Authors: Oliver Sacks
This was recognized by others too—and it was said that though the master was raving, his style was “pure James” and, indeed, “late James.”
S
ometimes withdrawal from drugs or alcohol may cause a delirium dominated by hallucinatory voices and delusions—a delirium which is, in effect, a toxic psychosis, even though the person is not schizophrenic and has never had a psychosis before. Evelyn Waugh provided an extraordinary account of this in his autobiographical novel
The Ordeal of Gilbert Pinfold
.
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Waugh had been a very heavy drinker for years, and at some point in the 1950s he had added a potent sleeping draft (an elixir of chloral hydrate and bromide) to the
alcohol. The draft grew stronger and stronger, as Waugh wrote of his alter ego, Gilbert Pinfold: “He was not scrupulous in measuring the dose. He splashed into the glass as much as his mood suggested and if he took too little and woke in the small hours he would get out of bed and make unsteadily for the bottle and a second swig.”
Feeling ill and unsteady, and with his memory occasionally playing tricks on him, Pinfold decides that a cruise to India might be restorative. His sleeping mixture runs out after two or three days, but his drinking stays at a high level. Barely has the ship got under way than he starts to have auditory hallucinations; most are of voices, but on occasion he hears music, a dog barking, the sound of a murderous beating administered by the captain of the ship and his doxy, and the sound of a huge mass of metal being thrown overboard. Visually, everything and everyone seems normal—a quiet ship with unremarkable crew and passengers, steaming quietly past Gibraltar into the Mediterranean. But complex and sometimes preposterous delusions are engendered by his auditory hallucinations: he understands, for example, that Spain has claimed sovereignty over Gibraltar and will be taking possession of the vessel, and that his persecutors possess thought-reading and thought-broadcasting machines.
Some of the voices address him directly—tauntingly, hatefully, accusingly; they often suggest that he commit suicide—although there is a sweet voice, too (the sister of one of his tormentors, he understands), who says she is in love with him, and asks if he loves her. Pinfold says he must see her, as well as hear her, but she says that this is impossible, that it is “against the Rules.” Pinfold’s hallucinations are exclusively auditory,
and he is not “allowed” to see the speaker—for this might shatter the delusion.
Such elaborate deliria and psychoses have a top-down as well as a bottom-up quality, like dreams. They are volcano-like eruptions from the “lower” levels in the brain—the sensory association cortex, hippocampal circuits, and the limbic system—but they are also shaped by the intellectual, emotional, and imaginative powers of the individual, and by the beliefs and style of the culture in which he is embedded.
A
great many medical and neurological conditions, as well as all sorts of drugs (whether taken for therapeutic purposes or for recreation), can produce such temporary, “organic” psychoses. One patient who stays most vividly in my mind was a postencephalitic man, a man of much cultivation and charm, Seymour L. (I refer to him and his hallucinations briefly in
Awakenings
). When given a very modest dose of L-dopa for his parkinsonism, Seymour became pathologically excited and, in particular, started to hear voices. One day he came up to me. I was a kind man, he said, and he had been shocked to hear me say, “Take your hat and your coat, Seymour, go up to the roof of the hospital, and jump off.”
I replied that I would not dream of saying anything like that to him, and that he must be hallucinating. “Did you
see
me?” I continued.
“No,” Seymour answered, “I just heard you.”
“If you hear the voice again,” I said to him, “look round and see if I am there. If you cannot see me, you will know it is a hallucination.” Seymour pondered this briefly, then shook his head.
“It won’t work,” he said.
The next day he again heard my voice telling him to take his hat and his coat, go up to the roof of the hospital, and jump off, but now the voice added, “And you don’t need to turn round, because I am really here.” Fortunately, Mr. L. was able to resist jumping, and when we stopped his L-dopa, the voices stopped, too. (Three years later, Seymour tried L-dopa again, and this time he responded beautifully, without a hint of delirium or psychosis.)
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. In addition to the overt delirium that may be associated with life-threatening medical problems, it is not uncommon for people to have slight delirium, so mild that it would not occur to them to consult a physician, and which they themselves may disregard or forget. Gowers, in 1907, wrote that migraine is “often attended by quiet delirium of which nothing can be subsequently recalled.”
There has always been inconsistency in defining delirium, and as Dimitrios Adamis and his colleagues pointed out in their review of the subject, it has frequently been confused with dementia and other conditions. Hippocrates, they wrote, “used about sixteen words to refer to and name the clinical syndrome which we now call delirium.” There was additional confusion with the medicalization of insanity in the nineteenth century, as German Berrios has noted, so that insanity was referred to as
délire chronique
. Even now the terminology is ambiguous, so that delirium is sometimes called “toxic psychosis.”
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. Just such an appearance of delirious images when closing the eyes, and their disappearance when the eyes are opened, is described by John Maynard Keynes in his memoir “Dr. Melchior”:
By the time we were back in Paris, I was feeling extremely unwell and took to my bed two days later. High fever followed.… I lay in my suite in the Majestic, nearly delirious, and the image of the raised pattern on the
nouveau art
wall-paper so preyed on my sensibilities in the dark that it was a relief to switch on the light and, by perceiving the reality, to be relieved for a moment from the yet more hideous pressure of its imagined outlines.
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. In a prefatory note to a later edition, Waugh wrote: “Three years ago Mr. Waugh suffered a brief bout of hallucinations resembling what is here described.… Mr. Waugh does not deny that ‘Mr. Pinfold’ is largely based on himself.” Thus we may accept
The Ordeal
as an autobiographic “case history” of a psychosis, an organic psychosis, albeit one written with a mastery of observation and description—and a sense of plot and suspense—that no purely medical case history has.
W. H. Auden once said that Waugh had “learned nothing” from his ordeal, but it at least enabled him to write a richly comic memoir, a new departure quite unlike anything he had written previously.
I
n 1992, I received a letter from Robert Utter, an Australian man who had heard me speak about migraine aura on television. He wrote, “You described how some migraine sufferers see elaborate patterns before their eyes … and speculated that they might be a manifestation of some deep pattern-generating function in the brain.” This reminded him of the experience that he routinely had upon going to bed:
This usually occurs at the moment when my head hits the pillow at night; my eyes close and … I see imagery. I do not mean pictures; more usually they are patterns or textures, such as repeated shapes, or shadows of shapes, or an item from an image, such as grass from a landscape or wood grain, wavelets or raindrops … transformed in the most extraordinary ways at a great speed. Shapes are replicated, multiplied, reversed in negative, etc. Color is added, tinted, subtracted. Textures are the most fascinating; grass becomes fur becomes hair follicles
becomes waving, dancing lines of light, and a hundred other variations and all the subtle gradients between them that my words are too coarse to describe.
These images and their subsequent changes appear and fade without my control. The experience is fugitive, sometimes lasting a few seconds, sometimes minutes. I cannot predict their appearance. They appear to take place not in my eye, but in some dimension of space before me. The strength of the imagery varies from barely perceptible to vivid, like a dream image. But unlike dreams, there are absolutely no emotional overtones. Though they are fascinating, I do not feel moved by them.… The whole experience seems to be devoid of meaning.
He wondered whether this imagery represented a sort of “idling” in the visual part of the brain, in the absence of perception.
What Mr. Utter described so vividly are not dreams but involuntary images or quasi-hallucinations appearing just before sleep—hypnagogic hallucinations, to use the term coined by the French psychologist Alfred Maury in 1848. They are estimated to occur in a majority of people, at least occasionally, although they may be so subtle as to go unnoticed.
While Maury’s original observations were all of his own imagery, Francis Galton provided one of the first systematic investigations of hypnagogic hallucinations, gathering information from a number of subjects. In his 1883 book
Inquiries into Human Faculty
, he observed that very few people might at first admit to having such imagery. It was only when he sent out questionnaires stressing the common and benign qualities of these hallucinations that some of his subjects felt free to speak about them.
Galton was struck by the fact that he, too, had hypnagogic hallucinations, even though it had taken time and patience for him to realize this. “Had I been asked, before I thought of carefully trying, I should have emphatically declared that my field of view in the dark was essentially of a uniform black, subject to an occasional light-purple cloudiness and other small variations,” he wrote. Once he began observing more closely, however, he saw that
a kaleidoscopic change of patterns and forms is continually going on, but they are too fugitive and elaborate for me to draw with any approach to truth. I am astonished at their variety.… They disappear out of sight and memory the instant I begin to think about anything, and it is curious to me that they should often be so certainly present and yet be habitually overlooked.
Among the scores of people who responded to Galton’s questionnaire was the Reverend George Henslow (“whose visions,” Galton wrote, “are far more vivid than mine”).
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One of Henslow’s hallucinations started with a vision of a crossbow, then of an arrow, then a flight of arrows, which changed into falling stars and then into flakes of snow. This was followed by a finely detailed vision of a rectory and then of a bed of red tulips. There were quickly changing images in which he reported visual association (for instance, arrows became stars, then snowflakes) but no narrative continuity. Henslow’s imagery was extremely vivid, but it had no quality of a dream or story.
Henslow emphasized how greatly these hallucinations differed from voluntary images; the latter were assembled slowly, bit by bit, like a painting, and seemed to be in the realm of everyday experience, while the former appeared spontaneously, unbidden and full-blown. His hypnagogic hallucinations were “very frequently of great beauty and highly brilliant. Cut glass (far more elaborate than I am conscious of ever having seen), highly chased gold and silver filigree ornaments; gold and silver flower-stands, etc.; elaborate colored patterns of carpets in brilliant tints.”
While Galton singled out this description for its clarity and detail, Henslow was only one of many who described essentially similar visions when they were in a quiet, darkened room, ready for sleep. These visions varied in vividness, from faint imagery such as Galton himself had to virtual hallucination, though such hallucinations were never mistaken for reality.
Galton did not regard the disposition to hypnagogic visions as pathological; he thought that while a few people might experience them frequently and vividly whenever they went to sleep, most (if not all) people experienced them at least on occasion. It was a normal phenomenon, although special conditions—darkness or closing the eyes, a passive state of mind, the imminence of sleep—were needed to bring it out.
F
ew other scientists paid much attention to hypnagogic visions until the 1950s, when Peter McKellar and his colleagues started what was to be a decades-long investigation of near-sleep hallucinations, making detailed observations of their content and prevalence in a large population (the student
body at the University of Aberdeen) and comparing them with other forms of hallucination, especially those induced by mescaline. In the 1960s, they were able to complement their phenomenological observations with EEG studies as their subjects passed from full wakefulness to a hypnagogic state.
More than half of McKellar’s subjects reported hypnagogic imagery, and auditory hallucinations (of voices, bells, or animal or other noises) were just as common as visual ones. Many of my own correspondents also describe simple auditory hallucinations: dogs barking, telephones ringing, a name being called.
In his book
Upstate
, Edmund Wilson described a hypnagogic hallucination of a sort that many people share:
I seem to hear the telephone ringing just before I am completely awake in the morning. At first, I would go to answer it, but find that it was not ringing. Now I simply lie in bed, and if the sound is not repeated, I know that it is imaginary and don’t get up.
Antonella B. hears music as she is falling asleep. The first time it happened, she wrote, “I heard a really nice classical piece, played by a big orchestra, very complex and unknown.” Usually, no images accompany her music, “just beautiful sounds that fill my brain up.”
Susan F., a librarian, had more elaborate auditory hallucinations, as she wrote in a letter:
For several decades, just as I am drifting off to sleep, I have heard sentences uttered. They are always grammatically correct, usually in English, and usually spoken by a man. (On a few occasions they were spoken by a woman and once in a language
I could not understand. I can recognize the differences between the Romance languages, Chinese, Korean, Japanese, Russian, and Polish, but it was none of these.) Sometimes the sentences are commands, such as “Go get me a glass of water,” but at other times they are just statements or questions. During the summer of 1993, I kept a log of what I heard. Here are some of the sentences: “Once he was walking in front of me”; “This is yours, perhaps”; “Do you know what the photo looks like?”; “Mama wants some cookies”; “I smell the unicorn”; “Go get a shampoo.”
What I hear bears no relationship to what I have read, seen, experienced or remembered on that day, previous day, week or year. Frequently when my husband is driving and we are on a long trip, I will nod off in the car. The sentences come very rapidly then. I will nod off for a second, hear a sentence in the twilight of waking, repeat the sentence to my husband, and then nod off again, hear another sentence in the twilight and so on, until I decide to wake up and stay awake.