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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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