by Oliver Sacks
The beauty of a case like Mrs O'C.'s is that it is at once 'Jack-sonian' and 'Freudian'. She suffered from a Jacksonian 'reminiscence', but this served to moor and heal her, as a Freudian 'anamnesis'. Such cases are exciting and precious, for they serve as a bridge between the physical and personal, and they will point, if we let them, to the neurology of the future, a neurology of living experience. This would not, I think, have surprised or outraged Hughlings Jackson. Indeed it is surely what he himself dreamed of-when he wrote of 'dreamy states' and 'reminiscence' back in 1880.
Penfield and Perot entitle their paper 'The Brain's Record of Visual and Auditory Experience', and we may now meditate on the form, or forms, such inner 'records' may have. What occurs, in these wholly personal 'experiential' seizures, is an entire replay of (a segment of) experience. What, we may ask, could be played in such a way as to reconstitute an experience? Is it something akin to a film or record, played on the brain's film projector or phonograph? Or something analogous, but logically anterior- such as a script or score? What is the final form, the natural form, of our life's repertoire? That repertoire which provides not only memory and 'reminiscence', but our imagination at every level, from the simplest sensory and motor images, to the most complex imaginative worlds, landscapes, scenes? A repertoire, a memory, an imagination, of a life which is essentially personal, dramatic and 'iconic'.
The experiences of reminiscence our patients have raise fundamental questions about the nature of memory (or mnesis)-these are also raised, in reverse, in our tales of amnesia or amnesis ('The Lost Mariner' and 'A Matter of Identity', Chapters Two and Twelve). Analogous questions about the nature of knowing (or gnosis) are raised by our patients with agnosias-the dramatic visual agnosia of Dr P. (The Man Who Mistook His Wife for a Hat'), and the auditory and musical agnosias of Mrs O'M. and Emily D. (Chapter Nine, The President's Speech'). And similar questions about the nature of action (or praxis) are raised by the motor bewilder-
ment, or apraxia, of certain retardates, and by patients with frontal-lobe apraxias-apraxias which may be so severe that such patients may be unable to walk, may lose their 'kinetic melodies', their melodies of walking (this also happens in Parkinsonian patients, as was seen in Awakenings).
As Mrs O'C. and Mrs O'M. suffered from 'reminiscence', a convulsive upsurge of melodies and scenes-a sort of hyper-mnesis and hyper-gnosis-our amnesic-agnosic patients have lost (or are losing) their inner melodies and scenes. Both alike testify to the essentially 'melodic' and 'scenic' nature of inner life, the 'Prous-tian' nature of memory and mind.
Stimulate a point in the cortex of such a patient, and there convulsively unrolls a Proustian evocation or reminiscence. What mediates this, we wonder? What sort of cerebral organisation could allow this to happen? Our current concepts of cerebral processing and representation are all essentially computational (see, for example, David Marr's brilliant book, Vision: A Computational Investigation of Visual Representation in Man, 1982). And, as such, they are couched in terms of 'schemata', 'programmes', 'algorithms', etc.
But could schemata, programmes, algorithms alone provide for us the richly visionary, dramatic and musical quality of experience-that vivid personal quality which makes it 'experience'?
The answer is clearly, even passionately, 'No!' Computational representations-even of the exquisite sophistication envisaged by Marr and Bernstein (the two greatest pioneers and thinkers in this realm)-could never, of themselves, constitute 'iconic' representations, those representations which are the very thread and stuff of life.
Thus a gulf appears, indeed a chasm, between what we learn from our patients and what physiologists tell us. Is there any way of bridging this chasm? Or, if that is (as it may be) categorically impossible, are there any concepts beyond those of cybernetics by which we may better understand the essentially personal, Proustian nature of reminiscence of the mind, of life? Can we, in short, have a personal or Proustian physiology, over and above the mechanical, Sherringtonian one? (Sherrington himself hints at this
in Man on His Nature (1940), when he imagines the mind as 'an enchanted loom', weaving ever-changing yet always meaningful patterns-weaving, in effect, patterns of meaning . . . )
Such patterns of meaning would indeed transcend purely formal or computational programmes or patterns, and allow the essentially personal quality which is inherent in reminiscence, inherent in all mnesis, gnosis, and praxis. And if we ask what form, what organisation, such patterns could have, the answer springs immediately (and, as it were, inevitably) to mind. Personal patterns, patterns for the individual, would have to take the form of scripts or scores-as abstract patterns, patterns for a computer, must take the form of schemata or programmes. Thus, above the level of cerebral programmes, we must conceive a level of cerebral scripts and scores.
The score of 'Easter Parade', I conjecture, is indelibly inscribed in Mrs O'M.'s brain-the score, her score, of all she heard and felt at the original moment and imprinting of the experience. Similarly, in the 'dramaturgic' portions of Mrs O'C.'s brain, apparently forgotten, but none the less totally recoverable, must have lain, indelibly inscribed, the script of her dramatic, childhood scene.
And let us note, from Penfield's cases, that the removal of the minute, convulsing point of cortex, the irritant focus causing reminiscence, can remove in toto the iterating scene, and replace an absolutely specific reminiscence or 'hyper-mnesia' by an equally specific oblivion or amnesia. There is something extremely important, and frightening here: the possibility of a real psycho-surgery, a neurosurgery of identity (infinitely finer and more specific than our gross amputations and lobotomies, which may damp or deform the whole character, but cannot touch individual experiences).
Experience is not possible until it is organised iconically; action is not possible unless it is organised iconically. 'The brain's record' of everything-everything alive-must be iconic. This is the final form of the brain's record, even though the preliminary form may be computational or programmatic. The final form of cerebral representation must be, or allow, 'art'-the artful scenery and melody of experience and action.
By the same token, if the brain's representations are damaged or destroyed, as in the amnesias, agnosias, apraxias, their recon-stitution (if possible) demands a double approach-an attempt to reconstruct damaged programs and systems-as is being developed, extraordinarily, by Soviet neuropsychology; or a direct approach at the level of inner melodies and scenes (as described in Awakenings, A Leg to Stand On and several cases in this book, especially 'Rebecca' (Chapter Twenty-one) and the introduction to Part Four). Either approach may be used-or both may be used in conjunction-if we are to understand, or assist, brain-damaged patients: a 'systematic' therapy, and an 'art' therapy, preferably both.
All of this was hinted at a hundred years ago-in Hughlings Jackson's original account of'reminiscence' (1880); by Korsakoff, on amnesia (1887); and by Freud and Anton in the 1890s, on agnosias. Their remarkable insights have been half-forgotten, eclipsed by the rise of a systematic physiology. Now is the time to recall them, re-use them, so that there may arise, in our own time, a new and beautiful 'existential' science and therapy, which can join with the systematic, to give us a comprehensive understanding and power.
Since the original publication of this book I have been consulted for innumerable cases of musical 'reminiscence'-it is evidently not uncommon, especially in the elderly, though fear may inhibit the seeking of advice. Occasionally (as with Mrs. O'C. and O'M.) a serious or significant pathology is found. Occasionally-as in a recent case report (NE/M, September 5, 1985)-there is a toxic basis, such as the over-use of aspirin. Patients with severe nerve-deafness may have musical 'phantoms'. But in most cases no pathology can be found, and the condition, though a nuisance, is essentially benign. (Why the musical parts of the brain, above all, should be so prone to such 'releases' in old age remains far from clear.)
16
Incontinent Nostalgia
If I encountered 'reminiscence' occasionally in the context of epilepsy or migraine, I encountered it commonly in my post-ence-phalitic patients excited by L-Dopa-so much so that I found myself calling L-Dopa 'a sort of strange and personal time-machine'. It was so dramatic in one patient that I made her the subject of a Letter to the Editor, published in the Lancet in June 1970, and reprinted below. Here, I found myself thinking of 'reminiscence' in its strict, Jacksonian sense, as a convulsive upsurge of memories from the remote past. Later, when I came to write the history of this patient (Rose R.) in Awakenings, I thought less in terms of 'reminiscence' and more in terms of 'stoppage' ('Has she never moved on from 1926?' I wrote)-and these are the terms in which Harold Pinter portrays 'Deborah' in A Kind of Alaska.
One of the most astonishing effects of L-Dopa, when given to certain postencephalitic patients, is the reactivation of symptoms and behaviour-patterns present at a much earlier stage of the disease, but subsequently 'lost'. We have already commented, in this connection, on the exacerbation or recurrence of respiratory crises, oculogyric crises, iterative hyperkineses, and tics. We have also observed the reactivation of many other 'dormant', primitive symptoms, such as myoclonus, bulimia, polydipsia, satyriasis, central pain, forced affects, etc. At still higher levels of function, we have seen the return and reactivation of elaborate, affectively charged moral postures, thought-systems, dreams, and memories-all 'forgotten', repressed, or
otherwise inactivated in the limbo of profoundly akinetic, and sometimes apathetic, postencephalitic illness.
A striking example of forced reminiscence induced by L-Dopa was seen in the case of a 63-year-old woman who had had progressive postencephalitic Parkinsonism since the age of 18 and had been institutionalised, in a state of almost continuous oculogyric 'trance', for 24 years. L-Dopa produced, at first, a dramatic release from her Parkinsonism and oculogyric en-trancement, allowing almost normal speech and movement. Soon there followed (as in several of our patients) a psychomotor excitement with increased libido. This period was marked by nostalgia, joyful identification with a youthful self, and uncontrollable upsurge of remote sexual memories and allusions. The patient requested a tape-recorder, and in the course of a few days recorded innumerable salacious songs, 'dirty' jokes and limericks, all derived from party-gossip, 'smutty' comics, nightclubs, and music-halls of the middle and late 1920s. These recitals were enlivened by repeated allusions to then-contemporary events, and the use of obsolete colloquialisms, intonations and social mannerisms irresistibly evocative of that bygone flappers' era. Nobody was more astonished than the patient herself: 'It's amazing,' she said. 'I can't understand it. I haven't heard or thought of those things for more than 40 years. I never knew I still knew them. But now they keep running through my mind.' Increasing excitement necessitated a reduction of the dosage of L-Dopa, and with this the patient, although remaining quite articulate, instantly 'forgot' all these early memories and was never again able to recall a single line of the songs she had recorded.
Forced reminiscence-usually associated with a sense of deja vu, and (in Jackson's term) 'a doubling of consciousness'-occurs rather commonly in attacks of migraine and epilepsy, in hypnotic and psychotic states, and, less dramatically, in everybody, in response to the powerful mnemonic stimulus of certain words, sounds, scenes, and especially smells. Sudden memory-upsurge has been described as occurring in oculogyric crises, as in a case described by Zutt in which 'thousands of memories
suddenly crowded into the patient's mind.' Penfield and Perot have been able to evoke stereotyped recalls by stimulating epileptogenic points in the cortex, and surmise that naturally occurring or artificially induced seizures, occurring in such patients, activate 'fossilised memory sequences' in the brain.
We surmise that our patient (like everybody) is stacked with an almost infinite number of 'dormant' memory-traces, some of which can be reactivated under special conditions, especially conditions of overwhelming excitement. Such traces, we conceive-like the subcortical imprints of remote events far below the horizon of mental life-are indelibly etched in the nervous system, and may persist indefinitely in a state of abeyance, due either to lack of excitation or to positive inhibition. The effects of their excitation or disinhibition may, of course, be identical and mutually provocative. We doubt, however, whether it is adequate to speak of our patient's memories as having been simply 'repressed' during her illness, and then 'depressed' in response to L-Dopa.
The forced reminiscence induced by L-Dopa, cortical probes, migraines, epilepsies, crises, etc. would seem to be, primarily, an excitation; while the incontinently nostalgic reminiscence of old age, and sometimes of drunkenness, seems closer to a disinhibition and uncovering of archaic traces. All of these states can 'release' memory, and all of them can lead to a re-experience and re-enactment of the past.
17
A Passage to India
Bhagawhandi P., an Indian girl of 19 with a malignant brain tumour, was admitted to our hospice in 1978. The tumour-an astrocytoma-had first presented when she was seven, but was then of low malignancy, and well circumscribed, allowing a complete resection, and complete return of function, and allowing Bhagawhandi to return to normal life.
This reprieve lasted for ten years, during which she lived life to the full, lived it gratefully and consciously to the full, for she knew (she was a bright girl) that she had a 'time bomb' in her head.
In her eighteenth year, the tumour recurred, much more invasive and malignant now, and no longer removable. A decompression was performed to allow its expansion-and it was with this, with weakness and numbness of the left side, with occasional seizures and other problems, that Bhagawhandi was admitted.
She was, at first, remarkably cheerful, seeming to accept fully the fate which lay in store, but still eager to be with people and do things, enjoy and experience as long as she could. As the tumour inched forward to her temporal lobe and the decompression started to bulge (we put her on steroids to reduce cerebral edema) her seizures became more frequent-and stranger.
The original seizures were grand mal convulsions, and these she continued to have on occasion. Her new ones had a different character altogether. She would not lose consciousness, but she would look (and feel) 'dreamy'; and it was easy to ascertain (and confirm by EEG) that she was now having frequent temporal-lobe
seizures, which, as Hughlings Jackson taught, are often characterised by 'dreamy states' and involuntary 'reminiscence'.
Soon this vague dreaminess took on a more defined, more concrete, and more visionary character. It now took the form of visions of India-landscapes, villages, homes, gardens-which Bhaga-whandi recognised at once, as places she had known and loved as a child.
'Do these distress you?' we asked. 'We can change the medication.'
'No,' she said, with a peaceful smile, 'I like these dreams-they take me back home.'
At times there were people, usually her family or neighbours from her home village; sometimes there was speech, or singing, or dancing; once she was in church, once in a graveyard; but mostly there were the plains, the fields, the rice paddies near her village, and the low, sweet hills which swept up to the horizon.
Were these all temporal-lobe seizures? This first seemed the case, but now we were less sure; for temporal-lobe seizures (as Hughlings Jackson emphasised, and Wilder Penfield was able by stimulation of the exposed brain to confirm-see 'Reminiscence') tend to have a rather fixed format: a single scene or song, unvaryingly reiterated, going with an equally fixed focus in the cortex. Whereas Bhagawhandi's dreams had no such fixity, but presented ever-changing panoramas and dissolving landscapes to her eye. Was she then toxic and hallucinating from the massive doses of steroids she was now receiving? This seemed possible, but we could not reduce the steroids-she would have gone into coma and died within days.
And a 'steroid psychosis', so-called, is often excited and disorganised, whereas Bhagawhandi was always lucid, peaceful and calm. Could
they be, in the Freudian sense, phantasies or dreams? Or the sort of dream-madness (oneirophrenia) which may sometimes occur in schizophrenia? Here again we could not be certain; for though there was a phantasmagoria of sorts, yet the phantasms were clearly all memories. They occurred side by side with normal awareness and consciousness (Hughlings Jackson, as we have seen, speaks of a 'doubling of consciousness'), and they were not ob-
viously 'over-cathected', or charged with passionate drives. They seemed more like certain paintings, or tone poems, sometimes happy, sometimes sad, evocations, revocations, visitations to and from a loved and cherished childhood.
Day by day, week by week, the dreams, the visions, came of-tener, grew deeper. They were not occasional now, but occupied most of the day. We would see her rapt, as if in a trance, her eyes sometimes closed, sometimes open but unseeing, and always a faint, mysterious smile on her face. If anyone approached her, or asked her something, as the nurses had to do, she would respond at once, lucidly and courteously, but there was, even among the most down-to-earth staff, a feeling that she was in another world, and that we should not interrupt her. I shared this feeling and, though curious, was reluctant to probe. Once, just once, I said, 'Bhagawhandi, what is happening?'
'I am dying,' she answered. 'I am going home. I am going back where I came from-you might call it my return.'
Another week passed, and now Bhagawhandi no longer responded to external stimuli, but seemed wholly enveloped in a world of her own, and, though her eyes were closed, her face still bore its faint, happy smile. 'She's on the return journey,' the staff said. 'She'll soon be there.' Three days later she died-or should we say she 'arrived', having completed her passage to India?
18
The Dog Beneath the Skin
Stephen D., aged 22, medical student, on highs (cocaine, PCP, chiefly amphetamines).