The Mind's Eye

by Oliver Sacks

  8. Kristen Pammer and her colleagues have also shown, using magneto-encephalography, that the visual word form area does not work in isolation; it is part of a widely distributed cerebral network. Indeed, some areas in the frontal and temporal lobes are activated by words before the visual word form area. They stress that the spread of activation flows in both directions, to and from the visual word form area.

  Nonetheless it is possible to separate the act of reading from meaning, as, for example, I do when I read a religious text in Hebrew. I have learned how the words sound, but have little idea of their meaning. Something similar happens with hyperlexic preschool children, usually autistic, who may be able to read an article in the New York Times fluently and correctly but without comprehension.

  9. When we met, Scribner gave me a brief memoir he had just dictated, describing his alexia and how he had adapted to it; subsequently he published this as an afterword in his last book, In the Web of Ideas, from which I am quoting here.

  10. Brain damage from a stroke, a tumor, or a degenerative disease may produce a lasting alexia, but there can also be a transient alexia, due to a temporary disturbance in the brain’s visual recognition systems, as can happen, for instance, with migraine. (This has been described by Fleishman et al. and Bigley and Sharp, among others.) I had such an experience driving to an appointment one morning, when I suddenly found myself unable to read the names of streets; they seemed to be written in a strange archaic script—Phoenician, perhaps—that I could not decipher. My first thought was of some external change. New York City is a popular location for filming, and the “altered” street signs, I presumed, were part of some elaborate cinematic setup. Then a sort of shimmering or scintillation around the letters gave me a clue—my alexia, I realized, was part of a migraine aura.

  Alexia can also occur in conjunction with epilepsy. I recently saw a patient who described how reading (and only reading) triggers her seizures, but their first manifestation is an alexia. The words and letters before her suddenly become unintelligible, and she recognizes this as the prodrome of a seizure, which will follow within seconds. If she is alone, she will lie down and recite the alphabet to herself. On regaining consciousness after a seizure, she has expressive and receptive aphasia—an inability to speak or comprehend speech—for twenty minutes or so.

  11. There are some differences, however. As Maryanne Wolf points out, for example, “motoric memory areas are far more activated in reading Chinese than in reading other languages, because that is how Chinese symbols are learned by young readers—by writing, over and over.” And the same reader may use somewhat different neural circuits for reading different languages.

  One may sometimes find bilingual people who, following a stroke, lose the ability to read one language but not another. This has been especially studied in Japan, where there are two forms of written language in common use (often both forms are used in the same sentence). Kanji, which has a set of more than three thousand characters, was derived from Chinese ideograms. Kana, a syllabic system that, like an alphabet, can represent any speech sound, has just forty-six symbols. Though kanji and kana are so different, both employ the visual word form area. Functional MRI studies by Nakayama and Dehaene, however, show subtle but significant differences in their representation within this area, and rare cases have been reported of alexia for kanji but not for kana, and vice versa.

  12. Wallace expressed it as follows:

  Natural selection could only have endowed savage man with a brain a few degrees superior to that of an ape, whereas he actually possesses one very little inferior to that of a philosopher.… It seems as if the organ had been prepared in anticipation of the future progress in man, since it contains latent capacities which are useless to him in his earlier condition.

  13. Gould provided a marvelous analysis of Wallace’s thinking in his essay “Natural Selection and the Brain,” reprinted in The Panda’s Thumb.

  14. The earliest written languages used pictorial or iconic symbols, which became increasingly abstract and simplified. There were thousands of distinct hieroglyphs in Egypt and tens of thousands of ideograms in classical Chinese; reading (and writing) such a language demands a great deal of training and, presumably, the dedication of a larger portion of the visual cortex. This, Dehaene suggests, may be why most human languages have tended to favor alphabetic systems.

  And yet there may be certain powers, certain qualities peculiar to ideograms. Jorge Luis Borges, who was well versed in Japanese poetry, spoke of the multiple connotations of kanji ideograms in an interview:

  The Japanese have achieved a wise ambiguity in their poetry. And that, I believe, is because of their particular form of writing itself, because of the possibilities that their ideograms present. Each one, according to its features, can have several connotations. Take, for example, the word “gold.” This word represents or suggests autumn, the color of leaves, or the sunset because of its yellow color.

  15. Recently, while eating and talking, Howard bit the tip of his tongue by accident, and for a few days it was swollen and painful to move. He said, “It rendered me, for a day or so, illiterate once again.”

  The tongue, with its exquisite sensitivity, has an especially large motor and sensory representation in the brain. For this reason, it can be used for a sort of reading, as Howard does. Remarkably, it can also be used for sensory substitution devices that may enable blind people to “see” (see the chapter “The Mind’s Eye”).

  Face-Blind

  IT IS WITH OUR FACES that we face the world, from the moment of birth to the moment of death. Our age and our sex are printed on our faces. Our emotions, the open and instinctive emotions which Darwin wrote about, as well as the hidden or repressed ones which Freud wrote about, are displayed on our faces, along with our thoughts and intentions. Though we may admire arms and legs, breasts and buttocks, it is the face, first and last, which is judged “beautiful” in an aesthetic sense, “fine” or “distinguished” in a moral or intellectual sense. And, crucially, it is by our faces that we can be recognized as individuals. Our faces bear the stamp of our experiences and character; at forty, it is said, a man has the face he deserves.

  At two and a half months, babies respond to smiling faces by smiling back. “As the child smiles,” Everett Ellinwood writes, “it usually engages the adult human to interact with him—to smile, to talk, to hold—in other words, to initiate the processes of socialization.… The reciprocal understanding mother-child relationship is possible only because of the continuing dialogue between faces.” The face, psychoanalysts consider, is the first object to acquire visual meaning and significance. But are faces in a special category as far as the nervous system is concerned?

  I have had difficulty recognizing faces for as long as I can remember. I did not think too much about this as a child, but by the time I was a teenager, in a new school, it was often a cause of embarrassment. My frequent inability to recognize schoolmates would cause them bewilderment and, sometimes, offense—it did not occur to them (why should it?) that I had a perceptual problem. I usually recognized close friends without much problem, especially my two best friends, Eric Korn and Jonathan Miller. But this was partly because I identified particular features: Eric had heavy eyebrows and thick spectacles, and Jonathan was tall and gangly, with a mop of red hair. Jonathan was a keen observer of postures, gestures, and facial expressions, and he seemingly never forgot a face. A decade later, when we were looking at old school photos, he could still recognize literally hundreds of our schoolmates, while I could not recognize a single one.

  It was not just faces. When I went for a walk or a bicycle ride, I would have to follow exactly the same route, knowing that if I deviated from it even slightly, I would be instantly and hopelessly lost. I wanted to be adventurous, to go to exotic places—but I could do this only if I bicycled with a friend.

  At the age of seventy-six, despite a lifetime of trying to compensate, I have no less trouble with faces and places. I am th
rown particularly when I see people out of context, even if I have been with them five minutes before. This happened one morning just after my appointment with my psychiatrist (I had been seeing him twice weekly for several years at this point). A few minutes after I left his office, a soberly dressed man greeted me in the lobby of the building. I was puzzled as to why this stranger seemed to know me, until the doorman addressed him by name—it was, of course, my own analyst. (This failure to recognize him came up as a topic in our next session—I think he did not entirely believe me when I maintained that it had a neurological basis rather than a psychiatric one.)

  A few months later, my nephew Jonathan Sacks came for a visit. We went out for a walk—I lived in Mount Vernon, New York, at the time—and it started raining. “We had better get back,” Jonathan said, but I couldn’t find my house or my street. After two hours of walking around, in which we both got thoroughly soaked, I heard a shout. It was my landlord; he said he had seen me pass the house three or four times, apparently failing to recognize it.

  In those years, I had to take the Boston Post Road to get from Mount Vernon to my hospital on Allerton Avenue in the Bronx. Though I took the same route twice a day for eight years, the road never became familiar to me, I never recognized the buildings on either side, and I would often turn the wrong way up the road, realizing it only when I came to one of two landmarks that were unmistakable, even for me: at one end, Allerton Avenue, which had a large sign, or, at the other, the Bronx River Parkway, which loomed over the Boston Post Road.

  I had been working with my assistant, Kate, for about six years when we arranged to rendezvous in a midtown office for a meeting with my publisher. I arrived and announced myself to the receptionist, but failed to note that Kate had already arrived and was sitting in the waiting area. That is, I saw a young woman there, but did not realize it was her. After about five minutes, smiling, she said, “Hello, Oliver. I was wondering how long it would take you to recognize me.”

  Parties, even my own birthday parties, are a challenge. (More than once, Kate has asked my guests to wear name tags.) I have been accused of “absentmindedness,” and no doubt this is true. But I think that a significant part of what is variously called my “shyness,” my “reclusiveness,” my “social ineptitude,” my “eccentricity,” even my “Asperger’s syndrome,” is a consequence and a misinterpretation of my difficulty recognizing faces.

  My problem with recognizing faces extends not only to my nearest and dearest, but also to myself. Thus on several occasions I have apologized for almost bumping into a large bearded man, only to realize that the large bearded man was myself in a mirror. The opposite situation once occurred at a restaurant with tables outside. Sitting at one of these sidewalk tables, I turned to the restaurant window and began grooming my beard, as I often do. I then realized that what I had taken to be my reflection was not grooming himself but looking at me oddly. There was in fact a gray-bearded man on the other side of the window, who must have been wondering why I was preening myself in front of him.

  Kate often cautions people in advance about my little problem. She tells visitors, “Don’t ask if he remembers you, because he will say no. Introduce yourself by name and tell him who you are.” (And to me, she says, “Don’t just say no—that’s rude and will upset people. Say, ‘I’m sorry, I am awful about recognizing people. I wouldn’t recognize my own mother.’ ”)1

  In 1988 I met Franco Magnani, the “memory artist,” and over the next couple of years I spent weeks with him, talking about his paintings, his life, and even traveling to Italy with him to revisit the village where he grew up. When I finally submitted an article about him to The New Yorker, Robert Gottlieb, who was then the magazine’s editor in chief, read the piece and said, “Very nice, fascinating—but what does he look like? Can you add some description?” I parried this awkward (and, to me, unanswerable) question by saying, “Who cares what he looks like? The piece is about his work.”

  “Our readers will want to know,” Bob said. “They need to picture him.”

  “I will have to ask Kate,” I said. Bob gave me a peculiar look.

  I assumed that I was just very bad at recognizing faces, as my friend Jonathan was very good—that this was within the limits of normal variation, and that he and I just stood at opposite ends of a spectrum. It was only when I went to Australia to visit my older brother Marcus, whom I had scarcely seen in thirty-five years, and discovered that he, too, had exactly the same difficulties recognizing faces and places that it dawned on me that this was something beyond normal variation, that we both had a specific trait, a so-called prosopagnosia, probably with a distinctive genetic basis.2

  That there were others like me was brought home in various ways. The meeting of two people with prosopagnosia, in particular, can be very challenging. A few years ago, I wrote to one of my colleagues to tell him that I admired his new book. His assistant then phoned Kate to arrange a meeting, and they settled on a weekend dinner at a restaurant in my neighborhood.

  “There may be a problem,” Kate said. “Dr. Sacks cannot recognize anyone.”

  “It’s the same with Dr. W.,” his assistant replied.

  “And another thing,” Kate added. “Dr. Sacks cannot find restaurants or other places; he gets lost very easily—he can’t even recognize his own building sometimes.”

  “Yes, it’s the same with Dr. W.,” his assistant said.

  Somehow, we did manage to meet and enjoyed dinner together. But I still have no idea what Dr. W. looks like, and he probably would not recognize me, either.

  Although such examples may seem comical, they are sometimes quite devastating. People with very severe prosopagnosia may be unable to recognize their spouse, or to pick out their own child in a group of others.

  Jane Goodall also has a certain degree of prosopagnosia. Her problems extend to recognizing chimpanzees as well as people—thus, she says, she is often unable to distinguish individual chimps by their faces. Once she knows a particular chimp well, she ceases to have difficulties; similarly, she has no problem with family and friends. But, she says, “I have huge problems with people with ‘average’ faces.… I have to search for a mole or something. I find it very embarrassing! I can be all day with someone and not know them the next day.”

  She adds that she, too, has difficulties in recognizing places: “I just don’t know where I am until I am very familiar with the route. I have to turn and look at landmarks so I can find my way back. This was a problem in the forest, and I often got lost.”

  In 1985, I published a case history called “The Man Who Mistook His Wife for a Hat,” about Dr. P., who had developed a very severe visual agnosia. He was not able to recognize faces or their expressions. Moreover, he could not identify or even categorize objects; thus, he was unable to recognize a glove, to recognize that it was an article of clothing, or that it resembled a hand. At one point he mistook his wife’s head for his hat.

  After Dr. P.’s story was published, I began to get letters from correspondents who would compare their difficulties in recognizing places and faces with his. In 1991, Anne F. wrote to me, describing her experiences:

  I believe that three people in my immediate family have visual agnosias: my father, a sister, and myself. We each have traits in common with your Dr. P., but, hopefully, not to the same degree. The most striking behavior we all share in common with Dr. P. is the prosopagnosia. My father, a man who has had a successful radio career here in Canada (his particular gift is an ability to mimic voices), was unable to recognize his wife in a recent photograph. At a wedding reception he asked a stranger to identify the man sitting next to his daughter (my husband of five years at the time).

  I have walked by my husband, while staring directly at his face, on several occasions without recognizing him. I have no difficulty recognizing him, however, in situations or places where I am expecting to see him. I am also able to recognize people immediately when they begin to speak, even if I’ve heard their voice only onc
e in the past.

  Unlike Dr. P., I feel I can read people well on an emotional level.… I don’t have the degree of agnosia for common objects that Dr. P. had. [However,] like Dr. P., I am totally incapable of establishing a topographical representation of space.… I have no memory for where I put things unless I verbally encode the location. Once an object leaves my hands, it drops off the edge of the world into a void.

  While Anne F. seems to have prosopagnosia and topographical agnosia on a genetic or familial basis, others may develop this (or any other form of agnosia) in consequence of a stroke, a tumor, an infection, or an injury—or, like Dr. P., a degenerative disease such as Alzheimer’s—that has damaged a particular part of the brain. Joan C., another correspondent, had an unusual history in this regard: she had developed a brain tumor in the right occipital lobe as an infant, and this was removed when she was two years old. It seems likely, though it is difficult to be certain, that her prosopagnosia was the result of either the tumor or the surgery. Her inability to recognize faces has often been misinterpreted by others. She notes, “I’ve been told that I’m rude, or a space cadet, or (according to a psychiatrist) suffering from a psychiatric disorder.”

  As I continued to receive more and more letters from people with prosopagnosia or topographical agnosia, it became clear to me that “my” visual problem was not uncommon and must affect many people around the world.