The Man Who Mistook His Wife For A Hat Part 6

'Yes, Father,' she said to me on one occasion.

'Yes, Sister,' on another.

'Yes, Doctor,' on a third.

She seemed to use the terms interchangeably.

'What am I?' I asked, stung, after a while.

'I see your face, your beard,' she said, 'I think of an Archimandrite Priest. I see your white uniform-I think of the Sisters. I see your stethoscope-I think of a doctor.'

'You don't look at all of me?'

'No, I don't look at all of you.'

'You realise the difference between a father, a sister, a doctor?'

'I know the difference, but it means nothing to me. Father, sister, doctor-what's the big deal?'

Thereafter, teasingly, she would say: 'Yes, father-sister. Yes, sister-doctor', and other combinations.

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). When I drew her attention to this, she said: 'Left/right. Right/left. Why the fuss? What's the difference?'

'Is there a difference?' I asked.

'Of course,' she said, with a chemist's precision. 'You could call them enantiomorphs of each other. But they mean nothing to me. They're no different for me. Hands . . . Doctors . . . Sisters . . . ' she added, seeing my puzzlement. 'Don't you understand? They mean nothing-nothing to me. Nothing means anything ... at least to me.'

'And . . . this meaning nothing . . . ' I hesitated, afraid to go on. '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.

Was this denial? Was this a brave show? Was this the 'cover' of some unbearable emotion? Her face bore no deeper expression whatever. Her world had been voided of feeling and meaning. 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.

Mrs B., though acute and intelligent, was somehow not present- 'de-souled'-as a person. I was reminded of William Thompson (and also of Dr P.). This is the effect of the 'equalisation' described by Luria which we saw in the preceding chapter and will also see in the next.

Postscript The sort of facetious indifference and 'equalisation' shown by this patient is not uncommon-German neurologists call it Witzel-sucht ('joking disease'), and it was recognised as a fundamental form of nervous 'dissolution' by Hughlings Jackson a century ago. It is not uncommon, whereas insight is-and the latter, perhaps mercifully, is lost as the 'dissolution' progresses. I see many cases a year with similar phenomenology but the most varied etiologies. Occasionally I am not sure, at first, if the patient is just 'being funny', clowning around, or schizophrenic. 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, unselec-tive, half-confabulatory stream . . . She may contradict herself completely within a few seconds . . . will say she loves music, she doesn't, she has a broken hip, she hasn't . . .

I concluded my observation on a note of uncertainty: 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. There ceases to be any 'centre' to the mind, though its formal intellectual powers may be perfectly preserved. The end point of such states is an unfathomable 'silliness', an abyss of superficiality, in which all is ungrounded and afloat and comes apart. Luria once spoke of the mind as reduced, in such states, to 'mere Brownian movement'. I share the sort of horror he clearly felt about them (though this incites, rather than impedes, their accurate description). They make me think, first, of Borges' 'Funes', and his remark, 'My memory, Sir, is like a garbage-heap', and finally, of the Dunciad, the vision of a world reduced to Pure Silliness-Silliness as being the End of the World: Thy hand, great Anarch, lets the curtain fall; And Universal Darkness buries All.

14.

The Possessed In Witty Ticcy Ray (Chapter Ten), I described a relatively mild form of Tourette's syndrome, but hinted that there were severer forms 'of quite terrible grotesqueness and violence'. I suggested that some people could accommodate Tourette's within a commodious personality, while others 'might indeed be "possessed", and scarcely able to achieve real ident.i.ty amid the tremendous pressure and chaos of Tourettic impulses'.

Tourette himself, and many of the older clinicians, used to recognise a malignant form of Tourette's, which might disintegrate the personality, and lead to a bizarre, phantasmagoric, pantomimic and often impersonatory form of 'psychosis' or frenzy. This form of Tourette's-'super-Tourette's'-is quite rare, perhaps fifty times rarer than ordinary Tourette's syndrome, and it may be qualitatively different, as well as far more intense than any of the ordinary forms of the disorder. This 'Tourette psychosis', this singular ident.i.ty-frenzy, is quite different from ordinary psychosis, because of its underlying, and unique, physiology and phenomenology. None the less, it has affinities, on the one hand, to the frenzied motor psychoses sometimes induced by L-Dopa and, on the other, to the confabulatory frenzies of Korsakov's psychosis (see above, Chapter Twelve). And like these it can almost overwhelm the person.

The day after I saw Ray, my first Touretter, my eyes and mind opened, as I mentioned earlier, when, in the streets of New York, I saw no less than three Touretters-all as characteristic as Ray, though more florid. It was a day of visions for the neurological eye. In swift vignettes I witnessed what it might mean to have Tourette's syndrome of ultimate severity, not only tics and convulsions of movement, but tics and convulsions of perception, imagination, the pa.s.sions-of the entire personality.

Ray himself had shown what might happen in the street. But it is not enough to be told. You must see for yourself. And a doctor's clinic or ward is not always the best place for observing disease-at least, not for observing a disorder which, if organic in origin, is expressed in impulse, imitation, impersonation, reaction, interaction, raised to an extreme and almost incredible degree. The clinic, the laboratory, the ward are all designed to restrain and focus behaviour, if not indeed to exclude it altogether. They are for a systematic and scientific neurology, reduced to fixed tests and tasks, not for an open, naturalistic neurology. For this one must see the patient unselfconscious, un.o.bserved, in the real world, wholly given over to the spur and play of every impulse, and one must oneself, the observer, be un.o.bserved. What could be better, for this purpose, than a street in New York-an anonymous public street in a vast city-where the subject of extravagant, impulsive disorders can enjoy and exhibit to the full the monstrous liberty, or slavery, of their condition.

'Street-neurology', indeed, has respectable antecedents. James Parkinson, as inveterate a walker of the streets of London as Charles d.i.c.kens was to be, forty years later, delineated the disease that bears his name, not in his office, but in the teeming streets of London. Parkinsonism, indeed, cannot be fully seen, comprehended, in the clinic; it requires an open, complexly interactional s.p.a.ce for the full revelation of its peculiar character (beautifully shown in Jonathan Miller's film Ivan). Parkinsonism has to be seen, to be fully comprehended, in the world, and if this is true of Parkinsonism, how much truer must it be of Tourette's. Indeed an extraordinary description from within of an imitative and antic ticqueur in the streets of Paris is given in 'Les confidences d'un ticqueur' which prefaces Meige and Feindel's great book Tics (1901), and a vignette of a manneristic ticqueur, also in the streets of Paris, is provided by the poet Rilke in The Notebook of Malte Laurids Brigge. Thus it was not just seeing Ray in my office but what I saw the next day that was such a revelation to me. And one scene, in particular, was so singular that it remains in my memory today as vivid as it was the day I saw it.

My eye was caught by a grey-haired woman in her sixties, who was apparently the centre of a most amazing disturbance, though what was happening, what was so disturbing, was not at first clear to me. Was she having a fit? What on earth was convulsing her- and, by a sort of sympathy or contagion, also convulsing everyone whom she gnas.h.i.+ngly, ticcily pa.s.sed?

As I drew closer I saw what was happening. She was imitating the pa.s.sers-by-if 'imitation' is not too pallid, too pa.s.sive, a word. Should we say, rather, that she was caricaturing everyone she pa.s.sed? Within a second, a split-second, she 'had' them all.

I have seen countless mimes and mimics, clowns and antics, but nothing touched the horrible wonder I now beheld: this virtually instantaneous, automatic and convulsive mirroring of every face and figure. But it was not just an imitation, extraordinary as this would have been in itself. The woman not only took on, and took in, the features of countless people, she took them off. Every mirroring was also a parody, a mocking, an exaggeration of salient gestures and expressions, but an exaggeration in itself no less convulsive than intentional-a consequence of the violent acceleration and distortion of all her motions. Thus a slow smile, monstrously accelerated, would become a violent, milliseconds-long grimace; an ample gesture, accelerated, would become a farcical convulsive movement.

In the course of a short city-block this frantic old woman frenetically caricatured the features of forty or fifty pa.s.sers-by, in a quick-fire sequence of kaleidoscopic imitations, each lasting a second or two, sometimes less, and the whole dizzying sequence scarcely more than two minutes.

And there were ludicrous imitations of the second and third order; for the people in the street, startled, outraged, bewildered by her imitations, took on these expressions in reaction to her; and those expressions, in turn, were re-reflected, re-directed, re-distorted, by the Touretter, causing a still greater degree of outrage and shock. This grotesque, involuntary resonance, or mutuality, by which everyone was drawn into an absurdly amplifying inter- action, was the source of the disturbance I had seen from a distance. This woman who, becoming everybody, lost her own self, became n.o.body. This woman with a thousand faces, masks, per-sonae-how must it be for her in this whirlwind of ident.i.ties? The answer came soon-and not a second too late; for the build-up of pressures, both hers and others', was fast approaching the point of explosion. Suddenly, desperately, the old woman turned aside, into an alley-way which led off the main street. And there, with all the appearances of a woman violently sick, she expelled, tremendously accelerated and abbreviated, all the gestures, the postures, the expressions, the demeanours, the entire behavioural repertoires, of the past forty or fifty people she had pa.s.sed. She delivered one vast, pantomimic egurgitation, in which the engorged ident.i.ties of the last fifty people who had possessed her were spewed out. And if the taking-in had lasted two minutes, the throwing-out was a single exhalation-fifty people in ten seconds, a fifth of a second or less for the time-foreshortened repertoire of each person.

I was later to spend hundreds of hours, talking to, observing, taping, learning from, Tourette patients. Yet nothing, I think, taught me as much, as swiftly, as penetratingly, as overwhelmingly as that phantasmagoric two minutes in a New York street.

It came to me in this moment that such 'super-Touretters' must be placed, by an organic quirk, through no fault of their own, in a most extraordinary, indeed unique, existential position, which has some a.n.a.logies to that of raging 'super-Korsakov's', but, of course, has a quite different genesis-and aim. Both can be driven to incoherence, to ident.i.ty-delirium. The Korsakovian, perhaps mercifully, never knows it, but the Touretter perceives his plight with excruciating, and perhaps finally ironic, acuity, though he may be unable, or unwilling, to do much about it.

For where the Korsakovian is driven by amnesia, absence, the Touretter is driven by extravagant impulse-impulse of which he is both the creator and the victim, impulse he may repudiate, but cannot disown. Thus he is impelled, as the Korsakovian is not, into an ambiguous relation with his disorder: vanquis.h.i.+ng it, being vanquished by it, playing with it-there is every variety of conflict and collusion.

Lacking the normal, protective barriers of inhibition, the normal, organically determined boundaries of self, the Touretter's ego is subject to a lifelong bombardment. He is beguiled, a.s.sailed, by impulses from within and without, impulses which are organic and convulsive, but also personal (or rather pseudo-personal) and seductive. How will, how can, the ego stand this bombardment? Will ident.i.ty survive? Can it develop, in face of such a shattering, such pressures-or will it be overwhelmed, to produce a Tour-ettized soul' (in the poignant words of a patient I was later to see)? There is a physiological, an existential, almost a theological pressure upon the soul of the Touretter-whether it can be held whole and sovereign, or whether it will be taken over, possessed and dispossessed, by every immediacy and impulse.

Hume, as we have noted, wrote: I venture to affirm . . . that [we] are nothing but a bundle or collection of different sensations, succeeding one another with inconceivable rapidity, and in a perpetual flux and movement.

Thus, for Hume, personal ident.i.ty is a fiction-we do not exist, we are but a consecution of sensations, or perceptions.

This is clearly not the case with a normal human being, because he owns his own perceptions. They are not a mere flux, but his own, united by an abiding individuality or self. But what Hume describes may be precisely the case for a being as unstable as a super-Touretter, whose life is, to some extent, a consecution of random or convulsive perceptions and motions, a phantasmagoric fluttering with no centre or sense. To this extent he is a 'Humean' rather than a human being. This is the philosophical, almost theological, fate which lies in wait, if the ratio of impulse to self is too overwhelming. It has affinities to a 'Freudian' fate, which is also to be overwhelmed by impulse- but the Freudian fate has sense (albeit tragic), whereas a 'Humean' fate is meaningless and absurd.

The super-Touretter, then, is compelled to fight, as no one else is, simply to survive-to become an individual, and survive as one, in face of constant impulse. He may be faced, from earliest childhood, with extraordinary barriers to individuation, to becoming a real person. The miracle is that, in most cases, he succeeds- for the powers of survival, of the will to survive, and to survive as a unique inalienable individual, are, absolutely, the strongest in our being: stronger than any impulses, stronger than disease. Health, health militant, is usually the victor.

PART THREE.

TRANSPORTS.

Introduction.

While we have criticised the concept of function, even attempting a rather radical redefinition, we have adhered to it nevertheless, drawing in the broadest terms contrasts based on 'deficit' or 'excess'. But it is clear that wholly other terms also have to be used. As soon as we attend to phenomena as such, to the actual quality of experience or thought or action, we have to use terms more reminiscent of a poem or painting. How, say, is a dream intelligible in terms of function?

We have always two universes of discourse-call them 'physical' and 'phenomenal', or what you will-one dealing with questions of quant.i.tative and formal structure, the other with those qualities that const.i.tute a 'world'. All of us have our own, distinctive mental worlds, our own inner journeyings and landscapes, and these, for most of us, require no clear neurological 'correlate'. We can usually tell a man's story, relate pa.s.sages and scenes from his life, without bringing in any physiological or neurological considerations: such considerations would seem, at the least, supererogatory, if not frankly absurd or insulting. For we consider ourselves, and rightly, 'free'-at least, determined by the most complex human and ethical considerations, rather than by the vicissitudes of our neural functions or nervous systems. Usually, but not always: for sometimes a man's life may be cut across, transformed, by an organic disorder; and if so his story does require a physiological or neurological correlate. This, of course, is so with all the patients here described.

In the first half of this book we described cases of the obviously pathological-situations in which there is some blatant neurological excess or deficit. Sooner or later it is obvious to such patients, or their relatives, no less than to their doctors, that there is 'something (physically) the matter'. Their inner worlds, their dispositions, may indeed be altered, transformed; but, as becomes clear, this is due to some gross (and almost quant.i.tative) change in neural function. In this third section, the presenting feature is reminiscence, altered perception, imagination, 'dream'. Such matters do not often come to neurological or medical notice. Such 'transports'-often of poignant intensity, and shot through with personal feeling and meaning-tend to be seen, like dreams, as psychical: as a manifestation, perhaps, of unconscious or preconscious activity (or, in the mystically-minded, of something 'spiritual'), not as something 'medical', let alone 'neurological'. They have an intrinsic dramatic, or narrative, or personal 'sense', and so are not apt to be seen as 'symptoms'. It may be in the nature of transports that they are more likely to be confided to psychoa.n.a.lysts or confessors, to be seen as psychoses, or to be broadcast as religious revelations, rather than brought to physicians. For it never occurs to us at first that a vision might be 'medical'; and if an organic basis is suspected or found, this may be felt to 'devalue' the vision (though, of course, it does not-values, valuations, have nothing to do with etiology).

All the transports described in this section do have more or less clear organic determinants (though it was not evident to begin with, but required careful investigation to bring out). This does not detract in the least from their psychological or spiritual significance. If G.o.d, or the eternal order, was revealed to Dostoievski in seizures, why should not other organic conditions serve as 'portals' to the beyond or the unknown? In a sense, this section is a study of such portals.

Hughlings Jackson, in 1880, describing such 'transports', or 'portals', or 'dreamy states', in the course of certain epilepsies, used the general word 'reminiscence'. He wrote: I should never diagnose epilepsy from the paroxysmal occurrence of 'reminiscence', without other symptoms, although I should suspect epilepsy if that super-positive mental state began to occur very frequently ... I have never been consulted for 'reminiscence' only . . .

But J have been so consulted: for the forced or paroxysmal reminiscence of tunes, of 'visions', of 'presences', or scenes-not only in epilepsy, but in a variety of other organic conditions. Such transports or reminiscences are not uncommon in migraine (see 'The Visions of Hildegard', Chapter Twenty). This sense of 'going back', whether on an epileptic or toxic basis, suffuses 'A Pa.s.sage to India' (Chapter Seventeen). A plainly toxic or chemical basis underlies 'Incontinent Nostalgia' (Chapter Sixteen) and the strange hyperosmia of Chapter Eighteen, 'The Dog Beneath the Skin'. Either seizure-activity or a frontal-lobe disinhibition determines the horrifying 'reminiscence' of 'Murder' (Chapter Nineteen).

The theme of this section is the power of imagery and memory to 'transport' a person as a result of abnormal stimulation of the temporal lobes and limbic system of the brain. This may even teach us something of the cerebral basis of certain visions and dreams, and of how the brain (which Sherrington called 'an enchanted loom') may weave a magic carpet to transport us.

15.

Reminiscence Mrs O'C. was somewhat deaf, but otherwise in good health. She lived in an old people's home. One night, in January 1979, she dreamt vividly, nostalgically, of her childhood in Ireland, and especially of the songs they danced to and sang. When she woke up, the music was still going, very loud and clear. 'I must still be dreaming,' she thought, but this was not so. She got up, roused and puzzled. It was the middle of the night. Someone, she a.s.sumed, must have left a radio playing. But why was she the only person to be disturbed by it? She checked every radio she could find-they were all turned off. Then she had another idea: she had heard that dental fillings could sometimes act like a crystal radio, picking up stray broadcasts with unusual intensity. 'That's it,' she thought. 'One of my fillings is playing up. It won't last long. I'll get it fixed in the morning.' She complained to the night nurse, who said her fillings looked fine. At this point another notion occurred to Mrs O'C: 'What sort of radio-station,' she reasoned to herself, 'would play Irish songs, deafeningly, in the middle of the night? Songs, just songs, without introduction or comment? And only songs that I know. What radio station would play my songs, and nothing else?' At this point she asked herself: 'Is the radio in my head?'

She was now thoroughly rattled-and the music continued deafening. Her last hope was her ENT man, the otologist she was seeing: he would rea.s.sure her, tell her it was just 'noises in the ear', something to do with her deafness, nothing to worry about. But when she saw him in the course of the morning, he said: 'No, Mrs O'C., I don't think it's your ears. A simple ringing or buzzing or rumbling, maybe: but a concert of Irish songs-that's not your ears. Maybe,' he continued, 'you should see a psychiatrist.' Mrs O'C. arranged to see a psychiatrist the same day. 'No, Mrs O'C.,' the psychiatrist said, 'it's not your mind. You are not mad-and the mad don't hear music, they only hear "voices". You must see a neurologist, my colleague, Dr Sacks.' And so Mrs O'C. came to me.

Conversation was far from easy, partly because of Mrs O'C.'s deafness, but more because I was repeatedly drowned out by songs- she could only hear me through the softer ones. She was bright, alert, not delirious or mad, but with a remote, absorbed look, as of someone half in a world of their own. I could find nothing neurologically amiss. None the less, I suspected that the music was 'neurological'.

What could have happened with Mrs O'C. to bring her to such a pa.s.s? She was 88 and in excellent general health with no hint of fever. She was not on any medications which might unbalance her excellent mind. And, manifestly, she had been normal the day before.

'Do you think it's a stroke, Doctor?' she asked, reading my thoughts.

'It could be,' I said, 'though I've never seen a stroke like this. Something has happened, that's for sure, but I don't think you're in danger. Don't worry, and hold on.'

'It's not so easy to hold on,' she said, 'when you're going through what I'm going through. I know it's quiet here, but I am in an ocean of sound.'

I wanted to do an electroencephalogram straightaway, paying special attention to the temporal lobes, the 'musical' lobes of the brain, but circ.u.mstances conspired to prevent this for a while. In this time, the music grew less-less loud and, above all, less persistent. She was able to sleep after the first three nights and, increasingly, to make and hear conversation between 'songs'. By the time I came to do an EEG, she heard only occasional brief s.n.a.t.c.hes of music, a dozen times, more or less, in the course of a day. After we had settled her and applied the electrodes to her head, I asked her to lie still, say nothing and not 'sing to herself, but to raise her right forefinger slightly-which in itself would not disturb the EEG-if she heard any of her songs as we recorded. In the course of a two-hour recording, she raised her finger on three occasions, and each time she did this the EEG pens clattered, and transcribed spikes and sharp waves in the temporal lobes of the brain. This confirmed that she was indeed having temporal-lobe seizures, which, as Hughlings Jackson guessed and Wilder Pen-field proved, are the invariable basis of 'reminiscence' and experiential hallucinations. But why should she suddenly develop this strange symptom? I obtained a brainscan, and this showed that she had indeed had a small thrombosis or infarction in part of her right temporal lobe. The sudden onset of Irish songs in the night, the sudden activation of musical memory-traces in the cortex, were, apparently, the consequence of a stroke, and as it resolved, so the songs 'resolved' too.

By mid-April the songs had entirely gone, and Mrs O'C. was herself once again. I asked her at this point how she felt about it all, and, in particular, whether she missed the paroxysmal songs she heard. 'It's funny you should ask that,' she said with a smile. 'Mostly, I would say, it is a great relief. But, yes, I do miss the old songs a little. Now, with lots of them, I can't even recall them. It was like being given back a forgotten bit of my childhood again. And some of the songs were really lovely.'

I had heard similar sentiments from some of my patients on L-Dopa-the term I used was 'incontinent nostalgia'. And what Mrs O'C. told me, her obvious nostalgia, put me in mind of a poignant story of H.G. Wells, 'The Door in the Wall'. I told her the story. 'That's it,' she said. 'That captures the mood, the feeling, entirely. But my door is real, as my wall was real. My door leads to the lost and forgotten past.'

I did not see a similar case until June last year, when I was asked to see Mrs O'M., who was now a resident at the same home. Mrs O'M. was also a woman in her eighties, also somewhat deaf, also bright and alert. She, too, heard music in the head and sometimes a ringing or hissing or rumbling; occasionally she heard 'voices talking', usually 'far away' and 'several at once', so that she could never catch what they were saying. She hadn't mentioned these symptoms to anybody, and had secretly worried, for four years, that she was mad. She was greatly relieved when she heard from the Sister that there had been a similar case in the Home some time before, and very relieved to be able to open up to me.

One day, Mrs O'M. recounted, while she was grating parsnips in the kitchen, a song started playing. It was 'Easter Parade', and was followed, in swift succession, by 'Glory, Glory, Hallelujah' and 'Good Night, Sweet Jesus'. Like Mrs O'C., she a.s.sumed that a radio had been left on, but quickly discovered that all the radios were off. This was in 1979, four years earlier. Mrs O'C. recovered in a few weeks, but Mrs O'M.'s music continued, and got worse and worse.

At first she would hear only these three songs-sometimes spontaneously, out of the blue, but for certain if she chanced to think of any of them. She tried, therefore, to avoid thinking of them, but the avoidance of thinking was as provocative as the thinking.

'Do you like these particular songs?' I asked, psychiatrically. 'Do they have some special meaning for you?'

'No,' she answered promptly. 'I never specially liked them, and I don't think they had any special meaning for me.'

'And how did you feel when they kept going on?'

'I came to hate them,' she replied with great force. 'It was like some crazy neighbour continually putting on the same record.'

For a year or more, there was nothing but these songs, in maddening succession. After this-and though it was worse in one way, it was also a relief-the inner music became more complex and various. She would hear countless songs-sometimes several simultaneously; sometimes she would hear an orchestra or choir; and, occasionally, voices, or a mere hubbub of noises.

When I came to examine Mrs O'M. I found nothing abnormal except in her hearing, and here what I found was of singular interest. She had some inner-ear deafness, of a commonplace sort, but over and above this she had a peculiar difficulty in the perception and discrimination of tones of a kind which neurologists call amusia, and which is especially correlated with impaired function in the auditory (or temporal) lobes of the brain. She herself complained that recently the hymns in the chapel seemed more and more alike so that she could scarcely distinguish them by tone or tune, but had to rely on the words, or the rhythm.* And although she had been a fine singer in the past when I tested her she sang flat and out of key. She mentioned, too, that her inner music was most vivid when she woke up, becoming less so as other sensory impressions crowded in; and that it was least likely to occur when she was occupied-emotionally, intellectually, but especially visually. In the hour or so she was with me, she heard music only once-a few bars of 'Easter Parade', played so loud, and so suddenly, she could hardly hear me through it.

When we came to do an EEG on Mrs O'M. it showed strikingly high voltage and excitability in both temporal lobes-those parts of the brain a.s.sociated with the central representation of sounds and music, and with the evocation of complex experiences and scenes. And whenever she 'heard' anything, the high voltage waves became sharp, spike-like, and frankly convulsive. This confirmed my thought that she had too a musical epilepsy, a.s.sociated with disease of the temporal lobes.

But what was going on with Mrs O'C. and Mrs O'M.? 'Musical epilepsy' sounds like a contradiction in terms: for music, normally, is full of feeling and meaning, and corresponds to something deep in ourselves, 'the world behind the music', in Thomas Mann's phrase-whereas epilepsy suggests quite the reverse: a crude, random physiological event, wholly unselective, without feeling or meaning. Thus a 'musical epilepsy' or a 'personal epilepsy' would seem a contradiction in terms. And yet such epilepsies do occur, though solely in the context of temporal lobe seizures, epilepsies of the reminiscent part of the brain. Hughlings Jackson described these a century ago, and spoke in this context of 'dreamy states', 'reminiscence', and 'physical seizures': It is not very uncommon for epileptics to have vague and yet exceedingly elaborate mental states at the onset of epileptic seizures . . . The elaborate mental state, or so-called intellectual aura, is always the same, or essentially the same, in each case.

"A similar inability to perceive vocal tone or expression (tonal agnosia) was shown by my patient Emily D. (see 'The President's Speech', Chapter Nine).

Such descriptions remained purely anecdotal until the extraordinary studies of Wilder Penfield, half a century later. Penfield was not only able to locate their origin in the temporal lobes, but was able to evoke the 'elaborate mental state', or the extremely precise and detailed 'experiential hallucinations' of such seizures by gentle electrical stimulation of the seizure-p.r.o.ne points of the cerebral cortex, as this was exposed, at surgery, in fully conscious patients. Such stimulations would instantly call forth intensely vivid hallucinations of tunes, people, scenes, which would be experienced, lived, as compellingly real, in spite of the prosaic atmosphere of the operating room, and could be described to those present in fascinating detail, confirming what Jackson described sixty years earlier, when he spoke of the characteristic 'doubling of consciousness': There is (1) the quasi-parasitical state of consciousness (dreamy state), and (2) there are remains of normal consciousness and thus, there is double consciousness ... a mental diplopia.

This was precisely expressed to me by my two patients; Mrs O'M. heard and saw me, albeit with some difficulty, through the deafening dream of 'Easter Parade', or the quieter, yet more profound, dream of 'Good Night, Sweet Jesus' (which called up for her the presence of a church she used to go to on 31st Street where this was always sung after a novena). And Mrs O'C. also saw and heard me, through the much profounder anamnestic seizure of her childhood in Ireland: 'I know you're there, Dr Sacks. I know I'm an old woman with a stroke in an old people's home, but I feel I'm a child in Ireland again-I feel my mother's arms, I see her, I hear her voice singing.' Such epileptic hallucinations or dreams, Penfield showed, are never phantasies: they are always memories, and memories of the most precise and vivid kind, accompanied by the emotions which accompanied the original experience. Their extraordinary and consistent detail, which was evoked each time the cortex was stimulated, and exceeded anything which could be recalled by ordinary memory, suggested to Penfield that the brain retained an almost perfect record of every lifetime's experience, that the total stream of consciousness was preserved in the brain, and, as such, could always be evoked or called forth, whether by the ordinary needs and circ.u.mstances of life, or by the extraordinary circ.u.mstances of an epileptic or electrical stimulation. The variety, the 'absurdity', of such convulsive memories and scenes made Penfield think that such reminiscence was essentially meaningless and random: At operation it is usually quite clear that the evoked experiential response is a random reproduction of whatever composed the stream of consciousness during some interval of the patient's past life ... It may have been [Penfield continues, summarising the extraordinary miscellany of epileptic dreams and scenes he has evoked] a time of listening to music, a time of looking in at the door of a dance hall, a time of imaging the action of robbers from a comic strip, a time of waking from a vivid dream, a time of laughing conversation with friends, a time of listening to a little son to make sure he was safe, a time of watching illuminated signs, a time of lying in the delivery room at birth, a time of being frightened by a menacing man, a time of watching people enter the room with snow on their clothes ... It may have been a time of standing on the corner of Jacob and Was.h.i.+ngton, South Bend, Indiana . . . of watching circus wagons one night years ago in childhood ... a time of listening to (and watching) your mother speed the parting guests ... or of hearing your father and mother singing Christmas carols.

I wish I could quote in its entirety this wonderful pa.s.sage from Penfield (Penfield and Perot, pp. 687ff.) It gives, as my Irish ladies do, an amazing feeling of 'personal physiology', the physiology of the self. Penfield is impressed by the frequency of musical seizures, and gives many fascinating and often funny examples, a 3 per cent incidence in the more than 500 temporal-lobe epileptics he has studied: We were surprised at the number of times electrical stimulation has caused the patient to hear music. It was produced from seventeen different points in 11 cases (see Figure). Sometimes it was an orchestra, at other times voices singing, or a piano AUDITORY EXPERIENTIAL RESPONSES TO STIMULATION.

1. A voice (14); Case 28. 2. Voices (14). 3. 1 voice (15). 4. A familiar voice (17). 5. A familiar voice (21). 6. A voice (23). 7. A voice (24). 8. A voice (25). 9. A voice (28); Case 29. 10. Familiar music (15). 11. A voice (16). 12. A familiar voice (17). 13. A familiar voice (18). 14. Familiar music (19). 15. Voices (23). 16. Voices (27); Case 4. 17. Familiar music (14). 18. Familiar music (17). 19. Familiar music (24). 20. Familiar music (25); Case 30. 21. Familiar music (23); Case 31. 22. Familiar voice (16); Case 32. 23. Familiar music (23); Case 5. 24. Familiar music (Y). 25. Sound of feet walking (1); Case 6. 26. Familiar voice (74). 27. Voices (22); Case 8. 28. Music (15); Case 9. 29. Voices (14); Case 36. 30. Familiar sound (16); Case 35. 31. A voice (16a); Case 23. 32. A voice (26). 33. Voices (25). 34. Voices (27). 35. A voice (28/ 36. A voice (33); Case 12. 37. Music (12); Case 11. 38. A voice (17d); Case 24. 39. Familiar voice (14). 40. Familiar voices (15). 41. Dog barking (17). 42. Music (78). 43. A voice (20); Case 13. 44. Familiar voice (i7J. 45. A voice (12). 46. Familiar voice (13). 47. Familiar voice (14). 48. Familiar music (15). 49. A voice (16); Case 14. 50. Voices (2). 51. Voices (3). 52. Voices (5). 53. Voices (6) 54. Voices (10). 55. Voices (11); Case 15. 56. Familiar voice (15). 57. Familiar voice (16). 58. Familiar voice (22); Case 16. 59. Music (10); Case 17. 60. Familiar voice (30). 61. Familiar voice (31). 62. Familiar voice (32); Case 3. 63. Familiar music (8). 64. Familiar music(10). 65.Familiar music (D2); Case 10. 66.Voices (11); Case7.

playing, or a choir. Several times it was said to be a radio theme song . . . The localisation for production of music is in the superior temporal convolution, either the lateral or the superior surface (and, as such, close to the point a.s.sociated with so-called musicogenic epilepsy).

This is borne out, dramatically, and often comically, by the examples Penfield gives. The following list is extracted from his great final paper: 'White Christmas' (Case 4). Sung by a choir 'Rolling Along Together' (Case 5). Not identified by patient, but recognised by operating-room nurse when patient hummed it on stimulation 'Hush-a-Bye Baby' (Case 6). Sung by mother, but also thought to be theme-tune for radio-programme 'A song he had heard before, a popular one on the radio' (Case 10) 'Oh Marie, Oh Marie' (Case 30). The theme-song of a radio-programme 'The War March of the Priests' (Case 31). This was on the other side of the 'Hallelujah Chorus' on a record belonging to the patient 'Mother and father singing Christmas carols' (Case 32) 'Music from Guys and Dolls' (Case 37) 'A song she had heard frequently on the radio' (Case 45) 'I'll Get By' and 'You'll Never Know' (Case 46). Songs he had often heard on the radio In each case-as with Mrs O'M.-the music was fixed and stereotyped. The same tune (or tunes) were heard again and again, whether in the course of spontaneous seizures, or with electrical stimulation of the seizure-p.r.o.ne cortex. Thus these tunes were not only popular on the radio, but equally popular as hallucinatory seizures: they were, so to speak, the 'Top Ten of the Cortex'.

Is there any reason, we must wonder, why particular songs (or scenes) are 'selected' by particular patients for reproduction in their hallucinatory seizures? Penfield considers this question and feels that there is no reason, and certainly no significance, in the selection involved: It would be very difficult to imagine that some of the trivial incidents and songs recalled during stimulation or epileptic discharge could have any possible emotional significance to the patient, even if one is acutely aware of this possibility.

The selection, he concludes, is 'quite at random, except that there is some evidence of cortical conditioning'. These are the words, this is the att.i.tude, so to speak, of physiology. Perhaps Penfield is right-but could there be more? Is he in fact 'acutely aware', aware enough, at the levels that matter, of the possible emotional significance of songs, of what Thomas Mann called the 'world behind the music'? Would superficial questioning, such as 'Does this song have any special meaning for you?' suffice? We know, all too well, from the study of 'free a.s.sociations' that the most seemingly trivial or random thoughts may turn out to have an unexpected depth and resonance, but that this only becomes evident given an a.n.a.lysis in depth. Clearly there is no such deep a.n.a.lysis in Penfield, nor in any other physiological psychology. It is not clear whether any such deep a.n.a.lysis is needed-but given the extraordinary opportunity of such a miscellany of convulsive songs and scenes, one feels, at least, that it should be given a try.

I have gone back to Mrs O'M. briefly, to elicit her a.s.sociations, her feelings, to her 'songs'. This may be unnecessary, but I think it worth trying. One important thing has already emerged. Although, consciously, she cannot attribute to the three songs special feeling or meaning, she now recalls, and this is confirmed by others, that she was apt to hum them, unconsciously, long before they became hallucinatory seizures. This suggests that they were already unconsciously 'selected'-a selection which was then seized on by a supervening organic pathology.

Are they still her favourites? Do they matter to her now? Does she get anything out of her hallucinatory music? The month after I saw Mrs O'M. there was an article in the New York Times ent.i.tled 'Did Shostakovich Have a Secret?' The 'secret' of Shostakovich, it was suggested-by a Chinese neurologist, Dr Dajue w.a.n.g-was the presence of a metallic splinter, a mobile sh.e.l.l-fragment, in his brain, in the temporal horn of the left ventricle. Shostakovich was very reluctant, apparently, to have this removed: Since the fragment had been there, he said, each time he leaned his head to one side he could hear music. His head was filled with melodies-different each time-which he then made use of when composing.

X-rays allegedly showed the fragment moving around when Shostakovich moved his head, pressing against his 'musical' temporal lobe, when he tilted, producing an infinity of melodies which his genius could use. Dr R.A. Henson, editor of Music and the Brain (1977), expressed deep but not absolute scepticism: 'I would hesitate to affirm that it could not happen.'

After reading the article I gave it to Mrs O'M. to read, and her reactions were strong and clear. 'I am no Shostakovich,' she said. 'I can't use my songs. Anyhow, I'm tired of them-they're always the same. Musical hallucinations may have been a gift to Shostakovich, but they are only a nuisance to me. He didn't want treatment-but I want it badly.'

I put Mrs O'M. on anticonvulsants, and she forthwith ceased her musical convulsions. I saw her again recently, and asked her if she missed them. 'Not on your life.' she said. 'I'm much better without them.' But this, as we have seen, was not the case with Mrs O'C, whose hallucinosis was of an altogether more complex, more mysterious, and deeper kind and, even if random in its causation, turned out to have great psychological significance and use.

With Mrs O'C. indeed the epilepsy was different from the start, both in terms of physiology and of'personal' character and impact. There was, for the first 72 hours, an almost continuous seizure, or seizure 'status', a.s.sociated with an apoplexy of the temporal lobe. This in itself was overwhelming. Secondly, and this too had some physiological basis (in the abruptness and extent of the stroke, and its disturbance of deep-lying emotional centres' uncus, amygdala, limbic system, etc., deep within, and deep to the temporal lobe), there was an overwhelming emotion a.s.sociated with the seizures and an overwhelming (and profoundly nostalgic) content-an overwhelming sense of being-a-child again, in her long-forgotten home, in the arms and presence of her mother.

It may be that such seizures have both a physiological and a personal origin, coming from particular charged parts of the brain but, equally, meeting particular psychic circ.u.mstances and needs: as in a case reported by Dennis Williams (1956): A representative, 31 (Case 2770), had major epilepsy induced by finding himself alone among strangers. Onset: a visual memory of his parents at home, the feeling 'How marvellous to be back'. It is described as a very pleasant memory. He gets gooseskin, goes hot and cold, and either the attack subsides or proceeds to a convulsion.