Man Who MIstook His Wife for a Hat (4 page)

   'Ach, you doctors, you're such Philistines!' she exclaimed. 'Can you not see
artistic development
-how he renounced the realism of his earlier years, and advanced into abstract, nonrepresenta-tional art?'

   'No, that's not it,' I said to myself (but forbore to say it to poor Mrs P.). He had indeed moved from realism to nonrepresentation to the abstract, yet this was not the artist, but the pathology, advancing-advancing towards a profound visual agnosia, in which all powers of representation and imagery, all sense of the concrete, all sense of reality, were being destroyed. This wall of paintings was a tragic pathological exhibit, which belonged to neurology, not art.

   And yet, I wondered, was she not partly right? For there is often a struggle, and sometimes, even more interestingly, a collusion between the powers of pathology and creation. Perhaps, in his cubist period, there might have been both artistic and pathological development, colluding to engender an original form; for as he lost the concrete, so he might have gained in the abstract, developing a greater sensitivity to all the structural elements of line, boundary, contour-an almost Picasso-like power to see, and equally depict, those abstract organisations embedded in, and normally lost in, the concrete. . . . Though in the final pictures, I feared, there was only chaos and agnosia.

   We returned to the great music room, with the Bosendorfer in the centre, and Dr P. humming the last torte.

   'Well, Dr Sacks,' he said to me. 'You find me an interesting case, I perceive. Can you tell me what you find wrong, make recommendations?'

   '1 can't tell you what I find wrong,' I replied, 'but I'll say what I find right. You are a wonderful musician, and music is your life. What I would prescribe, in a case such as yours, is a life which consists entirely of music. Music has been the centre, now make it the whole, of your life.'

   This was four years ago-I never saw him again, but I often wondered about how he apprehended the world, given his strange loss of image, visuality, and the perfect preservation of a great musicality. I think that music, for him, had taken the place of image. He had no body-image, he had body-music: this is why he could move and act as fluently as he did, but came to a total confused stop if the 'inner music' stopped. And equally with the outside, the world … *

   In
The World as Representation and Will,
Schopenhauer speaks of music as 'pure will'. How fascinated he would have been by Dr P., a man who had wholly lost the world as representation, but wholly preserved it as music or will.

   And this, mercifully, held to the end-for despite the gradual

   *Thus, as I learned later from his wife, though he could not recognise his students if they sat still, if they were merely 'images', he might suddenly recognise them if they
moved.
'That's Karl,' he would cry. '1 know his movements, his body-music'

   advance of his disease (a massive tumour or degenerative process in the visual parts of his brain) Dr P. lived and taught music to the last days of his life.

   
Postscript

   How should one interpret Dr P.'s peculiar inability to interpret, to judge, a glove as a glove? Manifestly, here, he could not make a cognitive judgment, though he was prolific in the production of cognitive hypotheses. A judgment is intuitive, personal, comprehensive, and concrete-we 'see' how things stand, in relation to one another and oneself. It was precisely this setting, this relating, that Dr P. lacked (though his judging, in all other spheres, was prompt and normal). Was this due to lack of visual information, or faulty processing of visual information? (This would be the explanation given by a classical, schematic neurology.) Or was there something amiss in Dr P.'s attitude, so that he could not relate what he saw to himself?

   These explanations, or modes of explanation, are not mutually exclusive-being in different modes they could coexist and both be true. And this is acknowledged, implicitly or explicitly, in classical neurology: implicitly, by Macrae, when he finds the explanation of defective schemata, or defective visual processing and integration, inadequate; explicitly, by Goldstein, when he speaks of 'abstract attitude'. But abstract attitude, which allows 'categorisation', also misses the mark with Dr P.-and, perhaps, with the concept of'judgment' in general. For Dr P.
had
abstract attitude- indeed, nothing else. And it was precisely this, his absurd ab-stractness of attitude-absurd because unleavened with anything else-which rendered him incapable of perceiving identity, or particulars, rendered him incapable of judgment.

   Neurology and psychology, curiously, though they talk of everything else, almost never talk of 'judgment'-and yet it is precisely the downfall of judgment (whether in specific realms, as with Dr P., or more generally, as in patients with Korsakov's or frontal-lobe syndromes-see below, Chapters Twelve and Thirteen) which constitutes the essence of so many neuropsychological disorders.

   Judgment and identity may be casualties-but neuropsychology never speaks of them.

   And yet, whether in a philosophic sense (Kant's sense), or an empirical and evolutionary sense, judgment is the most important faculty we have. An animal, or a man, may get on very well without 'abstract attitude' but will speedily perish if deprived of judgment. Judgment must be the
first
faculty of higher life or mind-yet it is ignored, or misinterpreted, by classical (computational) neurology. And if we wonder how such an absurdity can arise, we find it in the assumptions, or the evolution, of neurology itself. For classical neurology (like classical physics) has always been mechanical-from Hughlings Jackson's mechanical analogies to the computer analogies of today.

   Of course, the brain
is
a machine and a computer-everything in classical neurology is correct. But our mental processes, which constitute our being and life, are not just abstract and mechanical, but personal, as well-and, as such, involve not just classifying and categorising, but continual judging and feeling also. If this is missing, we become computer-like, as Dr P. was. And, by the same token, if we delete feeling and judging, the personal, from the cognitive sciences, we reduce
them
to something as defective as Dr P.-and we reduce
our
apprehension of the concrete and real.

   By a sort of comic and awful analogy, our current cognitive neurology and psychology resemble nothing so much as poor Dr P.! We need the concrete and real, as he did; and we fail to see this, as he failed to see it. Our cognitive sciences are themselves suffering from an agnosia essentially similar to Dr P.'s. Dr P. may therefore serve as a warning and parable-of what happens to a science which eschews the judgmental, the particular, the personal, and becomes entirely abstract and computational.

   It was always a matter of great regret to me that, owing to circumstances beyond my control, I was not able to follow his case further, either in the sort of observations and investigations described, or in ascertaining the actual disease pathology.

   One always fears that a case is 'unique', especially if it has such

   extraordinary features as those of Dr P. It was, therefore, with a sense of great interest and delight, not unmixed with relief, that I found, quite by chance-looking through the periodical
Brain
for 1956-a detailed description of an almost comically similar case, similar (indeed identical) neuropsychologically and phenomeno-logically, though the underlying pathology (an acute head injury) and all personal circumstances were wholly different. The authors speak of their case as 'unique in the documented history of this disorder'-and evidently experienced, as I did, amazement at their own findings. * The interested reader is referred to the original paper, Macrae and Trolle (1956), of which I here subjoin a brief paraphrase, with quotations from the original.

   Their patient was a young man of 32, who, following a severe automobile accident, with unconsciousness for three weeks, '. . . complained, exclusively, of an inability to recognise faces, even those of his wife and children'. Not a single face was 'familiar' to him, but there were three he could identify; these were workmates: one with an eye-blinking tic, one with a large mole on his cheek, and a third 'because he was so tall and thin that no one else was like him'. Each of these, Macrae and Trolle bring out, was 'recognised solely by the single prominent feature mentioned'. In general (like Dr P.) he recognised familiars only by their voices.

   He had difficulty even recognising himself in a mirror, as Macrae and Trolle describe in detail: 'In the early convalescent phase he frequently, especially when shaving, questioned whether the face gazing at him was really his own, and even though he knew

   *Only since the completion of this book have I found that there is, in fact, a rather extensive literature on visual agnosia in general, and prosopagnosia in particular. In particular I had the great pleasure recently of meeting Dr Andrew Kertesz, who has himself published some extremely detailed studies of patients with such agnosias (see, for example, his paper on visual agnosia, Kertesz 1979). Dr Kertesz mentioned to me a case known to him of a farmer who had developed prosopagnosia and in consequence could no longer distinguish (the faces of) his
cows,
and of another such patient, an attendant in a Natural History Museum, who mistook his own reflection for the diorama of an
ape.
As with Dr P., and as with Macrae and Trolle's patient, it is especially the animate which is so absurdly misperceived. The most important studies of such agnosias, and of visual processing in general, are now being undertaken by A. R. and H. Damasio (see article in Mesulam [1985], pp. 259-288; or see p. 79 below).

   it could physically be none other, on several occasions grimaced or stuck out his tongue "just to make sure." By carefully studying his face in the mirror he slowly began to recognise it, but "not in a flash" as in the past-he relied on the hair and facial outline, and on two small moles on his left cheek.'

   In general he could not recognise objects 'at a glance', but would have to seek out, and guess from, one or two features- occasionally his guesses were absurdly wrong. In particular, the authors note, there was difficulty with the
animate.

   On the other hand, simple schematic objects-scissors, watch, key, etc.-presented no difficulties. Macrae and Trolle also note that: 'His
topographical memory
was strange: the seeming paradox existed that he could find his way from home to hospital and around the hospital, but yet could not name streets
en route
[unlike Dr P., he also had some aphasia] or appear to visualize the topography.'

   It was also evident that visual memories of people, even from long before the accident, were severely impaired-there was memory of conduct, or perhaps a mannerism, but not of visual appearance or face. Similarly, it appeared, when he was questioned closely, that he no longer had visual images in his
dreams.
Thus, as with Dr P., it was not just visual perception, but visual imagination and memory, the fundamental powers of visual representation, which were essentially damaged in this patient-at least those powers insofar as they pertained to the personal, the familiar, the concrete.

   A final, humorous point. Where Dr P. might mistake his wife for a hat, Macrae's patient, also unable to recognise his wife, needed her to identify herself by a visual
marker,
by '. . . a conspicuous article of clothing, such as a large hat'.

   
2

   The Lost Mariner*

   You have to begin to lose your memory, if only in bits and pieces, to realise that memory is what makes our lives. Life without memory is no life at all . . . Our memory is our coherence, our reason, our feeling, even our action. Without it, we are nothing … (I can only wait for the final amnesia, the one that can erase an entire life, as it did my mother's . . .)

   –Luis Bunuel

   This moving and frightening segment in Bunuel's recently translated memoirs raises fundamental questions-clinical, practical, existential, philosophical: what sort of a life (if any), what sort of a world, what sort of a self, can be preserved in a man who has lost the greater part of his memory and, with this, his past, and his moorings in time?

   It immediately made me think of a patient of mine in whom these questions are precisely exemplified: charming, intelligent, memoryless Jimmie G., who was admitted to our Home for the

   *After writing and publishing this history I embarked with Dr Elkhonon Goldberg- a pupil of Luria and editor of the original (Russian) edition of
The Neuropsychology of Memory
-on a close and systematic neuropsychological study of this patient. Dr Goldberg has presented some of the preliminary findings at conferences, and we hope in due course to publish a full account.

   A deeply moving and extraordinary film about a patient with a profound amnesia
(Prisoner of Consciousness),
made by Dr Jonathan Miller, has just been shown in England (September 1986). A film has also been made (by Hilary Lawson) with a prosopagnosic patient (with many similarities to Dr P.). Such films are crucial to assist the imagination: 'What
can
be shown
cannot
be said.'

   Aged near New York City early in 1975, with a cryptic transfer note saying, 'Helpless, demented, confused and disoriented.'

   Jimmie was a fine-looking man, with a curly bush of grey hair, a healthy and handsome forty-nine-year-old. He was cheerful, friendly, and warm.

   'Hiya, Doc!' he said. 'Nice morning! Do I take this chair here?' He was a genial soul, very ready to talk and to answer any questions I asked him. He told me his name and birth date, and the name of the little town in Connecticut where he was born. He described it in affectionate detail, even drew me a map. He spoke of the houses where his family had lived-he remembered their phone numbers still. He spoke of school and school days, the friends he'd had, and his special fondness for mathematics and science. He talked with enthusiasm of his days in the navy-he was seventeen, had just graduated from high school when he was drafted in 1943. With his good engineering mind he was a 'natural' for radio and electronics, and after a crash course in Texas found himself assistant radio operator on a submarine. He remembered the names of various submarines on which he had served, their missions, where they were stationed, the names of his shipmates. He remembered Morse code, and was still fluent in Morse tapping and touch-typing.