Oliver Sacks - The man who mistook his wife for a hat

I had stopped at a florist on my way to his apartment and bought myself an extravagant red rose for my buttonhole. Now I removed this and handed it to him. He took it like a botanist or morphol-ogist given a specimen, not like a person given a flower.

About six inches in length,' he commented. 'A convoluted red form with a linear green attachment.'

'Yes,' I said encouragingly, 'and what do you think it is, Dr P.?'

'Not easy to say.' He seemed perplexed. 'It lacks the simple symmetry of the Platonic solids, although it may have a higher symmetry of its own. … I think this could be an inflorescence or flower.'

'Could be?' I queried.

'Could be,' he confirmed.

'Smell it,' I suggested, and he again looked somewhat puzzled, as if I had asked him to smell a higher symmetry. But he complied courteously, and took it to his nose. Now, suddenly, he came to life.

'Beautiful!' he exclaimed. 'An early rose. What a heavenly smell!' He started to hum 'Die Rose, die Lillie . . .' Reality, it seemed, might be conveyed by smell, not by sight.

I tried one final test. It was still a cold day, in early spring, and I had thrown my coat and gloves on the sofa.

'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?'

Yes,' I said, 'and what would it contain?'

'It would contain its contents!' said Dr P., with a laugh. 'There are many possibilities. It could be a change purse, for example, for coins of five sizes. It could . . .'

I interrupted the barmy flow. 'Does it not look familiar? Do you think it might contain, might fit, a part of your body?'

No light of recognition dawned on his face.*

No child would have the power to see and speak of 'a contin-

* Later, by accident, he got it on, and exclaimed, 'My God, it's a glove!' This was reminiscent of Kurt Goldstein's patient 'Lanuti', who could only recognise objects by trying to use them in action.

uous surface . . . infolded on itself,' but any child, any infant, would immediately know a glove as a glove, see it as familiar, as going with a hand. Dr P. didn't. He saw nothing as familiar. Visually, he was lost in a world of lifeless abstractions. Indeed, he did not have a real visual world, as he did not have a real visual self. He could speak about things, but did not see them face-to-face. Hughlings Jackson, discussing patients with aphasia and left-hemisphere lesions, says they have lost 'abstract' and 'propositional' thought-and compares them with dogs (or, rather, he compares dogs to patients with aphasia). Dr P., on the other hand, functioned precisely as a machine functions. It wasn't merely that he displayed the same indifference to the visual world as a computer but-even more strikingly-he construed the world as a computer construes it, by means of key features and schematic relationships. The scheme might be identified-in an 'identi-kit' way-without the reality being grasped at all.

The testing I had done so far told me nothing about Dr P.'s inner world. Was it possible that his visual memory and imagination were still intact? I asked him to imagine entering one of our local squares from the north side, to walk through it, in imagination or in memory, and tell me the buildings he might pass as he walked. He listed the buildings on his right side, but none of those on his left. I then asked him to imagine entering the square from the south. Again he mentioned only those buildings that were on the right side, although these were the very buildings he had omitted before. Those he had 'seen' internally before were not mentioned now; presumably, they were no longer 'seen'. It was evident that his difficulties with leftness, his visual field deficits, were as much internal as external, bisecting his visual memory and imagination.

What, at a higher level, of his internal visualisation? Thinking of the almost hallucinatory intensity with which Tolstoy visualises and animates his characters, I questioned Dr P. about Anna Kar-enina. He could remember incidents without difficulty, had an undiminished grasp of the plot, but completely omitted visual characteristics, visual narrative, and scenes. He remembered the words of the characters but not their faces; and though, when

asked, he could quote, with his remarkable and almost verbatim memory, the original visual descriptions, these were, it became apparent, quite empty for him and lacked sensorial, imaginal, or emotional reality. Thus, there was an internal agnosia as well*

But this was only the case, it became clear, with certain sorts of visualisation. The visualisation of faces and scenes, of visual narrative and drama-this was profoundly impaired, almost absent. But the visualisation of schemata was preserved, perhaps enhanced. Thus, when I engaged him in a game of mental chess, he had no difficulty visualising the chessboard or the moves- indeed, no difficulty in beating me soundly.

Luria said of Zazetsky that he had entirely lost his capacity to play games but that his 'vivid imagination' was unimpaired. Zazetsky and Dr P. lived in worlds which were mirror images of each other. But the saddest difference between them was that Zazetsky, as Luria said, 'fought to regain his lost faculties with the indomitable tenacity of the damned,' whereas Dr P. was not fighting, did not know what was lost, did not indeed know that anything was lost. But who was more tragic, or who was more damned- the man who knew it, or the man who did not?

When the examination was over, Mrs P. called us to the table, where there was coffee and a delicious spread of little cakes. Hungrily, hummingly, Dr P. started on the cakes. Swiftly, fluently, unthinkingly, melodiously, he pulled the plates towards him and took this and that in a great gurgling stream, an edible song of food, until, suddenly, there came an interruption: a loud, peremptory rat-tat-tat at the door. Startled, taken aback, arrested by the interruption, Dr P. stopped eating and sat frozen, motionless, at the table, with an indifferent, blind bewilderment on his face. He saw, but no longer saw, the table; no longer perceived it as a

*I have often wondered about Helen Keller's visual descriptions, whether these, for all their eloquence, are somehow empty as well? Or whether, by the transference of images from the tactile to the visual, or, yet more extraordinarily, from the verbal and the metaphorical to the sensorial and the visual, she did achieve a power of visual imagery, even though her visual cortex had never been stimulated, directly, by the eyes? But in Dr P.'s case it is precisely the cortex that was damaged, the organic prerequisite of all pictorial imagery. Interestingly and typically he no longer dreamed pictonally-the 'message' of the dream being conveyed in nonvisual terms.

table laden with cakes. His wife poured him some coffee: the smell titillated his nose and brought him back to reality. The melody of eating resumed.

How does he do anything? I wondered to myself. What happens when he's dressing, goes to the lavatory, has a bath? I followed his wife into the kitchen and asked her how, for instance, he managed to dress himself. 'It's just like the eating,' she explained. 'I put his usual clothes out, in all the usual places, and he dresses without difficulty, singing to himself. He does everything singing to himself. But if he is interrupted and loses the thread, he comes to a complete stop, doesn't know his clothes-or his own body. He sings all the time-eating songs, dressing songs, bathing songs, everything. He can't do anything unless he makes it a song.'