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 institutionalised, 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 psychomotor excitement with increased libido. This period was marked by nostalgia, joyful identification with a youthful self, and uncontrollable upsurge of remote sexual 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, ‘smutty’ 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. Nobody 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 associated with a sense of déjà 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 Passage 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 circumscribed, 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 massive 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 obviously ‘over-cathected’, or charged 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.
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?’