Ignatieff has conceded that Scar Tissue is a deeply autobiographical work inspired by the death of his own mother from Alzheimer’s disease.¹ The unnamed narrator is a philosopher whose own life disintegrates as the strain of caring for his ailing mother increases, ending in the morbid conviction that the disease has taken hold of him too. Scar Tissue is thus not for the faint hearted; don’t expect many jokes or witty asides. But Ignatieff, who has been described as “finding in most experiences ‘an academic question’ or something ‘philosophically interesting,’”¹ reflects on the meaning of illness with a depth seen in few other novels.

The narrator describes this work as his “time capsule”, reflecting the fragmentary narrative structure: “What is there? A newsclipping. Photographs. A PET scan. A speech I gave to the Alton Rotarians. A memoir of an illness, as yet not understood. Fragments of a philosophical exercise I wrote in the midst of what was happening and then abandoned when I came to my senses. Then there are some pieces of fiction, some pieces of dialogue, to simulate what happened.”(page 9) These themes are brought skilfully together as the narrator attempts to make sense of the suffering of his mother, to find 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. That is how she should be remembered. That is what I must rescue from her dying, if such a thing can be done.”(page 1)

Scar Tissue discusses the mystery of memory in great detail. His mother paints the narrator during a summer holiday. This is a moment of particular closeness and tenderness for them. The resultant portrait, however, is “of a child watching his childhood vanish before his eyes”. The narrator confronts the artist: “ . . .[I] asked her why she had painted me looking so gloomy. She said, ‘Your face in repose looks so sad.’ And I can remember thinking: Am I sad? I don’t feel sad. How did she know? In her picture I get to see myself through her eyes, and I think it takes me about as deep into myself as I am ever likely to go.”(page 17) His mother’s last painting is a copy of Mantegna’s Christ Descending into Limbo with what is apparently her only ever self portrait. Years before she is noticeably failing she has seen far enough into herself to spot the Alzheimer’s approaching and so stopping her most profound communication with the world, through the medium of paint and canvas. Years later, after his mother is ravaged by dementia the narrator reflects upon her knowledge of him: “Sometimes at night, lying by her side, I think about all the memory that must remain inside her, trapped within the circuits, denied speech yet still present in her mind. She is the silent custodian of the shadow zone of my own life. She is the one who can tell me what I was like before I began to remember, the only one who can decipher those first senseless scenes when memory begins . . . I know (that memory) is somewhere within her, a trapped neural impulse, an infinitesimal synaptic spark in the circuitry of her mind.”(page 50) This conception of the dementing person as still holding a precious cargo of knowledge despite being unable to communicate fuels one of the most powerful scenes in the book. After his mother has undergone brain imaging, which shows conclusive evidence of dementia, the narrator confronts her doctor. The narrator says: “‘You keep telling me what has been lost, and I keep telling you something remains.’” This is a telling comment upon medicine, underlined by the doctor’s response: “‘I just see what I see. From the clinical point of view.’”

The narrator tries to develop his idea: “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 . . .

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

“‘Because,’ I say, ‘A lot depends on whether people like you treat her as a human being or not.’”(page 58)

Ignatieff further explores the worldview and motivation of doctors in his description of the narrator’s brother, a medical researcher. He studies Alzheimer’s disease in his lab, while remaining distant from his mother, hardly taking part in her care. This association of medical science with a less emotional character suggests an endeavour that may be worthy but possibly lacking in humanity, and it is a restatement of the cultural archetype of the dispassionate scientist. The narrator is shown an electron microscope view of the brain of an Alzheimer’s patient; “My brother is guiding me through these regions of inner space. The blurred brown oblongs are normal neurons. The dark blotches with long curving tails are called neurofibrillary tangles. At the centre of the image is a compacted black mass surrounded by a halo of inflammation. This is a deposit of amyloid protein, a form of scar tissue deep within this patient’s brain. Under the microscope, it resembles a galactic storm, a starburst from an extinguished universe. When I say it looks beautiful, my brother says that everything becomes more beautiful the more closely you observe it.”(page 130) Although the scientist is allowed to have an appreciation of beauty, this aesthetic is identified with observing. The narrator, in contrast, describes that which is beautiful in metaphorical terms; “a starburst from an extinguished universe”. Although this metaphor is derived from another branch of science the language used is highly suggestive of the apocalyptic effect that Alzheimer’s has had on the narrator’s own life; his mother’s death as the end of the universe. For the narrator, the microscope slide somehow comes to mean the “end of the universe” while science calmly describes the pathological features as “amyloid protein” and “neurofibrillary tangles”. It would be a grave mistake, of course, to see this scientific language as completely transparent; although “amyloid” does suggest a glass-like appearance. The language of science has a metaphorical aspect too; but of a more directly descriptive kind than that shown by our fatalistic narrator. The brother goes on to describe in detail more of the pathological features of Alzheimer’s, but it is debatable whether he infers any human meaning from the disease; the disease is a fact and it is available to be observed and so understood. Illness is the consequence of a pathological disease as displayed under the microscope, the human effects being regrettable but of less import ultimately than the autopsy report. This is a familiar criticism of scientific medicine, echoing Cassell’s description of “Medicine’s dehumanisation and impersonality”.³ If the suffering of the demented has meaning for the brother it is as a clue to solve a particularly tangled puzzle. The narrator states that: “My brother isn’t bothered by what he doesn’t know. The answers will surrender themselves eventually. There is a serenity in his science that makes me envious and unhappy . . . . [He] counts off on his fingers the things science will be able to do for this kind of patient one day: implantation of DNA to correct the genetic defect; chemicals to retard production of protein . . . . Tragedy is thus transformed into a manageable condition. ‘We’ll get there,’ he says.”(page 132) The brother is thus animated by a belief that science will provide “the answers” to the question of Alzheimer’s one day. Clearly this is a statement of scientistic faith rather than a repeatable observation or a rationally formulated theory. Further, the purpose of solving the puzzle is not stated: it could be to help future sufferers or simply because puzzles are fun to solve.

Scar Tissue is packed with ideas of relevance to medicine. Ignatieff introduces Moe, a motor neurone disease sufferer whose calm religious faith contrasts with the narrator’s anger and confusion. The association of illness with creativity is explored, with the strong suggestion that the fragmenting narrative, becoming more pronounced as the work proceeds, reflects the early disintegration of the narrator’s own mind. Add to this discussion of Shakespeare, Saint Augustine, the late works of Willem de Kooning and a lecture entitled “Illness and Stoicism” and there is plenty to engage the reflective physician. Ignatieff is a fine writer with a bewildering range of knowledge and enormous powers of synthesis. But no amount of erudition can disguise the profound pain that the “research” for this novel must have caused him. Ultimately the greatest gift of this book may well be empathy for the author’s suffering.