The Man Who Mistook His Wife for a Hat - critical summary review

Frequently described as “one of the great clinical writers of the 20th century” and a “poet laureate of contemporary medicine,” Oliver Sacks was a British neurologist and celebrated author of numerous bestselling collections of case studies of people with neurological disorders. “The Man Who Mistook His Wife for a Hat” is, quite probably, the one that most decisively substantiates Sacks’ lifelong belief that the brain is the “most incredible thing in the universe.” 

So, get ready to hear just a handful of Sacks’ 24 unforgettable and “richly human clinical tales,” and prepare to meet a few neurological patients who can be fittingly described as “travelers to unimaginable lands – lands of which otherwise we should have no idea or conception”!

Neurological losses – and the man who mistook his wife for a hat

“Neurology’s favorite word,” writes Oliver Sacks, “is ‘deficit,’ denoting an impairment or incapacity of neurological function: loss of speech, loss of language, loss of memory, loss of vision, loss of dexterity, loss of identity and myriad other lacks and losses of specific functions (or faculties).” However, neurological losses are different than other types of losses, because “if a man has lost a leg or an eye, he knows he has lost a leg or an eye; but if he has lost a self – himself – he cannot know it, because he is no longer there to know it.” 

Take, for example, Dr. P. – a musician of distinction, well known first as a singer and then as a teacher. As his students realized, in the later years of his life he could only recognize them by their voices. And it’s not like he had some problem with his eyes: he could see everything clearly. Yet, for some reason, he couldn’t distinguish faces properly. To make matters worse, he also started seeing faces where there were none. 

At first, it was even amusing to see Dr. P. patting the heads of water hydrants and parking meters thinking them children, but then it became quite worrisome and scary. So, Dr. P. went to an ophthalmologist, believing that some sort of diabetes might be affecting his vision. The ophthalmologist told him he didn’t have diabetes and referred him to Oliver Sacks, the author of this book. Not long after, Sacks diagnosed Dr. P. with a special case of visual agnosia – a condition in which a person can see quite well with their eyes, but cannot recognize or interpret the visual information gathered through the retina, due to tumors in the parietal lobes of the brain. 

Put simply, Dr. P. could see all the details clearly, but could not organize them properly. He could see all the trees and the shrubs, but never realize they make up a forest. When Sacks gave Dr. P. a flower and asked him what it is, Dr. P. replied: “A convoluted red form with a linear green attachment.” When he gave him a glove, Dr. P. once again could do nothing but describe the object: “a continuous surface infolded on itself […] with five outpouchings.” When pressed to guess its function, he replied as follows: “There are many possibilities. It could be a change purse, for example, for coins of five sizes.” 

Just like this glove, nothing was familiar or concrete to Dr. P, not even his wife! Looking for his hat at the end of his exam, he tried pulling his wife’s head off her neck and putting it on – he had confused the two! “Visually,” writes Sacks, Dr. P “was lost in a world of lifeless abstractions.” And he couldn’t even realize this, since the organ that usually does that was the organ malfunctioning – the brain!

What was Sacks’ recommendation to Dr. P. after the strange diagnosis? Music – or more precisely, “a life which consists entirely of music.” Because, you see, though an abstraction, music is never lifeless, and thus can compensate for the losses caused by visual agnosia. Dr. P. took up the advice – he lived and taught music to the last days of his life.

Neurological excesses – and the unforeseen advantages of Tourette’s

“Deficit” is not only neurology’s favorite word – it’s practically the only word neurologists use to describe a disturbance of function in the brain. Yet, there are some cases in which our brains malfunction due to excesses as well. They are not studied as much, because the very idea of “a disease which is ‘ebullient’ or ‘productive’ in character challenges the basic mechanistic concepts of neurology.” If a disease makes you feel better or helps you function more suitably, then why would you want to cure it? But if you don’t want to cure it, is it a disease at all?

First described near the end of the 19th century, Tourette’s syndrome is a neurodevelopmental disorder characterized by excess – an excess of nervous energy, that is. This leads to “a great production and extravagance of strange motions and notions: tics, jerks, mannerisms, grimaces, noises, curses, involuntary imitations and compulsions of all sorts, with an odd elfin humor and a tendency to antic and outlandish kinds of play.” Unlike lethargic Parkinsonian patients who need more dopamine to arouse them, patients with Tourette’s have “an excess of excitor transmitters in the brain,” so they “need to have their dopamine lowered by a dopamine antagonist, such as the drug haloperidol (Haldol).” 

So, it was Haldol that Sacks prescribed to Ray, a 24-year-old Tourette sufferer, soon after meeting him and diagnosing him sometime in 1971. The initial test was very promising: Ray became virtually tic-free for a period of two hours after being administered a small dosage of Haldol. However, a week later, Ray visited Sacks once again, with a black eye and a broken nose. “So much for your Haldol,” Ray told his doctor in an angry voice, throwing an expletive or two in between!

Though largely incapacitated by his Tourette, the disease also gave Ray an advantage in various games. For example, thanks to his uncontrollably great reflexes and “very sudden, nervous, frivolous shots,” he excelled at ping pong. Just like many “Touretters,” he was also attracted to – and great at – dodging fast-revolving doors. Because of the Haldol, he could now do neither – hence the black eye and the broken nose. “Suppose you could take away the tics,” he said to Sacks. “What would be left? I consist of tics – there is nothing else.” In the end, Ray opted for a compromise: to take Haldol during the workweek, and let things fly at the weekends. “So now there are two Rays,” concludes Sacks, “on and off Haldol. There is the sober citizen, the calm deliberator, from Monday to Friday; and there is 'witty ticcy Ray,’ frivolous, frenetic, inspired, at weekends. It is a strange situation, [but] Ray does make the best of it and has a full life.”

Transports: you are about to enter another dimension (by way of brain tumor)

In addition to neurological excesses or deficits – in both of which the problem is “physical” – there are also cases when our brain can “malfunction” on a psychical level, taking us to strange or beautiful places that seem imbued with meaning and significance. Grouping all of them under the name of “transports,” Sacks notes that due to their spiritual nature, these cases are rarely seen as “medical” or “neurological” issues, and are more often confided only to psychoanalysts and professors. Yet, there are numerous reminiscences, altered perceptions, imaginations and dreams that have clear organic determinants; this shouldn’t – and, in fact, doesn’t – make them less spiritual. “If God, or the eternal order, was revealed to Dostoyevsky in seizures,” comments Sacks, “why should not other organic conditions serve as ‘portals’ to the beyond or the unknown?”

In the case of 19-year-old Bhagawhandi P., the organic condition was an astrocytoma. The tumor first appeared in her brain when she was just a 7-year-old girl. After a year of treatments and a decade-long reprieve, it returned not long after her 18th birthday. This time it was malignant, invasive and no longer removable; fortunately, it was also much kinder than before, for instead of coming with an immediate need for chemotherapy, it came with frequent temporal-lobe seizures which, in dreamlike visions, took Bhagawhandi P. back to her home country of India. 

At first just occasional, the seizures became more frequent with each passing day. “We would see her rapt, as if in a trance, her eyes sometimes closed, sometimes open but unseeing, and always a faint, mysterious smile on her face,” Sacks remembers. “There was, even among the most down-to-earth staff, a feeling that she was in another world, and that we should not interrupt her.” “Bhagawhandi, what is happening?” Sacks asked the girl one day. “I am dying,” she answered. “I am going home. I am going back where I came from.” A week later, her return journey began: she “no longer responded to external stimuli and seemed wholly enveloped in a world of her own.” After three more days, she died – or maybe, opines Sacks, she just finally arrived home.

The world of the simple: the twin “calendar calculators” who couldn’t calculate

“A man may be very ‘low’ intellectually, […] wholly unable to comprehend the world as concepts,” remarks Sacks, “and yet fully able, and indeed gifted, in understanding the world as concreteness, as symbols.” In other words, even the simplest minds are capable of preserving some qualities – and, stranger yet, even enhancing them in some cases.

Take, for example, John and Michael, whom Sacks met in 1966 as 26-year-old twins variously diagnosed as “autistic, psychotic or severely retarded” ever since they turned 7. Intellectually incapacitated, the boys lived in a world of their own, completely incapable of caring for themselves. Also, they couldn’t do simple addition or subtraction with any accuracy, let alone comprehend what multiplication or division meant. Yet, even before Sacks met them, they were already well known from TV shows as extraordinary “calendar calculators.” What was so extraordinary about them? This.

Carl Friedrich Gauss, one of the greatest mathematicians in history, couldn’t work out an algorithm for the date of Easter; Michael and John – despite having IQs of 60 – could tell you the date of Easter in any year over a period of 80,000 years! The twins were also able to tell anyone – and almost instantly – the day of the week for any date in this same period. Perhaps most astoundingly, each of them could also perceive, within seconds, whether a 10-, 12-, or 20-digit number was prime or not – despite there being “no simple method of calculating primes.” And even if there was, notes Sacks, it would have been beyond the intellectual abilities of the twins.

So, what is it then that has given them these special powers? We might never know, but it’s certainly something in the brain – and an interesting incident gave Sacks some otherworldly idea. One day, a box of matches fell from a table, and discharged its contents on the floor. The twins cried simultaneously: “111!” Sacks counted the matches – that was their exact number. “How could you count the matches so quickly?” he asked the twins. “We didn't count,” they replied. “We saw the 111.” “I believe the twins, seemingly so isolated, live in a world full of friends,” Sacks remarks poignantly, referring to the numbers themselves. “[They] seem to employ a direct cognition – like angels,” Sacks concludes. “They see, directly, a universe and heaven of numbers.”

Final notes

A collection of “short narratives, essays, parables about patients with a great range of neurological and neuropsychiatric conditions,” “The Man Who Mistook His Wife for a Hat” demonstrates, over and over again, how much our perception of the world depends upon the proper functioning of our brain; and how difficult it is to notice when it is out of order.

Sacks’ knack for narrative detail and exceptional writing style is surpassed only by the breadth of his knowledge and the profoundness of his humanity. And even though ”Awakenings,” his 1973 account of his work with survivors of the encephalitis lethargica epidemic of the ‘20s, is arguably his best-known book – if not merely because of the eponymous 1990 Academy Award-nominated film starring Robert De Niro and Robin Williams – “The Man Who Mistook His Wife for a Hat” seems to be the book Oliver Sacks will most fondly be remembered by future generations. 

And that says a lot about it. 

12min tip

The brain is an incredible organ – but it is still just another organ. And just like your lungs or your liver, it can malfunction from time to time. And then the world suddenly changes. So, care about your brain as much as you do about your other organs. Even a slight glitch may lead to you stop being you. Literally.