His tumor, a slow-growing one, was huge when it was finally removed in 1976, but only in the later stages of its growth, as it destroyed the memory system in the temporal lobe, would it actually have prevented the brain from registering new events. But Greg had difficulties—not absolute, but partial—even in remembering events from the late sixties, events that he must have registered perfectly at the time. So beyond the inability to register new experiences, there had been an erosion of existing memories (a retrograde amnesia) going back several years before his tumor had developed. There was not an absolutely sharp cutoff here, but rather a temporal gradient, so that figures and events from 1966 and 1967 were fully remembered, events from 1968 or 1969 partially or occasionally remembered, and events after 1970 almost never remembered.
It was easy to demonstrate the severity of his immediate amnesia. If I gave him lists of words, he was unable to recall any of them after a minute. When I told him a story and asked him to repeat it, he did so in a more and more confused way, with more and more “contaminations” and misassociations—some droll, some extremely bizarre—until within five minutes his story bore no resemblance to the one I had told him. Thus when I told him a tale about a lion and a mouse, he soon departed from the original story and had the mouse threatening to eat the lion—it had become a giant mouse and a mini-lion. Both were mutants, Greg explained when I quizzed him on his departures. Or possibly, he said, they were creatures from a dream, or “an alternative history” in which mice were indeed the lords of the jungle. Five minutes later, he had no memory of the story whatever.
I had heard, from the hospital social worker, that he had a passion for music, especially for rock-and-roll bands of the sixties; I saw piles of records as soon as I entered his room and a guitar lying against his bed. So now I asked him about this, and with this there came a complete transformation—he lost his disconnectedness, his indifference, and spoke with great animation about his favorite rock bands and pieces—above all, of the Grateful Dead. “I went to see them at the Fillmore East, and in Central Park”, he said. He remembered the entire program in detail, but “my favorite”, he added, “is ‘Tobacco Road.’ ” The title evoked the tune, and Greg sang the whole song with great feeling and conviction—a depth of feeling of which, hitherto, he had not shown the least sign. He seemed transformed, a different person, a whole person, as he sang.
“When did you hear them in Central Park?” I asked.
“It’s been a while, over a year maybe”, he answered—but in fact they had last played there eight years earlier, in 1969. And the Fillmore East, the famous rock-and-roll theater where Greg had also seen the group, did not survive the early 1970s. He went on to tell me he once heard Jimi Hendrix at Hunter College, and Cream, with Jack Bruce playing bass guitar; Eric Clapton, lead guitar; and Ginger Baker, a “fantastic drummer.” “Jimi Hendrix”, he added reflectively, “what’s he doing? Don’t hear much about him nowadays.” We spoke of the Rolling Stones and the Beatles—“Great groups”, Greg commented, “but they don’t space me out the way the Dead do. What a group”, he continued, “there’s no one like them. Jerry Garcia—he’s a saint, he’s a guru, he’s a genius. Mickey Hart, Bill Kreutzmann, the drummers are great. There’s Bob Weir, there’s Phil Lesh; but Pigpen—I love him.”
This narrowed down the extent of his amnesia. He remembered songs vividly from 1964 to 1968. He remembered all the founding members of the Grateful Dead, from 1967. But he was unaware that Pigpen, Jimi Hendrix, and Janis Joplin were all dead. His memory cut off by 1970, or before. He was caught in the sixties, unable to move on. He was a fossil, the last hippie.
At first I did not want to confront Greg with the enormity of his time loss, his amnesia, or even to let involuntary hints through (which he would certainly pick up, for he was very sensitive to anomaly and tone), so I changed the subject and said, “Let me examine you.”
He was, I noted, somewhat weak and spastic in all his limbs, more on the left, and more in the legs. He could not stand alone. His eyes showed complete optic atrophy—it was impossible for him to see anything. But strangely, he did not seem to be aware of being blind and would guess that I was showing him a blue ball, a red pen (when in fact it was a green comb and a fob watch that I showed him). Nor indeed did he seem to “look”; he made no special effort to turn in my direction, and when we were speaking, he often failed to face me, to look at me. When I asked him about seeing, he acknowledged that his eyes weren’t “all that good”, but added that he enjoyed “watching” the TV. Watching TV for him, I observed later, consisted of following with attention the soundtrack of a movie or show and inventing visual scenes to go with it (even though he might not even be looking toward the TV). He seemed to think, indeed, that this was what “seeing” meant, that this was what was meant by “watching TV”, and that this was what all of us did. Perhaps he had lost the very idea of seeing.
I found this aspect of Greg’s blindness, his singular blindness to his blindness, his no longer knowing what “seeing” or “looking” meant, deeply perplexing. It seemed to point to something stranger, and more complex, than a mere “deficit”, to point, rather, to some radical alteration within him in the very structure of knowledge, in consciousness, in identity itself. 35
35. Another patient, Ruby G., was in some ways similar to Greg. She too had a huge frontal tumor, which, though it was removed in 1973, left her with amnesia, a frontal lobe syndrome, and blindness. She too did not know that she was blind, and when I held up my hand before her and asked, “How many fingers?” would answer, “A hand has five fingers, of course.”
A more localized unawareness of blindness may arise if there is destruction of the visual cortex, as in Anton’s syndrome. Such patients may not know that they are blind, but are otherwise intact. But frontal lobe unawarenesses are far more global in nature—thus Greg and Ruby were not only unaware of being blind but unaware (for the most part) of being ill, of having devastating neurological and cognitive deficits, and of their tragic, diminished position in life.
I had already had some sense of this when testing his memory, finding his confinement, in effect, to a single moment—“the present”—uninformed by any sense of a past (or a future). Given this radical lack of connection and continuity in his inner life, I got the feeling, indeed, that he might not have an inner life to speak of, that he lacked the constant dialogue of past and present, of experience and meaning, which constitutes consciousness and inner life for the rest of us. He seemed to have no sense of “next” and to lack that eager and anxious tension of anticipation, of intention, that normally drives us through life.
Some sense of ongoing, of “next”, is always with us. But this sense of movement, of happening, Greg lacked; he seemed immured, without knowing it, in a motionless, timeless moment. And whereas for the rest of us the present is given its meaning and depth by the past (hence it becomes the “remembered present”, in Gerald Edelman’s term), as well as being given potential and tension by the future, for Greg it was flat and (in its meager way) complete. This living-in-the-moment, which was so manifestly pathological, had been perceived in the temple as an achievement of higher consciousness.
Greg seemed to adjust to Williamsbridge with remarkable ease, considering he was a young man being placed, probably forever, in a hospital for the chronically ill. There was no furious defiance, no railing at Fate, no sense, apparently, of indignity or despair. Compliantly, indifferently, Greg let himself be put away in the backwater of Williamsbridge. When I asked him about this, he said, “I have no choice.” And this, as he said it, seemed wise and true. Indeed, he seemed eminently philosophical about it. But it was a philosophicalness made possible by his indifference, his brain damage.
His parents, so estranged from him when he was rebellious and well, came daily, doted on him, now that he was helpless and ill; and they, for their part, could be sure, at any time, that he would be at the hospital, smiling and grateful for their visit. If he was not “waiting” fo
r them, so much the better—they could miss a day, or a few days, if they were away; he would not notice, but would be cordial as ever the next time they came.
Greg soon settled in, with his rock records and his guitar, his Hare Krishna beads, his Talking Books, and a schedule of programs—physiotherapy, occupational therapy, music groups, drama. Soon after admission he was moved to a ward with younger patients, where with his open and sunny personality he became popular. He did not actually know any of the other patients or the staff, at least for several months, but was invariably (if indiscriminately) pleasant to them all. And there were at least two special friendships, not intense, but with a sort of complete acceptance and stability. His mother remembers “Eddie, who had MS—they both loved music, they had adjacent rooms, they used to sit together—and Judy, she had CP, she would sit for hours with him, too.” Eddie died, and Judy went to a hospital in Brooklyn; there has been no one so close for many years. Mrs. F. remembers them, but Greg does not, never asked for them, or about them, after they had gone—though perhaps, his mother thought, he was sadder, at least less lively, for they stimulated him, got him talking and listening to records and inventing limericks, joking and singing; they pulled him out of “that dead state” he would otherwise fall into.
A hospital for the chronically ill, where patients and staff live together for years, is a little like a village or a small town: everybody gets to meet, to know, everybody else. I often saw Greg in the corridors, being wheeled to different programs or out to the patio, in his wheelchair, with the same odd, blind yet searching look on his face. And he gradually got to know me, at least sufficiently to know my name, to ask each time we met, “How’re you doing, Dr. Sacks? When’s the next book coming out?” (a question that rather distressed me in the seemingly endless eleven-year interim between the publication of Awakenings and A Leg to Stand On).
Names, then, he might learn, with frequent contact, and in relation to them he would recollect a few details about each new person. Thus he came to know Connie Tomaino, the music therapist—he would recognize her voice, her footfalls, immediately—but he could never remember where or how he had met her. One day Greg began talking about “another Connie”, a girl called Connie whom he’d known in high school.
This other Connie, he told us, was also, remarkably, very musical—“How come all you Connies are so musical?” he teased. The other Connie would conduct music groups, he said, would give out song sheets, play the piano-accordion at singsongs at school. At this point, it started to dawn on us that this “other” Connie was in fact Connie herself, and this was clinched when he added, “You know, she played the trumpet, too.” (Connie Tomaino is a professional trumpet player.) This sort of thing often happened with Greg when he put things into the wrong context or failed to connect them with the present.
His sense of there being two Connies, his segmenting Connie into two, was characteristic of the bewilderments he sometimes found himself in, his need to hypothesize additional figures because he could not retain or conceive of an identity in time. With consistent repetition Greg might learn a few facts, and these would be retained. But the facts were isolated, denuded of context. A person, a voice, a place, would slowly become “familiar”, but he remained unable to remember where he had met the person, heard the voice, seen the place. Specifically, it was context-bound (or “episodic”) memory that was so grossly disturbed in Greg—as is the case with most amnesiacs.
Other sorts of memory were intact,—thus Greg had no difficulty remembering or applying geometric truths that he had learned in school. He saw instantly, for example, that the hypotenuse of a triangle was shorter than the sum of the two sides—thus his semantic memory, so-called, was fairly intact. Again, he not only retained his power to play the guitar, but actually enlarged his musical repertoire, learning new techniques and fingering with Connie; he also learned to type while at Williamsbridge—so his procedural memory was also unimpaired.
Finally, there seemed to be some sort of slow habituation or familiarization—so that he became able, within three months, to find his way about the hospital, to go to the coffee shop, the cinema, the auditorium, the patio, his favorite places. This sort of learning was exceedingly slow, but once it had been achieved, it was tenaciously retained.
It was clear that Greg’s tumor had caused damage that was complex and curious. First, it had compressed or destroyed structures of the inner, or medial, side of both the temporal lobes—in particular, the hippocampus and its adjacent cortex, areas crucial for the capacity to form new memories. With such damage, the ability to acquire information about new facts and events is devastated—there ceases to be any explicit or conscious remembrance of these. But while Greg was so often unable to recall events or encounters or facts to consciousness, he might nonetheless have an unconscious or implicit memory of them, a memory expressed in performance or behavior. Such implicit ability to remember allowed him to become slowly familiar with the physical layout and routines of the hospital and with some of the staff, and to make judgments on whether certain persons (or situations) were pleasant or unpleasant. 36
36. That implicit memory (especially if emotionally charged) may exist in amnesiacs was shown, somewhat cruelly, in 1911, by Edouard Claparède, who, when shaking hands with such a patient whom he was presenting to his students, stuck a pin in his hand. Although the patient had no explicit memory of this, he refused, thereafter, to shake hands with him.
While explicit learning requires the integrity of the medial temporal lobe systems, implicit learning may employ more primitive and diffuse paths, as do the simple processes of conditioning and habituation. Explicit learning, however, involves the construction of complex percepts—syntheses of representations from every part of the cerebral cortex—brought together into a contextual unity, or “scene.” Such syntheses can be held in mind for only a minute or two—the limit of short-term memory—and after this will be lost unless they can be shunted into long-term memory. Thus higher-order memorization is a multistage process, involving the transfer of perceptions, or perceptual syntheses, from short-term to long-term memory. It is just such a transfer that fails to occur in people with temporal lobe damage. Thus Greg can repeat a complicated sentence with complete accuracy and understanding the moment he hears it, but within three minutes, or sooner if he is distracted for an instant, he will retain not a trace of it, or any idea of its sense, or any memory that it ever existed.
Larry Squire, a neuropsychologist at the University of California, San Diego, who has been a central figure in elucidating this shunting function of the temporal lobe memory system, speaks of the brevity, the precariousness, of short-term memory in us all; all of us, on occasion, suddenly lose a perception or an image or a thought we had vividly in mind (“Damn it”, we may say, “I’ve forgotten what I wanted to say!”), but only in amnesiacs is this precariousness realized to the full.
Yet while Greg, no longer capable of transforming his perceptions or immediate memories into permanent ones, remains stuck in the sixties, when his ability to learn new information broke down, he has nevertheless adapted somehow and absorbed some of his surroundings, albeit very slowly and incompletely. 37
37. A.R. Luria, in The Neuropsychology of Memory, remarks that all his amnesiac patients, if hospitalized for any length of time, acquired “a sense of familiarity” with their surroundings.
Some amnesiacs (like Jimmie, the patient with Korsakov’s syndrome whom I described in “The Lost Mariner”) have brain damage largely confined to the memory systems of the diencephalon and medial temporal lobe; others (like Mr. Thompson, described in “A Matter of Identity”) are not only amnesiac but have frontal lobe syndromes, too; yet others—like Greg, with immense tumors—tend to have a third area of damage as well, deep below the cerebral cortex, in the fore-brain, or diencephalon. In Greg, this widespread damage had created a very complicated clinical picture, with sometimes overlapping or even contradictory symptoms and syndromes.
Thus
though his amnesia was chiefly caused by damage to the temporal lobe systems, damage to the diencephalon and frontal lobes also played a part. Similarly there were multiple origins for his blandness and indifference, for which damage to the frontal lobes, diencephalon, and pituitary gland was in varying degrees responsible. In fact, Greg’s tumor first caused damage to his pituitary gland; this was responsible not only for his gain in weight and loss of body hair but also for undermining his hormonally driven aggressiveness and assertiveness, and hence for his abnormal submissiveness and placidity.
The diencephalon is especially a regulator of basic functions—of sleep, of appetite, of libido. And all of these were at a low ebb with Greg—he had (or expressed) no sexual interest; he did not think of eating, or express any desire to eat, unless food was brought to him. He seemed to exist only in the present, only in response to the immediacy of stimuli around him. If he was not stimulated, he fell into a sort of daze.
Left alone, Greg would spend hours in the ward without spontaneous activity. This inert state was at first described by the nurses as “brooding”; it had been seen in the temple as “meditating”; my own feeling was that it was a profoundly pathological mental “idling”, almost devoid of mental content or affect. It was difficult to give a name to this state, so different from alert, attentive wakefulness, but also, clearly, quite different from sleep—it had a blankness resembling no normal state. It reminded me somewhat of the vacant states I had seen with some of my postencephalitic patients and, as with them, went with profound damage to the diencephalon. As soon as one talked to him, or if he was stimulated by sounds (especially music) near him, he would “come to”, “awaken”, in an astonishing way.