hat2 - HAT Z 1 The Man Who Mistook His Wifefor a Hat 15 But...

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Unformatted text preview: HAT Z 1 The Man Who Mistook His Wifefor a Hat 15 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 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 mu.-. 16 Part One: Losses time — eating songs, dressing songs, bathing songs, everything. He can’t do anything unless he makes it a sohg.’ While we were talking my attention was caught by the pictures on the walls. ‘Yes,’ Mrs P. said, ‘he was a gifted painter as well as a singer. The School exhibited his pictures every year.’ I strolled past them curiously — they were in chronological order. All his earlier work was naturalistic and realistic, with vivid mood and atmosphere, but finely detailed and concrete. Then, years later, they became less vivid, less concrete, less realistic and naturalistic; but far more abstract, even geometrical and cubist. Finally, in the last paintings, the canvasses became nonsense, or nonsense to me — mere chaotic lines and blotches of paint. I commented on this to Mrs P. ‘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, non-representational 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 non-representation to the abstract, but 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. V We returned to the great music-room, with the Bosendorfer in the centre, and Dr P. humming the last torte. 1 The Man Who M istook His Wy‘e for a Hot 17 ‘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 ?’ ‘I 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 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 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 seeing, this relating, that Dr .P. lacked (though his . judging, in all other spheres, was prompt and normal). Was ‘ 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. ‘I know his movements, his body-music.’ 18 Part One: Losses this due to lack of visual information, or faulty processing of visual information? (This would be the explanation given by a I 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 abstractness 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. _ 1 Of course, the brain is a machine and a computer - I The Man Who Mistook His Wy’efor a Hat 19 everything in classical neurology is correct. But our mental 4.1;: processes, which constitute our being and life, are not just W; 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 1;- computer-like, as Dr P. was. And, by the same token, if we delete feeling and judging, the personal, from the cognitive * “W” sciences, we reduce them to something as defective as Dr P. - -~~ and we reduce our apprehension of the concrete and real. 1» »--- By a sort of comic and awful analogy, our current cognitive l neurology and psychology resembles nothing so much as poor L 7'1" Dr R! We need the concrete and real, as he did; and we fail to «w»— see this, as he failed to see it. Our cognitive sciences are themselves suffering from an agnosia essentially similar to Dr Z? P.’s. Dr P. may therefore serve as a warning and parable — of 7 what happens to a science which eschews the judgmental, the particular, the personal, and becomes entirely abstract and computational. w. I It was always a matter of great regret to me that, owing to circumstances beyond my control, I was not able to follow his ‘37:? 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 ::Co’micall‘y similar case, similar (indeed identical) neuro- sychologically and phenomenologically, though the under- ying pathology (an acute head injury) and all personal circumstances were wholly different. The authors speak of their A case as ‘unique in the documented history of this disorder’ - ftmdevidently experienced, as I did, amazement at their own “ findings.‘ The‘interested reader is referred to the original ‘ " Only since the completion of this book have I found that there is, in fact, a 20 Part One: Losses 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 82, 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.) be 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, 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 notrecognise 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 rather extensive literature on visual agnosia in general, and prosopagnosia, in particular, though so scattered, and in so many languages, that it is easily overlooked. In particular I had the great pleasure recently of meeting Dr Andrew Kertesz, who has an unrivalled knowledge of the world literature on the subject and 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. 1 The Man Who Mistook His Wye for a Hat 21 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 visualise 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’. Bibliography CHAPTER fiEFERENCEs 1. The Man Who Mistook Hi5 Wyefor a Hat Macrae, D. ‘The defect of function in visual agnosia’, Brain and Trolle, E. (1956) 7: 94-110 Kertesz, A. ‘Visual agnosia: the dual deficit of perception and recognition’, Cortex (1979) I5: 403- 19. Mart, D. See below under Chapter 15. 2. The Lost Mariner Korsakov’s original (1887) contribution and his later works have not been translated. A full bibliography, with translated excerpts and discussion, is given in A.R. Luria’s Neuropsychology g” Memory (op. cit), which itself provides many striking examples of amnesia akin to that of ‘The Lost Mariner’. Both here, and in the preceding case-history, I refer to Anton, POtzl and Freud. Of these only Freud’s monograph — a work of great importance - has been translated into English: . Anton, G. ‘Uber die Selbstwarnehmung der Herderkrankungen des Gehims durch den Kranken’, Arch. Psychiat. (1899) 32. Freud, S. Zur Aufi’assung der Aphasia, Leipzig 1891. Authorised English tr., by E. Stengel, as 0n Aphasia: a Critical Study, New York 1953. P6tzl, 0. Die Aphasielehre vom Stand/)th der klinischen Psychiatric: Die Optische-agnostischen Sto'rungen, Leipzig 1928'. The syndrome Potzl describes is not merely visual, but may extend to a complete unawareness of parts, or one half, of the body. As such it is also relevant to the themes of Chapters 3, 4 and 8. It is also referred to in my book A Leg to Stand On (1984). Sterman,A.B. et al ‘The acute sensory neuropathy syndrome’, Annals ofNeurology (1972) 7: 354-8. 3. The Disembodied Lady Sherrington, C.S. The Integrative Action «J the Nervous System, Cambridge 1906, esp. pp. 835-43. Man on his Nature, Cambridge 1940, ch. 11, esp. pp. 328-9, has the directest relevance to this patient’s condition. 230 Bibliography Marr, D. Vision: A Computational Investigation of Visual Representation in Man, San Francisco 1982. This is a work of extreme originality and importance, published posthumously (Marr contracted leukemia while still a young man). Penfield shows us the forms of the brain’s final representations — voices, faces, tunes, scenes — the ‘iconic’: Marr shows us what is not intuitively obvious, or ever normally experienced — the form of the brain’s initial representations. Perhaps I should have given this reference in Chapter 1 -— it is certain that Dr P. had some ‘Marr-like’ deficits, difficulties in forming what Marr calls a ‘primal sketch’ in, addition to, or underlying, his physiognomonic difficulties. Probably no neurological study of imagery, or memory, can dispense with the considerations raised by Man'. 16. Incontinent Nostalgia jelliffe, 8.12. I Psychopathology 9f Forced Movements and Oculogyn'c Crises 9f Lethargic Encephalitis, London 1932, esp. p.114ff. discussing Zutt’s paper of 1980. See also the case of ‘Rose R.’ in Awakenings, London 1973; 3rd. ed. 1988. 17. A Passage to India I am not acquainted with the literature on this subject. I have, however, had personal experience of another patient - also with a glioma, with increased intracranial pressure and seizures, and on steroids — who, as she was dying, had similar nostalgic visions and reminiscences, in her case of the mid-West. 18. The Dog Beneath the Skin Bear, D. ‘Temporal-lobe epilepsy: a syndrome of sensory-limbic hyperconnection’, Cortex (1979) 15: 357-84. Brill, A.A. ‘The sense of smell in neuroses and psychoses’, Psychoanalytical Quarterly (1982) 1: 7-42. Brill’s lengthy paper covers much more ground than its title would indicate. In particular it contains a detailed consideration of the strength and ...
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