Oliver Sacks: A Neurologist Examines 'The Mind's Eye' Neurologist Oliver Sacks is famous for his case studies of people with neurological disorders that cause unusual problems with perception. In The Mind's Eye, Sacks turns to himself, explaining how an eye tumor affected his vision and perception of the world.

Oliver Sacks: A Neurologist Examines 'The Mind's Eye'

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This is FRESH AIR. I'm Terry Gross.

In his books like "The Man Who Mistook His Wife for a Hat" and "Awakenings," neurologist Oliver Sacks has written case studies of his patients who have unusual disorders that cause alarming and disorienting perceptual changes.

His new book, "The Mind's Eye," is devoted to visual disturbances. A couple of the chapters are autobiographical, and they came as quite a surprise to me, even though I've read several of his books and interviewed him several times. One chapter describes his inability to recognize people by their faces. This is a condition called prosopagnosia, which is being investigated by neurologists.

Another chapter is about the visual hallucinations and distortions that resulted from a melanoma, a cancerous tumor, behind his right eye. The tumor was removed, and the cancer had not spread.

Sacks is now 77. He's a practicing physician and a professor of neurology and psychiatry at Columbia University Medical Center.

Oliver Sacks, welcome back to FRESH AIR. I often say that I never really know what's going on in the lives of the people I interview. We last spoke in 2007 about your book "Musicophilia," about the neurological disorders that affect people's perceptions of music.

It was a fascinating interview, but I had no idea that, as we talked, you were in the process of losing sight in your right eye and that you had had surgery for a cancerous tumor in your eye. Why were you ready now to commit that to writing and to talk about it?

Dr. OLIVER SACKS (Professor of Neurology and Psychiatry, Columbia University Medical Center; Author, "The Mind's Eye"): Well, first, the current book is a visual book, rather than a musical one. Secondly, I think I've come to a sort of neutral place where the tumor is quiet, and nothing too much is happening.

But thirdly and perhaps most importantly - although I'm sorry this happened to me and is happening to me - I feel I might as well use it and investigate it and write about it and just speak of myself as I would speak of one of my patients or subjects.

GROSS: How much vision do you have now in your right eye?

Dr. SACKS: I have no vision in my right eye now, and the vision in my left eye is okay-ish, but sooner or later, I'm going to need cataract surgery.

GROSS: Now, you've kept a journal of your symptoms. You call it the melanoma journal. And included in that, you reprint some of this: your drawings of the visual distortions you were perceiving when you were in the process of losing vision in your right eye. How helpful has it been to keep that journal, and do you still have one?

Dr. SACKS: I still have it, although I don't make too many entries now. I've always kept journals, since I was 14 or so, for special experiences, whether it's traveling, going on a botanical excursion in Oaxaca, or lose - or having leg surgery or having an eye problem.

I think it allows me a certain detachment and power of reflection, and perhaps at a deeper level, writing helps me clarify what's going on for myself. And I'm, whatever that means, a born writer. I have to write about things, especially things which I feel intensely.

GROSS: Would you describe when you knew something was going wrong with your eye? And this was in December of 2005.

Dr. SACKS: Yes, it was a Saturday morning. I had gone for a swim, as I usually do, and then I went to the movies. And while the previews were on, I suddenly became conscious of a strange - some sort of visual instability and fluttering to my left.

And then when the previews stopped, I became conscious of a blazing, incandescent light on the left. I - for a moment, I thought it was a visual migraine, which I'm prone to, but it was soon clear that this was only in the right eye - not in the brain like a migraine - and that something unprecedented was happening.

I got very scared, or panicked. I wondered if I was bleeding into the eye or had detached a retina. I also noticed that some of the lights in the cinema were missing. There was a gap in my visual field to the left.

And I finally burst out of the cinema, hoping everything would be okay outside, but it wasn't okay. I saw an ophthalmologist that afternoon and told him my story, told him that a bit of the visual field seemed to be missing. And he looked into my eyes, and it then seemed to me that he drew back and gazed at me in a different way.

And he said: You've got something behind the retina. He said it could be a blood clot. It could be a tumor. He said if it's a tumor, I want to go over the worst possible scenario with you.

I really didn't catch too much else of what he said, because at that point, a voice in my head started shouting cancer, cancer.

Anyhow, I had a frightened weekend, and on - a couple of days later, I saw the man to whom I dedicate my book, an ocular oncologist called David Abramson. And he looked at things, did an ultrasound, then brought out a model of the eye and put a thing like a little black cauliflower or cabbage there. And for me, that was his way of indicating that I had a tumor and a black tumor, a melanoma.

GROSS: Which means it was a cancerous tumor.

Dr. SACKS: A cancerous tumor. And a melanoma has a particularly vicious reputation. When I was a medical student, they were all thought to be fatal within a few months. And - but then he immediately reassured me that the tumors in the eye are much less malignant and usually don't metastasize, don't disseminate. But one has to do something. You can't let it grow in the eye.

And he said in the old days, or 20 years ago, one would have removed the eye. But now one could use radiation and maybe lasering, and hopefully that would take care of it.

GROSS: So you had a procedure where they actually put radiation into the eye to try to kill the tumor. And so you were radioactive for that period of time.

Dr. SACKS: Yeah. I was very radioactive. And when I was in hospital, there was the trefoil on the door, and people couldn't come too near me. They couldn't embrace me. And I rather wanted to be embraced then, because I was sort of frightened - though I did hope with my intensely radioactive eye that I might use it to light up some fluorescent minerals.

I'm rather fond of fluorescence. You usually use an ultraviolet light, but X-rays and gamma rays will do. And I was hot. And I wanted to try it.

GROSS: So how effective was the procedure?

Dr. SACKS: There was quite a lot of swelling under the - with the tumor, that had to die down. And then three months later, I had some lasering, which is supposed to pick up any cancer cells which have survived the radiation.

And at that point, which is now in April, May of 2006, I thought I might have heard the end of matters. But then I started to get symptoms again later in that year. The tumor was very near my fovea. That's the part of the eye which has the finest vision and central vision. And because it was so close to the fovea, a little area had been - had not been lasered. But now that area started to grow again, and I needed more lasering. And finally in the following year, in June, I lost central vision with the lasering.

But by that time, I didn't mind it too much, because my vision was becoming tremendously distorted with that eye, and sometimes this slightly affected both eyes so that people, for example, were immensely elongated, like insects, and tilted to the left. And faces had strange, puffy swellings, rather like Francis Bacon paintings. And I was really quite glad when that sort of distortion could be replaced by nothingness.

GROSS: Can you describe some of the other, more unusual visual distortions you experienced in the process of losing the vision in your right eye?

Dr. SACKS: Well, something which struck me very early was a peculiar persistence of vision. I first noticed this, actually, when I was in the hospital, and the right eye was being radiated and covered with heavy bandage.

But I went in to wash my hands, and then, for some reason, closed my left eye, but saw the wash basin and the taps and the commode and everything perfectly clearly. And I thought: That's odd. The dressing over my right eye must be transparent. But, in fact, it was completely opaque.

And the - objectively, I had not been seeing anything, but yet for about 15 seconds, I saw a detailed picture of that washroom. And this was my persistence of vision, and it became very especially striking after I'd been lasered in '07.

GROSS: Any explanation for that phenomenon?

Dr. SACKS: This sort of phenomenon has been described by others in various conditions, but I think this, along with various other things I was getting at the time, was because of a sort of paradoxical hyperactivity in the visual parts of the brain. These were not receiving their usual input from the eye, and therefore, they heightened what one was getting from the other eye, as well as inventing various things for themselves.

GROSS: One really unusual phenomenon you described was that there was a period when you only saw the lower halves of people walking.

Dr. SACKS: Oh, yes. That was - I was very struck by that. This was actually the day after I'd had the lasering. And I went out. I was having breakfast with a friend. This was an outdoor cafe in the Village.

And I - all central vision had been obliterated, except for a little bit at the bottom. And so I just saw people's shoes and lower legs and trousers and skirts.

And it was - I mean, obviously, if I tilted my head back, I could see more of them, although I could only see a little bit at any time. And this sort of reminded me of a character in "Ulysses," a Senor Artifoni, who was never characterized as beyond a pair of stout trouser legs. And so my world became one of stout trouser legs and shoes for a little while.


GROSS: Since you've lost the sight in your right eye, you've lost stereoscopic vision.

Dr. SACKS: Yes.

GROSS: How does the world look different? Well, you've probably adjusted now. So let's go back to when you first lost the sight. Yeah.

Dr. SACKS: Well, I'm not sure that I have adjusted, or I may need to say what adjustment consists of. But before there was any adjustment, I found myself in an intensely flat world.

Steps and curbs just looked like horizontal lines on the ground. There was no sense of near and far, no sense of depth. Sometimes what was near and what was far would be conflated to make a single sort of absurd hybrid or chimera.

Going down stairs was particularly dangerous. I had to sort of feel out each stair with my foot because it looked flat. And sight is so dominant, that sometimes I would - as it were, the eye would argue with the foot and say look, it's flat, and that's that. You don't have another step.

I had many accidents at close quarters. I would go up to shake hands with someone, and I'd miss their hand. I'd pour them a glass of wine, but I'd pour the wine into their lap. And there were a lot of things like this, possibly more severe in my case, because I had been a lover of stereo vision and an ardent stereo photographer and very, very conscious of stereo vision, and I think probably unusually strong in stereo vision, and precisely that which I so depended on vanished.

GROSS: Did any of your other senses compensate for what you lost?

Dr. SACKS: I became more adept in using other cues: shadow, shading, perspective, occlusion. And to this extent, I've adapted. But the absence of real depth, the absence of stereo, is still absolute, and I think one - this is bound to occur if one only has one operative eye.

I occasionally seem to have dreams in stereo, but I don't know that one can trust descriptions of that. You know, as a stereo addict, I would often dream of looking through a stereoscope. And now I still sometimes dream of that, and I awakened into my flat world, where sometimes the fan in my room is about to hit the bedside lamp.

I know that they're six feet away from each other, but they still look on the same plane to me.

GROSS: Is it upsetting? You know what's going on. You're a neurologist. You have a very deep understanding of what the problem is. But is it still upsetting to perceive inaccurately?

Dr. SACKS: Yes, it is. It's both fascinating and upsetting. I've become rather fond of Medieval art, where, of course, there's no perspective and no sense of depth. This reminds me - to some extent, I feel I'm in a sort of 13th-century painting myself.

Some colleagues of mine at Harvard wrote an interesting paper, which I read several years ago. They noted that Rembrandt's eyes were so far apart and slightly divergent, that it seemed to them very unlikely that he could have used both eyes and could have had stereo vision.

And they observed this with a number of other artists and then started to wonder whether having one eye - or, in effect, only using one eye, might be an advantage for an artist.

I thought that was improbable, but I have to say that one of the minor compensations now of losing stereo is that I have a stronger sense of visual composition. The world looks to me very much like a canvas or a screen, with the appearances in perspective of objects on it.

Unfortunately, I can't paint or draw, as will be painfully evident to anyone who looks at my book. But it's - I can see that I never had quite the sense of visual composition before. Before, there were real objects in real space at different distances. Now, to some extent, there are just surfaces and colors which are juxtaposed to one another and moving. It's much more like a 2-D film.

GROSS: Have you rearranged the furniture and other objects in your home so that they look less like they're colliding with each other and that there's more space and perspective?

Dr. SACKS: Yes. I have tried to do that, although it doesn't always work. But this feeling of crowdedness and spacelessness is very strong. But I have been rearranging objects for another reason, which was that a year ago, I lost what little vision I had in the right eye completely. I had a hemorrhage there. And now I can't see anything to the right of my nose.

And more importantly, I not only lose sight, but I can't keep in mind that there are things to my right. So I tend to collide with people and things to my right.

And I was very amazed that simply losing an eye, rather than a part of the brain, could produce something like this. I've often seen patients who have had strokes or brain tumors, which maybe have blotted out half of their vision, and as well as the idea that there is anything to one side. But I didn't expect to get this myself.

But I do have it. So I need, on the whole, to keep things to the left. At first, I was afraid to walk in the streets because I kept bumping into things, and people suddenly appeared without any warning because I had no right-side, no peripheral vision.

Again, I've adapted to this somewhat, but only by being very, very conscious of it. And since there's a big slice of my vision missing, I can't just glance to the right. I have to turn my head and my upper body to the right. I have to crane and peer, and that can sometimes disturb people who are behind me because they feel I am staring at them.

But I certainly - I have to do this. And crossing roads is - becomes an occasion for extreme caution.

So both of these, the loss of stereo and the loss of right side, although one accommodates quite a lot, you accommodate by having to be careful.


GROSS: Let me get to another story about yourself that you tell in your new book, "The Mind's Eye." Another thing you've dealt with through your life is face blindness. You have great difficulty recognizing people's faces. I didn't even know there was such a disorder, that there was a name for that, that it's an official disorder. When did it start being defined as a disorder?

Dr. SACKS: Well, no doubt face blindness has always existed, and now one can read earlier accounts which didn't use the phrase but say this is what it must have been. The defining paper was by a German neurologist in the 1940s and he coined the term prosopagnosia - "prosopon" is the Greek for a face or a mask -for this apparently specific difficulty recognizing faces. He gave some case histories, and in one case a young soldier who had had a brain injury lost his ability to see faces, couldn't recognize his own wife if she was in nurse's uniform but did recognize a particular nurse. But it turned out that this was because she had such shining white teeth and that he recognized the shining teeth, although not the face.

But in "The Man Who Mistook His Wife For A Hat," my patient, Dr. P., couldn't recognize people but he could hardly recognize anything. For him, the agnosia -the term agnosia is used for a situation in which one sees something clearly but one can't ascribe any meaning to it, you can't recognize it. And "The Man Who Mistook His Wife For A Hat" had face blindness and every other sort of agnosia. But after the book was published, I started getting letters from people who said that they had had something like that, although restricted to faces, all their lives, and other people in their family had had it. And I found this very curious because I didn't know that there could be a sort of congenital face blindness. Although by that point I had already started to suspect myself because I had many, many embarrassments at school and I not only had difficulty with faces, I had difficulty with places as well.

And I found my brother in Australia, whom I hadn't met for 30 years, had exactly the same problems and I wondered if we both had some sort of syndrome. But it's really only in the last 10 years with the development of Internet and of some centers for research, one of them is by Professor Nukiyama at Harvard, that it's become apparent that something like two, two and a half percent of the population have fairly severe face blindness - severe enough to not recognize their colleagues or sometimes their children or sometimes themselves. I sometimes have difficulty recognizing myself, and...

GROSS: In a mirror.

Dr. SACKS: ...in a mirror, and there have been many ludicrous incidents in which I have apologized to my reflection, and another even more ludicrous incident in which I was sitting outside a restaurant and turned to the window and was using my reflection to comb my beard, which I have a habit of doing, and I saw my reflection was not combing its beard, but that on the other side of the window pane there was a bearded man who was puzzled as to why I was preening myself in front of him.

(Soundbite of laughter)

Dr. SACKS: So I'm not too sure of what I look like. But two, two and a half percent, this means there are, what, six or eight million Americans with this often quite disabling and embarrassing problem which has really hardly yet introduced either to the public or the medical literature.

GROSS: So if there is a disorder, whereas some people can't recognize faces, does that mean that there's a part of the brain that's reserved for facial recognition? And has MRIs and, you know, brain imaging in general had anything to say about that?

Dr. SACKS: Well, this is what was inferred in the 1940s, that such a special loss must have an equally specific basis. And one does in fact find that certain areas of the brain - of the visual brain on the left side are invariably involved if people suddenly become face blind from a stroke or a tumor. But we can now show, using imaging, that a particular part of the brain is involved in recognizing faces. Perhaps I should say several parts of the brain; they're all connected to one another. There's a sort of network going up from the most primitive part of the brain to the frontal lobes, which has become specialized for recognizing faces.

I say has become specialized because although there's certainly some innate tendency, things may depend very much on early life and training and either specifies things so that, say, if one is a Chinese child brought up in a Chinese environment one may have difficulty with European faces; they all look the same. This is what a Chinese friend of mine who is slightly prosopagnosic tells me. But there's a particular part of the brain and if that gets knocked out or if it fails to develop fully, as is probably the case with me and my two million brethren, then there are going to be difficulties.

GROSS: So since you have trouble recognizing faces, does facial beauty register on you? Do you care about facial beauty?

Dr. SACKS: Oh, I care very much. I can recognize facial expressions of all sorts. I think I'm as sensitive as the next man to facial beauty. So I can say that is a beautiful face and also somewhat sullen, but I have no idea whose it is.

(Soundbite of laughter)

GROSS: I got it. Okay. Let me quote something you say in the book. You say: I think that a significant part of what is variously called my shyness, my reclusiveness, my social ineptitude, my eccentricity, even my Asperger's syndrome, is a consequence and a mild misinterpretation of my difficulty recognizing faces.

So it sounds like it's had a pretty profound effect on your life.

Dr. SACKS: Well, I suspect so, although I wouldn't rule out any of the preceding five conditions.

GROSS: That you're also shy and reclusive...

(Soundbite of laughter)

GROSS: ...and socially inept.

(Soundbite of laughter)

Dr. SACKS: Yeah. However, some people react differently. Chuck Close has, the artist, has face blindness very severely.

GROSS: I was amazed to read that in your book.

Dr. SACKS: And he says he never knows whom he is with. But he is very extroverted and exuberant and he immediately opens conversations with these unrecognizable strangers and finds out, you know, what they do and what their interests are and who they are. So for him this almost incites a sort of social quality. Very interestingly it also incites his extraordinary art or plays a part here, because for him a face is only recognizable when it is flat and fixed as a photograph in two dimensions, and when it can then be isolated into little portions or pixels, if you want. And, of course, his extraordinary art is based on this.


GROSS: Is your expertise in neurological sensory disorders at all helpful to you in the sense that you can understand in the way that most people can't what's going on when you have a hallucination or a visual distortion? You've seen so many people live through this or lived through similar things. Your books always present these disorders as just really fascinating things about the human body - disturbing but fascinating. Can you ever see the, like, wow, isn't this fascinating aspect of your own problem?

Dr. SACKS: I can, and I sort of need to. And I think this probably goes back, you know, to my earliest years. I started getting visual migraines when I was four or five. In a visual migraine, part of the world may disappear, outlines may become distorted. You may see a giant scintillating zigzag. And when this first happened with me, I was terrified. But my mother, who was a doctor, and herself had visual migraine, explained to me, you know, in terms which a five-year-old could understand, that this was a little brain attack, it would only last a few minutes, and it wouldn't do one any harm. And that sort of defused the fear, but it left interest and fascination, and I think that was connected with the fact that my first book was on migraine, and especially visual migraine.

Now, I know that there are hallucinations which can occur, sometimes simple geometrical patterns, sometimes faces and landscapes when vision is impaired. These hallucinations do not indicate anything else wrong with a brain, so I'm glad to know that they are okay.

GROSS: So allow me to change the subject for a moment. There's a fascinating footnote in your book that says: In the '60s, during a period of experimenting with large doses of amphetamines, I experienced a different sort of vivid mental imagery. And this is in the chapter about the loss of vision in your right eye.

Dr. SACKS: Yeah.

GROSS: And so you just kind of toss this off in a footnote, that you were experimenting with amphetamines in the '60s and had visual distortions.

Dr. SACKS: Well, I sort of feel we all were, or at least those of my generation. And again, I'm glad to have survived that and so this is all...

GROSS: Mm-hmm. Mm-hmm.

Dr. SACKS: ...all more than 40 years ago. But I did have a period in which for about two weeks, when I actually wasn't taking anything, when something seemed to happen to my sensorium. That is to say, I became acutely sensitive to smells. I have a reasonable sense of smell but for two weeks I could recognize everyone I knew by smell. I could almost find my way around New York by smell. But I also found my visual imagery - which is very poor - greatly enhanced.

At that time I was doing neuropathology, which involved cutting brains and dissecting brains. And I found that structures in the brain or drawings of the brain I could image with great vividness and then draw almost as if they had been projected by a camera lucida or something like that. This amazed me because I was always particularly bad at drawing, and I'm now particularly bad again.

But for two weeks I had this sort of photographic memory, or eidetic memory, whatever it was, not simply visually - you know, but also musically. At the same time, I found it difficult to think abstractly and somewhat difficult to speak. And I seemed to be in a much more concrete sensory world than usual. Putting things in anatomical terms, it was almost as if I was using my right hemisphere more than my left.

GROSS: Did you find in the '60s, when you were trying amphetamines and smoking marijuana, that you learned things about perception and about unusual perception, about the mind's capabilities that you otherwise would not have understood?

Dr. SACKS: Absolutely. Although I will say that, you know, that visual migraine was also a teacher, and this meant, for example, that, well, when I studied patients with visual migraine, and that even more when I was with the "Awakenings" patients, who had many extraordinary states of mind and consciousness and perception, I think I often had more idea. I could more easily imagine what they were experiencing or talking about than I could if I had never had a migraine or taken anything.

GROSS: And - just curious - like when you were taking drugs, was it a pleasurable experience or just an unusual one that offered perceptions that you otherwise would not have had for better or for worse?

Dr. SACKS: I think I need to say that I'm not prescribing or recommending...

GROSS: No, I think you do need to say that. Yeah. Yeah. Good. Yeah.

(Soundbite of laughter)

Dr. SACKS: I'm not prescribing or recommending either migraine or drugs. But if one happens to have experienced one or the other, perhaps one should learn from it, as now I - hopefully I'm learning from my right eye. Yes, I mean I think one's - my motives were divided between curiosity and seeking pleasure.

GROSS: Your book, "The Mind's Eye," ends with a chapter about you losing vision in your right eye due to a cancerous tumor. And I want to read the last line of the book. You're writing - well, I'll just quote it. You say: Language, that most human invention, can enable what in principle should not be possible. It can allow all of us, even the congenitally blind, to see with another person's eyes.

So, that's a really beautiful thought about writing and literature. Is it hard for you to read now?

Dr. SACKS: Somewhat harder. I have to use a magnifying glass and I've slowed down a bit. I've tried talking books, but I'm a visual person. I need the printed word and I prefer it on paper rather than a screen. Although I have rather poor visual imagery - setting aside that little period in 1965...

(Soundbite of laughter)

Dr. SACKS: ...people often say that my writing makes them see things - that it brings images to their mind. And so I think visual description for me can do exactly this, that it can perform a function of providing an image and of seeing. And certainly, I think if you - oh, if you read, say, the works of a blind writer like Ved Mehta, there's a wonderful sensibility there and one hardly feels that anything is missing, or if something is missing that it is made transcendently compensated for by the power of language.

GROSS: One more question, and this has to do with your face blindness, your difficulty recognizing faces. We're speaking long-distance. You're at the NPR bureau in New York. I'm at WHYY in Philadelphia, so we're not seeing each other as we talk. Is that a good thing or a bad thing for you? Does it make a difference?

Dr. SACKS: I would prefer to see you, even though I might not recognize you.

(Soundbite of laughter)

GROSS: Right.

Dr. SACKS: But don't be offended because I might not recognize myself.

(Soundbite of music)

Dr. SACKS: But I think, actually, I have such a sense of your auditory presence that this is almost the same. This isn't always the case. Sometimes I'm, when there's just a microphone in front of me, I'm rendered dumb. I can't establish a conversation. But here it's different.

GROSS: Well, good. It's been such a pleasure to talk with you again. So I wish you well. Be well. Thank you for continuing to write about yourself and others. And thank you for coming back to FRESH AIR.

Dr. SACKS: Thank you very much. It's been a great pleasure.

GROSS: Oliver Sacks' new book is called "The Mind's Eye." You can read an excerpt on our website, freshair.npr.org.

I have good news for Stephen Sondheim fans. He's written a new book about his lyrics. I'm recording an interview with him that we expect to play Thursday. And you know that musical that he wrote for TV 44 years ago, "Evening Primrose," starring Anthony Perkins? Well, it's finally out on DVD.

David Bianculli will have a review after a break.

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