The man who mistook his wife for a hat

   Who

   MISTOOK

   HIS WIFE

   for

   a HAT

   
and other clinical tales

   To
Leonard Shengold, M.D.

   THE MAN WHO MISTOOK HIS WIFE FOR A HAT AND OTHER CLINICAL TALESCopyright © 1970,

   1981, 1983, 1984, 1985 by Oliver Sacks. All rights reserved. Printed in the United States of America. No part of this book may be used or reproduced in any manner whatsoever without written permission except in the case of brief quotations embodied in critical articles and reviews. For information address HarperCollins Publishers, 10 East 53rd Street, New York, NY 10022.

   Library of Congress Cataloging-in-Publication Data Sacks, Oliver W.

   The man who mistook his wife for a hat and other clinical tales.

   Bibliography: p.

   1. Neurology-Anecdotes, facetiae, satire, etc. I. Title.

   [RC351.S195 1987] 616.8 86-45686

   ISBN 0-06-097079-0 (pbk.)

   
Contents

   Preface
page vii

   
Part One - LOSSES
Introduction
page
3

   
1
The Man Who Mistook His Wife for a Hat
page 8

   
2
The Lost Mariner
page
23

   3 The Disembodied Lady
page
43

   4 The Man Who Fell out of Bed
page
55

   5 Hands
page
59

   6 Phantoms
page 66

   7 On the Level
page 71

   
8
Eyes Right!
page 77

   
9
The President's Speech
page 80

   
Part Two - EXCESSES
Introduction
page 87

   
10
Witty Ticcy Ray
page 92

   
11
Cupid's Disease
page 102

   
12
A Matter of Identity
page 108

   
13
Yes, Father-Sister
page 116

   
14
The Possessed
page 120

   
Part Three - TRANSPORTS
Introduction
page 129

   
15
Reminiscence
page 132

   
16
Incontinent Nostalgia
page 150

   
17
A Passage to India
page 153

   
18
The Dog Beneath the Skin
page 156

   
19
Murder
page 161

   
20
The Visions of Hildegard
page 166

   
Part Four - THE WORLD OF THE SIMPLE

   Introduction
page 173

   
21
Rebecca
page 178

   
22
A Walking Grove
page 187

   
23
The Twins
page
195

   24 The Autist Artist
page 214

   Bibliography
page 234

   
Preface

   The last thing one settles in writing a book,' Pascal observes, 'is what one should put in first.' So, having written, collected and arranged these strange tales, having selected a title and two epigraphs, I must now examine what I have done-and why.

   The doubleness of the epigraphs, and the contrast between them-indeed, the contrast which Ivy McKenzie draws between the physician and the naturalist-corresponds to a certain doubleness in me: that I feel myself a naturalist and a physician both; and that I am equally interested in diseases and people; perhaps, too, that I am equally, if inadequately, a theorist and dramatist, am equally drawn to the scientific and the romantic, and continually see both in the human condition, not least in that quintessential human condition of sickness-animals get diseases, but only man falls radically into sickness.

   My work, my life, is all with the sick-but the sick and their sickness drives me to thoughts which, perhaps, I might otherwise not have. So much so that I am compelled to ask, with Nietzsche: 'As for sickness: are we not almost tempted to ask whether we could get along without it?'-and to see the questions it raises as fundamental in nature. Constantly my patients drive me to question, and constantly my questions drive me to patients-thus in the stories or studies which follow there is a continual movement from one to the other.

   Studies, yes; why stories, or cases? Hippocrates introduced the historical conception of disease, the idea that diseases have a course, from their first intimations to their climax or crisis, and thence to their happy or fatal resolution. Hippocrates thus introduced the case history, a description, or depiction, of the natural history of disease-precisely expressed by the old word 'pathology.' Such

   histories are a form of natural history-but they tell us nothing about the individual and
his
history; they convey nothing of the person, and the experience of the person, as he faces, and struggles to survive, his disease. There is no 'subject' in a narrow case history; modern case histories allude to the subject in a cursory phrase ('a trisomic albino female of 21'), which could as well apply to a rat as a human being. To restore the human subject at the centre-the suffering, afflicted, fighting, human subject-we must deepen a case history to a narrative or tale; only then do we have a 'who' as well as a 'what', a real person, a patient, in relation to disease-in relation to the physical.

   The patient's essential being is very relevant in the higher reaches of neurology, and in psychology; for here the patient's personhood is essentially involved, and the study of disease and of identity cannot be disjoined. Such disorders, and their depiction and study, indeed entail a new discipline, which we may call the 'neurology of identity', for it deals with the neural foundations of the self, the age-old problem of mind and brain. It is possible that there must, of necessity, be a gulf, a gulf of category, between the psychical and the physical; but studies and stories pertaining simultaneously and inseparably to both-and it is these which especially fascinate me, and which (on the whole) I present here-may nonetheless serve to bring them nearer, to bring us to the very intersection of mechanism and life, to the relation of physiological processes to biography.

   The tradition of richly human clinical tales reached a high point in the nineteenth century, and then declined, with the advent of an impersonal neurological science. Luria wrote: 'The power to describe, which was so common to the great nineteenth-century neurologists and psychiatrists, is almost gone now. … It must be revived.' His own late works, such as
The Mind of a Mnemonist
and
The Man with a Shattered World,
are attempts to revive this lost tradition. Thus the case-histories in this book hark back to an ancient tradition: to the nineteenth-century tradition of which Luria speaks; to the tradition of the first medical historian, Hippocrates; and to that universal and prehistorical tradition by which patients have always told their stories to doctors.

   Classical fables have archetypal figures-heroes, victims, martyrs, warriors. Neurological patients are all of these-and in the strange tales told here they are also something more. How, in these mythical or metaphorical terms, shall we categorise the 'lost Mariner', or the other strange figures in this book? We may say they are travellers to unimaginable lands-lands of which otherwise we should have no idea or conception. This is why their lives and journeys seem to me to have a quality of the fabulous, why I have used Osier's
Arabian Nights
image as an epigraph, and why I feel compelled to speak of tales and fables as well as cases. The scientific and the romantic in such realms cry out to come together-Luria liked to speak here of 'romantic science'. They come together at the intersection of fact and fable, the intersection which characterises (as it did in my book
Awakenings)
the lives of the patients here narrated.

   But what facts! What fables! To what shall we compare them? We may not have any existing models, metaphors or myths. Has the time perhaps come for new symbols, new myths?

   Eight of the chapters in this book have already been published: 'The Lost Mariner', 'Hands', 'The Twins', and 'The Autist Artist' in the
New York Review of Books
(1984 and 1985), and 'Witty Ticcy Ray', 'The Man Who Mistook His Wife for a Hat', and 'Reminiscence' in the
London Review of Books
(1981, 1983, 1984)- where the briefer version of the last was called 'Musical Ears'. 'On the Level' was published in
The Sciences
(1985). A very early account of one of my patients-the 'original' of Rose R. in
Awakenings
and of Harold Pinter's Deborah in A
Kind of Alaska,
inspired by that book-is to be found in 'Incontinent Nostalgia' (originally published as 'Incontinent Nostalgia Induced by L-Dopa' in the
Lancet
of Spring 1970). Of my four 'Phantoms', the first two were published as 'clinical curios' in the
British Medical journal
(1984). Two short pieces are taken from previous books: 'The Man Who Fell out of Bed' is excerpted from A
Leg to Stand On,
and 'The Visions of Hildegard' from
Migraine.
The remaining twelve pieces are unpublished and entirely new, and were all written during the autumn and winter of 1984.

   I owe a very special debt to my editors: first to Robert Silvers of the
New York Review of Books
and Mary-Kay Wilmers of the
London
Review
of Books;
then to Kate Edgar, Jim Silberman of

   Summit Rooks in New York, and Colin Haycraft of Duckworth's

   in London, who between them did so much to shape the final

   book.

   Among my fellow neurologists I must express special gratitude to the late Dr James Purdon Martin, to whom I showed videotapes of 'Christina' and 'Mr MacGregor' and with whom I discussed these patients fully-'The Disembodied Lady' and 'On the Level' express this indebtedness; to Dr Michael Kremer, my former 'chief in London, who in response to A
Leg to Stand On
(1984) described a very similar case of his own-these are bracketed together now in 'The Man Who Fell out of Bed'; to Dr Donald Macrae, whose extraordinary case of visual agnosia, almost comically similar to my own, was only discovered, by accident, two years after I had written my own piece-it is excerpted in a postscript to 'The Man Who Mistook His Wife for a Hat'; and, most especially, to my close friend and colleague, Dr Isabelle Rapin, in New York, who discussed many cases with me; she introduced me to Christina (the 'disembodied lady'), and had known Jose, the 'autist artist', for many years when he was a child.

   I wish to acknowledge the selfless help and generosity of the patients (and, in some cases, the relatives of the patients) whose tales I tell here-who, knowing (as they often did) that they themselves might not be able to be helped directly, yet permitted, even encouraged, me to write of their lives, in the hope that others might learn and understand, and, one day, perhaps be able to cure. As in
Awakenings,
names and some circumstantial details have been changed for reasons of personal and professional confidence, but my aim has been to preserve the essential 'feeling' of their lives.

   Finally, I wish to express my gratitude-more than gratitude- to my own mentor and physician, to whom I dedicate this book.

   
New York
O.W.S.

   To talk of diseases is a sort of
Arabian Nights
entertainment.

   –William Osler

   The physician is concerned [unlike the naturalist] . . . with a single organism, the human subject, striving to preserve its identity in adverse circumstances.

   –Ivy McKenzie

   
PART ONE

   
LOSSES

   Introduction

   Neurology's favourite word is 'deficit', denoting an impairment or incapacity of neurological function: loss of speech, loss of language, loss of memory, loss of vision, loss of dexterity, loss of identity and myriad other lacks and losses of specific functions (or faculties). For all of these dysfunctions (another favourite term), we have privative words of every sort-Aphonia, Aphemia, Aphasia, Alexia, Apraxia, Agnosia, Amnesia, Ataxia-a word for every specific neural or mental function of which patients, through disease, or injury, or failure to develop, may find themselves partly or wholly deprived.

   The scientific study of the relationship between brain and mind began in 1861, when Broca, in France, found that specific difficulties in the expressive use of speech, aphasia, consistently followed damage to a particular portion of the left hemisphere of the brain. This opened the way to a cerebral neurology, which made it possible, over the decades, to 'map' the human brain, ascribing specific powers-linguistic, intellectual, perceptual, etc.-to equally specific 'centres' in the brain. Toward the end of the century it became evident to more acute observers-above all to Freud, in his book
Aphasia
-that this sort of mapping was too simple, that all mental performances had an intricate internal structure, and must have an equally complex physiological basis. Freud felt this, especially, in regard to certain disorders of recognition and perception, for which he coined the term 'agnosia'. All adequate understanding of aphasia or agnosia would, he believed, require a new, more sophisticated science.