Review of the week
Brian Butterworth
In Peter Brook’s play The Man Who, which opened last week at the National Theatre, we are presented with a series of neurological patients who seem, at first sight, to be impossibly exotic. A man with a detailed memory for 30 years ago cannot remember what happened in the last few minutes. Another man thinks his left leg is someone else’s amputated limb, and tries to hurl it out of bed, throwing himself to the floor in the process. Most famously, there is the professor of music who mistakes his wife for a hat. In fact, such cases are not at all exotic, but are usually due to the most mundane of causes: strokes.
What makes them puzzling for doctor and layman alike is the way they create a conflict between the patient’s true and mistaken beliefs about reality. How could the professor mistake his wife for a hat? And how could he know that he was mistaken? This makes these conditions seem like a form of madness, where belief and reality also fall apart. Indeed, patients suffering them are still misdiagnosed as being schizophrenic or demented.
A central theme of Brook’s marvellous play – based on Oliver Sacks’ book – is the conflict between everyone else’s reality and a patient’s view of the world. A stroke can distort this view in incredibly precise ways. It may affect part of the right hemisphere of the brain, making the patient “neglect” just the left side of his world. There is no fuzziness. The right side is as clear as it is for you or me.
The patients will not see a friend standing to the left of his mid-line. If he hears the friend speaking from the left, he will turn to the right to find him. The Italian neurologist Eduardo Bislach found that, in some patients, the neglected left side was not of the visible world only, but of the mental world. If the patient was asked to describe a familiar place, such as the Piazza del Duomo in Milan, looking, in his mind’s eye, from the cathedral door, he would accurately record the north (right) side of the square, and completely ignore the south side. When the patient was asked to imagine himself looking across the square towards the cathedral, he would then describe the south side.
In one of the most moving moments in Brook’s play, a patient with left-sided neglect, brilliantly portrayed by the Japanese actor Yoshi Oida, shaves himself looking into a mirror. With great care he shaves exactly the right half of his face, and is entirely convinced the job is finished. The doctors force him to confront reality by asking him to look at himself in a video monitor. Of course, the left half of his face is now presented to the right side of his visual world. When he puts his right hand to his right cheek he can feel that he has shaved himself completely, but he can see in the monitor that half of his face is not shaved. The conflict cannot be resolved and he says, with desperate incomprehension: “Please stop. Stop that.”
Strokes that damage the left hemisphere can lead to problems with speech and language – called “aphasia”. Some patients become almost speechless, and can utter at will only a few phrases. David Howard, an English psychologist, reported the case of a woman who could say just “yes”, “no”, “cor blimey” and “flippin’ ‘eck”. In The Man Who, there is a character who can only say “yes” or “difficult” to whatever the doctor asks.
Other patients can be fluent. Words pour out, but they are incomprehensible – although the speaker believes he is making perfect sense. This condition is called “jargon aphasia”. When one patient I studied was asked to name a box of kitchen matches, he said: “Waitress. Waitrixes. A backland and another bank. For bandicks I think they are. I believe they’re zandicks. I’m sorry, but they’re called like flitters landocks.”
Many people hearing an old man talking like this would think he was mad. Even some doctors might diagnose dementia. After all, he could not name a common household object; he seems to ramble incoherently. In fact, on non-verbal IQ tests, this man was well above average. It was the language regions of the brain that were affected.
Wondering whether the patient was talking some sort of code, I enlisted the help of war-time code-breakers from Cambridge to help me break it. It turned out, not surprisingly perhaps, not to be a code, but nevertheless it did seem sometimes to convey a meaning.
Bruce Myers, in The Man Who, depicts a character based in part on this patient. Brook’s script and Myers’s performance bring out very effectively the gap between the speaker’s intention and the scrambled words. The audience can sense the general meaning and the emotional tone of the speech, without understanding one of the sentences.
The doctor in the play confronts the patient with a recording of his scrambled speech. The conflict between the patient’s belief that he is making sense and the reality is at its sharpest. There is a moment of terrible lucidity as the patient realises he is condemned to talk like this.
Brook and his cast developed this play, first in French and then in English, for more than three years. They studied patients at the Salpetrire Hospital in Paris, attended medical conferences, and talked to endless specialists. Their portrayal of the patients is scrupulously accurate and unsentimental. The cast of four alternate between playing patients and doctors – a reminder that any of us could become an “exotic” case.
Brian Butterworth is Professor of Cognitive Neuropsychology at University College, London. Peter Brook’s internationally acclaimed The Man Who is on at the Market Theatre from September 7 to 11