The man who mistook his wife for a hat

by Oliver Sacks

  There may be an immense latent period between the primary infection and the advent of neurosyphilis, especially if the primary infection has been suppressed, not eradicated. I had one patient, treated with Salvarsan by Ehrlich himself, who developed tabes dorsalis-one form of neurosyphilis-more than fifty years later.

  But I had never heard of an interval of seventy years-nor of a self-diagnosis of cerebral syphilis mooted so calmly and clearly.

  'That's an amazing suggestion,' I replied after some thought. 'It would never have occurred to me-but perhaps you are right.'

  She was right; the spinal fluid was positive, she did have neurosyphilis, it was indeed the spirochetes stimulating her ancient cerebral cortex. Now the question of treatment arose. But here another dilemma presented itself, propounded, with typical acuity, by Mrs K. herself. 'I don't know that I want it treated,' she said. 'I know it's an illness, but it's made me feel well. I've enjoyed it, I still enjoy it, I won't deny it. It's made me feel livelier, friskier, than I have in twenty years. It's been fun. But I know when a good thing goes too far, and stops being good. I've had thoughts, I've had impulses, I won't tell you, which are-well, embarrassing and silly. It was like being a little tiddly, a little tipsy, at first, but if it goes any further . . .' She mimed a drooling, spastic dement. 'I guessed I had Cupid's, that's why I came to you. I don't want it to get worse, that would be awful; but I don't want it cured-that would be just as bad. I wasn't fully alive until the wrigglies got me. Do you think you could keep it just as it is?'

  We thought for a while, and our course, mercifully, was clear. We have given her penicillin, which has killed the spirochetes,

  but can do nothing to reverse the cerebral changes, the disinhi-bitions, they have caused.

  And now Mrs K. has it both ways, enjoying a mild disinhibi-tion, a release of thought and impulse, without any threat to her self-control or of further damage to her cortex. She hopes to live, thus reanimated, rejuvenated, to a hundred. 'Funny thing,' she says. 'You've got to give it to Cupid.'

  Postscript

  Very recently (January 1985) I have seen some of these same dilemmas and ironies in relation to another patient (Miguel O.), admitted to the state hospital with a diagnosis of 'mania', but soon realised to be suffering from the excited stage of neurosyphilis. A simple man, he had been a farmhand in Puerto Rico, and with some speech and hearing impediment, he could not express himself too well in words, but expressed himself, exhibited his situation, simply and clearly, in drawings.

  The first time I saw him he was quite excited, and when I asked him to copy a simple figure (Figure A) he produced, with great brio, a three-dimensional elaboration (Figure B)-or so I took it to be, until he explained that it was 'an open carton', and then tried to draw some fruit in it. Impulsively inspired by his excited imagination, he had ignored the circle and cross, but retained, and made concrete, the idea of 'enclosure'. An open carton, a carton full of oranges-was that not more exciting, more alive, more real, than my dull figure?

  A few days later I saw him again, very energised, very active, thoughts and feelings flying everywhere, high as a kite. I asked him again to draw the same figure. And now, impulsively, without pausing for a moment, he transformed the original to a sort of trapezoid, a lozenge, and then attached to this a string-and a boy (Figure C). 'Boy flying kite, kites flying!' he exclaimed excitedly.

  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,

  Excited elaboration ('an open carton')

  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?'

  The drawings of patients with Parkinsonism, as they are 'awakened' by L-Dopa, form an instructive analogy. Asked to draw a tree, the Parkinsonian tends to draw a small, meagre thing, stunted, impoverished, a bare winter-tree with no foliage at all. As he 'warms up', 'comes to', is animated by L-Dopa, so the tree acquires vigour, life, imagination-and foliage. If he becomes too excited, high, on L-Dopa, the tree may acquire a fantastic ornateness and exuberance, exploding with a florescence of new branches and foliage with little arabesques, curlicues, and what-not, until finally its original form is completely lost beneath this enormous, this baroque, elaboration. Such drawings are also rather characteristic of Tourette's-the original form, the original thought, lost in a jungle of embellishment-and in the so-called 'speed-art' of am-

  phetaminism. First the imagination is awakened, then excited, frenzied, to endlessness and excess.

  What a paradox, what a cruelty, what an irony, there is here- that inner life and imagination may lie dull and dormant unless released, awakened, by an intoxication or disease!

  Precisely this paradox lay at the heart of Awakenings; it is responsible too for the seduction of Tourette's (see Chapters Ten and Fourteen) and, no doubt, for the peculiar uncertainty which may attach to a drug like cocaine (which is known, like L-Dopa, or Tourette's, to raise the brain's dopamine). Thus Freud's startling comment about cocaine, that the sense of well-being and euphoria it induces '. . . in no way differs from the normal euphoria of the healthy person … In other words, you are simply normal, and it is soon hard to believe that you are under the influence of any drug'.

  The same paradoxical valuation may attach to electrical stimulations of the brain: there are epilepsies which are exciting and addictive-and may be self-induced, repeatedly, by those who are prone to them (as rats, with implanted cerebral electrodes, compulsively stimulate the 'pleasure-centres' of their own brain); but there are other epilepsies which bring peace and genuine well-being. A wellness can be genuine even if caused by an illness. And such a paradoxical wellness may even confer a lasting benefit, as with Mrs O'C. and her strange convulsive 'reminiscence' (Chapter Fifteen).

  We are in strange waters here, where all the usual considerations may be reversed-where illness may be wellness, and normality illness, where excitement may be either bondage or release, and where reality may lie in ebriety, not sobriety. It is the very realm of Cupid and Dionysus.

  12

  A Matter of Identity

  'What'll it be today?' he says, rubbing his hands. 'Haifa pound of Virginia, a nice piece of Nova?'

  (Evidently he saw me as a customer-he would often pick up the phone on the ward, and say 'Thompson's Delicatessen'.)

  'Oh Mr Thompson!' I exclaim. 'And who do you think I am?'

  'Good heavens, the light's bad-I took you for a customer. As if it isn't my old friend Tom Pitkins. . . Me and Tom' (he whispers in an aside to the nurse) 'was always going to the races together.'

  'Mr Thompson, you are mistaken again.'

  'So I am,' he rejoins, not put out for a moment. 'Why would you be wearing a white coat if you were Tom? You're Hymie, the kosher butcher next door. No bloodstains on your coat though. Business bad today? You'll look like a slaughterhouse by the end of the week!'

  Feeling a bit swept away myself in this whirlpool of identities, I finger the stethoscope dangling from my neck.

  'A stethoscope!' he exploded. 'And you pretending to be Hymie! You mechanics are all starting to fancy yourselves to be doctors, what with your white coats and stethoscopes-as if you need a stethoscope to listen to a car! So, you're my old friend Manners from the Mobil station up the block, come in to get your boloney-and-rye . . .'

  William Thompson rubbed his hands again, in his salesman-grocer's gesture, and looked for the counter. Not finding it, he looked at me strangely again.

  'Where am I?' he said, with a sudden scared look. 'I thought I

  was in my shop, doctor. My mind must have wandered . . . Yo
u'll he wanting my shirt off, to sound me as usual?'

  'No, not the usual. I'm not your usual doctor.'

  'Indeed you're not. I could see that straightaway! You're not my usual chest-thumping doctor. And, by God, you've a beard! You look like Sigmund Freud-have I gone bonkers, round the bend?'

  'No, Mr Thompson. Not round the bend. Just a little trouble with your memory-difficulties remembering and recognising people.'

  'My memory has been playing me some tricks,' he admitted. 'Sometimes I make mistakes-I take somebody for somebody else . . . What'll it be now-Nova or Virginia?'

  So it would happen, with variations, every time-with improvisations, always prompt, often funny, sometimes brilliant, and ultimately tragic. Mr Thompson would identify me-misidentify, pseudo-identify me-as a dozen different people in the course of five minutes. He would whirl, fluently, from one guess, one hypothesis, one belief, to the next, without any appearance of uncertainty at any point-he never knew who I was, or what and where he was, an ex-grocer, with severe Korsakov's, in a neurological institution.

  He remembered nothing for more than a few seconds. He was continually disoriented. Abysses of amnesia continually opened beneath him, but he would bridge them, nimbly, by fluent confabulations and fictions of all kinds. For him they were not fictions, but how he suddenly saw, or interpreted, the world. Its radical flux and incoherence could not be tolerated, acknowledged, for an instant-there was, instead, this strange, delirious, quasi-coherence, as Mr Thompson, with his ceaseless, unconscious, quick-fire inventions, continually improvised a world around him-an Arabian Nights world, a phantasmagoria, a dream, of ever-changing people, figures, situations-continual, kaleidoscopic mutations and transformations. For Mr Thompson, however, it was not a tissue of ever-changing, evanescent fancies and illusion, but a wholly normal, stable and factual world. So far as he was concerned, there was nothing the matter.

  On one occasion, Mr Thompson went for a trip, identifying himself at the front desk as 'the Revd. William Thompson', ordering a taxi, and taking off for the day. The taxi-driver, whom we later spoke to, said he had never had so fascinating a passenger, for Mr Thompson told him one story after another, amazing personal stories full of fantastic adventures. 'He seemed to have been everywhere, done everything, met everyone. I could hardly believe so much was possible in a single life,' he said. 'It is not exactly a single life,' we answered. 'It is all very curious-a matter of identity.'*

  Jimmie G., another Korsakov's patient, whom I have already described at length (Chapter Two), had long since cooled down from his acute Korsakov's syndrome, and seemed to have settled into a state of permanent lostness (or, perhaps, a permanent now-seeming dream or reminiscence of the past). But Mr Thompson, only just out of hospital-his Korsakov's had exploded just three weeks before, when he developed a high fever, raved, and ceased to recognise all his family-was still on the boil, was still in an almost frenzied confabulatory delirium (of the sort sometimes called 'Korsakov's psychosis', though it is not really a psychosis at all), continually creating a world and self, to replace what was continually being forgotten and lost. Such a frenzy may call forth quite brilliant powers of invention and fancy-a veritable confabulatory genius-for such a patient must literally make himself (and his world) up every moment. We have, each of us, a life-story, an inner narrative-whose continuity, whose sense, is our lives. It might be said that each of us constructs and lives, a 'narrative', and that this narrative is us, our identities.

  If we wish to know about a man, we ask 'what is his story-his real, inmost story?'-for each of us is a biography, a story. Each of us is a singular narrative, which is constructed, continually, unconsciously, by, through, and in us-through our perceptions,

  *A very similar story is related by Luria in The Neuropsychology of Memory (1976), in which the spell-bound cabdriver only realised that his exotic passenger was ill when he gave him, for a fare, a temperature chart he was holding. Only then did he realise that this Scheherazade, this spinner of 1001 tales, was one of 'those strange patients' at the Neurological Institute.

  our feelings, our thoughts, our actions; and, not least, our discourse, our spoken narrations. Biologically, physiologically, we are not so different from each other; historically, as narratives-we are each of us unique.

  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.

  This narrative need, perhaps, is the clue to Mr Thompson's desperate tale-telling, his verbosity. Deprived of continuity, of a quiet, continuous, inner narrative, he is driven to a sort of nar-rational frenzy-hence his ceaseless tales, his confabulations, his mythomania. Unable to maintain a genuine narrative or continuity, unable to maintain a genuine inner world, he is driven to the proliferation of pseudo-narratives, in a pseudo-continuity, pseudo-worlds peopled by pseudo-people, phantoms.

  What is it like for Mr Thompson? Superficially, he comes over as an ebullient comic. People say, 'He's a riot.' And there is much that is farcical in such a situation, which might form the basis of a comic novel. * It is comic, but not just comic-it is terrible as well. For here is a man who, in some sense, is desperate, in a frenzy. The world keeps disappearing, losing meaning, vanishing-and he must seek meaning, make meaning, in a desperate way, continually inventing, throwing bridges of meaning over abysses of meaninglessness, the chaos that yawns continually beneath him.

  But does Mr Thompson himself know this, feel this? After finding him 'a riot', 'a laugh', 'loads of fun', people are disquieted,

  *Indeed such a novel has been written. Shortly after 'The Lost Mariner' (Chapter Two) was published, a young writer named David Gilman sent me the manuscript of his book Croppy Boy, the story of an amnesiac like Mr Thompson, who enjoys the wild and unbridled license of creating identities, new selves, as he whims, and as he must-an astonishing imagination of an amnesiac genius, told with positively Joycean richness and gusto. 1 do not know whether it has been published; 1 am very sure it should be. I could not help wondering whether Mr Gilman had actually met (and studied) a 'Thompson'-as I have often wondered whether Borges' 'Funes', so uncannily similar to Luria's Mnemonist, may have been based on a personal encounter with such a mnemonist.

  even terrified, by something in him. 'He never stops', they say. 'He's like a man in a race, a man trying to catch something which always eludes him.' And, indeed, he can never stop running, for the breach in memory, in existence, in meaning, is never healed, but has to be bridged, to be 'patched', every second. And the bridges, the patches, for all their brilliance, fail to work-because they are confabulations, fictions, which cannot do service for reality, while also failing to correspond with reality. Does Mr Thompson feel this? Or, again, what is his 'feeling of reality'? Is he in a torment all the while-the torment of a man lost in unreality, struggling to rescue himself, but sinking himself, by ceaseless inventions, illusions, themselves quite unreal? It is certain that he is not at ease-there is a tense, taut look on his face all the while, as of a man under ceaseless inner pressure; and occasionally, not too often, or masked if present, a look of open, naked, pathetic bewilderment. What saves Mr Thompson in a sense, and in another sense damns him, is the forced or defensive superficiality of his life: the way in which it is, in effect, reduced to a surface, brilliant, shimmering, iridescent, ever-changing, but for all that a surface, a mass of illusions, a delirium, without depth.

  And with this, no feeling that he has lost feeling (for the feeling he has lost), no feeling that he has lost the depth, that unfathomable, mysterious, myriad-levelled depth which somehow defines identity or reality. This strikes everyone who has been in contact with him for any time-that under his fluency, even his frenzy, is a strange loss of feeling-that feeling, or judgment, which distinguishes between 'real' and 'unreal', 'true' and 'untrue' (one cannot speak o
f 'lies' here, only of 'non-truth'), important and trivial, relevant or irrelevant. What comes out, torrentially, in his ceaseless confabulation, has, finally, a peculiar quality of indifference … as if it didn't really matter what he said, or what anyone else did or said; as if nothing really mattered any more.

  A striking example of this was presented one afternoon, when William Thompson, jabbering away, of all sorts of people who were improvised on the spot, said: 'And there goes my younger brother, Bob, past the window', in the same, excited but even and indifferent tone, as the rest of his monologue. I was dumbfounded

  when, a minute later, a man peeked round the door, and said: 'I'm Bob, I'm his younger brother-I think he saw me passing by the window.' Nothing in William's tone or manner-nothing in his exuberant, but unvarying and indifferent, style of monologue-had prepared me for the possibility of. . . reality. William spoke of his brother, who was real, in precisely the same tone, or lack of tone, in which he spoke of the unreal-and now, suddenly, out of the phantoms, a real figure appeared! Further, he did not treat his younger brother as 'real'-did not display any real emotion, was not in the least oriented or delivered from his delirium- but, on the contrary, instantly treated his brother as unreal, effacing him, losing him, in a further whirl of delirium-utterly different from the rare but profoundly moving times when Jimmie G. (see Chapter Two) met his brother, and while with him was unlost. This was intensely disconcerting to poor Bob-who said 'I'm Bob, not Rob, not Dob', to no avail whatever. In the midst of confabulations-perhaps some strand of memory, of remembered kinship, or identity, was still holding (or came back for an instant)-William spoke of his elder brother, George, using his invariable present indicative tense.

  'But George died nineteen years ago!' said Bob, aghast.