topics: |  psychology | case-study | perception | memory

When I got this copy in the 1980s from a book club in the US, it immediately enchanted me, and was perhaps one of the prime movers for my growing interest in Cognitive Science.

It records a fascinating series of cases observed by a neurologist in his rounds. The cases are counterintuitive, and provoke serious thoughts about the fragile interconnections that keep us going and maintain our sense of identity. Even the smallest slip and we may feel that one of our legs is not ours, or that someone we know intimately is a complete stranger.

Excerpts

4 The Man Who Fell out of Bed

[Sacks is called in to this case as a medical student. A new patient — a young man — seemed very nice, very normal... But after waking up from a snooze, he got very excited and somehow contrived to fall out of bed, and was now sitting on the floor, loudly refusing to go back to bed.]

When I arrived I found the patient lying on the floor by his bed and
staring at one leg. His expression contained anger, alarm, bewilderment and
amusement — bewilderment most of all, with a hint of consternation. I asked
him if he would go back to bed, or if he needed help, but he seemed upset
by these suggestions and shook his head. 

I squatted down beside him, and took the history on the floor. He had come
in, that morning, for some tests, he said. He had no complaints, but the
neurologists, feeling that he had a ‘lazy’ left leg — that was the very
word they had used— thought he should come in. He had felt fine all day,
and fallen asleep towards evening.

When he woke up he felt fine too, until he moved in the bed. Then he found,
as he put it, ‘someone’s leg’ in the bed — a severed human leg, a horrible
thing!  He was stunned, at first, with amazement and disgust — he had never
experienced, never imagined, such an incredible thing. He felt the leg
gingerly. It seemed perfectly formed, but ‘peculiar’ and cold. At this point
he had a brainwave.  He now realized what had happened: it was all a joke! A
rather monstrous and improper, but a very original, joke! It was New Year’s
Eve, and everyone was celebrating. Half the staff were drunk; quips and
crackers were flying; a carnival scene. Obviously one of the nurses with a
macabre sense of humor had stolen into the Dissecting Room and nabbed a leg,
and then slipped it under his bedclothes as a joke while he was still fast
asleep. He was much relieved at the explanation; but feeling that a joke was
a joke, and that this one was a bit much, he threw the damn thing out of the
bed. But — and at this point his conversational manner deserted him, and he
suddenly trembled and became ashenpale— when he threw it out of bed, he
somehow came after it — and now it was attached to him.

‘Look at it!’ he cried, with revulsion on his face. ‘Have you ever seen
such a creepy, horrible thing? I thought a cadaver was just dead. But this
is uncanny! And somehow — it’s ghastly — it seems stuck to me!’ He seized
it with both hands, with extraordinary violence, and tried to tear it off
his body, and, failing, punched it in an access of rage.

‘Easy!’ I said. ‘Be calm! Take it easy! I wouldn’t punch that leg like
that.’

‘And why not?’ he asked, irritably, belligerently.

‘Because it’s your leg,’ I answered. ‘Don’t you know your own leg?’

[...]

But I want to ask you one final question. If this — this thing — is not
your left leg’ (he had called it a ‘counterfeit’ at one point in our talk,
and expressed his amazement that someone had gone to such lengths to
‘manufacture’ a ‘facsimile’) ‘then where is your own left leg?’

Once more he became pale — so pale that I thought he was going to faint. ‘I
don’t know, he said. ‘I have no idea.  It’s disappeared. It’s gone. It’s
nowhere to be found ...

5 Hands

Madeleine J., 60 years old, is a congenitally blind woman with cerebral
palsy, who had been looked after by her family at home throughout her
life. She was in a pathetic condition — with spasticity and
athetosis, i.e., involuntary movements of both hands...

[But she was not retarded.]  Quite the contrary: she spoke freely, indeed
eloquently (her speech, mercifully, was scarcely affected by spasticity),
revealing herself to be a high-spirited woman of exceptional intelligence and
literacy.

‘You’ve read a tremendous amount,’ I said. ‘You must be really at home with
Braille.’

‘No, I’m not,’ she said. ‘All my reading has been done for me— by
talking-books or other people. I can’t read

Braille, not a single word. I can’t do anything with my hands — they are
completely useless.’

She held them up, derisively. ‘Useless godforsaken lumps of dough — they don’t
even feel part of me.’

I found this very startling. The hands are not usually affected by cerebral
palsy — at least, not essentially affected... unlike the legs,
which may be completely paralyzed...

Miss J.’s hands were mildly spastic and athetotic, but her sensory
capacities — as I now rapidly determined — were completely intact: she
immediately and correctly identified light touch, pain, temperature, passive
movement of the fingers. There was no impairment of elementary sensation, as
such, but, in dramatic contrast, there was the profoundest impairment of
perception. She could not recognize or identify anything whatever — I placed
all sorts of objects in her hands, including one of my own hands. She could
not identify — and she did not explore; there were no active ‘interrogatory’
movements of her hands — they were, indeed, as inactive, as inert, as useless,
as ‘lumps of dough’.

This is very strange, I said to myself. How can one make sense of all this?
There is no gross sensory ‘deficit’. Her hands would seem to have the
potential of being perfectly good hands — and yet they are not. Can it be that
they are functionless—’useless’—because she had never used them? Had being
‘protected’, ‘looked after’, ‘babied’ since birth prevented her from the
normal exploratory use of the hands which all infants learn in the first
months of life?

Had she been carried about, had everything done for her, in a manner that had
prevented her from developing a normal pair of hands? And if this was the
case — it seemed far-fetched, but was the only hypothesis I could think of—
could she now, in her sixtieth year, acquire what she should have acquired in
the first weeks and months of life?

[...]

I thought of the infant as it reached for the breast. ‘Leave Madeleine her
food, as if by accident, slightly out of reach on occasion,’ I suggested to
her nurses. ‘Don’t starve her, don’t tease her, but show less than your usual
alacrity in feeding her.’ And one day it happened — what had never happened
before: impatient, hungry, instead of waiting passively and patiently, she
reached out an arm, groped, found a bagel, and took it to her mouth. This was
the first use of her hands, her first manual act, in sixty years, and it
marked her birth as a ‘motor individual’ (Sherrington’s term for the person
who emerges through acts). It also marked her first manual perception, and
thus her birth as a complete ‘perceptual individual’. Her first perception,
her first recognition, was of a bagel, or ‘bagelhood’—as Helen Keller’s first
recognition, first utterance, was of water (‘waterhood’).

After this first act, this first perception, progress was extremely rapid. As
she had reached out to explore or touch a bagel, so now, in her new hunger,
she reached out to explore or touch the whole world. Eating led the way — the
feeling, the exploring, of different foods, containers, implements,
etc. ‘Recognition’ had somehow to be achieved by a curiously roundabout sort
of inference or guesswork, for having been both blind and ‘handless’ since
birth, she was lacking in the simplest internal images (whereas Helen Keller
at least had tactile images). Had she not been of exceptional intelligence
and literacy, with an imagination filled and sustained, so to speak, by the
images of others, images conveyed by language, by the word, she might have
remained almost as helpless as a baby.

A bagel was recognized as round bread, with a hole in it; a fork as an
elongated flat object with several sharp tines.  But then this preliminary
analysis gave way to an immediate intuition, and objects were instantly
recognized as themselves, as immediately familiar in character and
‘physiognomy’, were immediately recognized as unique, as ‘old friends’. And
this sort of recognition, not analytic, but synthetic and immediate, went
with a vivid delight, and a sense that she was discovering a world full of
enchantment, mystery and beauty.

Evolving into a sculptor

The commonest objects delighted her — delighted her and stimulated a desire
to reproduce them. She asked for clay and started to make models: her first
model, her first sculpture, was of a shoehorn, and even this was somehow
imbued with a peculiar power and humor, with flowing, powerful, chunky
curves reminiscent of an early Henry Moore.

And then — and this was within a month of her first recognitions — her
attention, her appreciation, moved from objects to people. There were
limits, after all, to the interest and expressive possibilities of things,
even when transfigured by a sort of innocent, ingenuous and often comical
genius. Now she needed to explore the human face and figure, at rest and in
motion. To be ‘felt’ by Madeleine was a remarkable experience. Her hands,
only such a little while ago inert, doughy, now seemed charged with a
preternatural animation and sensibility. One was not merely being
recognized, being scrutinized, in a way more intense and searching than any
visual scrutiny, but being ‘tasted’ and appreciated meditatively,
imaginatively and aesthetically, by a born (a newborn) artist. They were,
one felt, not just the hands of a blind woman exploring, but of a blind
artist, a meditative and creative mind, just opened to the full sensuous
and spiritual reality of the world. These explorations too pressed for
representation and reproduction as an external reality.

She started to model heads and figures, and within a year was locally
famous as the Blind Sculptress of St.  Benedict’s. Her sculptures tended to
be half or three-quarters life size, with simple but recognizable features,
and with a remarkably expressive energy. For me, for her, for all of us,
this was a deeply moving, an amazing, almost a miraculous, experience. Who
would have dreamed that basic powers of perception, normally acquired in
the first months of life, but failing to be acquired at this time, could be
acquired in one’s sixtieth year? What wonderful possibilities of late
learning, and learning for the handicapped, this opened up. And who could
have dreamed that in this blind, palsied woman, hidden away, inactivated,
over-protected all her life, there lay the germ of an astonishing artistic
sensibility (unsuspected by her, as by others) that would germinate and
blossom into a rare and beautiful reality, after remaining dormant,
blighted, for sixty years?

Postscript

The case of Madeleine J., however, as I was to find, was by no means
unique. Within a year I had encountered another patient (Simon K.) who also
had cerebral palsy combined with profound impairment of vision. While Mr K.
had normal strength and sensation in his hands, he scarcely ever used them
— and was extraordinarily inept at handling, exploring, or recognizing
anything. Now we had been alerted by Madeleine J., we wondered whether he
too might not have a similar ‘developmental agnosia’—and, as such, be
‘treatable’ in the same way. And, indeed, we soon found that what had been
achieved with Madeleine could be achieved with Simon as well. Within a year
he had become very ‘handy’ in all ways, and particularly enjoyed simple
carpentry, shaping plywood and wooden blocks, and assembling them into
simple wooden toys. He had no impulse to sculpt, to make reproductions — he
was not a natural artist like Madeleine. But still, after a half-century
spent virtually without hands, he enjoyed their use in all sorts of ways.

This is the more remarkable, perhaps, because he is mildly retarded, an
amiable simpleton, in contrast to the passionate and highly gifted
Madeleine J. It might be said that she is extraordinary, a Helen Keller, a
woman in a million — but nothing like this could possibly be said of simple
Simon. And yet the essential achievement — the achievement of hands —
proved wholly as possible for him as for her. It seems clear that
intelligence, as such, plays no part in the matter — that the sole and
essential thing is use.