The Man Who Mistook His Wife for a Hat: "Yes, Father-Sister"

Mrs B., a former research chemist, had presented with a rapid personality change, becoming 'funny' (facetious, given to wisecracks and puns), impulsive—and 'superficial' ('You feel she doesn't care about you,' one of her friends said. 'She no longer seems to care about anything at all.')

Mrs B., a former research chemist, had presented with a rapid personality change, becoming 'funny' (facetious, given to wisecracks and puns), impulsive—and 'superficial' ('You feel she doesn't care about you,' one of her friends said. 'She no longer seems to care about anything at all.')

At first it was thought that she might be hypomanic, but she turned out to have a cerebral tumour. At craniotomy there was found, not a meningioma as had been hoped, but a huge carcinoma involving the orbitofrontal aspects of both frontal lobes.

When I saw her, she seemed high-spirited, volatile—'a riot' (the nurses called her)—full of quips and cracks, often clever and funny.

When I saw her, she seemed high-spirited, volatile—'a riot' (the nurses called her)—full of quips and cracks, often clever and funny.

Testing left-right discrimination was oddly difficult, because she said left or right indifferently (though there was not, in reaction, any confusion of the two, as when there is a lateralising defect of perception or attention).

‘This meaninglessness...does this bother you? Does this mean anything to you?'
‘Nothing at all,’ she said promptly, with a bright smile, in the tone of one who makes a joke, wins an argument, wins at poker.

Nothing any longer felt ‘real' (or ‘unreal'). Everything was now ‘equivalent' or ‘equal'—the whole world reduced to a facetious insignificance.

I found this somewhat shocking—her friends and family did too—but she herself, though not without insight, was uncaring, indifferent, even with a sort of funny-dreadful nonchalance or levity.

I found this somewhat shocking—her friends and family did too—but she herself, though not without insight, was uncaring, indifferent, even with a sort of funny-dreadful nonchalance or levity.

Mrs B., though acute and intelligent, was somehow not present—'de-souled'—as a person.

The sort of facetious indifference and ‘equalisation' shown by this patient is not uncommon—German neurologists call it Witzelsucht (‘joking disease'), and it was recognised as a fundamental form of nervous ‘dissolution' by Hughlings Jackson a century ago.

I see many cases a year with similar phenomenology but the most varied etiologies.

Thus, almost at random, I find the following in my notes on a patient with cerebral multiple sclerosis, whom I saw (but whose case I could not follow up) in 1981: She speaks very quickly, impulsively, and (it seems) indifferently...so that the important and the trivial, the true and the false, the serious and the joking, are poured out in a rapid, unselective, half-confabulatory stream...

How much is cryptamnesia-confabulation, how much frontal-lobe indifference-equalisation, how much some strange schizophrenic disintegration and shattering-flattening?

Of all forms of ‘schizophrenia' the ‘silly-happy', the so-called ‘hebephrenic', most resembles the organic amnestic and frontal lobe syndromes.

They are the most malignant, and the least imaginable—and no one returns from such states to tell us what they were like.

In all these states—‘funny' and often ingenious as they appear—the world is taken apart, undermined, reduced to anarchy and chaos.

In all these states—‘funny' and often ingenious as they appear—the world is taken apart, undermined, reduced to anarchy and chaos.

The end point of such states is an unfathomable ‘silliness', an abyss of superficiality, in which all is ungrounded and afloat and comes apart.