Kevin Patterson – on the nervous system.

Halifax, Nova Scotia
August 3, 2000

Dear Paul:

These days I’m working on the neurology service, as a part of my internal medicine residency. (One year to go, almost exactly. Sometimes it goes as slowly as a summer afternoon in the heat: Breathe in. Breathe out. Good God, how could it still only be August?)

Neurology is two things: strokes, first, and then everything else – miscellaneous dysfunctions of nerve, brain and muscle, whose defects exist at diverse and molecular levels, rather than as a clot sitting in a vessel like a crude clog in a bit of plumbing.

The received wisdom is that strokes are dull and familiar and usually not treatable, and manifested by a depressingly monotonous array of facial drooping, dead limbs and inarticulate speech, and that the interesting part of neurology lies in the oddities of Azorean myoclonus and Familial Periodic Paralysis – strange and obscure disease entities whose near-infinite variety testifies to the literally incomprehensible (to me, anyway) complexity of the mammalian nervous system.

But recently I’m finding myself altogether more interested in strokes. It is true that they are dully oppressive events, not much treatable, at least in the curing sort of way, and so treating them is bereft of the easy sense of gratification that treating a large heart attack can carry, for instance. There, you get the drugs into someone fast enough and you can watch the effects of the clot melt away on the ECG. The blood pressure climbs and the water in the lungs dissipates – it is really the most privileged situation to find oneself in. The irony is that we use the same drug to try to dissolve clots in the brain, too – it simply works far better on the heart. This is because you can injure the heart and it can still cope; it isn’t that complicated and it has a certain amount of built-in redundancy. You shoot a bullet into a car and it might keep on going – try the same thing with your Palm Pilot and it’s another story. This is exactly what I find so compelling and so awful about strokes. Because they take out just one discrete bit of the brain at a time they reveal in demonstrable, obvious ways the importance of milligram-sized pieces of brain, and thus the extraordinary complexity of our wiring. Of the way we think. Of us.

Not long ago I cared for a man who had had a stroke; he could see reasonably well, and could write complicated and lucid sentences, yet he could no longer read. “Alexia without agraphia,” said the neurologist. When I looked puzzled, he said, “a common thing with left occipital infarcts.” The man’s visual-association cortex could not work, or at least that portion of it that is responsible for recognizing words.

The idea that writing and reading could be fundamentally distinct capabilities at the level of our hardware astonishes me maybe even more than it should. As the neurologist put it, shrugging, “you can write with your eyes closed, after all.”

I’ve been thinking about that ever since.

It feels otherwise. It feels like the only way to write is to read as you do so and to taste the words and recall and reflect upon them. Reading is the back swing and writing the fore: each step inextricably dependent on the other. This is true in several frames of reference – in the most immediate, how do you know if what you’ve written is even legible, let alone coherent, if you cannot read it? And in the longer view, everything we ever write is a recapitulation of something else that we’ve read. We form our ideas about how to write a letter from the letters we’ve read, and it is the same with novels and reports and pitches. Hand someone a harmonica who’s never heard music and they will sound even worse than harmonica players usually do, I imagine. But then, I’d have imagined you’d have to be able to read to be able to write.

But there are luthiers I’ve read of who only play a few notes themselves, and vintners who abstain. I’ve met men who have sold pot for a living for years who themselves never smoke. There are, I expect, legless shoemakers, apartment-dwelling gardeners, vegetarian butchers, colour-blind painters; and I think that sex-trade workers who are numb to the pleasures of the flesh may be the rule, rather than the exception.

The obviousness of the statement strikes me even as I write it: there is nothing about creating a thing that mandates understanding it.

I wonder what the future holds for this man. I wonder if his interest and ability in writing will fade with its utility. Grocery lists, phone numbers, To Do lists – none of these will work for him anymore. He will live instead in the world of spoken words and insist on calls rather than letters. It will not be that much poorer an existence, I suspect.

In his hospital room his children and grandchildren crowded to the walls and struggled not to mouth the answers to him when I asked him to read simple words. I asked them not to, and they looked ashamed, like eighth graders caught passing notes in a quiz. In a few minutes I moved on and went to learn about a man whose stroke had left him blind but entirely unaware of having suffered any ill effects of any sort. Notwithstanding the bruises on his nose and the scrapes on his shins.

We are strange and complicated creatures. Even leaving our souls entirely aside.

Kevin