The man who mistook his wife for a hat

by Oliver Sacks

  A careful consideration of these accounts and figures leaves no room for doubt concerning their nature: they were indisputably migrainous, and they illustrate, indeed, many of the varieties of visual aura earlier discussed. Singer (1958), in the course of an extensive essay on Hildegard's visions, selects the following phenomena as most characteristic of them:

  In all a prominent feature is a point or a group of points of light, which shimmer and move, usually in a wave-like manner, and are most often interpreted as stars or flaming eyes [Figure B]. In quite a number of cases one light, larger than the rest, exhibits a series of concentric circular figures of wavering form [Figure A]; and often definite fortification-figures are described, radiating in some cases from a coloured area [Figures C and D]. Often the lights gave that impression of working, boiling or fermenting, described by so many visionaries . . .

  Hildegard writes:

  The visions which I saw I beheld neither in sleep, nor in dreams, nor in madness, nor with my carnal eyes, nor with the ears of the flesh, nor in hidden places; but wakeful, alert, and with the eyes of the spirit and the inward ears, I perceive them in open view and according to the will of God.

  One such vision, illustrated by a figure of stars falling and being quenched in the ocean (Figure B), signifies for her 'The Fall of the Angels':

  I saw a great star most splendid and beautiful, and with it an exceeding multitude of falling stars which with the star followed southwards . . . And suddenly they were all annihilated, being turned into black coals . . . and cast into the abyss so that I could see them no more.

  Such is Hildegard's allegorical interpretation. Our literal interpretation would be that she experienced a shower of phosphenes in transit across the visual field, their passage being succeeded by a negative scotoma. Visions with fortification-figures are represented in her Zelus Dei (Figure C) and Sedens Lucidus (Figure D), the fortifications radiating from a brilliantly luminous and (in the original) shimmering and coloured point. These two visions are combined in a composite vision (first picture), and in this she interprets the fortifications as the aedificium of the city of God.

  Great rapturous intensity invests the experience of these auras, especially on the rare occasions when a second scotoma follows in the wake of the original scintillation:

  The light which I see is not located, but yet is more brilliant than the sun, nor can I examine its height, length or breadth, and I name it 'the cloud of the living light'. And as sun, moon, and stars are reflected in water, so the writings, sayings, virtues and works of men shine in it before me . . .

  Sometimes I behold within this light another light which I name 'the Living Light itself . . . And when I look upon it every sadness and pain vanishes from my memory, so that I am again as a simple maid and not as an old woman.

  Invested with this sense of ecstasy, burning with profound theo-phorous and philosophical significance, Hildegard's visions were instrumental in directing her towards a life of holiness and mysticism. They provide a unique example of the manner in which a physiological event, banal, hateful or meaningless to the vast majority of people, can become, in a privileged consciousness, the substrate of a supreme ecstatic inspiration. One must go to Dostoievsky who experienced on occasion ecstatic epileptic auras to which he attached momentous significance, to find an adequate historical parallel.

  There are moments, and it is only a matter of five or six seconds, when you feel the presence of the eternal harmony … a terrible thing is the frightful clearness with which it manifests itself and the rapture with which it fills you. If this state were to last more than five seconds, the soul could not endure it and would have to disappear. During these five seconds I live a whole human existence, and for that I would give my whole life and not think that I was paying too dearly . . .

  PART FOUR

  THE WORLD OF THE SIMPLE

  Introduction

  When I started working with retardates several years ago, I thought it would be dismal, and wrote this to Luria. To my surprise, he replied in the most positive terms, and said that there were no patients, in general, more 'dear' to him, and that he counted his hours and years at the Institute of Defectology among the most moving and interesting of his entire professional life. He expresses a similar sentiment in the preface to the first of his clinical biographies (Speech and the Development of Mental Processes in the Child, Eng. tr. 1959): 'If an author has the right to express feelings about his own work, I must note the warm sense with which I always turn to the material published in this small book.'

  What is this 'warm sense' of which Luria speaks? It is clearly the expression of something emotional and personal-which would not be possible if the defectives did not 'respond', did not themselves possess very real sensibilities, emotional and personal potentials, whatever their (intellectual) defects. But it is more. It is an expression of scientific interest-of something that Luria considered of quite peculiar scientific interest. What could this be? Something other than 'defects' and 'defectology', surely, which are of rather limited interest in themselves. What is it, then, that is especially interesting in the simple?

  It has to do with qualities of mind which are preserved, even enhanced, so that, though 'mentally defective' in some ways, they may be mentally interesting, even mentally complete, in others. Qualities of mind other than the conceptual-this is what we may explore with peculiar clarity in the simple mind (as we may also

  in the minds of children and 'savages'-though, as Clifford Geertz repeatedly emphasises, these categories must never be equated: savages are neither simple nor children; children have no savage culture; and the simple are neither savages nor children). Yet there are important kinships-and all that Piaget has opened out for us in the minds of children, and Levi-Strauss in the 'savage mind', awaits us, in a different form, in the mind and world of the simple.*

  What awaits our study is equally pleasing to the heart and mind, and, as such, especially incites the impulse to Luria's 'romantic science'.

  What is this quality of mind, this disposition, which characterises the simple, and gives them their poignant innocence, transparency, completeness and dignity-a quality so distinctive we must speak of the 'world' of the simple (as we speak of the 'world' of the child or the savage)?

  If we are to use a single word here, it would have to be 'con-creteness'-their world is vivid, intense, detailed, yet simple, precisely because it is concrete: neither complicated, diluted, nor unified, by abstraction.

  By a sort of inversion, or subversion, of the natural order of things, concreteness is often seen by neurologists as a wretched thing, beneath consideration, incoherent, regressed. Thus for Kurt Goldstein, the greatest systematiser of his generation, the mind, man's glory, lies wholly in the abstract and categorical, and the effect of brain damage, any and all brain damage, is to cast him out from this high realm into the almost subhuman swamplands of the concrete. If a man loses the 'abstract-categorical attitude' (Goldstein), or 'prepositional thought' (Hughlings Jackson), what remains is subhuman, of no moment or interest.

  I call this an inversion because the concrete is elemental-it is what makes reality 'real', alive, personal and meaningful. All of this is lost if the concrete is lost-as we saw in the case of the

  *All of Luria's early work was done in these three allied domains, his field-work with children in primitive communities in Central Asia, and his studies in the Institute of Defectology. Together these launched his lifelong exploration of human imagination.

  almost-Martian Dr P., 'the man who mistook his wife for a hat', who fell (in an un-Goldsteinian way) from the concrete to the abstract.

  Much easier to comprehend, and altogether more natural, is the idea of the preservation of the concrete in brain damage-not regression to it, but preservation of it, so that the essential personality and identity and humanity, the being of the hurt creature, is preserved.

  This is what we see in Zazetsky-'the ma
n with a shattered world'-he remains a man, quintessentially a man, with all the moral weight and rich imagination of a man, despite the devastation of his abstract and propositional powers. Here Luria, while seeming to be supporting the formulations of Hughlings Jackson and Goldstein, is, at the same time, turning their significance upside down. Zazetsky is no feeble Jacksonian or Goldsteinian relic, but a man in his full manhood, a man with his emotions and imagination wholly preserved, perhaps enhanced. His world is not 'shattered', despite the book's title-it lacks unifying abstractions, but is experienced as an extraordinarily rich, deep and concrete reality.

  I believe all this to be true of the simple also-the more so as, having been simple from the start, they have never known, been seduced by, the abstract, but have always experienced reality direct and unmediated, with an elemental and, at times, overwhelming intensity.

  We find ourselves entering a realm of fascination and paradox, all of which centres on the ambiguity of the 'concrete'. In particular, as physicians, as therapists, as teachers, as scientists, we are invited, indeed compelled, towards an exploration of the concrete. This is Luria's 'romantic science'. Both of Luria's great clinical biographies, or 'novels', may indeed be seen as explorations of the concrete: its preservation, in the service of reality, in the braindamaged Zazetsky; its exaggeration, at the expense of reality, in the 'supermind' of the Mnemonist.

  Classical science has no use for the concrete-it is equated with the trivial in neurology and psychiatry. It needs a 'romantic' science to pay it its full due-to appreciate its extraordinary powers . . . and dangers: and in the simple we are confronted with the

  concrete head-on, the concrete pure and simple, in unreserved intensity.

  The concrete can open doors, and it can close them too. It can constitute the portal to sensibility, imagination, depth. Or it can confine the possessor (or the possessed) to meaningless particulars. We see both of these potentials, as it were amplified, in the simple.

  Enhanced powers of concrete imagery and memory, Nature's compensation for defectiveness in the conceptual and abstract, can tend in quite opposite directions: towards an obsessive preoccupation with particulars, the development of an eidetic imagery and memory, and the mentality of the Performer or 'whiz kid' (as occurred with the Mnemonist, and in ancient times, with over-cultivation of the concrete 'art of memory'*: we see tendencies to this in Martin A. (Chapter Twenty-two), in Jose (Chapter Twenty-four), and especially the Twins (Chapter Twenty-three), exaggerated, especially in the Twins, by the demands of public performance, coupled with their own obsessionalism and exhibitionism.

  But of much greater interest, much more human, much more moving, much more 'real'-yet scarcely even recognised in scientific studies of the simple (though immediately seen by sympathetic parents and teachers)-is the proper use and development of the concrete.

  The concrete, equally, may become a vehicle of mystery, beauty and depth, a path into the emotions, the imagination, the spirit- fully as much as any abstract conception (perhaps indeed more, as Gershom Scholem (1965) has argued in his contrasts of the conceptual and the symbolic, or Jerome Bruner (1984) in his contrast of the 'paradigmatic' and the 'narrative'). The concrete is readily imbued with feeling and meaning-more readily, perhaps, than any abstract conception. It readily moves into the aesthetic, the dramatic, the comic, the symbolic, the whole wide deep world of art and spirit. Conceptually, then, mental defectives may be cripples-but in their powers of concrete and symbolic apprehen-

  *See Francis Yates' extraordinary book so titled (1966).

  sion they may be fully the equal of any 'normal' individual. (This is science, this is romance too . . . ) No one has expressed this more beautifully than Kierkegaard, in the words he wrote on his deathbed. 'Thou plain man!' (he writes, and I paraphrase slightly). 'The symbolism of the Scriptures is something infinitely high . . . but it is not "high" in a sense that has anything to do with intellectual elevation, or with the intellectual differences between man and man . . . No, it is for all . . . for all is this infinite height attainable.'

  A man may be very 'low' intellectually-unable to put a key to a door, much less understand the Newtonian laws of motion, wholly unable to comprehend the world as concepts, and yet fully able, and indeed gifted, in understanding the world as concrete-ness, as symbols. This is the other side, the almost sublime other side, of the singular creatures, the gifted simpletons, Martin, Jose, and the Twins.

  Yet, it may be said, they are extraordinary and atypical. I therefore start this final section with Rebecca, a wholly 'unremarkable' young woman, a simpleton, with whom I worked twelve years ago. I remember her warmly.

  21

  Rebecca

  Rebecca was no child when she was referred to our clinic. She was nineteen, but, as her grandmother said, 'just like a child in some ways'. She could not find her way around the block, she could not confidently open a door with a key (she could never 'see' how the key went, and never seemed to learn). She had left/ right confusion, she sometimes put on her clothes the wrong way- inside out, back-to-front, without appearing to notice, or, if she noticed, without being able to get them right. She might spend hours jamming a hand or foot into the wrong glove or shoe-she seemed, as her grandmother said, to have 'no sense of space'. She was clumsy and ill-coordinated in all her movements-a 'klutz', one report said, a 'motor moron' another (although when she danced, all her clumsiness disappeared).

  Rebecca had a partial cleft palate, which caused a whistling in her speech; short, stumpy fingers, with blunt, deformed nails; and a high, degenerative myopia requiring very thick spectacles-all stigmata of the same congenital condition which had caused her cerebral and mental defects. She was painfully shy and withdrawn, feeling that she was, and had always been, a 'figure of fun'.

  But she was capable of warm, deep, even passionate attachments. She had a deep love for her grandmother, who had brought her up since she was three (when she was orphaned by the death of both parents). She was very fond of nature, and, if she was taken to the city parks and botanic gardens, spent many happy hours there. She was very fond too of stories, though she never learned to read (despite assiduous, and even frantic, attempts), and would implore her grandmother or others to read to her. 'She has a

  hunger for stories,' her grandmother said; and fortunately her grandmother loved reading stories and had a fine reading voice which kept Rebecca entranced. And not just stories-poetry too. This seemed a deep need or hunger in Rebecca-a necessary form of nourishment, of reality, for her mind. Nature was beautiful, but mute. It was not enough. She needed the world re-presented to her in verbal images, in language, and seemed to have little difficulty following the metaphors and symbols of even quite deep poems, in striking contrast to her incapacity with simple propositions and instructions. The language of feeling, of the concrete, of image and symbol, formed a world she loved and, to a remarkable extent, could enter. Though conceptually (and 'proposition-ally') inept, she was at home with poetic language, and was herself, in a stumbling, touching way, a sort of 'primitive', natural poet. Metaphors, figures of speech, rather striking similitudes, would come naturally to her, though unpredictably, as sudden poetic ejaculations or allusions. Her grandmother was devout, in a quiet way, and this also was true of Rebecca: she loved the lighting of the Sabbath candles, the benisons and orisons which thread the Jewish day; she loved going to the synagogue, where she too was loved (and seen as a child of God, a sort of innocent, a holy fool); and she fully understood the liturgy, the chants, the prayers, rites and symbols of which the Orthodox service consists. All this was possible for her, accessible to her, loved by her, despite gross perceptual and spatio-temporal problems, and gross impairments in every schematic capacity-she could not count change, the simplest calculations defeated her, she could never learn to read or write, and she would average 60 or less in IQ tests (though doing notably better on the verbal than the performance parts of the test). Thus she was a 'moron',
a 'fool', a 'booby', or had so appeared, and so been called, throughout her whole life, but one with an unexpected, strangely moving, poetic power. Superficially she was a mass of handicaps and incapacities, with the intense frustrations and anxieties attendant on these; at this level she was, and felt herself to be, a mental cripple-beneath the effortless skills, the happy capacities, of others; but at some deeper level there was no sense of handicap or incapacity, but a feeling of calm and com-

  pleteness, of being fully alive, of being a soul, deep and high, and equal to all others. Intellectually, then, Rebecca felt a cripple; spiritually she felt herself a full and complete being.

  When I first saw her-clumsy, uncouth, all-of-a-fumble-I saw her merely, or wholly, as a casualty, a broken creature, whose neurological impairments I could pick out and dissect with precision: a multitude of apraxias and agnosias, a mass of sensorimotor impairments and breakdowns, limitations of intellectual schemata and concepts similar (by Piaget's criteria) to those of a child of eight. A poor thing, I said to myself, with perhaps a 'splinter skill', a freak gift, of speech; a mere mosaic of higher cortical functions, Piagetian schemata-most impaired.

  The next time I saw her, it was all very different. I didn't have her in a test situation, 'evaluating' her in a clinic. I wandered outside-it was a lovely spring day-with a few minutes in hand before the clinic started, and there I saw Rebecca sitting on a bench, gazing at the April foliage quietly, with obvious delight. Her posture had none of the clumsiness which had so impressed me before. Sitting there, in a light dress, her face calm and slightly smiling, she suddenly brought to mind one of Chekov's young women-Irene, Anya, Sonya, Nina-seen against the backdrop of a Chekovian cherry orchard. She could have been any young woman enjoying a beautiful spring day. This was my human, as opposed to my neurological, vision.