The man who mistook his wife for a hat (22 page)

   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).

   Vivid dream one night, dreamt he was a dog, in a world unimaginably rich and significant in smells. ('The happy smell of water . . . the brave smell of a stone.') Waking, he found himself in just such a world. 'As if I had been totally colour-blind before, and suddenly found myself in a world full of colour.' He did, in fact, have an enhancement of colour vision ('I could distinguish dozens of browns where I'd just seen brown before. My leather-bound books, which looked similar before, now all had quite distinct and distinguishable hues') and a dramatic enhancement of eidetic visual perception and memory ('I could never draw before, I couldn't "see" things in my mind, but now it was like having a camera lucida in my mind-I "saw" everything, as if projected on the paper, and just drew the outlines I "saw". Suddenly I could do the most accurate anatomical drawings.') But it was the exaltation of
smell
which really transformed his world: 'I had dreamt I was a dog-it was an olfactory dream-and now I awoke to an infinitely redolent world-a world in which all other sensations, enhanced as they were, paled before smell.' And with all this there went a sort of trembling, eager emotion, and a strange nostalgia, as of a lost world, half forgotten, half recalled.*

   * Somewhat similar states-a strange emotionalism; sometimes nostalgia, 'reminiscence' and
deja
vu associated with intense olfactory hallucinations, are characteristic of 'uncinate seizures', a form of temporal-lobe epilepsy first described by Hughlings Jackson about a century ago. Usually the experience is rather specific, but sometimes there is a generalised intensification of smell, a hyperosmia. The uncus, phylogenet-

   (continued)

   'I went into a scent shop,' he continued. 'I had never had much of a nose for smells before, but now I distinguished each one instantly-and I found each one unique, evocative, a whole world.' He found he could distinguish all his friends-and patients-by smell: 'I went into the clinic, I sniffed like a dog, and in that sniff recognised, before seeing them, the twenty patients who were there. Each had his own olfactory physiognomy, a smell-face, far more vivid and evocative, more redolent, than any sight face.' He could smell their emotions-fear, contentment, sexuality-like a dog. He could recognise every street, every shop, by smell-he could find his way around New York, infallibly, by smell.

   He experienced a certain impulse to sniff and touch everything ('It wasn't really real until I felt it and smelt it') but suppressed this, when with others, lest he seem inappropriate. Sexual smells were exciting and increased-but no more so, he felt, than food smells and other smells. Smell pleasure was intense-smell displeasure, too-but it seemed to him less a world of mere pleasure and displeasure than a whole aesthetic, a whole judgment, a whole new significance, which surrounded him. 'It was a world overwhelmingly concrete, of particulars,' he said, 'a world overwhelming in immediacy, in immediate significance.' Somewhat intellectual before, and inclined to reflection and abstraction, he now found thought, abstraction and categorisation, somewhat difficult and unreal, in view of the compelling immediacy of each experience.