Wednesday, October 01, 2003

Piece of His Mind

Into the Silent Land: Travels in Neuropsychology

By: Todd E. Feinberg M.D.


 “Why does raw meat give me a hard-on?” a patient asks at the beginning of Into the Silent Land. This is a startling first sentence for a book about neuropsychology. The initial reaction of some readers may be that it is deliberately shocking, perhaps exploitive, a reaction that will, however, prove unwarranted as they read on. Paul Broks, senior lecturer and honorary consultant in neuropsychology at Derriford Hospital in Plymouth, England, and a regular contributor to the British publication Prospect, is not an ordinary neuropsychologist and this is not an ordinary book.

When I opened Into the Silent Land, I was surprised to learn that Broks and I have much in common. The first sentence of the blurb inside the book’s dust jacket asks: “How does the brain construct a ‘self,’ the essence of who we are as individuals?” The first sentence on the dust jacket of my recent book Altered Egos: How the Brain Creates the Self (Oxford University Press, 2001) is: “It may be the deepest mystery of philosophy, psychology, and neuroscience: how does the brain unite to create the self, the subjective ‘I’?” It was, therefore, with considerable interest and a little trepidation that I turned to the text. The odd thing is that after having read this book—not once, but twice—I am not sure what the author’s claims about the self actually are. I am certain, however, that Into the Silent Land is a unique and fascinating exploration of the brain and mind, unlike any I have ever read.

Why is this book so captivating? Above all, I think, it is because Broks uses his clinical experiences with neurological patients and their conditions to explore and lay bare his concerns and beliefs about his self. The book’s main title, Into the Silent Land, is from the poem “Remember” by Christina Rossetti:

Remember me when I am gone away,

Gone far away into the silent land;

When you can no more hold me by the hand,

Nor I half turn to go yet turning stay.

Broks is inviting us to accompany him on a trip, a journey of self-discovery. Certainly he teaches the reader a good deal about the effects of brain disease on the mind and self, but his deeper concern is telling us how his explorations of the brain pathology of his patients have affected his understanding of his life, career, mind, and sense of mortality.


The patient with the meat fetish is Michael, a man (his age is not given but we know he is married) who fell from a tree while attempting to extricate a wayward kite. He cracked his head on a stone and fractured his skull. A bleed into Michael’s right frontal lobe led to a prolonged coma. Although most of Michael’s body survived and recovered, his brain did not. There was a new Michael, one who could not stop talking to or touching strangers and who insisted on giving money to beggars. His wife could tolerate most of the behaviors of this new man in her life, but she could not abide his newly acquired love of porn videos.

Michael is but one of the arresting clinical vignettes introduced by Broks. Later on, we learn about the “eggshell boy,” an unfortunate 17-year-old who fell through an elevator shaft and almost died. The surgeons “had done their best to piece him together again,” like Humpty Dumpty, but now his shaved head was asymmetrical “with a deep oval depression like the shell of a hardboiled egg cracked with a spoon.” I have examined many such patients in my career and should be inured to this sort of thing, but Broks’s graphic description of this boy made me cringe. As vivid and beautifully rendered as is his description of the eggshell boy, however, it is the author’s unflinching description of his own reaction that makes his book unique.

The clinical vignettes in Into the Silent Land are selected to illustrate the central problem that preoccupies Broks in this book: defining the relationship between the objective brain as a biological and tangible object and the self as privately and subjectively experienced. 


The clinical vignettes in Into the Silent Land are selected to illustrate the central problem that preoccupies Broks in this book: defining the relationship between the objective brain as a biological and tangible object and the self as privately and subjectively experienced. One of my favorite chapters, “I Think Therefore I am Dead,” addresses this issue in a particularly creepy but fascinating way. It is as eerie a tale as any episode in the old Twilight Zone television series.

The action takes place in “Harry’s room,” a small seminar room on the tenth floor of the hospital that is named after its deceased neuropathologist. Broks is alone there, working on his laptop. A thin band of light comes from the single window at the room’s far end. Along the walls are glass-fronted oak cabinets with shelves of specimen jars, each displaying a part or whole human brain suspended in a yellow liquid. Harry’s room gives new meaning to the expression “If these walls could talk.”

The brains in the jars are pathology specimens. Many medical schools have such collections, of course. The brains exemplify pathologies such as brain tumors, infections, strokes, and diseases such as Alzheimer’s and Parkinson’s and are used for teaching. Among the specimens in Harry’s room are three brains standing in a row that tell a particularly curious story. As Broks inimitably puts it: “The first brain was caught with the second brain’s wife and was dispatched with a pistol shot to the back of the head. After putting an end to its wife, the second brain finally dispatched itself. The woman’s brain, third in line, completes the set.” Her brain, it turns out, is the best preserved of the three; she was shot in the heart. It was a tale that Harry had enjoyed telling.

Broks’s manner of relating this story— this brain did this, that brain did that— emphasizes the entirely physical nature of the brains floating in the jars. In so doing, it heightens the contrast between the brain as a biological organ and the subjective intangibles such as love, passion, and murderous jealousy that the brain produces.

This vignette serves as the starting point for a chapter that evolves into Broks’s stream-of-consciousness meditation on his own insecurities as a neuropsychologist. With startling honesty, he declares: “My area of supposed expertise, neuropsychology, is the subject about which I feel the most profound ignorance.” In particular, Broks expresses deep and enduring perplexity about the mind-body problem and the “world knot”—the difficult problem of resolving the contrast between the objective and subjective aspects of experience. He confesses: “… when it comes to understanding the relationship between the brain and conscious mind, my ignorance is deep and there is nowhere to turn.”

For instance, Broks cannot comprehend why consciousness, unlike the brain, occupies no particular physical location in space. Even more disturbing to the author, although mental lives are filled with an abundance of sensory experiences (philosophers call them “qualia”), when we examine the brain “... there is nothing much to see. Not a spark of colour or whisper of sound and no signs of intelligent life. As you wander through this silent land, you can describe its geography adequately enough in the third person, but, quite obviously, not the first.” Here is the silent land that Broks invites us to explore with him: the terrain of the physical brain that gives no hint of sound, or light, or life. 

It is this quality of existential uncertainty and exquisite frustration, deftly conveyed, that gives Broks’s narrative its edge and effect on the reader.

For Broks, his inability to give a satisfactory account of how the brain generates consciousness is as ridiculous as would be an airline pilot’s inability to describe the principles of flight or a physician’s ignorance of the physiology and anatomy of the human body. Broks wants us to ponder the issue of consciousness and the relationship between the “raw meat” of the brain (as Colin McGinn put it in The Mysterious Flame) and the intangibility of the subjective mind; even more, he forces the reader to become as disturbed by this conundrum as is he. It is this quality of existential uncertainty and exquisite frustration, deftly conveyed, that gives Broks’s narrative its edge and effect on the reader.

Not that Broks makes an effort to solve this puzzle; that is not his intention. Indeed, he reminds us that Ludwig Wittgenstein’s conception of the job of philosophy was not finding solutions to problems but correcting important misunderstandings. Our minds are knotted up with fundamental misunderstandings, which the philosopher strives to untie, so he can “show the fly the way out of the fly-bottle” in Wittgenstein’s famous phrase.

Broks’s musings on the nature of consciousness in this chapter are seamlessly interwoven with the clinical report he is drafting in Harry’s room, and his thoughts on his patient’s clinical condition keep alternating with his thoughts about the nature of consciousness. Broks likes to do this, to create a melange of philosophy, personal reflection, and clinical case reporting, alighting on one topic after another like a bee cross-pollinating flowers. Each domain of reflection enhances and deepens the next, so that in the end the reader emerges with a broadened perspective on the nature of the question.

The report concerns a patient, Jeanie, who suffers from severe dementia. She is only 53 years old, young for a patient with dementia. Its ultimate cause is a mystery, like the mind-body problem itself, although Jeanie exhibits features of Cotard’s syndrome, a condition in which the patient expresses the delusional belief that he is dead. For Broks, Jeanie’s key problem is a disconnection between her feelings and thoughts that leads to the dissolution of the core of her self.

Broks seems to suspect that ultimately the origin of the self and consciousness is not in the individual mind at all. Instead, “What we refer to as the ‘self’ is a product of biological and social forces arising from the interaction of individual, isolated brains.” The search for the biological basis of consciousness, the “Holy Grail of neuroscience,” within individual brains “can lead only to ‘fool’s gold.’”

At the end of the chapter, Harry’s room is almost dark. Broks finishes his report and turns off his computer. As he leaves, he stops to examine one of the shelved brains a bit more closely. The label is “Subarachnoid haemorrhage.” Broks sighs: “How’s it going, Harry?”

Beautiful! It is so like a neuropathologist to donate his own brain to his collection. This little twist to the tale might seem to the lay reader so bizarre as to be unbelievable, but I have known many Harrys in my career who would take macabre delight in just such a gesture. Broks, who earlier in the chapter mentions Hamlet, with this denouement gives his story an “Alas, poor Yorik” quality that stayed with me for days.


In the final analysis, Broks is so disturbed by his failure to penetrate the mind-brain relationship that he gives serious consideration to beliefs that are anathema to most of today’s neuroscientists. Thus, he ponders Cartesian dualism and even—God forbid— “Mysterianism,” the position that the true nature of consciousness is beyond human comprehension. He feels guilty even considering these ideas, as if he were betraying all that is right and good about his chosen profession.

In a chapter entitled “Right This Way, Smiles a Mermaid,” Broks reports a dream. At least, I think it is a dream, but he often blurs the distinctions among dream, fantasy, and reality. It could just as easily be a fantasied dream. In it, he is summoned before a neuroscience tribunal chaired by “Collicula Brodmann, President of the Academy.” The inside joke here (and there are many in the book) is that the term colliculus—as in the superior and inferior colliculi of the brainstem—comes from the Latin word for “symmetric mounds” (as in breasts). The Brodmann system of neuroanatomical designation is the most widely used method of cortical neuroanatomical identification.

The tribunal takes Broks to task for his heretical notions about the mind. “Neuroscience is a broad church … but there is concern that you may be drifting towards Mysterianism.” For these notions, he is charged with bringing his profession and the field of neuroscience into disrepute. Broks then avows that, although he is not a Mysterian, he does not believe that we have found the solution to the mind-body problem—and is not sure that we are even asking the right questions. The fly remains in the bottle, and Broks remains a neurophilosophical agnostic. Indeed, by the end of this tale, Broks does not seem to care so very much because he gets to sleep with Collicula. For the moment, that is enough.

The penultimate chapter of Into the Silent Land is a science fiction gem in which a mechanical snafu in a teleportation machine yields two identical individuals, one on Earth and the other on Mars. This predicament forces the unfortunate duplicated individual(s) to ponder the question: What actually is a “self?” 


The penultimate chapter of Into the Silent Land is a science fiction gem in which a mechanical snafu in a teleportation machine yields two identical individuals, one on Earth and the other on Mars. This predicament forces the unfortunate duplicated individual(s) to ponder the question: What actually is a “self?” What is this “I” to which we refer when we speak of ourselves? In the story, Derek, the technician who operates the teleportation machine, suggests that one can divide beliefs about the self into two broad camps. One camp, “Ego Theory,” holds that the self or ego has ontological reality. There is an “inner I” that has an enduring existence and so gives coherence to our thoughts and actions. Derek contrasts this point of view with the “Bundle Theory,” the position that we are “nothing but a pack of neurons.” This camp holds that there is no inner ego or “I.” The subjective self is an illusion, a myth. Our minds are nothing more than a series of actions and experiences without any central ego binding them into anything that could meaningfully be called a “self.” Although Derek promotes the bundle theory, the story leaves the reader (and, by inference, Broks) undecided as to which schema is right.

Broks’s thought experiment here is mind-bending and fun. This is not the place to argue for my own viewpoint, but, in brief, I have suggested that selves do indeed exist and that to deny it avoids rather than solves our conundrum. I believe that when we have a proper understanding of what selves actually are and develop a correct understanding of the relationship between brains, minds, and scientific reduction that the self can be understood as a nested hierarchy of subjective meaning and purpose created by the brain.

In the final analysis, however, I do not think Broks really cares any more what the ultimate reality of the self is. In fact, I suspect he is a closet Mysterian. More to the point, I think he has decided that the answers to these neurophilosophical puzzles are not all that important, not really worth getting all hot and bothered over. He ends Into the Silent Land by relating his wife’s experience with breast cancer and how it affected their relationship. It is a touching story about love and life. I think Broks has decided that they are all that really matters.   


From Into the Silent Land: Travels in Neuropsychology, by Paul Broks. © 2003 by Paul Broks. Reprinted with permission of Atlantic Monthly Press.

THE SPACE BEHIND THE FACE The Illusion is irresistible. Behind every face there is a self. We see the signal of consciousness in a gleaming eye and imagine some ethereal space beneath the vault of the skull, lit by shifting patterns of feeling and thought, charged with intention. An essence. But what do we find in that space behind the face, when we look?

The brute fact is there is nothing but material substance: flesh and blood and bone and brain. I know, I’ve seen. You look down into an open head, watching the brain pulsate, watching the surgeon tug and probe, and you understand with absolute conviction that there is nothing more to it. There’s no one there. It’s a kind of liberation.

The illusion is irresistible, but not indissoluble. It is more than twenty years since my clinical training at a rehabilitation hospital for people with neurological disorders. I was a student of clinical psychology, but was drawn mostly to neurology. For as long as I could remember I had been interested in the workings of the brain and, one way or another, as a clinician or scientist, I expected to make a career in neuropsychology, the science of brain and mind. Neuro-rehab was a place to start. One of the patients was a seventeen-year-old boy who had stepped into an empty shaft through which he fell three floors, almost to his death. The surgeons had done their best to piece him together again, but now the dome of his shaven head was asymmetrical: convex on the right, concave on the left, with a deep oval depression like the shell of a hard-boiled egg cracked with a spoon.

His faced worked relentlessly, writhing with anger and dread. Mostly anger. He would groan and grunt, and sometimes howl, but, apart from occasional volleys of obscenity, he was incapable of speech. This is not uncommon. People without ordinary speech due to brain injury sometimes have the capacity to summon up the vilest gobs of abuse. I didn’t know that at the time. It came as a shock. Sometimes they can also sing, but this boy never sang. He sat contorted in his wheelchair, head turned sideways and back at an uncomfortable angle, limbs buckled with spasticity, a stream of saliva dribbling from the corner of his mouth.

The priapism was a final, humiliating twist. Due to a quirk of the damage to his nervous system he was continually troubled by a painful erection. The young women tending him—nurses, physios, and occupational therapists—pretended not to notice.

I felt pity for him, but also revulsion. As a raw trainee not yet acclimatized, I found him grotesque. What disturbed me most was the flickering screen of his face: bleak images of a soul in torment. Or so I imagined. Then I began to consider what might remain of a ‘soul’ or a ‘self’. I began to doubt there was anything at all going on behind that face. He should be allowed to die, I thought, and not just for his own sake. How did he look to his mother? Could she even bear to look?

The chaos of his face drained my sympathy. It broke the rules. A face should allow public access to the private self. It’s an ancient convention of the human race. There is a universal system of signals. But this young man’s facial displays worked like a subterfuge, denying knowledge of what lay behind. Perhaps nothing lay behind.

Then, one day, I happened to be around when the boy’s mother came to visit. I watched as she cradled his broken head into her arms. For the time that she was with him, but not much longer, an extraordinary transformation came over his face. It became still. The rage subsided. He seemed to regain his humanity. Here were two selves, not just a mother and a broken shell of a son. The whole was greater than the sum of its parts.

Maybe it was a failure of imagination that led me to sense a seeping away of the boy’s self once his mother had gone, but the capacity I discovered in myself to see a fellow human being as less than a person was an appalling revelation. In such circumstances how are we to distinguish failure of empathy from valid observation? Perhaps they amount to the same thing.  

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Scientific Advisory Board
Joseph T. Coyle, M.D., Harvard Medical School
Kay Redfield Jamison, Ph.D., The Johns Hopkins University School of Medicine
Pierre J. Magistretti, M.D., Ph.D., University of Lausanne Medical School and Hospital
Robert Malenka, M.D., Ph.D., Stanford University School of Medicine
Bruce S. McEwen, Ph.D., The Rockefeller University
Donald Price, M.D., The Johns Hopkins University School of Medicine

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