Orrin Devinsky, a former student of Geschwind's, has been a pioneer himself in the investigation of temporal lobe epilepsy and the great range of neuropsychiatric experiences which may be a.s.sociated with it-autoscopy, out-of-body experiences, deja vu and jamais vu, hyperfamiliarity, and ecstatic states during seizures, as well as personality changes between seizures. He and his colleagues have been able to perform clinical and video EEG monitoring in patients as they are having ecstatic-religious seizures, and thus to observe the precise coinciding of their "theophanies" with seizure activity in temporal lobe seizure foci (nearly always these are right-sided).9

Such revelations may take different forms; Devinsky has told me of one woman who, following a head injury, started to have brief episodes of deja vu and a strange, indescribable smell. After a cl.u.s.ter of these complex partial seizures, she entered an exalted state in which G.o.d, with the form and voice of an angel, told her to run for Congress. Though she had never been religious or political before, she acted on G.o.d's words at once.10

On occasion, ecstatic hallucinations can be dangerous, although this is very rare. Devinsky and his colleague George Lai described how one of their patients had a seizure-related vision in which "he saw Christ and heard a voice that commanded him to kill his wife and then himself. He proceeded to act upon the hallucinations," killing his wife and then stabbing himself. This patient ceased to have seizures after the seizure focus in his right temporal lobe was removed.

Such epileptic hallucinations bear a considerable resemblance to the command hallucinations of psychosis, even though the epileptic patient may have no psychiatric history. It takes a strong (and skeptical) person to resist such hallucinations and to refuse them either credence or obedience, especially if they have a revelatory or epiphanic quality and seem to point to a special-and perhaps exalted-destiny.

As William James observed, an acute and pa.s.sionate religious conviction in a single person can sway thousands of people. The life of Joan of Arc exemplified this. People have puzzled for nearly six hundred years as to how a farmer's daughter with no formal education could have found such a sense of mission and succeeded in getting thousands of others to aid her in an attempt to drive the English out of France. The early hypotheses of divine (or diabolic) inspiration have given way to medical ones, with psychiatric diagnoses vying with neurological ones. Much evidence is available from the transcripts of her trial (and her "rehabilitation" twenty-five years later) and from the recollections of contemporaries. None of these is conclusive, but they do suggest, at least, that Joan of Arc may have had temporal lobe epilepsy with ecstatic auras.

Joan experienced visions and voices from the age of thirteen. These came in discrete episodes lasting seconds or minutes at most. She was very frightened by the first visitation, but later she derived great joy and an explicit sense of mission from her visions. The episodes were sometimes precipitated by the sounds of church bells. Joan described her first "visitations":

I was thirteen when I had a Voice from G.o.d for my help and guidance. The first time that I heard this Voice, I was very much frightened; it was mid-day, in the summer, in my father's garden ... I heard this Voice to my right, towards the Church; rarely do I hear it without its being accompanied also by a light. This light comes from the same side as the Voice. Generally it is a great light.... When I heard it for the third time, I recognized that it was the Voice of an Angel. This voice has always guarded me well, and I have always understood it; it instructed me to be good and to go often to Church; it told me it was necessary for me to come into France ... it said to me two or three times a week: "You must go into France." ... It said to me: "Go, raise the siege which is being made before the City of Orleans. Go!" ... and I replied that I was but a poor girl, who knew nothing of riding or fighting.... There is never a day when I do not hear this Voice; and I have much need of it.

Many other aspects of Joan's putative seizures, as well as evidence of her clarity, her reasonableness, and her modesty, were explored in a 1991 article by the neurologists Elizabeth Foote-Smith and Lydia Bayne. While they present a very plausible case, other neurologists disagree, and one cannot hope to see the matter definitively resolved. The evidence is soft, as it must be for all historical cases.

Ecstatic or religious or mystical seizures occur in only a small number of those who have temporal lobe epilepsy. Is this because there is something special-a preexisting disposition to religion or metaphysical belief-in these particular people? Or is it because the seizure stimulates particular parts of the brain that serve to mediate religious feeling?11 Both, of course, could be the case. And yet quite skeptical people, indifferent to religion, not given to religious belief, may-to their own astonishment-have a religious experience during a seizure.

Kenneth Dewhurst and A. W. Beard, in a 1970 paper, provided several examples of this. One related to a bus conductor who had an ecstatic seizure while collecting fares:

He was suddenly overcome with a feeling of bliss. He felt he was literally in Heaven. He collected the fares correctly, telling his pa.s.sengers at the same time how pleased he was to be in Heaven.... He remained in this state of exaltation, hearing divine and angelic voices, for two days. Afterwards he was able to recall these experiences and he continued to believe in their validity.... During the next two years, there was no change in his personality; he did not express any peculiar notions but remained religious.... Three years later, following three seizures on three successive days, he became elated again. He stated that his mind had "cleared." ... During this episode he lost his faith.

He now no longer believed in heaven and h.e.l.l, in an afterlife, or in the divinity of Christ. This second conversion-to atheism-carried the same excitement and revelatory quality as the original religious conversion. (Geschwind, in a 1974 lecture subsequently published in 2009, noted that patients with temporal lobe epilepsy might have multiple religious conversions and described one of his own patients as "a girl in her twenties who is now on her fifth religion.")

Ecstatic seizures shake one's foundations of belief, one's world picture, even if one has previously been wholly indifferent to any thought of the transcendent or supernatural. And the universality of fervent mystical and religious feelings-a sense of the holy-in every culture suggests that there may indeed be a biological basis for them; they may, like aesthetic feelings, be part of our human heritage. To speak of a biological basis and biological precursors of religious emotion-and even, as ecstatic seizures suggest, a very specific neural basis, in the temporal lobes and their connections-is only to speak of natural causes. It says nothing of the value, the meaning, the "function" of such emotions, or of the narratives and beliefs we may construct on their basis.

1. When Hippocrates wrote "On the Sacred Disease," he was bowing to the then-popular notion of epilepsy's divine origin, but he dismisses this in his opening sentence: "The disease called sacred ... appears to me no more sacred than other diseases, but has a natural cause from which it originates, like other affections."

2. Beginning in 1861, when he was twenty-four, Hughlings Jackson published many major papers-on epilepsy, aphasia, and other subjects, as well as what he called "evolution and dissolution in the nervous system." A selection of these, filling two large volumes, was published in 1931, twenty years after his death. In his later years, Jackson published a series of twenty-one short, gemlike papers in the Lancet under the t.i.tle Neurological Fragments. These were collected and published in book form in 1925.

3. David Ferrier, a contemporary of Gowers's, moved to London in 1870, where he was mentored by Hughlings Jackson (Ferrier became a great experimental neurologist in his own right-he was the first to use electrical stimulation to map the monkey's brain). One of Ferrier's epileptic patients had a remarkable synesthetic aura, in which she would experience "a smell like that of green thunder." (This is quoted by Macdonald Critchley in his 1939 paper on visual and auditory hallucinations.)

4. Hughlings Jackson described such seizures in 1875 and thought they might originate from a structure in the brain located beneath the olfactory cortex, the uncinate gyrus. In 1898 Jackson and W. S. Colman were able to confirm this by autopsy in Dr. Z., a patient who had died of an overdose of chloral hydrate. (More recently, David C. Taylor and Susan M. Marsh have recounted the fascinating history of Dr. Z., an eminent physician named Arthur Thomas Myers whose brother, F. W. H. Myers, had founded the Society for Psychical Research.)

5. In the 1946 film A Matter of Life and Death (called Stairway to Heaven in the United States), David Niven's character, a pilot, has complex epileptic visions that are always preceded by an olfactory hallucination (the smell of burnt onions) and a musical one (a recurrent theme of six notes). Diane Friedman has written a fascinating book about this, indicating how meticulous the director, Michael Powell, was in consulting neurologists about the forms of epileptic hallucinations.

6. Penfield was a great physiologist as well as a neurosurgeon, and in the process of searching for epileptic foci, he was able to map most of the basic functions of the living human brain. He showed, for example, exactly where sensations and movements of specific body parts were represented in the cerebral cortex-his sensory and motor homunculi are iconic. Like Weir Mitch.e.l.l, Penfield was an engaging writer, and after he and Herbert Jasper published their magnum opus, Epilepsy and the Functional Anatomy of the Human Brain, in 1958, he continued to write about the brain, as well as writing novels and biographies, until his death at eighty-six.

7. For Gowers and his contemporaries in the early twentieth century, memories were imprints in the brain (as for Socrates they were a.n.a.logous to impressions made in soft wax)-imprints that could be activated by the act of recollection. It was not until the crucial studies of Frederic Bartlett at Cambridge in the 1920s and 1930s that this cla.s.sical view could be disputed. Whereas Ebbinghaus and other early investigators had studied rote memory-how many digits could be remembered, for instance-Bartlett presented his subjects with pictures or stories and then questioned and requestioned them over a period of months. Their accounts of what they had seen or heard were somewhat different (and sometimes quite transformed) on each re-remembering. These experiments convinced Bartlett to think in terms not of a static thing called "memory," but rather a dynamic process of "remembering." He wrote:

Remembering is not the re-excitation of innumerable fixed, lifeless and fragmentary traces. It is an imaginative reconstruction, or construction, built out of the relation of our att.i.tude towards a whole active ma.s.s of organized past reactions or experience.... It is thus hardly ever really exact.

8. Penfield sometimes used the term "flashback" for experiential hallucinations. The term is also used in quite different contexts, as in post-traumatic flashbacks, where there are recurrent hallucinatory replayings of traumatic events.

The term "flashback" is also used for a sudden, transient reexperiencing of a drug effect-suddenly feeling, for example, the effects of LSD, even though one has not taken it for months.

9. One such patient, who had very little in the way of religious interests as an adult, had his first religious seizure at a picnic, as Devinsky described to me: "His friends observed at first that he stared, became pale, and was unresponsive. Then suddenly, he began to run in circles for two or three minutes yelling, 'I am free! I am free!... I am Jesus! I am Jesus!' "

The patient later had a similar seizure which was recorded on video EEG, and, just before the seizure, Devinsky noted, the patient was slow to respond and disoriented regarding time and place:

When asked if there was anything wrong, he replied: "nothing is wrong, I am doing well ... I am very happy" and when asked whether he knew where he was, he replied with a smile and a surprised look: "Of course I know. I am in heaven right now;... I am fine."

He remained in this state for ten minutes, then went on to a generalized seizure. Later, he remembered his ecstatic aura "as if it were a vivid and happy dream" from which he had now awoken, but he had no memory of the questions put to him during the aura.

10. She ran as a Republican in a district that had been Democratic for a very long time, and lost by only a narrow margin. Whenever she appeared in public during her campaign, she said that G.o.d had told her to run, and this apparently persuaded thousands of people to vote for her, despite her manifest lack of political experience or skills.

11. The evidence here has been discussed in a number of books, including Kevin Nelson's The Spiritual Doorway in the Brain: A Neurologist's Search for the G.o.d Experience. It is also the theme of a novel, Lying Awake, by Mark Salzman; the protagonist is a nun who has ecstatic seizures in which she communes with G.o.d. Her seizures, it turns out, are caused by a tumor in her temporal lobe, and it must be removed before it enlarges and kills her. But will its removal also remove her portal to heaven, preventing her from ever communing with G.o.d again?

9

Bisected: Hallucinations in the Half-Field

One does not see with the eyes; one sees with the brain, which has dozens of different systems for a.n.a.lyzing the input from the eyes. In the primary visual cortex, located in the occipital lobes, at the back of the brain, there are point-to-point mappings of the retina onto the cortex, and it is here that light, shape, orientation, and location in the visual field are represented. Impulses from the eyes take a circuitous route to the cerebral cortex, some of them crossing to the opposite side of the brain as they do so, so that the left half of the visual field of each eye goes to the right occipital cortex, and vice versa. If, therefore, one occipital lobe is damaged (as by a stroke, for example), there will be blindness or impaired vision in the opposite half of the visual field-a hemianopia.

Besides the impairment or loss of vision to one side, there may be positive symptoms, too-hallucinations in the blind or purblind area. About 10 percent of patients with sudden hemianopia get such hallucinations-and immediately recognize them to be hallucinations.

In contrast to the relatively brief and stereotyped hallucinations of migraine or epilepsy, the hallucinations of hemianopia may continue for days or weeks on end; and, far from being fixed or uniform in format, they tend to be ever changing. Here, one might envisage not a small knot of irritable cells discharging paroxysmally, as in an attack of migraine or epilepsy, but a large area of the brain-whole fields of neurons-in a state of chronic hyperactivity, out of control and misbehaving because of the lessening of forces that normally control or organize them. The mechanism here thus resembles that of Charles Bonnet syndrome.

While such notions were implicit in Hughlings Jackson's vision of the nervous system as having hierarchically ordered levels (the higher levels controlling the lower ones, and lower ones starting to behave independently, even anarchically, if released from control by damage at the higher levels), the idea of "release" hallucinations was made explicit by L. Jolyon West in his 1962 book Hallucinations. A decade later, David G. Cogan, an ophthalmologist, published an influential paper that included short, vivid histories of fifteen patients. Some of them had damage to their eyes, some had damage to their optic nerves or tracts, some had occipital lobe lesions, some had temporal lobe lesions, and some had lesions in the thalamus or the midbrain. Lesions in any of these different places, it seemed, could break the normal network of controls and lead to a release of complex visual hallucinations.

Ellen O. was a young woman who came to see me in 2006, about a year after surgery for a vascular malformation in her right occipital lobe. The procedure was a fairly simple one, sealing off the swollen vessels of the malformation. As her doctors had warned her, she had some visual problems following the procedure: a blurring of vision to the left side, as well as some agnosia and alexia-difficulties recognizing people and printed words (English words looked like "Dutch," she said). These difficulties prevented her from driving for six weeks and interfered with her reading and enjoyment of television, but they were transient. She also had visual seizures in the first weeks after surgery. These took the form of simple visual hallucinations, flashes of light and color to the left that lasted a few seconds. The seizures came several times a day at first but had practically ceased by the time she returned to work. She was not too concerned about them, for her doctors had warned her that she might experience such aftereffects.

What they had not warned her about was that she might develop complex hallucinations later. The first of these, about six weeks after her surgery, was of a huge flower, occupying most of the left half of her vision. This had been stimulated, she thought, by seeing an actual flower in bright, dazzling sunlight; it seemed to burn itself into her brain, and the vision of it persisted in the left half of her visual field, "like an afterimage"-but an afterimage that lasted not for a few seconds but for an entire week. The following weekend, after her brother visited, she saw his face-or, rather, part of his profile, just one eye and cheek-for several days.1

Then she moved from abnormalities of perception-seeing things that were actually there, with perseveration or distortion-to hallucinations, seeing things that were not there. Visions of people's faces (including, at times, her own) became a frequent sort of hallucination. But the faces Ellen saw were "abnormal, grotesque, exaggerated," often just a profile with the teeth or perhaps one eye hugely magnified, completely out of scale with the rest of the features. At other times she saw figures with "simplified" faces, expressions, or postures-"like sketches or cartoons." Then Ellen started to hallucinate Kermit the Frog, the Sesame Street puppet, many times a day. "Why Kermit?" she asked. "He means nothing to me."

Most of Ellen's hallucinations were flat and still, like photographs or caricatures, though sometimes an expression would change. Kermit the Frog sometimes looked sad, sometimes happy, occasionally angry, though she could not connect his expressions with any of her own moods. Silent, motionless, ever changing, these hallucinations were almost continuous throughout her waking hours ("They are 24/7," she said). They did not occlude her vision but were superimposed like transparencies over the left half of her visual field. "They have been getting smaller lately," she told me. "Kermit the Frog is tiny now. He used to occupy most of the left half, and now he's down to a little fraction of it." Ellen wondered whether she would have these hallucinations for the rest of her life. I said that I thought their diminution a very good sign; perhaps one day Kermit would be too small to see at all.

What was going on in her brain? she asked me. Why, above all, was she getting these odd and sometimes nightmarish hallucinations of grotesque faces? From what depths did they come? Surely it was not normal to imagine such things. Was she becoming psychotic, going mad?

I told her that the impairment of vision on one side following her surgery had probably led to heightened activity in parts of the brain higher up in the visual pathway, in the temporal lobes, where figures and faces are recognized, and perhaps in the parietal lobes, too; and that this heightened, at times uncontrolled, activity was causing her complex hallucinations and also the extraordinary persistence of vision, the palinopsia, she was experiencing. The particular hallucinations which so horrified her-of deformed and dismembered faces or faces with exaggerated, monstrous eyes or teeth-were, in fact, typical of abnormal activity in an area of the temporal lobes called the superior temporal sulcus. They were neurological faces, not psychotic ones.

Ellen wrote to me periodically with updates, and six years after our initial visit, she wrote: "I would not say that I am entirely recovered from my visual problems; more that I am living more harmoniously with them. My hallucinations are much smaller, but they are still there. Mostly I see the colorful orb all the time, but it no longer distracts me as much."