The man who mistook his wife for a hat (17 page)

   even terrified, by something in him. 'He never stops', they say. 'He's like a man in a race, a man trying to catch something which always eludes him.' And, indeed, he can never stop running, for the breach in memory, in existence, in meaning, is never healed, but has to be bridged, to be 'patched', every second. And the bridges, the patches, for all their brilliance, fail to work-because they
are
confabulations, fictions, which cannot do service for reality, while also failing to correspond with reality. Does Mr Thompson feel
this?
Or, again, what
is
his 'feeling of reality'? Is he in a torment all the while-the torment of a man lost in unreality, struggling to rescue himself, but sinking himself, by ceaseless inventions, illusions, themselves quite unreal? It is certain that he is not at ease-there is a tense, taut look on his face all the while, as of a man under ceaseless inner pressure; and occasionally, not too often, or masked if present, a look of open, naked, pathetic bewilderment. What saves Mr Thompson in a sense, and in another sense damns him,
is
the forced or defensive superficiality of his life: the way in which it is, in effect, reduced to a surface, brilliant, shimmering, iridescent, ever-changing, but for all that a surface, a mass of illusions, a delirium, without depth.

   And with this, no feeling
that
he has lost feeling (for the feeling he has lost), no feeling
that
he has lost the depth, that unfathomable, mysterious, myriad-levelled depth which somehow defines identity or reality. This strikes everyone who has been in contact with him for any time-that under his fluency, even his frenzy, is a strange loss of feeling-that feeling, or judgment, which distinguishes between 'real' and 'unreal', 'true' and 'untrue' (one cannot speak of 'lies' here, only of 'non-truth'), important and trivial, relevant or irrelevant. What comes out, torrentially, in his ceaseless confabulation, has, finally, a peculiar quality of indifference … as if it didn't really matter what he said, or what anyone else did or said; as if nothing really mattered any more.

   A striking example of this was presented one afternoon, when William Thompson, jabbering away, of all sorts of people who were improvised on the spot, said: 'And there goes my younger brother, Bob, past the window', in the same, excited but even and indifferent tone, as the rest of his monologue. I was dumbfounded

   when, a minute later, a man peeked round the door, and said: 'I'm Bob, I'm his younger brother-I think he saw me passing by the window.' Nothing in William's tone or manner-nothing in his exuberant, but unvarying and indifferent, style of monologue-had prepared me for the possibility of. . . reality. William spoke of his brother, who
was
real, in precisely the same tone, or lack of tone, in which he spoke of the unreal-and now, suddenly, out of the phantoms, a real figure appeared! Further, he did not treat his younger brother as 'real'-did not display any real emotion, was not in the least oriented or delivered from his delirium- but, on the contrary, instantly treated his brother
as
unreal, effacing him, losing him, in a further whirl of delirium-utterly different from the rare but profoundly moving times when Jimmie G. (see Chapter Two) met
his
brother, and while with him was unlost. This was intensely disconcerting to poor Bob-who said 'I'm Bob, not Rob, not Dob', to no avail whatever. In the midst of confabulations-perhaps some strand of memory, of remembered kinship, or identity, was still holding (or came back for an instant)-William spoke of his
elder
brother, George, using his invariable present indicative tense.

   'But George died nineteen years ago!' said Bob, aghast.

   'Aye, George is always the joker!' William quipped, apparently ignoring, or indifferent to, Bob's comment, and went on blathering of George in his excited, dead way, insensitive to truth, to reality, to propriety, to everything-insensitive too to the manifest distress of the living brother before him.

   It was this which convinced me, above everything, that there was some ultimate and total loss of inner reality, of feeling and meaning, of soul, in William-and led me to ask the Sisters, as I had asked them of Jimmie G. 'Do you think William
has
a soul? Or has he been pithed, scooped-out, de-souled, by disease?'

   This time, however, they looked worried by my question, as if something of the sort were already in their minds: they could not say 'Judge for yourself. See Willie in Chapel', because his wisecracking, his confabulations continued even there. There is an utter pathos, a sad
sense
of lostness, with Jimmie G. which one does not feel, or feel directly, with the effervescent Mr Thompson.

   Jimmie has
moods,
and a sort of brooding (or, at least, yearning) sadness, a depth, a soul, which does not seem to be present in Mr Thompson. Doubtless, as the Sisters said, he had a soul, an immortal soul, in the theological sense; could be seen, and loved, as an individual by the Almighty; but, they agreed, something very disquieting had happened to him, to his spirit, his character, in the ordinary, human sense.

   It is
because
Jimmie is 'lost' that he
can
be redeemed or found, at least for a while, in the mode of a genuine emotional relation. Jimmie is in despair, a quiet despair (to use or adapt Kierkegaard's term), and therefore he has the possibility of salvation, of touching base, the ground of reality, the feeling and meaning he has lost, but still recognises, still yearns for . . .

   But for William-with his brilliant, brassy surface, the unending joke which he substitutes for the world (which if it covers over a desperation, is a desperation he does not feel); for William with his manifest indifference to relation and reality caught in an unending verbosity, there may be nothing 'redeeming' at all-his confabulations, his apparitions, his frantic search for meanings, being the ultimate barrier
to
any meaning.

   Paradoxically, then, William's great gift-for confabulation- which has been called out to leap continually over the ever-opening abyss of amnesia-William's great gift is also his damnation. If only he could be
quiet
, one feels, for an instant; if only he could stop the ceaseless chatter and jabber; if only he could relinquish the deceiving surface of illusions-then (ah then!) reality might seep in; something genuine, something deep, something true, something felt, could enter his soul.

   For it is not memory which is the final, 'existential' casualty here (although his memory
is
wholly devastated); it is not memory only which has been so altered in him, but some ultimate capacity for feeling which is gone; and this is the sense in which he is 'de-souled'.

   Luria speaks of such indifference as 'equalisation'-and sometimes seems to see it as the ultimate pathology, the final destroyer of any world, any self. It exerted, I think, a horrified fascination on him, as well as constituting an ultimate therapeutic challenge. He was drawn back to this theme again and again-sometimes in

   relation to Korsakov's and memory, as in
The Neuropsychology of Memory,
more often in relation to frontal-lobe syndromes, especially in
Human Brain and Psychological Processes,
which contains several full-length case-histories of such patients, fully comparable in their terrible coherence and impact to 'the man with a shattered world'-comparable, and, in a way, more terrible still, because they depict patients who do not realise that anything has befallen them, patients who have lost their own reality, without knowing it, patients who may not suffer, but be the most God-forsaken of all. Zazetsky (in
The Man with a Shattered World)
is constantly described as a
fighter,
always (even passionately) conscious of his state, and always fighting 'with the tenacity of the damned' to recover the use of his damaged brain. But William (like Luria's frontal-lobe patients-see next chapter) is so damned he does not know he is damned, for it is not just a faculty, or some faculties, which are damaged, but the very citadel, the self, the soul itself. William is 'lost', in this sense, far more than Jimmie-for all his brio; one never feels, or rarely feels, that there is a
person
remaining, whereas in Jimmie there is plainly a real, moral being, even if disconnected most of the time. In Jimmie, at least, re-connection is
possible
-the therapeutic challenge can be summed up as 'Only connect'.

   Our efforts to 're-connect' William all fail-even increase his confabulatory pressure. But when we abdicate our efforts, and let him be, he sometimes wanders out into the quiet and undemanding garden which surrounds the Home, and there, in its quietness, he recovers his own quiet. The presence of others, other people, excite and rattle him, force him into an endless, frenzied, social chatter, a veritable delirium of identity-making and -seeking; the presence of plants, a quiet garden, the non-human order, making no social or human demands upon him, allow this identity-delirium to relax, to subside; and by their quiet, non-human self-sufficiency and completeness allow him a rare quietness and self-sufficiency of his own, by offering (beneath, or beyond, all merely human identities and relations) a deep wordless communion with Nature itself, and with this the restored sense of being in the world, being real.

   
13

   
Yes, Father-Sister

   Mrs B., a former research chemist, had presented with a rapid personality change, becoming 'funny' (facetious, given to wisecracks and puns), impulsive-and 'superficial' ('You feel she doesn't care about you,' one of her friends said. 'She no longer seems to care about anything at all.') At first it was thought that she might be hypomanic, but she turned out to have a cerebral tumour. At craniotomy there was found, not a meningioma as had been hoped, but a huge carcinoma involving the orbitofrontal aspects of both frontal lobes.

   When I saw her, she seemed high-spirited, volatile-'a riot' (the nurses called her)-full of quips and cracks, often clever and funny.

   'Yes, Father,' she said to me on one occasion.

   'Yes, Sister,' on another.

   'Yes, Doctor,' on a third.

   She seemed to use the terms interchangeably.

   'What
am
I?' I asked, stung, after a while.

   'I see your face, your beard,' she said, 'I think of an Archimandrite Priest. I see your white uniform-I think of the Sisters. I see your stethoscope-I think of a doctor.'

   'You don't look at
all
of me?'

   'No, I don't look at all of you.'

   'You realise the difference between a father, a sister, a doctor?'

   'I
know
the difference, but it means nothing to me. Father, sister, doctor-what's the big deal?'

   Thereafter, teasingly, she would say: 'Yes, father-sister. Yes, sister-doctor', and other combinations.

   Testing left-right discrimination was oddly difficult, because she

   said left or right indifferently (though there was not, in reaction, any confusion of the two, as when there is a lateralising defect of perception or attention). When I drew her attention to this, she said: 'Left/right. Right/left. Why the fuss? What's the difference?'

   
'Is
there a difference?' I asked.

   'Of course,' she said, with a chemist's precision. 'You could call them
enantiomorphs
of each other. But they mean nothing to
me.
They're no different for
me.
Hands . . . Doctors . . . Sisters . . . ' she added, seeing my puzzlement. 'Don't you understand? They mean nothing-nothing to me.
Nothing means anything
… at least to me.'

   'And . . . this meaning nothing . . . ' I hesitated, afraid to go on. 'This meaninglessness . . . does
this
bother you? Does
this
mean anything to you?'

   'Nothing at all,' she said promptly, with a bright smile, in the tone of one who makes a joke, wins an argument, wins at poker.

   Was this denial? Was this a brave show? Was this the 'cover' of some unbearable emotion? Her face bore no deeper expression whatever. Her world had been voided of feeling and meaning. Nothing any longer felt 'real' (or 'unreal'). Everything was now 'equivalent' or 'equal'-the whole world reduced to a facetious insignificance.

   I found this somewhat shocking-her friends and family did too-but she herself, though not without insight, was uncaring, indifferent, even with a sort of funny-dreadful nonchalance or levity.

   Mrs B., though acute and intelligent, was somehow not present- 'de-souled'-as a person. I was reminded of William Thompson (and also of Dr P.). This is the effect of the 'equalisation' described by Luria which we saw in the preceding chapter and will also see in the next.

   
Postscript

   The sort of facetious indifference and 'equalisation' shown by this patient is not uncommon-German neurologists call it
Witzel-sucht
('joking disease'), and it was recognised as a fundamental

   form of nervous 'dissolution' by Hughlings Jackson a century ago. It is not uncommon, whereas insight is-and the latter, perhaps mercifully, is lost as the 'dissolution' progresses. I see many cases a year with similar phenomenology but the most varied etiologies. Occasionally I am not sure, at first, if the patient is just 'being funny', clowning around, or schizophrenic. Thus, almost at random, I find the following in my notes on a patient with cerebral multiple sclerosis, whom I saw (but whose case I could not follow up) in 1981:

   She speaks very quickly, impulsively, and (it seems) indifferently … so that the important and the trivial, the true and the false, the serious and the joking, are poured out in a rapid, unselec-tive, half-confabulatory stream . . . She may contradict herself completely within a few seconds . . . will say she loves music, she doesn't, she has a broken hip, she hasn't . . .

   I concluded my observation on a note of uncertainty: