Authors: Oliver Sacks
Hallucinations (19 page)
In 1990, Stephen had surgery to remove an epileptic focus in his right temporal lobe, and he felt so much better after the surgery that he decided to wean himself off medication. Then, unfortunately, he had another car accident, after which his seizures returned. These were not responsive to medication, and
he had to have much more extensive brain surgery in 1997. Nevertheless, he continues to need antiepileptic medication and to have various seizure symptoms.
Stephen feels that there has been a “metamorphosis” in his personality since the start of his seizures, that he has become “more spiritual, more creative, more artistic”—specifically, he wonders whether “the right side” of his brain (as he puts it) is being stimulated, coming to dominate him. In particular, music has assumed greater and greater importance for him. He had taken up the harmonica in his college days, and now, in his fifties, he plays “obsessively,” for hours. He often writes or draws for hours at a time, too. He feels that his personality has become “all or none”—he may be either hyperfocused or completely distracted. He has also developed a tendency to sudden rage: on one occasion, when a car cut him off, he attacked the offender physically, hurling a can at his car, then punching him. (He wonders, in retrospect, whether some seizure activity played a part in this.) Despite all his problems, Stephen L. is able to continue working in medical research, and he remains an engaging, sensitive, and creative person.
T
here was little that Gowers or his contemporaries could do for patients with complex or focal seizures, other than giving them sedative drugs like bromides. Many patients with epilepsy, especially temporal lobe epilepsy, were considered to be “medically intractable” until the introduction of the first specific antiepileptic drug in the 1930s—and even then the most severely affected patients could not be helped. But the 1930s also saw a much more radical, surgical approach,
undertaken by Wilder Penfield, a brilliant young American neurosurgeon working in Montreal, and his colleague Herbert Jasper. In order to remove the epileptic focus in the cerebral cortex, Penfield and Jasper first had to find it by mapping the patient’s temporal lobe, and this required the patient to be fully conscious. (Local anesthesia is used when opening the skull, but the brain itself is insensitive to touch and pain.) Over a twenty-year period, the “Montreal procedure” was carried out in more than five hundred patients with temporal lobe epilepsy. These people had very diverse seizure symptoms, but forty or so of them had what Penfield termed “experiential seizures,” in which, seemingly, a fixed and vivid memory of the past would suddenly burst into the mind with hallucinatory force, causing a doubling of consciousness: a patient would feel equally that he was in the operating room in Montreal and that he was, say, riding horseback in a forest. By systematically going over the surface of the exposed temporal cortex with his electrodes, Penfield was able to find particular cortical points in each patient where stimulation caused a sudden, involuntary recall—an experiential seizure.
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Removal of these points could prevent further such seizures, without affecting the memory itself.
Penfield described many examples of experiential seizures:
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 a time of listening to music, a time of looking in at the door of a dance hall, a time of imagining the action of robbers from a comic strip … 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.
Penfield’s notion of actual memories or experiences being reactivated has been disputed. We now know that memories are not fixed or frozen, like Proust’s jars of preserves in a larder, but are transformed, disassembled, reassembled, and recategorized with every act of recollection.
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And yet, some memories do, seemingly, remain vivid, minutely detailed, and relatively fixed throughout life. This is especially so with traumatic memories or memories carrying an intense emotional charge and significance. Penfield was at pains, however, to emphasize that epileptic flashbacks seem to lack any such special qualities.
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“It would be very difficult to imagine,” he wrote, “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.” He felt that the flashbacks consisted of “random” segments of experience, fortuitously associated with a seizure focus.
C
uriously, though Penfield described such a variety of experiential hallucinations, he made no reference to what we now call “ecstatic” seizures—seizures that produce feelings of ecstasy or transcendent joy, such as Dostoevsky described. Dostoevsky’s seizures started in childhood, but they became frequent only in his forties, after his return from exile in Siberia. In his occasional grand mal attacks, he would emit (his wife wrote) “a fearful cry, a cry that had nothing human about it,” and then fall to the floor, unconscious. Many of these attacks were preceded by a remarkable mystical or ecstatic aura—but sometimes there would be only the aura, without any subsequent
convulsions or lack of consciousness. The first occurred one Easter Eve, as his friend Sophia Kowalewski wrote in her
Childhood Recollections
(Alajouanine quotes this in his paper on Dostoevsky’s epilepsy). Dostoevsky was talking with two friends about religion when a bell started to toll midnight. Suddenly he exclaimed, “God exists, He exists!” He later went into detail about the experience:
The air was filled with a big noise and I tried to move. I felt the heaven was going down upon the earth and that it had engulfed me. I have really touched God. He came into me myself, yes God exists, I cried, and I don’t remember anything else. You all, healthy people, he said, can’t imagine the happiness which we epileptics feel during the second or so before our fit.… I don’t know if this felicity lasts for seconds, hours or months, but believe me, for all the joys that life may bring, I would not exchange this one.
He gave similar descriptions on a number of other occasions, and endowed several of the characters in his novels with seizures akin to, and sometimes identical with, his own. One such involves Prince Myshkin in
The Idiot
:
During these moments as rapid as lightning, the impression of the life and the consciousness were in himself ten times more intense. His spirit and his heart were illuminated by an immense sense of light; all his emotions, all his doubts, all his anxiety calmed together to be changed into a sovereign serenity made up of lighted joy, harmony and hope; then, his reason was raised up to the understanding of the final cause.
There are also descriptions of ecstatic seizures in
The Devils
,
The Brothers Karamazov
, and
The Insulted and the Injured
, while in
The Double
there are descriptions of “forced thinking” and “dreamy states” almost identical with what Hughlings Jackson was describing at much the same time in his great neurological articles.
Over and above his ecstatic auras—which always seemed to Dostoevsky revelations of ultimate truth, direct and valid knowledge of God—there were remarkable and progressive changes in his personality throughout the later parts of his life, his time of greatest creativity. Théophile Alajouanine, a French neurologist, observed that these changes were clear when one compared Dostoevsky’s early, realistic works with the great, mystical novels he wrote in later life. Alajouanine suggested that “epilepsy had created in the person of Dostoevsky a ‘double man’ … a rationalist and a mystic; each having the better of the other according to the moment … [and] more and more the mystical one seems to have prevailed.”
It was this change, seemingly progressing even between Dostoevsky’s seizures (“interictally,” in neurological jargon), that especially fascinated the American neurologist Norman Geschwind, who wrote a number of papers on the subject in the 1970s and 1980s. He noted Dostoevsky’s increasingly obsessive preoccupation with morality and proper behavior, his growing tendency to “get embroiled in petty arguments,” his lack of humor, his relative indifference to sexuality, and, despite his high moral tone and seriousness, “a readiness to become angry on slight provocation.” Geschwind spoke of all this as an “interictal personality syndrome” (it is now called “Geschwind syndrome”). Patients with it often develop an
intense preoccupation with religion (Geschwind referred to this as “hyper-religiosity”). They may also develop, like Stephen L., compulsive writing or unusually intense artistic or musical passions.
Whether or not an interictal personality syndrome develops—and it does not seem to be universal or inevitable in those who have temporal lobe epilepsy—there is no doubt that those who have ecstatic seizures may be profoundly moved by them, and even actively seek to have more such seizures. In 2003, Hansen Asheim and Eylert Brodtkorb, in Norway, published a study of eleven patients with ecstatic seizures; eight of them wished to experience their seizures again, and of these, five found ways to induce them. More than any other sort of seizure, ecstatic seizures may be felt as epiphanies or revelations of a deeper reality.
Orrin Devinsky, a former student of Geschwind’s, has been a pioneer himself in the investigation of temporal lobe epilepsy and the great range of neuropsychiatric experiences which may be associated with it—autoscopy, out-of-body experiences, déjà vu and jamais vu, hyperfamiliarity, and ecstatic states during seizures, as well as personality changes between seizures. He and his colleagues have been able to perform clinical and video EEG monitoring in patients as they are having ecstatic-religious seizures, and thus to observe the precise coinciding of their “theophanies” with seizure activity in temporal lobe seizure foci (nearly always these are right-sided).
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Such revelations may take different forms; Devinsky has told me of one woman who, following a head injury, started to have brief episodes of déjà vu and a strange, indescribable smell. After a cluster of these complex partial seizures, she entered an exalted state in which God, with the form and voice of an angel, told her to run for Congress. Though she had never been religious or political before, she acted on God’s words at once.
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On occasion, ecstatic hallucinations can be dangerous, although this is very rare. Devinsky and his colleague George Lai described how one of their patients had a seizure-related vision in which “he saw Christ and heard a voice that commanded him to kill his wife and then himself. He proceeded to act upon the hallucinations,” killing his wife and then stabbing himself. This patient ceased to have seizures after the seizure focus in his right temporal lobe was removed.
Such epileptic hallucinations bear a considerable resemblance to the command hallucinations of psychosis, even
though the epileptic patient may have no psychiatric history. It takes a strong (and skeptical) person to resist such hallucinations and to refuse them either credence or obedience, especially if they have a revelatory or epiphanic quality and seem to point to a special—and perhaps exalted—destiny.
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s William James observed, an acute and passionate religious conviction in a single person can sway thousands of people. The life of Joan of Arc exemplified this. People have puzzled for nearly six hundred years as to how a farmer’s daughter with no formal education could have found such a sense of mission and succeeded in getting thousands of others to aid her in an attempt to drive the English out of France. The early hypotheses of divine (or diabolic) inspiration have given way to medical ones, with psychiatric diagnoses vying with neurological ones. Much evidence is available from the transcripts of her trial (and her “rehabilitation” twenty-five years later) and from the recollections of contemporaries. None of these is conclusive, but they do suggest, at least, that Joan of Arc may have had temporal lobe epilepsy with ecstatic auras.
Joan experienced visions and voices from the age of thirteen. These came in discrete episodes lasting seconds or minutes at most. She was very frightened by the first visitation, but later she derived great joy and an explicit sense of mission from her visions. The episodes were sometimes precipitated by the sounds of church bells. Joan described her first “visitations”:
I was thirteen when I had a Voice from God for my help and guidance. The first time that I heard this Voice, I was very
much frightened; it was mid-day, in the summer, in my father’s garden … I heard this Voice to my right, towards the Church; rarely do I hear it without its being accompanied also by a light. This light comes from the same side as the Voice. Generally it is a great light.… When I heard it for the third time, I recognized that it was the Voice of an Angel. This voice has always guarded me well, and I have always understood it; it instructed me to be good and to go often to Church; it told me it was necessary for me to come into France … it said to me two or three times a week: “You must go into France.” … It said to me: “Go, raise the siege which is being made before the City of Orleans. Go!” … and I replied that I was but a poor girl, who knew nothing of riding or fighting.… There is never a day when I do not hear this Voice; and I have much need of it.
Many other aspects of Joan’s putative seizures, as well as evidence of her clarity, her reasonableness, and her modesty, were explored in a 1991 article by the neurologists Elizabeth Foote-Smith and Lydia Bayne. While they present a very plausible case, other neurologists disagree, and one cannot hope to see the matter definitively resolved. The evidence is soft, as it must be for all historical cases.