Everything in Its Place

by Oliver Sacks

  Clinical Tales

  Cold Storage

  In 1957, when I was a medical student under Richard Asher, I encountered his patient “Uncle Toby” and was fascinated by this strange meeting of fact and fable. Dr. Asher sometimes referred to it as a “Rip van Winkle case.” The story often came to my mind, vividly, when my own postencephalitic patients were “awakened” in 1969, and it has unconsciously haunted me for years.

  Dr. Asher had been on a house call to see a sick child. As he was discussing her treatment with the family, he noticed a silent, motionless figure in a corner.

  “Who’s that?” he asked.

  “That’s Uncle Toby—he’s hardly moved in seven years.”

  Uncle Toby had become an undemanding fixture in the house. His slowing down was so gradual at first that the family didn’t notice; but then, when it became more profound, it was—rather extraordinarily—just accepted by the family. He was fed and watered daily, turned, sometimes toileted. He was really no trouble; he was part of the furniture. Most people never noticed him, still, silent in the corner. He was not regarded as ill; he had just come to a stop.

  Dr. Asher spoke to this waxlike figure. There was no answer, no response. He put out his hand to take the pulse and encountered a hand cold to the touch, almost as cold as that of a corpse. But there was a faint, slow pulse: Uncle Toby was alive, suspended, apparently, in some strange icy stupor.

  Discussion with the family was odd and disquieting. They showed remarkably little concern for Uncle Toby, and yet, manifestly, they were caring and decent. Evidently, as sometimes happens with an insidious and insensible change, they had accommodated to it as it had happened. But when Dr. Asher spoke to them, and suggested that Uncle Toby be brought into the hospital, they agreed.

  And so Uncle Toby was admitted to the hospital, to a specially equipped metabolic care unit, which is where I encountered him. His temperature could not be measured by an ordinary clinical thermometer, so a special one, reserved for hypothermics, was fetched; it registered sixty-eight degrees Fahrenheit. Uncle Toby’s temperature was thirty degrees below normal. A suspicion was formed, immediately tested and confirmed: Uncle Toby had virtually no thyroid function, and his metabolic rate was reduced almost to zero. With scarcely any thyroid function, any metabolic stimulator or “fire,” he had sunk into the depths of a hypothyroid (or myxedema) coma: alive but not alive; in abeyance, in cold storage.

  It was clear what to do—it was a simple medical problem: we had only to give him a thyroid hormone, thyroxine, and he would come to. But this warming up, this refiring of metabolism, would have to be done very cautiously and slowly; his functions and his organs had accommodated to his hypometabolism. If his metabolism was stimulated too quickly, he might have cardiac or other complications. So slowly, very slowly, we started him on thyroxine, and very slowly he started to warm up…

  A week passed. There was nothing to see, though Uncle Toby’s temperature was now seventy-two degrees. It was only in the third week, with his body temperature now well over eighty degrees, that he began to move…and talk. His voice was exceedingly low, slow, and hoarse—like a phonograph record croaking round at a single revolution per minute. (Some of this croakiness was due to myxedema of the vocal cords.) His limbs, too, had been stiff and swollen with edema, but grew lither and more limber now with physiotherapy and use. After a month, though still cool, and slow in speech and motion, Uncle Toby had clearly “awakened,” and he evinced animation, awareness, and concern.

  “What’s happening?” he asked. “Why am I in hospital? Am I ill?” We countered by asking him what he had been feeling. “Sort of cool, sort of lazy, slowed down, you know.”

  “But Mr. Oakins,” we said—we called him “Uncle Toby” only among ourselves—“what happened in between feeling cool, feeling slow, and finding yourself here?”

  “Nothing much,” he answered. “Nothing I know of. I suppose I must have been really ill, passed out, and the family brought me here.”

  “And how long had you passed out for?” we asked, in a neutral tone.

  “How long? A day or two—couldn’t be any longer—my family would be sure to bring me in.”

  He scanned our faces curiously, intently.

  “There’s nothing more to this, nothing unusual?”

  “Nothing,” we reassured him, and made a quick exit.

  * * *

  —

  MR. OAKINS, it seemed, unless we misunderstood him, had no sense that any time had elapsed, certainly not any great length of time. He had felt queer; now he was better—simple, nothing to it. Could this be what he actually believed?

  We were given vivid confirmation of this later that same day, when the staff nurse came to us in some agitation. “He’s quite lively now,” she reported. “He has a real need to talk—he’s talking about his mates, his work. About Attlee, the king’s illness, the ‘new’ Health Service, and so on. He’s no idea what’s going on now. He seems to think it’s 1950.”

  Uncle Toby, as a person, a conscious entity, had slowed down and stopped, as if he had gone into a coma. He had been “away,” “absent,” for an unconscionable time. Not in a sleep, not in a trance, but deeply submerged. And now that he had emerged, those years were a blank. It was not amnesia, not “disorientation”; his higher cerebral functions, his mind, had been “out” for seven years.

  How would he react to the knowledge that he had lost seven years, and that much of what was exciting, important, dear to him had passed irretrievably away? That he himself was no longer contemporary but a piece of the past, an anachronism, a fossil strangely preserved?

  Rightly or wrongly, we decided on a policy of evasion (and not only evasion but frank deceit). This was planned, of course, as a temporary measure, until he had the physical and mental strength to come to terms with things, to withstand a profound shock.

  The medical staff made no efforts, therefore, to disabuse him of his belief that it was 1950. We watched ourselves closely, lest we give anything away; we forbade any careless talk; and we inundated him with newspapers and periodicals from 1950. He read these avidly, though he expressed surprise, on occasion, at our ignorance of the “news,” as well as the disgraceful, yellowed, dilapidated condition of the papers.

  And now—six weeks had passed—his temperature was almost normal. He looked fit and well, and considerably younger than his years.

  At this point came the final irony. He started to cough, to spit blood; he had a massive hemoptysis. Chest X-rays showed a mass in his chest, and bronchoscopy revealed a highly malignant, rapidly proliferating oat-cell carcinoma.

  We managed to find chest films, routine X-rays, from 1950, and there we saw, small and overlooked at the time, the cancer he now had. Such highly malignant, fulminating carcinomas are apt to grow rapidly and be fatal in months—yet he had had this for seven years. It seemed evident that the cancer, like the rest of him, had been arrested, in cold storage. Now that he was warmed up, the cancer raged furiously, and Mr. Oakins expired, in a fit of coughing, a matter of days later.

  His family let him sink into coldness, which saved his life; we warmed him up, and, in consequence, he died.

  Neurological Dreams

  However dreams are to be interpreted—the Egyptians saw them as prophecies and portents; Freud as hallucinatory wish fulfillments; Francis Crick and Graeme Mitchison as “reverse learning” designed to remove overloads of “neural garbage” from the brain—it is clear that they may also contain, directly or distortedly, reflections of current states of body and mind.

  Thus it is scarcely surprising that neurological disorders—in the brain itself or in its sensory or autonomic input—can alter dreaming in striking and specific ways. Every practicing neurologist must be aware of this, and yet we rarely question patients about their dreams. There is virtually nothing on this subject in the medical literature, but I think such question
ing can be an important part of the neurological examination, can assist in diagnosis, and can show how sensitive a barometer dreaming may be of neurological health and disease.

  I first encountered this many years ago while working in a migraine clinic. It became clear that there was not only a general correlation between the incidence of very intense dreams or nightmares and visual migraine auras but also, not infrequently, an entering of migraine aura phenomena into the dreams. Patients might dream of phosphenes or zigzags, of expanding scotomas or of colors or contours that wax and then fade. Their dreams might contain visual field defects or hemianopia or, more rarely, the phenomena of “mosaic” or “cinematic” vision.

  The neurological phenomena in such cases may appear direct and raw, intruding into the otherwise normal unfolding of a dream. But they may also combine with the dream, fuse with and be modified by its images and symbols. Thus the phosphenes of migraine are often dreamed of as fireworks displays, and one patient of mine sometimes embedded his nocturnal migraine auras in dreams of a nuclear explosion. He would first see a dazzling fireball with a typically migrainous, iridescent zigzag margin, coruscating as it grew, until it was replaced by a blind area (or scotoma) with the dream round its edge. At this point he would usually wake with a fading scotoma, intense nausea, and an incipient headache.

  If there are lesions in the occipital, or visual, cortex, patients may observe specific visual deficits in their dreams. Mr. I., the colorblind painter I described in An Anthropologist on Mars, had a central achromatopsia, and he remarked that he no longer dreamed in color. People with certain types of prestriate lesions may, while dreaming, be unable to recognize faces, a condition called prosopagnosia. And one patient of mine, with an angioma in his occipital lobe, knew that if his dreams were suddenly suffused with a red color, if they “turned red,” he was in for a seizure. If the damage to the occipital cortex is diffuse enough, visual imagery may vanish completely from dreams. I have encountered this, on occasion, as a presenting symptom of Alzheimer’s disease.

  * * *

  —

  ANOTHER PATIENT, a man who had focal sensory and motor seizures, dreamed that he was in court, being prosecuted by Freud, who kept banging on his head with a gavel as the charges were being read. But the blows, strangely, were felt in his left arm, and he awoke to find it numb and convulsing, in a typical focal seizure.

  The most common neurological or “physical” dreams are of pain, discomfort, hunger, or thirst, at once manifest and yet camouflaged in the scenery of the dream. Thus one patient, newly casted after a leg operation, dreamed that a heavy man had stepped, with agonizing effect, on his left foot. Politely at first, then with increasing urgency, he asked the man to move, and when his appeals were unheeded, he tried to shift the man bodily. His efforts were completely useless, and now, in his dream, he realized why: the man was made of compacted neutrons—neutronium—and weighed six trillion tons, as much as the earth. He made one last, frenzied attempt to move the immovable, then woke up with an intense viselike pain in his foot, which had become ischemic from the pressure of the new cast.

  Patients may sometimes dream of the onset of a disease before it physically manifests. A woman whom I described in Awakenings was stricken with acute encephalitis lethargica in 1926 and had a night of grotesque and terrifying dreams about one central theme: she dreamed she was imprisoned in an inaccessible castle, but the castle had the form and shape of herself. She dreamed of enchantments, bewitchments, entrancements; she dreamed she had become a living sentient statue of stone; she dreamed the world had come to a stop; she dreamed she had fallen into a sleep so deep that nothing could wake her; she dreamed of a death that was different from death. Her family had difficulty waking her the next morning, and when she awoke there was intense consternation: overnight, she had become parkinsonian and catatonic.

  Christina, a woman I described in The Man Who Mistook His Wife for a Hat, was admitted to the hospital before surgery to remove her gallbladder. She was placed on antibiotics for microbial prophylaxis; since she was an otherwise healthy young woman, no complications were expected. The night before surgery, though, she had a disturbing dream of peculiar intensity. She was swaying wildly, in the dream, very unsteady on her feet, could hardly feel the ground beneath her, could hardly feel anything in her hands, found them flailing to and fro, kept dropping whatever she picked up.

  She was distressed by this dream (“I never had one like it,” she said. “I can’t get it out of my mind”)—so distressed that we requested an opinion from the psychiatrist. “Preoperative anxiety,” he said. “Quite natural, we see it all the time.” But within a few hours the dream had become a reality, as the patient became incapacitated by an acute sensory neuropathy—she had lost the sense of proprioception and could no longer tell where her limbs were without looking. One must assume in such a case that the disease was already affecting her neural function and that the unconscious mind, the dreaming mind, was more sensitive to this than the waking mind. Such premonitory or precursory dreams may sometimes be happy in content and in outcome, too. Patients with multiple sclerosis may dream of remissions a few hours before they occur, and patients recovering from strokes or neurological injuries may have striking dreams of improvement before such improvement is objectively manifest. Here again, the dreaming mind may be a more sensitive indicator of neural function than examination with a reflex hammer and a pin.

  Some dreams seem to be more than precursory. One striking personal example (which I described at length in A Leg to Stand On) stays in my mind. While recovering from a leg injury, I had been told it was time to advance from using two crutches to just one. I tried this twice, and both times fell flat on my face. I could not consciously think how to do it. Then I fell asleep and had a dream in which I reached out my right hand, grabbed the crutch that hung over my head, tucked it under my right arm, and set off with perfect confidence and ease down the corridor. Waking from the dream, I reached out my right hand, grabbed the crutch that hung over the bed, and set off with perfect confidence and ease down the corridor.

  This, it seemed to me, was not merely premonitory but a dream that actually did something, a dream that solved the very motor-neural problem the brain was confronted with, achieving this in the form of a psychic enactment or rehearsal or trial: a dream, in short, that was an act of learning.

  Disturbances in body image from limb or spinal injuries almost always enter dreams, at least when they are acute, before any “accommodation” has been made. With my own deafferenting leg injury, I had reiterative dreams of a dead or absent limb. Within a few weeks, however, such dreams tend to cease, as there occurs a revision or “healing” of body image in the cortex. (Such changes in cortical mapping have been demonstrated in Michael Merzenich’s experiments with monkeys.) Phantom limbs, by contrast, perhaps because of continuing neural excitation in the stump, intrude themselves into dreams (as into waking consciousness) very persistently, though gradually telescoping and growing fainter with the passage of years.

  The phenomena of parkinsonism may also enter dreams. Ed W., a man of acute introspective ability, felt that the first expression of parkinsonism in him was a change in the style of his dreams. He would dream that he could move only in slow motion, or that he was “frozen,” or that he was rushing and could not stop. He would dream that space and time themselves had changed, kept “switching scales,” and had become chaotic and problematic. Gradually, over the ensuing months, these looking-glass dreams came true, and his bradykinesia and festination became obvious to others. But the symptoms had first presented themselves in his dreams.*

  Alterations in dreaming are often the first sign of response to L-dopa in patients with ordinary Parkinson’s disease, as well as in those with postencephalitic parkinsonism. Dreaming typically becomes more vivid and more emotionally charged (many patients remark that they are dreaming, suddenly, in brilliant color). Sometimes the realness
of these dreams is so extraordinary that they cannot be forgotten or thrown off after waking.

  Excessive dreaming of this sort, excessive both in sensory vividness and in activation of unconscious psychic content—dreaming akin, in some ways, to hallucinosis—is common in fever or delirium, as a reaction to many drugs (opiates, cocaine, amphetamines, and so on), and in states of drug withdrawal or REM rebound. A similar unbridled oneirism may occur at the start of some psychoses, where an initial mad or manic dream, like the rumbling of a volcano, may be the first intimation of the eruption to come.

  Dreaming, for Freud, was the “royal road” to the unconscious. Dreaming, for the physician, may not be a royal road, but it is a byway to unexpected diagnoses and discoveries, and to unexpected insights about how one’s patients are doing. It is a byway full of fascination, and should not be neglected.

  * Another man I know, one who has Tourette’s syndrome, felt that he frequently had “Touretty” dreams—dreams of a particularly wild and exuberant kind, full of unexpectednesses, accelerations, and sudden tangents. This changed when he was put on a tranquilizer, haloperidol; he then reported that his dreams had been reduced to “straight wish fulfillment, with none of the elaboration, the extravagances of Tourette’s.”