesson in what could be done to hold together a life in the face of ever-advancing perceptual and cognitive challenge. But it was in her art, her music, that Lilian not only coped with disease but transcended it. This was clear when she played the piano, an art that both demands and provides a sort of superintegration, a total integration of sense and muscle, of body and mind, of memory and fantasy, of intellect and emotion, of one’s whole self, of being alive. Her musical powers, mercifully, remained untouched by her disease.
Her piano playing always added a transcendent note to my visits, and it recalled her, no less crucially, to her identity as an artist. It showed the joy she could still get and give, whatever other problems were now closing in on her.
When I revisited Lilian and Claude in 2002, I found the apartment full of balloons. “It was my birthday, three days ago,” Lilian explained. She did not look well and seemed somewhat frail, although her voice and her warmth were entirely unchanged. She said that her visual powers had deteriorated further, and this was all too evident as she groped for a chair to sit down on, walked in the wrong direction, and got lost inside her own apartment. Her behavior now looked much more “blind,” reflecting not only her increasing inability to decipher what faced her but a complete lack of visual orientation.
She was still able to write letters, but reading, even the painfully slow letter-by-letter reading that she could do a few years before, had become impossible. She adored being read to—Claude would read to her from newspapers and books—and I promised to send her some audiotapes. She could still go out a little, walking around the block on her husband’s arm. The two of them were closer than ever, with her increasing disability.
Despite all this, Lilian felt that her ear was as good as it always was, and she had been able to continue a little teaching, with students from the music college coming to her apartment. Apart from this, though, she no longer played the piano much.
And yet, when I mentioned the Haydn quartet she had played for me before, her face lit up. “I was absolutely enthralled by that piece,” she said. “I’d never heard it before. It’s very rarely played.” And she described for me again how, unable to get it out of her head, she had arranged it, mentally, for the piano, overnight. I asked her to play it for me again. Lilian demurred, and then, persuaded, started for the piano, but went in the wrong direction. Claude corrected her gently. At the piano, she first blundered, hitting wrong notes, and seemed anxious and confused. “Where am I?” she cried, and my heart sank. But then she found her place and began to play beautifully, the sound soaring up, melting, twisting into itself. Claude was amazed and moved by this. “She hasn’t played at all for two or three weeks,” he whispered to me. As she played, Lilian stared upward, singing the melody softly to herself. She played with consummate artistry, with all the power and feeling she had shown before, as Haydn’s music swelled into a furious turbulence, a musical altercation. Then, as the quartet drew to its final, resolving chords, she said, simply, “All is forgiven.”
Recalled to Life
PATRICIA H. was a brilliant and energetic woman who represented artists, ran an art gallery on Long Island, and was a talented amateur painter herself. She had raised her three children and, nearing sixty, continued to lead an active and even, as her daughters put it, “glamorous” life, with scouting expeditions to the Village and frequent soirées at home—she loved to cook, and there would often be twenty people for dinner. Her husband, too, was a man of many parts—a radio broadcaster, a fine pianist who sometimes performed at nightclubs, and politically active. Both were intensely sociable.
In 1989, Pat’s husband died suddenly of a heart attack. Pat herself had had open-heart surgery for a damaged valve the year before, and had been put on anticoagulants. She had taken this in stride—but with her husband’s death, as one of her daughters said, “She seemed stunned, became very depressed, lost weight, fell in the subway, had accidents with the car, and would show up, as if lost, on our doorstep in Manhattan.” Pat had always been somewhat volatile in mood (“She would be depressed for a few days and take to her bed, then leap up in an opposite frame of mind and rush into the city, with a thousand engagements of one sort and another”), but now a fixed melancholy descended on her.
When, in January of 1991, she did not answer her phone for two days, her daughters became alarmed and called a neighbor, who, with the police, broke into Pat’s house to find her lying in bed unconscious. She had been in a coma for at least twenty hours, the daughters were told, and had suffered a massive cerebral hemorrhage. There was a huge clot of blood in the left half of her brain, her dominant hemisphere, and it was thought that she would not survive
After a week in the hospital with no improvement, Pat underwent surgery as a last-ditch measure. The results of this, her daughters were told, could not be predicted.
Indeed, it seemed at first, after the clot was removed, that the situation was dire. Pat would “stare . . . without seeming to see,” according to one of her daughters. “Sometimes her eyes would follow me, or seem to. We didn’t know what was going on, whether she was there.” Neurologists sometimes speak of “chronic vegetative states,” zombie-like conditions in which certain primitive reflexes are preserved but no coherent consciousness or self. Such states can be cruelly tantalizing, for there is often the feeling that the person is about to come to—but the states may last for months or even indefinitely. In Pat’s case, though, it lasted for two weeks and then one day, as her daughter Lari recalled, “I had a Diet Coke in my hand—she wanted it. I saw her eye it. I asked, ‘Do you want a sip?’ She nodded. Everything changed at that moment.”
Pat was conscious now, recognized her daughters, was aware of her condition and her surroundings. She had her appetites, her desires, her personality, but she was paralyzed on the right side, and, more gravely, she could no longer express her thoughts and feelings in words; she could only eye and mime, point or gesture. Her understanding of speech, too, was much impaired. She was, in short, aphasic.
“Aphasia” means, etymologically, a loss of speech, yet it is not speech as such which is lost but language itself—its expression or its comprehension, in whole or in part. (Thus, congenitally deaf people who use sign language may acquire aphasia following a brain injury or stroke and be unable to sign or understand sign language—a sign aphasia in every way analogous to the aphasia of speaking people.)
There are many different forms of aphasia, depending on which parts of the brain are involved, and a broad distinction is usually made between expressive aphasias and receptive aphasias—if both are present, this is said to be a “global” aphasia.
Aphasia is not uncommon; it has been estimated that one person in three hundred may have a lasting aphasia from brain damage, whether as the consequence of a stroke, a head injury, a tumor, or a degenerative brain disease. Many people, however, have a complete or partial recovery from aphasia. (There are also transient forms of aphasia, lasting only a few minutes, which may occur during a migraine or a seizure.)
In its mildest forms, expressive aphasia is characterized by a difficulty finding words or a tendency to use the wrong words, without compromise of the overall structure of sentences. Nouns, including proper names, tend to be especially affected. In more severe forms of expressive aphasia, a person is unable to generate full, grammatically complete sentences and is reduced to brief, impoverished, “telegraphic” utterances; if the aphasia is very severe, the person is all but mute, though capable of occasional ejaculations (such as “Damn!” or “Fine!”). Sometimes a patient may perseverate on a single word or phrase which is uttered in every circumstance, to their evident frustration. I had one patient who, after her stroke, could say nothing but “Thank you, Mama” and another, an Italian woman, who could utter only “Tutta la verità, tutta la verità.”
Hughlings Jackson, a pioneer explorer of aphasia in the 1860s and ’70s, considered that such patients lacked “propositional” speech, and that they had lost internal speech as well, so they could not speak or “propositionize,” even to themselves. He felt therefore that the power of abstract thought was lost in aphasia, and in this sense, he compared aphasics to dogs.
In his excellent book Injured Brains of Medical Minds, Narinder Kapur cites many autobiographical accounts of aphasia. One of these is from Scott Moss, a psychologist who had a stroke at the age of forty-three, became aphasic, and later described his experiences, which were very much in accord with Hughlings Jackson’s notions about the loss of inner speech and concepts:
When I awoke the next morning in the hospital, I was totally (globally) aphasic. I could understand vaguely what others said to me if it was spoken slowly and represented a very concrete form of action. . . . I had lost completely the ability to talk, to read and to write. I even lost for the first two months the ability to use words internally, that is, in my thinking. . . . I had also lost the ability to dream. So, for a matter of eight to nine weeks, I lived in a total vacuum of self-produced concepts. . . . I could deal only with the immediate present. . . . The part of myself that was missing was [the] intellectual aspect—the sine qua non of my personality—those essential elements most important to being a unique individual. . . . For a long period of time I looked upon myself as only half a man.
Moss, who had both expressive and receptive aphasia, also lost the ability to read. For someone who has only an expressive aphasia, it may still be possible to read and to write (provided the writing hand is not paralyzed by the stroke).1
Another account was that of Jacques Lordat, an eminent early-nineteenth-century French physiologist who provided an extraordinary description of his own aphasia after a stroke, sixty-odd years before Hughlings Jackson’s studies. His experiences were quite different from Moss’s:
Within twenty-four hours all but a few words eluded my grasp. Those that did remain proved to be nearly useless, for I could no longer recall the way in which they had to be coordinated for the communication of ideas. . . . I was no longer able to grasp the ideas of others, for the very amnesia that prevented me from speaking made me incapable of understanding the sounds I heard quickly enough to grasp their meaning. . . . Inwardly, I felt the same as ever. This mental isolation which I mention, my sadness, my impediment and the appearance of stupidity which it gave rise to, led many to believe that my intellectual faculties were weakened. . . . I used to discuss within myself my life work and the studies I loved. Thinking caused me no difficulty whatever. . . . My memory for facts, principles, dogmas, abstract ideas, was the same as when I enjoyed good health. . . . I had to realize that the inner workings of the mind could dispense with words.
Thus in some patients, even if they are totally unable to speak or understand speech, there may be perfect preservation of intellectual powers—the power to think logically and systematically, to plan, to recollect, to anticipate, to conjecture.2
Nevertheless, a feeling remains in the popular mind—and all too often in the medical mind, too—that aphasia is a sort of ultimate disaster which, in effect, ends a person’s inner life as well as their outer life. Something along these lines was said to Pat’s daughters, Dana and Lari. A little improvement, they were told, might occur, but Pat would need to be put away for the rest of her life; there would be no parties, no conversation, no art galleries anymore—all that had constituted the very essence of Pat’s life would be gone, and she would lead the narrow life of a patient, an inmate, in an institution.
Scarcely able to initiate conversation or contact with others, patients with aphasia face special dangers in chronic hospitals or nursing homes. They may have therapy of every sort, but a vital social dimension of their lives is missing, and they frequently feel intensely isolated and cut off. Yet there are many activities—card games, shopping trips, movies or theater, dancing or sports—that do not require language, and these can be used to draw or inveigle aphasic patients into a world of familiar activities and human contact. The dull term “social rehabilitation” is sometimes used here, but really the patient (as Dickens might put it) is being “recalled to life.”
Pat’s daughters were determined to do everything they could to bring their mother back into the world, to the fullest possible life her limitations allowed. “We hired a nurse who retaught my mother how to feed herself, how to be,” Lari said. “Mother would get angry, sometimes strike her, but she, the nurse, would never give up. Dana and I never left her side. We would take her out, wheel her to my apartment. . . . We would take her out to restaurants, or bring food in, have her hair done, her nails manicured. . . . We never stopped.”
Pat was moved from the acute care hospital where she had had surgery to a rehabilitation facility. After six months, she was finally moved to Beth Abraham Hospital, in the Bronx, where I first met her.
When Beth Abraham Hospital was opened, in 1919, it was called the Beth Abraham Home for Incurables, a discouraging name that was changed only in the 1960s. Originally accommodating some of the first victims of the encephalitis lethargica epidemic (some of whom were still living there more than forty years later, when I arrived), Beth Abraham expanded over the years to become a five-hundred-bed hospital with active rehabilitation programs aimed at helping patients with all sorts of chronic conditions: parkinsonism, dementias, speech problems, multiple sclerosis, strokes (and, increasingly, spinal or brain damage from bullet wounds or car accidents).
Visitors to hospitals for the chronically ill are often horrified at the sight of hundreds of “incurable” patients, many of them paralyzed, blind, or speechless. One’s first thought is often: Is life worth living in circumstances like these? What sort of a life can these people have? One wonders, nervously, how one would react to the prospect of being disabled and entering such a home oneself.
Then one may start to see the other side. Even if no cure, or only limited improvement, is possible for most of these patients, many of them can nonetheless be helped to reconstruct their lives, to develop other ways of doing things, capitalizing on their strengths, finding compensations and accommodations of every sort. (This, of course, depends upon the degree and type of neurological damage, and upon the inner and outer resources of the individual patient.)
If the first sight of a chronic hospital can be hard for visitors, it can be terrifying for a new inmate; many react with horror mixed with sadness, bitterness, or rage. (Sometimes this even results in a full-blown “admission psychosis.”) When I first met Pat, shortly after her admission to Beth Abraham in October of 1991, I found her angry, tormented, and frustrated. She did not yet know the staff or the layout of the place, and she felt that a rigid, institutional order was being imposed on her. She could communicate through gestures—these were passionate, if not always understandable—but she still had no coherent speech (though occasionally, the staff said, she would exclaim “Hell!” or “Go away!” when she was angry). While she seemed to understand a good deal of what people said to her, it became clear, on examination, that she was responding not so much to words as to the tone of voice, facial expression, and gestures.
When I tested her in the clinic, Pat could not respond to “Touch your nose,” either in speech or in writing. She could count (“one, two, three, four, five . . .”) as a sequence, but could not say individual numbers or count backward. The right side of her body remained completely paralyzed. Her neurological situation, I noted in my report, was “a bad one. I fear there may not be too much recovery of language functions, but intensive speech therapy, as well as physical therapy and occupational therapy, must certainly be tried.”
Pat yearned to speak, but was continually frustrated when, after huge efforts to get a word out, it would be the wrong word, or unintelligible. She would try to correct it, but often would become more unintelligible with every attempt to make herself understood. It started to dawn on her, I think, that her power of speech might never come back, and increasingly she retreated into silence. This inability to communicate was, for her, as for many patients with aphasia, far worse than the paralysis of half her body. I would sometimes see her, in this first year after her stroke, sitting alone in the corridor or in the patients’ dayroom, bereft of speech, surrounded by a sort of penumbra of silence, with a stricken and desolate look on her face.
But a year later, I found Pat much improved. She had developed a knack for understanding other people by their gestures and expressions as much as their words. She could indicate her own thoughts and feelings not by speech but by eloquent gesture and mime. She indicated, for example, fluttering a couple of tickets, that she would go to the movies if, and only if, a friend of hers could go, too. Pat had become less angry, more sociable, and very aware of all that was going on around her.
This represented an enormous social improvement—an improvement in her ability to communicate—but I was not sure how much it rested on actual neurological improvement. Friends and relatives of aphasic patients often think that there is more neurological recovery than there actually is, because many such patients can develop a remarkable compensatory heightening of other, non-linguistic powers and skills, especially the ability to read others’ intentions and meanings from their facial expressions, vocal inflections, and tone of voice, as well as all the gestures, postures, and minute movements that normally accompany speech.
Such compensation may give surprising powers to the aphasic—in particular, an enhanced ability to see through histrionic artifice, equivocation, or lying. I described this in 1985,3 when I observed a group of aphasic patients watching a presidential speech on television, and in 2000 Nancy Etcoff and her colleagues at Massachusetts General Hospital published a study in Nature which showed that people with aphasia were in fact “significantly better at detecting lies about emotion than people with no language impairment.” Such skills, they observed, apparently took time to develop, for they were not evident in a patient who had been aphasic for only a few months. This seemed to be the case with Pat, who had initially been far from expert in picking up others’ emotions and intentions but over the years had become preternaturally skillful at it. If aphasic people come to excel in understanding nonverbal communication, they can also become expert in conveying their own thoughts in the same way—and Pat was now starting to move towards a conscious and voluntary (and often inventive) representation of her thoughts and intentions by mime.
Yet while gesture and mime, lacking the grammar and syntax of real language, are usually spared in aphasia, they are not enough; they have only a limited ability to convey complex meanings and propositions (unlike a true sign language, such as deaf people use). These limitations often infuriated Pat, but a crucial change came when her speech pathologist, Jeannette Wilkens, discovered that though Pat could not read a sentence, she could recognize individual words (and that, indeed, her vocabulary was quite extensive). Jeannette had found this with other aphasic patients as they started to recover, and she had devised a sort of lexicon for them, a book of words arranged in categories of objects, people, and events, as well as moods and emotions.
Such a lexicon often worked, Jeannette found, when patients were closeted in one-on-one sessions with her, but many aphasic patients had difficulty reaching out to others—perhaps they were too shy, too depressed, or too disabled from other medical conditions to initiate contact with other people.4 None of this was the case with Pat, who had been outgoing and social all her life. She always carried the book on her lap or at the side of her wheelchair, so she could leaf through it rapidly with her left hand and find the words she needed. She would boldly approach someone, open her book to the right page, thrust it at them, and point to the subject she wanted to talk about.
Pat’s life expanded in all sorts of ways with her “bible,” as her daughters called it. Soon she was able to guide a conversation in any direction she wanted, a conversation that was on her part accomplished solely by gesture and mime—and this had to be done primarily with her left arm, for her right side was still completely paralyzed. Nevertheless, the combination of gesture and mime with the words in her book allowed her a remarkably full and exact expression of her needs and thoughts.
Inside the hospital, she became a central social figure, despite being unable to communicate in the usual way. Her room became a chat room, with other patients often dropping by. Pat would talk to her daughters on the phone, they said, “a hundred times a day,” though the conversations were all passive on her part, awaiting simple questions to which she could answer “yes” (she communicated “yes” by kisses), “no,” or “fine,” or by noises of approbation, amusement, or disapproval.
By 1996, five years after her stroke, Pat’s receptive aphasia had lessened; she was able to understand a little speech, though still unable to express herself in speech. She had certain fixed phrases, like “You’re welcome!” or “Fine!,” but could not name familiar objects or utter a sentence. She started to paint once again, using her left hand, and she was a terror at dominoes—her nonverbal representational systems were unimpaired. (It has long been understood that aphasia need not affect musical ability, visual imagery, or mechanical aptitude, and Nicolai Klessinger and his colleagues at the University of Sheffield have shown that numerical reasoning and mathematical syntax can be entirely intact even in patients who are unable to understand or produce grammatical language.)
It is often said that following a stroke or a brain injury, no further recovery is possible after twelve to eighteen months. While this may sometimes be so, I have seen this generalization proved false in many individual patients. And in the past few decades neuroscience has confirmed that the brain has more powers of repair and regeneration than was once believed. There is far more “plasticity,” too, a greater capacity for undamaged brain areas to take over some of the functions of damaged ones, provided the damage is not too extensive. And at a personal level, there are powers of accommodation: finding new ways or other ways of doing things when the original way is no longer available. Even five years after her stroke, I noted that Pat was still showing a continuing, though very limited, improvement in her receptive powers, her ability to understand language.
Nonetheless, despite her ability to ejaculate a few words, and her ability to understand single words whether spoken or written, Pat was still, basically, bereft of organized language and seemed unable to “propositionize” either internally or to others. Wittgenstein, the philosopher, distinguished two methods of communication and representation: “saying” and “showing.” Saying, in the sense of propositionizing, is assertive and requires a tight coupling of logical and syntactic structure with what it asserts. Showing is not assertive; it presents information directly, in a nonsymbolic way, but, as Wittgenstein was forced to concede, it has no underlying grammar or syntactic structure. (A few years after Wittgenstein’s Tractatus was published, his friend Piero Sraffa made a gesture, snapped his fingers, and said, “What is the logical structure of that?” Wittgenstein could not answer.)
As Noam Chomsky revolutionized the study of language, Stephen Kosslyn has revolutionized the study of imagery, and where Wittgenstein writes of “saying” and “showing,” Kosslyn speaks of “descriptive” and “depictive” modes of representation. These modes are both available to the normal brain, and they are complementary, so that one may sometimes use one mode or the other, and often both together. Pat had largely lost her powers of propositionizing, of asserting, of describing, and showed little likelihood of regaining these. But her powers of depiction, spared by the stroke, were remarkably heightened in reaction to her loss of language. Her power to read others’ gestures and expressions and her virtuosity in expressing herself through gesture and mime constituted the two sides—receptive and expressive—of her depictive power.
Pat was the youngest of seven siblings; her extended family had always played a central part in her life, and this extended further still when Lari’s daughter Alexa, Pat’s first grandchild, was born in 1993. Alexa, said Lari, “was born into Beth Abraham.” She would visit her grandmother frequently, and Pat always had a special toy or treat for her (“I don’t know how she got these things,” Lari marveled). Pat would often ask Alexa to take crackers to a friend down the hall who could not walk. Alexa and her two younger siblings, Dean and Eve, were all fascinated by Pat and liked to call her often on the phone when they were unable to visit her. Lari felt that they had a very active, very “normal” relationship with their grandmother, a relationship they all treasured.
One of the pages in Pat’s book contained a list of emotional states (she had picked these out from a word list prepared by Jeannette, the speech pathologist). When I asked her, in 1998, what her predominant mood was, she pointed to “happy.” There were other adjectives on the mood page, such as “furious,” “scared,” “tired,” “sick,” “lonely,” “sad,” and “bored”—all of which she had indicated, on occasion, in previous years.
In 1999, when I asked her the date, she pointed to “Wednesday, July 28”—a little miffed, perhaps, that I had insulted her with such a simple question. She indicated, using her “bible,” that she had been to half a dozen musicals and a couple of art galleries in the past few months, and that, now that it was summer, she would visit Lari on Long Island on the weekends and, among other things, swim. “Swim?” I asked, incredulous. Yes, Pat indicated; even with her right side paralyzed, she could still do the sidestroke. She had been a great long-distance swimmer, she indicated, in her youth. She told me how excited she was that Lari would be adopting a new baby in a few months. I was especially struck, on this visit, eight years after her stroke, by the fullness and richness of Pat’s daily experiences and her voracious love of life in the face of what one might judge to be devastating brain damage.
In 2000, Pat showed me photos of her grandchildren. She had visited them all the previous day, for the Fourth of July, and they had watched the tall ships and the fireworks on television. She was eager to show me the newspaper, with a picture of the Williams sisters playing tennis. Tennis, she indicated, had been one of her favorite sports, along with skiing, riding, and swimming. She was at pains to show me that her fingernails were manicured and painted, and she was dressed in a sun hat and sunglasses, on her way to sun herself on the hospital patio.
By 2002, Pat had become able to use a few spoken words. This was achieved by the use of familiar songs like “Happy Birthday” or “A Bicycle Built for Two,” which she would sing along with Connie Tomaino, Beth Abraham’s music therapist. Pat was able to get the feeling of the music and some of the words. For a few minutes afterward, this would “release” her voice and give her the ability to say some of the words, in a singsong fashion. She started carrying a tape recorder with a cassette of familiar songs, so she could get her language powers working. She demonstrated this with “Oh, What a Beautiful Morning,” followed by a melodious “Good morning, Dr. Sacks,” with a heavy, rhythmic emphasis on “morning.”
Music therapy is invaluable for some patients with expressive aphasia; finding that they can sing the words to a song, they are reassured that language is not wholly lost, that they still have access to words somewhere inside them. The question is then whether the language capacities embedded in song can be removed from their musical context and used for communication. This is sometimes possible to a limited extent, by reembedding words in a sort of improvised singsong.5 But Pat’s heart was not in this—she felt that her real virtuosity lay in her mimetic powers, her appreciation and use of gesture. She had achieved a skill and intuitiveness here amounting almost to genius.
Mimesis, the deliberate and conscious representation of scenes, thoughts, feelings, intentions, and so on, by mime and action, seems to be a specifically human achievement, like language (and perhaps music). Apes, which are able to “ape,” or imitate, have little power to create conscious and deliberate mimetic representations. (In Origins of the Modern Mind, the psychologist Merlin Donald suggests that a “mimetic culture” may have been a crucial intermediate stage in human evolution, between the “episodic” culture of apes and the “theoretic” culture of modern man.) Mimesis has a much larger and more robust cerebral representation than language, and this may explain why it is so often preserved in patients who have lost language. This preservation can allow remarkably rich communication, especially if it can be elaborated and heightened and combined, as in Pat’s case, with a lexicon.
Pat had always had a passion to communicate (“This was a woman who talked twenty-four hours a day,” Dana said), and it was the frustration of this loquacity that led to despair and fury when she first arrived at the hospital, and to her intense motivation and success in communicating once Jeannette got her going.
Pat’s daughters were sometimes amazed at her resilience. “Why isn’t she depressed,” Dana said, “given her earlier history of depression? How could she live like this, I thought at first. . . . I thought she would take a knife to herself.” Every so often, Dana related, her mother would make a gesture that seemed to say, “My God, what happened? What is this? Why am I in this room?” as if the raw horror of her stroke had hit her once again. But Pat was aware that she had, in a sense, been very lucky, even though half of her body remained paralyzed. She was lucky that her brain damage, though extensive, did not undermine her force of mind or personality; lucky that her daughters fought so hard from the beginning to keep her engaged and active and were able to afford extra aides and therapists; lucky, too, that she encountered a speech pathologist who observed her sensitively and minutely, one who was so personally inspiring and could provide her with a crucial tool, her “bible,” which worked so well.
Pat continued to remain active and engaged with the world. She was, as Dana said, the “darling” of the family, and of the floor at the hospital, too. She had not lost the power to captivate people (“She has even captivated you, Dr. Sacks,” Dana observed), and she could do a little painting with her left hand. She was grateful to be alive and to be able to do as much as she could, and this, Dana thought, was why her mood and morale were so good.
Lari expressed herself in similar terms. “It’s as if the negativity has been wiped away,” she told me. “She is much more consistent, appreciative of her life and gifts . . . of other people, too. She is conscious of being privileged, but this makes her kinder, more thoughtful to other patients who may be physically less disabled than she is but much less ‘adapted’ or ‘lucky’ or ‘happy.’ She is the opposite of a victim,” Lari concluded. “She actually feels that she has been blessed.”
One cool Saturday afternoon in November, I joined Pat and Dana for one of Pat’s favorite activities: shopping on Allerton Avenue, near the hospital. When we arrived in Pat’sroom—it was overflowing with plants, paintings, photos and posters, theater programs—Pat was awaiting us, already wearing a favorite coat.
As we went up Allerton Avenue, bustling on a weekend afternoon, I saw that half the shopkeepers knew Pat; they shouted “Hi, Pat!” as she bowled past in her wheelchair. She waved at the young woman in the health food store where she buys her carrot juice, and received a “Hi, Pat!” back. She waved to a Korean woman at the dry cleaner’s, blew a kiss, and had a kiss blown back. The woman’s sister, Pat was able to indicate to me, used to work in the fruit store. We entered a shoe shop, where Pat’s desires were very clear: she wanted a boot with fur inside, for the upcoming winter. “Zip or Velcro?” Dana inquired. Pat indicated no preference, but wheeled herself in front of the boot display and then, with great decisiveness, pointed to the boots she wanted. Dana said, “But they have laces!” Pat smiled and shrugged, meaning, “So what! Someone else will tie them.” She is not without vanity—the boots had to be elegant as well as warm. (“Velcro, indeed!” her expression said.) “What size? A nine?” Dana asked. No, Pat gestured, bisecting her finger; an eight and a half.
We stopped by the supermarket, where she always picks up a few things for herself and for others at the hospital. Pat knew every aisle and quickly picked two ripe mangoes for herself, a large bunch of bananas (most, she gestured, she would give away), some small doughnuts, and, at the checkout, three bags of candy. (She indicated that these were for the children of an orderly on her floor.)
As we moved on, laden with our purchases, Dana asked me where I had been earlier in the day. I said I had been to a meeting of the Fern Society at the New York Botanical Garden, adding, “I’m a plant person.” Pat, overhearing, made a wide gesture and pointed to herself, meaning, “You and I. We are both plant people.”
“Nothing has changed since her stroke,” Dana said. “She has all her old loves and passions. . . . The only thing is,” she added, smiling, “she has become a pain in the neck!” Pat laughed, agreeing with this.
We stopped at a coffee shop. Pat clearly had no difficulty with the menu, indicating that she wanted not home fries but French fries, with whole wheat toast. After the meal, Pat carefully applied lipstick. (“How vain!” Dana exclaimed, with admiration.) Dana wondered whether she could take her mother on a cruise. I mentioned the giant cruise ships I had seen go in and out of Curaçao, and Pat, intrigued, inquired with her book whether they set out from New York. I tried to draw a ship in my notebook; Pat laughed and, left-handed, did a much better one.
A Man of Letters
IN JANUARY OF 2002, I received a letter from Howard Engel, the Canadian writer known for his Benny Cooperman series of detective novels, describing a strange problem. One morning a few months before, he wrote, he had got up feeling fine. He dressed and made breakfast and then went to the front porch to get his newspaper. But the paper on his doorstep seemed to have undergone an uncanny transformation:
The July 31, 2001, Globe and Mail looked the way it always did in its make-up, pictures, assorted headlines and smaller captions. The only difference was that I could no longer read what they said. The letters, I could tell, were the familiar twenty-six I had grown up with. Only now, when I brought them into focus, they looked like Cyrillic one moment and Korean the next. Was this a Serbo-Croatian version of the Globe, made for export? . . .Was I the victim of a practical joke? I have friends who are capable of such things. . . . I wondered what I might do to them that would improve on this piece of foolery. Then, I considered the alternative possibility. I checked the Globe’s inside pages to see if they looked as strange as the front page. I checked the want ads and the comics. I couldn’t read them either. . . .
Panic should have hit me like the proverbial ton of bricks. But instead I was suffused with a reasonable, business-as-usual calm. “Since this isn’t somebody’s idea of a joke, then, it follows, I have suffered a stroke.”
Along with this realization came a memory of a case history he had read a few years earlier, my own “Case of the Colorblind Painter.”1 He remembered in particular how my patient, Mr. I., following a head injury, found himself unable to read the police accident report—he saw print of different sizes and types but could make nothing of it, and said it looked “like Greek or Hebrew.” He remembered, too, that Mr. I.’s inability to read, his alexia, had lasted for five days and then cleared.
Howard kept testing himself, turning over the pages, to see if everything would suddenly snap back to normal. Then he went into his library; maybe, he thought, “books would behave better than the newspaper.” The room looked normal, and he noted that he could still read his clock, but his books—some in French and German, as well as English—were all unintelligible, all full of the same “Oriental”-looking script.
He woke his son, and together they took a cab to the hospital. Along the way, Howard thought he saw “familiar landmarks in unfamiliar places,” and he could not read the names of streets as they passed, nor the words “Emergency Room” when they arrived at the hospital—though he at once recognized the picture of an ambulance over the door. He underwent a battery of tests, and these confirmed his own suspicion: he had indeed had a stroke; he was told that it affected a limited area of the visual parts of the brain, on the left side. During the intake interview at the hospital, he later recalled, he was somewhat confused: “I was unable to pinpoint my exact relationship to my son. . . . I forgot my name, my age, my address, and a dozen other things.”
Howard spent the next week in the neurology ward at Toronto’s Mount Sinai Hospital. During this time it became clear that he had other visual problems besides his inability to read: he had a large blind spot in the upper right quadrant of his visual field, and he had difficulties recognizing colors, faces, and everyday objects. These difficulties would come and go, he noted:
Familiar objects like apples and oranges suddenly look[ed] strange, as unfamiliar as an exotic piece of Asian fruit. A rambutan. I would surprise myself with not knowing whether I was holding an orange or a grapefruit, a tomato or an apple. Usually, I could sort them out by sniffing or squeezing.
He often forgot things he once knew perfectly well, and became shy of conversation, he wrote, “lest I forget the name of the prime minister or who wrote Hamlet.”
Yet he was surprised to find, as a nurse reminded him, that he could still write, even though he could not read; the medical term, she said, was “alexia sine agraphia.” Howard was incredulous—surely reading and writing went together; how could he lose one but not the other?2 The nurse suggested that he sign his name; he hesitated, but once he started, the writing seemed to flow all by itself, and he followed his signature with two or three sentences. The act of writing seemed quite normal to him, effortless and automatic, like walking or talking. The nurse had no difficulty reading what he had written, but he himself could not read a single word. To his eyes, it was the same indecipherable “Serbo-Croatian” he had seen in the newspaper.
We think of reading as a seamless and indivisible act, and as we read we attend to the meaning and perhaps the beauty of written language, unconscious of the many processes that make this possible. One has to encounter a condition such as Howard Engel’s to realize that reading is, in fact, dependent on a whole hierarchy or cascade of processes, which can break down at any point.
In 1890, the German neurologist Heinrich Lissauer used the term “psychic blindness” to describe how some patients, after a stroke, became unable to recognize familiar objects visually.3 People with this condition, visual agnosia, can have perfectly normal visual acuity, color perception, visual fields, and so on—yet be totally unable to recognize or identify what they are seeing.
Alexia is a specific form of visual agnosia, an inability to recognize written language. Since the French neurologist Paul Broca in 1861 had identified a center for the “motor images” of words, as he called it, and his German counterpart Carl Wernicke, a few years later, identified one for the “auditory images” of words, it seemed logical to nineteenth-century neurologists to suppose that there might also be an area in the brain dedicated to the visual images of words—an area that, if damaged, would produce an inability to read, a “word blindness.”4
In 1887, a French neurologist, Joseph-Jules Déjerine, was asked by an ophthalmologist colleague to see a highly intelligent, cultivated man who had suddenly lost the ability to read. Edmund Landolt, the ophthalmologist, wrote a short but vividly evocative portrait of the patient, and Déjerine, in his own paper on the subject, included a long excerpt from this.
They described how in October of that year, Oscar C., a retired businessman, found himself suddenly unable to read. (He had had some brief attacks of numbness in his right leg on previous days, but had paid little attention to them.) Though reading was impossible, Monsieur C. had no difficulty recognizing people and objects around him. Nevertheless, thinking that his eyes must be at fault, he consulted Landolt, who wrote:
Asked to read an eye chart, C is unable to name any letter. However, he claims to see them perfectly. He instinctively sketches the form of the letters with his hand, but he is nevertheless unable to say any of their names. When asked to write on a paper what he sees, he is able, with great difficulty, to recopy the letters, line by line, as if he were making a technical drawing, carefully examining each stroke in order to reassure himself that his drawing is exact. In spite of these efforts, he remains incapable of naming the letters. He compares the A to an easel, the Z to a serpent, and the P to a buckle. His incapacity to express himself frightens him. He thinks that he has “gone mad,” since he is well aware that the signs he cannot name are letters.5
Like Howard Engel, Monsieur C. was unable to read even the headlines of his morning paper, although he nonetheless recognized it, by its format, as his usual newspaper, Le Matin. And, like Howard, he could write perfectly well:
While reading is impossible, the patient . . . can write fluently and without any mistakes whatever material is dictated to him. But should he be interrupted in the middle of a phrase that he is writing . . . he becomes muddled and cannot start up again. Also, if he makes a mistake he can’t find it. . . . He can never reread what he has written. Even isolated letters do not make sense to him. He can only recognize them . . . by tracing the outlines of the letter with his hand. Therefore it is the sense of the muscular movement that gives rise to the letter name. . . .
He is able to do simple addition, since he recognizes, with relative ease, numbers. However, he is very slow. He reads the numbers poorly, since he cannot recognize the value of several numbers at once. When shown the number 112, he says, “It is a 1, a 1, and a 2,” and only when he writes the number can he say “one hundred and twelve.”6
There were some additional visual problems—objects appeared dimmer and a little blurred on the right side and completely devoid of color. These problems, along with the specificity of Oscar C.’s alexia, indicated to Landolt that the underlying problem was not in the eyes but in the brain; this led him to refer his patient to Déjerine.
Déjerine was fascinated by Monsieur C.’s condition and arranged to see him twice weekly at his clinic in Paris. In a monumental 1892 paper, Déjerine summarized his neurological findings succinctly and then, in a much more leisurely style, provided a general picture of his patient’s life:
C spends his days taking long walks with his wife. He has no difficulty walking and every day he does his errands on foot from the Boulevard Montmartre to the Arc de Triomphe and back. He is aware of what is happening around him, stops in front of stores, looks at paintings in gallery windows, etc. Only posters and signs in shops remain meaningless collections of letters for him. He often becomes exasperated by this, and though he has been so afflicted for four years, he has never accepted the idea that he cannot read, while remaining able to write. . . . In spite of patient exercises and much effort, he has never relearned the sense of letters and written words, nor has he ever relearned how to read musical notes.
Despite this, Oscar C., an excellent singer, could still learn new music by ear, and he continued to practice music with his wife every afternoon. And he continued to enjoy and excel at playing cards: “He is a very good card player, calculates very well, prepares his blows well in advance and wins most of the time.” (Déjerine did not comment on how Monsieur C. was able to “read” the cards, but it seems likely that he recognized the iconic images of hearts, diamonds, spades, clubs, jacks, queens, and kings—just as Howard Engel recognized the icon of an ambulance when he arrived at the emergency room. Number cards, of course, can also be recognized by their patterns.)
When Oscar C. died following a second stroke, Déjerine performed an autopsy and found two lesions in the brain: an older one, which had destroyed part of the left occipital lobe and which he presumed was responsible for Monsieur C.’s alexia, and a larger, recent lesion, which had probably caused his death.7
It is always difficult to make inferences from the appearance of the brain at autopsy; one may find damaged areas, but it is not always possible to see their manifold connections with other areas of the brain or to determine what controls what. Déjerine was well aware of this; nonetheless, he felt that by relating a specific neurological symptom—alexia—to damage in a particular area of the brain, he had, in principle, demonstrated what he called a “visual center for letters” in the brain.
Déjerine’s discovery of this area essential for reading would be confirmed over the next hundred years by scores of similar cases and autopsy reports of patients with alexia, irrespective of its cause.
By the 1980s, CT scanning and MRIs made it possible to visualize living brains with an immediacy and precision impossible in autopsy studies (where all sorts of secondary changes may blur the picture). Using this technology, Antonio and Hanna Damasio and, later, other researchers, were again able to confirm Déjerine’s findings, and to correlate their alexic patients’ symptoms with highly specific brain lesions.
With the development of functional brain imaging a few years later, it became possible to visualize the activity of the brain in real time, as subjects performed various tasks. A pioneer PET scan study in 1988 by Steven Petersen, Marcus Raichle, and their colleagues showed the different areas of the brain activated by reading words, listening to words, uttering words, and associating words. “For the first time in history,” as Stanislas Dehaene writes in his book Reading in the Brain, “the areas responsible for language had been photographed in the living human brain.”
Dehaene, a psychologist and neuroscientist, has specialized in studying the processes involved in visual perception, especially the recognition and representation of words, letters, and numbers. Using fMRI technology, which is much swifter and more sensitive than PET scanning, he and his colleagues have been able to focus even more closely on what he calls the visual word form area or, more informally, “the brain’s letterbox.”
Dehaene’s studies (with Laurent Cohen and others) have shown how the visual word form area can be activated in a fraction of a second by a single written word, and how this initial, purely visual activation then spreads to other areas of the brain—especially the temporal lobes and the frontal lobes.
Reading, of course, does not end with the recognition of visual word forms—it would be more accurate to say that it begins with this. Written language is meant to convey not only the sound of words but their meaning, and the visual word form area has intimate connections to the auditory and speech areas of the brain as well as to the intellectual and executive areas, and to the areas subserving memory and emotion.8 The visual word form area is a crucial node in a complex cerebral network of reciprocal connections—a network peculiar, it seems, to the human brain.
As a prolific writer and an omnivorous reader, accustomed to reading newspapers every morning and many books each week, Howard Engel wondered how he would manage life with his alexia, which showed no signs of clearing. In a world full of traffic signs, printed labels, and directions on everything from a prescription bottle to the television, ordinary life is a continuing, daily struggle for anyone with alexia. But for Howard, this was an even more desperate situation, for his whole life and identity (to say nothing of his livelihood) depended on his ability to read and write.
Being able to write without reading might be all right for a short letter or memorandum, a page or two. But for the most part, he thought, it “was like being told that the right leg had to be amputated but that I could keep the shoe and sock.” How could he hope to go back to his previous work—to write an elaborate narrative of crime and detection, full of plots and counterplots, to do all the corrections and revisions and redrafting a writer must do—without being able to read? He would have to get others to read for him, or perhaps get one of the ingenious new software programs that would allow him to scan what he had written and hear it read back to him by a computer. Both of these would involve a radical shift from the visuality of reading, the look of words on a page, to an essentially auditory mode of perception—going, in effect, from reading to listening and, perhaps, from writing to speech. Would this be desirable—or even possible?
Precisely this question had forced itself on another writer who consulted me ten years earlier. Charles Scribner, Jr., was also a man of letters; he presided over the publishing house established by his great-grandfather in the 1840s. In his sixties, he developed a visual alexia—probably as a result of a degenerative process in the visual parts of the brain. It was a devastating problem for a man who had published the work of Hemingway and others, a man whose life was centered on reading and writing.
As a book publisher, Scribner slightly disapproved of audiobooks, which had recently been introduced to the general public. But he decided nonetheless to reconstruct his entire literary life in an auditory mode. To his surprise, this did not prove as difficult as he expected. He even began to enjoy listening to audiobooks:
It never dawned on me that these spoken books would become a major part of my intellectual life and recreational reading. By now I must have “read” hundreds of books in this way. I was never a rapid reader as a boy, although my retention was high. Paradoxically, now that I was reading books on tape, my reading speed was better than ever and my retention just as good. I can fairly say that for me the discovery of this mode of reading was a kind of “open sesame” to my continued enjoyment of literature.9
Like Howard, Scribner preserved the power to write, but he was so deeply distressed by his inability to read what he had written that he decided to change to dictation, something he had never before tried. Luckily, this too was successful—dictation worked so well that it allowed him to complete more than eighty newspaper columns and two book-length memoirs about his life in publishing. “Perhaps,” he wrote, “it’s another instance of a handicap honing a skill.” Apart from his close friends and family, no one seemed aware that he had accomplished all this by switching to an entirely new mode.
One might have expected Howard, too, to turn to an auditory mode of “reading” and writing, but his course was very different.
After his week at Mount Sinai Hospital, he was moved to a rehabilitation hospital, where he spent almost three months studying himself, what he could and could not do. When he was not trying to read a paper or a get-well card, he found, he could forget about his alexia:
The sky looked blue, the sun shone on the hospital windows, the world hadn’t suddenly become unfamiliar. My alexia existed only when I had my head buried in a book. Print brought it on and reminded me that, yes, there was a problem. Thus was born the temptation to simply avoid reading.
But this, he quickly realized, was unacceptable to him as a reader and a writer. Audiobooks might do for some, but not for him. He still could not even recognize individual letters, but he was determined to read again.
Two months after his stroke, still living at the rehab hospital, Howard had continuing difficulties recognizing places; he would get lost within the hospital three or four times a day and could not find his own room until he finally learned to recognize its floor “by the way the light filled the hall just opposite the elevator.” He continued to have some object agnosia, too—even when he returned home after three months, he noted, “I kept finding cans of tuna in the dishwasher and jars of pencils in the freezer.”
But with reading, Howard noted some signs of improvement: “the words no longer looked like they were written in an unfamiliar alphabet. The letters themselves looked like ordinary English letters, not the Serbo-Croatian I had imagined [after] my stroke.”
There are two forms of alexia: a severe form which prevents even individual letters from being recognized and a milder form, in which letters can be recognized but only one by one, not simultaneously as words. Howard seemed to have moved, at this point, to the milder form—perhaps due to a partial recovery of the tissues affected by his stroke, or the brain’s use (or perhaps even construction) of alternative pathways.10
Given this neurological improvement, he was able, with his therapists, to explore new ways of trying to read. He would slowly and laboriously puzzle out words, letter by letter, forcing himself to decipher the names of streets and shops or the headlines of newspapers. “Familiar words,” he said,
including my own name, are unfamiliar blocks of type and have to be sounded out slowly. Each time a name recurs in an article or review, it hits me as unfamiliar on its last appearance as it does on the first.
Yet he persisted.
Even though the reading was slow and difficult—frustrating as hell at times—I was still a reader. The blast to my brain could not make me otherwise. Reading was hard-wired into me. I could no more stop reading than I could stop my heart. . . . The idea of being cut off from Shakespeare and company left me weak. My life had been built on reading everything in sight.
Howard’s reading grew somewhat easier with practice, though it might take him several seconds to make out a single word. “Words of different lengths,” he observed, “like cat, table and hippopotamus, are processed in my head at a different rate. Each added letter adds more weight to the load that I am trying to lift.” Scanning a page, reading in the usual sense, was still impossible, and “the whole process,” he wrote, “was exhausting beyond belief.” Sometimes, however, if he looked at a word, a couple of letters would suddenly jump out at him and be recognized—for example, the bi in the middle of his editor’s name, though the letters before and after this remained unintelligible. He wondered whether such “chunking” was the way he had originally learned to read as a child, perhaps the way we all learn to read, before we go on to perceive words, even sentences, as a whole. (Pairs and perhaps clusters of letters are particularly important in the construction and reading of words, and whether reading is being learned for the first time or relearned after a stroke, there seems to be a natural progress from seeing single letters to seeing letter pairs or sequences. Dehaene and his colleagues suggest that there may be special “bigram” neurons in the brain devoted to this.)
“I can make myself see that certain letter groupings are indeed familiar words,” Howard wrote to me, “but that comes only after I have stared at the page.”
Becoming a fluent reader is a difficult and multileveled task; most children need years of practice and instruction to achieve this (though a few precocious ones may learn to read by themselves, and at an early age). In some ways, Howard had been reduced to the level of a child first learning his ABC’s. But with a lifetime of experience as a reader, he could also bypass his disabilities to some extent, for his large vocabulary, his grammatical sense, and his command of literary and idiomatic English helped him to guess or infer words and even sentences from the slightest hint.
Whatever language a person is reading, the same area of inferotemporal cortex, the visual word form area, is activated. It makes relatively little difference whether the language uses an alphabet, like Greek or English, or ideograms, like Chinese.11 This has been confirmed by lesion studies such as Déjerine’s, and by imaging studies. And this idea is supported, too, by “positive” disorders—excesses or distortions of function produced by hyperactivity of the same area. The opposite of alexia, in this sense, is lexical or text hallucination, or phantom letters. People with disorders of the visual pathway (anywhere from the retina to the visual cortex) may be prone to visual hallucinations, and Dominic ffytche and his colleagues estimate that about a quarter of these patients who hallucinate see “text, isolated words, individual letters, numbers, or musical note hallucinations.” Such lexical hallucinations, as ffytche and his colleagues have found, are associated with conspicuous activation of the left occipitotemporal region, especially the visual word form area—the same area that, if damaged, produces alexia.
So whether we are examining patients with alexia, patients with lexical hallucinations, or normal subjects reading, in any language, we are forced to the same conclusion: that there exists, in every literate human being, an area in the dominant hemisphere—the language hemisphere—a neuronal system potentially available for the recognition of letters and words (and perhaps other forms of visual notation—mathematical or musical, for example).
This raises a deep problem: Why should all human beings have this built-in facility for reading, when writing is a relatively recent cultural invention?
Communication by the spoken word—and, therefore, its neural basis—has every mark of having evolved through the gradual processes of natural selection. The changing anatomy of the brain in prehistoric man has been worked out in some detail from endocranial casts and other fossil evidence, as have changes in the vocal tract. It is clear that the beginnings of speech go back hundreds of thousands of years. But this cannot be maintained in regard to reading, for writing emerged little more than five thousand years ago—far too recently to have occurred through evolution by natural selection. Though the visual word form area of the human brain appears so exquisitely tuned to the act of reading, it could not have evolved specifically for this purpose.
We might call this the Wallace problem, for Alfred Russel Wallace (who discovered natural selection independently of Darwin) became intensely concerned with the paradox of the human brain’s many potential abilities—lexical, mathematical, and so on—abilities that would be of little use in a primitive or prehistoric society. While natural selection could explain the appearance of immediately useful abilities, he felt, it could not explain the existence of potential powers that might become manifest only with the development of an advanced culture hundreds of thousands of years in the future.
Unable to attribute these human potentials to any natural process, Wallace found himself constrained to invoke the supernatural: God, he believed, must have implanted them in the human psyche. There could hardly, from Wallace’s perspective, be a better example of a divine gift—a unique new power, biding its time, in posse, waiting for the rise of a sufficiently advanced culture.12
Darwin, understandably, was horrified by this idea and wrote to Wallace, “I hope you have not murdered too completely your own and my child.” Darwin, for his part, had a much more open view of the process of natural selection and adaptation, foreseeing that biological structures might find uses very different from those for which they had originally evolved. (Stephen Jay Gould and Elisabeth Vrba called this sort of redeployment an “exaptation” rather than a direct adaptation.)13
How, then, did the visual word form area of the human brain arise? Does it exist in the brains of illiterate people? Does it have a precursor in the brains of other primates?
We are all faced with a world of sights and sounds and other stimuli, and our survival depends on making a rapid and accurate appraisal of these. Making sense of the world around us must be based on some sort of system, some swift and sure way of parsing the environment. Although seeing objects, defining them visually, seems to be instantaneous and innate, it represents a great perceptual achievement, one that requires a whole hierarchy of functions. We do not see objects as such; we see shapes, surfaces, contours, and boundaries, presenting themselves in different illumination or contexts, changing perspective with their movement or ours. From this complex, shifting visual chaos, we have to extract invariants that allow us to infer or hypothesize objecthood. It would be uneconomical to suppose that there are individual representations or engrams for each of the billions of objects around us. The power of combination must be called on; one needs a finite set or vocabulary of shapes that can be combined in an infinite number of ways, much as the twenty-six letters of the alphabet can be assembled (within certain rules and constraints) into as many words or sentences as a language ever needs.
There may be some objects that are recognized at birth, or soon after, like faces. But beyond this, the world of objects must be learned through experience and activity: looking, touching, handling, correlating the feel of objects with their appearance. Visual object recognition depends on the millions of neurons in the inferotemporal cortex, and neuronal function here is very plastic, open and highly responsive to experience and training, to education. Inferotemporal neurons evolved for general visual recognition, but they may be recruited for other purposes—most notably reading.
Such a redeployment of neurons is facilitated by the fact that all (natural) writing systems seem to share certain topological features with the environment, features which our brains evolved to decode. Mark Changizi, Shinsuke Shimojo, and their colleagues at Caltech examined more than a hundred ancient and modern writing systems, including alphabetic systems and Chinese ideograms, from a computational point of view. They have shown that all of them, while geometrically very different, share certain basic topological similarities. (This visual signature is not evident in artificial writing systems, such as shorthand, which are designed to emphasize speed more than visual recognition.) Changizi et al. have found similar topological invariants in a range of natural settings, and this has led them to hypothesize that the shapes of letters “have been selected to resemble the conglomerations of contours found in natural scenes, thereby tapping into our already-existing object recognition mechanisms.”
Writing, a cultural tool, has evolved to make use of the inferotemporal neurons’ preference for certain shapes. “Letter shape,” Dehaene writes, “is not an arbitrary cultural choice. The brain constrains the design of an efficient writing system so severely that there is little room for cultural relativism. Our primate brain only accepts a limited set of written shapes.”14
This is an elegant solution to the “Wallace problem”—indeed, it shows that there is no problem. The origin of writing and reading cannot be understood as a direct evolutionary adaptation. It is dependent on the plasticity of the brain, and the fact that even within the small span of a human lifetime, experience—experiential selection—is as powerful an agent of change as natural selection. Natural selection, for Darwin, did not forbid cultural and individual developments on a timescale hundreds of thousands of times faster than evolutionary development—on the contrary, it prepared the ground for them. We are literate not by virtue of a divine intervention, but through a cultural invention and a cultural selection that makes a brilliant and creative new use of a preexisting neural proclivity.
While the visual word form area is crucial in the recognition of words and letters, many other areas of the brain are involved in “higher” levels of reading. This enabled Howard, for instance, to infer words from their context. Even now, nine years after his stroke, he is unable to recognize many simple words at a glance—but his writer’s imagination does not just depend on reading.
While he was still in the rehab hospital, one of his therapists suggested that he keep a “memory book” to remind himself of appointments and to record his thoughts. As a lifelong keeper of journals, Howard was delighted by this idea. His new memory book proved to be an invaluable aid not only in stabilizing his still erratic memory but in reinforcing his identity as a writer:
I knew I could no longer rely on the “sticking plaster” of memory. I could forget a word in the second part of what I was saying, even though I had already used the word a moment earlier. . . . I learned to write things down in the “memory book” [the moment I thought of them]. . . . The memory book gave a lift to my sense of being in the driver’s seat of my life. [It] became my constant companion: part diary, part appointment book, part commonplace book. Hospitals, to a degree . . . breed a passive spirit; the memory book returned a piece of myself to me.
Keeping the memory book invited him, forced him, to write every day—not only at the level of forming legible words and sentences but at a much deeper creative level. His journal of hospital life, with its various routines and characters, began to stir his writer’s imagination.
Occasionally, with unusual words or proper names, Howard might be unsure of their spelling—he could not “see” them in his mind’s eye, imagine them, any more than he could perceive them when they were printed before him. Lacking this internal imagery, he had to employ other strategies for spelling. The simplest of these, he found, was to write a word in the air with his finger, letting a motor act take the place of a sensory one.
The great French neurologist Jean-Martin Charcot, in an 1883 lecture on a case of word blindness, describes a patient who, like Howard, has alexia sine agraphia. Charcot writes down the name of the hospital (which the patient himself has written earlier) and asks him to read it: “[The patient] is unable to do so at first; but he makes further efforts to do it and while he is accomplishing the task we notice that he traces, with the end of his right index finger, one of the letters which constitute the word, and with much trouble he says ‘La Salpêtrière.’” When Charcot gives him the name of a street to read, the patient “traces with his finger in space the letters which compose the word, and after a moment or two says, ‘It is the Rue d’Aboukir, the address of my friend.’”
Charcot’s patient improved rapidly in “reading” by tracing letters in the air, and within three weeks, his reading speed had increased nearly sixfold. He said, “I can read printing less well than writing, because in writing it is easier for me to mentally reproduce the letter with my right hand, whereas it is more difficult to reproduce the printed characters.” (“When reading printed matter,” Charcot noted, “it is convenient for him to have a pen in his hand.”) Concluding his lecture, Charcot emphasized, “Briefly put, one can say of him that he reads only in the act of writing.”
Increasingly and often unconsciously, then, Howard started to move his hands as he read, tracing the outlines of words and sentences still unintelligible to his eyes. And most remarkably, his tongue, too, began to move as he read, tracing the shapes of letters on his teeth or the roof of his mouth. This enabled him to read considerably faster (though it still might take him a month or more to read a book he could previously have read in an evening). Thus, by an extraordinary, metamodal, sensory-motor alchemy, Howard was replacing reading by a sort of writing. He was, in effect, reading with his tongue.15
More than three months after his stroke, Howard returned from rehab to a home he did not entirely recognize:
The house looked strange and familiar at the same time. . . . It was as though a movie set had been assembled from sketches of the real house and its rooms. Most peculiar was my office. I looked at my computer with a strange feeling. My whole office, where I had written several of my books, resembled a diorama in a museum. . . . On scribbled stick-on notes, my own handwriting looked strange, unfamiliar.
Would he ever be able to use this alien computer—once the main tool of his trade—again? With his son’s help, and to his own surprise, he started to test out his old computer skills and soon felt them coming back. But writing something creative was another matter. And reading, even reading his own erratic handwriting, was still agonizingly slow and difficult. Furthermore, as he later wrote,
I had been out of the world for months. I could no longer keep things straight in my head. What business did I have imagining that I might go back to my old desk and begin again? I was clearly unfit for fiction. I turned off the computer and took a long walk.
Nonetheless, Howard had been, in a sense, staying in practice, writing every day, if only in his memory book. At first, he wrote,
I had no thoughts of writing a book. That was not only well beyond my abilities, it was also beyond my imagination. But without my knowing it, another part of my brain was beginning to plot out a story. Images began popping into my head. Plots and plot twists began haunting my imagination. While I [had been] lying in my hospital bed . . . I was hard at work inventing story and characters and situations for the book I still didn’t know I was writing.
He decided to write—if he could—a new novel, following his mother’s old advice:
Write about what you know. . . . What I knew about now was my illness. I knew the hospital routines and the people around me. I could do a book that described what it was like to be out of things, flat on my back for a time with nurses and doctors ordering and reordering my days.
He would reintroduce his alter ego, the detective Benny Cooperman, but it would be a Cooperman transformed: the great detective, waking in a hospital bed, finds himself not only alexic but amnesic as well. His powers of inference, however, are intact and enable him to stitch together disparate clues, to figure out how he landed in the hospital and what happened in the mysterious few days he can no longer remember.
Howard moved into high gear, typing for hours each day on his computer. Within a few weeks, his imagination and creative flow enabled him to produce a first draft. The problem now was how to correct and revise the draft, given his problems with short-term memory and his inability to read in the normal way. He employed many devices using his word processor—indenting certain paragraphs, marking passages with different font sizes—and after he had done as much as he could by himself, he got his editor to read the entire book aloud to him, so that he could engrave its overall structure in his memory and reorganize it in his mind. This painstaking process took many months of hard labor, but his abilities to remember and revise mentally, like Lilian Kallir’s ability to arrange piano scores in her mind, steadily increased with practice.
His new novel (which he called Memory Book) was published in 2005, and this was followed in fairly rapid succession by another Benny Cooperman novel and, in 2007, a memoir, The Man Who Forgot How to Read. Howard Engel is still alexic, but he has found a way to remain a man of letters. That he was able to do so is a testament to many things: the dedication and skill of his therapists in rehab, his own determination to read again, and the adaptability of the human brain.
“The problems never went away,” Howard writes, “but I became cleverer at solving them.”
Face-Blind
IT IS WITH OUR FACES that we face the world, from the moment of birth to the moment of death. Our age and our sex are printed on our faces. Our emotions, the open and instinctive emotions which Darwin wrote about, as well as the hidden or repressed ones which Freud wrote about, are displayed on our faces, along with our thoughts and intentions. Though we may admire arms and legs, breasts and buttocks, it is the face, first and last, which is judged “beautiful” in an aesthetic sense, “fine” or “distinguished” in a moral or intellectual sense. And, crucially, it is by our faces that we can be recognized as individuals. Our faces bear the stamp of our experiences and character; at forty, it is said, a man has the face he deserves.
At two and a half months, babies respond to smiling faces by smiling back. “As the child smiles,” Everett Ellinwood writes, “it usually engages the adult human to interact with him—to smile, to talk, to hold—in other words, to initiate the processes of socialization. . . . The reciprocal understanding mother-child relationship is possible only because of the continuing dialogue between faces.” The face, psychoanalysts consider, is the first object to acquire visual meaning and significance. But are faces in a special category as far as the nervous system is concerned?
I have had difficulty recognizing faces for as long as I can remember. I did not think too much about this as a child, but by the time I was a teenager, in a new school, it was often a cause of embarrassment. My frequent inability to recognize schoolmates would cause them bewilderment and, sometimes, offense—it did not occur to them (why should it?) that I had a perceptual problem. I usually recognized close friends without much problem, especially my two best friends, Eric Korn and Jonathan Miller. But this was partly because I identified particular features: Eric had heavy eyebrows and thick spectacles, and Jonathan was tall and gangly, with a mop of red hair. Jonathan was a keen observer of postures, gestures, and facial expressions, and he seemingly never forgot a face. A decade later, when we were looking at old school photos, he could still recognize literally hundreds of our schoolmates, while I could not recognize a single one.
It was not just faces. When I went for a walk or a bicycle ride, I would have to follow exactly the same route, knowing that if I deviated from it even slightly, I would be instantly and hopelessly lost. I wanted to be adventurous, to go to exotic places—but I could do this only if I bicycled with a friend.
At the age of seventy-six, despite a lifetime of trying to compensate, I have no less trouble with faces and places. I am thrown particularly when I see people out of context, even if I have been with them five minutes before. This happened one morning just after my appointment with my psychiatrist (I had been seeing him twice weekly for several years at this point). A few minutes after I left his office, a soberly dressed man greeted me in the lobby of the building. I was puzzled as to why this stranger seemed to know me, until the doorman addressed him by name—it was, of course, my own analyst. (This failure to recognize him came up as a topic in our next session—I think he did not entirely believe me when I maintained that it had a neurological basis rather than a psychiatric one.)
A few months later, my nephew Jonathan Sacks came for a visit. We went out for a walk—I lived in Mount Vernon, New York, at the time—and it started raining. “We had better get back,” Jonathan said, but I couldn’t find my house or my street. After two hours of walking around, in which we both got thoroughly soaked, I heard a shout. It was my landlord; he said he had seen me pass the house three or four times, apparently failing to recognize it.
In those years, I had to take the Boston Post Road to get from Mount Vernon to my hospital on Allerton Avenue in the Bronx. Though I took the same route twice a day for eight years, the road never became familiar to me, I never recognized the buildings on either side, and I would often turn the wrong way up the road, realizing it only when I came to one of two landmarks that were unmistakable, even for me: at one end, Allerton Avenue, which had a large sign, or, at the other, the Bronx River Parkway, which loomed over the Boston Post Road.
I had been working with my assistant, Kate, for about six years when we arranged to rendezvous in a midtown office for a meeting with my publisher. I arrived and announced myself to the receptionist, but failed to note that Kate had already arrived and was sitting in the waiting area. That is, I saw a young woman there, but did not realize it was her. After about five minutes, smiling, she said, “Hello, Oliver. I was wondering how long it would take you to recognize me.”
Parties, even my own birthday parties, are a challenge. (More than once, Kate has asked my guests to wear name tags.) I have been accused of “absentmindedness,” and no doubt this is true. But I think that a significant part of what is variously called my “shyness,” my “reclusiveness,” my “social ineptitude,” my “eccentricity,” even my “Asperger’s syndrome,” is a consequence and a misinterpretation of my difficulty recognizing faces.
My problem with recognizing faces extends not only to my nearest and dearest, but also to myself. Thus on several occasions I have apologized for almost bumping into a large bearded man, only to realize that the large bearded man was myself in a mirror. The opposite situation once occurred at a restaurant with tables outside. Sitting at one of these sidewalk tables, I turned to the restaurant window and began grooming my beard, as I often do. I then realized that what I had taken to be my reflection was not grooming himself but looking at me oddly. There was in fact a gray-bearded man on the other side of the window, who must have been wondering why I was preening myself in front of him.
Kate often cautions people in advance about my little problem. She tells visitors, “Don’t ask if he remembers you, because he will say no. Introduce yourself by name and tell him who you are.” (And to me, she says, “Don’t just say no—that’s rude and will upset people. Say, ‘I’m sorry, I am awful about recognizing people. I wouldn’t recognize my own mother.’”)1
In 1988 I met Franco Magnani, the “memory artist,” and over the next couple of years I spent weeks with him, talking about his paintings, his life, and even traveling to Italy with him to revisit the village where he grew up. When I finally submitted an article about him to The New Yorker, Robert Gottlieb, who was then the magazine’s editor in chief, read the piece and said, “Very nice, fascinating—but what does he look like? Can you add some description?” I parried this awkward (and, to me, unanswerable) question by saying, “Who cares what he looks like? The piece is about his work.”
“Our readers will want to know,” Bob said. “They need to picture him.”
“I will have to ask Kate,” I said. Bob gave me a peculiar look.
I assumed that I was just very bad at recognizing faces, as my friend Jonathan was very good—that this was within the limits of normal variation, and that he and I just stood at opposite ends of a spectrum. It was only when I went to Australia to visit my older brother Marcus, whom I had scarcely seen in thirty-five years, and discovered that he, too, had exactly the same difficulties recognizing faces and places that it dawned on me that this was something beyond normal variation, that we both had a specific trait, a so-called prosopagnosia, probably with a distinctive genetic basis.2
That there were others like me was brought home in various ways. The meeting of two people with prosopagnosia, in particular, can be very challenging. A few years ago, I wrote to one of my colleagues to tell him that I admired his new book. His assistant then phoned Kate to arrange a meeting, and they settled on a weekend dinner at a restaurant in my neighborhood.
“There may be a problem,” Kate said. “Dr. Sacks cannot recognize anyone.”
“It’s the same with Dr. W.,” his assistant replied.
“And another thing,” Kate added. “Dr. Sacks cannot find restaurants or other places; he gets lost very easily—he can’t even recognize his own building sometimes.”
“Yes, it’s the same with Dr. W.,” his assistant said.
Somehow, we did manage to meet and enjoyed dinner together. But I still have no idea what Dr. W. looks like, and he probably would not recognize me, either.
Although such examples may seem comical, they are sometimes quite devastating. People with very severe prosopagnosia may be unable to recognize their spouse, or to pick out their own child in a group of others.
Jane Goodall also has a certain degree of prosopagnosia. Her problems extend to recognizing chimpanzees as well as people—thus, she says, she is often unable to distinguish individual chimps by their faces. Once she knows a particular chimp well, she ceases to have difficulties; similarly, she has no problem with family and friends. But, she says, “I have huge problems with people with ‘average’ faces. . . . I have to search for a mole or something. I find it very embarrassing! I can be all day with someone and not know them the next day.”
She adds that she, too, has difficulties in recognizing places: “I just don’t know where I am until I am very familiar with the route. I have to turn and look at landmarks so I can find my way back. This was a problem in the forest, and I often got lost.”
In 1985, I published a case history called “The Man Who Mistook His Wife for a Hat,” about Dr. P., who had developed a very severe visual agnosia. He was not able to recognize faces or their expressions. Moreover, he could not identify or even categorize objects; thus, he was unable to recognize a glove, to recognize that it was an article of clothing, or that it resembled a hand. At one point he mistook his wife’s head for his hat.
After Dr. P.’s story was published, I began to get letters from correspondents who would compare their difficulties in recognizing places and faces with his. In 1991, Anne F. wrote to me, describing her experiences:
I believe that three people in my immediate family have visual agnosias: my father, a sister, and myself. We each have traits in common with your Dr. P., but, hopefully, not to the same degree. The most striking behavior we all share in common with Dr. P. is the prosopagnosia. My father, a man who has had a successful radio career here in Canada (his particular gift is an ability to mimic voices), was unable to recognize his wife in a recent photograph. At a wedding reception he asked a stranger to identify the man sitting next to his daughter (my husband of five years at the time).
I have walked by my husband, while staring directly at his face, on several occasions without recognizing him. I have no difficulty recognizing him, however, in situations or places where I am expecting to see him. I am also able to recognize people immediately when they begin to speak, even if I’ve heard their voice only once in the past.
Unlike Dr. P., I feel I can read people well on an emotional level. . . . I don’t have the degree of agnosia for common objects that Dr. P. had. [However,] like Dr. P., I am totally incapable of establishing a topographical representation of space. . . . I have no memory for where I put things unless I verbally encode the location. Once an object leaves my hands, it drops off the edge of the world into a void.
While Anne F. seems to have prosopagnosia and topographical agnosia on a genetic or familial basis, others may develop this (or any other form of agnosia) in consequence of a stroke, a tumor, an infection, or an injury—or, like Dr. P., a degenerative disease such as Alzheimer’s—that has damaged a particular part of the brain. Joan C., another correspondent, had an unusual history in this regard: she had developed a brain tumor in the right occipital lobe as an infant, and this was removed when she was two years old. It seems likely, though it is difficult to be certain, that her prosopagnosia was the result of either the tumor or the surgery. Her inability to recognize faces has often been misinterpreted by others. She notes, “I’ve been told that I’m rude, or a space cadet, or (according to a psychiatrist) suffering from a psychiatric disorder.”
As I continued to receive more and more letters from people with prosopagnosia or topographical agnosia, it became clear to me that “my” visual problem was not uncommon and must affect many people around the world.
Face recognition is crucially important for humans, and the vast majority of us are able to identify thousands of faces individually, or to easily pick out familiar faces in a crowd. A special expertise is needed to make such distinctions, and this expertise is nearly universal not only in humans but in other primates. How, then, do people with prosopagnosia manage?
In the last few decades, we have become very conscious of the brain’s plasticity, how one part or system of the brain may take over the functions of a defective or damaged one. But this does not seem to occur with prosopagnosia or topographical agnosia; they are usually lifelong conditions that do not lessen as one grows older. People with prosopagnosia, therefore, need to be resourceful and inventive, need to find strategies, ways of circumventing their deficits: recognizing people by an unusual nose or beard, spectacles, or a certain sort of clothing.3 Many prosopagnosics recognize people by voice, posture, or gait; and, of course, context and expectation are paramount—one expects to see one’s students at school, one’s colleagues at the office, and so on. Such strategies, both conscious and unconscious, become so automatic that people with moderate prosopagnosia can remain unaware of how poor their facial recognition actually is, and are startled if it is revealed to them by testing (for example, with photographs that omit ancillary clues such as hair or eyeglasses).4
Thus, though I may be unable to recognize a particular face at a glance, I can recognize various things about a face: that there is a large nose, a pointed chin, tufted eyebrows, or protruding ears. Such features become identifying markers by which I recognize people. (I think, for similar reasons, I find it easier to recognize a caricature than a straightforward portrait or photograph.) I am reasonably good at judging age and gender, though I have made a few embarrassing blunders here. I am far better at recognizing people by the way they move, their “motor style.” And even if I cannot recognize particular faces, I am sensitive to the beauty of faces, and to their expressions.5
I avoid conferences, parties, and large gatherings as much as I can, knowing that they will lead to anxiety and embarrassing situations—not only failing to recognize people I know well, but greeting strangers as old friends. (Like many prosopagnosics, I avoid greeting people by name, lest I use the wrong one, and I depend on others to save me from egregious social blunders.)
I am much better at recognizing my neighbors’ dogs (they have characteristic shapes and colors) than my neighbors themselves. Thus when I see a youngish woman with a Rhodesian ridgeback hound, I realize that she lives in the apartment next to mine. If I see an older lady with a friendly golden retriever, I know this is someone from down the block. But if I should pass either woman on the street without her dog, she might as well be a complete stranger.
The idea that “the mind”—an immaterial, airy thing—could be embodied in a lump of flesh—the brain—was intolerable to seventeenth-century religious thinking; hence the dualism of Descartes and others. But physicians, observing the effects of strokes and other brain injuries, had long had reason to suspect that the functions of the mind and brain were linked. Toward the end of the eighteenth century, the anatomist Franz Joseph Gall proposed that all mental functions must arise from the brain—not from the “soul,” as many people imagined, or from the heart or the liver. Instead, he envisioned within the brain a collection of twenty-seven “organs,” each responsible for a different moral or mental faculty. Such faculties, for Gall, included what we would now call perceptual functions, such as the sensation of color or sound; cognitive faculties, like memory, mechanical aptitude, or speech and language; and even “moral” traits such as friendship, benevolence, or pride. For these heretical ideas, he was exiled from Vienna and wound up eventually in revolutionary France, where he hoped a more scientific approach might be embraced.6
The physiologist Jean-Pierre Flourens decided to investigate Gall’s theory by removing slices of the brain in living animals, chiefly pigeons. But he could not find any evidence to correlate specific areas of the cortex with specific faculties (perhaps because one needs very delicate and discrete ablations to do so, especially in the tiny pigeon cortex). So Flourens believed that the cognitive impairments his pigeons exhibited as he removed more pieces of cortex reflected only the amount of cortex removed, not its location, and what applied to birds, he felt, probably also applied to human beings. The cortex, he concluded, was equipotential, as homogeneous and undifferentiated as the liver. “The brain,” Flourens said, only half jesting, “secretes thought as the liver secretes bile.”
Flourens’s notion of an equipotential cortex dominated thought until the studies of Paul Broca in the 1860s. Broca performed autopsies on many patients with expressive aphasia, all of whom, he showed, had damage limited to the frontal lobes on the left side. In 1865, he was able to say, famously, “We speak with our left hemisphere,” and the notion of a homogeneous and undifferentiated brain, it seemed, was laid to rest.
Broca felt that he had located a “motor center for words” in a particular part of the left frontal lobe, an area we now call Broca’s area.7 This seemed to promise a new sort of localization, a genuine correlation of neurological and cognitive functions with specific centers in the brain. Neurology moved confidently ahead, identifying “centers” of every sort: Broca’s motor center for words was followed by Wernicke’s auditory center for words, and Déjerine’s visual center for words, all in the left hemisphere, the language hemisphere, and a center for visual recognition in the right hemisphere.
But while visual agnosia of a general sort was recognized in the 1890s, there was little idea that there could be agnosia for particular visual categories like faces or places—even though major figures like Hughlings Jackson and Charcot had already described specific agnosias for faces and places following damage to the posterior areas of the right hemisphere. In 1872, Jackson described a man who, following a stroke in this area, lost his ability “to recognize places and persons. At one time he did not know his wife . . . and having wandered from home was unable to find his way back.” Charcot, in 1883, provided an account of a patient who had enjoyed exceptional powers of visual imagery and memory, but lost these suddenly. Charcot describes how this man “cannot even recall his own face. Recently in a public gallery his path seemed to be stopped by a person to whom he was about to offer his excuses, but it was merely his own image reflected in a glass.”
Still, even by the middle of the twentieth century, many neurologists doubted whether the brain had category-specific recognition areas. This may have played a part in delaying the recognition of face-blindness, despite the evidence from clinical cases.
In 1947, Joachim Bodamer, a German neurologist, described three patients who were unable to recognize faces but had no other difficulties with recognition. It seemed to Bodamer that this highly selective form of agnosia needed a special name—it was he who coined the term “prosopagnosia”—and that such a specific loss must imply that there was a discrete area in the brain specialized for face recognition. This has been a matter of dispute ever since: is there a special system dedicated only to face recognition, or is face recognition simply one function of a more general visual recognition system? Macdonald Critchley, writing in 1953, was highly critical of Bodamer’s article and of the very idea of face-blindness. “It seems scarcely credible,” he wrote, “that human faces should occupy a perceptual category which is different from all other objects in space, animate and inanimate. Can there be any attribute of size, shape, colouring or motility which distinguishes a human face from other objects in such a way as to preclude identification?”
But in 1955, the English neurologist Christopher Pallis published a beautifully detailed and documented study of his patient A.H., a mining engineer at a Welsh colliery who had kept a journal and was able to give Pallis an articulate and insightful description of his experiences. One night in June of 1953, A.H. apparently suffered a stroke. He “suddenly felt unwell after a couple of drinks at his club.” He appeared to be confused and was taken home to bed, where he slept poorly. Getting up the following morning, he found his visual world completely transformed, as he reported to Pallis:
I got out of my bed. My mind was clear but I could not recognize the bedroom. I went to the toilet. I had difficulty finding my way and recognizing the place. Turning round to go back to bed I found I couldn’t recognize the room, which was a strange place to me.
I could not see colour, only being able to distinguish light objects from dark ones. Then I found out all faces were alike. I couldn’t tell the difference between my wife and my daughters. Later I had to wait for my wife or mother to speak before recognizing them. My mother is 80 years old.
I can see the eyes, nose, and mouth quite clearly but they just don’t add up. They all seem chalked in, like on a blackboard.
His difficulty was not limited to recognizing people in real life:
I cannot recognize people in photographs, not even myself. At the club I saw someone strange staring at me and asked the steward who it was. You’ll laugh at me. I’d been looking at myself in a mirror. . . . I later went to London and visited several cinemas and theatres. I couldn’t make head or tail of the plots. I never knew who was who. . . . I bought some copies of Men Only and London Opinion. I couldn’t enjoy the usual pictures. I could work out what was what by accessory details, but it’s no fun that way. You’ve got to take it in at a glance.
A.H. had other visual problems: a small defect in one corner of his visual fields, transient difficulty with reading, a total inability to perceive color, and difficulty identifying places. (He had initially had some odd sensations on the left side, too—a “heaviness” of the left hand and a “stinging” feeling in his left index finger and the left corner of his mouth.) But he had no object agnosia: he was able to sort out geometrical figures, to draw complex objects, to assemble jigsaw puzzles and play chess.
Since Pallis’s time, a number of patients with prosopagnosia have come to autopsy. Here the data are clear: virtually all patients who acquire prosopagnosia, irrespective of the cause, have lesions in the right visual association cortex, in particular on the underside of the occipitotemporal cortex; there is nearly always damage in a structure called the fusiform gyrus. These autopsy results gained additional support in the 1980s, when it became possible to visualize the brains of living patients by using CT scans and MRIs—here, too, prosopagnosic patients showed lesions in what came to be called the “fusiform face area.” (Abnormal activity in the fusiform face area has also been correlated with hallucination of faces, as Dominic ffytche and his colleagues have shown.)
In the 1990s, such lesion studies were complemented by functional imaging—visualizing the brains of people with fMRIs as they looked at pictures of faces, places, and objects. These functional studies demonstrated that looking at faces activated the fusiform face area much more strongly than looking at other test images.
That individual neurons in this area could show preferences was first demonstrated in 1969 by Charles Gross and his colleagues, using electrodes in the inferotemporal cortex of macaques. Gross found cells that responded dramatically to the sight of a monkey’s paw—but also, less strongly, to a variety of other stimuli, including a human hand. Subsequently, he found cells with a relative preference for faces.8
At this purely visual level, faces are distinguished as configurations, in part by detecting the geometrical relationships between eyes, nose, mouth, and other features (as Freiwald, Tsao, and Livingstone have established).9 But there is no preference at this level for individual faces; indeed, generic or cartoon faces can elicit the same responses as real ones.
Recognition of particular faces or objects is only achieved at a higher cortical level, in the multimodal area of the medial temporal lobe, which has rich reciprocal connections not only to the fusiform face area but to other areas subserving sensory association, emotion, and memory. Christof Koch, Itzhak Fried, and their colleagues have shown that cells in the multimodal medial temporal lobe area show remarkable specificity, responding only, for example, to images of Bill Clinton, or spiders, or the Empire State Building, or cartoons from The Simpsons. Specific neural units may also respond to hearing or reading the name of the person or object; thus in one patient, a set of neurons responded strongly to pictures of the Sydney Opera House and also to the letter string “Sydney Opera,” though not to the names of other landmarks, such as “Eiffel Tower.”10
Neurons in the medial temporal lobe are capable of encoding representations of individual faces, landmarks, or objects so that they can be easily recognized in a changing environment. Such representations can be constructed rapidly, within less than a day or two after exposure to an unfamiliar individual.
Although such studies involve electrode recordings from single neurons, each of these cells is connected to thousands of other neurons, each of which in turn is connected to thousands more. (Some single cells, moreover, may respond to more than one individual or object.) So a single cell’s response really represents the apex of an immense computational pyramid, perhaps drawing on direct or indirect inputs from the visual, auditory, or tactile cortex, text-recognition areas, memory and emotional areas, and so on.
In humans, some ability to recognize faces is present at birth or soon after. By six months, as Olivier Pascalis and his colleagues have shown in one study, babies are able to recognize a broad variety of individual faces, including those of another species (in this study, pictures of monkeys were used). By nine months, though, the babies became less adept at recognizing monkey faces unless they had received continuing exposure to them. As early as three months, infants are learning to narrow their model of “faces” to those they are frequently exposed to. The implications of this work for humans are profound. To a Chinese baby brought up in his own ethnic environment, Caucasian faces may all, relatively, “look the same,” and vice versa.11 One prosopagnosic acquaintance, born and raised in China, went to Oxford as a student and has lived for decades in the United States. Nonetheless, he tells me, “European faces are the most difficult—they all look the same to me.” It seems that there is an innate and presumably genetically determined ability to recognize faces, and this capacity gets focused in the first year or two, so that we become especially good at recognizing the sorts of faces we are likely to encounter. Our “face cells,” already present at birth, need experience to develop fully.
It is similar with many other capacities, from stereo vision to linguistic power: some predisposition or potential is built in genetically but requires stimulation, practice, environmental richness, and nourishment if it is to develop fully. Natural selection may bring about the initial predisposition, but experience and experiential selection are needed to bring our cognitive and perceptual capacities to their full realization.
The fact that many (though not all) people with prosopagnosia also have difficulty with recognizing places has suggested to some researchers that face and place recognition are mediated by distinct yet adjacent areas. Others believe that both are mediated by a single zone which is perhaps more oriented to faces at one end and to places at the other.
The neuropsychologist Elkhonon Goldberg, however, questions the whole notion of discrete, hardwired centers or modules with fixed functions in the cerebral cortex. He feels that at higher cortical levels there may be much more in the way of gradients, where areas whose function is developed by experience and training overlap or grade into one another. In his book The New Executive Brain, he speculates that a gradiential principle constitutes an evolutionary alternative to a modular one, permitting a degree of flexibility and plasticity impossible for a brain organized in a purely modular fashion.
While modularity, he argues, may be characteristic of the thalamus—an assemblage of nuclei with fixed functions, fixed inputs and outputs—a gradiential organization is more characteristic of the cerebral cortex, and becomes more and more prominent as one ascends from primary sensory cortex to association cortex, to the highest level of all, the frontal cortex. Modularity and gradients may thus coexist and complement one another.
People with prosopagnosia, even if their chief complaint is of face-blindness, often have difficulty recognizing other specific things. Orrin Devinsky and Martha Farah have remarked that some prosopagnosics are unable to distinguish an apple from a pear, say, or a pigeon from a raven, although they can correctly recognize the general category of “fruit” or “bird.” Joan C. described a similar problem: “I don’t recognize handwriting in the same way that I don’t recognize faces. That is, I might be able to identify a sample of handwriting by recognizing some salient feature or by seeing it in context, but otherwise, forget it. I’ve even failed to recognize my own handwriting.
Some researchers have proposed that prosopagnosia is not purely a problem with face-blindness, but one aspect of a more general difficulty in distinguishing the individuals in any class, whether the class is of faces, cars, birds, or anything else.
Isabel Gauthier and her colleagues at Vanderbilt tested a group of car experts and a group of expert birders, comparing them to a group of normal subjects. The fusiform face area, they found, was activated when all of the groups looked at pictures of faces. But it was also activated in the car experts when they were asked to identify particular cars, and in the birders when they were asked to identify particular birds. The fusiform face area is primarily tuned for facial recognition, but some of it, it seems, can be trained to distinguish individual items of other sorts. (If, then, an expert bird spotter or car buff is unlucky enough to acquire prosopagnosia, he will also, we might suspect, lose his facility for identifying birds or cars.)
The brain is more than an assemblage of autonomous modules, each crucial for a specific mental function. Every one of these functionally specialized areas must interact with dozens or hundreds of others, their total integration creating something like a vastly complicated orchestra with thousands of instruments, an orchestra that conducts itself, with an ever-changing score and repertoire. The fusiform face area does not work in isolation; it is a vital node in a cognitive network that stretches from the occipital cortex to the prefrontal area. Face-blindness may occur even with an intact fusiform face area, if the lower occipital face areas are damaged. And people with moderate prosopagnosia, like Jane Goodall or myself, can, after repeated exposure, learn to identify those we know best. Perhaps this is because we are using slightly different pathways to do so, or perhaps, with training, we can make better use of our relatively weak fusiform face areas.
Above all, the recognition of faces depends not only on the ability to parse the visual aspects of a face—its particular features and their overall configuration—and compare it to others, but the ability to summon the memories, experiences, and feelings associated with that face. The recognition of specific places or faces, as Pallis emphasized, goes with a particular feeling, a sense of association and meaning. While purely visual recognition of faces is mediated by the fusiform face area and its connections, emotional familiarity is mediated at a higher, multimodal level, where there are intimate connections with the hippocampi and amygdala, areas dedicated to memory and emotion. Thus A.H., after his stroke, lost not only his ability to identify faces but this sense of familiarity; every face and place appeared new to him and continued to do so even if seen again and again.
Recognition is based on knowledge; familiarity is based on feeling; but neither entails the other. The two have different neural bases and can be dissociated; thus, although both are lost in tandem with prosopagnosia, one can have familiarity without recognition or recognition without familiarity in other conditions. The former occurs in déjà vu and also in the “hyperfamiliarity” for faces described by Devinsky. Here a patient may find that everyone on the bus or on the street looks “familiar”—he may go up to them and address them as old friends, even while realizing that he cannot possibly know them all. My father was always very sociable and could recognize hundreds or even thousands of people, but his feeling of “knowing” people became exaggerated, perhaps pathological, as he moved into his nineties. He often attended concerts at the Wigmore Hall in London, and there, during the intermissions, he would accost everyone in sight, saying, “Don’t I know you?”
The opposite occurs in patients with Capgras syndrome, for whom people’s faces, though recognized, no longer generate a sense of emotional familiarity. Since a husband or wife or child does not convey that special warm feeling of familiarity, the Capgras patient will argue, they cannot be the real thing—they must be clever impostors, counterfeits. People with prosopagnosia have insight; they realize that their problems with recognition come from their own brains. People with Capgras syndrome, in contrast, remain immovable in their conviction that they are perfectly normal and it is the other person who is profoundly, even uncannily wrong.
People with acquired prosopagnosia, like A.H. or Dr. P., are relatively rare—most neurologists are likely to encounter such a patient once or twice in their career, if at all. Congenital prosopagnosia (or, as it is sometimes called, “developmental” prosopagnosia), such as I have, is much commoner, yet remains completely unrecognized by most neurologists. Heather Sellers, a lifelong prosopagnosic, wrote about this in a 2007 autobiographical essay: “I couldn’t recognize my husband’s children. . . . I hugged the wrong man in the grocery, thinking it was [my husband]. . . . My colleagues remained unidentifiable after a decade. . . . I kept introducing myself to neighbors.” When she consulted two separate neurologists for her problem, they both said that they had never seen it before, and it was “very rare.”12
One eminent neurologist who has written about visual agnosia confessed to me that he had not even heard of congenital prosopagnosia until very recently. This, however, is not entirely surprising, for people with congenital prosopagnosia do not generally consult neurologists about their “problem,” any more than someone with lifelong colorblindness would complain about it to an eye doctor. It is just the way they are.
But Ken Nakayama at Harvard, who investigates visual perception, has long suspected that prosopagnosia is relatively common but underreported. In 1999, he and his colleague Brad Duchaine, at University College London, began using the internet to seek subjects with face-blindness, and they received a startling response. They are now investigating several thousand people with lifelong prosopagnosia ranging from mild to cripplingly severe.13
While people with lifelong prosopagnosia do not have gross lesions in the brain, a recent study by Lucia Garrido and her colleagues showed that they do have subtle but distinct changes in the brain’s face-recognition areas. The condition also tends to be familial: Duchaine, Nakayama, and their colleagues have described one family in which ten members—both parents and seven of their eight children (the eighth could not be tested), as well as a maternal uncle—have it. Clearly there are strong genetic determinants at work here.
Nakayama and Duchaine have explored the neural basis of face and place recognition, generating new knowledge and insights at every level from the genetic to the cortical. They have also studied the psychological effects and social consequences of developmental prosopagnosia and topographical agnosia—the special problems these conditions can create for an individual in a complex social and urban culture.
The range seems to extend in a positive direction, too. Russell, Duchaine, and Nakayama have described “super-recognizers,” people with extraordinarily good face-recognition abilities, including some who seem to have indelible memories of virtually every face they have ever seen. Alexandra Lynch, one of my correspondents, described her own uncanny ability to recognize people:
It happened again yesterday. I was on my way down into the subway in Soho when I identified someone fifteen feet ahead of me (back turned, talking intimately with his friend) as a man I knew, or had seen before. In this case, it was Mac, who used to be a family friend’s art dealer. I had last seen him (briefly) two years earlier, at an opening in midtown. I’m not sure I’ve ever spoken with him beyond an introduction a good ten years ago.
This is an integral part of my life—I catch a passing glimpse of someone and, with no real effort, flash, place the face—yes, that’s the girl who served us wine at an East Village bar last year (again, in a totally different neighborhood, and at night not during the day). It is true that I’m a big fan of people, of humanity and diversity . . . but to my knowledge I make no effort to record the physical traits of ice cream servers, shoe salesmen and friends of friends of friends. Even a slim wedge of face, or the way someone walks two blocks away at dusk, can trigger my mind to zero in on a match.
The super-recognizers, Russell et al. write, “are about as good as many [lifelong] prosopagnosics are bad”—that is, they are about two or three standard deviations above average, while the most severe prosopagnosics have face-recognizing abilities two or three standard deviations below average. Thus the difference between the best face recognizers and the worst among us is comparable to that between people with an IQ of 150 and an IQ of 50, with others filling every level in between. As with any bell curve, the vast majority of people are somewhere in the middle.
Severe congenital prosopagnosia is estimated to affect at least 2 percent of the population—six million people in the United States alone. (A much higher percentage, perhaps 10 percent, are markedly below average in face identification but not cripplingly face-blind.) For these people, who have difficulty recognizing their husbands, wives, children, teachers, and colleagues, there is still no official recognition or public understanding.
This is in marked contrast to the situation with another neurological minority, the 5 to 10 percent of the population with dyslexia. Teachers and others are more and more aware of the special difficulties and often special gifts which dyslexic children may have, and are starting to provide educational strategies and resources for them.
But for now, people with varying degrees of faceblindness must rely on their own ingenuity and strategies, starting with educating others about their unusual, but not rare, condition. Increasingly, prosopagnosia is the subject of books, websites, and support groups, where people with face-blindness or topographical agnosia are able to share experiences and, no less important, strategies for recognizing faces and places when the usual “automatic” mechanisms are compromised.
Ken Nakayama, who is doing so much to further the scientific understanding of prosopagnosia, also has a personal acquaintance with the subject, and posts this notice in his office and on his website:
Recent eye problems and mild prosopagnosia have made it harder for me to recognize people I should know. Please help by giving your name if we meet. Many thanks.
Stereo Sue
WHEN GALEN, in the second century, and Leonardo, thirteen centuries later, observed that the images received by the two eyes were slightly different, neither of them appreciated the full significance of these differences. It was not until the early 1830s that Charles Wheatstone, a young physicist, began to suspect that even though the brain somehow fused these images automatically and unconsciously, the disparities between the two retinal images were in fact crucial to the brain’s mysterious ability to generate a sensation of depth.
Wheatstone confirmed the truth of his conjecture by an experimental method as simple as it was brilliant. He made pairs of drawings of a solid object as seen from the slightly different perspectives of the two eyes and then designed an instrument that used mirrors to insure that each eye saw only its own drawing. He called the device a stereoscope, from the Greek for “solid vision.” If one looked into the stereoscope, the two flat drawings would fuse to produce a single three-dimensional drawing poised in space.
(One does not need a stereoscope to see stereo depth; it is relatively easy for most people to learn how to “free-fuse” such drawings, simply by diverging or converging the eyes. So it is strange that stereopsis was not discovered centuries before: Euclid or Archimedes could have drawn stereo diagrams in the sand, as David Hubel has remarked, and discovered stereopsis in the third century B.C. But they did not, as far as we know.)
Photography was invented only months after Wheatstone’s 1838 article describing his stereoscope, and stereo photographs quickly became popular.1 Queen Victoria herself was presented with a stereoscope after admiring one in the Great Exhibition at the Crystal Palace, and soon no Victorian drawing room was complete without one. With the development of smaller, cheaper stereoscopes, easier photographic printing, and even stereo parlors, there were few people in Europe or America who did not have access to stereo viewers by the end of the nineteenth century.
With stereo photographs, viewers could see the monuments of Paris and London or great sights of nature like Niagara Falls or the Alps in all their majesty and depth, with an uncanny verisimilitude that made them feel as if they were hovering over the actual scenes.2
In 1861, Oliver Wendell Holmes (who invented the popular handheld Holmes Stereo Viewer), in one of several Atlantic Monthly articles on stereoscopes, remarked on the special pleasure people seemed to derive from this magical illusion of depth:
The shutting out of surrounding objects, and the concentration of the whole attention . . . produces a dreamlike exaltation . . . in which we seem to leave the body behind us and sail into one strange scene after another, like disembodied spirits.
There are, of course, many other ways of judging depth besides stereo vision: the occlusion of distant objects by closer objects, perspective (the fact that parallel lines converge as they recede, and that distant objects appear smaller), shading (which delineates the shape of objects), “aerial” perspective (the blurring and blueing of more distant objects by the intervening air), and, most important, motion parallax—the changing appearance of spatial relationships as we move around in the world. All these cues, acting together, can give a sense of reality and space and depth. But the only way to actually perceive depth—to see it rather than judge it—is with binocular stereoscopy.3
In my boyhood home, in London during the 1930s, we had two stereoscopes: a large, old-fashioned wooden one, which took glass slides, and a smaller handheld one, which took cardboard stereo photographs. We also had books of bicolor anaglyphs—stereo photographs printed in red and green, which had to be viewed with a pair of glasses with one red and one green lens, which effectively restricted each eye to seeing only one of the images.
So when, at the age of ten, I developed a passion for photography, I wanted, of course, to make my own pairs of stereo photos. This was easy to do, by moving the camera horizontally about two and a half inches between exposures, mimicking the distance between the two eyes. (I did not yet have a double-lens stereo camera, which would take simultaneous stereo pairs.)
After reading how Wheatstone explored stereoscopic effects by exaggerating or reversing the disparity between the two images, I began experimenting with this, too. I started taking pictures with greater and greater separations between them, and then I made a hyperstereoscope, using a cardboard tube about a yard long with four little mirrors. With this, I could turn myself, in effect, into a creature with eyes a yard apart. I could look through the hyperstereoscope at a very distant object, like the dome of St. Paul’s Cathedral, which normally appeared as a flat semicircle on the horizon, and see it in its full rotundity, projecting towards me. I also experimented with making a “pseudoscope,” which transposed the views of the two eyes to reverse the stereo effect to some extent, making distant objects appear closer than near ones and even turning faces into hollow masks. This, of course, contradicted common sense, as well as all the other depth cues of perspective and occlusion—sometimes the images would rapidly shift back and forth from convex to concave, a bizarre and disorienting experience as the brain struggled to reconcile two rival hypotheses.4
After the Second World War, new techniques and forms of stereoscopy became popular. The View-Master, a little stereoscope made of plastic, took reels of tiny Kodachrome transparencies that one flicked through by pressing a lever. I fell in love with faraway America at this time, partly through View-Master reels of the grand scenery of the American West and Southwest.
One could also get Polaroid Vectographs, in which the stereo images were polarized at right angles to each other; these were viewed through a special pair of Polaroid glasses with the polarization of the lenses also at right angles, insuring that each eye saw only its own image. Such Vectographs, unlike the red-and-green anaglyphs, could be in full color, which gave them a special appeal.
Then there were lenticular stereograms, in which the two images were printed in alternating narrow vertical bands covered by clear, ridged plastic. The ridges served to transmit each set of images to the proper eye, eliminating the need for any special glasses. I first saw a lenticular stereogram just after the war, in the London Tube—an advertisement, as it happened, for Maidenform bras. I wrote to Maidenform, asking if I could have one of their advertisements, but got no reply; they must have imagined I was a sex-obsessed teenager, rather than a simple stereophile.
Finally, in the early 1950s, there were 3-D films (like the Madame Tussauds horror film, House of Wax), which one would look at through red-and-green or Polaroid glasses. As cinema, some of these were awful—but a few, like Inferno, were very beautiful and used stereo photography in an exquisite, delicate, unintrusive way.
Over the years, I amassed a collection of stereograms and books about stereoscopy. I became an active member of the New York Stereoscopic Society, and at our meetings I encountered other stereo buffs. We stereo enthusiasts subscribe to stereo magazines, and some of us attend stereo conventions. The most ardent take their stereo cameras and go on “stereo weekends.” Most people are not particularly conscious of what stereoscopy adds to their visual world, but we revel in it. While some may not notice any big difference if they close one eye, we stereophiles are sharply aware of a great change, as our world suddenly loses its spaciousness and depth and becomes as flat as a playing card. Perhaps our stereoscopy is more acute; perhaps we live, subjectively, in a deeper world; or perhaps we are simply more aware of it, as others may be more attuned to color or shape. We want to understand how stereoscopy works. The problem is not a trivial one, for if one can understand stereoscopy, one can understand not only a simple and brilliant visual stratagem but something of the nature of visual awareness, and of consciousness itself.
One has to lose the use of an eye for a substantial period to find how life is altered in its absence. Paul Romano, a sixty-eight-year-old retired pediatric ophthalmologist, recounted his own story in the Binocular Vision & Strabismus Quarterly. He had suffered a massive ocular hemorrhage, which caused him to lose nearly all sight in one eye. After a single day of monocular vision, he noted, “I see items but I often don’t recognize them: I have lost my physical localization memory. . . . My office is a mess. . . . Now that I have been reduced to a two-dimensional world I don’t know where anything is.”
The next day he wrote, “Things are not the same at all monocularly as they were binocularly. . . . Cutting meat on the plate—it is difficult to see fat and gristle that you want to cut away. . . . I just don’t recognize it as fat and gristle when it only has two dimensions.”
After almost a month, though Dr. Romano was becoming less clumsy, he still had a sense of great loss:
Although driving at normal speed replaces the loss of depth perception with motion stereopsis, I have lost my spatial orientation. There is no longer the feeling I used to have of knowing exactly where I am in space and the world. North was over here before—now I don’t know where it is. . . . I am sure my dead reckoning is gone.
His conclusion, after thirty-five days, was that “even though I adapt better to monocularity every day, I can’t see spending the rest of my life in this way. . . . Binocular stereoscopic depth perception is not just a visual phenomenon. It is a way of life. . . . Life in a two-dimensional world is very different from that in a three-dimensional world and very inferior.” As the weeks passed, Dr. Romano became more at home in his monocular world, but it was with enormous relief that, after nine months, he finally recovered his stereo vision.
In the 1970s, I had my own experience with losing stereoscopy when I was put in a tiny windowless room in a London hospital, following surgery for a ruptured quadriceps tendon. The room was scarcely bigger than a prison cell, and visitors complained of it, but I soon accommodated and even enjoyed it. The effects of its limited horizon did not become apparent to me until later, as I described in A Leg to Stand On:
I was moved into a new room, a new spacious room, after twenty days in my tiny cell. I was settling myself, with delight, when I suddenly noticed something most strange. Everything close to me had its proper solidity, spaciousness, depth—but everything farther away was totally flat. Beyond my open door was the door of the ward opposite; beyond this a patient seated in a wheelchair; beyond him, on the windowsill, a vase of flowers; and beyond this, over the road, the gabled windows of the house opposite—and all this, two hundred feet perhaps . . . seemed to lie like a giant Kodachrome in the air, exquisitely colored and detailed, but perfectly flat.
I had never realized that stereoscopy and spatial judgment could be so changed after a mere three weeks in a small space. My own stereoscopy had returned, jerkily, after about two hours, but I wondered what happened to prisoners, confined for much longer periods. I had heard stories of people living in rain forests so dense that their far point was only six or seven feet away. If they were taken out of the forest, it was said, they might have so little idea or perception of space and distance beyond a few feet that they would try to touch distant mountaintops with their outstretched hands.5
When I was a neurology resident in the early 1960s, I read the remarkable papers of David Hubel and Torsten Wiesel on the neural mechanisms of vision. Their work, which later won a Nobel Prize, revolutionized our understanding of how mammals learn to see, in particular of how early visual experience is critical for the development of special cells or mechanisms in the brain needed for normal vision. Among these are the binocular cells in the visual cortex, which are necessary to construct a sense of depth from retinal disparities. Hubel and Wiesel showed, in animals, that if normal binocular vision was rendered impossible by a congenital condition (as in Siamese cats, which are often born cross-eyed) or by experiment (cutting one of the muscles to the eyeballs, so that the subjects became walleyed), these binocular cells would fail to develop and the animals would permanently lack stereoscopy. A significant number of people develop similar conditions—collectively known as strabismus, or squint—a misalignment sometimes too subtle to attract notice but sufficient to interfere with the development of stereo vision.
Perhaps 5 or 10 percent of the population, for one reason or another, have little or no stereo vision, though they are often not aware of this and may learn it only after careful examination by an ophthalmologist or optometrist.6 Yet there are many accounts of stereo-blind people who nonetheless achieve remarkable feats of visuomotor coordination. Wiley Post, the first person to fly solo around the world, as famous in the 1930s as Charles Lindbergh, did so after losing an eye in his mid-twenties. (He went on to become a pioneer of high-altitude flight and invented a pressurized flight suit.) A number of professional athletes have been blind in one eye, and so was at least one eminent ophthalmic surgeon.
Not all stereo-blind people are pilots or world-class athletes, and some may have difficulty judging depth, threading needles, or driving—but by and large they manage to get along pretty well using only monocular cues.7 And those who have never had stereopsis but manage well without it may be hard put to understand why anyone should pay much attention to it. Errol Morris, the filmmaker, was born with strabismus and subsequently lost almost all the vision in one eye, but feels he gets along perfectly well. “I see things in 3-D,” he said. “I move my head when I need to—parallax is enough. I don’t see the world as a plane.” He joked that he considered stereopsis no more than a “gimmick” and found my interest in it “bizarre.”8
I tried to argue with him, to expatiate on the special character and beauty of stereopsis. But one cannot convey to the stereo-blind what stereopsis is like; the subjective quality, the quale, of stereopsis is unique and no less remarkable than that of color. However brilliantly a person with monocular vision may function, he or she is, in this one sense, totally lacking.
And stereopsis, as a biological strategy, is crucial to a diverse array of animals. Predators, in general, have forward-facing eyes, with much overlap of the two visual fields; prey animals, by contrast, tend to have eyes at the sides of their heads, which gives them panoramic vision, helping them spot danger even if it comes from behind. The hammerhead shark is a fearsome predator, partly because its bizarre head shape allows its forward-facing eyes a greater separation—a hammerhead is a living hyperstereoscope. Another astonishing strategy is found in the cuttlefish, whose wide-set eyes normally permit a large degree of panoramic vision but can be rotated forward by a special muscular mechanism when the animal is about to attack, giving it the binocular vision it needs for shooting out its tentacles with deadly aim.9
In primates like ourselves, forward-facing eyes have other functions. The huge, close-set eyes of lemurs serve to clarify the complexity of dark, dense foliage, which, if the head is kept still, is almost impossible to sort out without stereoscopic vision—and in a jungle full of illusion and deceit, stereopsis is indispensable in breaking camouflage. On the more exuberant side, aerial acrobats like gibbons might find it very difficult to leap from branch to branch without the special powers conferred by stereoscopy. A one-eyed gibbon might not fare too well—and the same might be true of a one-eyed shark or cuttlefish.
Stereoscopy is highly advantageous to such animals, despite its costs: the sacrifice of panoramic vision, the need for special neural and muscular mechanisms for coordinating and aligning the eyes, and, not least, the development of special brain mechanisms to compute depth from the disparities of the two visual images. Thus, in nature, stereoscopy is anything but a gimmick, even if some human beings manage, and may even enjoy certain advantages, without it.
In December of 2004, I received an unexpected letter from a woman named Sue Barry. She reminded me how we had met, in 1996, at a shuttle-launch party in Cape Canaveral (her husband, Dan, was an astronaut). We had been talking about different ways of experiencing the world—how, for example, Dan and other astronauts would lose their orientation, their sense of “up” and “down,” in the microgravity conditions of outer space and had to find ways of adapting. Sue then told me of her own visual world: since she had grown up cross-eyed, her eyes did not work in tandem, and so she viewed the world with one eye at a time, her eyes rapidly and unconsciously alternating. I asked if this was any disadvantage to her. No, she said, she got along perfectly well—she drove a car, she could play softball, she could do whatever anyone else could. She might not be able to see depth directly, as other people could, but she could judge it as well as anybody, using other cues.
I asked Sue if she could imagine what the world would look like if viewed stereoscopically. Sue said yes, she thought she could—after all, she was a professor of neurobiology, and she had read Hubel and Wiesel’s papers and much else on visual processing, binocular vision, and stereopsis. She felt that this knowledge had given her a special insight into what she was missing—she knew what stereopsis must be like, even if she had never experienced it.
But now, nearly nine years after our initial conversation, she felt compelled to write to me about this question:
You asked me if I could imagine what the world would look like when viewed with two eyes. I told you that I thought I could. . . . But I was wrong.
She could say this because now she had stereopsis—and it was beyond anything she could have imagined. She went on to give me details of her visual history, starting with her parents noticing that she was cross-eyed a few months after she was born:
The doctors told them that I would probably outgrow the condition. This may have been the best advice at the time. The year was 1954, eleven years before David Hubel and Torsten Wiesel published their pivotal papers on visual development, critical periods, and cross-eyed kittens. Today, a surgeon would realign the eyes of a cross-eyed child during the “critical period” . . . in order to preserve binocular vision and stereopsis. Binocular vision depends on good alignment between the two eyes. The general dogma states that the eyes must be realigned in the first year or two. If surgery is performed later than that, the brain will have already rewired itself in a way that prevents binocular vision.
Sue did have operations to correct her strabismus, first on the muscles of the right eye, when she was two, and then of the left eye, and finally of both eyes, when she was seven. When she was nine, her surgeon told her that she could now “do anything a person with normal vision could do except fly an airplane.” (Wiley Post, apparently, had already been forgotten by the 1960s.) She no longer looked cross-eyed to a casual observer, but she was half aware that her eyes were still not working together, that there was still something amiss, though she could not specify what it was. “No one mentioned to me that I lacked binocular vision, and I remained happily ignorant of the fact until I was a junior in college,” she wrote. Then she took a course in neurophysiology:
The professor described the development of the visual cortex, ocular dominance columns, monocular and binocular vision, and experiments done on kittens reared with artificial strabismus. He mentioned that these cats probably lacked binocular vision and stereopsis. I was completely floored. I had no idea that there was a way of seeing the world that I lacked.
After her initial astonishment, Sue began to investigate her own stereo vision:
I went to the library and struggled through the scientific papers. I tried every stereo vision test that I could find and flunked them all. I even learned that one was supposed to see a three-dimensional image through the View-Master, the toy stereo viewer that I had been given after my third operation. I found the old toy in my parents’ home, but could not see a three-dimensional image with it. Everyone else who tried the toy could.
At this point, Sue wondered whether there might be any therapy by which she could acquire binocular vision, but “the doctors told me that it would be a waste of my time and money to attempt vision therapy. It was simply too late. I could only have developed binocular vision if my eyes had been properly aligned by age two. Since I had read Hubel and Wiesel’s work on visual development and early critical periods, I accepted their advice.”
Twenty-five years passed—years in which Sue married and raised a family while pursuing an academic career in neurobiology. Though she had some difficulties with driving—merging on entrance ramps to freeways, she found it hard to estimate the speed of oncoming cars—she got along generally quite well with her monocular ways of judging space and distance. Once in a while, she even teased binocular people:
I took some tennis lessons with an accomplished pro. One day, I asked him to wear an eye patch so that he had to hit the ball using only one eye. I hit a ball to him high in the air and watched this superb athlete miss the ball entirely. Frustrated, he ripped off the eye patch and threw it away. I am ashamed to admit it, but I enjoyed watching him flounder, a sort of revenge against all two-eyed athletes.
But when Sue was in her late forties new problems began:
It became increasingly difficult to see things at a distance. Not only did my eye muscles fatigue more quickly, but the world appeared to shimmer when I looked in the distance. It was hard to focus on the letters on street signs or distinguish whether a person was walking toward or away from me. . . . At the same time, my glasses, used for distance vision, made me far-sighted. In the classroom, I could not read my lecture notes and see the students at the same time. . . . I decided it was time to get bifocals or progressive lenses. I was determined to find an eye doctor who would give me both progressive lenses to improve my visual acuity and eye exercises to strengthen my eye muscles.
She consulted Dr. Theresa Ruggiero, a developmental optometrist, who found that Sue’s eyes were developing various forms of imbalance—this sometimes happens after surgery for strabismus—so that the reasonable vision she had enjoyed for decades was now being undermined.
Dr. Ruggiero confirmed that I saw the world monocularly. I only used two eyes together when looking within two inches of my face. She told me that I consistently misjudged the location of objects when viewing them solely with my left eye. Most importantly, she discovered that my two eyes were misaligned vertically. The visual field of my left eye was about three degrees above that of my right. Dr. Ruggiero placed a prism in front of my right lens that shifted the entire visual field of the right eye upward. . . .Without the prism, I had trouble reading the eye chart on a computer screen across the room because the letters appeared to shimmer. With the prism, the shimmer was greatly reduced.
(“Shimmer,” Sue later explained, was perhaps too mild a term, for it was not like the shimmer one might see with a heat haze on a summer day—it was, rather, a rapid, dizzying oscillation of several times a second.)
Sue got her new eyeglasses, complete with the prism, on February 12, 2002. Two days later, she had her first vision-therapy session with Dr. Ruggiero—a long session in which, using Polaroid glasses to allow a different image to be presented to each eye, she attempted to fuse the two pictures. At first, she did not understand what “fusion” meant, how it was possible to bring the two images together; but after trying for several minutes she found she was able to do it, though only for a second at a time. Although she was looking at a pair of stereo images, she had no perception of depth; nevertheless, she had made the first step, achieving “flat fusion,” as Dr. Ruggiero called it.
Sue wondered whether, if she could hold her eyes aligned for longer, this would allow not just flat fusion but stereo fusion, too. Dr. Ruggiero gave her further exercises to stabilize her tracking and hold her gaze, and she worked on these exercises diligently at home. Three days later, something odd occurred:
I noticed today that the light fixture that hangs down from our kitchen ceiling looks different. It seems to occupy some space between myself and the ceiling. The edges are also more rounded. It’s a subtle effect but noticeable.
In her second session with Dr. Ruggiero, on February 21, Sue repeated the Polaroid exercise and tried a new one, using colored beads at different distances on a string. This exercise, known as the Brock string, taught Sue to fixate both eyes on the same point in space, so that her visual system would not suppress the images from one eye or the other but would fuse them together. The effect of this session was immediate:
I went back to my car and happened to glance at the steering wheel. It had “popped out” from the dashboard. I closed one eye, then the other, then looked with both eyes again, and the steering wheel looked different. I decided that the light from the setting sun was playing tricks on me and drove home. But the next day I got up, did the eye exercises, and got into the car to drive to work. When I looked at the rear-view mirror, it had popped out from the windshield.
Her new vision was “absolutely delightful,” Sue wrote. “I had no idea what I had been missing.” As she put it, “Ordinary things looked extraordinary. Light fixtures floated and water faucets stuck way out into space.” But it was “also a bit confusing. I don’t know how far one object should ‘pop out’ in front of another for a given distance between the two objects. . . . [It is] a bit like I am in a fun house or high on drugs. I keep staring at things. . . . The world really does look different.” She included some excerpts from her diary:
February 22: I noticed the edge of the open door to my office seemed to stick out toward me. Now, I always knew that the door was sticking out toward me when it was open because of the shape of the door, perspective and other monocular cues, but I had never seen it in depth. It made me do a double take and look at it with one eye and then the other in order to convince myself that it looked different. It was definitely out there.
When I was eating lunch, I looked down at my fork over the bowl of rice and the fork was poised in the air in front of the bowl. There was space between the fork and the bowl. I had never seen that before. . . . I kept looking at a grape poised at the edge of my fork. I could see it in depth.
March 1: Today, I was walking by the complete horse skeleton in the basement of the building where I work, when I saw the horse’s skull sticking out so much, that I actually jumped back and cried out.
March 4: While I was running this morning with the dog, I noticed that the bushes looked different. Every leaf seemed to stand out in its own little 3-D space. The leaves didn’t just overlap with each other as I used to see them. I could see the SPACE between the leaves. The same is true for twigs on trees, pebbles on the road, stones in a stone wall. Everything has more texture.
Sue’s letter continued in this lyrical vein, describing experiences utterly novel for her, beyond anything she could have imagined or inferred before. She had discovered for herself that there is no substitute for experience, that there is an unbridgeable gulf between what Bertrand Russell called “knowledge by description” and “knowledge by acquaintance,” and no way of going from one to the other.
One would think that the sudden appearance of an entirely new quality of sensation or perception might be confusing or frightening, but Sue seemed to adapt to her new world with remarkable ease. She was startled and disoriented at first, and had to calibrate her new visual perception of depth and distance with her actions and movements. But for the most part she felt entirely and increasingly at home with stereoscopy. Though she continues to be conscious of the novelty of stereo vision and indeed rejoices in it, she also feels now that it is “natural”—that she is seeing the world as it really is, as it should be. Flowers, she says, seem “intensely real, inflated,” where they were “flat” or “deflated” before.
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