The Man Who Mistook His Wife For a Hat
Dr Oliver Sacks was born in London in 1933, and educated in Oxford, California and in New York, where he is professor of Neurology at the Albert Einstein College of Medicine. His studies of bizarre neurological disorders are modern classics, raising profound questions about the mind and self-identity. Awakenings, which recounted the ‘time-machine’ effect of L-Dopa on patients who had for years been locked in a trance-like state following sleeping-sickness (encephalitis lethargica), was made into a feature film. This extract is from the title essay of his 1985 collection.
Dr P. was a musician of distinction, well-known for many years as a singer, and then, at the local School of Music, as a teacher. It was here, in relation to his students, that certain strange problems were first observed. Sometimes a student would present himself, and Dr P. would not recognise him; or, specifically, would not recognise his face. The moment the student spoke, he would be recognised by his voice. Such incidents multiplied, causing embarrassment, perplexity, fear – and, sometimes, comedy. For not only did Dr P. increasingly fail to see faces, but he saw faces when there were no faces to see: genially, Magoo-like, when in the street, he might pat the heads of water-hydrants and parking-meters, taking these to be the heads of children; he would amiably address carved knobs on the furniture, and be astounded when they did not reply. At first these odd mistakes were laughed off as jokes, not least by Dr. P. himself. Had he not always had a quirky sense of humour, and been given to Zen-like paradoxes and jests? His musical powers were as dazzling as ever; he did not feel ill – he had never felt better; and the mistakes were so ludicrous – and so ingenious – that they could hardly be serious or betoken anything serious. The notion of there being ‘something the matter’ did not emerge until some three years later, when diabetes developed. Well aware that diabetes could affect his eyes, Dr P. consulted an ophthalmologist, who took a careful history, and examined his eyes closely. ‘There’s nothing the matter with your eyes,’ the doctor concluded. ‘But there is trouble with the visual parts of your brain. You don’t need my help, you must see a neurologist.’ And so, as a result of this referral, Dr P. came to me.
It was obvious within a few seconds of meeting him that there was no trace of dementia in the ordinary sense. He was a man of great cultivation and charm, who talked well and fluently, with imagination and humour. I couldn’t think why he had been referred to our clinic.
And yet there was something a bit odd. He faced me as he spoke, was oriented towards me, and yet there was something the matter – it was difficult to formulate. He faced me with his ears, I came to think, but not with his eyes. These, instead of looking, gazing, at me, ‘taking me in’, in the normal way, made sudden fixations – on my nose, on my right ear, down to my chin, up to my right eye – as if noting (even studying) these individual features, but not seeing my whole face, its changing expressions, ‘me’, as a whole. I am not sure that I fully realised this at the time – there was just a teasing strangeness, some failure in the normal interplay of gaze and expression. He saw me, he scanned me, and yet…
‘What seems to be the matter?’ I asked him at length.
‘Nothing that I know of,’ he replied with a smile, ‘but people seem to think there’s something wrong with my eyes.’
‘But you don’t recognise any visual problems?’
‘No, not directly, but I occasionally make mistakes.’
I left the room briefly, to talk to his wife. When I came back Dr P. was sitting placidly by the window, attentive, listening rather than looking out. ‘Traffic,’ he said, ‘street sounds, distant trains – they make a sort of symphony, do they not? You know Honegger’s Pacific 234?’
What a lovely man, I thought to myself. How can there be anything seriously the matter? Would he permit me to examine him?
‘Yes, of course, Dr Sacks.’
I stilled my disquiet, his perhaps too, in the soothing routine of a neurological exam – muscle strength, co-ordination, reflexes, tone… It was while examining his reflexes – a trifle abnormal on the left side – that the first bizarre experience occurred. I had taken off his left shoe and scratched the sole of his foot with a key – a frivolous-seeming but essential test of a reflex – and then, excusing myself to screw my ophthalmoscope together, left him to put on the shoe himself. To my surprise, a minute later, he had not done this.
‘Can I help?’ I asked.
‘Help what? Help whom?’
‘Help you put on your shoe.’
‘Ach,’ he said, ‘I had forgotten the shoe’, adding, sotto voce, ‘The shoe? The shoe?’ He seemed baffled.
‘Your shoe,’ I repeated. ‘Perhaps you’d put it on.’
He continued to look downwards, though not at the shoe, with an intense but misplaced concentration. Finally his gaze settled on his foot: ‘That is my shoe, yes?’
Did I mis-hear? Did he mis-see?
‘My eyes,’ he explained, and put a hand to his foot. ‘This is my shoe, no?’
‘No, it is not. That is your foot. There is your shoe.’
‘Ah! I thought that was my foot.’
Was he joking? Was he mad? Was he blind? If this was one of his ‘strange mistakes’, it was the strangest mistake I had ever come across.
I helped him on with his shoe (his foot), to avoid further complication. Dr P. himself seemed untroubled, indifferent, maybe amused. I resumed my examination. His visual acuity was good: he had no difficultly seeing a pin on the floor, though sometimes he missed it if it was placed to his left.
He saw all right, but what did he see? I opened out a copy of the National Geographic Magazine, and asked him to describe some pictures in it.
His responses here were very curious. His eyes would dart from one thing to another, picking up tiny features, individual features, as they had done with my face. A striking brightness, a colour, a shape would arrest his attention and elicit comment – but in no case did he get the scene-as-a-whole. He failed to see the whole, seeing only details, which he spotted like blips on a radar screen. He never entered into relation with the picture as a whole – never faced, so to speak, its physiognomy. He had no sense whatever of a landscape of scene.
I showed him the cover, an unbroken expanse of Sahara dunes.
‘What do you see here?’ I asked.
‘I see a river,’ he said. ‘And a little guest-house with its terrace on the water. People are dining out on the terrace. I see coloured parasols here and there.’ He was looking, if it was ‘looking’, right off the cover, into mid-air and confabulating non-existent features, as if the absence of features in the actual picture had driven him to imagine the river and the terrace and the coloured parasols.
I must have looked aghast, but he seemed to think he had done rather well. There was a hint of a smile on his face. He also appeared to have decided that the examination was over, and started to look round for his hat. He reached out his hand, and took hold of his wife’s head, tried to lift it off, to put it on. He had apparently mistaken his wife for a hat! His wife looked as if she was used to such things.
I could make no sense of what had occurred, in terms of conventional neurology (or neuropsychology). In some ways he seemed perfectly preserved, and in others absolutely, incomprehensibly devastated. How could he, on the one hand, mistake his wife for a hat and, on the other, function, as apparently he still did, as a teacher at the Music School?
I had to think, to see him again – and to see him in his own familiar habitat, at home.
A few days later I called on Dr P. and his wife at home, with the score of the Dichterliebe in my briefcase (I knew he liked Schumann), and a variety of odd objects for the testing of perception. Mrs P. showed me into a lofty apartment, which recalled fin-de-siecle Berlin. A magnificent old Bosendorfer stood in state in the centre of the room, and all round it were music stands, instruments, scores… There were books, there were paintings, but the music was central. Dr P. came in and, distracted, advanced with outstretched hand to the grandfather clock, but, hearing my voice, corrected himself, and shook hands with me. We exchanged greetings, and chatted a little of current concerts and performances. Diffidently, I asked him if he would sing.
‘The Dichterliebe!’ he exclaimed. ‘But I can no longer read music. You will play them, yes?’
I said I would try. On that wonderful old piano even my playing sounded right, and Dr P. was an aged, but infinitely mellow Fischer-Dieskau, combining a perfect ear and voice with the most incisive musical intelligence. It was clear that the Music School was not keeping him on out of charity…
I had stopped at a florist on my way to his apartment and bought myself an extravagant red rose for my buttonhole. Now I removed this and handed it to him. He took it like a botanist or morphologist given a specimen, not like person given a flower.
“About six inches in length,’ he commented. ‘A convoluted red form with a linear green attachment.’
‘Yes,’ I said encouragingly, ‘and what do you think it is, Dr P.?’
‘Not easy to say.’ He seemed perplexed. ‘It lacks the simple symmetry of the Platonic solids, although it may have a higher symmetry of its own… I think this could be an inflorescence or flower.’
‘Could be?’ I queried.
‘Could be,’ he confirmed.
‘Smell it,’ I suggested, and he again looked somewhat puzzled, as if I had asked him to smell a higher symmetry. But he complied courteously, and took it to his nose. Now, suddenly, he came to life.
‘Beautiful!’ he exclaimed. ‘An early rose. What a heavenly smell!’ He started to hum ‘Die Rose, die Lillie…’ Reality, it seemed, might by conveyed by smell, not by sight.
I tried one final test. It was still a cold day, in early spring, and I had thrown my coat and gloves on the sofa.
‘What is this?’ I asked, holding up a glove.
‘May I examine it?’ he asked, and, taking it from me, he proceeded to examine it as he had examined the geometrical shapes.
‘A continuous surface,’ he announced at last, ‘infolded on itself. It appears to have’ – he hesitated – ‘five outpouchings, if this is the word.’
‘Yes,’ I said cautiously. ‘You have given me a description. Now tell me what it is.’
‘A container of some sort?’
‘Yes.’ I said, ‘and what would it contain?’
‘It would contain its contents!’ said Dr P. with a laugh. ‘There are many possibilities. It could be a change-purse, for example, for coins of five sizes. It could…’
I interrupted the barmy flow. ‘Does it not look familiar? Do you think it might contain, might fit, a part of your body?’
No light of recognition dawned on his face. Later, by accident, he got it on, and exclaimed, ‘My God, it’s a glove!’ This was reminiscent of Kurt Goldstein’s patient ‘Lanuti’, who could only recognise objects by trying to use them in action.
No child would have the power to see and speak of ‘a continuous surface… infolded on itself’, but any child, any infact, would immediately know a glove as a glove, see it as familiar, as going with a hand. Dr P. didn’t. He saw nothing as familiar. Visually, he was lost in a world of lifeless abstractions. Indeed, he did not have a real visual world, as he did not have a real visual self. He could speak about things, but did not see them face-to-face. Hughlings Jackson, discussing patients with aphasia and left-hemisphere lesions, says they have lost ‘abstract’ and ‘propositional’ thought – and compares them with dogs (or, rather, he compares dogs to patients with aphasia). Dr P., on the other hand, functioned precisely as a machine functions. It wasn’t merely that he displayed the same indifference to the visual world as a computer construes it, by means of key features and schematic relationships. The scheme might be identified – in an ‘identi-kit’ way – without the reality being grasped at all…
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. stated 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 perceives it as a table laden with cakes. His wife poured him some coffee: the smell titillating 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 t 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 canvases 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, non-representational 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 non-representation to the abstract, but 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.
Source: Oliver Sacks, The Man Who Mistook His Wife for a Hat, London, Picador, Pan Book, 1986.