I am sitting alone in the small seminar room on the tenth floor. This is known as "Harry's room." I am at the head of a long oak table, working at a laptop computer. The door is at my back and the single window at the other end of the room sheds a thin, early evening light. On the shelves are rows of display jars containing specimens of human brain, each suspended in a liquid the colour of watery piss. This is Harry's collection. The specimens are arranged according to pathology: tumours, cerebrovascular disease, degenerative disorders, and so on. There are whole brains, half brains, and parts of brain. Close to my right shoulder, there swims a cerebellum. The room is ineffably still.
Among the relics of natural disease and degeneration are three victims of unnatural violence. Their stories intertwine. The first brain was caught with the second's wife and was dispatched with a pistol shot to the back of the head. Then after putting an end to its wife, the second brain dispatched itself. The woman's brain, third in line, completes the set. Hers is perfectly intact. She got it in the heart, according to Harry. I once told him that I thought she might have been better placed between the other two, to keep the rivals apart. "Even in death," I said, "you can sense their contempt for one another." It didn't seem to worry him. And anyway, I wondered, what was she doing here? Her brain was not illustrating a pathology of any kind. Harry's response was that she exemplified the normal, intact brain. He wouldn't concede that in displaying the specimens in this way he was also creating a tableau, showcasing the fickle heart as much as the fragile brain. All the same, it was a tale he seemed fond of telling.
The material substance of the brain was bread and butter to Harry, a neuropathologist, but not to me. I remember the ambivalence I felt when I first held a human brain in the palm of my hand; the fascination but also the distaste. I was surprised, and moved, by how heavy it felt. Perhaps a part of me had expected it to be weightless, like a mental image or a train of thought. I was eager to confirm for myself that the internal structures matched the familiar textbook pictures but somehow, I felt disinclined to start cutting. I imagined the worlds it had created. The stuff of the brain is the source of the conscious self and the fountainhead of every private universe. It's all in there. Everything. "I could be bounded in a nut-shell and count myself a king of infinite space," Hamlet said, "were it not that I have bad dreams." The infinite space was within the shell of his head. And so, inescapably, were the dreams. But looking around now at these dead-still, grey-beige objects, it is hard to see them as erstwhile progenitors of infinite space. They each represent the opposite: a singularity. A point at which the universe has collapsed. I love the stillness of this place and the hum of the void-the sense of worlds dissolved and dissipated passions. It fills me with a sense of being. I am not yet pickled meat. The light is fading and the pale amber sky at the horizon now almost matches the colour of the liquid in the jars. There is a single bright star.
My area of supposed expertise is the subject about which I feel the most profound ignorance. I am ignorant of many things. For instance, I know nothing of the Russian language. Quantum physics is beyond me. Keynesian economics? The workings of the internal combustion engine? Irish political history? My knowledge of such things consists of vague notions poorly understood, loosely grasped general principles, and collections of disjointed facts. But I could take lessons in Russian and mug up on Irish history and the other things. I will never master the mathematics for a proper understanding of quantum mechanics, but I can appreciate something of the flavour of the subject from the popular writings of experts, and take comfort from the fact that, fundamentally, it seems to be beyond them, too.
When it comes to understanding the relationship between the brain and the conscious mind, my ignorance is deep and there is nowhere to turn. An ocean of incomprehension heaves beneath the textbook-confident surface of plain facts and technicalities which I present to my colleagues and patients. I have a clear picture of the material components of the brain and am prepared to ad lib at length about features of its functional architecture-the interlocking systems and subsystems of perception, memory and action. But quite how our brains create that private sense of self-awareness in which we all float around is a mystery. I have no idea how the trick is achieved. Wouldn't it be absurd for an airline pilot to deny knowledge of the principles of flight, or for a physician to claim ignorance of the basics of human physiology and anatomy? Yet I, a neuropsychologist, can't account for how the brain generates conscious awareness. Worse still, I find myself edging towards a doubt that it means anything at all to say that the brain generates consciousness.
The stillness of this room seems to contain a physical force. Thoughts feel amplified and a little unruly, movements feel exaggerated. In solitude there is a natural tendency to personify one's surroundings. It is difficult to resist the sense of being observed. Hardly anyone uses Harry's room these days and Harry, of course, doesn't come here any more. There are small committee meetings once a month and an occasional journal club. Otherwise it is used as I am using it now, as a quiet space for catching up with discharge letters and clinical reports.
I've been trying to finish a report. The patient, William, has a dementing illness and seems to be rapidly fading away. He is only 53. It's not Alzheimer's, I'm pretty sure of that, but we have yet to come up with a firm diagnosis. I saw him this morning in a side room. He'd been sharing a bay with five other beds on the main neurology ward until a couple of nights ago, when he became agitated and began to develop delusional ideas about the other patients. A nurse had found him at three in the morning, packing a case and preparing to leave. "I don't want to cause trouble," he told her in a whisper, "but I'm not like the rest of them. I shouldn't be here. They're all homosexuals."
This morning he was cheerful. An orderly had just brought him a cup of tea. His wife, 20 years younger, was feeding their new baby on the other side of the bed. Anne, she was called. We sat and chatted, with sunshine streaming through the uncurtained window. Cheerful as William was, he was becoming preoccupied with thoughts of death. "I've often wondered," he said, "what happens, medically speaking, when you die." He wanted to know what happened when a patient died on the ward. What were the procedures? How could the doctors be sure the person was dead? Where did the body go? Who took it? "We have work to do," I said, "shall we press on?"
First, I check his general orientation for time, place and person. Fine. He knows who I am, where we are, the day of the week and the month. He is quick to supply autobiographical information and seems fully aware of his present circumstances. Next, I begin to probe different aspects of mental function with some standard bedside tests. One of these is a verbal fluency task in which he must generate words with a designated initial letter. The first letter is "F." "Fire, flag, funeral," he says, "will that do?" "Tell me some more-as many as you can," I urge him, but the allotted 60 seconds runs dry with nothing more to show. He manages just one word for "A" and another three for "S." From letter fluency, we move on to categories. "Let's see how many different kinds of four-legged animal you can think of," I say, and William pinches the bridge of his nose. Half a minute goes by with no response. The baby, now asleep in her carry-cot, begins to stir, but then settles. I remind William of his task. "You know," he tells me, "I seem to be having problems with this one. Four-legged animals? For some reason I can only think of three-legged animals." I notice the trace of a smile on Anne's lips but her eyes are dull as lead.
I realise that it might appear mad to be questioning the role of the brain in consciousness. There can be no doubt that brains and self-awareness are in close alignment. My brain and I are never far apart, and I accept that I am sitting here, in Harry's room, with my living brain, conscious and self-aware, whereas those lifeless specimens on the shelves are not. I am thinking thoughts, listening and looking. I can hear occasional sounds of traffic from the street far below. The taste of coffee is still in my mouth and I feel the contact between elbow and table, knuckles and chin, as I lean forward to read the text on the computer screen. With conscious deliberation, I have been stringing words together through the play of fingers on keyboard, intermittently catching and turning over unsolicited, idle thoughts and images. (At one point, I find myself humming a Bob Marley tune. It drifts in from nowhere). And there, through the window, I see a star, a hundred million miles away but simultaneously also in my head. Its image enters my eye and flow-charts through the visual systems of my brain, finds a link with memory and language, and, from outer space, gains a name and a location in semantic space: "Venus." Consciousness is tethered to the brain. I am not mad. All this is going on somewhere between my ears.
But if you go into the skull, visit the interior of the brain, you will find that there is nothing much to see. Not a spark of colour or whisper of sound and no signs of intelligent life. You can describe the geography of this silent land adequately enough in the third person but, obviously, not in the first. From here, it seems that consciousness does not have a particular location. Where precisely between the ears is it? Does it fill the skull like a gas? Of course not. And it is no more to be found in the hills and dales of the frontal lobes or on the slopes of the Rolandic fissure than in the chair you are sitting on. The more you search the terrain, the closer your analysis of substance and structure, the faster the will-o'-the-wisp recedes. We are embodied, but nowhere traceable within the physical structures of the body. I don't believe in immaterial mindstuff, nor in souls detachable from bodies, and I'm not saying that the brain isn't necessary for consciousness. Whether it is sufficient is another matter.
William grew tired of my tests and lost concentration. In the middle of some mental arithmetic, he slowed to a stop and I let him sit and stare for a while. Anne was sitting back in her chair, head resting against the wall, eyes closed. The baby was asleep. Hospitals are never quiet, but you find pockets of resignation and weariness where time itself seems becalmed. The sounds of the outside world are distant and abstract. We each withdrew into our private worlds. William, I imagined, was roaming some high plateau of bewilderment in pursuit of three-legged animals; the baby was drifting contentedly on a pond of mother's milk. I didn't presume to imagine what Anne was thinking.
From one perspective it seems that consciousness must have a physical location (people's pains and pleasures go where people go) yet, from another, the same suggestion seems faintly absurd. Once inside the head it becomes clear that consciousness is not a "thing" to be located. And even if we think of it as a "function" or a "process" rather than a "thing" what sense does it make to say that the crucial elements reside in this or that brain region? You can't pin it down. Nor does it depend in some mysterious way on the integrated functioning of the whole brain. I have seen many patients who, as a result of surgery, injury or disease, have had much less than whole brains and they've seemed quite conscious as far as I could tell.
Some philosophers, dismissed by others as "mysterians," argue that the "problem of consciousness" exceeds human mental capacity in the way that differential calculus or the concept of democracy are beyond the intellectual scope of a rabbit or a pigeon. I find this view comforting-but then I'm more of a clinician than a scientist. In my trade, incorrigible optimism can be counterproductive. Best to accept that some problems have no solution. For Wittgenstein, philosophy had something in common with medicine. The philosopher's treatment of a question, he said, is like the treatment of an illness. Our minds are knotted with misconceptions about the world and the job of philosophy is to unravel the knot; or, as he said, to show the fly the way out of the fly-bottle. Philosophy is not so much about finding solutions to problems as about correcting fundamental misunderstandings. But the days when the problem of consciousness lived quietly in the cloisters of academic philosophy, no trouble to anyone, are gone. These days, the redefined field of "consciousness studies" is a garden of delights, swarming with philosophers and scientists of every stripe. Debate is lively, sometimes strident-with the neuroscientists shouting loudest of all above their noisy brain scanners. How does the mental arise from the material? How can subjective experience be reconciled with that soggy mass occupying the skull? Most of them expect a solution. The chimera of consciousness rises like a vapour and entices them to believe that it is only a matter of time before a way is found to account for subjective, first-person phenomena in objective, third-person terms. Despite the intellectual energy currently pouring into this enterprise, philosophical and scientific, I think that the fly is still stuck in the bottle.
Eventually William said, "Am I dead?" I didn't respond immediately. Anne's eyes remained closed. I let the silence flow. William smiled. His face was lit with a benign perplexity. "I am just wondering," he said. "Have I died?" There was a smear of toothpaste around the corner of his mouth and he was unshaven. He had neglected to fasten some of the buttons of his pyjama top, exposing a flabby belly. But there was a glint in his eye. He was developing his theme. "In the middle of the night I was convinced," he said. "I thought they would come to take me away. No, I wasn't afraid. I waited to see what would happen. And then someone did come. It was a tall man. He just watched, and I tried to say something but my lips wouldn't move. Then the tall man left."
Anne spoke: "We've been through this before, William. You get confused sometimes. You're not going to die. Not for a long time." Given the uncertainty of her husband's diagnosis, this was not necessarily the case. William gave no indication that he was listening. "I can't say for sure that I am dead," he continued, "but things are not the same. I don't feel real. It seems to me I might be dead." His expression dimmed. "How would I know if I was dead?" William, I had just noted, was well-oriented for time, place and person. He knew the day and the month, the name of the hospital, and he was clear about his name, age and address. As for being dead or alive, he was all at sea. I wrote on my notepad: Cotard's?
I once saw an old woman who was profoundly depressed. "Bury me," she said, "You might as well, I've been dead for some time." She believed that her insides had rotted away. I tried to reason with her but it was useless. "Look," I said, "you're here talking to me. How can you be dead?" "Just words," she replied. A world of shadows flickered around her, human figures came and went, the curtains billowed, nights fell, days broke. But she felt no connection with any of this. Time hollowed her carcass and words fell dead at her feet. That was the first time I'd come across Cotard's syndrome. It's usually associated with severe depression but is sometimes seen in cases of neurological disease. The person sinks into a nihilistic delusional state, often, as in this case, to the extent that they believe they no longer exist. The condition takes its name from the French psychiatrist, Jules Cotard, who in 1882 published a series of case studies of people suffering what he called le d?lire de n?gation. The clinical presentation differed somewhat from patient to patient, but delusions of self-negation were common. These ranged from the belief that parts of the body were missing, or had putrefied, to the complete denial of bodily existence. The expressed belief that one is dead is not a defining feature of the syndrome. In fact, of the eight "pure" cases reported by Cotard (excluding a further three with concomitant persecutory delusions or other debilitating illness) only one embraced death as an explanation of her condition. Others slipped into non-existence, or skirted the abyss, somehow defying the conventional understanding that ceasing to exist must be tantamount to death. There were even some patients locked in the paradoxical state of denying their bodily existence yet at the same time believing themselves to be immortal.
What drives such strange delusions? They might be seen, in psychological terms, as the psychotic end point of a downward spiral of self-accusatory, self-diminishing, ultimately self-annihilating, depressive thought processes. But William, peering quizzically into the void, is not depressed. His case, at least, seems to call for a neurobiological explanation. One suggestion is that Cotard's arises from a disturbance of brain mechanisms which ordinarily bind sensation and thought to the neural systems underlying emotion. This ancient duty is performed by the limbic system, deep inside the cerebral hemispheres. A prime function of this system, an evolutionary raison d'être, is to create states of readiness for action. It does this through the implementation of so-called "affect programs." If your sensory systems inform you that there is a crazed-looking man fast approaching with an axe, your body will enlist the affect program identified with fear. Before you have time even to experience your terror, before the eye-bulging, voltage surge of awareness, various physiological systems will have reconfigured themselves in preparation for a response. You will turn and run. The thought, "I am terrified" will follow hot on your heels, though, most likely, will have entered the past tense by the time it catches up. I was terrified, you will later recall.
But what is this "I" that claims the terror, and what is the "you" that reflects upon the experience? It is not a single thing, nor a thing at all. It is, in its most primitive form, just a principle of biological organisation. The affect programs, so this story goes, not only guide adaptive interaction with the external world but, as a by-product of this process, they also form the biological point of origin of the self. By imbuing perceptions, thoughts and actions with an emotional hue (however pale) they give cohesion to experience. Feelings are generated which form the basis of our sense of identity. They create the conditions for ownership of thoughts and for agency in the control of actions. These perceptions, thoughts, wishes, beliefs, and actions are mine. I feel it. Their common cause is centred upon my needs and motivations, made manifest through the affect programs of my limbic brain. I feel I think, therefore I am. But this is merely a functional description of the biological roots of the self. Don't ask where the feeling of the feeling comes from; or the feeling of the feeling of the feeling. Such questions tighten the knot and set the fly a-buzzing.
Beyond this unelaborated, biological core there are dimensions of the self with a past and a future as well as a raw present, defined in autobiographical terms: the narrative self. But in Cotard's syndrome the core has dissolved. Cognition is decoupled from feeling and, consequently, thoughts and actions have no fixed moorings. There is no "I" left to claim ownership. It disintegrates; the fragments drift apart. One patient believed she had become little more than fresh air: "just a voice, and if that goes, I won't be anything."
If there is a way to untie the "knot of knots" problem of consciousness, perhaps the first move is to acknowledge that we are not only physically embodied but also embedded in the world about us. The mind may be local to the body and the brain but is also, in different ways, distributed beyond biological boundaries. The notion of the "extended mind" has been gaining currency in cognitive science, but ideas of a related kind were developed 50 years ago by the Russian neuropsychologist, Alexander Luria. For Luria, psychological phenomena were part of the natural world and so subject to the laws of nature, but he also recognised that the structure of the mind has a social aspect. He thought that scientific psychology should be aligned with the biological sciences, but believed that one could never fully understand the relationship between the brain and the mind by treating the brain as a closed biological system. The working brain has to be understood not only as part of a larger biological system (the rest of the body) but also as a component of wider environmental systems. What we refer to as "the self" is a product of biological and social forces. It arises from the interaction of individual, isolated brains. From this view, the search for the seat of consciousness within the circuitry of an individual brain can lead only to fool's gold. If, as Wittgenstein said, philosophical problems demand treatment rather than solutions, the distinction between the core biological self and the extended, narrative self may be the first part of the therapeutic formula.
William became fascinated with his teacup. "Look at this," he said, "Is it real? It doesn't look real." He contemplated the object as if it had materialised out of thin air, and then he turned to me. "And what about you," he said, "Are you real?" I had stopped taking notes and sat, hands clasped over my head, pondering the innocent question. "Believe me," I said, "I'm real and so are you. Take my word for it." "I think I can trust you," he said, but he wasn't sure. I think I can. I think. I think. His words were struggling for life and his gaze slid loosely across the pale blue paint of the wall. I think I can. Moving with a mother's grace, Anne lifted the sleeping baby from the cot and placed the bundle of blankets and pink flesh in William's arms. He began to weep. It was time for me to go. "He's more himself after a good cry," Anne said. "That makes sense," I told her.
Jules Cotard died at the age of 49. He succumbed to diptheria after nursing one of his children to recovery. I recall this fossilised fact of biography as I stack my case notes. The glow of the computer screen is now brighter than the sky and, when the machine shuts down, Harry's room is almost dark. Paradoxically, as the gloom descends, the jars along the walls gain a kind of luminescence, as if they have absorbed the receding light. My report is finished. The laptop lid closes with a satisfying click and I go across to take a closer look at one of the brain specimens. The printed label reads: Subarachnoid haemorrhage. I say aloud: "How's it going, Harry?" n
Postscript: "William" turned out to have a treatable condition, Hashimoto's disease, which causes inflammation of the brain. When I last saw him he had started a course of steroids aimed at reducing the inflammation and was making progress. He did not doubt that he was alive.
Antonio Damasio explores the biological bases of the self in "The Feeling of What Happens: Body, Emotion and the Making of Consciousness" (Heinemann, 1999)
©Paul Broks
