Review of The Man Who Mistook His Wife For A Hat

Recognizing Reality

Historically, Dr. Oliver Sacks explains, neurology and neuro-psychology focused on the study of cognitive functions mediated by the left hemisphere of the brain. The right hemisphere once – and unjustly so – was thought to house more primitive functions. Yet, its quite intricate mechanisms, while perhaps less obvious, mediate cognitive functions such as recognizing reality. Patients with right hemisphere syndromes find it difficult to understand their own problems, just as observers find it challenging to understand these patients’ inner workings. Sacks found that his neurological patients’ problems manifested in four categories:

1. “Losses”

Classical neurology sees the brain as a machine and a computer. But human mental processes are not merely abstract and mechanical, they are personal as well. These processes involve not only classifying and categorizing, but also judging and feeling. If any of these abilities are missing, a person becomes as computer-like as Dr. P., once a musician of distinction and a teacher at a local music school.

People at school first noticed his problems. If a student came to speak to him, Dr. P. did not recognize him or her until the student spoke. Dr. P. also saw faces when there were no faces to see. He might address fire hydrants and parking meters as if they were children. But if you engaged in one-to-one conversation with him, it was clear that Dr. P. didn’t suffer from dementia. 

A man of great charm, he spoke well and fluently. He did not think anything was wrong with him. His eye exams were normal. But when he looked at a picture, he failed to see the scene as a whole. He saw only the details. Sacks recalls that after he examined Dr. P., the musician didn’t put his shoes back on. When the doctor asked why not, Dr. P. inquired, holding his foot, “Is this my shoe?”  

Nothing was familiar to Dr. P. He did not appear to have any visual references. When given a flower, he described it as, “about six inches in length with a convoluted red form and a linear green attachment.” Examining a glove, he described, “a continuous surface enfolded on itself with five outpouchings.” To test Dr. P.’s inner world, Sacks asked him to imagine entering a local intersection and to describe the buildings he would pass. Dr. P. listed the buildings on his right side, but none on his left. 

Dr. P.’s wife explained that he performs every daily task while singing to himself.  If she interrupts him, he stops and doesn’t seem to know what’s going on. Sacks writes that when Dr. P. thought his exam was over, he looked around for his hat.  He reached out and took hold of his wife’s head. He tried to pull it off her neck and put it on his head. His wife appeared accustomed to this manifestation.

Dr. P. taught music for the rest of his life. This wonderful musician had made music the center of his life. Sacks conjectures that it may have taken the place of images. Through music and his intellect, he was able to compensate as his visual centers deteriorated. A massive tumor or degenerative process in the visual parts of his brain gradually took over his brain and his functions.

In illuminating neurological losses, Sacks then recounts the case of Jimmie, “The Lost Mariner,” who was charming and intelligent, but had no memory of recent events. He spoke with enthusiasm about his days in the Navy. He liked science and math and had become an assistant radio operator on a submarine. He recalled his life vividly until the end of WWII. Then, his memories stopped. When Sacks asked him to identify the year, he would say, “’Forty-five, man. We won the war.”

Jimmie wasn’t aware of this deep tragic loss in himself. The 30 years since WWII did not seem to exist for him. Such cases of memory loss are called “Korsakov’s syndrome.” In Jimmie’s case, various tests such as the EEG and brain scans found no massive brain damage. The Navy reported that he remained in the service until 1965 and was competent at that time. However, a report from Bellevue hospital from 1971 found him, “totally disoriented…with an advanced organic brain syndrome, due to alcohol.”

Despite his mental losses, if Jimmie gave something his emotional or spiritual attention – such as art or music or Mass – his attention span or mood would persist for a while. Then peace would appear to come over him. He could have manifested either Korsakov’s or dementia, because in such cases the possibility remains of reintegration through art or by touching the human spirit.

Christina, “The Disembodied Lady,” was a healthy 27-year-old woman. She liked sports, had two young children and worked as a computer programmer. She was admitted to the hospital for the routine removal of gall stones. Sacks recounts that the day before the surgery, she had a disturbing dream in which she was swaying and standing unsteadily; in her dream, she could hardly feel the ground below her feet. Later that day, the dream came true.

The day of her surgery, Christina couldn’t stand unless she looked down at her feet. She couldn’t hold anything in her hands. She told Sacks she felt disembodied. She experienced a collapse of muscle tone over her entire body. Her arms flailed, but she seemed unaware of them, as if she were receiving no information from her periphery. Her control loops for muscle tone and movement appeared to have broken down. She seemed to experience an almost total loss of “proprioception,” that is, the author explains, her “parietal lobes were working, but had nothing to work with.” A spinal tap revealed an acute “polyneuritis” affecting the sensory roots of her spinal and cranial nerves.

In time, Christina learned to walk again and to conduct her daily routines, but her life never returned to normal. She remained in rehabilitation for a year. She returned home, rejoined her children and went back to work at her computer terminal. However, she had to do everything by vision, not by feel. She had permanently lost her sense of proprioception. She felt as if her body were dead, but not her mind or identify. Sacks writes of her compassionately as the first of her kind, the first “disembodied” human being. 

2. “Excesses”  

Neurology’s favorite word is “deficit.” A function is either normal or faulty.  However, the author reveals the opposite face of deficits: a superabundance of function. No word exists for this in neurology. Instead, a condition that is “ebullient or productive in character challenges the basic mechanistic concepts of neurology.” Sacks expresses the opinion that these diseases have never attracted the attention they deserve.

Take “Witty Ticcy Ray,” a 24-year-old man who suffered from Tourette’s syndrome, which manifests as too much nervous energy. Patients’ brains have an excess of “excitor transmitters,” especially dopamine. Multiple, violent tics almost incapacitated Ray. They affected him every few seconds from age four, yet he managed to graduate from high school and college. After graduation, he held and lost a dozen jobs. Bosses fired him because of his tics. Involuntarily shouting curse words – a symptom of Tourette’s – threatened his marriage.  

Like many Tourette’s sufferers, Sacks writes, Ray was remarkably musical. His Tourette’s proved an advantage in games – especially Ping-Pong. His quick reflexes and reaction time made his shots winners. But Ray was in despair, so to treat his Tourette’s, his doctor started him on minute doses of the drug Haldol.

A week later Ray told the doctor that Haldol was throwing him off balance. The drug interfered with his timing and his quick reflexes. His tics became slow and extended. Ray couldn’t imagine life without his disease, but he considered that possibility over months of deep therapy. When his doctor tried Haldol again, Ray had no tics and no significant side effects. At work, his movements and judgments were slow and deliberate; his marriage was happy. He became slower in repartee. He lost his skill at Ping-Pong and no longer had wild creative surges, so he made a momentous decision. He would take Haldol “dutifully throughout the working week,” but not on weekends. Ray found a way to lead a full life, despite Tourette’s and Haldol.

Natasha, age 90, suffered from “Cupid’s Disease.” She claimed she felt young, energetic and “frisky,” but Sacks notes, her friends began to worry. Even Natasha realized that she was feeling too charged up and came to think that she must be sick. Natasha said something in her brain was making her high, a condition she identified herself, drawing on her past.  When she’d lived in a brothel in Salonika 70 years earlier, she’d contracted syphilis, known then as Cupid’s Disease.

Her illness had gone through a long latent period between primary infection and the reappearance of neurosyphilis. Now, Natasha’s spinal fluid tested positive for syphilis; its spirochetes stimulated her cerebral cortex. She wasn’t sure she wanted treatment. She enjoyed life. Penicillin killed the spirochetes, but it didn’t reverse her cerebral changes. Sacks concludes the case by noting that Natasha enjoyed a mild “disinhibition” with no threat to her self-control or damage to her cortex.

3. “Transports”

Sack’s third category of neurological disorders, transports, focuses on reminiscence, altered perception, imagination or a dream state. These patients’ dreams appear as physical manifestations or as spiritual experiences. In these cases, the power of memory and imagery can transport someone suffering from abnormalities in the brain’s temporal lobes and limbic system. 

To understand the impact of reminiscence, Sacks asks you to consider Mrs. O’C., 88, who lived in an old age home. She dreamed of her childhood in Ireland. The songs she used to sing were prominent in her dreams, and when she awoke, she still heard the music playing, loud and clear. She thought she was still dreaming, but she wasn’t. She couldn’t find the source of the music. She went to ENT, psychiatry and neurology doctors. By the time she had an EEG, she heard the music only occasionally. The test confirmed temporal lobe seizures in parts of the brain known to process audible information. The Irish songs in the night, with their memory traces, were the result of a stroke. As the stroke resolved, the music resolved.

Such seizures may have a physiological and a personal origin. Mrs. O’C. later told Sacks that her father had died before she was born and her mother died before she was five. She was sent to the United States to live with a forbidding aunt. She had tried, but never succeeded, to remember her early life in Ireland and to recapture lost childhood memories. Now with her dream and its songs, she felt as if she’d opened a door that had been sealed all her life.

In the case of “The Dog Beneath the Skin,” Steven, 22, a medical student, was high on cocaine, PCP and amphetamines when he had a vivid dream one night that he was a dog. When he woke, Sacks recounts, he found himself in an world rich in smells and perception. His color vision was enhanced; his sense of smell became strong and discerning. He sniffed like a dog, and he could recognize people, places and emotions by smell. He felt an impulse to smell everything and nothing seemed real until he could sniff it.

After three weeks, Steven’s transformation ended, and his senses returned to normal. He felt a tremendous loss. He said he’d come to understand what people give up to be civilized and human. Sack’s diagnosis is that Stephen probably experienced an amphetamine-induced “dopaminergic” excitation. Now a physician, he sometimes yearns to “go back and be a dog again.”

4. “The World Of the Simple” 

A simple mind enhances or preserves some qualities. People can be “mentally defective,” Sacks suggests, but also mentally interesting. He recalls a patient named Rebecca, age 19, who had an IQ of 60 and couldn’t read, write or perform the simplest calculations. Yet, she understood the symbols and metaphors of poetry. She loved stories, and when she performed them onstage, nobody noticed anything unusual.

Nearly fatal meningitis in infancy left another patient, Marin, 61, with seizures, impulsiveness and retardation. His father, a famous opera singer, had imbued Marin with his love of music. Marin had an amazing musical memory; he knew “more than 2,000 operas,” and memorized the nine-volume Grove’s Dictionary of Music and Musicians. When Marin sang, Sacks says, his defects fell away as music granted him transcendence.

Twins John and Michael, 25, were diagnosed as autistic, psychotic or severely retarded.  Yet they could tell you immediately what day of the week a date would fall on – in the past, present or future. They couldn’t do simple math, but if a box of matches were emptied onto the floor, they both said, “111.” Asked how they knew the box held 111 matches, they said, “We didn’t count. We saw the 111.” They could name primes for 10 or 12 digit numbers, though math offers “no simple method” for quickly calculating primes of long numbers. Mysteriously, Sacks tells his readers, the twins’ minds held onto this ability, though they lost so much else.

An Artful Storyteller

Neurologist Oliver Sacks saw many cases of neurological disorders, yet he seemed to view each one of them less as a disorder and more as a unique gift that enabled people to interact with the world in special ways. He was interested in the human stories behind his patients’ conditions as much as he was a curious scientist fascinated with the brain. As an artful storyteller, Sacks wrote about case studies – calling them “clinical tales” – and shared his insights in more than a dozen books; this bestseller is one of his earliest works.