The man who mistook his wife for a hat

by Oliver Sacks

  But this was only the case, it became clear, with certain sorts of visualisation. The visualisation of faces and scenes, of visual narrative and drama-this was profoundly impaired, almost absent. But the visualisation of schemata was preserved, perhaps enhanced. Thus, when I engaged him in a game of mental chess, he had no difficulty visualising the chessboard or the moves- indeed, no difficulty in beating me soundly.

  Luria said of Zazetsky that he had entirely lost his capacity to play games but that his 'vivid imagination' was unimpaired. Zazetsky and Dr P. lived in worlds which were mirror images of each other. But the saddest difference between them was that Zazetsky, as Luria said, 'fought to regain his lost faculties with the indomitable tenacity of the damned,' whereas Dr P. was not fighting, did not know what was lost, did not indeed know that anything was lost. But who was more tragic, or who was more damned- the man who knew it, or the man who did not?

  When the examination was over, Mrs P. called us to the table, where there was coffee and a delicious spread of little cakes. Hungrily, hummingly, Dr P. started on the cakes. Swiftly, fluently, unthinkingly, melodiously, he pulled the plates towards him and took this and that in a great gurgling stream, an edible song of food, until, suddenly, there came an interruption: a loud, peremptory rat-tat-tat at the door. Startled, taken aback, arrested by the interruption, Dr P. stopped eating and sat frozen, motionless, at the table, with an indifferent, blind bewilderment on his face. He saw, but no longer saw, the table; no longer perceived it as a

  *I have often wondered about Helen Keller's visual descriptions, whether these, for all their eloquence, are somehow empty as well? Or whether, by the transference of images from the tactile to the visual, or, yet more extraordinarily, from the verbal and the metaphorical to the sensorial and the visual, she did achieve a power of visual imagery, even though her visual cortex had never been stimulated, directly, by the eyes? But in Dr P.'s case it is precisely the cortex that was damaged, the organic prerequisite of all pictorial imagery. Interestingly and typically he no longer dreamed pictonally-the 'message' of the dream being conveyed in nonvisual terms.

  table laden with cakes. His wife poured him some coffee: the smell titillated his nose and brought him back to reality. The melody of eating resumed.

  How does he do anything? I wondered to myself. What happens when he's dressing, goes to the lavatory, has a bath? I followed his wife into the kitchen and asked her how, for instance, he managed to dress himself. 'It's just like the eating,' she explained. 'I put his usual clothes out, in all the usual places, and he dresses without difficulty, singing to himself. He does everything singing to himself. But if he is interrupted and loses the thread, he comes to a complete stop, doesn't know his clothes-or his own body. He sings all the time-eating songs, dressing songs, bathing songs, everything. He can't do anything unless he makes it a song.'

  While we were talking my attention was caught by the pictures on the walls.

  'Yes,' Mrs P. said, 'he was a gifted painter as well as a singer. The School exhibited his pictures every year.'

  I strolled past them curiously-they were in chronological order. All his earlier work was naturalistic and realistic, with vivid mood and atmosphere, but finely detailed and concrete. Then, years later, they became less vivid, less concrete, less realistic and naturalistic, but far more abstract, even geometrical and cubist. Finally, in the last paintings, the canvasses became nonsense, or nonsense to me-mere chaotic lines and blotches of paint. I commented on this to Mrs P.

  'Ach, you doctors, you're such Philistines!' she exclaimed. 'Can you not see artistic development-how he renounced the realism of his earlier years, and advanced into abstract, nonrepresenta-tional art?'

  'No, that's not it,' I said to myself (but forbore to say it to poor Mrs P.). He had indeed moved from realism to nonrepresentation to the abstract, yet this was not the artist, but the pathology, advancing-advancing towards a profound visual agnosia, in which all powers of representation and imagery, all sense of the concrete, all sense of reality, were being destroyed. This wall of paintings was a tragic pathological exhibit, which belonged to neurology, not art.

  And yet, I wondered, was she not partly right? For there is often a struggle, and sometimes, even more interestingly, a collusion between the powers of pathology and creation. Perhaps, in his cubist period, there might have been both artistic and pathological development, colluding to engender an original form; for as he lost the concrete, so he might have gained in the abstract, developing a greater sensitivity to all the structural elements of line, boundary, contour-an almost Picasso-like power to see, and equally depict, those abstract organisations embedded in, and normally lost in, the concrete. . . . Though in the final pictures, I feared, there was only chaos and agnosia.

  We returned to the great music room, with the Bosendorfer in the centre, and Dr P. humming the last torte.

  'Well, Dr Sacks,' he said to me. 'You find me an interesting case, I perceive. Can you tell me what you find wrong, make recommendations?'

  '1 can't tell you what I find wrong,' I replied, 'but I'll say what I find right. You are a wonderful musician, and music is your life. What I would prescribe, in a case such as yours, is a life which consists entirely of music. Music has been the centre, now make it the whole, of your life.'

  This was four years ago-I never saw him again, but I often wondered about how he apprehended the world, given his strange loss of image, visuality, and the perfect preservation of a great musicality. I think that music, for him, had taken the place of image. He had no body-image, he had body-music: this is why he could move and act as fluently as he did, but came to a total confused stop if the 'inner music' stopped. And equally with the outside, the world … *

  In The World as Representation and Will, Schopenhauer speaks of music as 'pure will'. How fascinated he would have been by Dr P., a man who had wholly lost the world as representation, but wholly preserved it as music or will.

  And this, mercifully, held to the end-for despite the gradual

  *Thus, as I learned later from his wife, though he could not recognise his students if they sat still, if they were merely 'images', he might suddenly recognise them if they moved. 'That's Karl,' he would cry. '1 know his movements, his body-music'

  advance of his disease (a massive tumour or degenerative process in the visual parts of his brain) Dr P. lived and taught music to the last days of his life.

  Postscript

  How should one interpret Dr P.'s peculiar inability to interpret, to judge, a glove as a glove? Manifestly, here, he could not make a cognitive judgment, though he was prolific in the production of cognitive hypotheses. A judgment is intuitive, personal, comprehensive, and concrete-we 'see' how things stand, in relation to one another and oneself. It was precisely this setting, this relating, that Dr P. lacked (though his judging, in all other spheres, was prompt and normal). Was this due to lack of visual information, or faulty processing of visual information? (This would be the explanation given by a classical, schematic neurology.) Or was there something amiss in Dr P.'s attitude, so that he could not relate what he saw to himself?

  These explanations, or modes of explanation, are not mutually exclusive-being in different modes they could coexist and both be true. And this is acknowledged, implicitly or explicitly, in classical neurology: implicitly, by Macrae, when he finds the explanation of defective schemata, or defective visual processing and integration, inadequate; explicitly, by Goldstein, when he speaks of 'abstract attitude'. But abstract attitude, which allows 'categorisation', also misses the mark with Dr P.-and, perhaps, with the concept of'judgment' in general. For Dr P. had abstract attitude- indeed, nothing else. And it was precisely this, his absurd ab-stractness of attitude-absurd because unleavened with anything else-which rendered him incapable of perceiving identity, or particulars, rendered him incapable of judgment.

  Neurology and psychology, curiously, though they talk of everything else, almost ne
ver talk of 'judgment'-and yet it is precisely the downfall of judgment (whether in specific realms, as with Dr P., or more generally, as in patients with Korsakov's or frontal-lobe syndromes-see below, Chapters Twelve and Thirteen) which constitutes the essence of so many neuropsychological disorders.

  Judgment and identity may be casualties-but neuropsychology never speaks of them.

  And yet, whether in a philosophic sense (Kant's sense), or an empirical and evolutionary sense, judgment is the most important faculty we have. An animal, or a man, may get on very well without 'abstract attitude' but will speedily perish if deprived of judgment. Judgment must be the first faculty of higher life or mind-yet it is ignored, or misinterpreted, by classical (computational) neurology. And if we wonder how such an absurdity can arise, we find it in the assumptions, or the evolution, of neurology itself. For classical neurology (like classical physics) has always been mechanical-from Hughlings Jackson's mechanical analogies to the computer analogies of today.

  Of course, the brain is a machine and a computer-everything in classical neurology is correct. But our mental processes, which constitute our being and life, are not just abstract and mechanical, but personal, as well-and, as such, involve not just classifying and categorising, but continual judging and feeling also. If this is missing, we become computer-like, as Dr P. was. And, by the same token, if we delete feeling and judging, the personal, from the cognitive sciences, we reduce them to something as defective as Dr P.-and we reduce our apprehension of the concrete and real.

  By a sort of comic and awful analogy, our current cognitive neurology and psychology resemble nothing so much as poor Dr P.! We need the concrete and real, as he did; and we fail to see this, as he failed to see it. Our cognitive sciences are themselves suffering from an agnosia essentially similar to Dr P.'s. Dr P. may therefore serve as a warning and parable-of what happens to a science which eschews the judgmental, the particular, the personal, and becomes entirely abstract and computational.

  It was always a matter of great regret to me that, owing to circumstances beyond my control, I was not able to follow his case further, either in the sort of observations and investigations described, or in ascertaining the actual disease pathology.

  One always fears that a case is 'unique', especially if it has such

  extraordinary features as those of Dr P. It was, therefore, with a sense of great interest and delight, not unmixed with relief, that I found, quite by chance-looking through the periodical Brain for 1956-a detailed description of an almost comically similar case, similar (indeed identical) neuropsychologically and phenomeno-logically, though the underlying pathology (an acute head injury) and all personal circumstances were wholly different. The authors speak of their case as 'unique in the documented history of this disorder'-and evidently experienced, as I did, amazement at their own findings. * The interested reader is referred to the original paper, Macrae and Trolle (1956), of which I here subjoin a brief paraphrase, with quotations from the original.

  Their patient was a young man of 32, who, following a severe automobile accident, with unconsciousness for three weeks, '. . . complained, exclusively, of an inability to recognise faces, even those of his wife and children'. Not a single face was 'familiar' to him, but there were three he could identify; these were workmates: one with an eye-blinking tic, one with a large mole on his cheek, and a third 'because he was so tall and thin that no one else was like him'. Each of these, Macrae and Trolle bring out, was 'recognised solely by the single prominent feature mentioned'. In general (like Dr P.) he recognised familiars only by their voices.

  He had difficulty even recognising himself in a mirror, as Macrae and Trolle describe in detail: 'In the early convalescent phase he frequently, especially when shaving, questioned whether the face gazing at him was really his own, and even though he knew

  *Only since the completion of this book have I found that there is, in fact, a rather extensive literature on visual agnosia in general, and prosopagnosia in particular. In particular I had the great pleasure recently of meeting Dr Andrew Kertesz, who has himself published some extremely detailed studies of patients with such agnosias (see, for example, his paper on visual agnosia, Kertesz 1979). Dr Kertesz mentioned to me a case known to him of a farmer who had developed prosopagnosia and in consequence could no longer distinguish (the faces of) his cows, and of another such patient, an attendant in a Natural History Museum, who mistook his own reflection for the diorama of an ape. As with Dr P., and as with Macrae and Trolle's patient, it is especially the animate which is so absurdly misperceived. The most important studies of such agnosias, and of visual processing in general, are now being undertaken by A. R. and H. Damasio (see article in Mesulam [1985], pp. 259-288; or see p. 79 below).

  it could physically be none other, on several occasions grimaced or stuck out his tongue "just to make sure." By carefully studying his face in the mirror he slowly began to recognise it, but "not in a flash" as in the past-he relied on the hair and facial outline, and on two small moles on his left cheek.'

  In general he could not recognise objects 'at a glance', but would have to seek out, and guess from, one or two features- occasionally his guesses were absurdly wrong. In particular, the authors note, there was difficulty with the animate.

  On the other hand, simple schematic objects-scissors, watch, key, etc.-presented no difficulties. Macrae and Trolle also note that: 'His topographical memory was strange: the seeming paradox existed that he could find his way from home to hospital and around the hospital, but yet could not name streets en route [unlike Dr P., he also had some aphasia] or appear to visualize the topography.'

  It was also evident that visual memories of people, even from long before the accident, were severely impaired-there was memory of conduct, or perhaps a mannerism, but not of visual appearance or face. Similarly, it appeared, when he was questioned closely, that he no longer had visual images in his dreams. Thus, as with Dr P., it was not just visual perception, but visual imagination and memory, the fundamental powers of visual representation, which were essentially damaged in this patient-at least those powers insofar as they pertained to the personal, the familiar, the concrete.

  A final, humorous point. Where Dr P. might mistake his wife for a hat, Macrae's patient, also unable to recognise his wife, needed her to identify herself by a visual marker, by '. . . a conspicuous article of clothing, such as a large hat'.

  2

  The Lost Mariner*

  You have to begin to lose your memory, if only in bits and pieces, to realise that memory is what makes our lives. Life without memory is no life at all . . . Our memory is our coherence, our reason, our feeling, even our action. Without it, we are nothing … (I can only wait for the final amnesia, the one that can erase an entire life, as it did my mother's . . .)

  –Luis Bunuel

  This moving and frightening segment in Bunuel's recently translated memoirs raises fundamental questions-clinical, practical, existential, philosophical: what sort of a life (if any), what sort of a world, what sort of a self, can be preserved in a man who has lost the greater part of his memory and, with this, his past, and his moorings in time?

  It immediately made me think of a patient of mine in whom these questions are precisely exemplified: charming, intelligent, memoryless Jimmie G., who was admitted to our Home for the

  *After writing and publishing this history I embarked with Dr Elkhonon Goldberg- a pupil of Luria and editor of the original (Russian) edition of The Neuropsychology of Memory-on a close and systematic neuropsychological study of this patient. Dr Goldberg has presented some of the preliminary findings at conferences, and we hope in due course to publish a full account.

  A deeply moving and extraordinary film about a patient with a profound amnesia (Prisoner of Consciousness), made by Dr Jonathan Miller, has just been shown in England (September 1986). A film has also been made (by Hilary Lawson) with a prosopagnosic patient (with many similariti
es to Dr P.). Such films are crucial to assist the imagination: 'What can be shown cannot be said.'

  Aged near New York City early in 1975, with a cryptic transfer note saying, 'Helpless, demented, confused and disoriented.'

  Jimmie was a fine-looking man, with a curly bush of grey hair, a healthy and handsome forty-nine-year-old. He was cheerful, friendly, and warm.

  'Hiya, Doc!' he said. 'Nice morning! Do I take this chair here?' He was a genial soul, very ready to talk and to answer any questions I asked him. He told me his name and birth date, and the name of the little town in Connecticut where he was born. He described it in affectionate detail, even drew me a map. He spoke of the houses where his family had lived-he remembered their phone numbers still. He spoke of school and school days, the friends he'd had, and his special fondness for mathematics and science. He talked with enthusiasm of his days in the navy-he was seventeen, had just graduated from high school when he was drafted in 1943. With his good engineering mind he was a 'natural' for radio and electronics, and after a crash course in Texas found himself assistant radio operator on a submarine. He remembered the names of various submarines on which he had served, their missions, where they were stationed, the names of his shipmates. He remembered Morse code, and was still fluent in Morse tapping and touch-typing.

  A full and interesting early life, remembered vividly, in detail, with affection. But there, for some reason, his reminiscences stopped. He recalled, and almost relived, his war days and service, the end of the war, and his thoughts for the future. He had come to love the navy, thought he might stay in it. But with the GI Bill, and support, he felt he might do best to go to college. His older brother was in accountancy school and engaged to a girl, a 'real beauty', from Oregon.

  With recalling, reliving, Jimmie was full of animation; he did not seem to be speaking of the past but of the present, and I was very struck by the change of tense in his recollections as he passed from his school days to his days in the navy. He had been using the past tense, but now used the present-and (it seemed to me) not just the formal or fictitious present tense of recall, but the actual present tense of immediate experience.