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Patients’ “text” and context: “The man who mistook his wife for a hat” by Oliver Sacks

Oliver Sacks is considered as one of the figures to whom we owe the practice of Narrative Medicine, even if this name was given later.

Sacks deals with neurological patients, taking care of diseases and people at the same time. He considers himself both a theorist and a playwright, attracted by the romantic aspect of narratives as well as by the scientific one. Sacks is interested in the context in which his patients live, their environment, always respecting the resources of the patients themselves, and spreads these narratives without altering them, so differently from the protocols of scientific publications.

The man who mistook his wife for a hat in 1985 is one of her most famous collections.

Dr P. was a musician of distinction, well-known for many years as a singer, and then, at the local School of Music, as a teacher. It was here, in relation to his students, that certain strange prob- lems were first observed. Sometimes a student would present him- self, and Dr P. would not recognise him; or, specifically, would not recognise his face. The moment the student spoke, he would be recognised by his voice. Such incidents multiplied, causing embarrassment, perplexity, fear—and, sometimes, comedy. For not only did Dr P. increasingly fail to see faces, but he saw faces when there were no faces to see: genially, Magoo-like, when in the street he might pat the heads of water hydrants and parking meters, taking these to be the heads of children; he would amiably address carved knobs on the furniture and be astounded when they did not reply. At first these odd mistakes were laughed off as jokes, not least by Dr P. himself. Had he not always had a quirky sense of humour and been given to Zen-like paradoxes and jests? His musical powers were as dazzling as ever; he did not feel ill—he had never felt better; and the mistakes were so ludicrous—and so ingenious—that they could hardly he serious or betoken anything serious. The notion of there being ‘something the matter’ did not emerge until some three years later, when diabetes developed. Well aware that diabetes could affect his eyes, Dr P. consulted an ophthalmologist, who took a careful history and examined his eyes closely. ‘There’s nothing the matter with your eyes,’ the doctor concluded. Tut there is trouble with the visual parts of your brain.

You don’t need my help, you must see a neurologist’ And so, as a result of this referral, Dr P. came to me.

It was obvious within a few seconds of meeting him that there was no trace of dementia in the ordinary sense. He was a man of great cultivation and charm who talked well and fluently, with imagination and humour. I couldn’t think why he had been re- ferred to our clinic.

And yet there was something a bit odd. He faced me as he spoke, was oriented towards me, and yet there was something the matter—it was difficult to formulate. He faced me with his ears,I came to think, but not with his eyes. These, instead of looking, gazing, at me, ‘taking me in’, in the normal way, made sudden strange fixations—on my nose, on my right ear, down to my chin, up to my right eye—as if noting (even studying) these individual features, but not seeing my whole face, its changing expressions, ‘me’, as a whole. I am not sure that I fully realised this at the time—there was just a teasing strangeness, some failure in the normal interplay of gaze and expression. He saw me, he scannedme, and yet . .

‘What seems to be the matter?’ I asked him at length.

‘Nothing that I know of,’ he replied with a smile, ‘but people seem to think there’s something wrong with my eyes.’

Tut you don’t recognise any visual problems?’
‘No, not directly, but I occasionally make mistakes.’
I left the room briefly to talk to his wife. When I came back,

Dr P. was sitting placidly by the window, attentive, listening rather than looking out. ‘Traffic,’ he said, ‘street sounds, distant trains— they make a sort of symphony, do they not? You know Honegger’sPacific 234?’

What a lovely man, I thought to myself. How can there be anything seriously the matter? Would he permit me to examine him?

‘Yes, of course, Dr Sacks.’

I stilled my disquiet, his perhaps, too, in the soothing routine of a neurological exam—muscle strength, coordination, reflexes, tone. . . . It was while examining his reflexes—a trifle abnormal on the left side—that the first bizarre experience occurred. I had taken off his left shoe and scratched the sole of his foot with a key—a frivolous-seeming but essential test of a reflex—and then, excusing myself to screw my ophthalmoscope together, left him to put on the shoe himself. To my surprise, a minute later, he had not done this.

`Can I help?’ I asked.
`Help what? Help whom?’
`Help you put on your shoe.’
`Ach,’ he said, ‘I had forgotten the shoe,’ adding, sotto voce,

`The shoe? The shoe?’ He seemed baffled.
`Your shoe,’ I repeated. ‘Perhaps you’d put it on.’
He continued to look downwards, though not at the shoe, with an intense but misplaced concentration. Finally his gaze settled on his foot: ‘That is my shoe, yes?’

Did I mis-hear? Did he mis-see?

`My eyes,’ he explained, and put a hand to his foot. ‘This is my shoe, no?’

‘No, it is not. That is your foot. There is your shoe.’
`Ah! I thought that was my foot.’
Was he joking? Was he mad? Was he blind? If this was one of his ‘strange mistakes’, it was the strangest mistake I had ever come across.

I helped him on with his shoe (his foot), to avoid further com- plication. Dr P. himself seemed untroubled, indifferent, maybe amused. I resumed my examination. His visual acuity was good: he had no difficulty seeing a pin on the floor, though sometimes he missed it if it was placed to his left.

He saw all right, but what did he see? I opened out a copy of the National Geographic Magazine and asked him to describe some pictures in it.

His responses here were very curious. His eyes would dart from one thing to another, picking up tiny features, individual features, as they had done with my face. A striking brightness, a colour, a shape would arrest his attention and elicit comment—hut in no case did he get the scene-as-a-whole. He failed to see the whole, seeing only details, which he spotted like blips on a radar screen. He never entered into relation with the picture as a whole—never faced, so to speak, its physiognomy. He had no sense whatever of a landscape or scene.

I showed him the cover, an unbroken expanse of Sahara dunes. `What do you see here?’ I asked.
‘I see a river,’ he said. ‘And a little guest-house with its terrace on the water. People are dining out on the terrace. I see coloured parasols here and there.’ He was looking, if it was ‘looking’, right off the cover into mid-air and confabulating nonexistent features, as if the absence of features in the actual picture had driven him to imagine the river and the terrace and the coloured parasols.

I must have looked aghast, but he seemed to think he had done rather well. There was a hint of a smile on his face. He also appeared to have decided that the examination was over and started to look around for his hat. He reached out his hand and took hold of his wife’s head, tried to lift it off, to put it on. He had apparently mistaken his wife for a hat! His wife looked as if she was used to such things.

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