Review : The Man Who Mistook His Wife For A Hat

I enjoyed An Anthropologist On Mars so much that Oliver Sack's The Man Who Mistook His Wife For A Hat was an obvious must-read.

Once again, I'm heavily biased towards the philosophical implications. Just how subjective is reality ? Is there a hard, out-there "stuff" creating the perceptive illusion of concrete "things", or is perception itself all there is ? More on this when I eventually tackle Berkeley...

But I should start by saying that Sacks does an outstanding job of getting at the human aspects of the conditions he addresses. A friend of mine thinks he's exploitative - I could not disagree more. I think he goes out of his way to present these patients with dignity and respect, as fellow human beings sometimes in need of treatment but often simply in need of understanding. I find his writing commendably empathetic, and the earnest attempt to get inside the minds of the sufferers of these unfortunate afflictions surely essential in treating mental health like any other medical condition. And whereas a lesser writer could use some of these cases to terrify and titillate, Sacks deftly deflects any concerns on the reader's part not towards their own hypothetical well-being, but towards sympathy for those actually affected.

The book is arranged into distinct themes, concerned with losses, excesses, "transports" (experiences being neither enhanced nor diminished but more generally altered) and "simple" (the world of those with generally reduced intellectual capacity). All of these are interesting. I will pick some of my favourite examples for future reference here, but I highly recommend reading this little book - not a single chapter fails to provoke interest.

Many examples of losses concern patients who had lost a "sense" we usually don't even realise we have. That is, our understanding of the world at a fundamental level is not dissimilar to reading, seeing meaningful patterns within the world. Thus does a circle become an O, a red light indicate that we should stop*, a jagged line resemble dangerous teeth... but it goes very much deeper than that. Shape, colour, motion, and other supposedly fundamental concepts may not be the Lockian "simple ideas", the direct perception of reality, that we often think they are : they themselves are subjectively read from the word rather than it thrusting its innate meaning upon us.

* And/or hire a prostitute.

The eponymous title is an interesting case. This particular man really did literally confuse his wife for a hat. He had lost the ability to visualise abstract concepts : he could see details of shapes and colours, but to assemble them into more general ideas became increasingly difficult. He could not even readily distinguish between a shoe and his own foot. One example :

"What is this ?" I asked, holding up a glove.
"May I examine it ?" he asked, and, taking it from me, he proceeded to examine it as he had examined the geometrical shapes.
"A continuous surface," he announced at last, "infolded on itself. It appears to have" - he hesitated - "five outpouchings, if this is the word."
"Yes," I said cautiously. "You have given me a description. Now tell me what it is."
"A container of some sort ?"

While Sacks describes him as lost in a "world of abstraction" I would describe it as the opposite*. He was lost in specificity - it was the abstract, the general, that utterly eluded him. He was fully capable of visualising details, allowing him to recognise people by highly specific, distinctive features. He could beat the author at chess and understand plot details of complex novels... but he could not remember visual information on the abstract level.

*Also Later Sacks uses the word "concrete" in a way that simply confuses me, but fortunately that case isn't one I've chosen to recount here.

Even weirder, his visual difficulties had a directional bias against anything to the left. Another patient took this to an extreme, seemingly having lost the very concept of "leftness". She understands it intellectually but not at the deeper, subconscious level : she can only turn right, having to go in a complete circle rather than turn a few degrees to her left, even having to rotate her plate incrementally to ensure she eats all the food on it. 

The idea of having a sense of "leftness" is hard to fathom, an example of the brain's oddly specific workings. In another example, a patient completely lost not only their actual sight but the very notion of vision, so they were completely unaware of having lost anything : all visual memories were gone and even the words relating to them made no sense. How in the world the brain can be altered like that... this is extraordinarily difficult to imagine.

It's worth a quote at this point just to emphasise that philosophically fascinating these cases may be, they are also tragic, and at the same time, hopeful. On a patient who was unable to form long-term memories so was trapped in the last minute or so of experience, he quotes another neuroscientist :

A man does not consist of memory alone. He has feeling, will, sensibilities, moral being - matters of which neuropsychology cannot speak. And it is here, beyond the realm of an impersonal psychology, that you may find ways to touch him, and change him. And the circumstances of your work allow this, for you work in a Home, which is like a little world, quite different from the clinics and institutions where I work. Neuropsychologically, there is little or nothing you can do, but in the realm of the Individual, there may be much you can do.

And there was. This patient was able to achieve a kind of peace through spiritual concerns, trapped forever in a minute, but able at least to avoid the existential horror that such an experience might all to easily otherwise provoke. Not all patients are so lucky, but some are more fortunate : some disorders, even if they are not fully understood, can be treated with great efficacy.

Proprioception is another strange one, more familiar to us than having a sense of "left" - it's the sense of how our body is arranged, how we know where our arms and legs are even in the dark. One patient lost this sense completely, becoming in effect body blind*. She was, however, able to compensate visually, eventually learning to lead a more-or-less normal life. But how one could do this, how one could move one's limbs and rely exclusively on vision in order to put them in the right place, is something I think most of us will find utterly inconceivable. What does it feel like to move your arm and not be intrinsically aware of its movement ?

* In Metazoa, which I shall eventually cover in a longer post over on PotC, Peter Godfrey-Smith suggests that the evolution of senses was partly driven by the evolution of action, that in controlling your own body you automatically gain some sense of how it interacts with the world. This case arguably suggests otherwise.

A less general affliction caused one man to be unaware of his own leg. He could see it, but was not aware it was part of his own body, seeing it as some ghastly dead thing, part of a cadaver put there as a joke. Another woman, blind from birth, was more fortunate. She had never learned to use her hands properly, convinced they were useless : she could sense touch and temperature with them, but had no sense of how to control them. Then at the age of sixty, with the relatively simple treatment of encouraging her to believe her hands were not "useless lumps of putty", and actually trying to use them... she did. She began integrating the tactile sensation of touch from her hands into her mental world, in effect gaining a whole new sense, and becoming proficient at sculpture.

The reverse case of "phantom limbs", where amputees still sense a limb no longer present, is more well-known. Less reported is that this condition is often necessary for the use of prosthetic limbs, that without sensing the limb is present, suffers cannot use the prosthetic. Phantoms which otherwise cause pain and discomfort can become essential :

It [the pain] goes away, when I strap the prosthesis on and walk. I still feel the leg then, vividly, but it's a good phantom, different - it animates the prosthesis, and allows me to walk.

While phantom limbs represent a sense which in a way shouldn't exist, it's also possible for the regular senses to become enhanced. I myself will vouch for this having experienced (as I've mentioned before) an acutely heightened sense of hearing after having my ears syringed. Indeed, each morning noises seem a little louder than at the end of the day, but this is as nothing compared to having been half-deaf for a week or so and then suddenly having one's audio faculty restored to full force. It was a remarkable experience, one that I'd care to repeat if it could be done without the temporary deafness and ear syringing.

Sacks describes a medical student who, after cocaine, gained a profoundly heightened sense of vision :

As if I had been totally colour-blind before, and suddenly found myself in a world full of colour. I could distinguish dozens of browns where I'd just seen brown before. My leather-bound books, which looked similar before, now all had quite distinct and recognisable hues. I could never draw before, I couldn't "see" things in my mind, but now it was like having a camera lucida in my mind - I "saw" everything, as if projected on the paper... Suddenly I could do the most accurate anatomical drawings.

He also experienced an acutely enhanced sense of smell, becoming - apparently - dog-like in his ability to smell places and people's emotions. Conversely, another patient lost their sense of smell and thought they had regained it, but testing indicated they had not - a case, I suppose, of nasal hallucinations.

Earlier we saw a case of the loss of the ability to form long-term memories. Sacks clearly believes that their is a good deal more to the soul of man than memory, but several tragic cases serve to illustrate this directly. One man had lost his memory but not the capacity for creativity. He lived in a world in continuous flux, utterly losing his inner narrative and continually re-inventing himself, ever few seconds generating new stories about who he really was.

It is comic, but it is not just comic - it is terrible as well. For here is a man who, in some sense, is desperate, in a frenzy. The world keeps disappearing, losing meaning, vanishing - and he must seek meaning, make meaning, in a desperate way, continually inventing, throwing bridges of meaning over abysses of meaninglessness, the chaos that yawns continually beneath him.... his life... reduced to a surface, brilliant, shimmering, iridescent, ever-changing, but for all that a surface, a mass of illusions, a delirium, without depth.

It is not memory which is the final, "existential" casualty here (although his memory is wholly devastated); it is not memory only which has been so altered in him, but some ultimate capacity for feeling which is gone; and this is the sense in which he has been "de-souled".

Likewise a female patient who retained their memory but lost all sense of the "meaning" of anything. They knew the intellectual definitions of words, but it just didn't seem to matter. Weirdest of all is not a detailed medical case but an anecdote, witnessing a woman on the street who was compelled to imitate the mannerisms of each and every passer-by, imitating forty of fifty people in a "whirlwind of identities" in a couple of minutes, before throwing up in an alley.

In the final section Sacks deals with idiots and morons. Yes, these are the terms he uses, and perhaps they were widely accepted in 1986. I have no idea what the polite term is these days, but Sacks would certainly not approve of the colloquial sense of the word "moron". The overall gist is that such people need to be treated as full human beings. Rather than lacking intelligence in a general sense, it's that they lack specific abilities. Testing, he says, unfortunately reduces them to mere problems rather than people - tests are by their nature designed to identify problems, and neglect the faculties which often remain fully-functional. Many of these people need to be treated for disorders, not as disorders - they can still have rich, complex emotional needs, which absolutely need to be accounted for in any treatment program.

I saw a quote recently that many autistic people could absolutely get on and do useful jobs if people would only leave them alone, with the interview process being a huge barrier. Sacks would definitely agree with this. He finds that contrary to accepted wisdom, the autistic can have their own emotional worlds - it is that they cannot recognise the inner emotional worlds of others that causes social problems.

And yet... sometimes something altogether stranger and more profound is going on. The final case I want to mention is that of the Twins, whose remarkable numerical power was truly bizarre. They could not do, could not comprehend, the simplest mathematical calculation, but could give the day of the date of any time in the next forty thousand years. They could instantaneously assess that 111 matches had fallen on the floor, spontaneously declaring "37", i.e. 111/3. 

Weirdest of all, on another occasion, Sacks relates how they would simply state large, apparently random numbers to each other, smiling in response*. Later Sacks realised these numbers were all primes. He joined in, giving them longer and longer numbers... eight figures...nine... and by themselves they went up to twenty-figure numbers. They did not understand mathematics at all, yet in some sense were doing extraordinary calculations in their heads.

* That's Numberwang !

Sacks believes that rather than calculating numbers, they were in some sense observing them directly - not that numbers are "real" things, but they were perceiving them as though this were so. They did not do mathematics by calculation, but by feeling and perception, almost literally seeing patterns. The age-old question of whether mathematics is an invention or a discovery rears its ugly head...

But not for the Twins. They were separated and effectively forced into menial, mediocre jobs in order to become "socially acceptable". One gets a palpable sense of Sack's disapproval here. The Twins, though indeed emotionally difficult, have lost their remarkable numerical faculty, reduced to bland mediocrity at society's behest. For all that some mental disorders are indeed disorders in need of treatment, it's hard not to wonder if at least sometimes this isn't more the fault of a prejudiced society than a genuine problem of individuals. The Twins, Sacks implies, lost a lot more than they gained. Though there is a wonderful philosophical aspect to all of this, these are all still real people - something we should never lose sight of. Or any other senses, if we can help it.