How can you fail to read only the word California

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… if you can't read the word California?

And how can you (despite the above) read the word California anyway, when you're expecting to see instances of it?

I'm reporting here on a real case, that of my late partner Jacques Transue, who exhibited just this configuration of (in)abilities. Such extremely selective ability constitutes a paradox of neurology (neurolinguistic division), of the sort that Oliver Sacks delights in. The key idea is some sort of cognitive split between what we know, or are able to do, EXPLICITLY, and what's there IMPLICITLY.

Background: I meant to post about this material last summer, when I read Sacks's piece in the New Yorker on amnesiac Clive Wearing (now in his book Musicophilia) and Ramachandran's Brief Tour of Human Consciousness. I lost several days in recollective despair about Jacques. (Jacques died in June 2003; yesterday was his death day.)

I then worked on sprucing up my my material on Jacques — what can I say, I'm an academic, scholar, and scientist, and when life presents me with data, I go with it — from earlier Stanford courses on speech errors, courses that included a section on aphasias and other neurological disorders involving language. (Jacques himself would have approved of my project. Long before he died, he made me promise that I would okay an autopsy, so that some knowledge might come out of his death.) This material is now available on my website, in two pieces: a brief medical history and language data from 1998-2002.

And then Emily Transue, Jacques's daughter, published her second book on her life in medicine (Patient by Patient, St. Martin's Press, 2008 — successor to On Call, same publisher, 2005), in which Jacques and his mother Monique, and their deaths, figure very prominently. [Advertisement: buy the book!]

So now I think it's time to talk about the California Paradox.

Here's the story: as a result of radiation therapy in 1980, many of the neurological connections and small blood vessels in Jacques's brain were, to speak non-technically, fried, but the consequences didn't appear clearly until 1991. Eventually Jacques exhibited a whole textbook of neurological symptoms, one of which was the fascinating condition anosognosia — not knowing you're impaired. But the most obvious problem was dementia, functionally similar to Alzheimer's (though caused by radiation).

The brain is amazing in its ability to work around difficulties. Faced with a world he increasingly didn't understand, Jacques reconfigured things to fit the world he knew. He couldn't believe he was in California and so hypothesized that he was in Ohio (several places, including Columbus, where he and I lived for many years), Pennsylvania (where his parents lived, and where he went to college), New Jersey, or New York — in what Elizabeth Daingerfield Zwicky and I came to call Newohiolvania.

The technical term is confabulation. People construct new realities that embrace aspects of what they're confronted with but don't threaten their sense of who they are (even if that's drastically at odds with what the rest of us experience — with what Elizabeth and I referred to as "consensus reality").

So Jacques, believing that he couldn't possibly be in California (though for twelve years in a row, he and I spent part of the year in Palo Alto), erased the problematic word. We would go out in the neighborhood around his dementia care facility in Menlo Park (California), and he would remark on the information on car license plates: the numbers, the state slogans, the state NAMES. It was one of his preoccupations, and he was keen to say the data. But every California car (and there were of course a great many California cars) had an illegible state name; he'd say that the plate had mud on it, or wasn't readable for some other reason. Oregon yes, Nevada yes, California no.

Nor could he read CALIFORNIA BANK and similar signs on offices. The word couldn't be California, because the place couldn't be California.

Now: how could this be? How could someone not be able to read California (on license plates or signs) but be able to read Oregon and Nevada and all the rest?

First idea: the patient has a specific deficit. This is not entirely crazy, given reports of other patients with very specific deficits: for instance, a man who has difficulty in producing or recognizing names of fruits and vegetables, while being able to produce and recognize other nouns with little difficulty. (Such specialized disabilities have been a particular interest of Alfonso Caramazza and his collaborators. As a result of this work, some of us have a special place in our hearts for the Fruit and Vegetable Man.)

The usual account of such specializations is that they arise from damage to some very localized area of the brain; it's as if (and I stress the "as if") there were a fruit-and-vegetable zone in some people's brains, and that low blood flow to or nerve damage in that zone leads to a very specific deficit.

It's hard to credit this proposal for Jacques's problems with California. Not only would a brain area have to be devoted specifically to this one lexical item (this is not preposterous; after all, lexical items have to be — as we say, metaphorically — stored SOMEWHERE), but it would have to be dissociable from all the many connections the rest of us have, in particular, to other state names.

And in fact there is evidence that is not what Jacques was doing (or what was happening to him). On occasion, I was away for a while, from a day to several weeks. Then Jacques was faced with the task of searching for me. I wasn't there (typically, Elizabeth was), but I should have been, so he scanned for me.

Crucial fact: for some years, I'd had license plates for my car from both Ohio and California, and changed them as we went back and forth between the two states. Jacques knew this. So when he was out on the street he was looking for my car, and my car might have California license plates.

In this situation he could read California on license plates. Which led him to detect me in cars of all types, driven by people of all types (Asian-American women, young black men, whatever). The license plate, formerly incomprehensible, ruled.

I still marvel at all of this. He could read, implicitly, the word California, and that ability enabled him to reject, explicitly, any perception that he was reading the word California — unless, of course, he was expecting to see this word.

The distinction between implicit and explicit knowledge turns up in lots of places. For Jacques, it turned up in what happened when he tried to access (more metaphors) knowledge about daily life. If you asked him where his wallet was, he'd have to search through all the possible places his wallet might be. But if you asked him to give you a dollar, he'd pull out his wallet (from his right back pocket, where he'd kept it since he was a child), without thinking.

Towards the end of his life, his son Kit visited, and Jacques was delighted to see someone he knew he liked (though he couldn't say who Kit was). At the end of his visit, Kit pushed Jacques's wheelchair over a bump between the patio and the central part of the care facility. "Thank you, Kit", Jacques said. When he tried to recover names, he couldn't, but when he unreflectingly reached for a name, he could sometimes get it.

All this meant that it was hopeless to try to assess his abilities directly, by questioning him or asking him to do things. In fact, the physicians gave up on such testing early on, in favor of asking for regular reports from me. 

In general, dementia patients often exhibit unsuspected abilities in favorable circumstances, and the course of their illness is not uniformly downhill, but something more erratic. Jacques was not at all unusual in these respects, though the California thing was an extra twist.

 

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20 Comments »

  1. Mark Paris said,

    June 5, 2008 @ 4:45 pm

    I find this particularly interesting because we are dealing with my father in law's diminished capacity right now. At times he seems quite lucid, but at other times it is apparent that his perception of reality is not the same as ours. I finally arrived at the metaphor of a dream world, where memories, experiences and current stimuli sort of float around and randomly rise to the surface of his consciousness, at which point he constructs a narrative to fit them. Sometimes that narrative fits the real world, and sometimes it doesn't.

  2. Nathan Myers said,

    June 5, 2008 @ 4:47 pm

    My grandfather, in his later years, was not suffering from any diagnosable dementia, but he was unable to voice the word "monogamous". (I should mention, in passing, that he was deeply, deeply devoted to my grandmother.) We discovered the phenomenon when he officiated at my wedding. He was able to manage to pronounce "'nogamous", which sufficed. I don't know of any other words he had trouble with.

  3. mgh said,

    June 5, 2008 @ 5:35 pm

    Thanks for sharing this story with us. The phenomenon of forgetting, in healthy individuals, is amazing — there is some fact, you've forgotten it, it seems gone, and then all of a sudden you remember it. Where was it? How did it come back?

    Although it's not important for the compelling nature of your story, I did want to ask why you attributed the symptoms from 1991 to the radiation from 1980.

  4. Sili said,

    June 5, 2008 @ 7:08 pm

    Please accept my (late) condolances.

    I remember Jacques from at least one of your earlier posts, but I never realised that he had passed. It is obvious how important he was to you.

    Thank you, indeed, for sharing. I think that your openness on this blog has paid some part in my own realisation of my bisexuality. – But this is not the forum to share.

    Since you were too modest to do it yourself, though:
    On Call: A Doctor's Days and Nights in Residency
    Patient by Patient: Lessons in Love, Loss, Hope, and Healing from a Doctor's Practice

  5. Robert said,

    June 5, 2008 @ 7:18 pm

    Why did you have two license plates at the same time? How is this preferable to just having one "primary" state of registration and letting the car be out of its primary state part of the time? Was it actually registered actively in two states at once? Is that even legal?

  6. Arnold Zwicky said,

    June 5, 2008 @ 7:38 pm

    To mgh: we didn't know this then, but the massive cerebral-spinal radiation following excision of medullar blastoma (without which you basically don't have a chance) is pretty much guaranteed to lead to radiation dementia (and a lot more) about ten years down the line. Most of the medullar blastoma victims are children, 5-10, so they turn into vegetables in their teenage or young adult years. It's very cruel.

    Jacques and I had ten good years. Not a bad bargain. But I lost a good part of twelve years in the prime of my life, just caring for him. Who knows what things would have been like otherwise?

  7. rootlesscosmo said,

    June 5, 2008 @ 9:46 pm

    Let me add my belated condolences, and my gratitude for the patience and tenderness that come through very clearly in your account of his dementia and the way you and the others negotiated it. The person I love defines love as "caring for someone else's well-being," and has little time for alternative emotions that sometimes are given that name. It's a great thing to experience, on either end, and I'm sorry your beloved left.

  8. Charles said,

    June 6, 2008 @ 2:46 am

    My condolences as well. What a fascinating and odd memory to have as a keepsake.

  9. Amanda said,

    June 6, 2008 @ 3:18 am

    The explicit vs implicit knowledge thing is fascinating. My daughter, 18 months, is currently doing something very similar with colours. She can pick up a pair of socks and say "pink socks" or a ball and say "blue ball", but if you say "what colour is this ball?" or "where is the blue ball?", she doesn't know. She's definitely not colour-blind – once she's identified a colour she can easily find other instances of that colour. I assume (and hope) that this is part of normal development. What does this tell us about the brain? I guess immature brains and those damaged in some way have some parallels.

  10. Jeremy H. said,

    June 6, 2008 @ 10:13 am

    I read the language data on your website. It is so sad, and yet so interesting to read. It shows that what you read on someone's blog gives absolutely not a clue about the person who writes it — which, in this case, is too bad. It was useful for him that you are a linguist. He was very lucky to have you (and your daughter) taking care of him.

  11. Nat Williams said,

    June 6, 2008 @ 11:11 am

    Was Jacques' block on the word 'California' only present in situations where the appearance of the word would be inconsistent with his actually being in Ohio? If he, say, read a newspaper article about something in California, as he could just as easily do from Ohio, did he still have the problem? You wrote that he could read the word when he expected it; was it the expectation that made the difference, or the conflict with his reality?

    I still remember watching my father go through cancer treatments and the immense frustration and sadness from both ends when he knew what he wanted to say, but was unable to communicate it. All I can really say is that it totally sucks.

  12. Arnold Zwicky said,

    June 6, 2008 @ 11:50 am

    To Robert: California had a law (probably still does) requiring that cars be registered in California within 30 days of residence (even if temporary); the law was, I believe, directed primarily at people with registration in Nevada. California made arrangements with several states (including Nevada and Ohio) to allow for dual registration, for people who spent part of their year (more than 30 days) in California but weren't changing their permanent state of residence; the point was for California to get the license fees.

    From 1985 through 1998, I was in California (with my car) for at least one three-month stretch a year, occasionally two. So (at my father's advice) I obeyed the law and got registration in California.

    Yes, we commuted, by car, between Ohio and California for years. Well, towards the end Jacques could no longer manage the car trip and we flew. At that point I had a car in each state (and lent it to friends when we were out of that state).

  13. Arnold Zwicky said,

    June 6, 2008 @ 1:20 pm

    Jeremy H.: "I read the language data on your website. It is so sad, and yet so interesting to read. It shows that what you read on someone's blog gives absolutely not a clue about the person who writes it — which, in this case, is too bad."

    Well, Language Log is not *my* blog. I don't post about my life here, except insofar as there's something of linguistic interest in the story. I *have* posted extensively about my experiences, feelings, and opinions on the newsgroup soc.motss. Some of these postings appear in the anthology of memorable soc.motss postings:

    http://www.soc-motss.org/doc/motss_posts.html

    in particular, there's an archive of my postings about jacques and me, from 1992 through 2004:

    http://www.soc-motss.org/doc/motss_posts_jacques.html

  14. Nancy Wright said,

    June 6, 2008 @ 1:40 pm

    Although I didn't have the linguistic perspective, the notes I kept during my mother's final years with Alzheimer's (1995-98) are eerily similar in spots to the medical data on your website.

    One day when I arrived at the dementia unit where Mom was living, she looked at me with astonishment and said, "You look JUST like my son-in-law's wife!!"

  15. Janice Huth Byer said,

    June 6, 2008 @ 2:37 pm

    Jacques' fascinating behavior seems somehow related to the commonly experienced phenomenon of performing learned behavior better for not thinking about it explicitly. Or am I merely associating it? At 58, I've actually had need to test my little theory, at times, successfully, by consciously "lightening up" on my mental search as a means of enabling implicit memory. "Thank you, Kit" is the kind of statement I've heard myself make after talking a while to someone, whose name I was embarrassed not to remember upon greeting. This is not to trivialize what is described – just me trying to grasp it. Being widowed for ten years, I'm in great sympathy with Arnold's still missing his beloved Jacques.

  16. Jeremy H. said,

    June 6, 2008 @ 2:44 pm

    @Arnold Zwicky, Your writings about your life with Jacques would make a wonderful book, I'm sure you must have thought of this.

  17. Kate said,

    June 8, 2008 @ 9:54 am

    Wow. My belated condolences also. What a fascinating story.

    Jacques was clearly so, so lucky to have you, and reading this made me respect you not just academically, but personally.

  18. Douglas said,

    June 8, 2008 @ 9:41 pm

    Reminds me of "banner blindness", where people used to seeing useless advertising banners are able to tune them out.

  19. ShatBrickner said,

    June 9, 2008 @ 11:49 am

    TL;DR

  20. Arnold Zwicky said,

    June 11, 2008 @ 10:28 am

    Nat Williams asks: "Was Jacques' block on the word 'California' only present in situations where the appearance of the word would be inconsistent with his actually being in Ohio? If he, say, read a newspaper article about something in California, as he could just as easily do from Ohio, did he still have the problem?"

    His problem with "California" appeared only when we had moved permanently to California, in September 1998. By then he wasn't reading much — certainly not newspapers or magazines — and probably getting very little out of what he did read. I have no record of his coping with printed news of events in California.

    At one point Elizabeth and I brought books to him about sights in northern California, some of which Jacques recognized and named. I don't recall whether he read, or used, the word "California" in these picture-book sessions, but he probably did.

    But then in March 1999 he got a postcard (carefully printed, for legibility) from his mother, saying that his parents were going to visit his daughter in Seattle and then come to California to see him. He halted reading partway through (before California came up), saying he couldn't understand what she was saying.

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