Several unequivocal announcements about its status preface Scar Tissue: the cover says A NOVEL in small caps, the ISBN listing says “Fiction,” and the copyright page bears the statement, “This is a work of fiction. No resemblance to persons alive or dead is either stated or implied.” Yet this book, concerning a mother’s descent into Alzheimer’s, reads like a memoir, not only in its autobiographical opening (“I do not want to remember her last hour”) and its autobiographical end (“My fate has come to meet me. My voyage has begun”), but also, and chiefly, in its restriction to a single life.

The novel typically looks to a broader society for its canvas and though the term “lyric novel” has been used for a fiction that takes place chiefly in the mind and life of one person, even Virginia Woolf balanced Mrs. Dalloway with Septimus Smith. Thus one cannot help reading Scar Tissue as autobiography, even while one accepts that Michael Ignatieff has elaborated fictionally upon its painful situation—a son confronting the gradual disintegration of a much-loved mother. Even an autobiographer can claim privileged knowledge of only one sensibility—his own—and the personalities surrounding him (in Ignatieff’s case the father, brother, and wife of the protagonist) are necessarily fictional creations. And even an autobiographer cannot know how his own life will end—so the envisaged future, too, must be a fiction.

Recent theorizing about autobiography has treated it almost always (wrongly, I think) as a subgenre of fiction. Such theory rightly notes the unavoidably fictional aspects of autobiography, but it refuses to acknowledge the disparity between the imaginative impulse of autobiography and the imaginative impulse of fiction. Fiction favors wildness (even if it is the decorous wildness of Emma’s matchmaking or the secret wildness of Madame Merle’s plotting), and it obeys laws of internal form. Autobiography requires strictness (even if it deceives itself on fact), and it respects the contour of a life. Fiction begins in creation; autobiography begins in the given.

The given, here, is the decay of the mother’s mind. From it, everything else follows: the anguish of the narrating son and of his father, the irritation of the narrator’s neglected wife, the pragmatism of the narrator’s physician brother. Though other people in the story (the narrator’s grandmother, his mistress, his son) have proper names, the central characters do not. The narrating “I” refers always to “my father,” “my mother,” “my wife,” “my brother.” The other actors have no reality apart from his sense of them; their lives do not go on elsewhere; they exist only in his presence. This narcissism seems foreign to the form of the novel where we expect that the novelist will depart from himself and imaginatively participate in the whole life of at least one other person. Even the narrator’s mother—“my mother”—has no life of her own; her consciousness is not available to us, and we do not see her own judgment about what is happening to her. Perhaps some day there will be a novel imagining Alzheimer’s from the inside, but Scar Tissue is not that book.

Perhaps it is even incorrect to call it a novel about a mother’s decline; it is more aptly described as a novel about a son’s disintegration as he faces the loss of his mother. Whether he would have disintegrated so completely had his mother experienced a terminal illness of the “body” rather than of the “mind,” it is not possible to guess. What is peculiarly distressing about Alzheimer’s is that it is a disease of the body manifesting itself as a disease of the mind; and while all mental illness may be described in that way, other mental illnesses are not terminal and do not seem to leave the victim without a soul. A radically changed soul may inhabit the manic-depressive or the schizophrenic during periods of illness, or even during an entire lifetime; but soullessness is the evil result of Alzheimer’s, and the gradual fading of his mother’s soul as dementia takes over is the infliction that the narrator of this novel (henceforth called N) cannot bear.

N’s ostensible motive for writing is to “redeem” his mother’s dying:

There must be some way to redeem this, some way to believe that the banal heartlessness of it all was not for nothing. There must be some way back to the unscarred beginnings, when she was in her painting clothes, barefoot, sipping a beer, humming to herself, happy and far away.

The end of the novel arrives without the redemption’s having happened. N cannot find a life apart from his mother’s death, which he believes will also be his own. In that sense, the novel is faithful to the horrors it recounts, and to the overwhelming metaphysical stain on life which Alzheimer’s leaves on its witnesses. Dementia makes nonsense of all cultural forms of encountering death, from Roman stoicism to the Christian “making a good death” to the “stages” of resignation described by Elizabeth Kubler-Ross. Gibberish accompanies N’s mother to her death, and some of the best pages of this novel are about N’s futile attempts to converse with his mother as she loses language:


I now spent every morning with my mother before going off to teach my classes and every evening as well, though by then she was in her wheelchair and I was the only person who could understand what she was saying.

“She gone gospedal.”

“Really? I didn’t know that. Who’s gone to the hospital?”

“Gospedal Shirley.”

“But you haven’t seen Shirley since you were a little girl.”

She laughs, cunning, sly. “Shirley lost the shirt.”

“I don’t think so.”

“Yes, Shirley…”

“What did Shirley do”

Long pause. “Who?”

Then she would look out of the window and say,

“It is…boscon…”

“What has gone?”

“Boscon,” she would repeat, as if I hadn’t understood anything.

“Boston. My brother is in Boston.”

She shook her head, as if to say,

“You’re not paying attention.”

“OK. Right, Boscon, not Boston. So boscon who?”

“No, no, no…” She shakes her head. It is no use. “He is in vazal.”

Go along with this, you think. Let her take you where she wants to.

“Do you think so?”

“Yes,” she says, and you are sure she is talking about Father.

“Father is dead.”

She nods. “Pebbles,” is what she says,

Yes, there were pebbles. Round, flinty pebbles and moist brown earth, piled high all round the coffin. Yes, Mother, pebbles….

Lunatic conversations by the hour, she looking at me, as if to say, “Am I making sense?”

The desperation of trying to interpret lunacy takes over, as N vainly tries to tell himself he is still conversing with his mother, that his mother still has conversational intentions and conversational meanings. Through such means, Ignatieff suggests the intimate link between N and his mother; when she ceases to be, he fears he will cease to be.

As N becomes entwined in the folie à deux with his mother, his other personal relationships become strained. His mornings and evenings at the nursing home eventually become intolerable to his wife:

It was after dinner one night in our kitchen, and I was seeking my own hurt and hers.

“You’re bored with the whole thing, aren’t you?” I said.

“Don’t start.”

“You are. You think, ‘I’ve got kids here and a house to run, and he can’t snap out of it. All he does is go down to that damned nursing home and sit and talk to his mother, who can’t talk about anything anyway.’ That’s what you think.”

Even when their son inadvertently interrupts the quarrel, N is relentless;

“You stay right where you are.” I shouldn’t have done this, but I couldn’t stop. “You’ve got the right to hear everything between us. You’re old enough. So here it is. Your mother thinks I shouldn’t be carrying on about my dad, shouldn’t be carrying on about my mother. That I should just grow up and act my age….”

I could see all the grey in my wife’s hair, all the wear in her face and all the hurt I caused, but I couldn’t stop the bitterness from pouring out of me. She was looking at me as if she didn’t know who I was, as if our twenty-one years together were nothing….

There were tears in her eyes when she said, “I really do not understand.”

The filial bond, for N, proves stronger than the marital one. Into the abyss of inconsolable grief, N throws all his past life.

In the emotional void caused by the hostility of the marriage, Ignatieff introduces a dea ex machina, a convenient-to-hand Filipina nurse at the nursing home named Miranda, all heart and no language to speak of (by comparison with N’s educated and vocal wife):

Miranda was a quiet woman, petite and dark, with a small gold cross round her neck. She came from Mindanao in the Philippines and she spoke with a soft Asian accent….

“You look sad. Father dies. I read the case notes, sorry.”

It will surprise no one that this paragon of healing touch becomes N’s mistress, through her own initiative. He is glad to have a wordless body next to him: “For that was what Miranda had in such mysterious abundance, the gift of silent, attentive, watchful understanding.” Miranda also has oracular powers; meeting N’s physician brother on a single occasion, she says, gratifyingly, “Your brother is a strange man…. He is too hard.” (Though N half-heartedly defends his brother, Miranda’s view seems to be his own.)


Miranda is dispensed with almost as easily as she was fictively procured: “I told Miranda it wasn’t her fault, but I felt ashamed of having been with her…. Then, for the first time, I felt all her anger, all the resentment of having helped me and having got so little in return…. ‘In Mindanao they say a man like you is…”‘ But she does not finish, and N leaves, for good. Miranda (“O brave new world that has such creatures in it!”) suddenly is allowed feminist resentment, in ways that do not match her former character. Nor does she shed light on N’s character, unless we are to feel that being with her is a form of passivity-unto-death.

The other secondary character with a name is Moe, a patient of N’s brother. The brother brings N to see Moe, who has Lou Gehrig’s disease, amyotrophic lateral sclerosis, perhaps the disease most feared next to Alzheimer’s. Moe is far gone in his illness, but he can still blow on a straw to activate the keyboard of his computer, and communicate on his monitor. A sign in his room says, “If Choking or Gagging, Sit Me Upright.” N decides to get to know Moe, and Moe types out messages (in lower-case) of a stoic exaltation:

i was angry for about three years. it ate me up, then i stopped being angry. now i pray to jesus christ.

When N objects (“I tell him that I will not pray to someone who makes him suffer like this”), Moe (who, N tells us, has “mischievous eyes” and a “sense of humour”) continues his almost mystic speech:

i lie here; i cannot move; however, i can listen, think, pray. how is it i feel love? and where is it coming from?

Unlike N’s wife, Moe’s wife understands suffering: “Five years spent in the company of illness have refined her pretty face into something grave and fine.” N sits by Moe thinking, “Nothing can save us but the word, the messages we send from deep in the shaft of sickness.” As if by telepathy, up on Moe’s screen come letters spelling “believe in the word.” At this point, the novel has become entirely too programmatic: paired with Alzheimer’s, the disease of the paralyzed mind in the working body, we have ALS, the disease of the working mind in the paralyzed body.

The same urge to create balanced opposites occurs in the conflict between N and his brother. N is the philosophy teacher, his brother the neuropathologist: they embody, again too schematically, the two cultures, the humanistic versus the scientific. “My brother,” N reflects, “isn’t bothered by what he doesn’t know. The answers will surrender themselves eventually. There is a serenity in his science which makes me envious and unhappy.” The brother takes N to his lab at the hospital, and shows him a slide of neurofibrillary tangles in the brain of a woman in her late sixties; he continues with a PET scan transparency, followed by the DNA scan, which shows a defect on chromosome 21:

The cascade begins there, he says.

To my brother the word cascade means only the sequence of pathological effects, but for me the word has menace. I see a body tumbling down a black, liquid-filled chute.

Here, in one brief moment, is the crisis of the book. The scientist describes Alzheimer’s in one way, the writer in another. As they leave the lab, N realizes that his brother has been analyzing the lab report of their own mother. “‘I don’t like looking at her like this,’ I say, feeling that we have gone too far and have crossed some line of decency.” The words “like this” suggest that the neutral descriptive and analytic terminology of medicine seems somehow indecent to the “humanist” as an adequate language with which to describe his mother’s case. Yet the dice are loaded, here, as one brother improbably leads the other through a series of diagnostic records while concealing the fact that they are the records of their mother. Would anyone do this? And if so, is not that concealment, rather than the medical language, the source of whatever “indecency” is present?

If we remain within N’s view, however, we can see his entire story as an extended attempt to find adequate language for a human condition quite minutely describable by scientific language, if not yet explained by medicine. The revulsion from medical language that Ignatieff describes is one widely shared, but it is important to point out that it is not shared by all. One of the anecdotes about Yeats in old age, recounted in Gogarty’s brief memoir but also by family members, concerns Yeats’s having requested a letter from his doctor to take to Rapallo, in case he should fall ill while in Italy. Yeats demanded to see the letter, and, reading it, burst out into a joyous laugh, saying to his companion: “Do you know what I am? I am an advanced atherosclerotic!” But then Yeats did not live in the present anxiety about the “reduction” (as people say) of the human to “the mechanical.”

For some of us, the ongoing discoveries of the physical and physiological operations of the world are a matter of enormous satisfaction. Cowering before the spectacle of Alzheimer’s, some of us are almost ill with relief when something is discovered about it, when some light is shed on its etiology and its cellular disorder. The expansion of knowledge, and the vocabulary that evolves with each such expansion, seem to us gifts not only to the scientific side of life but also to its “humanistic” side, which has a way of deriving vital profit from every new gain in our acquaintance with the materiality of the world. Think of what Whitman and Tennyson got from geology and evolutionary science; think of what A. R. Ammons has gained from quantum mechanics and astrophysics. These do not seem “reductions” of the human but sources of new analogies for the human.

Yet the vocabulary describing PET scans and chromosomal defects, however accurate, will never be sufficient to describe the psychological effects of Alzheimer’s, its destruction of feeling. Something like the novelist’s talent will always be needed to describe how disease affects family life and intimate experience. In The Magic Mountain, Mann showed himself equally fascinated by the medical and the psychological, and by the vocabularies generated by each. Ignatieff cannot be so hospitable to the medical viewpoint; he resents its detached inquisitiveness in the midst of human tragedy. The rather strained reconciliation with his brother arrived at by N as his brother takes him in his arms and as, later, they bury their mother, does not stop the restless debate in N’s philosophic mind, which accelerates to a vertiginous extent at the close of the book. All the questions raised by the loss in Alzheimer’s of memory, language, and selfhood pour through N’s mind in a wild and furious stream, his “cascade” of philosophical incoherence matching his mother’s “cascade” of neurological tangles:

What was mine? [he asks, querying the very notion of identity] What was the margin beyond inheritance?… Human identity is neurochemical. Human identity is measured in pica-litres. Infinitely small amounts of neurotransmitter fluid, microscopic levels of electrical charge make the difference between selfhood and loss…. Is a disease observed altered by the attempt to observe it?…Does understanding anything make a difference, if there is nothing you can do to stop it happening?

If Scar Tissue is in part organized like a philosophical dialogue (N versus his brother, his wife versus Miranda, his mother versus Moe, neurology versus psychology, physical treatment versus metaphysical “understanding,” and so on), it also, in its best moments, escapes its own rigidity. Those best moments are, it seems to me, its most unpretentious ones, in which Ignatieff gives a memorable description of the catastrophic undoing of a self by Alzheimer’s, and the almost equally catastrophic effect on its suffering witnesses: N’s father dies from the strain of taking care of his demented wife, and N himself becomes deranged from the attempt to take upon himself the entire disintegration of his mother.

As the Alzheimer’s plot unfolds, N recalls the premonitory episode of his maternal grandmother; she begins to repeat herself and soon, discovered wandering on the road, she is unable to tell the concerned policeman her name. When the child N and his mother arrive at the police station to reclaim her, she does not recognize her grandchild. The heritability of Alzheimer’s (not inevitable, not even likely, but with a raised probability of occurrence) is therefore evident to N when his mother shows the first sign of an altered personality:

She had always loved making time stretch and expand, so that lunch might start about one and still be staggering to a more or less drunken conclusion around four in the afternoon. Now she wanted to get meals over with, so that she would even reach over to take your plate away before you had finished eating. If you said, “What’s the hurry?” she would stop, between kitchen and the table, with a plate in her hand, and you could see her thinking, “Why am I like this?”

N blames his father, and his post-retirement demands on her. But she gets worse, first forgetting where she left her glasses: “First the glasses, then the purse. Then the shoes. After that, the pots left boiling on the stove. After that, a roast left to carbonise itself in the oven.” Language begins to fail. N comes up from the city to help; cooking dinner, his mother says, “Where’s that thing…flip…things…with?” meaning the spatula. When her husband does not want to give her her purse, reminding her, “If I give it to you, you will lose it, my darling,” she demands it and then loses it again:

“What do you need it for?” he pleads. “You’re at home. Where do you think you’re going?”

She puts her hand to her face. “Just tell me where my goddamned purse is.”

She is aware of what is happening, will not complain, even treats it as a joke: “I’m sure I will make a cheerful old nut. Don’t you think so? In any case…it’ll be much worse for you,” a prophecy perhaps true. During his father’s absence at a conference, N is in charge of his mother, who is fretful at his father’s absence:

“Where is Dad?”

“He is out now, but he’ll be back soon.”

“That’s wonderful,” she says. Three minutes later she looks puzzled.

“But Dad…”

“He’s away at work, but he’ll be back later.” I haven’t got it in me to tell her that he is going to be away for two weeks. “And what are you doing here? I mean it’s nice, but…”

“I’m your son, for Chrissake.” I’m laughing when I say this.

“I see.”

At first, I try to count the number of times she asks these questions. On the first day, I lose track at sixty-three.

The decline continues. “All the time now, she looks frightened…. Everything depends on keeping to a routine. Otherwise she becomes agitated and upset.” But she can still read aloud from a page. Though her son cares for her tenderly, he also finds horrifying reserves of anger in himself. “One night, she fails yet again to set the table properly. I shove her aside, slam the knives and forks into their proper place and hiss, ‘Try Mother, try. For Christ’s sake.’ ” As things get worse, N’s mother hits her husband, she looks hunted, she ages rapidly; her son has fantasies of smothering her while they are alone in the house. She is taken to a doctor for evaluation, and N, repelled by the doctor’s callousness, as he sees it, begins his long strategy of denial, challenging the doctor:

“You keep telling me what has been lost, and I keep telling you something remains….”

I want to say that my mother’s true self remains intact, there at the surface of her being, like a feather resting on the surface tension of a glass of water, in the way she listens, nods, rests her hand on her cheek, when we are together. But I stumble along and just stop.

The doctor tries to help me out. “This seems to matter to you.”

The doctor says that “disinhibition” has not yet begun in his mother. “Disinhibition” is an ugly word,” N says, retaliating with the only weapon in his arsenal, his superior knowledge of language. The crisis of naming, so important in the book, makes its first appearance:

It is pointless to go on and we both know it. The doctor looks at Mother’s PET scans and sees a disease of memory function, with a stable name and a clear prognosis. I see an illness of selfhood, without a name or even a clear cause.

The illness continues. She begins to spill things and N’s father dresses her in washable nylon clothes. “The trouble was, and you couldn’t explain this to Father, the new clothes made Mother look like the inmate of a nursing home.” She tries to escape the house, and N wakes to find his father struggling with her in the hallway; she strikes him, then falls to her knees searching for the pieces of her broken necklace; her husband joins her. “I stood on the stairs watching my parents sobbing on all fours in the dark.”

N’s mother is still aware enough to realize, after her husband’s stroke, that he is dead. There is a grim dismantling of the farm by N and his brother, and then the search for a nursing home begins. They take their mother to the one they choose, and Ignatieff faces up to describing what a nursing home looks like:

In the lobby, there were some old people in wheelchairs with bibs round their chins watching television….

When we came out of the elevator on to her floor, a small man who looked Italian tried to take my hand, and an old woman in a wheelchair, with huge black eyes, was cooing and beckoning. Next to her in the hallway was a Chinese woman who was asleep, strapped to a chair and beside her a huge black man, between forty and fifty years old, with muscular arms, who was tied to a chair, so he wouldn’t fall out.

With reason, N’s mother looks him straight in the eye, “cornered, enraged, helpless,” and says “Get out.”

A week later, he visits her again, and finds her sunk, aged, in a chair in the TV room:

Six patients were dozing in front of a TV set fixed high on the wall…. A big black man was strapped into his wheelchair…and was grinding his teeth while watching a woman on TV demonstrating bleach powder in front of a washing machine. The colour balance was so bad that the woman on the television had an orange shimmer all around her body, as if she was radioactive, but nobody seemed to notice…. In the corner was [an] old woman in a pink Terylene dress, sunk in her chair, staring out of the window.

“Hello, Mother,” I said.

“Hello,” she said, as if she had never been anywhere else.

From this point onward, it is mostly N’s story, as he spirals downward into despair. But the relief one feels at having Alzheimer’s tracked through its disabling stages, in print, in a truthful way, at having the awful atmosphere of nursing homes described without evasion, is the relief occasioned by art. This is not awfulness for the sake of awfulness, but awfulness in the service of pain and wrongness. The charming mother, the shy and thoughtful painter, the intuitive presence in the house, is now a body without a soul. There remains only the scene of her death, and the crisis of language recurs in N as he asks himself what he should write down, and what conceal in silence:

No one knows any more what should be said and unsaid, what should be respected and kept in silence. No one knows any more what proprieties should attend a person’s dying….

I do not know whether it is an act of faithfulness to her or a betrayal of the dignity she never lost, to say that she had bitten her tongue, to say that there was blood flowing across her mouth and lips which my brother kept wiping away. I do not know whether I have the right to say, though I will do so, that her body was shaken with epileptic tremors and that she took enormous, terrifying breaths that went on and on until you could not believe she had the strength for them…

Her mouth was open wide, as in those portraits by Francis Bacon of caged prisoners in their final extremity. I watched and listened to those terrifying, rattling, hoarse breaths.

At this point N dismisses his original hope that his writing may redeem what has happened. “What happens,” he says after his mother’s death, “cannot be redeemed…. I knew that all my words could only be in vain.”

It is here, in spite of one’s admiration for Ignatieff’s harsh and accurate descriptions, that one might cavil. He writes in a Hemingwayesque cadence with incantatory repetitions quite at variance with the colloquial description of the nursing home: “No one knows any more….No one knows any more,” and “I do not know whether…. I do not know whether.” Words begin to take on that tinge of archaism that Hemingway seemed to think expressed a vaguely Spanish nobility: “in their final extremity”; “words could only be in vain”:

But in truth we make nothing. We live, and we cannot shape life. It is much too great for us, too great for any words. A writer must refuse to believe this, must believe there is nothing that cannot somehow be said.

It could be argued that there is nothing inappropriate in these homiletic cadences since they are voiced in the presence of a mother’s death, to which they pay homage and on which they hope to confer dignity. Nevertheless, they seem stagy to me, and the dignity they hope to confer seems a hollow one. The violent dismissiveness of N’s mother—“Get out”—seems finally more dignified, because truer. Rhetoric cannot coat the bitter pill of mortality any more than it can coat the metallic taste of medical terminology. Though Ignatieff sometimes sees N with a degree of irony, there seems to be no authorial irony directed toward N’s words at his mother’s deathbed.

If Ignatieff doesn’t know what sort of words can be pronounced over the grotesque, undignified, and soulless death caused by Alzheimer’s, and has recourse to a fuzzy sonorousness, perhaps it is because he, like most people, cannot bear the thought of life’s being ultimately “meaningless,” a word implying that the concept “human life” and the concept “meaning” could somehow intersect. Only if life could have “meaning” in some ultimate sense would it be sad for life to be “meaningless.” If life has no meaning, can have no meaning beyond its own embodiment, then a death from Alzheimer’s is no more meaningless than a death from anything else, a premature soullessness no more metaphysically tragic than the ultimate soullessness we must all come to. In a final crescendo, N contrasts “two forms of death,” one in which consciousness remains to the end, and one in which Alzheimer’s obliterates consciousness. N envisages the latter for himself; “The words I utter will make no sense, not even to me.” Yet he then sails, or rather soars, into a last peroration, which announces an ungrounded faith in “meaning” even during the moment of truth from Alzheimer’s that he foresees for himself:

But I know that there is a life beyond this death, a time beyond this time. I know that at the very last moment, when everything I ever knew has been effaced from my mind, when pure vacancy has taken possession of me, then light of the purest whiteness will stream in through my eyes into the radiant and empty plain of my mind. Then I will be face to face at last with a pure and heartless reality beyond anything a living soul can possibly imagine.

I confess I don’t know how I am to take this. Is N believable? Am I supposed to be swept into the diapason of his vision? (If so, the passage fails to do its work, at least for this reader.) If I am to judge him deranged, then how am I to feel about his (apparently sane) rendition of his mother’s last moments? I fear that Ignatieff is not being ironic, and that he actually believes in the dying vision of the improbably “radiant” mind. His talent for rendering the sordid and the inexplicable seems radically at war with this sentimentality, a sentimentality that also sabotages, in aesthetic terms, N’s interlude with Miranda and Moe’s joyous prayerfulness. A sad irony: the desperation of N’s attempt to make his mother’s death something larger and better than it was ultimately prevents this book from reaching the tragic stature to which it seems to aspire.

This Issue

October 20, 1994