THE+MAN+WHO+MISTOOK+HIS+WIFE+FOR+A+HAT+--+EXCESSES


 * 10. WITTY TICCY RAY**


 * This case study turns the lens on Tourette's Syndrome. Tourette's raises several big questions regarding brain function and personality for Sacks. First, it notes that the presence of abnormal brain function can //improve// certain abilities and capacities, while provoking dysfunctional behavior. Second, it suggests that there are times when the cure is worse than the disease, as shown by Ray's experience with Haldol. Third, it queries why some brain dysfunctions appear and disappear and whether physiologically or chemically abnormal structures can be consistent with normal overall function. Fourth, it questions whether there can be a clean break between personality and the brain function. Tourette's was originally viewed as possession, where the victim was compelled to display tics and spasms, but as Ray's case indicates, it may also be intrinsically connected to personality and self-identity.**

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 * Sacks begins with the history of the diagnosis, and particularly its curious ill-fit within the canons of medical science of the late 19th century.**
 * pg. 92. "In 1885 Gilles de la Tourette, a pupil of Charcot, described the astonishing syndrome which now bears his name. 'Tourette's Sydnrome', as it was immediately dubbed, is characterised by an excess of nervous energy, and a great production and extravagance of strange motions and notions: tics, jerks, mannerisms, grimaces, noises, curses, involuntary imitations and compulsions of all sorts, with an odd elfin humour and a tendency to antic and outlandish kinds of play . . . It was clear to Tourette, and his peers, that this syndrome was a sort of possession by primitive impulses and urges: but also that it was a possession with an organic basis -- a very definite (if undiscovered) neurological disorder . . . others might indeed be 'possessed' and scarcely able to achieve real identity amid the tremendous pressure and chaos of Tourettic impulses. There was always . . . a fight between an 'It' and an 'I'."

**As Sacks notes, after its first identification, a flood of cases was discovered, only to disappear from medical vocabulary in the first half of the 20th century.** media type="youtube" key="jJYu_YA2skU" height="400" width="552" align="center"
 * pg. 93-4. "The forgetting of sleepy-sickness . . . and the forgetting of Tourette's have much in common. Both disorders were extraordinary, and strange beyond belief -- at least, the beliefs of a contracted medicine. They could not be accommodated in the conventional frameworks of medicine, and therefore they were forgotten and mysteriously 'disappeared' . . . Was it possible that Tourette's was not a rarity, but rather common -- a thousand times more common, say, than previously supposed."
 * The neurological base of Tourette's are disturbances in the lower "animal" brain that upset the upper "human brain" cortex. The "It" of Tourette's is similar to the impulsive "Id" of Freudian Psychology. Sacks sees it as exploring the nexus between the mind as a body organ and the mind as the seat of the human personality.**
 * pg. 95-6. The 'It' in Tourette's, like the 'It' in Parkinsonism and chorea, reflects what Pavlov called 'the blind force of the subcortex', a disturbance of those primitive parts of the brain which govern 'go' and 'drive'. In Parkinsonism, which affects motion but not action as much, the disturbance lies in the midbrain and its connections. In chorea -- which is a chaos of fragmentary quasi-actions -- the disorder lies in higher levels of the basal ganglia. In Tourette's, where there is excitement of the emotions and the passions, a disorder of the primal, instinctual bases of behaviour, the disturbance seems to lie in the very highest parts of the 'old brain': the thalamus, hypothalamus, limbic system and amygdala, where the basic affective and instinctual determinants of the personality are lodged. Thus Tourette's --- pathologically no less than clinically constitutes a sort of 'missing link' between body and mind, and lies, so to speak, between chorea and mania.

**The case of Ray illustrates both the difficulties Tourette's creates for operating with society and also many of the unique strengths of Ray.**
 * pg. 97. "[Ray] had been subject to these since the age of four and severely stigmatised by the attention they aroused, though his high intelligence, his wit, his strength of character and sense of reality enabled him to pass successfully through school and college, and to be valued and loved by a few friends and his wife . . . however, he had been fired from a dozen jobs -- always because of tics, never for incompetence -- was continually in crises of one sort or another . . . He was . . . remarkably musical . . . a weekend jazz drummer of real virtuosity, famous for his sudden and wild extemporisations . . . His Tourette's was also of advantage in various games, especially ping-pong . . . his abnormal quickness of reflex and reaction, but especially, again, because of 'improvisations', 'very sudden, nervous, //frivolous// shots' . . . which were so unexpected or startling as to be virtually unanswerable."


 * Ray is put on Haldol to suppress the tics, but he finds that it creates problems because it changes his personality and impairs his reflexes and reactions, making him unable to do things that he did before. Sacks observes that**
 * pg. 98. "He was understandably discouraged by this experience -- and this thought -- and also by another thought which he now expressed. 'Suppose you //could// take away the tics -- there is nothing else.' He seemed at least jokingly, to have little sense of his identity except as a ticqueur: he called himself the 'the ticcer of President's Broadway', and spoke of himself, in the third person, as 'witty ticcy Ray', adding that he was so prone to 'ticcy witticisms and witty ticcicisms' that he scarcely knew whether it was a gift or a curse. He said he could not imagine life without Toruette's, nor was he sure he would care for it."

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 * This confessional video shows how some individuals deal with the emotions of Tourette's, both the stigma and feeling of not being in full control of oneself (and common theme in this section).**

**Ray summarizes what the inner experience of Tourette's and Haldol is like and compares it to what "normal" people experience. Once again, it is not the amount of tics or the sedation of Haldol, but the lack of choice over one's state -- and one's identity -- that is most troubling.** media type="youtube" key="sVD9XSRiH9U" height="400" width="552" align="center"
 * pg. 101. "Having Tourette's is wild, like being drunk all the while. Being on Haldol is dull, makes one square and sober, and neither state is really free . . . You 'normals', who have the right transmitters in the right places at the right times in our brains, have all feelings, all styles, available all the time -- gravity, levity, whatever is appropriate. We Touretters don't: we are forced into levity by our Tourette's and forced into gravity when we take Haldol. //You// are free, you have a natural balance: we must make the best of an artificial balance."


 * 11. CUPID'S DISEASE**


 * This case study looks at a woman who has contracted neurosyphilis, a sexually-transmitted disease that affects the nervous system. It makes two general points. The first is how context, in this case -- age, determines whether behavior is normal or not. The friskiness, flirtiness, and euphoria displayed by the patient would not be out of character for a typical teenager, the problem is because she is behaving like a teenager at age 89. The second, is, once again, whether cures can be worse than the brain dysfunction untreated. Is it possible to be //too// happy? If it is a problem, is it one we should try to cure. Sacks first recounts the details of the patient's discovery of her "Cupid's Disease."**
 * pg. 102-3. "'You're 89, Natasha, this have been going on for a year. You were always so temperate in feeling -- and now this extravagance! You are an old woman, nearing the end. What could justify such a sudden euphoria?' And as soon as I though of euphoria, things took on a new complexion . . . 'You're sick, my dear,' I said to myself. 'You're feeling //too// well, you have to be ill?' 'Ill? Emotionally? Mentally Ill?' 'No, not emotionally -- physically ill. It was something in my body, my brain, that was making me high. And then I thought -- goddam it, it's Cupid's Disease!' 'Cupid's Disease?' I echoed, blankly. I had never heard of the term before. 'Yes, Cupid's Disease -- syphilis . . .'"


 * Although there is an established therapy to treat neurosyphilis, the patient asks if she must be cured. The only thing she fears is that it gets worse, out of control, but she is content with her current condition.**
 * pg. 103. "'I don't know that I //want// it treated,' she said. 'I know it's an illness, but it's made me feel //well//. I've enjoyed it, I still enjoy it, I won't deny it. It's made me feel livelier, friskier, than I have in twenty years. It's been fun. But I know when a good thing goes too far, and stops being good. I've ha thoughts, I've had impulses, I won't tell you, which are -- well, embarrassing and silly. It was like being a little tiddly, a little tipsy, at first, but if it goes any further . . .' She mimed a drooling, spastic dement. 'I guessed I had Cupid's, that's why I came to you. I don't want it to get worse, that would be awful; but I don't want it cured -- that would be just as bad. I wasn't fully alive until the wrigglies got me. //Do you think you could keep it just as it is?//'"


 * Sacks seems to concur with his patient, both noting that disease-induced (and chemically-induced) euphoria is not something different than real good feeling.**
 * pg. 107. "What a paradox, what a cruelty, what an irony, there is here -- that inner life and imagination may lie dull and dormant unless released, awakened, by an intoxication or disease! Precisely this paradox lay at the heart of //Awakenings//; it is responsible too for the seduction of Tourette's . . . and, no doubt, for the peculiar uncertainty which may attach to a drug like cocaine . . . Thus Freud's startling comment about cocaine, that the sense of well-being and euphoria it induces ' . . . in no way differs from the normal euphoria of the healthy person . . . In other words, you are simply normal, and it is soon hard to believe that you are under the influence of any drug.'"


 * 12. A MATTER OF IDENTITY**


 * This case study parallels the earlier case of the "LOST MARINER" where an individual suffers from amnesia. However, unlike the previous case, where Jimmie was able preserve some connection and identity and some thread of his long-term memory before a certain point, the patient in this case must constantly forge new narratives and new identities around a "pithed" or hollow core of identity. While it may seem outwardly that he is handling his brain dysfunction better than Jimmie, Sacks disagrees.**


 * This case study reminds me of a section of the philosopher Soren Kierkegaard's book //Either/Or// where he describes a thin "Humean" (personality is just the product of environmental impressions) person who always chooses immediate gratification. Kierkegaard's narrator accuses this person of being a person at a masquerade who constantly shifts from one mask to another; does he not know that the music will end and he will be unmasked only to reveal a hollow, empty person behind all the facades? Bluster is often the result of deep insecurity and Mr. Thompson's endless confabulations are an attempt to mask his unacknowledged awareness that there is no there, there. Another recent popular culture examination of this theme is the Satoshi Kon's Anime miniseries, Paranoia Agent (literally a "stand-in for anxiety"), whose main characters create violent or saccharine fronts to cover their inner anxieties. This is perhaps why Sacks thinks it is important that doctors and neurologists pay attention to narrative and identity and not reduce the brain to electrical impulses and chemical combinations. Let us begin with Sacks description of the case:**
 * pg. 109. "He remembered nothing for more than a few seconds. he was continually disoriented. Abysses of amnesia continually opened beneath him, but he would bridge them, nimbly, by fluent confabulations and fictions of all kinds. For him they were not fictions, but how he suddenly saw, or interpreted, the world. Its radical flux and incoherence could not be tolerated, acknowledged, for an instant -- there was, instead, this strange, delirious, quasi-coherence, as Mr. Thompson, with his ceaseless, unconscious, quick-fire inventions, continually improvised a world around him -- an Arabian Nights world, a phantasmagoria, a dream, of ever-changing people, figures, situations -- continual, kaleidoscopic mutations and transformations. For Mr Thompson, however, it was not a tissue of ever-changing, evanescent fancies and illusion, but a wholly normal, stable and factual world. So far as //he// was concerned, there was nothing the matter."


 * Sacks, as many others have (Jerome Bruner; Alasdair MacIntyre), notes the importance of narrative to maintaining a coherent identity. A narrative means that we are not simply trapped in a interminable present, buffeted and molded by our environment, but we tell a fundamental story about ourselves that coheres our identity: where we come from, who we are, and where we are headed. Without a narrative, we have no identity and the mind collapses in on itself.**
 * pg. 110-1. "Such a frenzy may call forth quite brilliant powers of invention and fancy -- a veritable confabulatory genius -- for such a patient //must literally make himself (and his world) up every moment.// We have each of u, a life-story, an inner narrative -- whose continuity, whose sense, //is// our lives. It might be said that each of us constructs and lives, a 'narrative', and that this narrative //is// us, our identities. If we wish to know about a man, we ask 'what is his story -- his real, inmost story?' -- for each of us //is// a biography, a story. Each of us //is// a singular narrative, which is constructed, continually, unconsciously, by, through, and in us -- through our perceptions, our feelings our thoughts, our actions; and, not least, our discourse, our spoken narrations. Biologically, physiologically, we are no so different from each other; historically, as narratives -- we are each of us unique. To be ourselves we must //have// ourselves -- possess, if need be re-possess, our life-stories. We must 'recollect' ourselves, recollect the inner drama, the narrative, of ourselves. A man //needs// such a narrative, a continuous inner narrative to maintain his identity, his self.
 * Sacks explains how Thompson's endless tale-telling is a defense mechanism and that explains his behavior.**
 * pg. 111-12. "This narrative need, perhaps, is the clue to Mr. Thompson's desperate tale-telling, his verbosity. Deprived of continuity, of a quiet, continuous, inner narrative, he is driven to a sort of narrational frenzy -- hence his ceaseless tales, his confabulations, his mythomania. Unable to maintain a genuine inner world, he is driven to the proliferation of pseudo-narratives, in a pseudo-continuity, pseudo-worlds people by pseudo-people, phantoms . . . What saves Mr. Thompson in a sense, and in another sense damns him, //is// the forced or defensive superficiality of his life: the way in which it is, in effect, reduced to a surface, brilliant, shimmering, iridescent, ever-changing, but for all that a surface, a mass of illusions, a delirium, without depth."
 * Sacks makes the explicit comparison to Jimmie in the LOST MARINER and their relative ability to cope with the identical Korsakov's Syndrome**
 * pg. 114-5. "It is //because// Jimmie is 'lost' that he //can// be redeemed or found at least for a whole, in the mode of genuine emotion relation. Jimmie is in despair, a quiet despair (to use or adapt Kierkegaard's term), and therefore he has the possibility of salvation, of touching base, the ground of reality, the feeling and the meaning he has lost, but still recognises, still yearns for . . . But for William -- with his brilliant, brassy surface, the unending joke which he substitutes for the world (which if it covers over a desperation, is a desperation he does not feel); for William with his manifest indifference to relation and reality caught in an unending verbosity, there may be nothing 'redeeming' at all -- confabuations, his apparitions, his frantic search for meanings, being the ultimate barrier //to// any meaning . . . William . . . is so damned he does not know he is damned, for it is not just a faculty, or some faculties, which are damaged, but the very citadel, the self, the soul itself. William is 'lost', in this sense, far more than Jimmie -- for all his brio, one never feels, or rarely feels, that there is a //person// remaining, whereas in Jimmie there is plainly a real, moral being, even if disconnected most of the time. In Jimmie, at least, re-connection is //possible// -- the therapeutic challenge can be summed up as 'Only connect'."


 * 13. YES FATHER-SISTER**


 * In this short case study, Sacks extends and explores a point made in the previous: the real loss for those with "excesses" is that they can be lost in seas of triviality with no anchor. Earlier, Sacks had discussed the importance of judgment, the ability to discern real from unreal, good from bad, etc. This patient is devoid of judgment, even to the point that words are meaningless and irrelevant. She is lacking a self that cares about what she says to an extreme level; everything is a joke, but the situation is not humorous.**
 * pg. 117. "They're no different for //me//. Hands . . . Doctors .. . Sisters . . .' she added, seeing my puzzlement. 'Don't you understand? They mean nothing -- nothing to me. //Nothing means anything . . .// at least to me.' 'And . . . this meaning nothing . . .' I hesitated, afraid to go on. 'This meaninglessness . . .does //this// bother you? Does //this// mean anything to you?' 'Nothing at all,' she said promptly, with a bright smile, in the tone of one who makes a joke, wins an argument, wins at poker. Was this denial? Was this a brave show? Was this the 'cover' of some unbearable emotion? Her face bore no deeper expression whatever. her world had been voided of feeling and meaning. Nothing any longer felt 'real' (or 'unreal'). Everything was now 'equivalent' or 'equal' -- the whole world reduced to a facetious insignificance."
 * The mind desires order and continuity, but without memory or narrative to anchor it descends into "Humean froth" and silly irrelevance.**
 * pg. 118. "In all these states -- 'funny' and often ingenious as they appear -- the world is taken apart, undermined, reduced to anarchy and chaos. There ceases to to be any 'centre' to the mind, though its formal intellectual powers may be perfectly preserved. The end point of such states is an unfathomable 'silliness', an abyss of superficiality, in which all is ungrounded and afloat and comes apart. Luria once poke of the mind as reduced, in such states, to 'mere Brownian movement'. I share the sort of horror he clearly felt about them."

14. THE POSSESSED


 * As noted earlier, Tourette's was though to be akin to possession, where the "It" of the syndrome battled the "I" of the self. In the previous cases, the seriousness of the syndrome was relatively mild and the patients were able to live relatively normal lives through adaptation and medication. Sacks develops his argument about the nature of Tourette's, but also makes an important side point about the differences between clinical observation, which removes many of the stimuli that are part and parcel of the dysfunction, and "street-neurology" where the syndromes are observed in natural settings.**


 * First, his point on the importance of "street-neurology"**
 * pg. 121. "'Street-neurology', indeed, has respectable antecedents. James Parkinson, asinveterate a walker of the streets of London as Charles Dickens was to be, forty years later, delineated the disease that bears his name, not in his office, but in the teeming streets of London. Parkinsonism, indeed, cannot be fully seen, comprehended, in the clinic; it requires an open, complexly interactional space for the full revelation of its peculiar character . . . Parkinsonism //has// to be seen, to be fully comprehended, in the world, and if this is true of Parkinsonism, how much truer must it be of Tourette's."


 * Sacks recounts one instance of his own "street-neurology" where he witnessed an individual with super-Tourette's, who feeds off others in a vicious cycle, producing greater and greater spasms, tics, and emulations.**
 * pg. 122. "As I drew closer I saw what was happening. //She was imitating the passers-by// -- if 'imitation' is not too pallid, too passive, a word. Should we say, rather, that she was caricaturing everyone she passed? Within a second, a split-second, she 'had' them all. I have seen countless mimes and mimics, clowns and antics, but nothing touched the horrible wonder I now beheld: this virtually instantaneous, automatic and convulsive mirroring of every face and figure. But it was not just an imitation, extraordinary as this would have been in itself. The woman not only took on, and took in, the features of countless people, she took them //off//. Every mirroring was also a parody, a mocking, an exaggeration of salient gestures and expressions, but an exaggeration in itself no less convulsive than intentional -- a consequence of the violent acceleration and distortion of all her motions. Thus a slow smile, monstrously accelerated, would become a violent, milliseconds-long grimace; an ample gesture, accelerated, would become a farcical convulsive movement."
 * Sacks expands his analysis by drawing a contrast between the Korsakovian disorders (deficits) and Tourettic disorders (excesses). Where deficits are discrete and concrete: the limits of the loss are known compared to normal function and therefore can be engaged, adapted to or compensated for to achieve normal function, excesses have no limit, they are more than, supra-normal in many different ways and direction. Some of theses excesses allow those with Tourettic disorders to surpass normal brain function in a variety of ways, but here is no form to take hold of.**
 * pg. 123-4. "For where the Korsakovian is driven by amnesia, absence, the Touretter is driven by extravagant impulse -- impulse of which he is both creator and the victim, impulse he may repudiate, but cannot disown. Thus he is impelled, as the Korsakovian is not, into an ambiguous relation with his disorder: vanquishing it being vanquished by it, playing with it-- there is every variety of conflict and collusion. Lacking the normal, protective barriers of inhibition, the normal, organically determined boundaries of self, the Touretter's ego si subject to a lifelong bombardment. He is beguiled, assailed, by impulses from within an dwithout impulses which are organic and convulsive, but also personal (or rather pseudo-personal) and seductive. How will, how //can//, the ego stand this bombardment? Will identity survive? Can it //develop//, in face of such a shattering, such pressures -- or will it be overwhelmed, to produce a 'Toruettized soul' . . ."


 * 15. REMINISCENCE**


 * This section of the book deals with what Sacks terms "transports." Transports are cases where the patient experiences visual or audio hallucinations: seeing or hearing something that is not there. They are usually caused by seizures. Usually, when individuals have hallucinations or hear things, the suspicion is that they are suffering from some sort of psychosis, such as schizophrenia, but those are not the examples that Sacks raises. In these cases, Sacks believes that these hallucinations are created by organically-stimulated recall of memories causes by seizures in the memory sections of the brain. Sacks describes his first case:**
 * pg. 133. "Conversation was far from easy, partly because of Mrs. O'C.'s deafness, but more because I was repeatedly drowned out by songs -- she could hear me through the softer ones. She was bright, alert, no delirious or mad, but with a remote, absorbed look, as someone half in a world of their own. I could find nothing neurological amiss. None the less, I suspected that he music //was// neurological."


 * One question Sacks raises is why certain songs or memories are selected. Seizures tend to be thought of as random or uncontrolled, while music is organized and intentional. Does the brain "select" certain memories for replay or is it simply random impulses and brain chemistry? Sacks seems to favor the former explanation, however, the onset of the symptoms seem to be related to physiological events such as seizures and strokes.**
 * pg. 134. ". . . she was indeed having temporal-lobe seizures, which . . . are the invariable basis of 'reminiscence' and experiential hallucinations. But why should she suddenly develop this strange symptom? I obtained a brainscan, and this showed that she had indeed had a small thrombosis or infarction in part of her right temporal lobe. The sudden onset of Irish songs in the night, the sudden activation of musical memory-traces in the cortex, were, apparently, the consequence of a stroke, and as it resolved, so the songs 'resolved' too."


 * Sacks describes these cases as musical epilepsy, a seeming contradiction in terms, but notes that hallucinations at the onset of epileptic seizures are not uncommon.**
 * pg. 136. But what //was// going on with Mrs. O'C. an Mrs O'M? 'Musical epilepsy' sounds like a contradiction in terms: for music, normally, is full of feeling and meaning, and corresponds to something deep in ourselves . . . whereas epilepsy suggests quite the reverse: a crude, random physiological event, wholly unselective, without feeling or meaning. Thus a m'musical epilepsy' or a 'personal epilepsy' would seem a contradiction in terms. And yet such epilepsies do occur, though solely in the context of temporal lobe seizures, epilepsies of the reminiscent part of the brain."


 * Sacks is careful to emphasize the role of memory in these hallucinations because they are not made of whole cloth, but seem to be involuntary recalls of stored images and information like ordinary memory and convey the same feeling to the patient as nostalgic memory**.
 * pg. 137-8. "Such stimulations would instantly call forth intensely vivid hallucinations of tunes, people, scenes, which would be experienced, lived, as compellingly real, in spite of the prosaic atmosphere of the operating room, and could be described to those present in fascinating detail . . . such epileptic hallucinations or dreams . . . are never phantasies: they are always memories, and memories of the most precise and vivid kind, accompanied by the emotions which accompanied the original experience . . . the total stream of consciousness was preserved in the brain, and, as such, could always be evoked or called forth, whether by the ordinary needs and circumstances of life, or by the extraordinary circumstances of an epileptic or electrical stimulation."


 * Sacks believes that the memories are recalled purposefully by the brain, although he cannot eliminate their neurological origin.**
 * pg. 143. " . . . I cannot help thinking that if one has to have seizures, this man . . . manged to have the right seizures at the right time. In Mrs. O'C.'s case the nostalgic need was more chronic and profound . . . 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."


 * Sacks closes making a common point: the brain is both an organ, but it also the locus of identity. When the brain is damaged, it cannot just be repaired neurologically or physiologically, but identity, meaning, and narrative must be reconstructed.**
 * pg. 148-9. "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 reconstiution (if possible) demands a double approach . . . "

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 * 16. INCONTINENT NOSTALGIA**


 * This chapter deals with another type of reminiscence: the type that is "incontinent" or uncontrolled, whether induced chemically (like L-dopa) or by a neurological or physical event: the memories that have been repressed or hiding, suddenly bubble up in a rush.**
 * pg. 151. "Forced reminiscence -- usually associated with a sense of //deja vu//, and . . . '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 . . . 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 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 simply 'repressed' during her illness, and then 'depressed' in response to L-Dopa . . . 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**


 * Unlike the first two case studies in this section, which deal with audio hallucinations, this one is a visual hallucination. A young girl with a brain tumor begins to have visions of her home village in India. Like the other hallucinations, they are precipitated by seizures -- grand mal seizures in this case, but she seems to lie in a peaceful, dream-like state. Sacks provides the basic details:**
 * pg. 153-5. "The original seizures were //grand mal// convulsions, and these she continued to have on occasion. Her new one had a different character altogether. She would not lose consciousness, but she wold look (and feel) 'dreamy'; and it was easy to ascertain (and confirm by EEG) that she was now having frequent temporal-lobe seizures . . . 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 Bhagawandi 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.' . . . Once, just once, I said, 'Bhagawandi, what is happening?' 'I am dying,' she answered. 'I am going back where I cam from -- you might call it my return.'"


 * Sacks tries to rule out other causes of the hallucinations, favoring the notion that the mind knows what the person needs and provides the images that will take care of the person.**
 * pg. 154-55. ". . . 'steroid psychois', so -called, is often excited and disorganized, wehreas Bhagawwhandi was lways lucid, peaceful and calm. Could they be, in the Freudian sense, phantasies or dream? 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 phatasmagoria of sorts, yet the phantasms were clearly all memories. They occurred side by side with normal awareness and consciousness . . . they were not 'over-cathetcted', or changed 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."


 * 18. THE DOG BENEATH THE SKIN**


 * This case study looks at a rarer type of hallucinations -- olfactory. This case describes the case of a person who, after experimenting with hallucinogenic drugs, begins to smell like a dog, with an overly sensitive smell sense. The sense of smell is easy to overlook. We all think we can easily live without this sense; we do not think of it as being deaf or blind. However, it is critically important to memory. Some people think that the sense of smell becomes sublimated over our development to give way to other senses that become dominant, such as sight and taste.**


 * Sacks' colleague describes the revelation of a heightened sense of smell. Imagine what a dream simply of smells would be. Think about your pet dog and how it leads with its nose and how it reacts to the smell of food or its master.**
 * pg. 156. "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 sensation, enhanced as they were, paled before smell.' And with allt his there went a sort of trembling, eager emotion, and a strange nostalgia, as of a lost world, half forgotten, half recalled."


 * However, the heightened sense of smell did not last, but the memory of the smells remained. Smells often activate memories. We know the smell of our own bed (because we sweat into it and it takes on our own scent) and know it immediately from a hotel bed. We can pick the scent of individuals off their clothes (ever wear someone's varsity jacket?). In addition, the most common ethnic epithet, shared by just about everyone about someone else, is that they smell. Sacks' colleague marvels over the vividness of the smells he remembers from his time "as a dog."**
 * pg.157-8. "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 too. I see now what we give up in being civilised and human. We need the other -- the "primitive" -- as well.' Sixteen years have passed -- and study days, amphetamine days, are long over. There has never been any recurrence of anything remotely similar . . . 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!'"


 * In the postscript, Sacks discusses the case of an individual who had lost their sense of scent. What is key is the sense of unexpected loss.**
 * pg. 159. "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 gorund 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."


 * 19. MURDER**


 * This case deals with an individual who killed a woman while on PCP and other hallucinogenic drugs. He sincerely did not have any memory of the murder, until a head injury brought back the memory in full vivid detail. Both the repression and the de-repression of the memory indicate the neurological elements of memory. Sacks describes the patient after the memory of the murder came back.**
 * pg. 162. "He sustained a severe head injury. . . he started to recover. And now, at this point, the 'nightmares' began. The returning, the re-dawning, of conscious 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 God!' 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 'hypermnesis' -- a breakthrough of genuine, veridical, terrifyingly heightened memories?"


 * 20. THE VISIONS OF HILDEGARD**

This is a case of a picture is worth a thousand words. Because Hildegard von Bingen illustrated her visions, we can infer several elements about the cause of her hallucinations. Sacks concludes that her visions were caused by migraines due to the plethora of symbols in the visions such as fortifications and scotomas that are consistent with the visual effects of migraines.