2018-02-23 18:58:03 +00:00
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---
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created_at: '2015-08-30T20:35:52.000Z'
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title: The man who mistook his wife for a hat (1983)
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url: http://www.lrb.co.uk/v05/n09/oliver-sacks/the-man-who-mistook-his-wife-for-a-hat
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author: lermontov
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points: 217
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story_text:
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comment_text:
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num_comments: 26
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story_id:
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story_title:
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story_url:
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parent_id:
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created_at_i: 1440966952
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_tags:
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- story
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- author_lermontov
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- story_10144420
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objectID: '10144420'
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2018-06-08 12:05:27 +00:00
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year: 1983
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2018-02-23 18:58:03 +00:00
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---
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2018-03-03 09:35:28 +00:00
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The scientific study of the relationship between brain and mind began in
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1861, when Broca, in France, found that specific difficulties in the
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expressive use of speech (aphasia) consistently followed damage to a
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particular portion of the left hemisphere of the brain. This opened the
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way to a cerebral neurology, which made it possible, over the decades,
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to ‘map’ the human brain, ascribing specific powers to equally specific
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‘centres’ in the brain.
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Towards the end of the century it became evident to more acute observers
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– above all, Freud, in his book on Aphasia (1891) – that this sort of
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mapping was too simplistic, that all mental performances had an
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intricate internal structure, and must have an equally complex
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physiological basis. He felt this, especially, in regard to certain
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disorders of recognition and perception, for which he coined the term
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‘agnosia’. An adequate understanding of aphasia or agnosia would, he
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believed, require a new, more sophisticated science.
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The new science of brain/mind which Freud envisaged came into being in
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the Second World War, in Russia, as the joint creation of A.R. Luria
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(and his father R.A. Luria), Leontev, Anokhin, Bernstein and others, and
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was called by them ‘neuropsychology’. The development of this immensely
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fruitful science was the life-work of A.R. Luria, and considering its
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revolutionary importance, was somewhat slow in reaching the West. It was
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set out, systematically, in a monumental book, Higher Cortical Functions
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in Man (translated into English in 1966), and, in a wholly different
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way, in a biography or ‘pathography’ – The Man with a Shattered World
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(which appeared in English in 1973). Although these books were almost
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perfect in their way, there was a whole realm which Luria had not
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touched. Higher Cortical Functions in Man treated only those functions
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which appertained to the left hemisphere of the brain; similarly,
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Zazetsky, the man with the shattered world, had a huge lesion in the
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left hemisphere – the right was intact. Indeed, the entire history of
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neurology and neuropsychology can be seen as a history of the
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investigation of the left hemisphere.
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One important reason for the neglect of the right hemisphere, the
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‘minor’ hemisphere, as it has always been called, is that while it
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is easy to demonstrate the effects of variously-located lesions on the
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left side, the corresponding syndromes of the right hemisphere are much
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less distinct. Anatomically, too, the right hemisphere is less
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differentiated than the left: it does not have hundreds of
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clearly-demarcated regions like the left, but instead has a relatively
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homogeneous appearance. It was presumed, usually contemptuously, to be
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more primitive than the left, the latter being seen as the unique flower
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of human evolution. And in a sense this is correct: the left hemisphere
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is more sophisticated and specialised, a very late outgrowth of the
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primate, and especially hominid, brain. On the other hand, it is the
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right hemisphere which, controls the crucial powers of recognising
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reality which every living creature must have in order to survive. The
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left hemisphere, like a computer tacked onto the basic creatural brain,
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is designed for programs and schematics; and classical neurology was
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more concerned with schematics than with reality, so that when, at last,
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some of the right-hemisphere syndromes emerged, they were considered
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bizarre.
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There had been attempts in the past – for example, by Anton in the 1890s
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and Pötzl in the 1930s – to explore right-hemisphere syndromes, but
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these attempts themselves had been bizarrely ignored. In The Working
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Brain, one of his last books, Luria devoted a short but tantalising
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section to right-hemisphere syndromes, ending: ‘These still completely
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unstudied defects lead us to one of the most fundamental problems – to
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the role of the right hemisphere in direct consciousness ... The study
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of this highly important field has been so far neglected ... It will
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receive a detailed analysis in a special series of papers ... in
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preparation for publication.’ Luria did, finally, write some of these
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papers, in the last months of his life, when mortally ill. He never saw
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their publication, nor were they published in Russia: he sent them to
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Richard Gregory in England. They will appear in Gregory’s Oxford
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Companion to the Mind.
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Inner difficulties and outer difficulties match each other here. It is
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not only difficult, it is impossible for patients with certain
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right-hemisphere syndromes to know their own problems. Moreover, this
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peculiar anosognosia is observed only in such patients, and it is
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singularly difficult for the observer, however sensitive, to understand
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what it must be like to be in this situation. Left-hemisphere syndromes,
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by contrast, are relatively easily imagined. Although right-hemisphere
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syndromes are as common as left-hemisphere syndromes – why should they
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not be? – one will find a thousand descriptions of left-hemisphere
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syndromes in the neurological and neuropsychological literature for
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every description of a right-hemisphere syndrome. It is as if such
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syndromes were somehow alien to the whole temper of neurology and yet,
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as Luria says, they are of the most fundamental importance, so much so
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that they may demand a new sort of neurology, a ‘romantic science’, as
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he liked to call it. Luria thought a science of this kind would be best
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introduced by a story – a detailed case-history of man with a profound
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right-hemisphere disturbance, a case-history which would at once be the
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complement and opposite of The Man with a Shattered World. In one of his
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last letters he wrote: ‘Publish such histories, even if they are just
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sketches. It is a realm of great wonder.’
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Dr P. lived on the East Coast of the United States. He was well-known
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for many years as a singer, and then, at the local Academy of Music, as
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a teacher. It was here that certain strange mistakes were first
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observed. Sometimes a student would present himself, and Dr P. would not
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recognise him; or, specifically, would not recognise his face. The
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moment the student spoke, he would be recognised by his voice. Such
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incidents multiplied, causing embarrassment, perplexity, fear – and,
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sometimes, comedy. For not only did Dr P. increasingly fail to see
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faces, but he saw faces when there were no faces to see: genially,
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Magoo-like, when in the street, he might pat the heads of water-hydrants
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and parking-meters, taking these to be the heads of children; he would
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amiably address carved knobs on the furniture, and be astounded when
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they did not reply. At first these odd mistakes were laughed off as
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jokes, not least by Dr P. himself. Had he not always had a quirky sense
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of humour, and been given to Zen-like paradoxes and jests? His musical
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powers were as dazzling as ever; he did not feel ill – he had never felt
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better; and the mistakes were so ludicrous – and so ingenious – they
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could hardly be serious or betoken anything serious. The notion of their
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being ‘something the matter’ did not emerge until some three years
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later, when diabetes developed. Well aware that diabetes could affect
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his eyes, Dr P. consulted an ophthalmologist, who took a careful
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history, and examined him closely. ‘There’s nothing the matter with your
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eyes,’ the doctor concluded. ‘But there is trouble with the visual parts
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of your brain. You don’t need my help, you must see a neurologist.’ And
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so, as a result of this referral, Dr P. came to me.
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It was obvious within a few seconds of meeting him that Dr P. was a man
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of great cultivation and charm, who talked well and fluently, with
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imagination and humour. I couldn’t think why he had been referred to our
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clinic.
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Yet there was something a bid odd: some failure in the normal interplay
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of gaze and expression. He saw me, he scanned me, and yet ...
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‘What seems to be the matter?’ I asked him at length.
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‘Nothing that I know of,’ he replied with a smile, but people seem to
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think there’s something wrong with my eyes.’
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‘But you don’t recognise any visual problems?’
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‘No, not directly, but I occasionally make mistakes.’
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I left the room briefly to talk to his wife. When I came back Dr P. was
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sitting placidly by the window, attentive, listening rather than looking
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out. ‘Traffic,’ he said. ‘Street sounds, distant trains – they make a
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sort of symphony, do they not? Do you know Honegger’s Pacific 231?’ What
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a lovely man, I thought to myself, how can there be anything seriously
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the matter? Would he permit me to examine him? ‘Yes, of course, Dr
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Sacks.’
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I stilled my disquiet, his perhaps too, in the soothing routine of a
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neurological exam – muscle strength, co-ordination, reflexes, tone. It
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was while examining his reflexes – a trifle abnormal on the left side –
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that the first bizarre experience occurred. I had taken off his left
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shoe and scratched the sole of his foot with a key – a frivolous-seeming
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but essential test of a reflex – and then, excusing myself to screw my
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ophthalmoscope together, left him to put on the shoe himself. To my
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surprise, a minute later, he had not done this.
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‘Can I help?’I asked.
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‘Help what? Help whom?’
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‘Help you put on your shoe.’
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‘Ach,’ he said, ‘I had forgotten the shoe,’ adding, sotto voce: ‘The
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shoe\! The shoe?’ He seemed baffled.
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‘Your shoe,’ I repeated. ‘Perhaps you’d put it on.’
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He continued to look downwards, though not at the shoe, with an intense
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but misplaced concentration. Finally his gaze settled on his foot: ‘That
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is my shoe, yes?’
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Did I mishear? Did he mis-see? ‘My eyes,’ he explained, and put a hand
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to his foot. ‘This is my shoe, no?’
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‘No, it is not. That is your foot. There is your shoe.’
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‘Ah\! I thought that was my foot.’
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Was he joking? Was he mad? Was he blind? If this was one of his ‘strange
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mistakes’, it was the strangest mistake I had ever come across.
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I helped him on with his shoe (his foot), to avoid further complication.
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Dr P. himself seemed untroubled, indifferent, maybe amused. I resumed my
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examination. His visual acuity was good: he had no difficulty seeing a
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pin on the floor, though sometimes he missed it if it was placed to his
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left.
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He saw all right, but what did he see? I opened out a copy of the
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National Geographic Magazine, and asked him to describe some pictures in
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it. His eyes darted from one thing to another, picking up tiny features,
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as he had picked up the pin. A brightness, a colour, a shape would
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arrest his attention and elicit comment, but it was always details that
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he saw – never the whole. And these details he ‘spotted’, as one might
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spot blips on a radar-screen. He had no sense of a landscape or a scene.
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2018-02-23 18:19:40 +00:00
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I showed him the cover, an unbroken expanse of Sahara dunes.
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2018-03-03 09:35:28 +00:00
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‘What do you see here?’I asked.
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‘I see a river,’ he said. ‘And a little guesthouse with its terrace on
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the water. People are dining out on the terrace. I see coloured parasols
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here and there.’ He was looking, if it was ‘looking’, right off the
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cover, into mid-air, and confabulating non-existent features, as if the
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absence of features in the actual picture had driven him to imagine the
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river and the terrace and the coloured parasols.
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I must have looked aghast, but he seemed to think he had done rather
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well. There was a hint of a smile on his face. He also appeared to have
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decided the examination was over, and started to look round for his hat.
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He reached out his hand, and took hold of his wife’s head, tried to lift
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it off, to put it on. He had apparently mistaken his wife for a hat\!
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His wife looked as if she was used to such things.
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I could make no sense of what had occurred, in terms of conventional
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neurology (or neuropsychology). In some ways he seemed perfectly
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preserved, and in others absolutely, incomprehensibly devastated. How
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could he, on the one hand, mistake his wife for a hat and, on the other,
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function, as apparently he still did, as a teacher at the Music Academy?
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A few days later I called on Dr P. and his wife at home, with the score
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of the Dichterliebe in my briefcase (I knew he liked Schumann), and a
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variety of odd objects for the testing of perception. Mrs P. showed me
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into a lofty apartment which recalled Fin-de-Siècle Berlin. A
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magnificent old Bosendorfer stood in state in the centre of the room,
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and all round it were music-stands, instruments, scores ... There were
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books, there were paintings, but the music was central. Dr P. came in, a
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little bowed and distracted, advanced with outstretched hand to the
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grandfather clock, but, hearing my voice, corrected himself, and shook
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hands with me. We exchanged greetings, and chatted a little of current
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concerts. Diffidently, I asked him if he would sing.
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‘The Dichterliebe\!’ he exclaimed. ‘But I can no longer read music. You
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will play them, yes?’ I said I would try. On that wonderful old piano
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even my playing sounded right, and Dr P. was an aged, but infinitely
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mellow Fischer-Dieskau, combining a perfect ear and voice with the most
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incisive musical intelligence. It was clear that the Music Academy was
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not keeping him on out of charity.
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Dr P.’s temporal lobes were obviously intact, he had a wonderful musical
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cortex: what, I wondered, was going on in his parietal and occipital
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lobes, and especially in his right visual cortex? I carry the Platonic
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solids in my neurological kit, and decided to start with these.
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‘What is this?’ I asked, drawing out the first.
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‘A cube, of course.’
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‘Now this?’ I asked, brandishing another.
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He asked if he might examine it, which he did swiftly and
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systematically: ‘A dodecahedron, of course. And don’t bother with the
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others – I’ll get the eicosahedron too.’
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Abstract shapes clearly presented no problems. What about faces? I took
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out a pack of cards. All of these he identified instantly, including the
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jacks, queens, kings, and the joker. But these, after all, are stylised
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designs and it was impossible to tell whether he saw faces or merely
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patterns. I decided I would show him a volume of cartoons which I had in
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my briefcase. Here, again, for the most part, he did well. Churchill’s
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cigar, Schnozzle’s nose: as soon as he had picked out a key feature he
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could identify the face. But cartoons, again, are formal and schematic.
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It remained to be seen how he would do with real faces, realistically
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represented.
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I turned on the television, keeping the sound off, and found an early
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Bette Davis film. A love scene was in progress. Dr P. failed to identify
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the actress – but this could have been because she had never entered his
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world. What was more striking was that he failed to identify the
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expressions on her face or her partner’s, though in the course of a
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single torrid scene these passed from sultry yearning through passion,
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surprise, disgust and fury to a melting reconciliation. Dr P. could make
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nothing of any of this. He was very unclear as to what was going on, or
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who was who, or even what sex they were. His comments on the scene were
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positively Martian.
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It was – just – possible that some of his difficulties were associated
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with the unreality of a celluloid, Hollywood world; and it occurred to
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me that he might be more successful in identifying faces from his own
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life. On the walls of the apartment there were photographs of his
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family, his colleagues, his pupils, himself. I gathered a pile of these
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together, and with some misgivings, presented them to him. What had been
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funny, or farcical, in relation to the movie, was tragic in relation to
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real life. By and large, he recognised nobody: neither his family, nor
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his colleagues, nor his pupils, nor himself. He recognised a portrait of
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Einstein, because he picked up the characteristic hair and moustache;
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and the same thing happened with one or two other people. ‘Ach, Paul\!’
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he said, when shown a portrait of his brother. ‘That square jaw, those
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big teeth, I would know Paul anywhere\!’ But was it Paul he recognised,
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or one or two of his features, on the basis of which he could make a
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reasonable guess as to the subject’s identity? In the absence of obvious
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‘markers’, he was utterly lost. It was distressing to watch him
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approaching these faces as if they were abstract puzzles or tests. He
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did not relate to them. Some were identified: not one was familiar. A
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face, for him, was not the semblance of a human being – it was merely an
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aggregation of features.
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I had stopped at a florist on my way to his apartment and bought myself
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an extravagant red rose for my buttonhole. Now I removed this and handed
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it to him. He took it like a botanist or morphologist given a specimen,
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not like a person given a flower.
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‘About six inches in length,’ he commented, ‘a convoluted red form with
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a linear green attachment.’
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‘Yes,’ I said encouragingly, and what do you think it is, Dr P.?’
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‘Not easy to say.’ He seemed perplexed. ‘It lacks the simple symmetry of
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the Platonic solids, although it may have a higher symmetry of its own
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... I think this could be an inflorescence or flower.’
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‘Could be?’ I queried.
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‘Could be,’ he confirmed.
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‘Smell it,’ I suggested, and he again looked somewhat puzzled, as if I
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had asked him to smell a higher symmetry. But he complied courteously,
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and took it to his nose. Now, suddenly, he came to life.
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‘Beautiful\!’ he exclaimed. ‘An early rose. What a heavenly smell\!’ He
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started to hum ‘Die Rose, die Lillie ...’ Reality, it seemed, might be
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conveyed by smell, not by sight.
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I tried one final test. It was still a cold day, in early spring, and I
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had thrown my coat and gloves on the sofa.
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‘What is this?’ asked, holding up a glove.
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‘May I examine it?’ he asked, and, taking it from me, he proceeded to
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examine it as he had examined the geometrical shapes.
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‘A continuous surface,’ he announced at last, ‘infolded on itself. It
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appears to have’ – he hesitated – ‘five outpouchings, if that is the
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word.’
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‘Yes,’ I said cautiously. ‘You have given me a description. Now tell me
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what it is.’
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‘A container of some sort?’
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‘Yes,’ I said, ‘and what would it contain?’
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‘It would contain its contents\!’ said Dr P., with a laugh. There are
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many possibilities. It could be a change-purse, for example, for coins
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of five sizes. It could ...’
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I interrupted the barmy flow. ‘Does it not look familiar? Do you think
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it might contain, might fit, a part of your body?’
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2018-02-23 18:19:40 +00:00
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No light of recognition dawned on his face.
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2018-03-03 09:35:28 +00:00
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No child would have the power to see and speak of ‘a continuous surface
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... infolded on itself’, but any child, any infant, would immediately
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know a glove as a glove, see it as familiar, as going with a hand. Dr P.
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didn’t. He saw nothing as familiar. Visually, he was lost in a world of
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lifeless abstractions. Indeed he did not have a real visual world, as he
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did not have a real visual self. He could speak about things, but did
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not see them face-to-face. Hughlings Jackson, discussing patients with
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aphasia and left-hemisphere lesions, says they have lost ‘abstract’ and
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‘propositional’ thought – and compares them with dogs (or, rather, he
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compares dogs to patients with aphasia). Dr P., on the other hand,
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functioned precisely as a machine functions. It wasn’t merely that he
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displayed the same indifference to the visual world as a computer but –
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even more strikingly – he construed the world as a computer construes
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it, by means of key features and schematic relationships.
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The testing I had done so far told me nothing about Dr P.’s inner world.
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Was it possible that his visual memory and imagination were still
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intact? I asked him to imagine entering one of our local squares from
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the north side, to walk through it, in imagination or in memory, and
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tell me the buildings he might pass as he walked. He listed the buldings
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on his right side, but none of those on his left. I then asked him to
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imagine entering the square from the south. Again he mentioned only
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those buildings that were on the right side, although these were the
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very buildings he had omitted before. Those he had ‘seen’ internally
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before were not mentioned now – presumably, they were no longer ‘seen’.
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It was evident that his difficulties with leftness, his visual field
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deficits, were as much internal as external, bisecting his visual memory
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and imagination.
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It was entirely in keeping with his condition that he could remember the
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plot of a novel and things that the characters said, but had no sense of
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their physiognomy; that he could remember what happened to them but not
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the scenes in which they took part. What surprised me was that when I
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engaged him in a game of mental chess he had no difficulty in
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visualising the chessboard – indeed, had no difficulty in beating me.
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Luria said of Zazetsky that he had entirely lost his capacity to play
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games but that his ‘vivid imagination’ was unimpaired. Zazetsky and Dr
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P. lived in worlds which were mirror images of each other. But the
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saddest difference between them was that Zazetsky, as Luria said, fought
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to regain his lost faculties with the ‘tenacity of the damned’, whereas
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Dr P. did not even know that anything was lost.
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When the examination was over, Mrs P. called us to the table, where
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there was coffee and a delicious spread of little cakes. Hungrily,
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hummingly, Dr P. started on the cakes. Swiftly, fluently, unthinkingly,
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melodiously, he pulled the plates towards him, and took this and that,
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in a great gurgling stream, an edible song of food, until, suddenly,
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there came an interruption: a loud, peremptory rat-ta-tat at the door.
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Startled, taken aback, arrested, by the interruption, Dr P. stopped
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eating, and sat frozen, motionless, at the table, with an indifferent,
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blind, bewilderment on his face. He saw, but no longer saw, the table;
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no longer perceived it as a table laden with cakes. His wife poured him
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some coffee: the smell titillated his nose, and brought him back to
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reality. The melody of eating resumed.
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How does he do anything, I wondered to myself? What happens when he’s
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dressing, goes to the lavatory, has a bath? I followed his wife into the
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kitchen and asked her how, for instance, he managed to dress himself.
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‘It’s just like the eating,’ she explained. ‘I put his usual clothes
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out, in all the usual places, and he dresses without difficulty, singing
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to himself. He does everything singing to himself. But if he is
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interrupted and loses the thread, he comes to a complete stop, doesn’t
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know his clothes – or his own body. He sings all the time – eating
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songs, dressing songs, bathing songs, everything. He can’t do anything
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unless he makes it a song.’
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We returned to the great music-room, with the Bosendorfer in the centre,
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and Dr P. humming the last torte. ‘Well, Doctor Sacks,’ he said to me.
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‘You find me an interesting “case”, I perceive. Can you tell me what
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you find wrong, make recommendations?’
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I can’t tell you what I find wrong,’ I replied, ‘but I’ll say what I
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find right. You are a wonderful musician, and music is your life. What I
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would prescribe, in a “case” such as yours, is a life which consists
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entirely of music. Music has been the centre, now make it the whole of
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your life.’
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This was four years ago. I never saw him again. But I often wondered how
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he apprehended the world, given his loss of image and visuality and the
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perfect preservation of his musicality. I think that music for him had
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taken the place of image: he had no body image – he had body music. This
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is why he could move and act as fluently as he did, but came to a total
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stop if the ‘inner musk’ stopped. In The World as Will and
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Representation Schopenhauer speaks of music as pure will. How fascinated
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he would have been by Dr P., a man who had wholly lost the world as
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representation but wholly preserved it as music, or will. And this,
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mercifully, held to the end, for despite the gradual advance of the
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disease – a massive tumour or degenerative process in the visual parts
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of his brain – Dr P. lived and taught music to the last days of his
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life.
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