By Oliver Sacks September 05, 2021 ⋅ 12 min read ⋅ Books
Part I: Losses
The strange figures that appear in this book are travelers to unimaginable lands, lands of which otherwise we should have no idea or conception.
Deficit: an impairment or incapacity of neurological function.
Chapter 1: The Man Who Mistook His Wife for a Hat
Dr. P was a musician that couldn’t recognize faces but saw faces in inanimate objects.
Dr. P also couldn’t recognize his shoe and didn’t sense a scene or landscape as a whole, only focusing on details.
When Dr. P was leaving the neurologist’s office, he tried to lift off his wife’s head to put it on as a hat. He had apparently mistaken his wife for a hat!
In the absence of obvious facial markers, Dr. P couldn’t recognize people, even in photographs of family and colleagues.
Interestingly, Dr. P also couldn’t recognize objects and mostly described them, not identifying them.
E.g. Dr. P described a rose as “About six inches in length. A convoluted red form with a linear green attachment” and a glove as “A continuous surface infolded on itself. It appears to have five outpouchings, if this is the word.”
In Dr. P’s imagination, he could only describe buildings on his right side, not his left.
It’s clear that his difficulties with leftness, his visual field deficits, were as much internal as external.
Dr. P had a profound visual agnosia where all powers of representation and imagery, all sense of the concrete and reality, were being destroyed.
Dr. P had a downfall of judgment which constitutes the essence of so many neuropsychological disorders.
Judgment is the most important faculty we have.
Our cognitive sciences are themselves suffering from an agnosia similar to Dr. P’s.
Dr. P therefore serves as a warning and parable of what happens to science when it becomes too descriptive and detail-oriented.
For Dr. P, it wasn’t just visual perception, but visual imagination and memory, the fundamental powers of visual representation, were essentially damaged.
Dr. P and a similar case both didn’t have pictorial dreams.
It would later be known that Dr. P has a case of prosopagnosia and hemispatial neglect.
Chapter 2: The Lost Mariner
Jimmie is the case of a 40 year old marine that believed he was nineteen and forgot recent memories after a short period of time.
Whatever was said or shown to him was forgotten in a few seconds if it wasn’t used.
In other words, Jimmie couldn’t form new memories.
He sometimes retained faint memories, some dim echo or sense of familiarity.
It wasn’t that Jimmie didn’t memorize, it’s that he didn’t retain what he memorized, possibly due to overwriting the memories.
He is isolated in a single moment of being, with a moat of forgetting all around him.
Jimmie had Korsakov’s syndrome, a loss of memory for recent events.
Why did Jimmie’s amnesia stop at 1945? Why didn’t it go further back including his entire life or after 1945? We don’t know.
Interestingly, Jimmie could learn his way around the nursing home such as knowing where the rooms were.
Jimmie both was and wasn’t aware of this deep, tragic loss in himself.
E.g. If a person loses their leg or eye, they know they’ve lost a leg or eye. However, if they lose their self, they can’t know because they’re no longer there to know it.
Even though Jimmie has no memory beyond a few seconds, Jimmie is still conscious.
Jimmie mentions how “I haven’t felt alive for a very long time.”
His face wore a look of infinite sadness and resignation.
Retrograde amnesia is very common in cases of Korsakov’s.
That one can lose the greater part of a lifetime has a peculiar, uncanny horror.
In other patient, a sudden thrombosis resulting in the immediate death of the visual parts of the brain. This caused the patient to become cortically blind and lose all visual images and memories.
Yet this other patient had no sense of loss. It’s as if he were never born with sight to begin with.
His whole visual life had been erased and erased permanently in the instant of his stroke.
Such patients, fossilized in the past, can only be at home in the past. Time, for them, has come to a stop.
Chapter 3: The Disembodied Lady
Christina is 27 years old and worked as a computer programmer at home.
Three days before a scheduled surgery, Christina was given an antibiotic for microbial prophylaxis. This was purely routine, a precaution, with no expected complications.
On the day of surgery, Christina couldn’t hold anything in her hands and couldn’t stand on her own. The antibiotic caused acute polyneuritis of the spinal sensory roots affecting proprioception.
Christina couldn’t feel her body, she felt weird, disembodied.
Tests revealed a very profound and almost total loss of proprioceptive information from the toes to her head.
Her parietal lobes were working, but they had nothing to work with, no data from sensors.
There was slight loss of other sensory modalities too such as light touch, temperature, and pain.
Proprioception is like the eyes of the body, the way the body sees itself.
Christina felt like she was blind to her body.
In the end, the damage to her proprioceptive fibers persisted and there was no neurological recovery a year later.
There has been none in the past eight years.
However, over the course of weeks, Christina replaced the normal unconscious feedback of proprioception by an equally unconscious feedback by vision.
Interestingly, speech also uses proprioceptive feedback so Christina had to use audition instead of proprioception to speak.
While Christina had no neurological recovery, she did have a very considerable functional recovery.
Did the substitutions dispense of the disembodied feeling?
No, Christina continues to feel, with the loss of proprioception, that her body is dead, not-real, not-hers.
There are no words to describe how Christina feels, only analogies such as feeling that her body is blind and deaf to itself.
When Christina painfully and clumsily mounts a bus, she receives angry snarls: ‘What’s wrong with you lady? Are you drunk?’
What can she answer, that she has no proprioception?
The lack of social support and sympathy is an additional trial.
This is what happens to those with disorders of the hidden senses.
Chapter 4: The Man Who Fell out of Bed
A man fell out of bed because he thought his own leg hasn’t his and tried to get rid of it by throwing the leg away.
But the man is attached to the leg so he fell too.
This is a case of foreign limb syndrome where a patient believes their own limb to be foreign, dead, and needs removal.
Chapter 5: Hands
Madeleine is a 60 year old woman that’s congenitally blind with cerebral palsy.
She couldn’t identify anything placed into her hands even though light touch, pain, temperature, and movement were intact. She lost tactile perception.
To Madeleine, her hands were as useless as lumps of dough.
The author attempts to get Madeleine to train her hands to recognize objects because he suspects that Madeleine’s disability isn’t due to malfunctioning biology, but due to a lack of training and use as there was always a caregiver to help Madeleine.
And it worked, the first object that Madeleine grabs is a bagel in a fit of hunger and frustration.
Soon, she began recognizing objects not out of analysis of features, but using immediate intuition.
This sort of recognition, not analytic, but synthetic and immediate, went with vivid delight and a sense of discovery.
Who would’ve dreamed that the basic powers of perception, normally acquired in the first months of life, but failing to be acquired by Madeleine, could be acquired in one’s sixtieth year?
The case of Madeleine isn’t unique as another patient was also able to learn tactile perception.
Such cases of developmental agnosia may be rare, but one commonly sees cases of acquired agnosia, which shows the fundamental principle of use.
It’s crucial to get such patients to use their hands and feet to regain function.
Chapter 6: Phantoms
Phantom: a persistent image or memory of part of the body, usually a limb, for months or years after its loss.
This chapter contains a collection of short stories on phantom limb syndrome.
It’s well known that a central pathological disorder, such as a sensory stroke, can cure a phantom.
All amputees know that a phantom limb is essential if an artificial limb is to be used. The lack of a phantom limb may be disastrous for recovery.
Interestingly, pain before loss of the limb, such as an ingrown toenail, persist with the phantom limb.
Chapter 7: On the Level
Mr. MacGregor says that others think he’s always tilted like the Leaning Tower of Pisa, but he himself doesn’t believe so.
The author sees that he’s leaning about 20 degrees off center and when a video of MacGregor walking is replayed to himself, he sees his own tilt.
This imbalance was caused by Parkinson’s disease knocking out his brain’s “level” meter.
Our balance system uses three sources of information: vestibular, proprioceptive, and vision.
However, they’re not all weighted the same with vestibular the highest, proprioceptive the middle, and vision the lowest.
To fix his tilt MacGregor suggested that “I just need a level. I can’t use the levels inside my head, but why couldn’t I use levels outside my head, levels I could see, I could use with my eyes?”
MacGregor then suggested eye glasses with an inbuilt level, that way MacGregor can correct himself by checking the level, which worked to correct MacGregor’s tilt.
Chapter 8: Eyes Right!
Mrs. S, a woman in her sixties, suffered a massive stroke affecting the deeper and back portions of her right cerebral hemisphere.
Due to the stroke, she’s lost all idea of ‘left’ with regard to both the world and her own body.
Mrs. S has a case of hemispatial/unilateral neglect for the left world.
She knows it intellectually and can understand it, but it’s impossible for her to know directly.
While she ignores the left side of the mirror and only puts makeup on the right side of her face, using a video camera to record her works to get her to see the left side but it has weird results.
When shown the video screen, she exclaimed “Take it away!” as if frightened by her own face.
Chapter 9: The President’s Speech
Review of aphasia and how even though patients with aphasia can’t understand the direct meaning of words, they can infer the meaning through other features of speech.
There are also cases of the opposite of aphasia and lack tone in their voice, people with robotic voices. These patients have tonal agnosia.
Such tonal agnosia are associated with disorders of the right temporal lobe, while aphasia is associated with disorders of the left temporal lobe.
Tonal agnosia also means you can’t understand tone in other people’s voices.
Paradoxically, sometimes you need to have lost a function, such as meaning or tone, to remain undeceived.
Part II: Excesses
The meaning of “deficit” is limited in that it doesn’t capture an excess or abundance of function.
Chapter 10: Witty Ticcy Ray
Tourette’s syndrome is characterized by an excess of nervous energy, and great production and extravagance of strange motions and notions: tics, jerks, mannerisms, grimace, noises, curses, involuntary imitations and compulsions.
No two cases of Tourette’s are the same.
Patients with Tourette’s syndrome seem to have an excess of excitatory transmitters in the brain, especially dopamine.
Chapter 11: Cupid’s Disease
An elderly woman had neurosyphilis that she didn’t want cured because it made her feel alive.
While she was treated with penicillin, the brain damage had already been done so she got the best of both worlds: no disease but its benefits.
Chapter 12: A Matter of Identity
Mr. Thompson would misidentify the author as dozens of different people and was diagnosed with Korsakov’s.
He was continually disoriented and abysses of amnesia continually opened beneath him.
However, Thompson would bridge his contradictions with fluent confabulations and fictions of all kinds.
He would ceaselessly, unconsciously, and quickly improvise a world around him.
We have in each of us a life-story, an inner narrative, whose continuity is our lives. And that this narrative is us, our identity.
A person needs such a narrative to maintain their identity, their self.
For Thompson who is unable to maintain a genuine narrative or continuity, he is driven to create one, to create pseudo-narratives.
A deeper and more insidious symptom that Thompson had was indifference.
E.g. When told that his older brother was dead for years, Thompson had no emotion in his response.
There was some ultimate and total loss of inner reality, of feeling and meaning.
Thompson doesn’t realize that anything is wrong with himself; he’s lost his own reality.
Thompson is so damned that he doesn’t know he is damned.
Chapter 13: Yes, Father-Sister
Mrs. B presented with a rapid personality change due to a carcinoma tumor in both frontal lobes.
To Mrs. B, everything was equivalent/equal, the whole world reduced to a facetious insignificance.
This indifference is not uncommon and is informally called the “joking disease”.
No one returns from such states to tell us what they were like.
In these states, there ceases to be any center to the mind, although its formal intellectual powers may be perfectly preserved.
The end point of such states is an unfathomable silliness, an abyss of superficiality.
Chapter 14: The Possessed
Review of an extreme form of Tourette’s with symptoms of psychosis.
Where the Korsakovian is driven by amnesia, the Tourette is driven by extravagant impulse.
Part III: Transports
Chapter 15: Reminiscence
The theme of this section is the power of imagery and memory to transport a person due to abnormal stimulation of the temporal and limbic systems.
Mrs. O’C keep hearing Irish songs even though her ears heard nothing.
The cause was due to temporal lobe seizures from a small thrombosis in her right temporal lobe.
When the thrombosis cleared up, the songs disappeared too.
This is a form of musical epilepsy.
Such epileptic hallucinations or dreams are never fantasies, they’re always memories, and memories of the most precise and vivid kind, accompanied by the emotions which accompanied the original experience.
Penfield was surprised at the number of times electrical stimulation caused the patient to hear music.
Sometimes these seizures would evoke nostalgia for the past during childhood.
Mrs. O’C would come to miss her seizures because they completed her missing childhood. Another case where the deficit was actually beneficial to the patient.
A neurosurgery of identity.
Chapter 16: Incontinent Nostalgia
One astonishing effect of L-Dopa is the reactivation of symptoms and behavior-patterns present at a much earlier stage of the disease, but subsequently lost.
Chapter 17: A Passage to India
Temporal lobe seizures are often characterized by dreamy states and involuntary reminiscence.
Chapter 18: The Dog Beneath the Skin
Stephen dreamt he was a dog; it was an olfactory dream. No further notes on this chapter.
Chapter 19: Murder
Donald killed his girlfriend while under the influence of drugs and was sent to a psychiatric hospital.
While there, Donald got severe brain damage while riding a bike and relived his memories of killing his girlfriend.
After much therapy and medication, Donald made a recovery.
Chapter 20: The Visions of Hildegard
Skipped over this chapter on a religious text.
Part IV: The World of the Simple
What quality of mind gives simple people their innocence, transparency, and completeness?
It would have to be their concreteness. Their world is vivid, intense, yet simple because it isn’t complicated by abstraction.
Chapter 21: Rebecca
Rebecca is a 19 year old woman that was clumsy and a klutz.
She was very shy due to her impairments but had a hunger for stories.
Despite her gross perceptual and spatiotemporal problems and an IQ less than 60, she still was able to love deeply and understand poems.
Intellectually, Rebecca felt a cripple; spiritually, she felt herself a full and complete being.
Rebecca’s case shows how we pay far too much attention to the defects of our patients and far too little to what was intact or preserved.
The narrative or symbolic power of stories gives a sense of the world, a concrete reality in the imaginative form of symbol and story.
Chapter 22: A Walking Grove
Martin, aged 61, was admitted to our Home towards the end of 1983 having become Parkinsonism and unable to look after himself.
He had an amazing musical memory, memorizing two thousand operas and enjoyed modest fame as a walking encyclopedia.
Martin was often childish, sometimes spiteful, and prone to sudden tantrums. He also used childish words like “mudpie”.
However, this childlike behavior went away after Martin started attending church and singing, his passion.
One speaks of idiot savant as if they had an odd knack or talent of a mechanical sort, with no real intelligence or understanding.
But these people do have a genuine intelligence for their field.
Chapter 23: The Twins
The twins, John and Michael, at 26 years old had been diagnosed as autistic, psychotic, or severely retarded.
Both were considered as idiot savants for their remarkable documentary memories of the tiniest visual details of their own experience.
Another impressive skill of theirs was an unconscious, calendrical algorithm that enabled them to say at once on what day of the week a date did or will fall on.
However, the twins can’t do simple addition or subtraction with any accuracy, and don’t comprehend what multiplication and division are.
It’s suspected that these calendar calculations don’t involve memory at all, but instead use an unconscious algorithm.
Something mysterious, though commonplace, is operating here, the mysterious human ability to form unconscious algorithms on the basis of examples.
The twins are also able to tell you, given a date, the weather and the events of any day in their lives from about their fourth year on.
The twins also had an impressive numerosity sense as when a box of matches was accidentally spilled onto the floor, both twins said “111” immediately which matched the number of matches.
When probed on how they did this, they said they didn’t count but instead “saw” 111.
The twins may use a simple algorithm to find out the day of the week by finding the total number of days from today to that date, dividing by seven, and the reminder tells you which day the date falls on.
Chapter 24: The Autist Artist
The case of Jose, the autist artist.
For, as the stars stand, he will probably do nothing, and spend a useless, fruitless life, as so many other autistic people do, overlooked, unconsidered, in the back ward of a state hospital.