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 beginn
ing 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.”
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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’s room—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.
1. Macdonald Critchley described how Dr. Samuel Johnson lost all ability to speak when he suffered a stroke at the age of seventy-three. “In the middle of the night,” Critchley wrote, “he awoke and immediately realized that he had sustained a stroke.” To satisfy himself that he was not losing his sanity, Johnson composed a Latin prayer in his mind, but found he could not say it aloud. The next morning, June 17, 1783, he gave his servant a note he had been able to write for his next-door neighbor:
Dear Sir, It hath pleased almighty God this morning to deprive me of the powers of speech; and, as I do not know that it may be his farther good pleasure to deprive me soon of my senses, I request you will, on the receipt of this note, come to me, and act for me, as the exigencies of my case may require.
Johnson continued writing letters, with his accustomed richness and magniloquence, over the next few weeks, while he slowly recovered the ability to speak. In some of the letters, though, he made uncharacteristic mistakes, sometimes omitting a word or writing the wrong word; he then corrected his mistakes upon rereading.
2. This was very much the case with Sir John Hale, the distinguished historian, who had a stroke that left him with expressive aphasia. His wife, Sheila Hale, in her book The Man Who Lost His Language, provides a vivid and moving account of her husband’s aphasia, so devastating at first, and how he was able, partly through the power of expert and continuing therapy, to recover, even years later, much of what had seemed irreparably lost. And she brings out how even medical professionals may dismiss aphasic patients as “incurable” or treat them as idiots, despite their manifest intelligence.
3. “The President’s Speech,” a chapter in The Man Who Mistook His Wife for a Hat.
4. Some of Wilkens’s extraordinary therapeutic powers may have gone with the fact that she herself was quadriplegic (having broken her neck in a car accident at the age of eighteen) but nevertheless led an extremely full life and was deeply interested in other people. Seeing the fortitude and resilience of a therapist in some ways even more disabled than themselves inspired Wilkens’s patients to work harder for her, and for themselves.
5. I have written more extensively about music therapy for aphasia in a chapter of Musicophilia.
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 hims
elf, 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.”