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7/27/2019 Dr. Jose Delgado - Psychological Responses in the Human to Intracerebral Electrical Stimulation (1964)

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Psychological Responses in the Human

to Intracerebral Electrical Stimulation

GEORGE F. MAHL, Ph.D., ' ALBERT ROTHENBERG, M.D.,JOSE M. R. DELGADO, M.D., and HANNIBAL HAMLIN, M.D.

During interviews, intracerebral electrical stimulation of sharply localized areas inthe temporal lobe of a young woman with psychomotor epilepsy consistently pro-duced ego-alien ideational experiences similar to those observed by Penfield. Theresponses were associated with considerable anxiety and with evoked electricalseizure activity. The use of the interview as the observational situation and care-ful study of the interview tape-recordings made it possible to discover that thecontent of the ideational experiences was often a function of her prestimulation"mental content." This find ing led to an examination of Penfield's formulationsand to some alternative hypotheses about mechanisms that might be involved inpsychic responses to temporal-lobe stimulation

IHIS is a report of some observablepsychological effects of intracerebralstimulation in a patient with psychomo-tor epilepsy. Diagnostic study with theimplanted electrode technique devel-oped by Delgado- :t u provided the op-portunity to make these observations.

Our interest in responses to brainstimulation originated with Penfield's re-port20 ' 21 of perceptual and memorial re-sponses to openfield stimulation of thetemporal lobe in the human, and withKubie's general discussion lr> based partlyon Penfield's work. Othe rs had also

demonstrated, in animals, correlationsbetween functions of the frontotemporalregion and emotions17 :" as well as feed-

From the Departments of Psychiatry and ofPhysiology, Yale University School of Medi-

cine, New Haven, Conn.

Presented in part at the Annual Meeting ofth e American Psychosomatic Society, Rochester,

N . Y., April 1962.

Received for publication Jan. 21, 1964.

'Fe l low, Center for Advanced Study in theBehavioral Sciences, Stanford, Calif., duringperiod of study reported.

ing and sexual activity. Th e arousal offear, which could motivate learning, bystimulation of areas related to the fron-totemporal region had also been demon-strated.4' 5

In a previous paper14 we reported awide range of responses to frontotem-poral stimulation during interviews in aboy with psychomotor epilepsy. Percep-tual-cognitive changes, similar to thoseobserved by Penfield, varied from dis-crete sensory experiences to deja vu-likephenomena. Emotional effects rangedfrom stimulation-bound, friendly inter-action with the interviewer, to erotic

bodily sensations and direct verbaliza-tion of the wish to be a girl. The re-sponses seemed to be a function of thesite of stimulation within a given inter-view; some stimulation effects variedfrom interview to interview.

Questions arising from the precedinginvestigations guided the present study.Given the fact that a patient was beingstudied diagnostically with the implant-ed-electrode technique, which makes itpossible to observe stimulation effects in

337



338 INTRACEREBRAL ELECTRICAL STIMULATION

the relatively unrestricted interview situ-ation repeated over a number of days:

1. What, if any, perceptual, memorial,emotional, and behavioral events wouldresult from stimulation of the surfaceand deeper areas of the frontotemporalregion in this individual?

2. If such events did occur with stim-ulation would they be a function of

localization of stimulation?3. Would they be a function of elec-trical seizure activity?

4. Would the possible psychologicalresults of stimulation be codeterminedby the interview interaction? Would theybe constant or variable from interviewto interview?

The Patient

The subject was a 27-year-old womanof Italian extraction. She was a house-

wife who had been married 8 years andhad one child, a 5-year old daughter.Her general health had been good asidefrom a long history of periodic head-aches which she associated with "ner-vousness."

The patient had a history, however, ofapproximately 5% years of psychomotorseizures and petit mal-like spells. Shealso had had at least one grand malseizure. Although there was some indi-cation she might have had some seizuresearlier, the patient first became specific-

ally aware of "forgetting spells" aroundthe time of her only pregnancy. Shortlythereafter she began experiencing briefepisodes of "funny feelings" consistingof ill-defined gustatory or olfactory sen-sations combined with a feeling of anxi-ety and a sensation in her chest whichshe could only describe with a clutchingor gripping gesture of the hand. Theseepisodes gradually increased in frequen-cy. A year prior to the present study shehad two spontaneous seizures, with lossof consciousness for approximately 1-2min. Both seizures occurred dur ing her

menses and the second included tonicand clonic movem ents. At tha t point shewas hospitalized at Massachusetts Gen-eral Hospital for clinical studies. EE Grevealed higher voltage on the left, spik-ing and short runs of 4-6 c.p.s. primarilyin the left temporal and parietal regions.Some activity was also seen occasionallyon the right side in the same areas.

Hyperventilation increased the abnor-mality, especially on the left, and the re-sponse to photic stimulation was normal.The record was considered moderatelyabnormal with a preponderance in theleft temporal area. Left carotid arterio-gram was normal and pneumoencephal-ogram was unremarkable. On dischargefrom the hospital, the patient was placedon Dilantin sodium."

Although she experienced no majorepisodes involving loss of consciousnessor tonic-clonic movements during a 3-month period on Dilantin, her "funnyfeelings" continued at a frequency of 1-2 times a week. She was then started onMysoline.f Nev ertheless , these latterseizures became as frequent as twice aday by the time the present study oc-curred.

At that time the patient spontaneouslyreported that she had three separatetypes of seizures, involving:

1. The aura of an ill-defined taste orsmell, anxiety, and a sensation in herchest (When she experienced these"funny feelings," she often tried to de-

scribe them to herself. As she did soshe spelled out a word, letter by letter,"g-l-u-f")

2. All of the foregoing combined witha perceptual change in which the envi-ronment seemed dull and unfamiliar andshe could not read print on a page, to-gether with feeling acutely anxious andwanting to go home from wherever shewas

3. The aura of taste or smell, spelling

*Parke, Dav is & Company, Detroit, Mich.

+Ayprst Laboratories, New York, N. Y.

PSYCHOSOMATIC MEDICINE



MAHL ET AL . 339

of "g-l-u-f," and a "blank spell" whereinshe did not hear what people said

The patient also frequently experi-enced an urge to defecate and urinate,but it was not clear whether it accom-panied any particular type of seizure.Generally, she could not describe thetaste or smell, although on one occasionshe experienced a "gassy" smell. During

her brief "blank spells," she usually con-tinued whatever motor act she was per-forming, according to other observers.

Although relatively little personal his-tory is available, the patient appeared tobe of average intelligence, rather warm,and free of major psychiatric disorder.Qualities of somewhat excessive depend-ence on the interviewer, some seductive-ness, and a slight tendency to histrionicscombined with a marital sexual historybordering on frigidity led the investiga-tors to regard her as being mildly ormoderately hysterical in personality

structure. The role of her personality inthe somewhat confused picture of psy-chomotor symptoms described above re-mains indeterminate.

Procedure

Data Recording and Collection

The patient entered the hospital (a largestate mental institution where the investi-gation was conducted) on Sept. 29, 1955.Final preoperative evaluation includedmedical and psychological interviews and

EEG study with scalp electrodes. Medica-tion ceased upon admission and was with-held during the course of the investigation.

The patient was left-handed from birth.Because of the apparent left-sided pre-ponderance of the abnormality, the decisionwas made to implant two multilead elec-trodes and one surface electrode in the leftfrontotemporal region. This was done onSept. 30 through a burr hole with the pa-tient under local anesthesia.

The electrodes, pictured in Fig. 1, havebeen described in detail elsewhere.2':t Eachneedle is approximately 12 cm. long (50mm. being in the brain substance) and 0.5

VOL. XXVI, NO. 4, 1964

FIG. 1. Plate and needle electrodes.

mm. in diameter. The needle electrode con-tains seven leads which terminate at asmany points 8 mm. apart. The final leadterminates at the tip. Each plate electrode,made of polyethylene, is approximately 12cm. long and also contains seven leadswhich terminate 5 mm. apart along thelength of the p late. The leads of each elec-trode protrude externally to a socket.

Figure 2 indicates the location of the

electrodes. We succeeded in obtaininglateral, but not coronal X-rays. A crisis ofnausea and faintness in the patient devel-oped each time X-ray was attempted, pre-venting the taking of coronal X-rays. Theresult is that our ability to locate the elec-trode positions is impaired. Our opinion is,however, that (1) the plate was located onthe inferolateral part of the left frontal lobe,with Contact 1 at the pole; (2) the anteriorneedle (Ant. Ndl.) was located in the in-ferior part of the fronto-temporal region(The tip was curved and probably in theleft temporal pole.); and (3) the posteriorneedle (Post. Ndl.), starting in the middle



340 IN T R A C ER EB R A L EL EC T R IC A L ST IM U L A T ION

FIG. 2. Lateral X-ray showing electrodepositions in left frontotemporal area. Plateextends forward on surface of inferolateralpart of left frontal lobe. Tip of anteriorneedle is curved within pole of temporallobe. Posterior needle is directed towardmidline.

temporal convolution, was directed toward

the midline. (Contact 1 at the electrode tipwas probably close to the midline. Points 3and 4 were probably within the white mat-ter of the temporal lobe.*)

EEG recording was done continuouslythroughout the interviews to be described,and at other times as well. Bipolar record-ings, usually of adjacent pairs of electrodepoints, were made with an eight-channelGrass recorder, Mo del 111-13. Electrica lstimulations were applied through variouselectrode point pairs with a Grass stimula-tor (Model S-4, containing an isolation

"Recording and stimulation by means of the

implanted electrodes indicated definite abnor-

mality in the tip of the left temporal lobe.

Consequently, the anterior 5 cm. of this lobe

was resected on Oct. 18, 1955. Histological ex-

amination of the specimen revealed the needle

tracts. The subsequent medical history of this

patient was as fol lows: Medication with myso-

l ine was continued after the operation of Oct.

18 through 1956, and through a pregnancy in

1957. Medication was gradual ly decreased dur-

ing 1958 and by June 1961 the patient had

taken no medication for 2 years. At that tim e

she had occasional petit mal episodes lasting a

few seconds, with rare gustatory aura and

occasional difficulty in name-finding.

u n i t ) , set to deliver unidirectional pulses,0.5 msec, in duration, at a frequency of 100c.p.s. Th e stimulations lasted 5 sec. andranged from 5 to 10 v, 0.5-1.0 ma.

One of us (G.F.M.) participated in aseries of "unstructured" interviews with thepatient in order to provide a natural, spon-taneous flow of behavior which might re-flect effects of stimula tion. Th e intervie werattempted to engage in interaction with thepatient that was largely determined by her

needs , interests, affects and immediate ex-periences. Illustrative interview summariespresented later convey the general natureof the interviews.

Table 1 presents general informationabout the interviews. There were two pre-operative interviews for contrast with thesix posto perativ e interviews. Two of thelatter were without stimulation. Thus, theplan permitted contrasting the stimulationinterviews with both pre- and postoperative,nonstimulation interviews. The schedulealso allowed for some check on the role ofincreasing familiarity between the patientand the interviewer, or other progressive

changes over time, for one of the postopera-tive nonstimulation interviews preceded thestimulation interviews while the other fol-lowed them.

The stimulation schedules themselves areshown in Table 2. There are two importantfeatures about these schedules. The firstpertains to which electrode point pairs werestimu lated in the interview s. Stimulationsat all needle points and various plate pointswere done in Interviews 4, 5, and 6 in or-der to survey the stimulation effects. By theend of Interview 6, it appeared to the in-terviewer that plate stimulations were evok-

ing no psychological responses, in contrastto quite obvious results of the needle stimu-lations. Therefore, the schedule for Inter-view 7 called only for needle stimulations,and these at the higher level of the voltagerange used. Stimulations at Post. Ndl. 1-2were omitted in Interviews 6 and 7 becausethey had produced intense pain in the pa-tient's jaw and tong ue in Intervie ws 4 and 5.The second important feature of the sched-ule pertains to the temporal sequence ofthe stimulation sites. Within each interviewthe general plan was to stimulate each pairof points in a given sequence and again




MAHL £7- AL . 341

TABLE 1. GENERA L INFORMATION ON INTERVIEWS OF PATIE NT WITH

PSYCHOMOTOR EPILEPSY

Interview

No

1

2

3

4

5

6

7

8

Date

and time

9/29/559 P.M.

9/30/551 1 A.M.

P.M.

10/ 1/551 1 A.M.

10/ 1/55

4:30 P.M.

10/ 1/5510 P.M.

10/ 2/552 P.M.

10/ 2/554 P.M

10/ 2/55

7 P.M.

Duration {mm.)

64

58

61

102

80

65

60

40

No .

stimulation*

0

0

0

19

16

14

9

0

General conditions

Preop . s i t t i ng , normal lyclothed; recorded int.

Preop.; Pt. in bed, hospitalgarb; recorded int.

Electrode implant., localanesth.Postop.; Pt. in bed; EEG re-

cording, recorded int.

Postoperative; Pt. in bed;

EEG recording, Electricalstimulation, recorded int.

Same as Int. 4

Same as Int. 4

Same as Int. 4

Same as Int. 4 except nostim.

with that sequence inverted. Further, thesequence for Interviews 6 and 7 reversedthat for Interviews 4 and 5. The temporalcharacteristics of the schedules providesome control for sequential effects of stimu-lation or interview interaction that wouldprevent valid observation of stimulus locali-zation.

The interviewer knew the stimulationschedule for each interview—the points tobe stimulated, the sequence, and theplanned approximate times of stimulation.

He also could anticipate the exact momentof stimulation, for the coinvestigator (J.D.)administering the stimulations from the ad-jacent room signalled them by means of adim light placed out of sight of the patientbut visible to the interviewer. In our previ-ous study the interviewer did not knowwhen stimulations occurred, but a trainedpsychological observer was monitoring boththe interview and the administration ofstimuli. The observer was thus able to in-form the coinvestigator of any detrimentaleffects of particular stimulations and also tonote important effects of particular stimula-tions that indicated further stimulation at

VOL. XXVI. NO. 4 1964

those sites should be repeated. We feel thatthis procedure involving an "uncontami-nated" interviewer and an informed psycho-logical observer as a monitor is superior tothat using the informed interviewer. In thepresent study, however, we had no trainedobserver to fill the monitoring role. In ouropinion, it was not in the best interest ofthe patient or the research to have, in addi-tion, an uninformed interviewer.

The patient was told the general diag-nostic purpose of the electrode implanta-

tion and that both stimulation and record-ings would be done at times by means ofthe electrodes. She was also told that some-times stimulation produced reactions, feel-ings, and ideas and that sometimes it didnot. We did not tell the patient which werestimulation or nonstimulation interviews,nor the sites or times of stimulations.

The EEG recorders, stimulator, one taperecorder, and the members of the researchteam concerned mainly with neurophysio-logical factors (J.D., H.H.) were in an ob-servation room adjacent to the patient'sroom during the interviews. This tape re-corder recorded the interviews and signals




TABLE 2. STIMUL ATION SCHEDULES OF INTERVIEWS

Time of

Him.

15'30"

18'18"22'31"

25'50"

30-56"35'51"

40'58"48'25"53'32"57'12"60-43"

64'42"69-07"72'31"80-16"85'41"

93'42"98'35"

101'37"

8'13"11'47"15-41"

19'39"24'19"27'47"31-20"

35'13"39'52"44-03"47'34"54'37"58'33"

62'28"

Slim.No .

Electrode

point *

INTERVIEW 4

123456789

1011

1213141516171819

Ant. Ndl. 1-2Ant. Ndl. 1-2Ant. Ndl. 3-4Ant. Ndl. 3-4Ant. Ndl. 5-6Ant. Ndl. 5-6Post. Ndl. 1-2Post. Ndl. 3-4

Post. Ndl. 5-6Plate 3-5Plate 6-7

Plate 6-7Plate 3-5Post. Ndl. 5-6Post. Ndl. 3-4Post. Ndl. 1-2Ant. Ndl. 5-6Ant. Ndl. 3-4Ant. Ndl. 1-2

INTERVIEW 6

1

23456789

10111213

14

Plate 6-7Plate 3-5Post Ndl. 5-6Post. Ndl. 3-4Ant. Ndl. 5-6Ant. Ndl. 3-4Ant. Ndl. 1-2Ant. Ndl. 1-2Ant. Ndl. 3-4Ant. Ndl. 5-6Post. Ndl . 3-4Past. Ndl. 5-6Plate 3-5

Plate 6-7

Volt*

5105

10575555555555555

5555555555555

5

Time of

Him.

5'13"10'14"14-51"20-50"25'35"29'57"37'46"39'54"43'55"

48'05"51'46"55'19"59'48"68-09"72'27"76'47"

7'28"13'36"19-31"

28 '11"33-12"37'55"

42'57"47-40"53'30"

Stim.Ifo.

Electrode

point»

INTERVIEW 5

123456789

10111213141516

Ant. Ndl. 1-2Ant. Ndl. 3-4Ant. Ndl. 5-6Post. Nd l. 1-2Post. Ndl. 3-4Post. Ndl. 5-6Plate 3-4Plate 6-7Plate 5-6Plate 3-5Post Ndl. 5-6Post. Ndl. 3-4Post. Ndl. 1-2Ant. Ndl. 5-6Ant. Ndl. 3-4Ant. Ndl. 1-2

INTKRVIEVV 7

1

23456789

Post. Ndl. 5-6Post. Ndl. 3-4Ant. Ndl. 5-6Ant. Ndl. 3-4Ant. Ndl. 1-2Ant. Ndl. 1-2Ant. Ndl. 3-4Ant. Ndl. 5-6Post. Ndl. 3-4

Volts

1010

710

55

1010

1010

5

510

71010

77

101010101010

7

indicating the onset and termination of thestimulations. Th e latter could also be de-termined directly from EEG recordings. Asecond recorder taped the interviews but nosignals indicating stimulation. These pro-visions made it possible to study the inter-views repeatedly and to collate the exactmoment of stimulation, interview changes,and the EEG recordings.

Methods of Study

All interviews were transcribed. Th e

t imes, site, and voltage of each stimulationwere noted in the typescript. Two of usthen joined forces for the study of the inter-view recordings and typescripts, one (A.R.)entering the work at this point for the firstt ime, with no preconceptions as to theeffects of stimulation.

Working together, and using both therecordings and typescripts, we first studiedthe entire series of interviews several timesto identify possible stimulation effects. Atthis phase we were guided by the following:

1. Any perceptual, ideational, affective




MAHL ETAL 343

or other event that was not obviously ac-counted for by the interaction was to be re-garded as a possible response to stimulation.

2. This was especially so if the event oc-curred simultaneously with, or shortly after,stimulation.

This preliminary screening resulted in thefollowing potential response categories:

1. References to 12. Se ns at io ns ofhead pain coldness

2. Jaw sensations 13. Urination3. Tongue sensa- 14. G ra sp s inter-tions viewer

4. Eye sensations 15. Praying5. Skin sensations 16. Dizziness6. Olfactory sen- 17. Dissociated re-

sations sponse7. Respiratory sen- 18. Pressured

sations speech8. T hi rs t se ns a- 19. Extrinsic idea-

tions tional response*9. Hunger sensa- 20. Intrinsic idea-

tions tional response*10. Genital refer- 21 . Reduced inter-

ences action11. Se ns ati on s of 22 Increased man-

warmth ifest anxiety23. Defensiveness of report

We then carefully reexamined the stimu-lation interview records several times andtabulated, by stimulation sites, all the oc-currences of Categories 1-20, inclusive. Acategory was judged to be a possible re-sponse to the last stimulation that occurredand was tabulated only if both judgesagreed on its occurrence.

We again listened to the recordings ofthe stimulation interviews and independent-ly rated categories 21, 22, and 23 for theintervals following each stimulation, usingthree scales: For "Interaction," zero desig-nated no change, with reduced interactionprogressing from zero to —2 (markedly re-duced) and increased interaction progress-ing from zero to +2 (markedly increased)."Manifest Anxiety" and "Defensiveness"were rated from 1 (low) to 3 (high).

We determined the reliability and com-puted the means of the ratings by the twojudges for each stimulation interval. Themean ratings were then tabulated by stimu-lation sites.

*The meaning of these categories is clarified

under Results.

VOL. XXVI, NO. 4. 1964

The neurophysiologist independently ex-amined all EEG recordings and identifiedall seizure activity, its duration, its locus,and whether it was spontaneous or evokedby stimulation.

Results

Illustrative Interview Summaries

Summaries of the first, third, fourth,seventh, and eighth interviews are pre-sented below so as to give first a generalimpression of the interaction with thepatient before electrode implantation,after operation but without stimulation,during stimulation interviews, and final-ly, without stimulation but with otherconditions continuing unchanged.

Interview 1 (Preoperative, no EEGtracings, face to face, patient in streetclothes)Within the first few minutes, the pa-

tient begins asking about the forthcom-ing operation (i.e., electrode implanta-tion) and openly acknowledges heranxiety about it. When asked about herunderstanding of the procedure, shesays, Tin supposed to have these thingsput in and they're supposed to findwhere the difficulty is." She then asks aflood of detailed questions about theoperation and subsequent diagnosticstudy and frequently intersperses a ref-erence to the fact that she has had aheadache all day because she is so nerv-

ous about what is facing her.After the interviewer indicates that he

considers her anxiety natural, she relaxessomewhat and is able to give a fairlydetailed description of her characteristicseizure patter ns. She reveals tha t she hasbeen seizure-free for the 8 days immedi-ately preceding her entry into the hos-pital. Although the interviewer indicatesthat such a short seizure-free period hasno special significance, she becomes pre.occupied about this and wonders wheth-er her seizures could have been productsof her imagination. The interviewer re-




assures her that this is unlikely and shebecomes concerned with trying to findan explanation of her illness. In a be-mused, sometimes almost hopeful way,she asks whether her seizures could becaused by an allergy to chemicals shehandles at work. She wond ers, too,whether arising very early in the morn-ing to go to work or falling and hittingher head at age 17 could have producedthe condition.

Approximately halfway through the in-terview the patient reveals some concernabout being in a psychiatric hospital andthen asks the interviewer directly whathe thinks about her now that he hastalked with her. When the interviewerresponds noncommittally by talkingabout her clinical condition, there is achange in the patient's affect and thequality of her interaction which persistsmore or less throughout the remainder ofthe interview. First, there is a short

silence and a reduction in the patient'shigh level of participation and her spon-taneous verbal productions. The inter-viewer asks her what she is thinkingabout. Then , in a somewhat sad anddecidedly intimate way, she says thatshe is concerned about what the inter-viewer thinks of her and the fact that heseems to be staring at her. She labelsthis concern an "inferiority complex"and says that generally she feels thatpeople do not like her and talk abouther. She feels the interviewer believesthere is really something wrong with her.

There is more discussion of her seizurepatterns and the specifics of the opera-tive proce dure. Repea tedly, she asks forreassurance that she can be helped, thatshe will not have a convulsion during thetests (EEG recordings) and that heranxiety is normal. She tends to believethat she can't be helped and seems tohave a negative outlook. Finally, towardthe end of the interview, she becomesmanifestly tearful and reveals that sheis preoccupied with the idea that shemight die. She is reluctan t to hav e the

interview terminate and engages himwith a fresh series of questions at theend.

The most striking features of the in-terview are the patient's understandableanxiety, her openness in acknowledgingthe anxiety, and her attempts to handleher feelings by asking numerous ques-tions and trying to find an explanation

for her illness. She participates activelyin the discussion and is fairly intimate,almost seductive, in her relationship tothe interviewer at several points.

Interview 3 (First postoperative day;EEG tracings from intracerebral elec-trodes; no stimulations; patient in bed)The interview begins with a detailed

discussion of the operative experience.The patient minimizes being disturbedby the procedure, but says she is disap-pointed that she did not receive gasanesthesia and was aware of everything

that happened. She tells of difficultysleeping afterward because of head painand general discomfort. Thro ugho ut theinterview she complains of head pain inthe areas of electrode implantation, ab-dominal distention, eructation, and backpains. She is restless and, from time totime, she reports that she is sweating.

After the discussion of the operation,the patient presses the interviewer forsome statement about what the proce-dure has shown so far and when she cango home. When he indicates that this hasnot been decided, she becomes some-what subdued and unspontaneous. Asbefore, however, she responds to the in-terviewer's questions and the discussionturns to some factual material about herliving conditions, her daughter and herwork historv. At one point, she describestemper outbursts at work and the inter-viewer asks her if she has gotten madduring her stay at the hospital. Althoughshe flatly denies having been mad, achange in the qualitv of her interactionwith the interviewer ensues. First, sheasks him if she "talks puzzled" (i.e.,




MAHL ET AL . 345

seem confuse d). Wh en he reassures herthat she does not, she complains of themonotony and the heat and then beginssmiling and laughing in a provocative,slightly coquettish way. Although sheattributes this laughter to concern aboutthe interviewer studying her, she admitsthat she feels "less nervous" now afterlaughing.

During the remainder of the interview,she returns to many of the concerns inthe first two interviews. She wonders ifher illness is imagined and if she is in-sane and will have to stay in the hosp ital.At one point, she reveals a specific con-cern that she might have cancer. In dis-tinction to previous interviews, she fre-quently becomes overtly irritated withthe interviewer. She complains that heasks too many questions and accuses himof knowing what's wrong with her butnot telling her. Then , when the inter-viewer tries to explain that he is merely

trying to get to know her better, she be-comes argum entative. This irritation al-ternates with short spontaneous bursts oflaughter. The laughter seems to functionprimarily as a release of her anxietvabout the test procedure, her illness and,at times, her interaction with the inter-viewer. How ever, it also has a friendlysometimes coquettish quality. She her-self attributes her bursts of laughter toconcern about the interviewer looking ather with he r "head all shaved off."

Toward the end of the interview, she

becomes preoccupied with a swellingunder her eye and a sensation of muscletwitching in the eye itself. She complainsthat the interviewer's tobacco smellsfunny.

The interview differs mainly from thetwo previous ones in her many physicalcomplaints and her preoccupation withher physical sensations. At the same timeshe appears more relaxed and seems re-lieved that the operation is over. Shecontinues to talk about her concernsopenly and reveals a previously un-spoken fear of hav ing cancer. She ex-


presses irritation freely and laughs agood deal. Although this irritation andlaughter is certainly partly a function ofher anxiety, the free expression of thesefeelings seems to represent for thiswoman a growing sense of comfort andintimacy with the interviewer. Unlikethe case in previous interviews, there islittle discussion of seizure history andonly brief recounting of material abouther family.

Interview 4 (First postoperative day,5 hr. later; intracerebral EEG tracings;stimulations; patient in bed)The patient spontaneously reports, for

the first time, sudden and discrete idea-tional experiences and sudden, at timespainful, sensations in her jaw and wet-ness on her tongue . Characteristically,these experiences and sensations inter-rupt the conversation and do not appearto be related to any specific type of sub-

ject, quality of interaction or externalstimulus within the room.

The interview begins with the pa-tient's report that she felt nauseous andon the verge of fainting during a skullX-ray procedure that was carried outafter the last interview. After describingthis discomfort in some detail she saysshe is feeling much better now and shedoes appear to be fairly relaxed. Th einterviewer then asks the patient to tellhim a little more about herself, whatshe was like as a little girl, for example.

She responds openly with the remarkthat "I was my mother's pet," and in afreely-flowing exchange speaks briefly ofher adolescent datings, marriage, herhusband, and her concern that peopledon't like her, mentioning her specificconcern about what the interviewer andhis colleagues think of her.

She spontaneously speaks of how closeshe feels to her mother. She then tellsof how she worried about past illnessesof her mother: a broken leg and a uterinecyst, for examp le. She worries about th efact that her mother is old and won't




always be alive. She tells how she ha scalled her mother on the phone everyday since she's been married and of howher mother took care of "the baby," i.e.,the patient's daugh ter. She goes on todescribe her daughter in some detail andexpresses regret that she had to workinstead of staying home with her daugh-ter. How ever, she says, she always tried

to take good care of her daughter; shesaw that she had prompt medical care,for example. (During the segment of theinterview summarized in this paragraphthe first three stimulations occurred, thefirst two at Ant. Ndl. 1-2 and the thirdat Ant. Ndl. 3-4).

The interview then turns to a discus-sion of working. They needed the moneyshe earned . Her husb and works on "find-ings," which she explains means unfin-ished jewelry. At this point, Stim. 4 atAnt. Ndl. 3-4 occurs and the patientspontaneously reports the first of theintrusive ideational experiences. Whenshe said "findings" she heard a fellow"saying some word silly." (All ideationalresponses are described in detail in theAppendix. The patient tells the inter-viewer about this experience and men-tions that the wife of the fellow sheheard just lost a baby and that he was a"hot sketch" (i.e., a joker, a "card").

The patient then wonders what theinterviewer's colleagues are doing in thenext room and starts to speak about herseizures. She tries to recall how long ago

they started and is associating them withher pregnancy when Stim. 5 at Ant. Ndl.5-6 occurs. She sounds startled and says,"My mind just went off again . . . (to). . . the fellow's wife . . . I don't knowwhat she said." The patient says thatshe spoke to this woman on the phonejust after she had lost her baby . Th epatient then becomes subdued and quiet.The interviewer interrupts a very longpause by asking what she is thinkingabout. While the patient answers thatshe was thinking of how she has not had

a seizure for 10 days up to then, but that

her mind has "gone off' in this interview,Stim. 6 at Ant. Ndl. 5-6, is administeredand she immediately says, "See that girlcame again" and ". . . all of a sudden itseems like she was saying, like a saying.. . . It's somethin' that she says to me along time ago."

Spontaneously, the patient resumes thetopic of her husband's work but then be-

comes quie t. Stim. 7 at Post. Nd l. 1-2occurs and causes the patient to startleand say that "oh boy, I opened mymouth too much." She describes her sen-sation: "Like a snap . . . like a wire tomy tongue." She says she felt frightenedand asks the interviewer to look at hertongue for it feels "like a little wet . . . Ithought maybe I was bleeding." At thepatient's request the interview is then in-terrupted so she can urinate. When theinterviewer returns to the patient's room,Stim. 8 at Post. Ndl. 3-4 takes place and

she says the word "kerchief intrudedinto her thoughts.

The patient then becomes particularlysubdued . The next half hour she is gen-erally q uiet, interacting episodically withthe interviewer as she comments inter-mittently and briefly about how stronghis tobacco smells; the possibility shemight vomit again when skull X-rays aretaken; her physical discomfort from theoperation; the heat; her anxiety over thepresent hospital admission; an antici-pated visit of her family; and an incident

in which a young woman made fun ofthe way she talked. During this unevent-ful half-hour period, Stims. 9, 10, 11, 12,13 and 14 occur and are seemingly unre-lated to the transient episodes of inter-action.

Following Stim. 15 at Post. Ndl. 3-4the patient says "a word came" to herbut does not elaborate when the inter-viewer questions her ab out it. She seemsto be especially defensive and then startsa rapid, unconnected discourse on diffi-culties she has had with underarm boils.Conversation about this is suddenly dis-




MAHL ET AL . 347

rupted by another jaw an d tongue sensa-tion upon Stim. 16 at Post. Ndl. 1-2. Thepatient seems overtly anxious and aftera few more remarks about her past boilsshe becomes subdued again and con-tinues so, increasingly, until the end ofthe interview some 15 min. later. In themeantime Stim. 17, 18, and 19 in the Ant.Ndl. occur.

Interview 7 (Second postoperative day,2 hr. after Interview 6; intracerebralEEG tracings; stimulations; patient inbed)This interview is a little more than half

as long as Interview 4. Also, the stimu-lation schedule differs in the several re-spects mentioned earlier. One importantdifference is that only stimulation sitesthat have been associated with the idea-tional experiences are used and thesestimulations are all at the higher 7- and10-v levels.

The major features of the intervieware the high concentration of ideationalexperiences (five over a relatively shortperiod of time), the patient's high levelof anxiety, and her defensiveness in re-porting wha t she is experiencing. Shebrings up little spontaneously, except forthe sudden ideational experiences, andher general evasiveness is marked, incontrast to the openness of the early in-terviews. When questioned in detailabout the ideational experiences, thepatient cannot decide whether she actu-

ally heard people saying words to her orwhether she thought about the words.However, she does say that they are notmerely words which she associates withpast events; the words, sentences, andconversations occur at the time she re-ports them.

The interview opens with some dis-cussion of her husband's visit that after-noon and she talks again about herdaughter. She knows that her daughteris concerned about her and wonders ifthe girl says prayers for her every night.She admits that she, herself, has said

VOL. XXVI. NO. 4, 1944

silent prayers while in the hosp ital. Brief-

ly then, the conversation turns to herplans to quit work. Again she wond ersabout the causes of her illness. There isa short pause following Stim. 2 at Post.Ndl. 3-4, and she says, "Ooh, a crazyword just came to me." As the inter-viewer tries to elicit clarification of theexperience, she begins to wonder if thesewords that come to her are products ofher imagination just as she wonderedpreviously whether her spells were dueto her imagination. She becomes quie tand appears thoughtful. When the inter-viewer inquires if she is worried aboutanything, she replies that she guessesshe isn't. Stimulation 3 at Ant. Ndl. 5-6occurs as the interviewer asks what shemeans by that. After a short paus e, shestates: "You says that and somethingcame to me. . . . Seemed like somebodyelse said somethin'. I don't know wha tit was now." She becomes qu ite su bdued

and highly anxious. She says that she isscared and is sweating. After Stim. 4,Ant. Ndl. 3-4, she is subdue d and startleswhen the clock marks the quarter hour.She then becomes very quiet remarkingfinally that her head is throbbing be-cause she is so nervous. After a shortsilence, suddenly she startles, grasps theinterviewer' arm, and utters a sharp,high-pitched gasp—all with Stim. 5 atAnt. Ndl. 1-2. When the interviewerasks what happened, she replies "noth-ing." He persists and finally she tellshim only that she is saying prayers, Hail

Marys. (While something obviously hadhappened, this could not be counted asan ideational response in our data.) Afew minutes later she suddenly gaspsand grasps the interviewer's arm againwhen Stim. 6, at the same site, occurs.At first, she will not tell the interviewerwha t happ ened . Finally, she tells him:"I think it wasn't nice . . . it musta beendirty . . . maybe a word . . . it wasn't aswear word." The patient thinks shesaid the word . She resumed prayingsilently, explaining "just saying my pray-



348 INTRACEREBRAL E L E C T R I C A L S T I M U L A T I O N

ers so my mind won't drift some place."Twice more she reports the sudden

onset of ideational experiences. One ofthese occurs with Stim. 8, Ant. Ndl. 5-6.It consists of a conversation between twopeople and seems of hallucinatory inten-sity. She resumes saying Hail Marys toherself. With the final stimulation atPost. Ndl. 3-4, she whispers "Purse onto

school." She thinks she said "Pake intoschool." At the end of the interview thereis a brief discussion of the prayers andshe reveals that she has often said thisparticular prayer in the past when shehas been concerned that she is about tohave an episode.

Interview 8 (Second postoperative day,3 hr. later; intracerebral EEG tracings;no stimulations; patient in bed)During the interval between this inter-

view and the previous one, the patienthad an episode in which objects seemed

dull to her. This occurred w hile she wasalone in the room, and seemed to lastabout a half hour. Wh en it termina ted,she thought of her family and everythingseemed clear all at once.

At the beginning of this interview, shereports feeling tired and nervous andcomplains of a head ache ag ain. She be-comes more relaxed, however, as theinterview progresses and returns to thehigh level of spontaneous interactionwith the interviewer which she mani-fested in the preoperative interviews.

There is only one brief reduction of ver-bal interaction during this interview. Itoccurs after a discussion of her forth-coming operation (in which the tip ofthe left temporal lobe will be ampu-tated.) The tone of the interview isfriendly. Discussion of the patien t's earlylife and her family predominates. Also,the patient asks the interviewer somequestions about himself and his training.

There are no sudden psychological ex-periences. Occasionally, the patient won-ders why she is not having them. Shebecomes worried at times when she

moves too much and seems to be mo-mentarily expecting something to hap-pen. Several times during the interviewshe complains that her nose itches andoccasionally reports that her head hurts,but no other physical sensations are re-ported . Toward s the end of th e inter-view, she becomes teasing and some-what verbally seductive to the inter-

viewer. She apologizes for havin g gottenangry at him on occasion and reportsfeeling much more relaxed at the end.

Analysis of the Effects of Stimulation

The jaw and tongue sensations and theunusual ideational experiences wereclearly results of stimulation. Ta ble 3presents the frequency of these reactionsat the various stimulation sites. The re-mainder of Categories 1-20 eithershowed no consistent relation to specificstimulations or were not unique to the

stimulation interviews. The categoriesManifest Anxiety, Interaction, and De-fensiveness will be considered later.

Jaw and Tongue SensationsTable 3 shows that these sensations

occurred each time Post. Ndl. 1-2 wasstimulated, once out of the 8 Post. Ndl.3-4 stimulations, and once in the 7 Post.Ndl. 5-6 stimulations. The sensationsnever occurred with the 27 Ant. Ndl. or12 Plate stimulations, nor did the sensa-tions occur in any nonstimulation inter-view.

The following summaries, consisting ofcondensed verbatim interview excerpts,illustrate the nature of the jaw andtongue sensations. The interviewer didnot observe any unusual facial move-ments during these responses.

INTERVIEW 4 (Stim. 7, Post. Ndl. 1-2, 5

v.). Immediately upon stimulation the

patient said, "Oooh," and then described

her experience in the following words: "Oh.

boy, I opened my mouth too much—like a

snap—like a wire to my tongue—I musta

opened my mouth too much—As I went to

talk to you, I opened by mouth, like. Over

he re it hurts . I just felt like a snap— look onPSYCHOSOMATIC MEDICINE



MAHL ET AL 349

TABLE 3. FREQUENCY O F OCCURRE NCE OF JAW AND TONGUE SENSATIONS AN D UNUSUAL

IDEATIONAL EXPERIENCES ACCORDING TO STIMULATION POINTS

Stimulation points

Jaw Sens.Tongue Sens."Extrinsic" ideation-

al experience!:"Intrinsic" ideation-

al experience II

5v7v

lOv

Ant.Ndl.1-2

Ant.Ndl.3-4

Ant.Ndl.5-6

Post.Ndl.1-2

Post.Ndl.3-4

Post.Ndl.

5-6Plate3-4

No. OF SENSATIONS OR E XPE RI E NCE S

00

IS

0

405

00

3?

0

405

00

8

0

N o. OF

432

44

0

0

I"0

1

6

1M0

0

0

STIMULATIONS

2

0

2

620

610

00

0

0

001

Plate3-5

00

0

0

401

Plate5-6

00

0

0

0

01

Plate6-7

0

0

0

0

4

01

*Only with 5-v stimulations.tQuestionable response.tldeational experience in which someone other than the patient speaks.

SOnly with 10-v stimulations.II Ideational experience in which a word "comes to" patient or she actually speaks.

my hand—I got like perspiration. [I'm]frightened. Is there anything on my tongue?—I felt, you know, like a little wet on mytongue. I thought maybe I was bleeding—"—"Yeah [it frightened m e] . Did you seeme jump? I think I have to pass my water."(The interview is interrupted while patienturinates. Comments to nurse included: "I'mso warm. I'm sweating somethin' awful.Still going. Boy, I can't stop. Boy, I'm stillgoing.")

INTERVIEW 5 (Stitn. 4, Post. Ndl. 1-2, 10v.). With stimulation, the patient ex-claimed as if in pain and said, "Oh, right inmy ear and then my mouth again—Oh, Igot like a shock then. Through my ear, andthrough my jaw again. And, I didn't movemy mouth—It felt like water or somethingwet on my tongue—[It was like] a sharppain—Tastes funny. I feel as though mymouth smells or something."

INTERVIEW 5 (Stitn. 12, Post. Ndl. 1-2,10«. ). With stimulation the patientscreamed and moaned, "I'm afraid." Shethen described what had happened as fol-


lows: "Oh, did I feel it—Oooh, I'm afraid—Ohhh, right in my ear—into my tongue.It felt like water—I don't know—hope Idon't get it again—Today's been a helluvaday—[It felt as if] my jaw cracked—wassharp through there—and then—like itwent on my tongue—like on top of mytongue—or is there water. My eve is sore."

It was obvious that pain and fear ac-companied the complex of sensationsevoked by Post. Ndl. 1-2 stimulations

and that the pain and fear increased withthe ch ange from 5 v to 10 v. W e decidedto omit any further stimulations at theseelectrode points.

Extrinsic and Intrinsic IdeationalExperiencesThese terms refer to two distinct types

of events evoked by stimulations in twodistinct areas.

LATENCY. The experiences appar-ently occurred simultaneously with stim-ulation. At times this was obviously sofor the patient often verbalized them




immediately. On other occasions, itcould be definitely inferred that the ex-periences coincided with stimulation forshe often thereupon fell silent andthoughtful, or startled and grasped theinterviewer's arm, etc. When asked whatshe was thinking of, the patient wouldthen give some indication of the unusualideational experiences.

GENERAL NATURE OF EXPERIENCES.

The nature of the experiences can bestbe realized by examining the summariesof them contained in the Appendix.These summaries, consisting of con-densed verbatim excerpts from the inter-views, reflect the paucity and sketchinessof the patient's descriptions. Sometimesthe patient seemed to be trying veryhard to tell us all she could, but at othersshe appeared to be concealing inten-tionally the content of the experiences.

The experiences are complex in nature,

but all have one thing in common: asudden ego-alien intrusion of "words,""expressions," or "sayings" into the pa-tient's awareness. To varied degrees, atvarious times, the experiences have thequalities of peremptoriness, memory,hallucination, illusion, and active motorexpression in speech.

DISTINCTION BETWEEN 'EXTRINSIC' AND

'INTRINSIC'. Careful examination ofthe patient's description of the ideationalexperiences suggests that they were oftwo general kinds.

In "extrinsic" responses the patientreadily and unambiguously attributedthe "word," "expression," or "saying" tosomeone else. In most instances she gavesome identifying characteristic of theperson—name, sex, traits, etc. Furth er,there was a distinct auditory quality tothe experiences; at times they appearedto be hallucinatory.

The patient's spontaneous report ofwhat we have called "intrinsic" experi-ences always included a statement that"a word came to me." In one instance,she actually uttered "nonsense" words

with stimulation: "Purse into school."This description never applied to the ex-trinsic responses. Furthermore, the men-tion of another person entered into onlytwo descriptions of the intrinsic experi-ences. She did not identify those peopleand their role in the experience was am-biguous.

DEPENDENCE OF IDEATIONAL EXPERI-

ENCES ON LOCUS OF STIMUL ATION. A t

no time in any of the nonstimulation in-terviews did the patient report or giveindirect evidence that ideational experi-ences had occurred. Wh en they did oc-cur in the stimulation interviews theywere associated with stimulation at spe-cific sites. Tables 3 and 4 demonstratethe localization phenom enon. In Tab le 4the N's in the cells are too small formeaningful use of a statistical test ofsignificance, such as Chi-square, but thetabulation shows the following:

1. Ideational experiences occurredwith stimulation in the needle electrodes,but never with plate stimulation.

2. There was a very marked associa-tion of extrinsic responses with Ant. Ndl.stimulations and of intrinsic responseswith Post. Ndl. 3-4 stimula tions. Th etabulation for the 19 ideational responsesshows this relationship (T able 5) . Evenwithin each needle area, the localizationwas narrowly prescribed . Thu s, intrinsicresponses were associated with only Post.Ndl. 3-4 stimulations, and extrinsic re-

TABLE 4. IDEATIONAL RESPONSES

ACCORDING TO STIMULATION POINT

No ideational response*Ex- In- 2

Stim. points trinsir trinsic Neither Him.

Ant. Ndl. 1-2Ant. Ndl. 3-4Ant. Ndl. 5-6Post. Ndl. 1-2Post. Ndl. 3-4Post. Ndl. 5-6Plate, all points

2

1380100

13

00006006

861417

1239

999487

1258




MAHL ET AL 351

TABLE 5.

Kind ofresponse

Extrinsic

Intrinsic

DISTRIBUTION

RESPONSES

Ant.Ndl.

points

120

12

OF IDEATIONAL

Post. Ndt.

167

136

19

p < .003 (ti), Fisher's Exact Test.

sponses were most strongly related toAnt. Ndl. 5-6 stimulations.

3. The effects of the Ant. Ndl. stimu-lations suggest a "gradient." Th e onlystimulations at Ant. Ndl. 1-2 and 3-4producing ideational responses werethose of 10-v intensity. Fur ther, th ecloser the site of the 10-v stimulation toAnt. Ndl. 5-6, the more likely were theseresponses to occur. These findings mayrepresent a difference in "thresholds" atthe various points in the Ant. Ndl., or

they may indicate a transmission of thehigher voltage excitations from Ant. Ndl.1-2 and 3-4 to Ant. Ndl. 5-6 loci.

4. The one anomalous extrinsic ex-perience with Post. Ndl. 3-4 stimulationposed a difficulty in classification. Th esubject provided few cues for us. Itactually resembles an intrinsic responsein that the patient seemed to speak auto-matically. The a ttribution of a word tothe interviewer was the deciding factorin classifying this experience in the ex-trinsic category. Yet such a ttribution

may in this case have resulted from herattempts to integrate the experience.

Stimulus localization for the ideationalexperiences appeared consistently in allfour stimulation interviews.

RELATIONSHIP OF IDEATIONAL EXPERI-

ENCES AN D ELECTRICAL SEIZURE ACnVITY.

There was no relationship between theideational experiences and the patient'sspontaneous electrical seizure activity.A great many instances of spontaneouselectrical seizure activity occurred in theEEG records and none was related tem-


TABLE 6. IDEATIONAL EXPERIENCES WITH

ALL STIMULATIONS IN RELATION TO

EVOCATION OF SEIZURE

Seizure evokedNo. of stimulations Yes No 2

Evoking ideationalexperiences

Not evoking ideationalexperiences

2

15

13

28

4

26

30

19

39

58

porally with any of the ideational experi-ences.

There was, however, an association be-tween evoked after-discharge and theideational experiences. Table 6, coveringall stimulations, shows the nature of thisrelationship.

Considering al l electrode points, therewere many evoked electrical seizureswithout ideational experiences, but if

there was an ideational experience it wasvery likely to have been associated withevoked seizure activity.

The tabulation in Table 7 is limited tothe Ant. Ndl. and Post. Ndl. 3-4 stimu-lations—i.e., those sites that evoked theideational experiences.

The comparison of the two tabulationsshows that there were 10 out of 23 stim-ulations at points other than Ant. Ndl.points and the Post. Ndl. 3-4 points thatevoked seizure activity without evokingan ideational response, but there were

TABLE 7. IDEATIONAL EXPERIENCES WITH

ANTERIOR NEEDLE AND POSTERIOR NEEDLE

3-4 STIMULATIONS IN RELATION TO

EVOCATION OF SEIZURE

No. of stimulations

With ideationalexperience

Without ideationalexperience

Seizure evokedYes

15

318

X2

=

No

4

1317

s

19

163 5

10 p <.OO5



352 INTRACEREBRAL ELECTRICAL STI MULATI ON

only 3 of 35 such stimulations in the Ant.

Ndl. and at Post. Ndl. 3-4.

All four ideational experiences not as-

sociated with evoked electrical seizure

activity were extrinsic ones, and were

among 9 such experiences elicited by 7-

and 10-v stimulations. Furthermore,

three of these four extrinsic experiences

resulted from stimulation at Ant. Ndl. 1-2

and 3-4—i.e., the less sensitive of theextrinsic response points of the anterior

electrode. We cannot interpret these data

at present.

RELATIONSHIP BETWEEN IDEATIONAL EX-

PERIENCES AND INTERVIEW CONTENT AND

INTERACTION. To study this relation-

ship, one must make more complex as-

sumptions than are required for the ob-

servations presented so far. If not, the

relationship appears to be minimal or

nonexistent. In the following analysis we

assumed, as a working hypothesis, that

the ideational experiences are related to

the interview content and interaction in

the same manner as Freud7

assumed the

manifest dream content was related to

the dream associations. Our premises in-

cluded a specific assumption that com-

ments made by the patient as she elabo-

rated about her experiences referred to

"intermediate ideas" linking the experi-

ences to interview content or interaction.

Viewed within this general framework,

8 of the 19 ideational experiences appear

related to the immediate interview con-

tent or interaction, arbitrarily defined as

that occurring within 2 min. before the

stimulus onset. Five of these 8 experi-

ences seem to be also associatively con-

nected to more remote interview material

—i.e., that occurring any time in the

same interview earlier than 2 min. be-

fore stimulation. The following sum-

maries show the nature of these apparent

relationships. Italicized words indicate

elements common to the experiences and

the interview content and "intermediate

ideas."

(1)STIMULATION

Ant. Ndl. 3-4, 10 v, Stim. 4, Interview 4.

IDEATIONAL EXPERIENCE

Experience concerned "the way this per-

son talked." The patient consistently related

the experience to her utterance of the word

"findings" a few seconds before stimulation.

She heard a man "sayin some word silly."

The man is one of a "married couple," the

"wife just lost a baby." "He was a hot

sketch . . . he was like a—a laugh." Later

in the interview the patient mentioned that

she had spoken with the man's wife over

the telephone.

RELATED INTERVIEW MATERIAL

Immediate The interaction at the time

of stimulation included a lack of under-

standing by the interviewer of the patient's

vernacular. The following is a verbatim

record of this interaction.

P: The three fellas are partners. (I.e., her

brother and two other men.)

I: I see. And what do they do with that?

P: Findings. My husband works there.I: What do they do?

P. Findings.

I: What does that mean?

P: It's unfinished jewelry. (Onset of stim-

ulus )

Just before the preceding interchange the

interviewer had not understood the patient

when she mentioned her brother's unusual

first name. And 80 sec. before this (100

sec. before stimulation) the interviewer

had laughed quietly when the patient said

her husband suffered from a "sa-psy-chrtii-

oliac." These interchanges must have been

affect-laden for the patient, for later in the

interview she spontaneously told of a timesomeone had "made fun of the way I talk."

Remote In the first 5 min. of the inter-

view, the patient had told how she met her

husband on a double date involving another

couple and married shortly. There were

several references to "baby" and her moth-

er's pet. "My mother figured to have me for

old age—instead I got married." She later

spoke of the closeness between herself and

her mother, of how she has worried about

her mother's illnesses, and how she is con-

cerned that her mother will die some day.

She said she has called her mother on the

phone every day since her marriage and




M AW. ET AL . 353

mentioned that her mother took care of the"baby" (i.e., patient's daughter) while sheherself worked. She went on to describeher daughter fondly and expressed regretthat she had to work instead of caring forher. She said she took good care of her any-way for she called the doctor right awaywhenever her daughter had a cold—"n omatter what she had."

(2)STIMULATION

Ant. Ndl. 5-6, 5 v, Stim. 5, Interview 4.IDEATIONAL EXPERIENCE

The experience concerned the wife of the"fella" of the "married couple" who ap-peared in the experience described above.The patient heard the woman say some-thing.

The patient told of talking to the womanon the phone one day. "She just had losther baby." Later the patient added thatthis had been a miscarriage—i.e., before thebaby was born.RELATED INTERVIEW MATERIAL

Immediate Just before stimulation thepatient was speaking as follows: "How longhave I been gettin' those feelings [i.e.,seizures]? Gee, if I could only rememberhow long ago it started. I know I had themwhen the baby was born—even before thebaby was—ooh (sounds startled—onset ofstimulus)—even before the b aby wasborn."

Remote Patient had been talking andthinking about this woman, her husband,and the fact she had lost her baby in thecourse of describing the preceding ideation-al experience. All of the interview material

regarded as remotely related to that experi-ence may also be regarded as remotely re-lated to this one, especially that involvingreferences to couple, marriage, baby, illnessand death, separation between mother andchild, telephoning.

(3)STIMULATION


The same woman who appeared in thepreceding experience now reappeared andsaid something that she had said to thepatient "a long time ago."


RELATED INTERVIEW MATERIALImmediate When stimulation occurred,

the patient was speaking of the length oftime she had been seizure-free:P: I's just thinkin'—ah—today's the tenth

day I don't feel nothin'.I: Mhm.P: And then like, you know, like I told

you, my mind just went off for a minute.I: Yeah.

P: But th's—that's not like—ah—I: That's not like the beginning of thespell.

P: Oh, no-ooo (onset of stimulus).I: Mhm.P: I mean it jus'—See, that girl came to me

again.Remote Before the previous stimulus,

the patient had wondered "how long ago"her seizures had started and had associatedthem with her pregnancy and the birth ofher baby. The previous ideational responseshad involved, first indirectly and then di-rectly, the woman appearing in the presentone.

(4)STIMULATION

Post. Ndl. 3-4, 5 v, Stim. 8, Interview 4.IDEATIONAL EXPERIENCE

A word, possibly "kerchief" occurred tothe patient.RELATED INTERVIEW MATERIAL

Immediate One minute before stimula-tion the patient had told the interviewer:"I'm all wet—I mean I'm sweatin—warm—." (At a later time in the study when shecomplained of sweating and the heat, thepatient asked the interviewer to get her a

handkerchief from the drawer of her bed-side table.)

Remote Just before these remarks theinterview had been disrupted because ofthe patient's urge to urinate. She com-plained to the nurse who came in to assisther of "sweatin somethin awfuf and alsoasked the nurse for toilet tissue and later tobe dried after urinating. The last stimulus(not included here) had produced a sen-sation that her tongue was wet and bleed-ing.

All of these immediate and remote refer-ences concern body functions often, or pos-sibly, involving the use of a handkerchief.




(5 )STIMULATION

Post. Ndl. 3-4, 5 v, Stim. 12, Interview 5.

IDEATIONAL EXPERIENCEUpon cessation of the stimulus, the pa-

t ient mumbled in an automatic way ". . .

feel better tomorrow," She went on to say

". . . seemed like you said another word—like another word. I don't know the nameof the word."

RELATED INTERVIEW MATERIALI m m e d i a t e When stimulus occurred,interviewer was saying, "It'll feel better to-

morrow."

(6 )STIMULATION


IDEATIONAL EXPERIENCEPatient heard someone saying "Don't be

like this one. . ."

RELATED INTERVIEW MATERIAL

I m m e d i a t e In the minute precedingstimulation the patient was comparing th e

ideational experiences with her seizures and

was trying to explain the nature of the idea-tional experiences.

R e m o t e The previous stimulus (not in-

cluded here) had caused th e words "floatsin the t ide" to come to her. This, he r firstideational experience of this interview, led

he r to express concern over why she was

having such experiences. After the presentexperience she again wondered why she was

having them and related them to fears of

being insane. "The nut house always comesto my head."

()

STIMULATION


The patient heard a female voice, per-

haps a girl, saying something about a baby.Perhaps it was "/ got a baby . . . sister."RELATED INTERVIEW MATERIAL

I m m e d i a t e At the t ime of stimulationthe pat ient was speaking about her daugh-ter's wish that the patient have a baby so

she could have a baby sister or brother. The

patient was also wishing this herself:

P : (speaking spontaneously of the topic)She (i.e., her daughter ) wants a babysister or baby brother so bad.

I: Does she?

P: "?? a baby sister" she keeps saying thaiall the time.

I: Mhm. How about you?P : Hum.

I: How about you—do you want to haveanother child?

P. Oh—ah (clears throat—stimulus oc-

curs) something just came to me rightthen, etc.

After describing the resulting ideational

experience, the patient says: "I wouldn ' tmind bein'—you know, having anotherbaby—I was thinking about it before."

(8 )STIMULATION


IDEATIONAL EXPERIENCE

The patient heard th e voice of a girl whoworked with her speaking to her: "A (pa-

t ients name) , that guy is—tough." The pa-

t ient added: "The girl says to me tha t her

brother-in-law says something about some-

one's gotta go to work— ."

RELATED INTERVIEW MATERIALI m m e d i a t e Stimulation occurred as the

patient was speaking of her "spells" at work

and of actual operations performed at work:

P: Like—ah—when I used to get those—ah—like I'd be workin—

I: Mhm.

P: and I'd have the tool in my hand, and

wrap it up in a direction sheet, you

know?

I: Yeah.

P: And—ah—sometimes the object would

seem strange.

I. Mhm.

P. Like—ah—(onset of stimulus) —I: Yeah?

P: Seemed like somebody just came to me.

Etc.The patient identified either the

people or the words, or both, in the pre-

ceding eight ideational experiences. She

also did this for three other ideational

experiences, but it was impossible to see

any obvious relationship between them

and the interview content or interaction.

The following was specified about these

three experiences:

1. A girl named "Jeannette," who

worked with the patient, said something.




MAHL ET AL 355

2. The words "floats in the tide" cameto the patient.

3. The words "purse into school" an d"pake into school" came to the patient.She uttered the first phrase, apparentlywhen it "came to her."

There were eight additional ideationalexperiences that could not be relatedeasily to the interview content or inter-

action. In none did the patie nt specifythe person or the words involved. Thefollowing statements represent what sheconveyed about these eight responses.

1. A word came to her.2. A "person said a saying."3. "Some girl" said "something true."4. Somebody said something.5. A word came to her.6. A "crazy" word came to her.7. Somebody said something.8. Somebody said a "dirty" wordPATIENT'S REACTION TO IDEATIONAL EX-

PERIENCES. The patient's descriptions

of the experiences show that they seemedintrusive, and were nearly always com-pletely out of context and of strange—often disorganized—content. She desiredan explanation for them, apparently forboth their occurrence per se and theircontent.

In general the experiences frightenedher. At various times she gave the fol-lowing manifest signs of her anxiety:

1. A startled response in which shegasped "Oh" or suddenly grasped theinterviewer's arm

2. Perspiring3. Spontaneous statements that she

was "scared" or "nervous" and statementsthat the experiences made her think of"the nut house"

4. Uncontrollable laughter5. Concern about anticipated experi-

ences ("God knows what word is gonnacome to me next.")

6. Silent praving—"Hail Mary s" ("Justsaying mv pravers so my mind won'tdrift someplace.")

7. Reduced communication and whatappeared to be attempts to conceal the

VOL. XXVI, NO. 4. 1964

TABLE 8. RELIABILITY OF JUDGES' RATINGS

Variable

Anxiety levelDefensiveness

of reportInteraction level

Agreement betwee% ratert (%)

Obtained

72

7863

Chanceexpectation

33.3

33.325.

n

P

<.001

<.001<.001

content of the experiences from the in-terviewer (Long silences, monosyllabiccomments, changing the subject: "Don'task me." Telling the interviewer thatsomething came to her, but then sayingnothing but "I don't know" when askedabout it.)

For systematic observations we usedthe crude rating scales of the patient'sanxiety level, defensiveness of reporting,and level of interaction and independ-ently rated each stimulation interval onthe three variables.

The data of Table 8 show that th e twojudges w ere a ble to make reliable ratings.The average of the ratings by the twoobservers was used for subsequentanalysis.

The ideational responses were accom-panied by increased manifest anxiety(x

2 = 4.176, p < .05) and increased de -fensiveness of report (x2 = 3.183; p =.05). The level of interaction did notchange consistently with the occurrenceof ideational responses.*

Discussion

The presentation of our results hasanswered the questions posed in the in-troduction. Her e we wish to relate cer-tain of our limited observations to thevery extensive ones of Penfield and hisassociates which have been describedand conceptualized over the last 25

*The only other positive finding concerningthe three rated variables was the very highanxiety level accompaning the painful jaw andtongue sensations. The ratings did not varydirectly w ith point or voltage of stimulation,

or with interviews.




years.18

'20

~27

's0 Where comparable, our

observations are similar to those of Pen-field. The use of the interview situationand of verbatim recordings for subse-quent study provided us the opportunity,however, to observe certain events whichPenfield has not reported. These em-pirical extensions suggest a qualificationin Penfield's interpretation of some ofthe effects of temporal-lobe stimulationand an alternative interpretation of theobservable phenomena.

Electrical stimulation of the epilepto-genic, left temporal lobe of our patientevoked "psychical"* responses . Evenwithin the limited range of loci madeavailable by the needle electrodes, theseeffects were dependent upon the specificlocation of stimulation within the tem-poral lobe. Furthermore, stimulation ofthe inferolateral cortex of the left frontallobe, by means of the plate electrode,did not elicit psychical responses, nor

any other observable ones. In their gen-eral outline, these findings are consistentwith Penfield's observations that psy-chical responses may follow stimulationof specific areas in the pathological tem-poral lobe of patients with psychomotorepilepsy.

•Penfteld uses this term to distinguish tem-poral-lobe cognitive and perceptual responsesfrom the simple sensory and motor effects i>fstimulation in the other regions of the cere-brum. Stimulation at the very tip of the pos-terior needle produced pinful jaw and tonguesensations. The lack of adequate X-rays pre-

cludes exact interpretation of these responses.Penfleld has never observed such sensationsupon stimulation of the tempo ral lobe. PhanorPerot, M.D., Montreal Neurological Insti tute, acolleague of Penfleld, wrote us in a personalcommunication: "From the description given ofthe posterior needle, it seems fairly clear thatthe responses of sensation in the law and tonguewere due to stimulation of the third division ofthe trigeminal nerve and/or the dura around i t.W e have often seen this kind of response withstimulation at operation where the dura wasstimulated or manipulation was carried outaround the nerve in the middle part of thefloor of the middle fossa." W e are excludingthe jaw and tontrue sensations from our discus-sion of temporal-lobe responses.

Our "extrinsic" responses appear to beidentical with Penfield's category of hal-lucinatory or experiential responses. Our"intrinsic" responses seem most similarto Penfield's category of automatism, forthey included nonsensical and unrelatedspeech and "forced thinking" and oc-curred with stimulation of deep struc-tures in the temporal lobe. The lattermight very well be included in the peri-amygdaloid region reported to be theplace of origin for such responses.30 Ourpatient did not, however, seem amnesicfor her intrinsic responses which is char-acteristic for the automatisms observedby Penfield.

With the present patient, in contrastto the one described previously,14 therewere no clear-cut instances of Penfield'sinterpretive response category . This is acategory of a variety of illusory experi-ences such as deja vu, depersonalization,illusory emotional perceptions of the en-

vironment, and changes in apparent mag-nitude or proximity of sounds or visualstimuli. Once, remarks by the inter-viewer sounded altered, and there wasa vague d£ja vu quality in the patient'sdescription of some of her extrinsic ex-periences (Stim. 6, Interview 4; andStim. 5, Interview 6 ). These seemed tobe the closest aproximations to the in-terpretive response category, if indeedthey are tha t. Since Penfield has foundthat certain of the interpretive responsesare limited to the nondominant hemi-

sphere, the fact that we stimulated inonly one side mav account for thesenegative findings. The patient's left sidemay actually have been dominant forsome functions even though she wasleft-handed. Dominances may shift in-dependently for different functions.27

We are more interested in the inter-pretation of the nature of the extrinsicresponses, which as we have mentionedare identical with Penfield's experientialresponses. Penfield22"2* interprets theseresponses as the detailed re-enactments

of previous experiences, the hallucina-PSYCHOSOMATIC MEDICINE



MAHL £7" AL 357

tory evocation of memories by the stim-ulus activation of their neuronal counter-part recorded in a part of the brain thatis outside of, but intimately connectedwith, the temporal lobe. Do the extrinsicresponses of our patient fit this formula-tion?

It is important to realize at the outsetthat the sketchy, fragmentary nature of

our patient's reports about these experi-ences do not convey, when reduced towritten, paraphrased, and excerptedpresentation, the full impact of the pa-tient's actual behavior during the inter-view or during the replaying of the tape-recordings. Her manifestations of sur-prise, as well as her verbal descriptions,leave little doubt that she experiencedauditory hallucinations upon stimulationin the anterior needle.

Possibly she was reliving past experi-ences in these hallucinatory episodes,but the available evidence is inconclu-

sive. In five of the 13 extrinsic experi-ences, the patient identified the peopleshe heard as being ones she knew andthus heard in the past. In one of thesefive experiences, a man was talking"silly," as he often had in the past, andin three more of the five experiences thepatient identified the words spoken asactually having been said by these peo-ple in the past. We cannot say whe therthe content of the other eight extrinsicexperiences referred to the patient's pastor not. The patient ma de no reference to

the past in describing them, a circum-stance that could be due to a variety offactors. Defensiveness of reporting andinstantaneous repression, arising fromthe fear of insanity as well as from otheranxiety and guilt over the content of theexperiences, could very well have pre-vented the patient from providing themissing memorial reference for theseeight experiences. However, even if wesimply do not concern ourselves withthese eiffht experiences, we must stillevaluate the five "positive" hallucinatory

experiences. While the evidence of theirVOL. XXVI, NO. 4, 1964

occurrence is vivid and impressive, thedescriptions of the experiences are toofragmentary ever to determine if theywere, in all respects, the actual relivingof previous experiences. Our data seemto justify a more conservative conclusion.Stimulation produced hallucinatory ex-periences containing perceptions fromthe past, but it is not known if theirorganization into the hallucinatory ex-periences replicated any actual previousexperience. In other words, we cannottell whether the hallucinatory experi-ences were the equivalent of dreams orpsychotic hallucinations or the equiva-lent of an exact "playback."

These considerations led us to reviewthe basis upon which Penfield concludedthat stimulation resulted in the exact"flash-back" activation of memories. Alarge number, if not the majority, of theresponse protocols Penfield h as publishedresemble our patient's descriptions in

their sketchiness. He has obtained morecomplete reports on some occasions, buthe has not provided in any detail thekind of evidence, and the technique forobtaining it, that was taken as proof thatthe patients were actually reliving thepast on these occasions. That his patientswere having experiences involving pastperceptions seems indisputable. But heretoo we can see no basis for making afinal judgment as to whether the hallu-cinatory experiences were essentiallynew creations based on memories, analo-

gous to dreams, or simply playbacks.Evidence pertaining to this issue of

the essential nature of the hallucinatoryexperiences will be extremely valuable.It will also be very difficult to obtain. Atthe outset it will be necessary to haveadequately detailed descriptions of theexperiences, undistor^ed by defensiveand synthetic trends in the patient's re-ports. These are clearly discernible inthe protocols of the Appendix. And then,when determining if an experience is anexact playback of previous ev ents, it will

be necessary to control carefully for




similar defensive and synthetic trends,and other types of distortion, in thethinking of whatever witnesses are uti-lized.

Our consideration of the exact natureof the hallucinatory experiences is re-lated to our observations about the rela-tionship between the interview contentprior to stimulation and the content ofthe experiences themselves. Some of theobservations about this relationship pre-sented under Results are admittedly in-ferential, and some are equivocal as tothe role of interview content w ith respectto repetitive stimulation at the samelocus. But two of them show in a veryobvious and unequivocal way thatthoughts of the patient at the momentof stimulation may be related to theperceptual content evoked by the stimu-lation. These are the experiences elicitedby Stim. 10, Interview 6, and Stim. 8,Interview 7, both at Ant. Ndl. 5-6. Im-

mediately before the first of these twostimulations, the patient was talkingabout her daughter's desire for a babysister and, if the p atient is to be believed,she herself was then thinking that shewould like to have anothe r baby. Withstimulation, the patient hears a femalevoice say "I got a baby . . . sister." Justbefore the other stimulation, the patientwas speaking of her "spells" at work andof actual details of her work. Upon stim-ulation she hears the voice of a girl whoused to work with her. And the words

uttered by the girl include the phrase,"someone's gotta go to work." (Baldwin 1

reports a very similar observation. Thevisual hallucinatory responses of a 28-year-old man varied in content with thesex and identity of the observer seatedbefore him in the opera ting room. Onewonders if the same kind of thing hasgone undetected in Penfield's studies.Could it have happened, for example, inthe case of Penfield's young boy patientwho, upon one stimulation, said, "mymother is telling my brother he has got

his coat on backw ards. I can just hear

them."23 Had this boy thought to him-self prior to stimulation that those in theoperating room "had their clothes onbackwards"?)

The preceding observations suggestthe following hypothesis: The patient's"mental content" at the time of stimula-tion is a determinant of the content ofthe resulting hallucinatory experiences."

This hypothesis is testable and couldopen-up a new dimension in temporal-lobe stimulation studies. It modifiesPenfield's interpretation-3 '24 that theexact memorial material elicited by stim-ulation is primarily a random matter. Ac-cording to the preceding hypothesis thiscould not be the case.

The hypothesis also accounts for cer-tain stimulation sequence effects. Pen-field has observed that if stimulation ata point X elicits a particular hallucina-tory response, additional stimulations atthis or even at another "positive" point

may elicit responses with related contentif the stimulations occur at short timeintervals, whereas the thematic contentwill be unrelated if the time intervalsare long. Our own data confirm theseobservations. Thus, in Interview 4, therewas a run of three hallucinatory re-sponses with related content when stim-ulations were only 5 min. apart althoughat two different positive points; laterstimulation at one of these points elicitedquite different content:

Interview 4Stim. 4, Ant. Ndl 3-4: A man says some

word "silly." 5'Stim. 5, Ant Ndl. 5-6: The man's wife

said some thing. 5'Stim. 6, Ant. Ndl. 5-6: The man's wife

said something she had said a long timeago.

Interview 7Stim. 8, Ant. Ndl. 5-6: A girl the patient

worked with said, "(Patient's name) that

•Anyone made uncomfortable by the term

"mental content" can substitute for it more

modern terms such as "cognitions," "cognitive

structures," etc.




M A H L ET AL. 359

guy was tough," and apparently repeatedstatements made by her brother-in-lawabout "someone's gotta go to work."Penfield's interpretation24 of such a se-quence is that the difference in contentof the first and last experience was theresult of "a random re-enactment," andthat the thematic relatedness of the firstthree responses depended upon neuronalfacilitation. Accord ing to our hypo thesis,the first experience consisted of a manspeaking in a silly fashion just becausethe patient was preoccupied with herown speech and the concern that shesounded silly to the male interviewer atthe time of stimulation . Similarly, thecontent of the last experience pertainedto work just because she was thinkingand talking about work at the momentof that stimulation. But the same processseems to account for the relatedness ofthe first three experiences, for she wasstill thinking about the content and as-

sociated thoughts of the preceding ex-perience when the next stimulation oc-curred. The same hypothesized deter-minant function of mental content pres-ent at the time of stimulation accountsfor the selection of memory elementsappearing in any one hallucination, andalso for the similarities and disparitiesamong the responses.

There are at least two alternative hy-potheses, related but differing in pointsof emphasis, concerning the process ormechanism that might mediate the rela-

tionship between prestimulation mentalcontent and the hallucinatory responses.Both hypotheses assume that consciousmental content is always accompaniedby unequal, subliminal excitation of as-sociated memory traces.

The first, or facilitation, hypothesismakes the additional assumption that ex-citation resulting from electrical stimula-tion summates with the background,latent excitation of the memory traces,thus raising the total excitation of thetraces. The excitation level of one ormore traces may thus reach the percep-

VOL. XXVI. NO. 4, 1964

tual threshold. The trace that had thehighest level of latent excitation beforestimulation would form the content ofthe hallucinatory experience if this con-sisted of a single event or would be themost intense element of a complex hal-lucinatory response. When the conscioustheme is a continuing one, the distribu-tion of the unequal, subliminal excita-tions of associated memory traces might

change, keeping pace with varying ac-cents in the conscious mental content.Stimulations occurring under these con-ditions would then produce a series ofthematically related hallucinatory experi-ence, though the specific details neednever be the same . This first hypothesiscan be illustrated by the first three re-sponses of our patient in Interview 4.Here one could assume that the overtinterchanges concerning couples, babies,etc., and finally the patient's speech, wasaccompanied by subliminal excitation of

a network of memory traces of experi-ences with the "hot sketch" couple. (Weare making no assumption about the "di-rection of causality" here; only one of"association.") At the time of stimulationthe excitation of traces of "silly speech"of the man in this pair would have beenmore intense than the excitation level oftraces concerning the woman. There-fore, with stimulation, a trace of theman's "silly speech" was raised aboveperceptual threshold and the patientheard him say a "word silly." But by thetime the next stimulus came, the patient

had spoken of the man's wife. Now theexcitation level was greatest on tracesconcerning her, so that with the nextstimulation the patient heard the wifespeak. If we include psychodynamic con-siderations, we increase the flexibilityand explanatory power of this first hy-pothesis. We might then, for example,be able to account for the absence of re-sponse at positive electrode points on thegrounds that the subliminal trace-excita-tions reach sufficient prestimulation in-tensity only when the conscious content




is affect-laden or is sufficiently instinc-tualized in the psychoanalytic sense. Orthe perceptual threshold might vary withthe patient's strengh of defenses at themoment of stimulation.

The hypothesis is also useful in thatit yields predictions that are conceivablytestable. Its basic prediction, and theone that sharply distinguishes it from

the alternative hypothesis to be men-tioned, is that the hallucinatory experi-ences are in fact the re-enactment ofprevious experiences—exact playbacks.

The first hypothesis, even without thepsychodynamic considerations, drawsupon the thinking of both Penfield andFreud's topographic model.7 The secondhypothesis rests almost completely onenduring concepts of Freud's early meta-psychology.

A striking resemblance exists betweenthe relation of the hallucinatory re-sponses to their prestimulation mentalcontent and the relation of dreams totheir dream thoughts. In our two clearexamples ("I got a baby . . . sister" and". . . someone's gotta go to work"),verbally expressed thoughts are fol-lowed, upon stimulation, by relevantconcrete, sensory percepts with memorialqualities. If the patient had gone to bedpreoccupied with thoughts of work orof her daughter's desire for a baby sisterand d reamt, she might have hallucinatedin her dreams exactly what she did uponelectrical stimulation of her temporal

lobe. Freud's explanation of such anevent is indicated in the following quo-tations:7

. . . a dream is thinking that persists . .in the state of sleep, (p. 550).

[some analysts] seek to find the essence ofdreams in their latent content and in so do-ing they overlook the distinction betweenthe latent dream-thoughts and the dream-work. AT BOTTOM DREAMS ARENOTHING OTHER THAN A PARTICU-LAR FORM OF THINKING. MADE POS-SIBLE BY THE CONDITIONS OF THESTATE OF SLEEP. IT IS THE DREAM-

WHICH CREATES THAT FORM,AND IT ALONE IS THE ESSENCE OFDREAMING—THE EXPLANATION OFITS PECULIAR NATURE, (pp. 506-507: afootnote added by Freud in 1925—capitals,ours; italics, Freud's)

But dreams differ from day-dreams in theirsecond characteristic: namely, in the factof their ideational content being trans-formed from thoughts into sensory images,

to which belief is attached and which ap-pear to be experienced . . . it is not only indreams that such transformations of ideasinto sensory images occur: they are alsofound in hallucinations and visions, whichmay appear as independent entities, so tosay, in health or as symptoms in the psycho-neuroses. In short, the relation which weare examining now is not in any respect anexclusive one. (p. 535, italics ours)

If we said, "such transformations ofideas into sensory images are also foundin the hallucinatory responses to elec-trical stimulation of the temporal lobe,"we would be stating the essence of thesecond hypothesis about our observa-tions. For this alternative conceptualiza-tion, which might be called the altered-state hypothesis, is that the essenial effectof stimulation is to alter the state ofconsciousness of the patient in such away that primary-process thinking re-places secondary-process thinking. InFreud's metapsychology, primary-processthinking is epitomized by the hallucina-tory revival of memory traces achievedby the displacements and condensations

of the memory-trace excitations so thatthey eventually reach perceptual thresh-old intensity. Since the displacementsand condensations introduce varying de-grees of distortion into the revival, itmay range from relatively exact repro-ductions of the past to such extremelydistorted revivals that strange "created"experiences occur. All are hallucinatory.In the normal adult this primary-processmode of thinking occurs most character-istically in sleep and similar states ofconsciousness such as occur in hypna-




M A H L ET AL. 361

gogic reverie upon falling asleep and inhypnosis.13

According to this second hypothesis,then, electrical stimulation of the tem-poral lobe does not directly activatememory traces in the ganglionic record.Instead it induces a state of conscious-ness which makes it more probable thatprimary-process modes of functioning

will prevail. If there is a background ofsubliminally excited memory traces in theganglionic record at the time of stimula-tion, then all the conditions exist for theoccurrence of hallucinatory experiences,and the content of these experienceswould necessarily be related to the pre-stimulation mental events, for it wouldbe determined partly by them.

According to this second hypothesisthe hallucinatory experiences would becompounded of memory traces, butwould not themselves necessarily be

exact re-enactments of the past. Ther ecould be a range from exact revival toseemingly novel content. This predic-tion is conceivably testable. Since thefirst and second hypotheses make twodifferent predictions on this matter, acritical test of them would be very im-portan t. *

As with th e facilitation hypothesis, theintroduction of psychodynamic consid-erations might increase the predictive orexplanatory power of the altered-statehypothesis. In addition to the kinds of

•In many of Penfleld's protocols the patientsspontaneously describe their experiences as

dreams or dreaming. And his patients, as our

present one, often fel t there was a similari ty

between the experiential responses and their

aurae. Perh aps they sensed the similarity in

the states themselves. Penfield frequently re-

lated the experiential responses to dreams in

his earl ier papers and once commented2* that:

"Experience with cortical stimulation brings

one to the conclusion that these induced mental

states are like dreams." (p. 179)

But he was expl ici tly referring to the me-

morial dimension of dreams and hal lucinatory

responses rather than to the states themselves

and their basic attributes, such as modes of

thinking.

considerations discussed earlier in thatconnection, other questions originatingin Freud's dream studies now naturallyarise: Will hallucinatory responses occurwith stimulation only if conflictful men-tal content—ideas, wishes, etc.—has beenactivated prior to stimulation? Does theseemingly frequent "trivial" content ofthe hallucinatory experiences, a matter

often remarked by Penfield, merely serveas the cover for inhibited content? Someobservations in this patient and the onepreviously reported14 suggest that thequestions deal with possibilities. Someof the present patient's responses seemedto be related to affect-laden bu t inhibitedthoug hts. Thu s, in the case of the firstexperience, where the man spoke in asilly fashion, the patient did not thenspeak of her concern over how shesounded to the interviewer in spite ofthe repeated transactions determined byher speech that occurred just beforestimulation. Later , however, this con-cern was expressed in a derivative, affec-tive fashion. In the case of her response,"I got a baby . . . sister," the patient didnot voice her own desires to be pregnantat the time she spoke of her daughter'swish. Later she did. It is as though shehallucinated her own desires, adding the"sister" as an afterthought. Finally, weknow that in the last stimulation inter-view on at least one occasion she hearda "dirty word," refused to speak of allher experiences, and reacted by praying.

In our previous paper we reported thatthe boy patient said upon stimulation,"I'd like to be a girl." In a follow-upinterview, he recalled this statement butnegated it, and he disrupted the inter-view when thwarted in this defensivereaction. The altered-state hypothesisreadily encompasses these observations.

There is another implication of thealtered-state hypothesis which speaksfurther in its favor. It can also accoun tfor many of the changes in perception ofexternal events and in self-perception





which may occur with temporal-lobestimulation . The se consist of thosechanges which Penfield classifies as "in-terpretive illusions" and which are takento indicate that temporal-lobe stimula-tion has not only activated ganglionicmemory traces but has also interferedwith the process of scanning traces andcomparing present perceptions with

them.In psychoanalytic theory, a change in

state of consciousness is basically de-pendent upon a change in distributionof attention cathexes. And the distribu-tion of attention is a fundamental deter-minant of perception.0"1- We are indebtedto Rapaport2R for the systematizing andcreative elaboration of this material. Thetheory directly implies that any changein consciousness characterized by a tran-sition towards primary process modes ofthought would also be accompanied bydisturbances in perception of the self orthe external world, or both.

In our research we found the samekind of hallucinatory responses upontemporal-lobe stimulation as Penfielddiscovered. In this discussion we havequestioned, however, whether the hallu-cinatory responses are typically exact re-enactments of the past or are, to varyingdegrees, new creations compounded ofmemories of the past. Either interpre-tation seems possible in the light ofpresent evidence. We then discussed ourobservations and hypothesis that themental content at the time of stimulationwas a determinant of the content of thehallucinatory responses. Next we sug-gested two alternative hypotheses to ac-count for such a relationship. We alsocited some observations suggesting thattemporal-lobe stimulation may facilitatethe expression of inhibited wishful oraffective ideas. We have just speculatedthat the altered-state hypothesis couldaccount for both the hallucinatory re-sponses and the interpretive illusions.Each of these issues can be the subject

of, and merits, further investigation in itsown right.

Taken as a whole, these considerationssuggest a single unifying hypothesis:Electrical stimulation of the epihpto-genic temporal lobe may induce a stateof consciousness in which there is a shifttowards primary-process organizationand away from secondary-process organ-ization of behavior. This state of affairsmay have several consequences. Th econscious and unconscious mental con-tent present at the time of stimulationmay be manifested in hallucinatory ex-periences. Disturbances in perception ofthe self or of the external world mayoccur. Finally, there may be a change inthe drive-defense organization such thatmore direct drive manifestations are dis-played or both drive and defense be-come more primitive and intense. Ac-cording to this hypothesis, then, the ef-fect of stimulation is to provide the

general neural conditions in which thespecific consequences may occur accord-ing to their own mechanisms. A discus-sion of how stimulation may do this is amajor question in itself. Even if therewere time and space to attempt it, wecannot improve upon the suggestionsspecifically concerned with the role ofthe temporal lobe in states of awarenesswhich Kubie included in his brilliantpaper.15

We share with Kubie and the psycho-analysts who discussed his paper—Kris,

Lewin, Margolin, and Ostow—the beliefand the hope that research on the effectsof stimulation of the temporal lobe,pioneered by Penfield, pro vides one pointof significant interaction between neuro-physiology and psychoanalysis. The as-pect of Penfield's work which excited themost interest among psychoanalysts wasthat dealing with memo ries. By andlarge it was granted that stimulationdirectly activated memories and pro-duced re-enactments of the past. Th equestion of interest became, "Are theserepressed memories?" We believe these




MAHL ET M. 363

particular reactions were premature, theresult of an enthusiastic reunion. W ehave also concluded, however, that thereare many points at which psychoanalysisand this area of neurophysiology canhave significant encounters. Our limitedempirical observations and our theo-retical consideration of the work in thisarea led us in a direction anticipated by

Bertram Lewin16

in the following para-phrased remarks from his discussion ofKubie's paper:

The most interesting part of this paper isthat which deals with the material pro-duced by electric stimulation and the inter-pretatio n of this mat erial. Her e certainlywe need much cautious and at the sametime imaginative handling . . . the patient'sproductions should be treated with all themethods that we employ when confrontedby the material of free association. . . . I twould be wrong . . . to assume that elec-tric stimulation provokes a direct catharsis.

. . . We can find in all these productions acomplicated structure, which should yieldto ordinary analytic methods of approach.The appearance of visual representationsand other states resembling dreaming needshandling more according to dream the-orv . . .

Summary

Two multilead needle electrodes wereimplanted within the left temporal lobeof a young woman with intractable psy-

chomotor epilepsy. A multilead pla te

*During our earl ier col laboration with Dr.

John Higgins, the possibi l i ty of interpreting

stimulation effects in terms of primary process

organization occurred to us. We did not pur-

sue that l ine of thought at that time, however,

possibly because the stimulus effects observed

then did not include hallucinatory responses.

These, after all , fit the simplest paradigm—

dreams—of primary process thinking. Also, we

were very fortunate subsequently to have the

benefi t of studying with Drs. Wil l iam Pious

and David Rapaport, who opened our eyes to

the content and broad appl ication of Freud's

general metapsychology.

VOL XXVI, NO. 4, 1944

electrode was placed on the inferior-lateral surface of her left frontal lobe.EEG tracings were recorded from andelectrical stimuli were administered,with certain controls, through these elec-trodes during four unstructured inter-views. Nonstimulation interviews pre-ceded and followed the stimulation in-terviews. All interviews were tape-re-

corded and transcribed for subsequentstudy.

Stimulations in the plate electrode pro-duced no observable responses. Stimu-lations at the tip of one depth electrodeproduced painful jaw and tongue sensa-tions, indicating that the tip of this elec-trode was outside the temporal lobe.Stimulations at other points in bothdepth electrodes, within the temporallobe, produced two distinct kinds ofideational experiences: (1) The subjectsaid people "came to her mind" and

seemed to be speaking. Th e experiencesseemed to vary from thoughts, to vividmemories, to hallucinations. (2) A wordor expression "came to her" but nobodywas saying it. Th e words were some-times remembered expressions, nonsensewords, and "dirty" words and at timesthe subject could not or would not de-scribe them. The ideational experiencesresulted from sharply localized stimula-tion. They were associated with evoked,but not spontaneous, electrical seizureactivity. The subject experienced themas ego-alien, with considerable overt

anxiety, and was defensive in reportingthem. Th e findings resemble and extendPenfield's observations obtained with adifferent procedure.

The use of the interview and carefulstudy of the recordings, however, per-mitted the discovery that the content ofthe ideational experiences was often re-lated to the patient's mental content justbefore or at the time of stimulation.Minimally, this discovery requires cer-tain modifications in Penfield's theoret-ical interpretations . Maximally, it leads




to quite different interpretations. Certainalternative hypotheses, extensions ofFreud's metapsychology, are discussed.The mutual implication of psychoanaly-sis and temporal-lobe stimulation studiesfor each other, emphasized by Kubie, isnoted.

333 Cedar St.

New Haven, Conn.

References

1. BALDWIN, M. "Electrical Stimulationof th e Mesial Temporal Region." Elec-trical Studies on the UnanesthetizedBrain, Ramey, E. R. and O'Doherty,D. S. (EDS.) Hoeber , New York, I960.Pages 159-176.

2. DELGADO, J. M. R. Permanent im-plantation of multilead electrodes inthe brain. Yale } . Biol, & Med. 24:351,1952.

3 DELGADO, J. M. R. "Elektroenzephalo-

graphic der tieferen Zellmassen de sGehirns." (Electroencephalography ofthe deeper cell masses of the brain.)In Einftihrung in die StereotaktischenOperationen mit einem Atlas des Men-

schlichen Gehirns. (Introduction toStereotaxis with an Atlas of the HumanBrain.) G. Schaltenbrand and P.Bailey. Thiem e, Stuttgart, 1959. pp.401-419 .

4. D E L G A D O , J. M. R., RO BE RT S , W. W.,

and MILLEF, N. Learning motivatedby electrical stimulation of the brain.Am. J. Physiol. 279:587, 1954.

5. D E L G A D O , J. M. R., ROSVOLD, H. E.,

and LOONEY, E. Evoking conditionedfear by electrical stimulation of sub-

cortical structures in the monkey brain./ . Comp. <b Physiol. Psychol. 49:373 ,1956.

6. FREUD, S. (1895) Project for a Scien-tific Psychology. In The Origins ofPsychoanalysis. Bonapar te, M., Freud,A. , and Kris, E., (EDS. ) . Basic, New

York, 1954.

7. FREUD, S. (1900) The Interpretationof Dreams. Standard Edition of Com-

plete Psychological Works of SigmundFreud. Vol. 4 and 5. Hogarth Press,London, 1953.

8. FREUD, S. (1911) Formulation on theTwo Principles of Mental Functioning.Standard Edition of Complete Psycho-logical Works of Sigmund Freud. Vol.12, Hogarth Press, London, 1958, pp .218-226.

9. FREUD, S. (1915) The Unconscious.Standard Edition of Complete Psycho-logical Works of Sigmund Freud. Vol.14, Hogarth Press, London, 1957, pp .

166-204.10. FREUD, S. (1917) A Metapsychological

Supplement to th e Theory of Dreams.Standard Edition of Complete Psycho-logical Works of Sigmund Freud. Vol.14, Hogarth Press, London, 1957, pp .222-235.

11. FREUD, S. (1925) A Note upon th e'Mystic Writing Pad." Standard Edi-tion of Complete Psychological Worksof Sigmund Freud. Vol. 19, Hogar thPress, London, 1961, pp . 227-232.

12. FREUD, S. (1925) Negation. StandardEdition of Complete PsychologicalWorks of Sigmund Freud. Vol. 19,Hogarth Press, London, 1 961, pp. 235-

239.

13. G I L L , M., and B R E N M A N , M. Hypnosis

and Related States. Internat. Univ.Press, New York, 1959.

14. H ICG IN S , J. W., M A H L , G. F., D E L G A D O ,

J. M. R., and HAMLIN, H. Behavioralchanges during intracerebral electricalstimulation. A.M.A. Arch. Neurol. bPsychiat. 76:399, 1956.

15 . KUBIE, L. S. Some implications forpsychoanalysis of modern concepts ofthe organization of th e brain. Psycho-analyt. Quart. 22:21, 1953.

16. LEWIN, B. Discussion of "Some impli-cations for psychoanalysis of modernconcepts of the organization of th ebrain," by L. S. Kubie. Psychoanalyt.Quart. 22:61, 1953.

17. M A C L E A N , P. D., and D E L G A D O , J.

M. R. Electrical and chemical stimula-tions of frontotemporal portion of thelimbic system in the waking animal.Electroencephalog. Clin. Neurophysiol.5:91, 1953.

18. M U L L A N , S., and P E N F I E L D , W. Illu-

sions of comparative interpretation and

emotion. A.M.A. Arch. Neurol. Psy-chiat. 81:269, 1959.




M AHL ET AL. 365

19. OLDS, J., and MILKER, P. Positive re-

inforcement produced by electrical

stimulation of septal area and other re-

gions of rat brain. / . Comp. <b Physiol.

Psychol. 47:419, 1954.

20. PENFIELD, W. The cerebral cortex inman. A.M.A. Arch. Neurol. Psychiat.

40:417, 1938.

21. PENFIELD, W. Memory mechanisms.

A.M.A. Arch. Neurol. Psychiat. 67:

178, 1952.22. PENFIELD, W. The Excitable Cortex in

Conscious Man. (The Sherrington

Lectures V). Thomas, Springfield, 111.,

1958.

23. PENFIELD, W. The interpretive cortex.

Science 129:1719, 1959.

24. PENFIELD, W. A surgeon's chance en-counter with mechanisms related toconsciousness. / . Roy. Coll. Surgeons

Edinburgh 5:173, 1960.

25. PENFIELD, W., and JASPEH, H. Epi-

lepsy and the Functional Anatomy ofthe Human Brain. Little, Boston, 1954.

26. PENFIELD, W., and RASMUSSEN, T. The

Cerebral Cortex of Man. Macmillan,

New York, 1952.

27. PENFIELD, W., and ROBERTS, L. Speech

and Brain Mechanisms. Princeton

Univ. Press, Princeton, N. J., 1959.

28. RAPAPOHT, D. Organization and Pa-

thology of Thought. Columbia, New

York, 1951.

29. RAPAPORT, D. "On the Psychoanalytic

Theory of Motivation." In NebraskaSymposium on Motivation, Jones, M.

R. ( E D . ) . Univ. Nebraska Press, Lin-

coln, 1960, pp. 173-247.

30. ROBERTS, L. "Activation and Inter-

ference of Cortical Functions." In

Electrical Stimulation of the Brain,

Sheer, D. E. ( E D . ) , Texas Press, 1961,

pp . 533-553.

31 . SCHREINER, L., and KLING, A. Be-

havioral changes following rhine-

cephalix injury in cat. / . Neurophysiol.

16:643, 1953

Appendix

A. Summaries of ExtrinsicIdeational Experiences

Content of experience

INTERVIEW 4

No. 4 When stimulation ended, pa -

Ant. Ndl. tient said: "You know, I just felt

3-4, lOv funny, just now—I told you

they work on findings [a t jewel-ry factory where husband

works], right, then all of a sud-

den somethin' else came to me—these the people—the waythis person talked. This mar-ried couple—as though the fel-low came into my mind—as

though like he was saying some-

thin'—like oh my mind drifted

for a minute—to somethin

foolish, I mean I wasn't even

thinkin' of it—I just said some

word to you, and it seemed like

—he used to be a hot sketch—


Stimulation Content of experience

as though he said—and it

seemed like he was coming out

with some word—sayin' some

word silly—"

No. 5 With stimulation patient said,

Ant. Ndl. "Ooh," and then described what

5-6, 5v happened in following terms:

"My mind just went off again—

[to] th e fella's wife—I don'tknow what she said—I mean—

just seemed a little strange fora minute—I was lookin', starin*

—one day I was talking to heron th e phone—the couple weknow—she just had lost herbaby. I don't know, I happened

to just think of it."

No. 6 Immediately with cessation of

Ant. Ndl. stimulation patient said: "See,5-6, 7v that girl came to me again." She

described it as follows: ". . .

just now, just as though she was

gonna sav somethin'—isn't that




Stimulation Content of experience Stimulation Content of experience

funny—all of a sudden it seemslike she was saying— it's some-thin that she says to me a longtime ago—Gee, I can't remem-ber the words."

No. 2Ant. Ndl.3-4, lOv

No. 3Ant. Ndl.5-6, 7v

No. 12

Ant. Ndl.3-4, 5v


INTERVIEW 5

Immediately upon cessation ofstimulation patient said: "It's asif my mind just went off again.I thought of somethin'." She de-scribed the experience as fol-lows: "[I thought] of some girlwho worked with me, I guess—somethin ' just came to me—see, I forget it—was just athought that comes to me—it'ssomebody else now—How comeI've been thinkin' of people?—like a sayin that she said—somekind of a sayin' but I can't re-member how it goes. I think itwas Jeanette."

With stimulation patient said:"I just thought of somethin' else—n ow I can't think of it." Herdescriptive comments were:"Somethin else came to me, an-other saying and it went— Ican't think of it now. How comethese things are comin' like that—I mean all of a sudden— l ike,oh a person sayin—/ don'tknow who it was though."When stimulation occurred, in-terviewer was saying, "It'll feelbetter tomorrow." (i.e., herh e a d ) . Upon cessation of stim-ulus patient mumbled in an au-tomatic way: ". . . feel bette rtomorrow" and became thought-ful. She described her experi-ence : "111 tell ya'— seemed likeyou said another word—like an-other word, I don't know thename of the word."

With cessation of stimulus, pa-tient said: "Another personcam e to me ." Her descriptiveremarks were: ". . . was just as

though somebody was sayin'something—I don't know who itwas— as though I could hearthem saying something— like asaying—maybe something true—it must have been a girl."

No. 15 A few seconds after cessationAnt. Ndl. of stimulation , pati ent said: ". . .

3-4, lOv somethin puzzled again," Inremarking further, she said: "Ican't explain it—like a puzzle—puzzled—as though somebodysaid somethin'—I can't remem-ber—could I imagine it?—Iknow that they weren't here,they just came to my mind."

INTERVIEW 6


No. 10

Ant. Ndl.5-6, 5v

During stimulation, patientstarted following remarks: "See.Now look, I just got the—I just

thought of somebody again."Her description was as follows:"Oh, I can't think of it now—somebody was thinking of s—I don't know, it's all mixed up—As though somebody was think-in'—of how somebody used anexpression—It just came to methat—someone was saying, like'Don't be like this one'—andthen how this person says anexpression—I guess I'm mixedup—."

Immediately after start of stim-

ulation, patient said: "Some-thing just came to me rightthen." She remarked about thisexperience as follows: "It mustabeen the same person [who said"Don't be like this one" some 20min. earlier!]—seems like a g—it must be something about ababy—it comes to me fast andthen it goes away—she says tom e 7 got a baby . . . sister'—orsomething — she — somethingcomes to me—someone sayssomething—I don' t know—Iwas thinkin' of—I wouldn't




M A H L ET AL. 367

Content of experience Stimulation Content of experience

mind—having another baby—Iwas thinkin' about it before . . ."[NOTE: Just prior to stimulationpatient was talking about herdaughter 's wish to have a babysister or brother.]

INTERVIEW 7

No. 3 Interviewer asked patien t if sheAnt. Ndl. was worried about anything.5-6, lOv She replie d: "No, I guess not. "

Interviewer asked, "What doyou mean, you guess not?" The nstimulation occurred . In a fewseconds, patient commented:"You just says that and some-thin" came to me—oh, I don'tknow [what]—what did youjust say to me?— seemed likesomebody else said somethnig.I don't know what it was now."

No. 6 Immediately upon stimulation.Ant. Ndl. patient reached and grasped in-1-2, lOv terviewer's arm. She remained

silent and though tful. Uponprodding by interviewer as towhat happened when she sud-dently grasped his arm, shesaid: "I felt the thing again, Iguess," and continued: "Funny—trying to figure out what thatw a s — / think it wasn't nice— itmust have been dirty—I don'tknow what i t was—maybe aword— wasn 't a swear word— I

don't think— something foolish—somebody else might havesaid it—a saying—I don't know,I think it was dirty. . ."

No. 8 With stimulation, patient said,Ant. Nd l. "Seem ed like some body just5-6,10 v came to me— '[Patient's name]

that guy is . . .'—a girl said itto me—[Patient 's name]—Ican't think of it now. See it goesright off—like the girl comes—somebody says to her '(Patient'sname) the— that guy was tough'

— The girl says to me, that her


brother-in-law says somethingabout someone's gotta go towork—Oh, I don 't know , I'mmixed up—a girl said it—some-body that worked with me—."

B. Summaries of Intrinsic

Ideational Experiences

INTERVIEW 4

No. 8Post. Ndl.3-4, 5v

No. 15Post. Ndl.3-4, 5v

With stimulation, patient ap-peared to be uncomfortable.When interviewer asked if shewas, patient said, "Funny wordcame to me and I don't knowwhat it is—I don't know if it is'kerchief or what—that wordcame to me when I—like Ithought it—Well, before whenI used to get these feelings—like I call funny feelings— if I

kinda put my hand this way, de-pending like how I sat—a wordwould come to me— seemed likesomeone was makin' a commentwhen it occurred to me."

With stimulation patient felt shehad "opened her mouth toohard again" and then said thatwhen she felt this she had beenthinking of " . . . a word, I don ' tknow—tryin' to remember it—aword that came to me—nobodywas saying it."

I NT E RVI E W 6

No. 4 Pati ent fell silent for 20 sec. fol-Post. Ndl. lowing stim ulation and inter-3-4, 5v rupted pause saying, "A word

just came to me—like an ex-pression— 'Floats in the tide' Ithink—how come I 've been get-ting expressions lately—youknow, I was just staring overthere and then seemed like Iheard like, ah, like I rememberthat that somebody used thatexpression—as though some-body used that expression—




Stimulation Content of experience Stimulation Content of experience

there's nobody here—as thoughI know that someone used thatexpression—it didn't sound likethat expression—but like I re-member, oh, like I keep sayingthe expression then it comes outto that—that's how I got thosefunny feelings."

No. 11 Upon stimulation patient sud-Post. Ndl. denly fell silent and looked3-4, 5v thoughtful. She maintained this

silence steadfastly for 40 sec.during which interviewer at-tempted to find out what shewas thinking. Finally, she said,"A word musta come into myhead, but I don't know what itis." She sparsely commentedfurther: "I don't know what itreally is—I don't know whatthe word is—I don't know theword. I'd tell you if I knew the

word. I told you other words Icould think of—suppose an-other word comes to me. Godknows what w ord is gonna cometo me next—I don't know whatthe word was. Now don't ask

INTERVIEW 7

No. 2 With stimulation patient said:Post. Ndl. "Ooh, a crazy word just came to3-4, 7v me." Her description of her ex-

perience: "I can't think of itnow—I was trying to make out

the word. It just came to me,just for a minute—all of a sud-den—could that be my imagi-nation—this word came to meand I was about to say it to you—I couldn't make it out now—it's coming to me, nobody wassayin'—sounded like a lottawords."

3-4,7v Immediately upon stimulationNo. 9 patient broke a markedly un-Post. Ndl. communicative period with a

whispered nonsensical phrase:"Purse onto—" "What did I

say?" She then went on to sayfor clarification: "Purse intoschool—see that just came tome—I think I says 'Pake intoschooY—it doesn't make anysense—Did I say that?" [I.e.,"Pake into school"].


dr. jose delgado - psychological responses in the human to intracerebral electrical stimulation...

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