The Man Who Mistook His Wife for a Hat

Sacks recounts his experience meeting with a music teacher named Dr. P. Although Dr. P. was a brilliant musician, he could not recognize the faces of his students, his family, or even himself in photographs. Sacks meets with Dr. P. and observes the way he perceives or fails to perceive multiple objects. When Sacks asks Dr. P. to put on his shoe, Dr. P. looks at his foot and thinks it is his shoe; when he sees his shoe, he thinks it is his foot. Dr. P. can describe a rose in abstract terms but can’t recognize what it is until he smells it. When asked to describe entering a town square, he remembers only the buildings on his left, not those on his right.

At Dr. P.’s home, Sacks notices paintings Dr. P. had created over the course of his life. At first, the paintings are clear and detailed, but as they progress, his paintings become more and more abstract until the shapes are no longer recognizable. Dr. P. sees things abstractly but cannot recognize how visual stimuli fit together and what it means. He recognizes individual parts of faces and cartoon faces, but he cannot recognize or remember faces from TV, nor can he interpret emotional expressions. However, the recognition of movement, the unique aspects of gait and posture of a person, present no problem. He cannot see a student who is sitting still, but he can recognize them once they start moving. Sacks calls this “body music.” Dr. P.’s wife explains that Dr. P. functions in the world—getting dressed, bathing, etc.—by singing songs that help him maintain the rhythm of basic performance. If he stops singing, he seems lost.

Although his behavior is unusual, Dr. P. does not seem troubled by his conduct or recognize it as odd. He does not even know that he has a problem. At the beginning of the chapter, he tells Sacks that “other people” have said he has a problem with his eyes, but as Sacks notes, the problem is not with his eyes, but with his brain. While Dr. P. can take in visual information, he cannot process it correctly. He cannot see how visual data fit together to form a whole picture.

At the end of the chapter, Sacks encourages Dr. P. to rely on music to help him with his visual agnosia. He never sees the man again but hears that Dr. P. was able to continue teaching until the end of his life.

Postscript

Sacks relates a similar case—“The Defect of Function in Visual Agnosia”—recorded by Donald Macrae and Elli Trolle in the 1956 edition of Brain. The subject was injured in a car accident and developed “face blindness” shortly after. Unlike Dr. P., this man fought to regain his faculties. The author also directs readers to Dr. Andrew Kertesz’s 1979 research “Visual Agnosia: The Dual Deficit of Perception and Recognition” to learn more about visual agnosia.

Sacks tells the story of his 79-year-old patient Jimmie G., who believed that he was 19 years old and that it was still 1945. When Sacks shows him a mirror, Jimmie is deeply confused and agitated. He quickly forgets his distress when the mirror is removed. Sacks realizes that although Jimmie is otherwise bright and intelligent, he is incapable of creating new memories. The man’s backstory further perplexes Sacks. Jimmie grew up in Connecticut and entered the Navy when he was 19. He continued serving until 1965, and reports suggest he had no neurological problems until the end of his service when he began drinking heavily. Nobody can explain when exactly Jimmie lost his ability to create new memories, or why his memories don’t extend beyond 1945.

This is a case of Korsakoff’s syndrome (spelled Korsakov’s in the text), an amnesic (memory) disorder that typically results from alcohol use and a subsequent vitamin B1 deficiency. A. R. Luria reports a similar case of a man named Zazetsky who lost his ability to make memories, but Zazetsky knew there was something wrong and continued to fight to regain his lost capabilities. Jimmie G., by contrast, is not aware of his condition unless confronted by Sacks or others. Even then, he exhibits only a brief recognition that quickly passes. When Jimmie’s brother visits, Jimmie does not recognize him. He has trouble believing that the old man in front of him could be his sibling, who he also believes should still be a young man.

Sacks wonders whether a person can be complete without their memories. Jimmie lives a fragmented life and does not form new connections. Sacks asks the nuns at Jimmie’s home if they believe he has a “soul,” and they tell Sacks to observe him in the chapel. Sacks witnesses Jimmie displaying deep concentration in prayer. He never solves the mystery of Jimmie’s retrograde amnesia, but he helps him gain a greater emotional awareness and engagement with the world—his “soul,” as Sacks terms it—by engaging in the arts, gardening, and prayer.

Postscript

Sacks later learns of another patient who had Korsakoff’s. Stephen R.’s condition took effect in 1980, and he was unable to make new memories after 1978. This man was fine in his own home, where he recognized everything around him. However, Stephen R. would become confused when he went outside and saw new buildings or when he saw friends who had aged. The man’s wife eventually brought him to a psychiatric hospital, where he lived out his life in terror and confusion. Sacks considers how those with Korsakoff’s experience some degree of retrograde amnesia, although the results can vary greatly. In learning about Stephen R.’s “agony,” Sacks raises the question of what society can do for people experiencing this syndrome.

Christina is an athletic, intelligent 27-year-old woman who enjoys horseback riding and playing sports. She needs routine surgery for gallstones. After taking antibiotics, she has a bad dream about being unable to feel her body. When she wakes up, the dream comes true; she develops severe sensory polyneuropathies that result in an interruption of Christina’s “proprioception,” or the body’s general awareness of itself via movement, action, and location. Essentially, Christina becomes “disembodied” from herself.

Proprioception, or kinesthesia, allows a person to reach for a glass of water and find it easily. Such movements require that the body’s proprioception works in tandem with two other systems—vision and the vestibular system (the balance organs). If one of the three fails, the others might compensate. Christina realizes that she will need to compensate for her body’s inability to sense the self by relying on her other senses. She will need to use her eyes and ears to manage her movements in the world because her body no longer understands how.

Three months after Christina met with Sacks, she is better adjusted to her condition. She can sit up straight, speak, walk, and live a relatively normal life. Her movements look affected and unusual, and she speaks as though on stage. (The ability to speak also depends on proprioception.) Unlike with other disabilities, people may not recognize that Christina experiences nerve damage that makes movement and speech difficult for her.

Postscript

Sacks learns later that many people have lost proprioception after taking pyridoxine (B6), usually as part of a weight loss program. They eventually regain their faculties when they stop taking the supplements.

A man goes to a clinic because he believes his leg is fake. At the clinic, he falls out of bed in the middle of the night and simultaneously appears agitated, amused, and confused. The man is certain that the leg in his bed is actually someone else’s severed leg. He surmises that because it is New Year’s Eve, the nurses must have gotten drunk, gone to the morgue to get a corpse’s leg, and then left it in his bed as a prank. He attempts to push his own leg off the bed and follows it to the floor. Even once he is fully awake and looking at himself in the light, he cannot tell that the leg is his, nor can he say where his real leg might have gone. Sacks asks the man where his own, true leg is, and the man can’t tell him.

Postscript

After the publication of this story, Sacks receives a letter from eminent neurologist Dr. Michael Kremer. Kremer shares his story of a patient who experienced the same loss of awareness as Sacks’s patient. Both patients exhibit hemiplegic limbs, or one-sided paralysis. 

Sacks recounts the story of Madeline J., a 60-year-old congenitally blind woman with cerebral palsy. Her family cared for her throughout her life, and Sacks finds her to be very intelligent, literate, and knowledgeable. He believes that she reads using braille, but she tells him others read to her. She cannot read braille because she cannot use her hands.

Sacks wonders if this is, in fact, the case: Does Miss J. have nonfunctional hands, or has she a kind of “learned agnosia” because she never had opportunities to use her hands? He instructs the nurses to leave Miss J.’s food just out of reach so that she will be forced to reach for her meals. This works almost immediately, and Miss J. is able to grasp a bagel. After training, Miss J. begins sculpting and takes great joy in this independent creative activity.

Postscript

Sacks tells a similar story of Simon K., who has cerebral palsy and a vision condition As a result, Simon rarely used his hands, even though they are strong and capable. Once Sacks teaches Simon how to use his hands, Simon is able to do carpentry and make simple toys.

Sacks discusses phantom limbs. One of the preeminent researchers in the field is American neurologist Silas Weir Mitchell, who studied soldiers who lost limbs during the Civil War. Weir Mitchell documented what he called these “sensory ghosts,” observing that the experience of having a phantom limb can be either painless or painful.

Sacks recounts the story of a sailor who accidentally cut off his finger. The soldier still felt the finger for 40 years and worried that it would poke him in the eye when he went to scratch his nose. Then, he mysteriously lost the phantom finger and all sense of his real fingers at the same time.

Sacks references Dr. Michael Kremer, writing that a phantom limb is critical to the person gaining control over a prosthetic limb. One patient recounts how he must “wake up” his phantom limb in the morning before he puts on his prosthetic. He does this by slapping the stump of his leg when he wakes up until he can feel his phantom again, after which the mental memory of the phantom is incorporated into the artificial one, thereby making it a part of his body.

Sacks recounts how he once experienced a loss of proprioception in his own legs, which he documented in his 1984 autobiographical essay, A Leg to Stand On. Although he had use of his legs, he couldn’t feel them. Sacks felt like he was at sea, unable to stand up straight unless he looked down at his limbs. Sacks questions whether the phantoms people feel are “real” or imaginary. He says that what science may not be able to tell, a patient describing their lived experience can clarify. These patients seem very certain of what they feel despite what may or may not be there.

Postscript

Many patients experience phantom pain, which is the persistence of the pain that the person originally felt in the limb. Sometimes, it refers to a pain that arises after amputation. One patient complained of a pain due to an ingrown toenail they had before amputation. Sacks maintains that the pain is real and not “imaginary.”

Nine years ago, Sacks met Mr. MacGregor, who was told he walked at a tilt. When Sacks asks him to walk across the room, MacGregor starts out straight but quickly begins tilting, although he doesn’t sense this tilt. Sacks films the man and when confronted with evidence, Mr. MacGregor starts to understand his problem. Sacks explains that a part of the inner ear helps people keep their balance. Mr. MacGregor was a carpenter in his younger years and used a level to keep things straight when building. He compares his problem to not having a “level” in his inner ear.

When Sacks invites him to walk while looking into a mirror, Mr. MacGregor can keep his balance. Sacks recalls Chapter 3 and reminds the reader about the three mechanisms that help a person to walk: proprioception, organs of balance (the vestibular system), and vision. Mr. Macgregor can rely on sight to compensate for his inner ear deficit when looking in a mirror, but they agree he can’t look at a mirror all the time.

On his own, Mr. MacGregor comes up with an idea to create a level that he can use when walking. He attaches the level to the inside of his glasses. The innovation proves so helpful that several other patients at the clinic have them made for themselves.

Sacks recounts the story of Mrs. S., who had a stroke and lost all concept of the left side of the world. Mrs. S. was a bright woman, but after her stroke, she could see nothing in the left hemisphere of her perceptions. If someone brought her food, she could only see and eat from the right side of the plate. When she put on make-up, she only put it on half of her face. She knew something was wrong, but she still could not see what she didn’t see. To compensate for this, she would turn right in a full circle to get to the left side of anything. If she wanted to eat a full meal, she would eat from the right side. Then, she would rotate herself around until the remainder of the plate is visible.

Sacks experiments by showing Mrs. S. a video of herself, using the video stream as a mirror. Mrs. S. is shocked to see the left side of herself again. Although she can now see her left side, she still can’t feel it. This disturbs her, and she asks to have the video removed. Sacks notes that this video could possibly help others who experience the same problem, if they got used to it.

Postscrit

Sacks notes that a more thorough book on this subject, Principles of Behavioral Neurology (1985), edited by M. Marsel Mesulam, was released at almost the same time as this book. He could not reference that book in his writing but directs the reader to it now. Mesulam explains the concept of “neglect,” in which patients like Mrs. S. act like their left hemisphere does not exist or is of no consequence.

Sacks recounts an incident when he heard patients in the aphasia ward laughing at the president’s speech. The unnamed actor-turned-politician is clearly Ronald Reagan. Aphasia is a disorder in which a person is unable to understand or express speech. This disorder results from damage to the left hemisphere of the brain. People with aphasia do not understand words, but they are strongly sensitive to tone and body language. Their interpretive skills grow until often their friends and relatives don’t know that they have a condition. Clinicians can only test for aphasia when they use a toneless, mechanical voice, like a computer. Only without these contextual clues can clinicians confirm that those with aphasia can’t understand their words alone. Those with aphasia are sometimes compared to dogs because dogs can “read” body language without intellectually understanding words.

Henry Head in his 1926 treatise on aphasia, Aphasia and Kindred Disorders of Speech, maintains that it is hard to fool or deceive a person with aphasia because they can pick up on subtle clues and detect when a person is being dishonest. The aphasia patients were laughing at the president’s speech because they could hear the false tones in his voice. The patients perceived the tones with a heightened ability, which made the subtle phoniness utterly “grotesque” to them.

Conversely, some patients experience tonal agnosia, which affects the right hemisphere of the brain. People with tonal agnosia understand words but miss tone of voice or emotional cues. One such woman, Emily D. was in the ward. Emily was a former English teacher and somewhat of a poet. In regard to the speech, she says that the president’s grammar is bad and suggests that he is either impaired or hiding something from the audience. Unlike the aphasia patients, Emily is laughing at the president’s words, not his tonal cues.

Sacks concludes with a paradox. He remarks that “normals” have a willingness to be deceived and wouldn’t make the same observations as Emily and the other patients. The latter have lost their ability to be deceived by “cunning” words and tones due to their conditions.