An uncommon medical event happened to me ten years ago, which both left me with a medical problem, and presented an unusual opportunity. I could say it left me with an illness, but after a decade of experience with it, I hesitate to call it that. I have learned to live with and know it, and I regard my life since that occurrence as living in a ringside seat at a physiological process ordinarily covered and obscured in normal life.
I am speaking of what I can call musical hallucinosis, involuntary music in the head. I hear music, at first I would say all the time. Now I qualify that. At the beginning, I described it as there always; now I say "whenever I listen". Is it right to say it is there all the time? It is there whenever I wish to check on it. Or whenever I am not attending to, or focused upon, or thinking about, anything else. Does that make it always?
I did say "whenever I wish to check". Ordinarily, there is some interval between wishing to do something and doing it. But there is no intervening time here. The music is there the moment I have the thought of listening for it, before I can start an active process of listening. It seems as if it is there waiting. Where is it? Somewhere in the distance, usually over my right shoulder. About half a mile away.
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The summer of 1995 was an exciting time. I am 92 now, and I must admit that my adult life has been exciting much of the time (this does not mean without the range of emotions, lows as well as highs). In July of that year, I was scheduled to address the International Psychoanalytic Congress at its opening session in San Francisco, the second such meeting in the United States in the history of the IPA. The theme of the Congress, and the subject of my talk and a panel discussion of which it was a part, was to be on "Psychic Reality".
Psychoanalysis, in the century of Freud, had established that ideas, feelings, fantasies, thoughts, i.e., the potpourri of mental products, are as ubiquitous, and as much determinants of human health and happiness, or illness and malfunctioning, as the somatic, the physical world of the body. A dream, or fantasy, or an affect, anxiety or worry, or a feeling of guilt, or shame or depression, is a reality, an entity, although a psychic one, as much as a thing or action or event in the external "real world". Humans are affected, and guided, equally by both. Psychic reality and external reality share their effects on the subject who navigates between them.
I was steeped in thinking about this, and aiming to formulate these ideas effectively.
There was a complication lurking, however, which I had decided to put aside for a time. About a month before the opening of the Congress, I thought I felt an increase in dyspnea on exertion, a little too much shortness of breath on walking fast, or straining, or at a sudden lurching forward faster than usual. I experienced this on several occasions, as when going up a staircase from a parking lot rather rapidly to get to a concert at the Music Center on time. It was not severe but definite, and I felt it as a possible signal. To explain why, it was exactly such a subjective experience that had led to my heart operation some 15 years previously. Nothing more than a slight increase of normal shortness of breath that I felt while playing tennis, which I was not sure of but which alerted me, and led to my having my first stress test, at age 67, in 1980. The cardiologist stopped the test abruptly from what he saw on the electrocardiogram, and directed me to an angiogram. A few days later, I was in open-heart surgery. Five obstructed coronary vessels were treated by by-passes. There were no complications; the result was excellent; I was playing tennis again in a little over two weeks.
Back to the summer of 1995. On a visit to San Francisco to visit my daughter a few weeks before the International meeting, I had mentioned my concerns to a cardiologist friend who was her neighbor. He ventured the thought that another angiogram was in order. I agreed, but feeling this was not an immediate threat, I decided to do this after the Congress, not without trepidation, but taking that chance. A day or two after the meeting, while still in the Bay area, I went for the test in my friend's office. Before presenting me with the unexpected findings, the angiographer-friend informed me that what he would tell me would sound alarming but that I should not be alarmed. The result showed four or five vessels almost completely obstructed, the same as had preceded my first operation. I chose to return to Los Angeles, to enter surgery again there. This was with a different cardiac surgeon than before, in UCLA, where I myself taught. The previous procedure had been at Cedars-Sinai, with a surgeon who had since retired.
It is an aftermath of that second surgical experience that I wish to report, partly in connection with the subject of the two interwoven realities of human life, the physical and the psychological, and, as I came to experience them in a unique way, to other interesting theoretical issues of the functioning of the brain and the mind to which they led. The clinical data, in which I am now both the observer and the observed, besides being rare in its content, presents is an unusual opportunity.
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Although it can be a difficult if not agonizing decision to submit to this surgical procedure, the choice was made easier for me by the test results. Almost complete blockage of all of my previous bypassed vessels left me with little to ponder. I had been living asymptomatically mostly on collaterals.
It is of interest that less than a decade before my previous operation in 1980, an analytic patient of mine had undergone the first bypass operation I had known or probably heard of. I remember my countertransference at that time, my horror at the thought, my admiration of the patient, and my doubts about his judgment. I remember thinking, as debates raged about the new procedure, that certainly the new vessels would undergo the same pathological processes as the now-afflicted ones, so what was the use. I had no scientific information, just my reasoning.
As universal as trauma is, and as much as all people are affected by it, each person processes similar events in his individual ways. What had been considered shell shock in the first World War, presumably due to petechial hemorrhages in the brain, became battle fatigue, then war neuroses, during World War 2. A colleague psychiatrist who was in the German Army during World War 1, Ernst Simmel, wrote at that early time that neuroses occurring at the front, however much related to battle and present danger, reflected each soldier's individual history, his original childhood fears and terrors.
So it was with my patient and his surgery. As I had the opportunity to listen on the couch to his pre and post-operative associations, there was a remarkable confluence of traumatic dreams or fantasies as he emerged from this early instance of heart surgery, with his preoperative dreams and associations stemming from his life history. His father, a chicken dealer, would take his son with him to the "shoichet". The patient's memories of his childhood were steeped in pictures of father and the schoichet cutting off the heads of chickens, removing their insides, and of blood running down the table (reminiscent of the childhood of the artist, Chaim Soutine). He remembered being caught by his father as he was trying to look up his mother's dress and his fear of having everything cut off. His picture of his mother was that of a lioness calmly 'chomping' everything within sight without concern for the mayhem around her.
Materially successful and accomplished, this man was nevertheless a case of the most classical and overt castration anxiety one could see clinically. This type of psychopathology--based on one of the two basic anxieties that course through life, the other being separation anxiety-- is overlooked and considered not to be present in the therapeutic ambience of today, a theoretical orientation with which I take issue. The patient's dreams, fantasies, and free associations during the years of analysis were ruminatively about castration fear, seeking out, coming close to, and then avoiding danger, and of aggressive retaliation.
In his immediate postoperative state, in what was neither a dream nor fantasy, but more akin to a prolonged series of hypnopompic hallucinations during a long period of waking up, this 50-plus- year-old man went through vivid images of lying on a concrete slab, while someone opened his heart and collected the blood in large pails and buckets at the side of the table. He remembered these nightmarish anxieties during periods of revival of consciousness in three postoperative weeks that he was semi comatose. In the period that followed, he had a recurring 'fantasy-dream'--i.e., a fantasy while he was awake or semi-awake and a dream when he fell asleep--in which there was a fusion between the recent surgical experience and the chicken 'operations' of the past. In this fantasy-dream, the patient is on a slab which he described as a combination of an operating table and the counter on which the chickens were cut. Around the table and looking down at him are the surgical team, his father and the schoichet, his wife who looks grim and sneering like his mother, and his children, his sons and daughters and their spouses, all of them in collusion. The patient is being opened up and disemboweled: a combination of a human, a chicken, and a piece of cattle. The table is tilted, the organs are thrown into a barrel nearby, and the blood drips down into a pail at the low end of the table. Periodically the pail is taken away, the blood emptied, and the pail brought back ready for more. Everything is being chopped off, his head, his limbs, his genitals. It is a continuous nightmare. The terror, which is indescribable, is followed by periods of depression and giving up. Occasionally there are moments of rest.
There were other fantasies, dreams, and associations--of being in a mortuary and smelling the embalming fluid, of riding in a railroad hospital car with bodies sticking out, of being inside an open hearth furnace. While he was said to be near death at the operation, the patient recovered fairly well, and lived 6-7 years, at which time he died of coronary disease.
As this type of surgery grew common, I came to know other patients' accounts, and reports of colleagues and friends, of their hallucinatory experiences around the procedure. Each had his own version, linked to his life history. One colleague told how he was consumed with his relationship to his father, and went over countless incidents in which he now regretted his actions. Another kept experiencing visual and cognitive scenes of his being poor, homeless, and wandering about. Less than a decade after my patient's account, I was to be on the same gurney, filtering the same experience through my own mind and life history.
It was now the second time around. I saw my new heart surgeon only once, about a week before the operation, for probably no more than 15-20 minutes, during which time he put a stethoscope to my heart, and asked if I had any questions. I had none at hand. He then performed his necessary routine task of informing me that there were of course risks. There could be infection, a stroke, even death. But these were a small percentage, I looked like a good case, although this was my second bypass, and there was the matter of my age (this time just in front of 82). When I demonstrated my reaction to his input, he asked if I still wanted to go ahead, I could cancel if I wished. I felt his approach unfeeling, even cruel, but this was easily overruled by my awe and need. I said I would go ahead. I then had to sign that I knew one possible outcome was not to survive.
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I entered the hospital on a Sunday night for a Monday operation with an ease that surprised me as well as my family. I did not have any horrible memories of the former procedure 15 years before, after the angiogram that showed similar obstruction. I had been anaesthetized quite easily and woke up to cheery reports. All had gone well; I probably had long repressed the anxiety and discomfort. The intervening years had conditioned me favorably to this miracle of science.
In the corridor the next morning from my bed to the operating room, I was being given an intravenous, which had been started in my room. That was the last I remembered preoperatively. My next memory was a cognitive, kinesthetic, not so much affective one. I had made one request of the surgeon, and repeated this to the anesthetist who interviewed me in the hospital room the night before the surgery, the same as I had emphasized to the doctor who was to give me anesthesia 15 years before. I gagged easily; in fact, since I had had a number of throat-spasm choking episodes on certain occasions over many years, would he be sure to remove the intubation tube from my throat before I awoke. The first time around, the reply was "of course", and I thankfully remembered that I had no breathing obstruction when I awoke in the intensive care unit. This time, the surgeon had said that could be arranged, but when the time came, the anesthetist obviously heard it for the first time, and said it would depend, he could not promise, they had to first be sure that my breathing was good enough.
My first memory now, before coming to, was a sensation of what I thought was a large metal cross, almost the width of my chest, being pulled out of my chest, ripping everything in its way. I wondered how it would get past my shoulders, yet it did not seem like a big deal. There was no panic or even significant anxiety. I thought I was in the corridor coming from the O.R. at that time, that they were fulfilling my request to get a tube out before I awoke. There was no pain or wrench, and it quickly faded out. When I came to in the I.C.U., I had no experience of them removing the tube, although my throat felt raw. Later, my son told me that the tube did come out in the I.C.U., and that I kept grimacing and clearing my throat for a while afterward, and had a hoarse voice for some time. I had misinterpreted that procedure as taking place in the corridor, the last place I remembered before I woke up. In my analytic writing, I had long felt that claustrophobia was a converging point of all anxieties, and that the claustrum, the space that was closing in, was the symbol for choking, no air to breathe, the ultimate somatic background for anxiety.
In the I.C.U., as I became aware, the care was astonishing, constant, devoted, intimate. A succession of beautiful nurses, crisply dressed, attended closely, their faces next to mine, clapping my back vigorously, even too much, encouraging, cajoling. All the nurses but one were close, and helping; one in particular came back often to see me. One was stiff, kept away, and I felt caused me at one point to be catheterized unnecessarily, with which I had future trouble. The "good nurse" appeared off her shift to counter this. This was all a mixture of fantasy and reality, plenty of each. My wife felt the same, even later writing a commendation for Wendy, the good one. In the I.C.U., I was partially, I think even a good deal clear, though with many distortions as well. I felt I was extremely well treated, like a V.I.P. Again this was built on some perceptions and a piece of knowledge.
Probably only shortly after I came to, two visitors appeared from behind a curtain, and smilingly greeted me, a man and a well-dressed woman. I looked in amazement. I had by the merest chance just recently looked at the latest issue of a magazine "U.C.L.A. Medicine". I recognized one face before me from a full-page photo on the cover of the new Dean of the Medical School, whom I had never met. I figured how he was there. One of my patients, who knew him, and who had learned of my operation, phoned him and told him to check up on me and tell him how I was. This was what had actually happened. I said to him now, with a wave of bravado, "I know you. You are the Dean. I just read your interview". He seemed more than pleased. The two, he and his administrative assistant, could not have been more solicitous. To his inquiry "How are you?", I remember-I thought standing up and coming close to him but I am sure from a lying down position-that I gave him a slow and deliberate answer, "The brutality and sadism of this operation has never been acknowledged nor spoken about". To his startle, I added "But it is of course a miracle, of science and of your staff".
I recovered nicely, more or less like the first go-around. A few days of plenty of physical discomfort and periods of confusion, then up and around for a few days, and I was ready to leave the hospital before a week was up.
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No one escapes a clouded state after open-heart bypass surgery. To me it is a controlled experiment of how the trauma of that much body assault affects anyone's mind who lives on a heart-lung machine while his heart is worked on disconnected. Or an equivalent accident. The nature of the cloudy state is always a combination of the extent of the physical insult and the contents of the process through which the individual filters it. In a book I wrote on "My Life in Theory", the last line was, "Life is a combination of what has to be, and what we make of that".
What one makes of such a physical disruption has two sides, the desire for safety, and the avoidance of pain. Trauma, the experience of unabsorbable unpleasure, brings out both streams of motives, to minimize the hurt and to bring satisfaction instead. The particular confusion I was bathed in during the days after waking brought out both. My mental state was a combination of the external onslaught and attempts to overcome. After a day or so in the I.C.U., I graduated to the next upward phase, to a hospital room with intensive and constant monitoring. Here my cloudy and confused state was more conscious, becoming evident to me in stages.
On one hand, there were a plethora of cognitive hallucinations and distortions of perception, made up mostly of objects or equipment around the room. Where there was furniture, lamps, pictures hanging, I saw sculptures of all types, mostly grotesque and unreal, but all pointing with various linkages to known experiences or events. I saw an Egyptian goddess and other personages (we had been to Egypt in the recent past). I saw a small, round, grinning head of Judge Lance Ito between a plastic sheet and a blanket (I was an avid watcher of the O.J. trial, had been studying it psychoanalytically, had a strong personal feeling about the proceedings, and felt the Judge had been inappropriately immune from criticism). I saw gnomes and pygmies and various unknown creatures, if not scary at least puzzling, but mostly images that I could in some strained way connect to experiences or events. On looking closer, mostly at grimacing, leering, threatening figures, I also became able to see the underlying mundane material from which I was constructing these images. I would then be uncertain as to which set of thinking was concrete, real, the one I lived by.
At the same time, my overall mental state leaned toward omnipotence and megalomania, was expansive in the service of denial. As I was wheeled into my new room from the ICU, I imagined, or looked for a message pinned to the wall, like a banner with which my children had greeted me when I had returned home over 30 years ago, after I had been elected President of the American Psychoanalytic Association. While there was no such item, I began to see writing on the wall. I then saw that the script had no border, and wondered how it could be a note, then that the writing stretched out and covered the entire wall, from floor to ceiling. Then I saw that it was continuous, stretching and spreading to the adjacent walls and the entire ceiling. Then I saw that the handwritten message was moving, scrolling over the whole room, counterclockwise. I tried to make out the words, but could not. I attributed this to my limited vision at this distance. But here and there among the words I made out my name, in somewhat bolder print, so I continued to believe - or hope - there was a letter of welcome and greeting and congratulations to me (from the surgeon or our common friend, the Dean). What it all spelled was victory, achievement, mission accomplished, the operation was a complete success--a fantasy, hope, facts I hardly yet knew.
I was confused, and in some conflict over my judgment, but gradually I was disillusioned. There was a large horizontal tag on the door which I read in the same vein, as some personal greeting or announcement, but with increasing doubts. When I pointed to it and asked the nurse what it said, she told me it was the room number. Over the next days, there was moving script on the television screen, first when it was on, then also when it was off. When the script moved off the screen past the borders of the television set on to the walls and over the ceiling, I began to know it was coming from me, not an external message. But I still continued to watch it. After a while, I could detach from it. Over time, it was no longer there. I live and work in Los Angeles, the place of scripts and movies. And I write a lot. That's how my delirious, unchecked mind put all this together.
These were cognitive, with their accompanying affective, distortions. I early knew they would go away. A kind of manic humor helped; I remember when a doctor asked me matter of factly "How do you feel?" I said something like, "Great, never felt better in my life". And an erotic haze, transferred to the nurses in the new situation, along with fantasies that they were returning it. Gradually, as my dancing visual images and their accompanying fanciful activities diminished, I began to attend more to my physical discomforts, which were not minor. This second time around, my legs were butchered, as they had cut and searched deeper into the secondary venous system of both legs for good-enough vessels to use for transplantation. The scars, in the fronts and backs of both legs, and alongside one knee, were mostly held together this time not by sutures but by quite thick metal clamps. They looked to me like one would clip strips of leather together hurriedly or temporarily - and felt as such. With the mental state slightly better, or at least clearer, the physical effects came more to be suffered.
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In the I.C.U. on the first or second day, I began to be aware that I was hearing and listening to singing outside my hospital room. At first it was automatic and I was mostly not aware that I was listening, but gradually I began to attend to it more and more. Where I first thought it was sporadic, I soon became conscious of the fact that whenever I listened actively, it was there. My immediate thought was that there is a Rabbi in a school out there, and he seems pretty busy. The voice was sonorous, deep, slow, a chanting, "dovening" (praying) rhythm, which I began to interpret as a head Rabbi teaching others to become and sing like Rabbis. At first my thoughts were fleeting. When I still heard it at night, and even very late as I was trying to sleep, and remembered that this singing had been continuous even during the day, I thought the Rabbi and his students were certainly conscientious and persistent. They must also work late.
I remembered that there was a religious building, a Hillel Foundation, out there on the college campus, in the general area of the University hospital. That must be it. The sounds are coming from there; they certainly waft up far to reach my window, but so it is. I also heard the singing in early morning, as soon as I awakened. The first songs were funereal, somber, serious, elegiac, music for a memorial. At one point, I told myself, although humorously, they must be for me, that I must be dead. They were hymnal; they reminded me of a song around my Bar-Mitzvah. I had sung in a choir on that occasion, a rare and never repeated activity. I also sang a solo then, which I uncharacterically always remembered. This was a song that came back now. "tvi-ee-ee-ee-ee-anu, el ha-a kaadshechaka, b'motsvoiya, b'motsvoiya..." Not infrequently, I had hummed or even jokingly sang this solo, along with other songs and tunes of my boyhood days, to my children, making up Hebrew words after the few that I remembered. The chanting also brought to mind my father in the synagogue, whom we would accompany on the Holy days. The whole atmosphere brought back my pre-adolescent days, my solemn (yet light-hearted) and attentive father, his devotion and his values.
When I once asked my wife and my visiting children about that school out there, they looked at me funny. My son, an artist and musicologist, whose acute perceptions I have always admired, smiled, and said "There's no singing or music outside". That gave me a start. Another incident that made me pause and wonder was when I called my daughter's attention to the singing "in that Hillel Foundation across the street", and she replied, "Dad, your surgeon's name is Hillel". Hillel Laks, famous for heart transplants in children, had performed the operation. As a psychoanalyst, a signal and query flashed across my brain. But I quickly put it aside.
The music continued through the hospital stay. But the songs changed. I did not realize until much later that they followed, or rather may have indicated, changed moods. The tunes became more active and movement-oriented, such as what I came to recognize as "The Chattanooga Choo-Choo, and "The Atchison, Topeka and the Santa Fe", to me marching songs of going places. I heard them and sang along with them, in good and improving spirits. I did not think about or question them but went along. I hummed and quietly sang and swayed with the music. Along with them, I felt, coincidentally, I was rapidly getting better.
I left the hospital in about a week, about the same time as after the first operation 14 years before. In the day or two before I left, the music was becoming really lively. I thought nothing about the fact that one of the songs shortly before I left was, when the words came to me, "When Johnny comes marching home again, Hurrah! Hurrah!" the next words, which I looked up much later, were "We'll give him a hearty welcome then/Hurrah! Hurrah!/The men will cheer and the boys will shout/The ladies they will all turn out/And we'll all feel gay,/When Johnny comes marching home."
I accepted the song, was happy, and sang along with it. But it still came from the outside. It was not until the day I left that the thought hit me. As I was being driven home, I mused for a moment that I would miss the music. But when finally, far enough away for me to be sure, we came to the hills of Brentwood, where I lived, and I suddenly realized that the songs had come with me, and were still there, way off over my right shoulder, I was struck, and wondered, half afraid, "My God, it's me. They are coming from me. They are in me somewhere. I am singing".
The involuntary and automatic music became a symptom, the most enduring after-effect of the entire experience (besides, I hope, the results of the by-passed coronary vessels). It has stayed with me from then on, and has become a fixture of my life. I hear a tune all the time, or whenever I listen, mostly without words, which I can supply if I know them. Usually, if I want the words, I have to struggle to get them, even if I have just been with that tune recently. While the music continues to sound as if outside me, I have become familiar with a new dimension of me. The songs come on their own, and I listen. I am listening to me.
There was, and still is, a kind of humor, perhaps a grim humor, connected with all of this. This is not to say that it has been without anxiety. There has also been panic, which I am happy to say was short-lived. At the beginning I had to wonder: Will I ever get over it? Will I be able to stand it? Will it over-rule everything, all thinking; will it consume me, or my mind, like some invisible, ethereal, mental cancer? What's going to happen? Will I have to live with this forever? Will I be able to?"
I can bring the tunes on in the most effortless way. I have only to begin to "think" about one bar of the music, or one word of a lyric, and the total work rushes in and gets going. It is like the most sensitive remote control; I don't have to press a button, I just think it and it is instantly there; remarkable. It then stays as long as "it" wishes--or as long as I let it. The latter, not to allow it to continue, is not that easy. It is like a radio with only a turn-on key. I can turn it on in a split second, but there is no "off" button. The power to turn it off is the problem. At first it was quite impossible. At the beginning, more than once I went all night without sleeping, when I was trying hard and actively to master it. I would say that now I have acquired more "control". I can cut the attention, and concern, anxiety and even beginning panic. I can get into it in the early stages, and "turn my mind" to other things, and thus get rid of the pest. By not thinking about it. But try not thinking about something. I have sort of learned how. It is only the next morning that I know I succeeded.
I said the sound comes from high up and behind me. It also comes from way down. There are elements of both, up from a canyon, yet also blown down from above. In the first dirge period, the deep voice came from God, or a Moses figure, with a long, white beard. I saw an ad about solar energy, and the figure of Zeus or God blowing down from above; this confirmed it for me. A deep hollow voice about a half mile away, in the canyon behind my home, drums on and on. I want it not to. It seems to me that the only way I will be able to live with it is to regard it as a good neighbor. But perhaps not without some merriment, even joy. The God-like level changed when the moods toned down.