Psychology Classics

oliver sacks man who mistook his wife for a hat cover image

The Man Who Mistook His Wife For A Hat
Oliver Sacks

As neurologist Oliver Sacks notes at the beginning of this book, which was a massive bestseller around the world and made him famous, he has always been equally interested in diseases and people. A lifetime's work convinced him that it is often less a matter of 'what disease does this person have', than 'what person has the disease'. You can't examine a patient as if they are an insect – you are talking about a self.

This is all the more important in neurology, which involves a physical dysfunction of the brain that often affects a person's sense of who they are. In The Man Who Mistook His Wife For a Hat, he aimed to show that even when their normal faculties desert them, there remains an unmistakable uniqueness, a person, that is still there. How people adapt or reinvent themselves in the face of mental or physical setbacks was to Sacks, who has seen so many such cases, amazing.

The book's 24 chapters detail a myriad of strange and interesting cases which give it the page-turning quality of a novel. Part One of the book is titled 'Losses'. The chapters relate to people who have battled to return to a sense of normal self after suffering some debilitating loss of mental faculty.

Jimmie's Lost Decades

Without memories, is it possible to have a self?

Sacks tells of a the case of Jimmie G, a 49 year old admitted to the old people's home where Sacks was working in 1975. Jimmie was a handsome, healthy man and very genial.

He had been drafted into the US Navy upon his graduation from school, and became a radio operator on a submarine. But while talking about his personal history and family life, Sacks noticed that Jimmie was talking in the present tense. He asked Mr G what year it was. Jimmie replied to the effect of '1945 of course!' For Jimmie, the war was won, Truman was president, and he is looking forward to going to college on the GI Bill. He believes he is 19.

Sacks went out of the consulting room, and returning two minutes later Jimmie seemed to have no idea who he is. It is as if their session had never happened. Jimmie is apparently living in a permanent present, with his longer term memory stopping dead in 1945. With his ability in science he has no trouble solving complex problems in tests, but is disturbed by what seem like major changes in the world around him. He cannot deny that the man in the mirror is in his late forties, and is not able to explain it. Sacks wrote in his notes that his patient was “without a past (or future), stuck in a constantly changing, meaningless moment.” He diagnosed the condition as Korsakov's, damage to the mamillary bodies in the brain caused by alcohol. This affects memory, with the rest of the brain experiencing no change.

Sacks located Jimmie's brother, who noted that Jimmy had left the navy in 1965 and without the structure it provided began drinking heavily. For some reason he had experienced retrograde amnesia, with memory stopping in 1945.

Sacks asked Jimmie to keep a diary so that he knew what he had done the day before, but this did nothing to give him a sense of continuity as it was as if the events he read about happened to someone else. Like Mr Thompson, the other Korsakov's sufferer mentioned above, he seemed to have been 'de-souled' – something was missing in terms of a self. And yet...

Sacks asked the religious Sisters in the home whether they thought Jimmie had indeed lost his 'soul'. Somewhat affronted, they responded by telling him to watch Jimmie when he was in chapel. When Sacks went to observe him there, it was a different Jimmie. He seemed lost in the act of worship and the ritual of the mass, somehow more 'together' than before. The level of spiritual meaning was obviously enough to overcome his normal mental chaos. Sacks wrote: “Memory, mental activity, mind alone, could not hold him; but moral attention and action could hold him completely.” The same was true if he was in the garden or looking at art or listening to music.            

Thus, although Jimmie was dead to the normal experience of memory which we feel gives us a sense of self, at other times he was evidently a fully alive person, gaining meaning from experience. Through a careful regimen of like activity he was able to maintain a sense of calm;   there was still some part of him, whether a 'soul' or a 'self' - that had found a way to exist despite  the disease.

The self vs. Tourette's

Part Two of the book is titled 'Excesses'. The cases looked at involve not a loss but a superabundance of certain functions: flights of fancy, exaggerated perception, irrational exuberance, manias. These 'hyper-states' actually give the person involved a heightened sense of life that 'normality' does not. Though technically ill, such conditions give subjects the feel of great well-being and zest for life (although in the back of their mind there is the feeling that it cannot last). They meld with a person's identity, so that some people may not want to be cured.

One example of neurological excess is a syndrome first described in 1885. Gilles de la Tourette was a pupil of the pioneering neurologist Charcot (as was Freud) and recorded the condition of tics, extravagant motions, cursing, funny noises, mad humor and strange compulsions. There were varying degrees of the condition and it was manifested differently in each sufferer, from benign to violent. Because of its inexplicable strangeness and relative rarity, Tourette's was largely forgotten about by the medical world.

However, it never went away, and by the 1970s there was a Tourette's Syndrome Association which grew to have thousands of members. Research confirmed Tourette's initial belief that it was a brain disorder, centred in the 'old brain' (the most primitive part of the human brain) involving the thalamus, hypothalamus, limbic system and amygdala, the instinctual areas which together formed the basic personality. Touretters were found to have more than the usual amount of excitor transmitters in their brains, particularly the transmitter dopamine (people with Parkinson's have a lack of dopamine). They could be treated with a the drug haldol, which counteracts the excess.

But Tourette's is not simply a matter of brain chemistry, for there are times – such as singing, dancing or acting – that a Touretter loses their normal tics and behaviors. In such cases, Sacks observes, the 'I' of the person seems to overcome the 'It' of their condition. Normal people assume that they own their perceptions, reactions and movements, so it is easy to have a strong sense of self. The Touretter is so constanly bombarded with uncontrollable impulses that it is amazing if their ego can manage to keep a sense of self. Some people, Sacks notes, are able to 'take' Tourette's and incorporate it into their personality, even making use of the way it increases the rate of thinking; others are simply possessed by it.

* * *

Ray, 24, came to Sacks with a rather extreme version of Tourette's. Every few seconds he would go into a convulsive tic, which frightened everyone except for those who knew him well. With a high intelligence, wit, humor and sound character, Ray had actually got through school and college, and even married. He had obtained jobs but had been fired from each for his behavior, which was pugnacious and included the blurting out of swear words. His Tourette's was a 'sudden intruder' that he did his best to incorporate into his weekend role as a jazz drummer, producing sometimes wild drum solos. The only time he was free of his condition was while asleep, just after sex or when deeply engaged in some task.

Ray was willing to try haldol, but was worried what would be left of him if his tics went away. He had, after all, been like this since he was 4. When the drug began to work, Ray had to deal with himself as a different person. During the week, when at work, the drug made him a sober, tic-free – even dull - individual, but as he missed his old intense, convulsive, wisecracking self (the only self he had ever known), he chose not to take the drug on the weekend so he could be 'witty, ticcy Ray' as he called himself.

In this case, who was Ray's real self? Sacks does not offer an answer, but points to the story as an example of 'resilience of spirit' – there is always some 'I' inside us that seeks to assert itself, even in the face of an extreme 'It' that can take us over.

The enchanted loom

Sacks notes that our current model for understanding of the brain is based on the computer. But he asks: could algorithms and programs account for the rich way we experience reality, in terms of the dramatic, the artistic, the musical? How do we reconcile the idea of memories being held in the back of the brain's computer, and reminiscence of the type expressed by Proust and other great writers in works of literature? Surely a human is not just a 'thinking machine' but a being that lives through the meaningfulness of experience, having an 'iconic' representation of reality that takes account of the vivid sense of things, the wholeness of them.

The English physiologist Charles Sherrington imagined the brain as 'an enchanted loom' constantly weaving patterns of meaning. This analogy, Sacks suggests, is surely better than the computer in explaining the very personal nature of experience and the gaining of meaning with time. His own analogy for understanding the brain is in terms of 'scripts and scores'. That is, our lives are akin to a script that makes sense of our lives as we go along, or perhaps a musical score that does the same. Ultimately, then, the prism through we which we grasp our lives should not be scientific or mathematical – this would do for the left brain's functioning perhaps - but artistic. For the right brain, which is so deeply involved with the creation of this thing we feel to be the 'self', meaning must be gained from “the artful scenery and melody of experience and action”. From one  angle humans may look like advanced robots responding to their environment via a neurological computer, but to form a 'self' requires something more. Sacks notes that, “...empirical science, empiricism, takes no account of the soul, no account of what constitutes and determines personal being.” It is this something that his patients were striving to get back or retain in the face of an invader.

Final comments

It is only when something goes neurologically wrong that we realize how much we take for granted the effort that goes into keeping up the feeling of being an autonomous being, always in control. We are a 'miracle of integration', Sacks says, and often underestimate just how strong is the will of the self to assert itself in the face of the forces of disintegration such as neurological damage or disease.

Were the brain merely like a computer it could not bring itself back from the edge of chaos to reestablish a sense of meaning and independence. Rather than simply efficient operation, the human mind strives for wholeness; it seeks to create meaning out of random sensation and experience.

A painting or a symphony is not just oil paint or musical sounds – it is meaning. In the same way, over a lifetime a human being becomes something greater than the sum of their parts. When that person dies they are mourned not because they were a 'good body', but because they represented a certain meaning. This is what Sacks writes about: the undefined, meaningful, precious self.



Source: 50 Psychology Classics: Who We Are, How We Think, What We Do. Insight and inspiration from 50 key books (Nicholas Brealey, London & Boston), Tom Butler-Bowdon.

50 Psych Classics Book Cover

50 Psychology Classics: Who We Are, How We Think, What We Do: Insight and Inspiration from 50 Key Books

"At long last a chance for those outside the profession to discover that there is so much more to psychology than just Freud and Jung. 50 Psychology Classics offer a unique opportunity to become acquainted with a dazzling array of the key works in psychological literature almost overnight".

Dr Raj Persaud, Consultant Psychiatrist, The Maudsley Hospital London, Gresham Professor for Public Understanding of Psychiatry

"This delightful book provides thoughtful and entertaining summaries of 50 of the most influential books in psychology. Its a "must read" for students contemplating a career in psychology".

VS Ramachandran MD PhD, Professor and Director, Center for Brain and Cognition, University of California, San Diego

"A brilliant synthesis. The author makes complex ideas accessible and practical, without dumbing down the material. I found myself over and over thinking, 'Oh, that's what that guy meant'.

Douglas Stone, Lecturer on Law at Harvard Law School, author of Difficult Conversations



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Oliver Sacks

Born in London in 1933 to physician parents, Sacks gained his medical degree at Oxford University. Moving to the United States in the 1960s, he did an internship in San Francisco and a residency at University of California, Los Angeles.

He settled in New York in 1965, and his work in the 1960s dealing with victims of 'sleepy sickness' at the Beth Abraham Hospital in the Bronx is well known. He treated them with a then-experimental drug, L-dopa, which enabled many to come back to normal life. The experiments became the subject of his book Awakenings (1973), which inspired a Harold Pinter play A Kind of Alaska and the Hollywood movie Awakenings starring Robert De Niro and Robin Williams.

In addition to having a private practice, Sacks is a clinical professor of neurology at the Albert Einstein College of Medicine and an adjunct professor of neurology at the New York University School of Medicine. He is also a consultant neurologist to the Little Sisters of the Poor religious order. He has received many honorary doctorates.

Other books include Seeing Voices: A Journey into the World of the Deaf (1990), An Anthropologist on Mars (1995), The Island of the Colorblind (1996), and Uncle Tungsten: Memories of a Chemical Boyhood (2001).

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