Case Studies Including the Man Who Mistook His Wife for a Hat, and the Curious Story of Phineas Gage

What can we learn from reflecting on the case studies of Phineas Gage
and those included in Oliver Sacks’ book titled The Man Who Mistook His
Wife for a Hat?
To what extent should those suffering from certain mental illnesses and
dementia be excused from also suffering the consequences of their
actions?
Why was Phineas Gage arguably the most famous schmuck in history
because of the horrific accident he suffered as a railroad worker in 1848?
What is it like to live your life unable to remember recent events, or
remember who your loved ones are? Why do dementia patients often
lash out at baffled bystanders, or even at those close family members
who take care of them?

Please, we welcome interesting questions in the
comments. Let us learn and reflect together!
We will end our video with additional reflections
from the sources we used in this video.
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How did I become involved in promoting awareness of dementia
patients? I was involved in a controversy where I halted the foreclosure of
an over-55 destitute condominium owner, who had advanced dementia,
who had no close family, and who had fallen behind in his condominium
maintenance fees. The foreclosure was halted so the court could appoint
a guardian to place him in an appropriate care facility, and then pay off
his back maintenance fees.
Why was everyone so upset? He had been harassing the people in the
office. He had an alcoholic girlfriend, who moved out after his money ran
out. There were numerous domestic disturbance calls to the police, and
there were unconfirmed reports of him waving a gun around. His
demented behavior was causing his neighbors to be quite upset, like it
was his fault.

The concept that someone could be so demented
that they are no longer responsible for their behavior
is hard for people to accept. After all, the concept
that we are all responsible for our actions, that we
always act out of free will, is a bedrock principle in
our legal and even religious institutions. But
unfortunately, as psychologists know, there are many
mentally ill who cannot control their actions.

The Scream, by Edvard Munch, 1893.
Sandra Day O’Conner was appointed to the Supreme Court by
Ronald Reagan, both suffered from dementia in their latter years.

One early and famous case history is that of Phineas Gage, who is perhaps the most
famous and influential schmuck in human history. I have listened to many
psychology lectures in Wondrium, the Teaching Company, and university lectures on
YouTube that retell the story of Phineas Gage, which I have heard a dozen times.
When my daughter in medical school told me that she was starting her psychology
section, I told her that she would soon hear the remarkable story of Phineas Gage.
Phineas Gage was working on the railroad one sunny day in September 1848. The
gang he was directing had drilled a hole where a metal rod tamping iron was
packing the powder and sand into the hole. He was distracted, and inadvertently
positioned his head over the hole. As he opened his mouth about to speak, a spark
ignited the powder, blasting the tamping iron behind his jaw and left eye, through
his skull. The tamping iron landed eighty feet away, smeared with bits of blood and
brain.

https://en.wikipedia.org/wiki/Phineas_Gage

Remarkably, Phineas Gage never lost consciousness and was not in tremendous pain.
He walked without assistance to an oxcart, and he rode sitting upright to the doctor’s
office half an hour away. He was vomiting and regurgitating blood, but the doctor
patched him up, and although he had a lengthy convalescence, he did live, and he
never suffered any extreme handicaps.
But the tamping iron did take out a big chunk of his cerebral cortex, the region of the
brain that scientists have since determined governs our inhibitions. His behavior
changed radically. Previously, Phineas Gage was a healthy, punctual, hardworking,
conscientious twenty-five-year-old employee, who was the best foreman working for
the railroad. After the accident, Phineas Gage started cursing, became rude and
abrasive to his coworkers, and was unable to follow through on any planned activity.
There were rumors that he started drinking and gambling and was guilty of
inappropriate sexual behavior. These behavior changes, plus the inability to manage
your financial affairs, are common markers for those who suffer from dementia today.

https://en.wikipedia.org/wiki/Phineas_Gage
The "cone of uncertainty" for the path taken by the tamping iron. Gage's mouth was open at
the moment of the explosion, and the front and back of his skull temporarily "hinged" apart as
the iron entered from below, then were pulled back together by the resilience of soft tissues
once the iron had exited through the top of Gage's head.

What are the odds of
developing dementia?
About seven percent
of people over 65 will
suffer from dementia
eventually.

In time, often other portions of the brain can assume the functions of a damaged
section. Dr Wikipedia reports that Phineas Gage may have recovered his ability to
control his emotions a few years later. He emigrated to Chile, where he was able to
hold a job driving a stagecoach, before passing about a decade after his accident
when he was thirty-six. It is indeed remarkable that he could function somewhat
normally after such a devastating trauma to his brain.
Did that tamping iron take out that part of Phineas Gage that controlled his moral
compass? The testimony of his associates and medical experts of the time would
agree, though it seems that in time his brain rewired and recovered at least some of
this compass.

Can dementia rob those with advanced dementia of
their moral compass? I did not ask, DOES dementia
rob some of their moral compass because, unlike the
sudden accident of Phineas Gage, dementia is gradual
at first, and does not really change the personality of
the patient, but rather accentuates their existing
personality. Someone who begins with a strong moral
compass will likely retain more of their compass as
their dementia progresses.

But there is a caveat: we must also emphasize that many
dementia patients do lash out as their dementia progresses,
mostly out of frustration, and in response to pain and discomfort
they experience because they are not eating well, or able to take
care of themselves, or perhaps have a urinary tract infection,
including many who wound have never struck out before their
dementia. The irrational behavior of those suffering from
dementia is such a problem that a page on the Alzheimer’s
Association website discusses why those with dementia also
often suffer from aggression and anger, and how to deal with it.

https://www.alz.org/help-support/caregiving/stages-behaviors/agression-anger
Causes Include:
Physical discomfort
Environmental Factors
Poor communication
See website for discussion

This means that whenever someone is seventy or
older, or sometimes younger, lashes out
inappropriately, or behaves in a sexually
inappropriate manner, even if that has always been
part of their personality, you can never rule out that
they are suffering from the early stages of dementia.
You have to show patience towards our elderly
citizens, you have to give them a break.

https://www.alz.org/help-support/caregiving/stages-behaviors/agression-anger

And we always repeat that there is a rare type of
dementia that is curable, and that tumors or other
metabolic or medical disorders can cause symptoms
that mimic dementia, so it is critical that the elderly
are seen by doctors, and that their doctors be
completely informed about all the health challenges
they face. And also fill up the grocery bag with all
their medications to make sure that combinations of
drugs are not causing problems.

- The hidden
self, or the
late stages of
dementia, and
Early stages of
dementia,
both by
Bieker, 2011

The Man Who Mistook His Wife for a Hat
Starry
Starry
Night by
Vincent
van
Gogh,
1889

One book that was continually mentioned in the footnotes was
Oliver Sacks’ The Man Who Mistook His Wife for a Hat, which is a
remarkable collections of case histories of patients with puzzling,
remarkable, and often tragic neural deficits of the brain. Many of
his patients were in a home for the aging, but he did not report
any cases that were obviously dementia, as they did not seem to
have the relatively quick deterioration that dementia patients
suffer. But they do illustrate the persistent inability of these
patients to control their behavior, their inability to better
themselves by simply trying harder, and their persistent
helplessness in the face of their mental conditions.

One curious story was the case of the man who mistook
his wife for a hat. Dr P. was a well-known musician, known
as a singer, then as a music teacher, but as he aged a
curious deficit evolved. He lost the ability to recognize
faces, but when they began to speak, he could identify
them by their voice. He could converse without difficulty
and intelligently. He did not feel ill, and he was a dazzling
singer, much like Glen Campbell and Tony Bennett who did
not lose their ability to perform until very late in the
course of their dementia.

Portrait of a man
in a white hat, by
Tadeusz
Makowski, 1913
Old man holding
the hat, by Jean-
Antoine Watteau,
1711

What was wrong? He went to see an ophthalmologist to
check his eyesight, but there was nothing wrong physically,
so he was referred to Dr Sacks, a neurologist. He
performed a reflex test, where he had to take his shoes off,
and afterwards Dr Sacks discovered that the patient did
not know how to put his shoe back on! The good doctor
had to help him put on his shoe, and then asked him to
describe pictures in a National Geographic magazine. He
could describe this detail or that but found that he had lost
the ability to describe the landscape as a whole!

Olive Trees, by
Van Gogh, 1889.
Vincent Van Gogh
suffered from
mental illness,
which provided
inspiration for his
paintings.

When the examination was over, Dr P. “looked
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.”
Later, our good doctor visited his house. Dr Sacks
remembered, “On the walls of his apartment were
photographs of his family, his colleagues, his pupils,
and himself.” “By and large, he recognized nobody:
neither his family, nor his colleagues, nor his pupils,
nor himself. He recognized a portrait of Einstein
because he picked up the characteristic hair and
mustache; and the same thing happened with one
or two other people.”
Man in the Hat, by Tichymeloun

Although he could distinguish the stylized pictures of
royalty on the playing cards, or maybe he saw the
letters J-Q-K. Also, he could not make sense of what
was happening in a movie playing on the television.
Dr P also reported that he could no longer dream
pictorially, and his wife said he could only perform
daily tasks if he sang while doing them. The visual
cortex of his brain suffered damage, his brain could
interpret sounds, but not sight.

The Chateaux, by
Paul Cézanne, 1905

The Music Lesson, by Aleksandra Ekster
Healing Qualities of Music and Performing

In addition to this case of Dr P, the music teacher, Dr
Sacks has several case histories where music can
stimulate many who suffer from neural deficits. Dr
Sacks states that even the profoundly retarded can
seemingly come alive when exposed to music:

Oliver Sacks writes, “Their uncouth
movements may disappear in a moment
with music and dancing. Suddenly, with
music, they know how to move. We see
how the retarded, unable to perform
fairly simple tasks involving perhaps four
or five movements of procedures in
sequence, can do these perfectly if they
work to music.” “What we see,
fundamentally, is the power of music to
organize, and to do this efficaciously, as
well as joyfully, when abstract or
schematic forms of organization fail.”

In our review of books about Alzheimer’s, the best
case study we have found is that of the biography of
Glen Campbell’s latter life by his fourth wife and
widow Kim, which shows both how his personality
slowly transitioned into dementia, and how music
and his musical performances appeared to slow his
descent into advanced dementia.

https://youtu.be/F9NmDiiPowI
Includes the Ten Early
Signs and Symptoms
from Alzheimer’s
Association website.

Both Glen Campbell and Tony Bennett had a final performance, sharing
with the audience that they were indeed suffering from Alzheimer’s. Tony
Bennett’s last performance included duets with Lady Gaga, who was his
New York neighbor and who often visited his studio to practice their
duets. Both these musicians had little difficulty performing their old
songs with panache, but had great difficulty performing new songs,
though a teleprompter helped some.
Likewise, Rita Hayworth also continued her acting career through the
earlier stages of her Alzheimer’s, and her performance helped her
dementia to subside, though she found it increasingly difficult to
remember her lines.

Dr Sacks has a touching story about Rebecca, who
was profoundly retarded from birth, unable to walk
around the block, clothed herself with difficulty, and
was unable to unlock her door with a key. The rituals,
the candles, and the bowing in her Orthodox Jewish
services brought her comfort, but she did not
perform well in the workshops and odd jobs that
were intended to give her focus. But she loved to
perform in a special theater group.

Dr. Philippe
Pinel at the
Salpêtrière,
1795 by Tony
Robert-Fleury.
Pinel ordering
the removal of
chains from
patients at the
Paris Asylum
for insane
women.

Dr Sacks remembers, “She loved the theater
group, it composed her. She did amazingly
well: she became a complete person, poised,
fluent, with style, in each role. If you saw
Rebecca on the stage, for this theater group
became her life, one would never even guess
that she was mentally defective.”
Dr Sacks concludes, “We pay far too much
attention to the defects of our patients, as
Rebecca was the first to tell me, and far too
little to what was intact or preserved.”

This same concept that rather than trying to improve
dementia patients, in a foolish attempt to make them
normal again, we should rather seek to encourage and
enhance those joyous activities and capabilities they have
remaining, is a theme in the video inspired by the
wonderful book by Joanne Koenig Coste, Learning to Speak
Alzheimer’s. She not only cared for her husband who
suffered from early onset dementia, but also cared for
many dementia patients in a facility for many years after
his death.

Amnesia: Harry Truman is President Forever

Jimmy G was admitted to the nursing home where Dr Sacks was in attendance in
1975, he had a severe case of retrograde amnesia. Jimmy remembered his wartime
experiences like they were yesterday. He enlisted in the Navy when he was
seventeen in 1943, and by 1945 America had just won the war, FDR had died at
Warm Springs, and Harry Truman was giving the Russians hell. When he first
examined him, our good doctor made the mistake of showing Jimmy his face in the
mirror. He panicked! Who was that grey-haired man? He knew he was all of
nineteen years old!
Jimmy was looking forward to attending college on the GI Bill, he was proud that his
older brother was studying accounting and would soon get married. Dr Sacks
obtained his records from the Navy, he was discharged in 1965, but found his way to
Bellevue Mental Hospital in 1971, where his heavy drinking and cirrhosis of the liver
led to a diagnosis of “advanced organic brain-syndrome.” He was dumped in a
substandard nursing home until he was transferred to Dr Sacks’ nursing home.

Jimmy could converse in witty conversation, he could play a good
game of checkers, but did not have the attention span for chess,
and he performed well on cognition tests. They contacted his
brother, they discovered they had not been in contact for thirty
years, his brother said his drinking became uncontrollable after
he retired from the Navy. They convinced him to visit Jimmy in
the hospital, but that only made him angry. In a deep sense, he
recognized his brother, but he was so angry. Who was this
strange, unsettling fifty-year-old man? His real brother was only
twenty-one!

Was his amnesia caused by his drinking, or did he
drink to crowd out his creeping amnesia, or did they
feed on each other? We learned that Rita Hayworth
also was drinking heavily in her early years of
dementia. We can ask the same question of her, did
her drinking worsen her dementia, or did she drink
because of her dementia, or both? Dr Sacks does say
that on rare occasions heavy drinking can contribute
to amnesia.

The
elderly
Rita
Hayworth
suffered
from
dementia.
Dancing
with Fred
Astaire.

Jimmy, like many with dementia, only remembers the past,
he remembers nothing of recent experiences. Unlike
dementia patients, his condition did not deteriorate
rapidly. He could cope in the hospital from day to day,
although like some dementia patients, seeing his image in
a mirror upset him, as it caused a conflict between his self-
image in his mind and his actual appearance.
Dr Sacks describes another case of another frenetic patient
who had no short-term memory whatsoever, forgetting
names and people.

Social alienation was one of the main themes in
Francisco Goya's masterpieces, such as The
Madhouse, painted in 1819. Social alienation is
part of dementia today, we want to blame the
demented for their unacceptable behavior.

Dr Sacks remembers that “Mr
Thompson would identify me,
misidentify, pseudo-identify
me, as a dozen different
people in the course of five
minutes. He would whirl,
fluently, from one guess, one
hypothesis, one belief, to the
next, without any appearance
of uncertainty. He never
knew who I was, or what and
where he was: an ex-grocer,
with severe Korsakov’s
Disease, in a neurological
institution.” He told “amazing
personal stories full of
fantastic adventures.”

We also reviewed an even more enlightening collection of
case histories of both dementia patients and their
caretakers, which helps alleviate the guilt many caregivers
feel when they react negatively to the dementia displayed
by their loved ones. Caregivers are discouraged when their
efforts are not appreciated by the loved ones they care for,
because their dementia has either robbed them of the
compassion they once felt or made their remaining
compassion fleeting and fickle.

Many police departments, particularly in my state,
Florida, have CIT police training programs through
NAMI which cover mental illness, but currently these
only cover autism, drug abuse issues, and mental
issues with younger offenders. But we do know that
there are discussions between the Alzheimer’s
Association, NAMI, and the police departments
locally to address this training issue, and perhaps
nationally as well.

Oliver Sacks’ wonderful book, the Man Who
Mistook His Wife for a Hat, is one of those rare
books that both clinicians and laymen can
benefit from reading and is cited by many other
books and studies. There is a hundred-page book
that analyzes further these case histories, and
that itself has close to five thousand citations.

https://www.taylorfrancis.com/books/mono/10.4324/9781912282548/analysis-oliver-sacks-man-mistook-wife-hat-clinical-tales-dario-krpan-alexander-connor

The review states that Dr Sacks found
it puzzling why so many doctors
preferred an impersonal approach to
their patients. “His ideas were so
influential that they heralded the
arrival of a broader movement –
narrative medicine – that placed
stronger emphasis on listening to and
incorporating patients’ experiences
and insights into their care.”

The original copyright was in 1970, it paralleled the anti-psychiatry movement that
sought to humanize the mentally ill patient and give him as much agency as
possible.
This book has twenty-four case studies that have fascinated clinicians. They include
a case where a patient cannot recognize anything on the left side of her body, or
even on the left side of her plate at mealtime, a patient whose drug use caused an
extremely heightened sense of smell, and an autistic artist who could draw
amazingly expressive illustrations with just a little encouragement.
He explored patients with Tourette’s Syndrome, which “is characterized by an excess
of nervous energy,” with “strange motions and notions: tics, jerks, mannerisms,
grimaces, noises, curses, involuntary imitations and compulsions of all sorts.” He
examined several cases of Parkinson’s, a gradual neurological disease. With
Parkinson’s, patients first experience tremors and difficulty walking, and as the
disease slowly progresses, symptoms of dementia manifest. In one case a patient
leaned a good twenty degrees when he walked.

Clinical Lesson at
the Salpêtrière,
by André
Brouillet, 1887.
Jean-Martin
Charcot was a
French
neurologist and
professor who
named Tourette
syndrome for his
intern, Georges
Gilles de la
Tourette. Charcot
is lecturing,
Tourette is in the
audience.

Clinical Lesson at
the Salpêtrière,
by André
Brouillet, 1887.
Jean-Martin
Charcot was a
French
neurologist and
professor who
named Tourette
syndrome for his
intern, Georges
Gilles de la
Tourette. Charcot
is lecturing,
Tourette is in the
audience.
He explored patients with Tourette’s Syndrome, which “is
characterized by an excess of nervous energy,” with “strange motions
and notions: tics, jerks, mannerisms, grimaces, noises, curses,
involuntary imitations and compulsions of all sorts.”

We have learned in our studies that sometimes a brain tumor can cause
dementia-like symptoms, and if the tumor can be removed, the dementia
dissipates. Oliver Sacks explored several cases of patients suffering brain
tumors, sometimes they cause changes in behavior, such as when one
droll chemist became funny, impulsive, and superficial. An Indian patient
had a malignant brain tumor that could not be removed, her tumor
caused vivid technicolor memories of the Indian landscape, villages,
homes, and gardens from her childhood. As death approached, pleasant
memories flooded over her that lasted most of the day. He examined
cases where strokes also caused hallucinations, as in the case of an Irish
lady whose stroke triggered songs she had heard in her childhood.

Krishna Fluting to
the Milkmaids,
Kangra painting,
1785

Oliver Sacks also ponders the visions of the
influential Hildegard of Bingen, the mystic who so
profoundly influenced medieval Catholicism. He
examines her illustrations of many of these visions,
saying that they indisputably resemble hallucinations
caused by visual auras of migraines.

Visions of Hildegard von Bingen, Catholic Saint

Visions of Hildegard von Bingen, Catholic Saint
Hildegard herself writes: “The visions which I saw beheld neither in sleep, 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.” “I have never fallen prey
to ecstasy n the visions, but I see them wide awake, day and night.”

This scientific observation should not damage the
faith of anyone, for when God does bless a saint with
visions, he would then cause their senses to perceive
the visions.

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