Arthur S., a surgeon who is also a fine amateur pianist, is losing his vision from macular degeneration. In 2007, he started “seeing” musical notation for the first time. Its appearance was extremely realistic, the staves and clefs boldly printed on a white background, “just like a sheet of real music”—and Arthur wondered for a moment whether some part of his brain was now generating his own original music. But when he looked more closely, he realized that the score was unreadable and unplayable. It was inordinately complicated, with four or six staves, impossibly complex chords with six or more notes on a single stem, and horizontal rows of multiple flats and sharps. It was, he said, “a potpourri of musical notation without any meaning.” He would see a page of this pseudo-music for a few seconds, and then it would disappear suddenly, replaced by another, equally nonsensical page. These hallucinations were sometimes intrusive, and might cover a page he was trying to read or a letter he was trying to write.
Though Arthur has been unable to read real musical scores for some years, he wonders, as Marjorie did, whether his lifelong immersion in music and musical scores might have determined the form of his hallucinations.8
He wonders, too, whether his hallucinations might progress. For about a year before he began to see musical notation, Arthur saw something much simpler: a checkerboard pattern. Will his musical notation be followed by even more complex hallucinations, such as people, faces, or landscapes, as his eyesight declines?
There is clearly a wide array, a whole spectrum, of visual disturbances which can occur when vision is lost or compromised, and originally the term “Charles Bonnet syndrome” was reserved for those whose hallucinations were related to eye disease or other ocular problems. But an essentially similar array of disturbances can also occur when the damage lies not in the eye itself but higher up in the visual system, especially the cortical areas involved in visual perception—the occipital lobes and their projections into the temporal and parietal lobes of the brain—as seems to be the case with Zelda.
Zelda was a historian who came to see me in 2008. She told me how her world of strange visual phenomena had started at a theater six years earlier, when the beige curtain in front of the stage suddenly seemed to be covered in red roses—the roses were three-dimensional, thrusting out of the curtain. When she closed her eyes, she still saw the roses. This hallucination lasted for a few minutes and then vanished. She was perplexed and frightened by this, and she went to consult her ophthalmologist, but he found no impairment of vision and no pathological changes in either eye. She saw her internist and cardiologist, but they could not provide any plausible explanation for this episode—or the countless episodes that followed. Finally she had a PET scan of her brain, which showed reduced blood flow in her occipital and parietal lobes, presumably the cause, or at least a possible cause, of her hallucinations.
Zelda has both simple and complex visual hallucinations. The simple ones may appear when she is reading or writing or watching television. One of her physicians asked her to keep a journal of her visions over a three-week period, and in it, she recorded, “As I write this page, it is becoming more and more covered by a pale green and pink lattice. . . . The garage walls, covered in white cinderblock, continually mutate . . . coming to resemble bricks, or clapboard, or being covered with damask, or flowers of different colors. . . . On the upper part of the walls in the hallway, shapes of animals. They were formed by blue dots.”
More complex hallucinations—battlements, bridges, viaducts, apartment houses—are especially common when she is being driven in a car (she gave up driving herself after her initial attack, six years ago). Once when she and her husband were driving along a snowy road, she was startled to see brilliant green bushes, their leaves glittering with icicles, to either side of the road. Another day, she saw a rather shocking sight:
As we drove away from the beauty parlor, I saw what looked like a teenage boy on the front hood of our car, leaning on his arms with his feet up in the air. He stayed there for about five minutes. Even when we turned he stayed on the hood of the car. As we pulled into the restaurant parking lot, he ascended into the air, up against the building, and stayed there until I got out of the car.
