The man who mistook his wife for a hat

by Oliver Sacks

  "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-prone 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 circumstances of life, or by the extraordinary circumstances 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 Washington, 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 passage 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 associated 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-prone 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 attitude, 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 associations' 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 analysis in depth. Clearly there is no such deep analysis in Penfield, nor in any other physiological psychology. It is not clear whether any such deep analysis 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 associations, 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 entitled 'Did Shostakovich Have a Secret?' The 'secret' of Shostakovich, it was suggested-by a Chinese neurologist, Dr Dajue Wang-was

  the presence of a metallic splinter, a mobile shell-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', associated 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 associated 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 circumstances 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.

  Williams relates this astounding story baldly, and makes no connection between any of its parts. The emotion is dismissed as purely physiological-inappropriate 'ictal pleasure'-and the possible relation of 'being-back-home' to being lonely is equally ignored. He may, of course, be right; perhaps it all is entirely physiological; but I cannot help thinking that if one has to have seizures, this man, Case 2770, managed to have the right seizures at the right time.

  In Mrs O'C.'s case the nostalgic need was more chronic and profound, for her father died before she was born, and her mother before she was five. Orphaned, alone, she was sent to America, to live with a rather forbidding maiden aunt. Mrs O'C. had no conscious memory of the first five years of her life-no memory of her mother, of Ireland, of 'home'. She had always felt this as a keen and painful sadness-this lack, or forgetting, of the earliest, most precious years of her life. She had often tried, but never succeeded, to recapture her lost and forgotten childhood memories. Now, with her dream, and the long 'dreamy state' which succeeded it, she recaptured a crucial sense of her forgotten, lost childhood. The feeling she had was not just 'ictal pleasure', but a trembling, profound and poignant joy. It was, as she said, like the opening of a door-a door which had been stubbornly closed all her life.

  In her beautiful book on 'involuntary memories' (A Collection of Moments, 1970), Esther Salaman speaks of the necessity to preserve, or recapture, 'the sacred and precious memories of childhood', and how impoverished, ungrounded, life is without these. She speaks of the deep joy, the sense of reality, which recapturing such memories may give, and she provides an abundance of marvellous autobiographical quotations, especially from Dostoievski and Proust. We are all 'exiles from our past', she writes, and, as such, we need to recapture it. For Mrs O'C, nearly ninety, approaching the end of a long lonely life, this recapturing of 'sacred and precious' childhood memories, this strange and almost miraculous anamnesis, breaking open the closed door, the amnesia of childhood, was provided, paradoxically, by a cerebral mishap.

  Unlike Mrs O'M. who found her seizures exhausting and tiresome, Mrs O'C. found hers a refreshment to the spirit. They gave her a sense of psychological grounding and reality, the elemental sense which she had lost, in her long decades of cut-offness and 'exile', that she had had a real childhood and home, that she had been mothered and loved and cared-for. Unlike Mrs O'M., who wanted treatment, Mrs O'C. declined anticonvulsants: 'I need these memories,' she would say. 'I need what's going on . . . And it'll end by itself soon enough.'

  Dostoievski had 'psychical seizures', or 'elaborate mental states' at the onset of seizures, and once said of these:

  You all, healthy people, can't imagine the happiness which we epileptics feel during the second before our fit… I don't know if this felicity lasts for seconds, hours or months, but believe me, I would not exchange it for all the joys that life may bring. (T. Alajouanine, 1963)

  Mrs O'C. would have understood this. She too knew, in her seizures, an extraordinary felicity. But it seemed to her the acme of sanity and health-the very key, indeed the door, to sanity and health. Thus she felt her illness as health, as healing.

  As she got better, and recovered from her stroke, Mrs O'C. had a period of wistfulness and fear. 'The door is closing,' she said. 'I'm losing it all again.' And indeed she did lose, by the middle

  of April, the sudden irruptions of childhood scenes and music and feeling, her sudden epileptic 'transports' back to the world of early childhood-which were undoubtedly 'reminiscences', and authentic, for, as Penfield has shown beyond doubt, such seizures grasp and reproduce a reality-an
experiential reality, and not a phantasy: actual segments of an individual's lifetime and past experience.

  But Penfield always speaks of 'consciousness' in this regard-of physical seizures as seizing, and convulsively replaying, part of the stream of consciousness, of conscious reality. What is peculiarly important, and moving, in the case of Mrs O'C., is that epileptic 'reminiscence' here seized on something unconscious-very early, childhood experiences, either faded, or repressed from consciousness-and restored them, convulsively, to full memory and consciousness. And it is for this reason, one must suppose, that though, physiologically, the 'door' did close, the experience itself was not forgotten, but left a profound and enduring impression, and was felt as a significant and healing experience. 'I'm glad it happened,' she said when it was over. 'It was the healthiest, happiest experience of my life. There's no longer a great chunk of childhood missing. I can't remember the details now, but I know it's all there. There's a sort of completeness I never had before.'

  These were not idle words, but brave and true. Mrs O'C.'s seizures did effect a kind of 'conversion', did give a centre to a centreless life, did give her back the childhood she had lost-and with this a serenity which she had never had before and which remained for the rest of her life: an ultimate serenity and security of spirit as is only given to those who possess, or recall, the true past.

  Postscript

  'I have never been consulted for "reminiscence" only . . . ' said Hughlings Jackson; in contrast, Freud said, 'Neurosis is reminiscence.' But clearly the word is being used in quite opposite senses- for the aim of psychoanalysis, one might say, is to replace false or fantastic 'reminiscences' by a true memory, or anamnesis, of the past (and it is precisely such true memory, trivial or profound, that

  is evoked in the course of psychical seizures). Freud, we know, greatly admired Hughlings Jackson-but we do not know if Jackson, who lived to 1911, had ever heard of Freud.