The Man Who Mistook His Wife For A Hat Part 7

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 psychoa.n.a.lysis, 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.

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 ent.i.tle 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 reconst.i.tute an experience? Is it something akin to a film or record, played on the brain's film projector or phonograph? Or something a.n.a.logous, 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 Ident.i.ty', Chapters Two and Twelve). a.n.a.logous 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 r.e.t.a.r.dates, 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 pa.s.sionately, '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, const.i.tute '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 ident.i.ty (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-st.i.tution (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 a.s.sist, 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 p.r.o.ne 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 astonis.h.i.+ng 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 inst.i.tutionalised, 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 psych.o.m.otor excitement with increased libido. This period was marked by nostalgia, joyful identification with a youthful self, and uncontrollable upsurge of remote s.e.xual 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, 's.m.u.tty' 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. n.o.body 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 a.s.sociated 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 Pa.s.sage 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 circ.u.mscribed, 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 ma.s.sive 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 pa.s.sionate 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 pa.s.sed, 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 pa.s.sage 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 a.s.sociated 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, s.e.xuality-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. s.e.xual 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.

Rather suddenly, after three weeks, this strange transformation ceased-his sense of smell, all his senses, returned to normal; he found himself back, with a sense of mingled loss and relief, in his old world of pallor, sensory faintness, non-concreteness and abstraction. 'I'm glad to be back,' he said, 'but it's a tremendous loss, (continued) ically part of the ancient 'smell-brain' (or rhinencephalon), is functionally a.s.sociated with the whole limbic system, which is increasingly recognised to be crucial in determining and regulating the entire emotional 'tone'. Excitation of this, by whatever means, produces heightened emotionalism and an intensification of the senses. The entire subject, with its intriguing ramifications, has been explored in great detail by David Bear (1979).

too. I see now what we give up in being civilised and human. We need the other-the "primitive"-as well.'

Sixteen years have pa.s.sed-and student days, amphetamine days, are long over. There has never been any recurrence of anything remotely similar. Dr D. is a highly successful young internist, a friend and colleague of mine in New York. He has no regrets- but he is occasionally nostalgic: 'That smell-world, that world of redolence,' he exclaims. 'So vivid, so real! It was like a visit to another world, a world of pure perception, rich, alive, self-sufficient, and full. If only I could go back sometimes and be a dog again!'

Freud wrote on several occasions of man's sense of smell as being a 'casualty', repressed in growing up and civilisation with the a.s.sumption of an upright posture and the repression of primitive, pre-genital s.e.xuality. Specific (and pathological) enhancements of smell have indeed been reported as occurring in paraphilia, fetis.h.i.+sm, and allied perversions and regressions.* But the disinhibition here described seems far more general, and though a.s.sociated with excitement-probably an amphetamine-induced dopaminergic excitation-was neither specifically s.e.xual nor a.s.sociated with s.e.xual regression. Similar hyperosmia, sometimes paroxysmal, may occur in excited hyper-dopaminergic states, as with some post-encephalitics on L-Dopa, and some patients with Tourette's syndrome.

What we see, if nothing else, is the universality of inhibition, even at the most elemental perceptual level: the need to inhibit what Head regarded as primordial and full of feeling-tone, and called 'protopathic', in order to allow the emergence of the sophisticated, categorising, affectless 'epicritic'.

The need for such inhibition cannot be reduced to the Freudian, nor should its reduction be exalted, romanticised, to the Blakean. Perhaps we need it, as Head implies, that we may be *This is well described by A.A. Brill (1932), and contrasted with the overall brilliance, the redolence, of the smell-world, in macrosomatic animals (such as dogs), 'savages' and children.

men and not dogs. * And yet Stephen D. 's experience reminds us, like G.K. Chesterton's poem, The Song of Quoodle', that sometimes we need to be dogs and not men: They haven't got no noses The fallen sons of Eve . . . Oh, for the happy smell of water, the brave smell of a stone!

Postscript I have recently encountered a sort of corollary of this case-a gifted man who sustained a head injury, severely damaging his olfactory tracts (these are very vulnerable in their long course across the anterior fossa) and, in consequence, entirely losing his sense of smell.

He has been startled and distressed at the effects of this: 'Sense of smell?' he says. 'I never gave it a thought. You don't normally give it a thought. But when I lost it-it was like being struck blind. Life lost a good deal of its savour-one doesn't realise how much 'savour' is smell. You smell people, you smell books, you smell the city, you smell the spring-maybe not consciously, but as a rich unconscious background to everything else. My whole world was suddenly radically poorer . . . '

There was an acute sense of loss, and an acute sense of yearning, a veritable osmalgia: a desire to remember the smell-world to which he had paid no conscious attention, but which, he now felt, had formed the very ground base of life. And then, some months later, to his astonishment and joy, his favourite morning coffee, which had become 'insipid', started to regain its savour. Tentatively he tried his pipe, not touched for months, and here too caught a hint of the rich aroma he loved.

Greatly excited-the neurologists had held out no hope of recovery-he returned to his doctor. But after testing him minutely, *See Jonathan Miller's critique of Head, ent.i.tled 'The Dog Beneath the Skin', in the Listener (1970).

using a 'double-blind' technique, his doctor said: 'No, I'm sorry, there's not a trace of recovery. You still have a total anosmia. Curious though that you should now "smell" your pipe and coffee . . .'

What seems to be happening-and it is important that it was only the olfactory tracts, not the cortex, which were damaged-is the development of a greatly enhanced olfactory imagery, almost, one might say, a controlled hallucinosis, so that in drinking his coffee, or lighting his pipe-situations normally and previously fraught with a.s.sociations of smell-he is now able to evoke or re-evoke these, unconsciously, and with such intensity as to think, at first, that they are 'real'.

This power-part conscious, part unconscious-has intensified and spread. Now, for example, he snuffs and 'smells' the spring. At least he calls up a smell-memory, or smell-picture, so intense that he can almost deceive himself, and deceive others, into believing that he truly smells it.

We know that such a compensation often occurs with the blind and the deaf. We think of the deaf Beethoven and the blinded Prescott. But I have no idea whether it is common with anosmia.

19.

Murder Donald killed his girl while under the influence of PCP. He had, or seemed to have, no memory of the deed-and neither hypnosis nor sodium amytal served to release any. There was, therefore, it was concluded when he stood trial, not a repression of memory, but an organic amnesia-the sort of blackout well described with PCP.

The details, manifest on forensic examination, were macabre, and could not be revealed in open court. They were discussed in camera-concealed from both the public and from Donald himself. Comparison was made with the acts of violence occasionally committed during temporal lobe or psych.o.m.otor seizures. There is no memory of such acts, and perhaps no intention of violence- those who commit them are considered neither responsible nor culpable, but are none the less committed for their own and others' safety. This was what happened with the unfortunate Donald.

He spent four years in a psychiatric hospital for the criminally insane-despite doubts as to whether he was either criminal or insane. He seemed to accept his incarceration with a certain relief-the sense of punishment was perhaps welcome, and there was, he doubtless felt, security in isolation. 'I am not fit for society', he would say, mournfully, when questioned. Security from sudden, dangerous uncontrol-security, and a sort of serenity too. He had always been interested in plants, and this interest, so constructive, and so remote from the danger zone of human relation and action, was strongly encouraged in the prison-hospital where he now lived. He took over its ragged, un-tended grounds, and created flower gradens, kitchen gardens, gardens of all sorts. He seemed to have achieved a sort of austere equilibrium, in which human relations, human pa.s.sions, previously so tempestuous, were replaced by a strange calm. Some considered him schizoid, some sane: everyone felt he had achieved a sort of stability. In his fifth year he started to go out on parole, being allowed to leave the hospital on weekend pa.s.ses. He had been an avid cyclist, and now he again bought a bike. And it was this which precipitated the second act of his strange history.

He was pedalling, fast, as he liked to, down a steep hill when an oncoming car, badly driven, suddenly loomed on a blind turn. Swerving to avoid a head-on collision, he lost control, and was flung violently, head-first, onto the road.

He sustained a severe head injury-ma.s.sive bilateral subdural hematomas, which were at once surgically evacuated and drained- and severe contusion of both frontal lobes. He lay in a coma, hemiplegic, for almost two weeks, and then, unexpectedly, he started to recover. And now, at this point, the 'nightmares' began.

The returning, the re-dawning, of consciousness was not sweet- it was beset by a hideous agitation and turmoil, in which the half-conscious Donald seemed to be violently struggling, and kept crying, 'Oh G.o.d!' and 'No!' As consciousness grew clearer, so memory, full memory, a now terrible memory, came with it. There were severe neurological problems-left-sided weakness and numbness, seizures, and severe frontal-lobe deficits-and with these, with the last of these, something totally new. The murder, the deed, lost to memory before, now stood before him in vivid, almost hallucinatory detail. Uncontrollable reminiscence welled up and overwhelmed him-he kept 'seeing' the murder, enacting it, again and again. Was this nightmare, was this madness, or was there now 'hyper-mnesis'-a breakthrough of genuine, veridical, terrifyingly heightened memories?

He was questioned in great detail, with the greatest care to avoid any hints or suggestions-and it was very soon clear that what he now showed was a genuine, if uncontrollable, 'reminiscence'. He now knew the minutest details of the murder: all the details revealed by forensic examination, but never revealed in open court-or to him.

All that had been, or seemed, previously lost or forgotten- even in the face of hypnosis or amytal injection-was now recovered and recoverable. More, it was uncontrollable; and still more, completely unbearable. He twice attempted suicide on the neuro-surgical unit and had to be heavily tranquilised and forcibly restrained.

What had happened to Donald-what was happening with him? That this was a sudden irruption of psychotic phantasy was ruled out by the veridical quality of the reminiscence shown-and even if it were entirely psychotic phantasy, why should it occur now, quite suddenly, unprecedentedly, with his head injury? There was a psychotic, or near psychotic, charge to the memories-they were, in psychiatric parlance, intensely or over-'cathected'-so much so as to drive Donald to incessant thoughts of suicide. But what would be a normal cathexis for such a memory-the sudden emergence, from total amnesia, not of some obscure Oedipal struggle or guilt, but of an actual murder?

Was it possible that with the loss of frontal-lobe integrity an essential prerequisite for repression had been lost-and that what we now saw was a sudden, explosive and specific 'de-repression'? None of us had ever heard or read of anything quite like this before, although all of us were very familiar with the general dis-inhibition seen in frontal-lobe syndromes-the impulsiveness, the facetiousness, the loquacity, the salacity, the exhibition of an uninhibited, nonchalant, vulgar Id. But this was not the character which Donald now showed. He was not impulsive, unselective, inappropriate, in the least. His character, judgment and general personality were wholly preserved-it was specifically and solely memories and feelings of the murder which now erupted uncontrollably, obsessing and tormenting him.

Was there a specific excitatory or epileptic element involved? Here EEG studies were especially interesting, because it was evident, using special (nasopharyngeal) electrodes, that in addition to the occasional grand mal seizures he had there was an incessant seething, a deep epilepsy, in both temporal lobes, extending down (one might surmise, but it would need implanted electrodes to confirm) into the uncus, the amygdala, the limbic structures-the emotional circuitry which lies deep to the temporal lobes. Penfield and Perot (Brain, 1963, pp. 596-697) had reported recurrent 'reminiscence', or 'experiential hallucinations', in some patients with temporal-lobe seizures. But most of the experiences or reminiscences which Penfield described were of a somewhat pa.s.sive sort- hearing music, seeing scenes, being present perhaps, but present as a spectator, not as an actor. * None of us had heard of such a patient re-experiencing, or rather re-enacting, a deed-but this apparently was what was happening with Donald. No clear decision was ever reached.

It remains only to tell the rest of the story. Youth, luck, time, natural healing, superior pre-traumatic function, aided by a Lu-rianic therapy for frontal-lobe 'subst.i.tution,' have allowed Donald, over the years, to make an enormous recovery. His frontal-lobe functions now are almost normal. The use of new anticonvulsants, only available in the last few years, have allowed effective control of his temporal-lobe seething-and here again, probably, natural recovery has played a part. Finally, with sensitive and supportive regular psychotherapy, the punitive violence of Donald's self-accusing superego has been mitigated, and the gentler scales of the ego now hold court. But the final, the most important, thing is this: that Donald has now returned to gardening. 'I feel at peace gardening,' he says to me. 'No conflicts arise. Plants don't have egos. They can't hurt your feelings.' The final therapy, as Freud said, is work and love.

Donald has not forgotten, or re-repressed, anything of the murder-if, indeed, repression was operative in the first place-but he is no longer obsessed by it: a physiological and moral balance has been struck.

*And yet this was not invariably so. In one particularly horrifying, traumatic case, recorded by Penfield, the patient, a girl of twelve, seemed to herself, in every seizure, to be running frantically from a murderous man who was pursuing her with a writhing bag of snakes. This 'experiential hallucination' was a precise replay of an actual horrid incident, which had occurred five years before.

But what of the status of the first lost, then recovered, memory? Why the amnesia-and the explosive return? Why the total blackout and then the lurid flashbacks? What actually happened in this strange, half-neurological drama? All these questions remain a mystery to this day.

20.

The Visions of Hildegard 'Vision of the Heavenly City'. From a ma.n.u.script of Hildegard's Scivias, written at Bingen about 1180. This figure is a reconstruction from several visions of migrainous origin.

The religious literature of all ages is replete with descriptions of 'visions', in which sublime and ineffable feelings have been accompanied by the experience of radiant luminosity (William James Figure A Figure B Figure C Figure D Varieties of migraine hallucination represented in the visions of Hilde-gard.

In Figure A, the background is formed of s.h.i.+mmering stars set upon wavering concentric lines. In Figure B, a shower of brilliant stars (phos-phenes) is extinguished after its pa.s.sage-the succession of positive and negative scotomas. In Figures C and D, Hildegard depicts typically migrainous fortification figures radiating from a central point, which, in the original, is brilliantly luminous and colored.