The man who mistook his wife for a hat

by Oliver Sacks

Vivid dream one night, dreamt he was a dog, in a world unimaginably rich and significant in smells. ('The happy smell of water . . . the brave smell of a stone.') Waking, he found himself in just such a world. 'As if I had been totally colour-blind before, and suddenly found myself in a world full of colour.' He did, in fact, have an enhancement of colour vision ('I could distinguish dozens of browns where I'd just seen brown before. My leather-bound books, which looked similar before, now all had quite distinct and distinguishable hues') and a dramatic enhancement of eidetic visual perception and memory ('I could never draw before, I couldn't "see" things in my mind, but now it was like having a camera lucida in my mind-I "saw" everything, as if projected on the paper, and just drew the outlines I "saw". Suddenly I could do the most accurate anatomical drawings.') But it was the exaltation of smell which really transformed his world: 'I had dreamt I was a dog-it was an olfactory dream-and now I awoke to an infinitely redolent world-a world in which all other sensations, enhanced as they were, paled before smell.' And with all this there went a sort of trembling, eager emotion, and a strange nostalgia, as of a lost world, half forgotten, half recalled.*

  * Somewhat similar states-a strange emotionalism; sometimes nostalgia, 'reminiscence' and deja vu associated with intense olfactory hallucinations, are characteristic of 'uncinate seizures', a form of temporal-lobe epilepsy first described by Hughlings Jackson about a century ago. Usually the experience is rather specific, but sometimes there is a generalised intensification of smell, a hyperosmia. The uncus, phylogenet-

  (continued)

  'I went into a scent shop,' he continued. 'I had never had much of a nose for smells before, but now I distinguished each one instantly-and I found each one unique, evocative, a whole world.' He found he could distinguish all his friends-and patients-by smell: 'I went into the clinic, I sniffed like a dog, and in that sniff recognised, before seeing them, the twenty patients who were there. Each had his own olfactory physiognomy, a smell-face, far more vivid and evocative, more redolent, than any sight face.' He could smell their emotions-fear, contentment, sexuality-like a dog. He could recognise every street, every shop, by smell-he could find his way around New York, infallibly, by smell.

  He experienced a certain impulse to sniff and touch everything ('It wasn't really real until I felt it and smelt it') but suppressed this, when with others, lest he seem inappropriate. Sexual smells were exciting and increased-but no more so, he felt, than food smells and other smells. Smell pleasure was intense-smell displeasure, too-but it seemed to him less a world of mere pleasure and displeasure than a whole aesthetic, a whole judgment, a whole new significance, which surrounded him. 'It was a world overwhelmingly concrete, of particulars,' he said, 'a world overwhelming in immediacy, in immediate significance.' Somewhat intellectual before, and inclined to reflection and abstraction, he now found thought, abstraction and categorisation, somewhat difficult and unreal, in view of the compelling immediacy of each experience.

  Rather suddenly, after three weeks, this strange transformation ceased-his sense of smell, all his senses, returned to normal; he found himself back, with a sense of mingled loss and relief, in his old world of pallor, sensory faintness, non-concreteness and abstraction. 'I'm glad to be back,' he said, 'but it's a tremendous loss,

  (continued) ically part of the ancient 'smell-brain' (or rhinencephalon), is functionally associated with the whole limbic system, which is increasingly recognised to be crucial in determining and regulating the entire emotional 'tone'. Excitation of this, by whatever means, produces heightened emotionalism and an intensification of the senses. The entire subject, with its intriguing ramifications, has been explored in great detail by David Bear (1979).

  too. I see now what we give up in being civilised and human. We need the other-the "primitive"-as well.'

  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!'

  Freud wrote on several occasions of man's sense of smell as being a 'casualty', repressed in growing up and civilisation with the assumption of an upright posture and the repression of primitive, pre-genital sexuality. Specific (and pathological) enhancements of smell have indeed been reported as occurring in paraphilia, fetishism, and allied perversions and regressions.* But the disinhibition here described seems far more general, and though associated with excitement-probably an amphetamine-induced dopaminergic excitation-was neither specifically sexual nor associated with sexual regression. Similar hyperosmia, sometimes paroxysmal, may occur in excited hyper-dopaminergic states, as with some post-encephalitics on L-Dopa, and some patients with Tourette's syndrome.

  What we see, if nothing else, is the universality of inhibition, even at the most elemental perceptual level: the need to inhibit what Head regarded as primordial and full of feeling-tone, and called 'protopathic', in order to allow the emergence of the sophisticated, categorising, affectless 'epicritic'.

  The need for such inhibition cannot be reduced to the Freudian, nor should its reduction be exalted, romanticised, to the Blakean. Perhaps we need it, as Head implies, that we may be

  *This is well described by A.A. Brill (1932), and contrasted with the overall brilliance, the redolence, of the smell-world, in macrosomatic animals (such as dogs), 'savages' and children.

  men and not dogs. * And yet Stephen D. 's experience reminds us, like G.K. Chesterton's poem, The Song of Quoodle', that sometimes we need to be dogs and not men:

  They haven't got no noses The fallen sons of Eve . . . Oh, for the happy smell of water, the brave smell of a stone!

  Postscript

  I have recently encountered a sort of corollary of this case-a gifted man who sustained a head injury, severely damaging his olfactory tracts (these are very vulnerable in their long course across the anterior fossa) and, in consequence, entirely losing his sense of smell.

  He has been startled and distressed at the effects of this: 'Sense of smell?' he says. 'I never gave it a thought. You don't normally give it a thought. But when I lost it-it was like being struck blind. Life lost a good deal of its savour-one doesn't realise how much 'savour' is smell. You smell people, you smell books, you smell the city, you smell the spring-maybe not consciously, but as a rich unconscious background to everything else. My whole world was suddenly radically poorer . . . '

  There was an acute sense of loss, and an acute sense of yearning, a veritable osmalgia: a desire to remember the smell-world to which he had paid no conscious attention, but which, he now felt, had formed the very ground base of life. And then, some months later, to his astonishment and joy, his favourite morning coffee, which had become 'insipid', started to regain its savour. Tentatively he tried his pipe, not touched for months, and here too caught a hint of the rich aroma he loved.

  Greatly excited-the neurologists had held out no hope of recovery-he returned to his doctor. But after testing him minutely,

  *See Jonathan Miller's critique of Head, entitled 'The Dog Beneath the Skin', in the Listener (1970).

  using a 'double-blind' technique, his doctor said: 'No, I'm sorry, there's not a trace of recovery. You still have a total anosmia. Curious though that you should now "smell" your pipe and coffee . . .'

  What seems to be happening-and it is important that it was only the olfactory tracts, not the cortex, which were damaged-is the development of a greatly enhanced olfactory imagery, almost, one might say, a controlled hallucinosis, so that in drinking his coffee, or lighting his pipe-situations normally and previously fraught with associations of smell-he is now able to evoke or re-evoke these, unconsciously, and with su
ch intensity as to think, at first, that they are 'real'.

  This power-part conscious, part unconscious-has intensified and spread. Now, for example, he snuffs and 'smells' the spring. At least he calls up a smell-memory, or smell-picture, so intense that he can almost deceive himself, and deceive others, into believing that he truly smells it.

  We know that such a compensation often occurs with the blind and the deaf. We think of the deaf Beethoven and the blinded Prescott. But I have no idea whether it is common with anosmia.

  19

  Murder

  Donald killed his girl while under the influence of PCP. He had, or seemed to have, no memory of the deed-and neither hypnosis nor sodium amytal served to release any. There was, therefore, it was concluded when he stood trial, not a repression of memory, but an organic amnesia-the sort of blackout well described with PCP.

  The details, manifest on forensic examination, were macabre, and could not be revealed in open court. They were discussed in camera-concealed from both the public and from Donald himself. Comparison was made with the acts of violence occasionally committed during temporal lobe or psychomotor seizures. There is no memory of such acts, and perhaps no intention of violence- those who commit them are considered neither responsible nor culpable, but are none the less committed for their own and others' safety. This was what happened with the unfortunate Donald.

  He spent four years in a psychiatric hospital for the criminally insane-despite doubts as to whether he was either criminal or insane. He seemed to accept his incarceration with a certain relief-the sense of punishment was perhaps welcome, and there was, he doubtless felt, security in isolation. 'I am not fit for society', he would say, mournfully, when questioned. « Security from sudden, dangerous uncontrol-security, and a sort of serenity too. He had always been interested in plants, and this interest, so constructive, and so remote from the danger zone of human relation and action, was strongly encouraged in the

  prison-hospital where he now lived. He took over its ragged, un-tended grounds, and created flower gradens, kitchen gardens, gardens of all sorts. He seemed to have achieved a sort of austere equilibrium, in which human relations, human passions, previously so tempestuous, were replaced by a strange calm. Some considered him schizoid, some sane: everyone felt he had achieved a sort of stability. In his fifth year he started to go out on parole, being allowed to leave the hospital on weekend passes. He had been an avid cyclist, and now he again bought a bike. And it was this which precipitated the second act of his strange history.

  He was pedalling, fast, as he liked to, down a steep hill when an oncoming car, badly driven, suddenly loomed on a blind turn. Swerving to avoid a head-on collision, he lost control, and was flung violently, head-first, onto the road.

  He sustained a severe head injury-massive bilateral subdural hematomas, which were at once surgically evacuated and drained- and severe contusion of both frontal lobes. He lay in a coma, hemiplegic, for almost two weeks, and then, unexpectedly, he started to recover. And now, at this point, the 'nightmares' began.

  The returning, the re-dawning, of consciousness was not sweet- it was beset by a hideous agitation and turmoil, in which the half-conscious Donald seemed to be violently struggling, and kept crying, 'Oh God!' and 'No!' As consciousness grew clearer, so memory, full memory, a now terrible memory, came with it. There were severe neurological problems-left-sided weakness and numbness, seizures, and severe frontal-lobe deficits-and with these, with the last of these, something totally new. The murder, the deed, lost to memory before, now stood before him in vivid, almost hallucinatory detail. Uncontrollable reminiscence welled up and overwhelmed him-he kept 'seeing' the murder, enacting it, again and again. Was this nightmare, was this madness, or was there now 'hyper-mnesis'-a breakthrough of genuine, veridical, terrifyingly heightened memories?

  He was questioned in great detail, with the greatest care to avoid any hints or suggestions-and it was very soon clear that what he now showed was a genuine, if uncontrollable, 'reminiscence'. He now knew the minutest details of the murder: all the details revealed

  by forensic examination, but never revealed in open court-or to him.

  All that had been, or seemed, previously lost or forgotten- even in the face of hypnosis or amytal injection-was now recovered and recoverable. More, it was uncontrollable; and still more, completely unbearable. He twice attempted suicide on the neuro-surgical unit and had to be heavily tranquilised and forcibly restrained.

  What had happened to Donald-what was happening with him? That this was a sudden irruption of psychotic phantasy was ruled out by the veridical quality of the reminiscence shown-and even if it were entirely psychotic phantasy, why should it occur now, quite suddenly, unprecedentedly, with his head injury? There was a psychotic, or near psychotic, charge to the memories-they were, in psychiatric parlance, intensely or over-'cathected'-so much so as to drive Donald to incessant thoughts of suicide. But what would be a normal cathexis for such a memory-the sudden emergence, from total amnesia, not of some obscure Oedipal struggle or guilt, but of an actual murder?

  Was it possible that with the loss of frontal-lobe integrity an essential prerequisite for repression had been lost-and that what we now saw was a sudden, explosive and specific 'de-repression'? None of us had ever heard or read of anything quite like this before, although all of us were very familiar with the general dis-inhibition seen in frontal-lobe syndromes-the impulsiveness, the facetiousness, the loquacity, the salacity, the exhibition of an uninhibited, nonchalant, vulgar Id. But this was not the character which Donald now showed. He was not impulsive, unselective, inappropriate, in the least. His character, judgment and general personality were wholly preserved-it was specifically and solely memories and feelings of the murder which now erupted uncontrollably, obsessing and tormenting him.

  Was there a specific excitatory or epileptic element involved? Here EEG studies were especially interesting, because it was evident, using special (nasopharyngeal) electrodes, that in addition to the occasional grand mal seizures he had there was an incessant seething, a deep epilepsy, in both temporal lobes, extending down

  (one might surmise, but it would need implanted electrodes to confirm) into the uncus, the amygdala, the limbic structures-the emotional circuitry which lies deep to the temporal lobes. Penfield and Perot (Brain, 1963, pp. 596-697) had reported recurrent 'reminiscence', or 'experiential hallucinations', in some patients with temporal-lobe seizures. But most of the experiences or reminiscences which Penfield described were of a somewhat passive sort- hearing music, seeing scenes, being present perhaps, but present as a spectator, not as an actor. * None of us had heard of such a patient re-experiencing, or rather re-enacting, a deed-but this apparently was what was happening with Donald. No clear decision was ever reached.

  It remains only to tell the rest of the story. Youth, luck, time, natural healing, superior pre-traumatic function, aided by a Lu-rianic therapy for frontal-lobe 'substitution,' have allowed Donald, over the years, to make an enormous recovery. His frontal-lobe functions now are almost normal. The use of new anticonvulsants, only available in the last few years, have allowed effective control of his temporal-lobe seething-and here again, probably, natural recovery has played a part. Finally, with sensitive and supportive regular psychotherapy, the punitive violence of Donald's self-accusing superego has been mitigated, and the gentler scales of the ego now hold court. 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 has not forgotten, or re-repressed, anything of the murder-if, indeed, repression was operative in the first place-but he is no longer obsessed by it: a physiological and moral balance has been struck.

  *And yet this was not invariably so. In one particularly horrifying, traumatic case, recorded by Penfield, the
patient, a girl of twelve, seemed to herself, in every seizure, to be running frantically from a murderous man who was pursuing her with a writhing bag of snakes. This 'experiential hallucination' was a precise replay of an actual horrid incident, which had occurred five years before.

  But what of the status of the first lost, then recovered, memory? Why the amnesia-and the explosive return? Why the total blackout and then the lurid flashbacks? What actually happened in this strange, half-neurological drama? All these questions remain a mystery to this day.

  20

  The Visions of Hildegard

  'Vision of the Heavenly City'. From a manuscript of Hildegard's Scivias, written at Bingen about 1180. This figure is a reconstruction from several visions of migrainous origin.

  The religious literature of all ages is replete with descriptions of 'visions', in which sublime and ineffable feelings have been accompanied by the experience of radiant luminosity (William James

  Figure A

  Figure B

  Figure C

  Figure D

  Varieties of migraine hallucination represented in the visions of Hilde-gard.

  In Figure A, the background is formed of shimmering stars set upon wavering concentric lines. In Figure B, a shower of brilliant stars (phos-phenes) is extinguished after its passage-the succession of positive and negative scotomas. In Figures C and D, Hildegard depicts typically migrainous fortification figures radiating from a central point, which, in the original, is brilliantly luminous and colored.

  speaks of 'photism' in this context). It is impossible to ascertain, in the vast majority of cases, whether the experience represents a hysterica] or psychotic ecstasy, the effects of intoxication, or an epileptic or migrainous manifestation. A unique exception is provided in the case of Hildegard of Bingen (1098-1180), a nun and mystic of exceptional intellectual and literary powers, who experienced countless 'visions' from earliest childhood to the close of her life, and has left exquisite accounts and figures of these in the two manuscript codices which have come down to us-Scivias and Liber divinorum operum ('Book of divine works').