The man who mistook his wife for a hat (13 page)

   We recognise this with dogs, and often use them for this purpose-to pick up falsehood, or malice, or equivocal intentions, to tell us who can be trusted, who is integral, who makes sense, when we-so susceptible to words-cannot trust our own instincts.

   And what dogs can do here, aphasiacs do too, and at a human and immeasurably superior level. 'One can lie with the mouth,' Nietzsche writes, 'but with the accompanying grimace one nevertheless tells the truth.' To such a grimace, to any falsity or impropriety in bodily appearance or posture, aphasiacs are preternatur-ally sensitive. And if they cannot see one-this is especially true of our blind aphasiacs-they have an infallible ear for every vocal nuance, the tone, the rhythm, the cadences, the music, the subtlest modulations, inflections, intonations, which can give-or remove-verisimilitude to or from a man's voice.

   In this, then, lies their power of understanding-understanding, without words, what is authentic or inauthentic. Thus it was the grimaces, the histrionisms, the false gestures and, above all, the false tones and cadences of the voice, which rang false for these wordless but immensely sensitive patients. It was to these (for them) most glaring, even grotesque, incongruities and improprieties that

   "Feeling-tone' is a favourite term of Head's, which he uses in regard not only to aphasia but to the affective quality of sensation, as it may be altered by thalmic or peripheral disorders. Our impression, indeed, is that Head is continually half-uncon-sciously drawn towards the exploration of 'feeling-tone'-towards, so to speak, a neurology of feeling-tone, in contrast or complementarity to a classical neurology of proposition and process. It is, incidentally, a common term in the U.S.A., at least among blacks in the South: a common, earthy and indispensable term. 'You see, there's such a thing as a feeling tone . . . And if you don't have this, baby, you've had it' (cited by Studs Terkel as epigraph to his 1967 oral history
Division Street: America).

   my aphasic patients responded, undeceived and undeceivable by words.

   This is why they laughed at the President's speech.

   If one cannot lie to an aphasiac, in view of his special sensitivity to expression and 'tone', how is it, we might ask, with patients- if there are such-who
lack
any sense of expression and 'tone', while preserving, unchanged, their comprehension for words: patients of an exactly opposite kind? We have a number of such patients, also on the aphasia ward, although, technically, they do not have aphasia, but, instead, a form of
agnosia,
in particular a so-called 'tonal' agnosia. For such patients, typically, the expressive qualities of voices disappear-their tone, their timbre, their feeling, their entire character-while words (and grammatical constructions) are perfectly understood. Such tonal agnosias (or 'apro-sodias') are associated with disorders of the
right
temporal lobe of the brain, whereas the aphasias go with disorders of the
left
temporal lobe.

   Among the patients with tonal agnosia on our aphasia ward who also listened to the President's speech was Emily D., with a glioma in her right temporal lobe. A former English teacher, and poetess of some repute, with an exceptional feeling for language, and strong powers of analysis and expression, Emily D. was able to articulate the opposite situation-how the President's speech sounded to someone with tonal agnosia. Emily D. could no longer tell if a voice was angry, cheerful, sad-whatever. Since voices now lacked expression, she had to look at people's faces, their postures and movements when they talked, and found herself doing so with a care, an intensity, she had never shown before. But this, it so happened, was also limited, because she had a malignant glaucoma, and was rapidly losing her sight too.

   What she then found she had to do was to pay extreme attention to exactness of words and word use, and to insist that those around her did just the same. She could less and less follow loose speech or slang-speech of an allusive or emotional kind-and more and more required of her interlocutors that they speak
prose
-'proper

   words in proper places'. Prose, she found, might compensate, in some degree, for lack of perceived tone or feeling. In this way she was able to preserve, even enhance, the use of 'expressive' speech-in which the meaning was wholly given by the apt choice and reference of words-despite being more and more lost with 'evocative' speech (where meaning is wholly given in the use and sense of tone).

   Emily D. also listened, stony-faced, to the President's speech, bringing to it a strange mixture of enhanced and defective perceptions-precisely the opposite mixture to those of our aphasiacs. It did not move her-no speech now moved her-and all that was evocative, genuine or false completely passed her by. Deprived of emotional reaction, was she then (like the rest of us) transported or taken in? By no means. 'He is not cogent,' she said. 'He does not speak good prose. His word-use is improper. Either he is braindamaged, or he has something to conceal.' Thus the President's speech did not work for Emily D. either, due to her enhanced sense of formal language use, propriety as prose, any more than it worked for our aphasiacs, with their word-deafness but enhanced sense of tone.

   Here then was the paradox of the President's speech. We normals-aided, doubtless, by our wish to be fooled, were indeed well and truly fooled
('Populus vult decipi, ergo decipiatur').
And so cunningly was deceptive word-use combined with deceptive tone, that only the brain-damaged remained intact, undeceived.

   
PART TWO

   
EXCESSES

   
Introduction

   'Deficit', we have said, is neurology's favourite word-its only word, indeed, for any disturbance of function. Either the function (like a capacitor or fuse) is normal-or it is defective or faulty: what other possibility
is
there for a mechanistic neurology, which is essentially a system of capacities and connections?

   What then of the opposite-an excess or superabundance of function? Neurology has no word for this-because it has no concept. A function, or functional system, works-or it does not: these are the only possibilities it allows. Thus a disease which is 'ebullient' or 'productive' in character challenges the basic mechanistic concepts of neurology, and this is doubtless one reason why such disorders-common, important, and intriguing as they are-have never received the attention they deserve. They receive it in psychiatry, where one speaks of excited and productive disorders- extravagances of fancy, of impulse . . . of mania. And they receive it in anatomy and pathology, where one speaks of hypertrophies, monstrosities-of teratoma. But physiology has no equivalent for this-no equivalent of monstrosities or manias. And this alone suggests that our basic concept or vision of the nervous system- as a sort of machine or computer-is radically inadequate, and needs to be supplemented by concepts more dynamic, more alive.

   This radical inadequacy may not be apparent when we consider only loss-the privation of functions we considered in Part One. But it becomes immediately obvious if we consider their excesses- not amnesia, but hypermnesia; not agnosia, but hypergnosia; and all the other 'hypers' we can imagine.

   Classical, 'Jacksonian' neurology never considers such disorders of excess-that is, primary superabundances or burgeonings of functions (as opposed to so-called 'releases'). Hughlings Jackson himself, it is true, did speak of 'hyper-physiological' and 'super-positive' states. But here, we might say, he is letting himself go, being playful, or, simply, just being faithful to his clinical experience, though at odds with his own mechanical concepts of function (such contradictions were characteristic of his genius, the chasm between his naturalism and his rigid formalism).

   We have to come almost to the present day to find a neurologist who even
considers
an excess. Thus Luria's two clinical biographies are nicely balanced:
The Man with a Shattered World
is about loss,
The Mind of a Mnemonist
about excess. I find the latter by far the more interesting and original of the two, for it is, in effect, an exploration of imagination and memory (and no such exploration is possible to classical neurology).

   In
Awakenings
there was an internal balance, so to speak, between the terrible privations seen before L-Dopa-akinesia, abou-lia, adynamia, anergia, etc.-and the almost equally terrible excesses after L-Dopa-hyperkinesia, hyperboulia, hyperdynamia, etc.

   And in this we see the emergence of a new sort of term, of terms and concepts other than those of function-impulse, will, dynamism, energy-terms essentially kinetic and dynamic (whereas those of classical neurology are essentially static). And, in the mind of the Mnemonist, we see dynamisms of a much higher order at work-the thrust of an ever-burgeoning and almost uncontrollable association and imagery, a monstrous growth of thinking, a sort of teratoma of the mind, which the Mnemonist himself calls an 'It'.

   But the word 'It', or automatism, is also too mechanical. 'Burgeoning' conveys better the disquietingly alive quality of the process. We see in the Mnemonist-or in my own overenergised, galvanised patients on L-Dopa-a sort of animation gone extravagant, monstrous, or mad-not merely an excess, but an organic proliferation, a generation; not just an imbalance, a disorder of function, but a disorder of generation.

   We might imagine, from a case of amnesia or agnosia, that there is merely a function or competence impaired-but we see from patients with hypermnesias and hypergnosias that mnesis and gnosis are inherently active, and generative, at all times; inherently, and-potentially-monstrously as well. Thus we are forced to move from a neurology of function to a neurology of action, of life. This crucial step is forced upon us by the diseases of excess- and without it we cannot begin to explore the 'life of the mind'. Traditional neurology, by its mechanicalness, its emphasis on deficits, conceals from us the actual life which is instinct in all cerebral functions-at least higher functions such as those of imagination, memory and perception. It conceals from us the very life of the mind. It is with these living (and often highly personal) dispositions of brain and mind-especially in a state of enhanced, and thus illuminated, activity-that we shall be concerned now.

   Enhancement allows the possibilities not only of a healthy fullness and exuberance, but of a rather ominous extravagance, aberration, monstrosity-the sort of 'too-muchness' which continually loomed in
Awakenings,
as patients, over-excited, tended to disintegration and uncontrol; an overpowering by impulse, image and will; possession (or dispossession) by a physiology gone wild.

   This danger is built into the very nature of growth and life. Growth can become over-growth, life 'hyper-life'. All the 'hyper' states can become monstrous, perverse aberrations, 'para' states: hyperkinesia tends towards parakinesia-abnormal movements, chorea, tics; hypergnosia readily becomes paragnosia-perversions, apparitions, of the morbidly-heightened senses; the ardours of 'hyper' states can become violent passions.

   The paradox of an illness which can present as wellness-as a wonderful feeling of health and well-being, and only later reveal its malignant potentials-is one of the chimaeras, tricks and ironies of nature. It is one which has fascinated a number of artists, especially those who equate art with sickness: thus it is a theme-at once Dionysiac, Venerean and Faustian-which persistently recurs in Thomas Mann-from the febrile tuberculous highs of
The Magic Mountain,
to the spirochetal inspirations in
Dr Faustus
and the aphrodisiac malignancy in his last tale,
The Black Swan.

   I have always been intrigued by such ironies, and have written of them before. In
Migraine
I spoke of the high which may precede, or constitute the start of, attacks-and quoted George Eliot's remark that feeling 'dangerously well' was often, for her, the sign or harbinger of an attack. 'Dangerously well'-what an irony is this: it expresses precisely the doubleness, the paradox, of feeling 'too well'.

   For 'wellness', naturally, is no cause for complaint-people relish it, they enjoy it, they are at the furthest pole from complaint. People complain of feeling ill-not well. Unless, as George Eliot does, they have some intimation of 'wrongness', or danger, either through knowledge or association, or the very excess of excess. Thus, though a patient will scarcely complain of being 'very well', they may become suspicious if they feel 'too well'.

   This was a central, and (so to speak) cruel, theme in
Awakenings,
that patients profoundly ill, with the profoundest deficits, for many decades, might find themselves, as by a miracle, suddenly well, only to move from there into the hazards, the tribulations, of excess, functions stimulated far beyond 'allowable' limits. Some patients realised this, had premonitions-but some did not. Thus Rose R., in the first flush and joy of restored health, said, 'It's fabulous, it's gorgeous!', but as things accelerated towards uncon-trol said, 'Things can't last. Something awful is coming.' And similarly, with more or less insight, in most of the others-as with Leonard L., as
he
passed from repletion to excess: 'his abundance of health and energy-of "grace", as he called it-became
too
abundant, and started to assume an extravagant form. His sense of harmony and ease and effortless control was replaced by a sense of
too-muchness
… a great surplus, a great
pressure
of . . . [every kind]', which threatened to disintegrate him, to burst him asunder.

   This is the simultaneous gift and affliction, the delight, the anguish, conferred by excess. And it is felt, by insightful patients, as questionable and paradoxical: 'I have too much energy,' one Tourette patient said. 'Everything is too bright, too powerful, too much. It is a feverish energy, a morbid brilliance.'