The man who mistook his wife for a hat (2 page)

   The new science of brain/mind which Freud envisaged came into being in the Second World War, in Russia, as the joint creation of A. R. Luria (and his father, R. A. Luria), Leontev, Anokhin, Bernstein and others, and was called by them 'neuropsychology.' The development of this immensely fruitful science was the lifework of A. R. Luria, and considering its revolutionary importance it was somewhat slow in reaching the West. It was set out, systematically, in a monumental book,
Higher Cortical Functions in Man
(Eng. tr. 1966) and, in a wholly different way, in a biography or 'pathography'-
The Man with a Shattered World
(Eng. tr. 1972). Although these books were almost perfect in their way, there was a whole realm which Luria had not touched.
Higher Cortical Functions in Man
treated only those functions which appertained to the left hemisphere of the brain; similarly, Zazetsky, subject
of The Man with a Shattered World,
had a huge lesion in the left hemisphere-the right was intact. Indeed, the entire history of neurology and neuropsychology can be seen as a history of the investigation of the left hemisphere.

   One important reason for the neglect of the right, or 'minor', hemisphere, as it has always been called, is that while it is easy to demonstrate the effects of variously located lesions on the left side, the corresponding syndromes of the right hemisphere are much less distinct. It was presumed, usually contemptuously, to be more 'primitive' than the left, the latter being seen as the unique flower of human evolution. And in a sense this is correct: the left hemisphere is more sophisticated and specialised, a very late outgrowth of the primate, and especially the hominid, brain. On the other hand, it is the right hemisphere which controls the crucial powers of recognising reality which every living creature must have in order to survive. The left hemisphere, like a computer tacked onto the basic creatural brain, is designed for programs and schematics; and classical neurology was more concerned with schematics than with reality, so that when, at last, some of the right-hemisphere syndromes emerged, they were considered bizarre.

   There had been attempts in the past-for example, by Anton in the 1890s and Potzl in 1928-to explore right-hemisphere syndromes, but these attempts themselves had been bizarrely ignored.

   In
The Working Brain,
one of his last books, Luria devoted a short but tantalising section to right-hemisphere syndromes, ending:

   These still completely unstudied defects lead us to one of the most fundamental problems-to the role of the right hemisphere in direct consciousness. . . . The study of this highly important field has been so far neglected. … It will receive a detailed analysis in a special series of papers … in preparation for publication.

   Luria did, finally, write some of these papers, in the last months of his life, when mortally ill. He never saw their publication, nor were they published in Russia. He sent them to R. L. Gregory in England, and they will appear in Gregory's forthcoming
Oxford Companion to the Mind.

   Inner difficulties and outer difficulties match each other here. It is not only difficult, it is impossible, for patients with certain right-hemisphere syndromes to know their own problems-a peculiar and specific 'anosagnosia', as Babinski called it. And it is singularly difficult, for even the most sensitive observer, to picture the inner state, the 'situation', of such patients, for this is almost unimaginably remote from anything he himself has ever known. Left-hemisphere syndromes, by contrast, are relatively easily imagined. Although right-hemisphere syndromes are as common as left-hemisphere syndromes-why should they not be?-we will find a thousand descriptions of left-hemisphere syndromes in the neurological and neuropsychological literature for every description of a right-hemisphere syndrome. It is as if such syndromes were somehow alien to the whole temper of neurology. And yet, as Luria says, they are of the most fundamental importance. So much so that they may demand a new sort of neurology, a 'per-sonalistic', or (as Luria liked to call it) a 'romantic', science; for the physical foundations of the
persona,
the self, are here revealed for our study. Luria thought a science of this kind would be best introduced by a story-a detailed case-history of a man with a profound right-hemisphere disturbance, a case-history which would at once be the complement and opposite of 'the man with a shattered world.' In one of his last letters to me he wrote: 'Publish

   such histories, even if they are just sketches. It is a realm of great wonder.' I must confess to being especially intrigued by these disorders, for they open realms, or promise realms, scarcely imagined before, pointing to an open and more spacious neurology and psychology, excitingly different from the rather rigid and mechanical neurology of the past.

   It is, then, less deficits, in the traditional sense, which have engaged my interest than neurological disorders affecting the self. Such disorders may be of many kinds-and may arise from excesses, no less than impairments, of function-and it seems reasonable to consider these two categories separately. But it must be said from the outset that a disease is never a mere loss or excess- that there is always a reaction, on the part of the affected organism or individual, to restore, to replace, to compensate for and to preserve its identity, however strange the means may be: and to study or influence these means, no less than the primary insult to the nervous system, is an essential part of our role as physicians. This was powerfully stated by Ivy McKenzie:

   For what is it that constitutes a 'disease entity' or a 'new disease'? The physician is concerned not, like the naturalist, with a wide range of different organisms theoretically adapted in an average way to an average environment, but with a single organism, the human subject, striving to preserve its identity in adverse circumstances.

   This dynamic, this 'striving to preserve identity', however strange the means or effects of such striving, was recognised in psychiatry long ago-and, like so much else, is especially associated with the work of Freud. Thus, the delusions of paranoia were seen by him not as primary but as attempts (however misguided) at restitution, at reconstructing a world reduced by complete chaos. In precisely the same way, Ivy McKenzie wrote:

   The pathological physiology of the Parkinsonian syndrome is the study of
an organised chaos,
a chaos induced in the first instance by destruction of important integrations, and reorganised on an unstable basis in the process of rehabilitation.

   As
Awakenings
was the study of 'an organised chaos' produced by a single if multiform disease, so what now follows is a series of similar studies of the organised chaoses produced by a great variety of diseases.

   In this first section, 'Losses', the most important case, to my mind, is that of a special form of visual agnosia: 'The Man Who Mistook His Wife for a Hat'. I believe it to be of fundamental importance. Such cases constitute a radical challenge to one of the most entrenched axioms or assumptions of classical neurology-in particular, the notion that brain damage,
any
brain damage, reduces or removes the 'abstract and categorical attitude' (in Kurt Goldstein's term), reducing the individual to the emotional and concrete. (A very similar thesis was made by Hughlings Jackson in the 1860s.) Here, in the case of Dr P., we see the very
opposite
of this-a man who has (albeit only in the sphere of the visual) wholly lost the emotional, the concrete, the personal, the 'real' . . . and been reduced, as it were, to the abstract and the categorical, with consequences of a particularly preposterous kind. What would Hughlings Jackson and Goldstein have said of
this?
I have often in imagination, asked them to examine Dr P., and then said, 'Gentlemen! What do you say
now?'

   
1

   The Man Who Mistook His Wife for a Hat

   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 strange 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, coordination, 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 difficulty 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 or 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 nonexistent 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.