The Man Who Mistook His Wife for a Hat (Oliver Sacks, Summary)

    
'The Man Who Mistook His Wife for a Hat and Other Clinical Tales' is a 1985 book by neurologist Oliver Sacks describing the case histories of some of his patients. Sacks chose the title of the book from the case study of one of his patients who has visual agnosia, a neurological condition that leaves him unable to recognize faces and objects.

The book comprises twenty-four essays split into four sections ("Losses", "Excesses", "Transports", and "The World of the Simple"), each dealing with a particular aspect of brain function. The first two sections discuss deficits and excesses (with particular emphasis on the right hemisphere of the brain), while the third and fourth sections describe phenomenological manifestations with reference to spontaneous reminiscences, altered perceptions, and extraordinary qualities of mind found in people with intellectual disabilities.

Book Information:
Subject : Neurology, psychology
Genre   : Case history
Publication date : 1985

PART 1: Losses

1 % 
"The Man Who Mistook His Wife for a Hat", about Dr. P, who has visual agnosia; however, before that diagnosis is reached, Dr. P consults an ophthalmologist when he develops diabetes, thinking that it might affect his vision. The ophthalmologist tells him that he does not have diabetes and instead refers him to Dr. Sacks (the author), to whom Dr. P describes his symptoms of visual agnosia.

Dr. P was supported by his wife and he had a special talent with respect to music. He was able to listen to the sounds and remember them, then use them in situations such as to identify the person in the room from noise he or she makes. The chapter ends with lines: "And this, mercifully, held to the end—for despite the gradual advance of his disease (a massive tumor or degenerative process in the visual parts of his brain) Dr P. lived and taught music to the last days of his life."

2 % 
"The Lost Mariner", about Jimmie G., who has anterograde amnesia (the loss of the ability to form new memories) due to Korsakoff's syndrome. He can remember nothing of his life since the end of World War II, including events that happened only a few minutes ago. He believes it is still 1945 (the segment covers his life in the 1970s and early 1980s), and seems to behave as a normal, intelligent young man aside from his inability to remember most of his past and the events of his day-to-day life. He struggles to find meaning, satisfaction, and happiness in the midst of constantly forgetting what he is doing from one moment to the next.

The postscript of this chapter has two lines that describe how Jimmie might have spent rest of his life: Such patients, fossilized in the past, can only be at home, oriented, in the past. Time, for them, has come to a stop. 

3 % 

"The Disembodied Lady", a unique case of a woman losing her entire sense of proprioception (the sense of the position of parts of the body, relative to other neighbouring parts of the body) due to vitamin b6 toxicity.

The woman named Christina in the book learns to live life alongside a body that is 'blind and deaf to itself' by coordinating her movements through careful observation through her eyes, her vision.

4 % 

"The Man Who Fell out of Bed", about a young man whom Dr. Sacks sees as a medical student. Sacks encounters the patient on the floor of his hospital room, where he tells Sacks that he woke up to find an alien leg in his bed. Assuming that one of the nurses had played a prank on him, he attempted to toss the leg out of bed, only to find that he was attached to it. Although Sacks attempts to persuade the patient that the leg is his own, he remains bewildered in an apparent case of somatoparaphrenia.

5 % Hands 

This chapter is about Madeleine J. who was admitted to St. Benedict’s Hospital near New York City in 1980, her sixtieth year, a congenitally blind woman with cerebral palsy, who had been looked after by her family at home throughout her life.

The patient had not used her hands the entire life and this rendered the patient in a situation where she compared her hands with 'lumps of dough'.

To fix her condition, the doctors tempt her into making movement to get her own food as stated in these lines:

‘Leave Madeleine her food, as if by accident, slightly out of reach on occasion,’ I suggested to her nurses. ‘Don’t starve her, don’t tease her, but show less than your usual alacrity in feeding her.’ And one day it happened— what had never happened before: impatient, hungry, instead of waiting passively and patiently, she reached out an arm, groped, found a bagel, and took it to her mouth. This was the first use of her hands, her first manual act, in sixty years, and it marked her birth as a ‘motor individual’ (Sherrington’s term for the person who emerges through acts). It also marked her first manual perception, and thus her birth as a complete ‘perceptual individual’. Her first perception, her first recognition, was of a bagel, or ‘bagelhood’—as Helen Keller’s first recognition, first utterance, was of water (‘waterhood’). 

6 % Phantoms 

A ‘phantom’, in the sense that neurologists use, is a persistent image or memory of part of the body, usually a limb, for months or years after its loss.

Regarding a 'phantom' Dr Michael Kremer writes: ‘Its value to the amputee is enormous. I am quite certain that no amputee with an artificial lower limb can walk on it satisfactorily until the body-image, in other words the phantom, is incorporated into it.’

7 % 

"On the Level", another case involving damaged proprioception. Dr. Sacks interviews a patient who has trouble walking upright and discovers that he has lost his innate sense of balance due to Parkinson's-like symptoms that have damaged his inner ears; the patient, comparing his sense of balance to a carpenter's spirit level, suggested constructing a similar level inside a pair of glasses. This enables him to judge his balance by sight and after a few weeks, the task of keeping his eye on the level became less tiring.

Opening lines from the chapter read like this:

‘What’s the problem?’ I asked, as Mr MacGregor tilted in.

'Problem? No problem—none that I know of... But others keep telling me I lean to the side: "You’re like the Leaning Tower of Pisa," they say. "A bit more tilt, and you’ll topple right over."'

‘But you don’t feel any tilt?’

‘I feel fine. I don’t know what they mean. How could I be tilted without knowing I was?’ 

To help himself from tilting, Mr MacGregor (through consultation with Dr Sacks) develops an engineered frame of glasses that tell him of any tilt in his body through respective tilt in a part of the engineered spectacles that he can moniter through vision.

8 % 

"Eyes Right" is about a woman in her sixties who has hemispatial neglect. She completely forgets the idea of "left" relative to her own body and the world around her. When nurses place food or drink on her left side, she fails to recognize that they are there. Dr. Sacks attempts to show the patient the left side of her body using a video screen setup; when the patient sees the left side of her body, on her right, she is overwhelmed with anxiety and asked for it to stop.

This chapter about Mrs S. who is unable to see anything on the left. Her disorder is named as 'hemi-inattention'.
"She has totally lost the idea of ‘left’, with regard to both the world and her own body.": a line in opening paragraph reads.

Through consultation with Dr Sacks she is able to manage her life as shown by the lines below:

Knowing it intellectually, knowing it inferentially, she has worked out strategies for dealing with her imperception. She cannot look left, directly, she cannot turn left, so what she does is to turn right—and right through a circle. Thus she requested, and was given, a rotating wheelchair. And now if she cannot find something which she knows should be there, she swivels to the right, through a circle, until it comes into view. 

9 % 

"The President's Speech" is about a ward of aphasiacs and agnosiacs listening to a speech given by an unnamed actor-president, "the old charmer", presumably Ronald Reagan. Many in the first group laughed at the speech, despite their inability to follow the words, and Sacks claims their laughter to be at the president's facial expressions and tone, which they find "not genuine". One woman in the latter group criticizes the structure of the president's sentences, stating that he "does not speak good prose".

This is important chapter that shows how easy it is to deceive the general public through careful manipulation of words, expressions and body language, but there are people with certain diabilities who only hear tone and see the expressions and cannot be fooled by the manipulation of words. A quote from this chapter: "Populus vult decipi, ergo decipiatur".

PART 2: Excesses

10 % Witty Ticcy Ray 

In the chapter title, Ray is the name of the patient.
This chapter is about the Tourette's Syndrome. It starts with the lines that also says so:

In 1885 Gilles de la Tourette, a pupil of Charcot, described the astonishing syndrome which now bears his name. Tourette’s syndrome’, as it was immediately dubbed, is characterized by an excess of nervous energy, and a great production and extravagance of strange motions and notions: tics, jerks, mannerisms, grimaces, noises, curses, involuntary imitations and compulsions of all sorts, with an odd elfin humor and a tendency to antic and outlandish kinds of play. 

The chapter has references to a chemical called L-DOPA, so here is a note about it: Does L dopa increase dopamine?
L-DOPA is a precursor to dopamine that passes the blood-brain barrier and is mainly taken up by the dopaminergic neurons that convert L-DOPA to dopamine and increase their dopamine production and storage.

Ref: sciencedirect

Another important note from the chapter:
As lethargic Parkinsonian patients need more dopamine to arouse them, as my post-encephalitic patients were ‘awakened’ by the dopamineprecursor L-Dopa, so frenetic and Tourettic patients must have had their dopamine lowered by a dopamine antagonist, such as the drug haloperidol (Haldol). 

On the other hand, there is not just a surfeit of dopamine in the Touretter’s brain, as there is not just a deficiency of it in the Parkinsonian brain. There are also much subtler and more widespread changes, as one would expect in a disorder which may alter personality: there are countless subtle paths of abnormality which differ from patient to patient, and from day to day in any one patient. Haldol can be an answer to Tourette’s, but neither it nor any other drug can be the answer, any more than L-Dopa is the answer to Parkinsonism.

A note from Wikipedia - Dopamine Antagonist:
A dopamine antagonist, also known as an anti-dopaminergic and a dopamine receptor antagonist (DRA), is a type of drug which blocks dopamine receptors by receptor antagonism. Most antipsychotics are dopamine antagonists, and as such they have found use in treating schizophrenia, bipolar disorder, and stimulant psychosis. Several other dopamine antagonists are antiemetics used in the treatment of nausea and vomiting. 

11 % Cupid’s Disease 

Note 1: Syphilis is a bacterial infection usually spread by sexual contact. The disease starts as a painless sore — typically on your genitals, rectum or mouth. Syphilis spreads from person to person via skin or mucous membrane contact with these sores.

Note 2: Neurosyphilis is a bacterial infection of the brain or spinal cord. It usually occurs in people who have had untreated syphilis for many years.

A note from the postscript:

Excited elaboration: The drawings of patients with Parkinsonism, as they are ‘awakened’ by L-Dopa, form an instructive analogy. Asked to draw a tree, the Parkinsonian tends to draw a small, meager thing, stunted, impoverished, a bare winter-tree with no foliage at all. As he ‘warms up’, ‘comes to’, is animated by L-Dopa, so the tree acquires vigor, life, imagination—and foliage. 

12 % A Matter of Identity 

This chapter talks about William Thompson. 

A paragraph in the book indicates what he might be suffering from:

Mr Thompson, only just out of hospital — his Korsakov’s had exploded just three weeks before, when he developed a high fever, raved, and ceased to recognize all his family — was still on the boil, was still in an almost frenzied confabulatory delirium (of the sort sometimes called ‘Korsakov’s psychosis’, though it is not really a psychosis at all), continually creating a world and self, to replace what was continually being forgotten and lost. 

This chapter has references to Jimmie G, who was our character in Chaper 2, with anterograde amnesia.

13 % Yes, Father-Sister 

The chapter is about a patient with: Witzelsucht

You can see in the chapter title that she is refering to a person with the words "Father-Sister".

Note from Wikipedia:
Witzelsucht (German: "joking addiction") is a set of pure and rare neurological symptoms characterized by a tendency to make puns, or tell inappropriate jokes or pointless stories in socially inappropriate situations. It makes one unable to read sarcasm. A less common symptom is hypersexuality, the tendency to make sexual comments at inappropriate times or situations. Patients do not understand that their behavior is abnormal, therefore they are nonresponsive to others' reactions. This disorder is most commonly seen in patients with frontal lobe damage, particularly right frontal lobe tumors or trauma. The disorder remains named in accordance with its reviewed definition by German neurologist Hermann Oppenheim, its first description as the less focused moria (pathologic giddiness or lunatic mood) by German neurologist Moritz Jastrowitz, was in 1888. 

Few lines from the chapter postscript:

The sort of facetious indifference and ‘equalization’ shown by this patient is not uncommon—German neurologists call it Witzelsucht (‘joking disease’), and it was recognized as a fundamental form of nervous ‘dissolution’ by Hughlings Jackson a century ago. 

14 % The Possessed 

This chapter talks about a woman whom Oliver Sacks suggests is having 'Super Touretter's Syndrome'.

PART 3: Transports 

In the first half of this book we described cases of the obviously pathological—situations in which there is some blatant neurological excess or deficit. Sooner or later it is obvious to such patients, or their relatives, no less than to their doctors, that there is ‘something (physically) the matter’. Their inner worlds, their dispositions, may indeed be altered, transformed; but, as becomes clear, this is due to some gross (and almost quantitative) change in neural function. 

In this third section, the presenting feature is reminiscence, altered perception, imagination, ‘dream’. Such matters do not often come to neurological or medical notice. Such ‘transports’—often of poignant intensity, and shot through with personal feeling and meaning—tend to be seen, like dreams, as psychical: as a manifestation, perhaps, of unconscious or preconscious activity (or, in the mystically-minded, of something ‘spiritual’), not as something ‘medical’, let alone ‘neurological’. They have an intrinsic dramatic, or narrative, or personal ‘sense’, and so are not apt to be seen as ‘symptoms’. It may be in the nature of transports that they are more likely to be confided to psychoanalysts or confessors, to be seen as psychoses, or to be broadcast as religious revelations, rather than brought to physicians.

15 % Reminiscence 

This chapter is about two women named as 'Mrs O’C' and 'Mrs O’M'.

Few lines from chapter seem to indicate what Mrs O’C might be suffering from:

‘Musical epilepsy’ sounds like a contradiction in terms: for music, normally, is full of feeling and meaning, and corresponds to something deep in ourselves, ‘the world behind the music’, in Thomas Mann’s phrase — whereas epilepsy suggests quite the reverse: a crude, random physiological event, wholly unselective, without feeling or meaning. Thus a ‘musical epilepsy’ or a ‘personal epilepsy’ would seem a contradiction in terms. And yet such epilepsies do occur, though solely in the context of temporal lobe seizures, epilepsies of the reminiscent part of the brain. Hughlings Jackson described these a century ago, and spoke in this context of ‘dreamy states’, ‘reminiscence’, and ‘physical seizures’:

It is not very uncommon for epileptics to have vague and yet exceedingly elaborate mental states at the onset of epileptic seizures... 

The elaborate mental state, or so-called intellectual aura, is always the same, or essentially the same, in each case. 

Note from epilepsysociety.org:

Musicogenic epilepsy is a rare form of complex reflex epilepsy with seizures induced by listening to music, although playing, thinking or dreaming of music have all been noted as triggers. Music may be provoked by different musical stimulus in different people. 

16 % Incontinent Nostalgia 

This chapter talks about "forced reminiscence induced by L-Dopa".

17 % A Passage to India 

This chapter talks about an Indian girl of 19 with malignant brain tumor who also developed 'grand mal convulsions'.

A grand mal seizure causes a loss of consciousness and violent muscle contractions. It's the type of seizure most people picture when they think about seizures. A grand mal seizure — also known as a generalized tonic-clonic seizure — is caused by abnormal electrical activity throughout the brain. [ Ref ]

18 % The Dog Beneath the Skin 

"The Dog Beneath the Skin", concerning a 22-year-old medical student, "Stephen D.", who, after a night under the influence of amphetamines, cocaine, and PCP, wakes to find he has a tremendously heightened sense of smell. Sacks would reveal many years later that he, in fact, was Stephen D.

19 % Murder 

The chapter starts straight on with the patient and the problem:

Donald killed his girl while under the influence of PCP. He had, or seemed to have, no memory of the deed—and neither hypnosis nor sodium amytal served to release any. There was, therefore, it was concluded when he stood trial, not a repression of memory, but an organic amnesia—the sort of blackout well described with PCP. 

Later in the chapter, we see that after an accident and brain injury, he seems to have a recollections of the murder event.

The chapter ends on a positive note with the lines:

But the final, the most important, thing is this: that Donald has now returned to gardening. ‘I feel at peace gardening,’ he says to me. ‘No conflicts arise. Plants don’t have egos. They can’t hurt your feelings.’ The final therapy, as Freud said, is work and love. Donald has not forgotten, or re-repressed, anything of the murder— if, indeed, repression was operative in the first place—but he is no longer obsessed by it: a physiological and moral balance has been struck.

But what of the status of the first lost, then recovered, memory? Why the amnesia—and the explosive return? Why the total blackout and then the lurid flashbacks? What actually happened in this strange, half-neurological drama? All these questions remain a mystery to this day. 

20 % The Visions of Hildegard 

Varieties of migraine hallucination are represented in the chapter "Visions of Hildegard". The hallucinations take the form of paintings and art. The chapter also takes us through interpretations of those paintings.

PART 4: The World of the Simple

21 % Rebecca 

The chapter talks about a retardate patient named Rebecca.

We are going to take you through the postscript of this chapter that shines some light on how to take care of people like Rebecca.

The power of music, narrative and drama is of the greatest practical and theoretical importance. One may see this even in the case of idiots, with IQs below 20 and the extremest motor incompetence and bewilderment. Their uncouth movements may disappear in a moment with music and dancing—suddenly, with music, they know how to move. We see how the retarded, unable to perform fairly simple tasks involving perhaps four or five movements or procedures in sequence, can do these perfectly if they work to music—the sequence of movements they cannot hold as schemes being perfectly holdable as music, i.e. embedded in music. The same may be seen, very dramatically, in patients with severe frontal lobe damage and apraxia— an inability to do things, to retain the simplest motor sequences and programmes, even to walk, despite perfectly preserved intelligence in all other ways. This procedural defect, or motor idiocy, as one might call it, which completely defeats any ordinary system of rehabilitative instruction, vanishes at once if music is the instructor. All this, no doubt, is the rationale, or one of the rationales, of work songs. 

What we see, fundamentally, is the power of music to organize— and to do this efficaciously (as well as joyfully!), when abstract or schematic forms of organization fail. Indeed, it is especially dramatic, as one would expect, precisely when no other form of organization will work. Thus music, or any other form of narrative, is essential when working with the retarded or apraxic—schooling or therapy for them must be centered on music or something equivalent. And in drama there is still more—there is the power of role to give organization, to confer, while it lasts, an entire personality. The capacity to perform, to play, to be, seems to be a ‘given’ in human life, in a way which has nothing to do with intellectual differences. One sees this with infants, one sees it with the senile, and one sees it, most poignantly, with the Rebeccas of this world. 

22 % A Walking Grove 

Martin A., aged 61, was admitted to our Home towards the end of 1983, having become Parkinsonian and unable to look after himself any longer. He had had a nearly fatal meningitis in infancy, which caused retardation, impulsiveness, seizures, and some spasticity on one side. He had very limited schooling, but a remarkable musical education—his father was a famous singer at the Met.

He lived with his parents until their death, and thereafter eked out a marginal living as a messenger, a porter, and a short-order cook— whatever he could do before he was fired, as he invariably was, because of his slowness, dreaminess or incompetence. It would have been a dull and disheartening life, had it not been for his remarkable musical gifts and sensibilities, and the joy this brought him—and others.

He had an amazing musical memory—’I know more than 2,000 operas,’ he told me on one occasion—although he had never learned or been able to read music. Whether this would have been possible or not was not clear—he had always depended on his extraordinary ear, his power to retain an opera or an oratorio after a single hearing.

The great sorrow of Martin’s life was that he could not follow his father, and be a famous opera and oratorio singer like him— but this was not an obsession, and he found, and gave, much pleasure with what he could do. He was consulted, even by the famous, for his remarkable memory, which extended beyond the music itself to all the details of performance. He enjoyed a modest fame as a ‘walking encyclopedia’, who knew not only the music of two thousand operas, but all the singers who had taken the roles in countless performances, and all the details of scenery, staging, dress and decor. (He also prided himself on a street-by-street, house-by-house, knowledge of New York—and knowing the routes of all its buses and trains.) Thus, he was an opera-buff, and something of an ‘idiot savant’ too. He took a certain child-like pleasure in all this—the pleasure of such eidetics and freaks. But the real joy— and the only thing that made life supportable—was actual participation in musical events, singing in the choirs at local churches (he could not sing solo, to his grief, because of his dysphonia), especially in the grand events at Easter and Christmas, the John and Matthew Passions, the Christmas Oratorio, the Messiah, which he had done for fifty years, boy and man, in the great churches and cathedrals of the city. He had also sung at the Met, and, when it was pulled down, at Lincoln Center, discreetly concealed amid the vast choruses of Wagner and Verdi.

23 % The Twins 

"The Twins" is about autistic savants. Dr. Sacks meets twin brothers who can neither read nor perform multiplication, yet are playing a "game" of finding very large prime numbers. While the twins were able to spontaneously generate these numbers, from six to twenty digits, Sacks had to resort to a book of prime numbers to join in with them. This was used in the 1993 film House of Cards starring Tommy Lee Jones. The twins also instantly count 111 dropped matches, simultaneously remarking that 111 is three 37s, an ability demonstrated by Dustin Hoffman's autistic character in the 1988 film Rain Man. This story has been questioned by Makoto Yamaguchi, who doubts that a book of large prime numbers could exist as described, and points out that reliable scientific reports only support approximate perception when rapidly counting large numbers of items. Autistic savant Daniel Tammet points out that the twins provided the matchbox and may have counted its contents beforehand, noting that he finds the value of 111 to be "particularly beautiful and matchstick-like".

24 % The Autist Artist 

"The Autist Artist", about a 21-year-old named Jose that had been deemed "hopelessly retarded" and had seizures; however, when given Sacks' pocket watch and asked to draw it, he composed himself and drew the watch in surprising detail.

The chapter ends on a very positive note about what else life might have to offer to him:

This brings us to our final question: is there any ‘place’ in the world for a man who is like an island, who cannot be acculturated, made part of the main? Can ‘the main’ accommodate, make room for, the singular? There are similarities here to the social and cultural reactions to genius. (Of course I do not suggest that all autists have genius, only that they share with genius the problem of singularity.) Specifically: what does the future hold for Jose? Is there some ‘place’ for him in the world which will employ his autonomy, but leave it intact? 

Could he, with his fine eye, and great love of plants, make illustrations for botanical works or herbals? Be an illustrator for zoology or anatomy texts? (See the drawing overleaf he made for me when I showed him a textbook illustration of the layered tissue called ‘ciliated epithelium’.) Could he accompany scientific expeditions, and make drawings (he paints and makes models with equal facility) of rare species? His pure concentration on the thing before him would make him ideal in such situations.

Or, to take a strange but not illogical leap, could he, with his peculiarities, his idiosyncrasy, do drawings for fairy tales, nursery tales, Bible tales, myths? Or (since he cannot read, and sees letters only as pure and beautiful forms) could he not illustrate, and elaborate, the gorgeous capitals of manuscript breviaries and missals? He has done beautiful altarpieces, in mosaic and stained wood, for churches. He has carved exquisite lettering on tombstones. His current ‘job’ is handprinting sundry notices for the ward, which he does with the flourishes and elaborations of a latter-day Magna Carta. All this he could do, and do very well. And it would be of use and delight to others, and delight him too. He could do all of these—but, alas, he will do none, unless someone very understanding, and with opportunities and means, can guide and employ him. For, as the stars stand, he will probably do nothing, and spend a useless, fruitless life, as so many other autistic people do, overlooked, unconsidered, in the back ward of a state hospital. 

A point the author makes while contrasting autism and schizophrenia:
Autism was once seen as a childhood schizophrenia, but phenomenologically the reverse is the case. The schizophrenic’s complaint is always of ‘influence’ from the outside: he is passive, he is played upon, he cannot be himself. The autistic would complain—if they complained—of absence of influence, of absolute isolation.