Authors: Oliver Sacks
Many people with mild cognitive impairment may be organized and oriented during the daytime—this is the case with Marlon, especially when he is at the senior center or at a church social, actively engaged with other people. But as
evening comes, there may be a “sundowning” syndrome, and fears and confusions start to proliferate.
Generally, in the daytime, Marlon’s hallucinatory figures deceive him briefly, for a minute or two, before he realizes they are figments. But late in the day, his insight breaks down, and he feels his threatening visitors as real. At night, when he finds “intruders” in his apartment, he is terrified—even though they seem uninterested in him. Many of them look “like criminals” and wear prison garb; sometimes they are “smoking Pall Malls.” One night one of his intruders was carrying a bloodstained knife, and Marlon yelled out, “Get out of here, in the name of the blood of Jesus!” On another occasion one of the apparitions left “under the door,” slipping away like a liquid or vapor. Marlon has ascertained that these figures are “like ghosts, not solid,” and that his arm will go right through them. Nevertheless, they
seem
quite real. He can laugh about this as we talk, but it is clear that he can be quite terrified and deluded when he is alone with his intruders in the middle of the night.
P
eople with CBS have, at least in part, lost the primary visual world, the world of perception. But they have gained, if only in an inchoate and fitful way, a world of hallucinations, a secondary visual world. The role CBS may play in an individual’s life varies enormously, depending on the sort of hallucinations that occur, how often they occur, and whether they are contextually appropriate, or frightening, or comforting, even inspiring. There are, at one extreme, those who may have had only a single hallucinatory experience in their life; others
may have had hallucinations, on and off, for years. Sometimes hallucinations can be distracting—seeing patterns or webs over everything, not knowing whether the food on one’s plate is real or hallucinatory. Some hallucinations are manifestly unpleasant, especially those that involve deformed or dismembered faces. A few are dangerous: Zelda, for instance, does not dare drive, since she may see the road suddenly bifurcate or people jumping on the hood of her car.
For the most part, however, the hallucinations of CBS are unthreatening and, once accommodated to, mildly diverting. David Stewart speaks of his hallucinations as being “altogether friendly,” and he imagines his eyes saying, “Sorry to have let you down. We recognize that blindness is no fun, so we’ve organized this small syndrome, a sort of coda to your sighted life. It’s not much, but it’s the best we can manage.”
Charles Lullin, too, enjoyed his hallucinations and would sometimes go into a quiet room for a brief hallucinatory break. “His mind makes merry with the images,” Bonnet wrote of his grandfather. “His brain is a theatre where the stage machinery puts on performances which are all the more amazing because they are unexpected.”
Sometimes the hallucinations of Charles Bonnet syndrome can inspire. Virginia Hamilton Adair wrote poetry as a young woman, publishing in the
Atlantic Monthly
and the
New Republic
. She continued to write poems during her career as a scholar and professor of English in California, but these, for the most part, remained unpublished. It was not until she was eighty-three and completely blind from glaucoma that she published her first book of poetry, the acclaimed
Ants on the Melon
. Two further collections followed, and in these new poems she made frequent reference to the Charles Bonnet hallucinations
that now visited her regularly, the visions given to her by “the angel of hallucinations,” as she put it.
Adair and, later, her editor sent me extracts from the journal she kept in the last years of her life. They were full of descriptions she dictated of her hallucinations as they occurred, including this:
I am maneuvered into a delightfully soft chair. I sink, submerged as usual in shades of night … the sea of clouds at my feet clears, revealing a field of grain, and standing about it a small flock of fowl, not two alike, in somber plumage: a miniature peacock, very slender, with its little crest and unfurled tail feathers, some plumper specimens, and a shore bird on long stems, etc. Now it appears that several are wearing shoes, and among them a bird with four feet. One expects more color among a flock of birds, even in the hallucinations of the blind.… The birds have turned into little men and women in medieval attire, all strolling away from me. I see only their backs, short tunics, tights or leggings, shawls or kerchiefs.… Opening my eyes on the smoke screen of my room I am treated to stabs of sapphire, bags of rubies scattering across the night, a legless vaquero in a checked shirt stuck on the back of a small steer, bucking, the orange velvet head of a bear decapitated, poor thing, by the guard of the Yellowstone Hotel garbage pit. The familiar milkman invaded the scene in his azure cart with the golden horse; he joined us a few days ago out of some forgotten book of nursery rhymes or the back of a Depression cereal box.… But the magic lantern show of colored oddities has faded and I am back in black-wall country without form or substance … where I landed as the lights went out.
1
. Draaisma’s book provides not only a vivid account of Bonnet’s life and work, but fascinating reconstructions of the lives of a dozen other major figures in neurology whose names are now remembered mostly for the syndromes named after them: Georges Gilles de la Tourette, James Parkinson, Alois Alzheimer, Joseph Capgras, and others.
2
. Or so it would seem. Recently I came across a marvelous 1845 report by Truman Abell, a physician who started to lose his sight in his fifty-ninth year and had become totally blind by 1842, four years later. He described this in an article for the
Boston Medical and Surgical Journal
.
“In this situation,” he wrote, “I often dreamed of having my sight restored, and of seeing the most beautiful landscapes. At length these landscapes began to appear in miniature
when awake
: small fields, a few feet square, would appear, clothed with green grass, and other vegetables, some in bloom. These would continue two or three minutes, and then disappear.” The landscapes were followed by an immense variety of other “illusions”—Abell did not use the word “hallucinations”—provided by “an internal sight.”
Over the course of several months, his visions increased in complexity. His “silent, but impudent visitors” were sometimes intrusive, with three or four people who would sit on his bed or “come to my bed-side, stoop down over me, and look directly into my eyes.” (Often his hallucinatory people seemed to acknowledge him, although CBS hallucinations typically do not interact with their hallucinators.) One night, he reported, “I was threatened to be run over about 10 o’clock by a drove of oxen; but having my presence of mind, I sat quiet, and with much crowding they all passed without touching me.”
Sometimes he saw ranks of thousands of people, splendidly dressed, forming columns that disappeared into the distance. At one point he saw “a column at least half a mile wide” of “men on horseback riding towards the west.… They continued to pass for several hours.”
“What I have here stated,” Abell wrote at the end of his detailed account, “must appear incredible to those unacquainted with the history of illusive visions.… How far my blindness contributed to produce such a result, I am not able to say. Never before have I been able to realize the ancient comparison of the human mind to a microcosm, or universe in miniature … [yet] the whole was confined within the organ of mental vision, and occupied, perhaps, a space of less than the tenth part of an inch square.”
3
. A particularly good description of hallucinations in CBS (“I See Purple Flowers Everywhere”) is provided by Lylas and Marja Mogk in their excellent book
Macular Degeneration
, written for patients with this condition.
4
. The reverse may also occur. Robert Teunisse told me how one of his patients, seeing a man hovering outside his nineteenth-floor apartment, assumed this was another one of his hallucinations. When the man waved at him, he did not wave back. The “hallucination” turned out to be his window washer, considerably miffed at not having his friendly wave returned.
5
. I have heard from at least a dozen people who, like Arthur and Marjorie, hallucinate musical notation; some of them have eye problems, some parkinsonism, some see music when they have a fever or delirium, some see it hypnopompically when they awaken. All but one are amateur musicians who often spend many hours a day studying scores. This very specialized and repetitive sort of visual study is peculiar to musicians. One may read books for hours a day, but one does not usually study print itself in such an intensive way (unless one is a type designer or proofreader, perhaps).
A page of music is far more complex visually than a page of print. With musical notation, one has not just the notes themselves but a very dense set of information contained in symbols for key signatures, clefs, turns, mordents, accents, rests, holds, trills, etc. It seems likely that intensive study and practice of this complex code somehow imprints it in the brain, and should any tendency to hallucination later develop, these “neural imprints” may predispose to hallucinations of musical notation.
And yet people with no particular training or even interest in music may also have hallucinations of musical notation, as Dominic ffytche has pointed out. In a letter to me, he wrote, “although prolonged exposure to music increases the likelihood of musical eyes, it is not a prerequisite.”
6
. I was reminded, when she said this, of a case I had heard of in which as a patient ate cherries from a bowl, they were replaced by hallucinatory cherries, a seemingly endless cornucopia of cherries, until, suddenly, the bowl was totally empty. And of another case, of a man with CBS who was picking blackberries. He picked every one he could see; then, to his delight, he saw four more he had missed—but these turned out to be hallucinations.
7
. Something about visual movement or “optic flow” seems to be especially provocative of visual hallucinations in people with CBS or other disorders. I met one elderly psychiatrist with macular degeneration who had experienced only a single episode of CBS hallucinations: he was being driven in a car and began to see, on the edges of the parkway, elaborate eighteenth-century gardens which reminded him of Versailles. He enjoyed the experience and found it much more interesting than the ordinary view of the roadside.
Ivy L., who also has macular degeneration, wrote:
As a passenger in cars, I began riding with my eyes closed. Now I often “see” a small, moving travel scene in front of me when my eyes are shut. I “see” open roads and sky, houses, and gardens. I do not “see” any people or vehicles. The scene constantly changes, showing unidentifiable houses in great detail sliding by when the car is in motion. These hallucinations never appear except when I am in a moving car.
(Mrs. L. also reported text hallucinations as part of her CBS, “brief periods when I would ‘see’ handwriting in huge letters across a large white wall, or the income tax figures imprinted on the drapes. These lasted several years, at intervals.”)
8
. Such correlations involve sizable regions of the brain; they are at a macro level. Correlations on a micro level, at least for elementary geometric hallucinations, have been proposed by William Burke, a neuro-physiologist who has experienced such hallucinations himself, due to macular “holes” in both eyes. He has been able to estimate the visual angles subtended by specific hallucinations and to extrapolate these into cortical distances. He concludes that the separation of his brickwork hallucinations corresponds to the separation of the physiologically active “stripes” in the V2 part of the visual cortex, while the separation of the dots he hallucinates corresponds to that of the “blobs” in the primary visual cortex. Burke hypothesizes that with diminished input from his damaged maculas, there is diminished activity in the macular cortex, releasing spontaneous activity in the cortical stripes and blobs that give rise to hallucinations.
9
. I have heard similar descriptions from other people who have both CBS and some dementia. Janet B. likes to listen to audiobooks and sometimes finds herself joined by a hallucinatory group of fellow listeners. They listen intently but never speak, do not respond to her questions, and seem unaware of her presence. At first, Janet realized that they were hallucinatory, but later, as her dementia advanced, she insisted that they were real. Once when her daughter was visiting and said, “Mom, there’s no one here,” she got angry and chased her daughter out.
A more complex delusional overlay occurred while she was listening to a favorite show on television. It seemed to Janet that the television crew had decided to use her apartment, and that it was set up with cables and cameras, that the show was actually being filmed at that moment in front of her. Her daughter happened to telephone her during the show, and Janet whispered, “I have to be quiet—they’re filming.” When her daughter arrived an hour later, Janet insisted that there were still cables all over the floor, adding, “Don’t you see that woman?”
Even though Janet was convinced of the reality of these hallucinations, they were entirely visual. People pointed, gestured, mouthed, but made no sound. Nor did she have any sense of personal involvement; she found herself in the midst of strange happenings, yet they seemed to have nothing to do with her. In this way they retained the typical character of CBS hallucinations, even though she insisted that they were real.
T
he brain needs not only perceptual input but perceptual
change
, and the absence of change may cause not only lapses of arousal and attention but perceptual aberrations as well. Whether darkness and solitude is sought out by holy men in caves or forced upon prisoners in lightless dungeons, the deprivation of normal visual input can stimulate the inner eye instead, producing dreams, vivid imaginings, or hallucinations. There is even a special term for the trains of brilliantly colored and varied hallucinations which come to console or torment those kept in isolation or darkness: “the prisoner’s cinema.”