by Oliver Sacks
Tactile hallucinations, too, can come with fever or delirium, as Johnny M. described: “When I had high fevers as a child I had very weird tactile hallucinations … a nurse’s fingers would switch from being beautiful smooth porcelain to rough, brittle-feeling twigs or my bed sheets would go from luscious satin to drenched, heavy blankets.”
Fevers are perhaps the commonest cause of delirium, but there may be a less obvious metabolic or toxic cause, as recently happened with a physician friend of mine, Isabelle R. She had had two months of increasing weakness and occasional confusion; finally she became unresponsive and was taken to the hospital, where she had a florid delirium, with hallucinations and delusions. She was convinced that a secret laboratory was hidden behind a picture on the wall of her hospital room—and that I was supervising a series of experiments on her. She was found to have extremely high levels of calcium and vitamin D (she had been taking large doses of these for her osteoporosis), and as soon as these toxic levels dropped, her delirium ceased, and she returned to normal.
Delirium is classically associated with alcohol toxicity or withdrawal. Emil Kraepelin, in his great 1904 Lectures on Clinical Psychiatry, included the case history of an innkeeper who developed delirium tremens from drinking six or seven liters of wine a day. He became restless and immersed in a dreamlike state in which, Kraepelin wrote,
particular real perceptions … are mingled with numerous very vivid false perceptions, especially of sight and hearing. As in a dream, a whole series of the most strange and remarkable events take place with occasional sudden changes of scene.… Given the vivid hallucinations of sight, the restlessness, the strong tremors, and the smell of alcohol, we have all the essential features of the clinical condition called delirium tremens.
The innkeeper had some delusions, too, perhaps produced by his hallucinations:
We learn, by questioning him, that he is going to be executed by electricity, and also that he will be shot. “The picture is not clearly painted,” he says; “every moment someone stands now here, now there, waiting for me with a revolver. When I open my eyes they vanish.” He says that a stinking fluid has been injected into his head and both his toes, which causes the pictures [he] takes for reality.… He looks eagerly at the window, where he sees houses and trees vanishing and reappearing. With slight pressure on his eyes, he sees first sparks, then a hare, a picture, a washstand-set, a half-moon, and a human head, first dully and then in colours.
While deliria such as the innkeeper’s may be incoherent, without any theme or connecting thread, other deliria convey the sense of a journey, or a play, or a movie, giving coherence and meaning to the hallucinations. Anne M. had such an experience after she had run a high temperature for several days. She first saw patterns whenever she closed her eyes to go to sleep; she described them as resembling Escher drawings in their sophistication and symmetry:
The initial drawings were geometric but then evolved into monsters and other rather unpleasant creatures.… The drawings were not in color. I was not enjoying this at all because I wanted to sleep. Once a drawing was complete it was copied so all four or six or eight quadrants of my visual field would be full of these identical pictures.
These drawings were succeeded by richly colored images that reminded her of Brueghel paintings. Increasingly, these too became full of monsters and subdivided themselves, polyopically, into a cluster of identical mini-Brueghels.
Then came a more radical change. Anne found herself in the back of “a 1950s Chinese bus on a propaganda tour of Chinese Christian churches.” She recalls watching a movie on religious freedom in China projected onto the rear window of the bus. But the viewpoint kept changing—both the movie and the bus suddenly tilted to odd angles, and it was unclear, at one point, whether a church spire she saw was “real,” outside the bus, or part of the movie. Her strange journey occupied the greater part of a feverish and insomniac night.
Anne’s hallucinations appeared only when she closed her eyes and would vanish as soon as she opened them.2 But other deliria may produce hallucinations that seem to be present in the real environment, seen with the eyes open.
In 1996, I was visiting Brazil when I started to have elaborate narrative dreams with extremely brilliant colors and an almost lithographic quality, which seemed to go on all night, every night. I had gastroenteritis with some fever, and I assumed that my strange dreams were a consequence of this, compounded, perhaps, by the excitement of traveling along the Amazon. I thought these delirious dreams would come to an end when I got over the fever and returned to New York. But, if anything, they increased and became more intense than ever. They had something of the character of a Jane Austen novel, or perhaps a Masterpiece Theatre version of one, unfolding in a leisurely way. These visions were very detailed, with all the characters dressed, behaving, and talking as they might in Sense and Sensibility. (This astonished me—for I have never had much social sense or sensibility, and my taste in novels inclines more to Dickens than Austen.) I would get up at intervals during the night, dab cold water on my face, empty my bladder, or make a cup of tea, but as soon as I returned to bed and closed my eyes again I was in my Jane Austen world. The dream had moved on while I was up, and when I rejoined it, it was as if the narrative had continued in my absence. A period of time had passed, events had transpired, some characters had disappeared or died, and other new ones were now on stage. These dreams, or deliria, or hallucinations, whatever they were, came every night, interfering with normal sleep, and I became increasingly exhausted from sleep deprivation. I would tell my analyst about these “dreams,” which I remembered in great detail, unlike normal dreams. He said, “What’s going on? You have produced more dreams in the past two weeks than in the previous twenty years. Are you on something?”
I said no—but then I remembered that I had been put on weekly doses of the antimalarial drug Lariam before my trip to the Amazon, and that I was supposed to take two or three further doses after my return.
I looked up the drug in the Physician’s Desk Reference—it mentioned excessively vivid or colorful dreams, nightmares, hallucinations, and psychoses as side effects, but with an incidence of less than 1 percent. When I contacted my friend Kevin Cahill, an expert in tropical medicine, he said that he would put the incidence of excessively vivid, colorful dreams closer to 30 percent—the full-blown hallucinations or psychoses were considerably rarer. I asked him how long the dreams would go on. A month or more, he said, because Lariam has a very long half-life and would take that long to be eliminated from the body. My nineteenth-century dreams gradually faded, though they took their time doing so.
Richard Howard, the poet, was thrown into a delirium for several days following back surgery. The day after the operation, lying in his hospital bed and looking up, he saw small animals all around the edges of the ceiling. They were the size of mice but had heads like those of deer; they were vivid: solid, animal-colored, with the movements of living creatures. “I knew they were real,” he said, and he was astonished when his partner, arriving at the hospital, could not see them. This did not shake Richard’s conviction; he was simply puzzled as to why his partner, an artist, could be so blind (after all, he was the one who was usually so good at seeing things). The thought that he might be hallucinating did not enter Richard’s mind. He found the phenomenon remarkable (“I’m not accustomed to things like a frieze of deer heads on mouse bodies”), but he accepted them as real.
The next day, Richard, who teaches literature at a university, began seeing another remarkable sight, a “pageant of literature.” The physicians, nurses, and hospital staff had dressed up as literary figures from the nineteenth century, and they were rehearsing the pageant. He was very impressed by the quality of their work, although he understood that some other observers were more critical. The “actors” talked freely among themselves, and with Richard. The pageant, he could see, took place on several floors of the hospital simultaneously; the floors seemed transparent to him, so that he could wa
tch all the levels of the performance at once. The rehearsers wanted his opinion, and he told them he thought it very attractively and intelligently done, delightful. Telling me this story six years later, he smiled, saying that even recollecting it was a delight. “It was a very privileged time,” he said.
When real visitors came, the pageant would disappear, and Richard, alert and oriented, chatted with them in his usual way. But as soon as they left, the pageant recommenced. Richard is a man with an acute and critical mind, but his critical faculty, it seems, was in abeyance during his delirium, which lasted for three days, and was perhaps provoked by opiates or other drugs.
Richard is a great admirer of Henry James—and James, as it happens, also had a delirium, a terminal delirium, in December 1915, associated with pneumonia and a high fever. Fred Kaplan describes it in his biography of James:
He had entered another imaginative world, one connected to the beginning of his life as a writer, to the Napoleonic world that had been a lifelong metaphor for the power of art, for the empire of his own creation. He began to dictate notes for a new novel, “fragments of the book he imagines himself to be writing.” As if he were now writing a novel of which his own altered consciousness was the dramatic center, he dictated a vision of himself as Napoleon and his own family as the imperial Bonapartes.… William and Alice he grasped with his regent hand, addressing his “dear and most esteemed brother and sister.” To them, to whom he had granted countries, he now gave the responsibility of supervising the detailed plans he had created for “the decoration of certain apartments, here of the Louvre and Tuileries, which you will find addressed in detail to artists and workmen who take them in hand.” … He was himself the “imperial eagle.”
Taking down the dictation, Theodora [his secretary] felt it to be almost more than she could bear. “It is a heart-breaking thing to do, though, there is the extraordinary fact that his mind does retain the power to frame perfectly characteristic sentences.”
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.”
Sometimes 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.3 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.)
1. 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.”
2. 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.
3. 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 Orde
al 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.
11
On the Threshold of Sleep
In 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.
