The Man Who Mistook His Wife for a Hat

“One important reason for the neglect of the right, or ‘minor,’ hemisphere, as it has always been called, is that while it is easy to demonstrate the effects of variously located lesions on the left side, the corresponding syndromes of the right hemisphere are much less distinct. It was presumed, usually contemptuously, to be more ‘primitive’ than the left, the latter being seen as the unique flower of human evolution. And in a sense this is correct: the left hemisphere is more sophisticated and specialized, a very late outgrowth of the primate, and especially the hominid, brain. On the other hand, it is the right hemisphere which controls the crucial powers of recognizing reality which every living creature must have in order to survive. The left hemisphere, like a computer tacked onto the basic creatural brain, is designed for programs and schematics; and classical neurology was more concerned with schematics than with reality, so that when, at last, some of the right hemisphere syndromes emerged, they were considered bizarre.”

Sacks clarifies his choice of subject matter—damages to the right hemisphere of the brain—and why this exploration is important. There is already significant research into the left hemisphere of the brain and what happens when it is damaged, but less so the effects of damage to the right. Sacks decisively relates stories of patients who experienced right-hemisphere damage and whose stories appear “bizarre.” In noting the shortsightedness of classical neurology, Sacks also introduces the theme of Romantic Science Versus Classical Science.

“Neurology’s favorite word is ‘deficit’, denoting an impairment or incapacity of neurological function: loss of speech, loss of language, loss of memory, loss of vision, loss of dexterity, loss of identity and myriad other lacks and losses of specific functions (or faculties).”

In Part 1, “Losses,” Sacks shares stories of patients who have such “deficits.” In the following three parts, he discusses neurological conditions that are not forms of deficits, thus critiquing and expanding upon the traditional model and attitude of neurologists. Throughout the book, Sacks develops the theme of A Holistic Approach to Neurology: Body, Mind, and Soul and proposes that neuroscience views patients as a whole person, not as their “deficits.” In listing “losses,” Sacks suggests that scientists are overlooking patients’ “gains.”

“But it must be said from the outset that a disease is never a mere loss or excess—that there is always a reaction, on the part of the affected organism or individual, to restore, to replace, to compensate for and to preserve its identity, however strange the means may be: and to study or influence these means, no less than the primary insult to the nervous system, is an essential part of our role as physicians.”

Sacks believes that neuroscience needs to widen its scope of study, so as not to focus only on “deficits.” He notes that patients will often consciously or unconsciously compensate for those deficits, and this ability to do so must also be studied and understood. In this way, Sacks is a proponent of A Holistic Approach to Neurology: Body, Mind, and Soul, which does not reduce patients to their illnesses.

“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?”

Sacks’s approach to treating patients is one of probing curiosity. He does not regard the patient or their brain as an object on which he will act. Instead, he respects the individual’s humanity and dignity. He wants to know how they think and feel—to get “under their skin,” both as a way of gaining empathy and as a way of understanding their condition.

“[J]udgment 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.”

Sacks develops the theme of Romantic Science Versus Classical Science by critiquing classical neurology. He posits that neurologists should reconsider what is important in understanding and restoring the human brain. People must have the ability to make judgments to survive, yet early neurology has not evolved to make this a priority. Sacks communicates the worth of that view through his stories.

“If a man has lost a leg or an eye, he knows he has lost a leg or an eye; but if he has lost a self—himself—he cannot know it, because he is no longer there to know it.”

Sacks’s exploration of the self and the soul underpins the theme of A Holistic Approach to Neurology: Body, Mind, and Soul. This introduces a topic Sacks will explore throughout the book: the self. Sacks questions how the self is neurologically and physically composed, and how a person knows what is real, subjectively or objectively. Sacks investigates whether the self can be restored once a person has lost one of the integral functions of their brain, such as memory. These are the more philosophical aspects that make Sacks’s writing different from that of classical neurologists.

“And so was Luria, whose words now came back to me: ‘A man does not consist of memory alone. He has feeling, will, sensibility, moral being […] It is here […] you may touch him and see a profound change.’ Memory, mental activity, mind alone, could not hold him; but moral attention and action could hold him completely.”

This quote is a response to Sacks’s concern that “The Lost Mariner,” Jimmie G., has lost his soul because he has lost his memories. Luria’s words help Sacks and the reader understand that there are many facets to having a “soul.” Ultimately, Sacks uses music, communion, art, and gardening to help Jimmie G. regain his sense of feeling, morality, and will, even if he cannot help Jimmie restore his memories. These healing activities represent the motif of well-being and develop the theme of A Holistic Approach to Neurology: Body, Mind, and Soul.

“What Wittgenstein writes here, of epistemology, might apply to aspects of one’s physiology and psychology—especially in regard to what Sherrington once called ‘our secret sense, our sixth sense’—that continuous but unconscious sensory flow from the movable parts of our body (muscles, tendons, joints), by which their position and tone and motion are continually monitored and adjusted, but in a way which is hidden from us because it is automatic and unconscious. Our other senses—the five senses—are open and obvious; but this—our hidden sense—had to be discovered, as it was, by Sherrington, in the 1890s.”

Sacks gives his reader a brief history of neurophysiologist Sir Charles Scott Sherrington’s discovery of proprioception, but he also raises some questions about the nature of knowing. As with much of what Sacks discusses, proprioception is an important sense that affects the everyday life of all human beings, yet its mechanics and even its existence is unknown. One aim of neuroscience is to understand “hidden” neurological functions.

“Christina listened closely, with a sort of desperate attention. ‘What I must do then,’ she said slowly, ‘is use vision, use my eyes, in every situation where I used—what do you call it?—proprioception before. I’ve already noticed,’ she added, musingly, ‘that I may “lose” my arms. I think they’re one place, and I find they’re another. This “proprioception” is like the eyes of the body, the way the body sees itself. And if it goes, as it’s gone with me, it’s like the body’s blind. My body can’t “see” itself if it’s lost its eyes, right? So I have to watch it—be its eyes. Right?’ ‘Right,’ I said, ‘right. You could be a physiologist.’ ‘I’ll have to be a sort of physiologist,’ she rejoined, ‘because my physiology has gone wrong, and may never naturally go right...’”

This quote demonstrates the “self-righting” tendency that Sacks sees in his patients and shows readers how effective patients can be in their own recovery. Christina—like Mr. MacGregor in Chapter 7, Natasha in Chapter 11, and others—all find solutions to their problems when given a chance. These patients find ways of adapting to their new circumstances, which illustrates the theme of Human Resilience.

“She started to model heads and figures, and within a year was locally famous as the Blind Sculptress of St. Benedict’s. Her sculptures tended to be half or three-quarters life size, with simple but recognizable features, and with a remarkably expressive energy. For me, for her, for all of us, this was a deeply moving, an amazing, almost a miraculous, experience. Who would have dreamed that basic powers of perception, normally acquired in the first months of life, but failing to be acquired at this time, could be acquired in one’s sixtieth year? What wonderful possibilities of late learning, and learning for the handicapped, this opened up. And who could have dreamed that in this blind, palsied woman, hidden away, inactivated, over-protected all her life, there lay the germ of an astonishing artistic sensibility (unsuspected by her, as by others) that would germinate and blossom into a rare and beautiful reality, after remaining dormant, blighted, for sixty years?”

Sacks uses the story of Madeline J. to illustrate how she learned to use her hands to sculpt later in life. He intentionally incorporates this uplifting vignette to underscore that patients with disabilities are capable of continued development. On another level, Sacks imparts an admonishment against over-protecting those with disabilities. Due to her family’s doubtless well-intentioned care, Miss J. had to wait until she was 60 years old to discover a talent that gave her great pleasure.

“Phantoms—Dead or Alive? There is often a certain confusion about phantoms—whether they should occur, or not; whether they are pathological, or not; whether they are ‘real’, or not. The literature is confusing, but patients are not—and they clarify matters by describing different sorts of phantoms.”

This excerpt showcases Sacks’s unique approach to neurology. He is less interested in measurable reality than he is in a patient’s perception of reality. Sacks often notes where other doctors or attendants dismiss patients’ claims, he is careful to consider their point of view as being equally as “real” as any objective reality. Sacks’s inclusive methods reflect Romantic Science Versus Classical Science.

“‘Let me think, let me think,’ he murmured, half to himself, drawing his shaggy white brows down over his eyes and emphasizing each point with his powerful, gnarled hands. ‘Let me think. You think with me—there must be an answer! I tilt to one side, and I can’t tell it, right? There should be some feeling, a clear signal, but it’s not there, right?’ He paused. ‘I used to be a carpenter,’ he said, his face lighting up. ‘We would always use a spirit level to tell whether a surface was level or not, or whether it was tilted from the vertical or not. Is there a sort of spirit level in the brain?’ I nodded. ‘Can it be knocked out by Parkinson’s disease?’ I nodded again. ‘Is this what has happened with me?’ I nodded a third time and said, ‘Yes. Yes. Yes.’”

This passage demonstrates Sacks’ ability to draw a clear picture of a character and to dramatize their mind at work. Sacks’s case studies are engaging and accessible, and he highlights the importance of providing each patient with personalized attention. Sacks treats his patients as competent individuals capable of learning about their conditions in order to devise solutions together. He enacts this approach with multiple patients, notably with Christina in Chapter 3 and with Mr. MacGregor in the passage above, taken from Chapter 7.

“‘Dangerously well’—what an irony is this: it expresses precisely the doubleness, the paradox, of feeling ‘too well.’”

Sacks utilizes rhetorical devices throughout the book. In particular, he draws readers to consider natural paradoxes to better understand the complexities of neurology. He continues to point out there is more to neuroscience than studying “deficits” in brain function. He introduces the problems of having excessive functioning in parts of the brain. Too much “wellness” can also be problematic, as in the case of Tourette’s, epilepsy, and the early stages of syphilis. Patients themselves can sense there is something wrong with feeling “too well,” which is paradoxical.

“I saw him for the third time a few days after this, and found him rather down, rather Parkinsonian (he had been given Haldol to quiet him, while awaiting final tests on the spinal fluid). Again I asked him to draw the figure, and this time he copied it dully, correctly, and a little smaller than the original (the ‘micrographia’ of Haldol), and with none of the elaborations, the animation, the imagination, of the others (Figure D). ‘I don’t “see” things any more,’ he said. ‘It looked so real, it looked so alive before. Will everything seem dead when I am treated?’”

In “Excesses,” Sacks points out the paradox that a person can feel “too well.” A patient treated with Haldol notes that rather than feeling appreciative of the cure, he feels it has taken something from him. This fits with one of Sacks’s ongoing observations that a neurological difference may have a benefit, and a “cure” may rob patients of their gifts.

“To be ourselves we must have ourselves—possess, if need be re-possess, our life-stories. We must ‘recollect’ ourselves, recollect the inner drama, the narrative, of ourselves. A man needs such a narrative, a continuous inner narrative, to maintain his identity, his self.”

In the case of Jimmie G. in “The Lost Mariner,” Sacks realizes a person can be more than just their memory or their narrative. They are a compilation of their feelings, moral compass, and spiritual experiences. In “A Matter of Identity,” Sacks faces this challenge again when he meets Mr. Thompson, who confabulates stories because he cannot remember the real ones. In “Reminiscence,” Mrs. O’C. feels more complete once the long-lost memories of her childhood in Ireland return. The need to remember is, for Sacks, a primary means of making and maintaining identity.

“In all these states—‘funny’ and often ingenious as they appear—the world is taken apart, undermined, reduced to anarchy and chaos. There ceases to be any ‘centre’ to the mind, though its formal intellectual powers may be perfectly preserved. The end point of such states is an unfathomable ‘silliness’, an abyss of superficiality, in which all is ungrounded and afloat and comes apart. Luria once spoke of the mind as reduced, in such states, to ‘mere Brownian movement’. I share the sort of horror he clearly felt about them (though this incites, rather than impedes, their accurate description). They make me think, first, of Borges’ ‘Funes’, and his remark, ‘My memory, Sir, is like a garbage-heap’, and finally, of the Dunciad, the vision of a world reduced to Pure Silliness—Silliness as being the End of the World: Thy hand, great Anarch, lets the curtain fall; And Universal Darkness buries All.”

Sacks describes what the Germans call the “joking disease.” Although Mrs. B. is not bothered by the fact that she cannot differentiate between unlike things and people, Sacks is horrified by this condition. His response to her “de-souled” state underlies his desire to treat the human soul in addition to the human brain. Through case studies like that of Mrs. B., Sacks develops the theme of A Holistic Approach to Neurology: Body, Mind, and Soul.

“‘I’m glad it happened,’ she said when it was over. ‘It was the healthiest, happiest experience of my life. There’s no longer a great chunk of childhood missing. I can’t remember the details now, but I know it’s all there. There’s a sort of completeness I never had before.’ These were not idle words, but brave and true. Mrs. O’C.’s seizures”

Mrs. O’C. says this about her aural hallucinations once they stop. Seizures caused her to hear the music of her childhood, and although she loses the exact details, the Irish songs affect her emotionally. Sacks states the hypothesis that memories are stored in the brain forever, even if they are not consciously accessible. Sacks also makes the point that sometimes the neurological challenges a person faces can be paradoxical and have an upside. He hints that the brain might know what a person wants and be able to supply it.

“Sixteen years have passed—and student days, amphetamine days, are long over. There has never been any recurrence of anything remotely similar. Dr D. is a highly successful young internist, a friend and colleague of mine in New York. He has no regrets—but he is occasionally nostalgic: ‘That smell-world, that world of redolence,’ he exclaims. ‘So vivid, so real! It was like a visit to another world, a world of pure perception, rich, alive, self-sufficient, and full. If only I could go back sometimes and be a dog again!’”

In “The Dog Beneath the Skin,” Sacks relates the story of a man who, due to his use of amphetamines, received a heightened sense of smell. Freud theorized that some of our sensory awareness must be sacrificed as we become more human. Sacks adds that humans also need the sensory world of animals to feel more alive. He contends that the value of physical sensations and emotional sensibility are as equal to that of intellectual capacity.

“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 recovers the memories of murdering his girlfriend. He is able to come to terms with those memories once he uses gardening as a therapeutic tool. Sacks helps many of his patients gain the ability to find “work and love.” In “The Lost Mariner,” Sacks helps Jimmie G. find a way to be useful and relate to his community. In “The Autist Artist,” Sacks proposes that rather than let José be left to atrophy in a state hospital, his artistic talents could be of practical use.

“There are moments, and it is only a matter of five or six seconds, when you feel the presence of the eternal harmony […] a terrible thing is the frightful clearness with which it manifests itself and the rapture with which it fills you. If this state were to last more than five seconds, the soul could not endure it and would have to disappear. During these five seconds I live a whole human existence, and for that I would give my whole life and not think that I was paying too dearly…”

Sacks quotes Russian novelist Fyodor Dostoyevsky, best known for Crime and Punishment (1866) and The Brothers Karamazov (1880). Dostoyevsky was a deeply religious man who experienced epileptic episodes and wrote firsthand accounts, like the one above, describing how they felt and how he interpreted them. Like Hildegard, Dostoyevsky recognized these as divine fits that granted him insight into the spiritual world. Sacks uses allusions to encourage readers to view neuroscience from a broader contextual lens.

“When I started working with retardates several years ago, I thought it would be dismal, and wrote this to Luria. To my surprise, he replied in the most positive terms, and said that there were no patients, in general, more ‘dear’ to him, and that he counted his hours and years at the Institute of Defectology among the most moving and interesting of his entire professional life.”

Sacks refers to his correspondence with A. R. Luria, whose research and publications influenced Sacks’s thinking on neurology. Luria offers Sacks a deeper understanding and appreciation of those who have neurological differences. In “The Lost Mariner,” Luria guided Sacks’s thinking about how to treat Jimmie G., and now Luria convinces him that “simple” patients have much to offer him. By relating this anecdote, Sacks asks the reader to reconsider their own prejudices against “the simple.”

“Classical science has no use for the concrete—it is equated with the trivial in neurology and psychiatry. It needs a ‘romantic’ science to pay it its full due—to appreciate its extraordinary powers […] and dangers: and in the simple we are confronted with the concrete head-on, the concrete pure and simple, in unreserved intensity. The concrete can open doors, and it can close them too. It can constitute the portal to sensibility, imagination, depth. Or it can confine the possessor (or the possessed) to meaningless particulars. We see both of these potentials, as it were amplified, in the simple.”

This excerpt thematically explores Romantic Science Versus Classical Science. Sacks demonstrates nuanced thinking on complex subjects. While he tends to have a positive outlook on his patients, seeing their potential and indeed the bright side of their conditions, he does acknowledge that some of his patients have lost or almost lost their souls. They may be too “damaged” to have meaningful lives. In Part 4, he sets expectations for the reader that they will see cases of both.

“Rebecca had an incredible ability to see the world—especially the natural world—as one poetic whole. She would stand outside, saying, “Look at the world, how beautiful it is. During the intervening months (between my first seeing her, in April, and her grandmother’s death that November) Rebecca—like all our ‘clients’ (an odious word then becoming fashionable, supposedly less degrading than ‘patients’), was pressed into a variety of workshops and classes, as part of our Developmental and Cognitive Drive (these too were ‘in’ terms at the time). It didn’t work with Rebecca, it didn’t work with most of them. It was not, I came to think, the right thing to do, because what we did was to drive them full-tilt upon their limitations, as had already been done, futilely, and often to the point of cruelty, throughout their lives. We paid far too much attention to the defects of our patients, as Rebecca was the first to tell me, and far too little to what was intact or preserved. To use another piece of jargon, we were far too concerned with ‘defectology,’ and far too little with ‘narratology’, the neglected and needed science of the concrete.”

As Sacks demonstrates numerous times, patients often know what is best for them and can come up with solutions to their own problems, if given a chance. Through Rebecca, Sacks comes to question classic methods of testing, which do not register a patient’s unique abilities. This case study helps develop the theme of Romantic Science Versus Classical Science.