In the 1946 film "A Matter of Life and Death", complex partial seizures were portrayed in detail and with surprising accuracy. This study was conducted to determine the nature of the medical collaboration in the preparation of the film as well as the reasons why the creative team of Michael Powell and Emeric Pressburger included these details, but elected to make them invisible to all but those with medical educations.
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INTRODUCTION
The 1946 English film, A Matter of Life and Death
1, starring David Niven, Roger Livesey and Kim Hunter, merits special attention from those interested in epilepsy. Written, produced and directed by Michael Powell and Emeric Pressburger (the creative team known as the Archers), the film includes a detailed description of complex partial seizures resulting from a head injury and probably subarachnoid haemorrhage. The intent of this paper is to bring attention to their scholarship and craftsmanship and to ask for assistance in determining one final question about the making of this film.
THE STORY
David Niven portrays an RAF pilot, Peter Carter, whose bomber is critically damaged during a mission flown 3 days before the end of World War II. He has given his parachute to another crewman, so he has no way to survive the impending crash. As the story begins, he is having by radio what he expects to be the last conversation of his life with June, an American air controller, played by Kim Hunter. Each quickly develops strong feelings for the other, but soon Peter must sign off. Then, turning to his dead co-pilot and saying that he expects to join him in Heaven in a few minutes, he jumps from his plane into the foggy sea.
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To Peter's great surprise, he awakens on a beach and determines that he is not in Heaven, but rather in England. Better yet, June happens to be riding home from the airfield on her bicycle. When they recognize each other, they fall instantly in love.
All would be well except that something unusual is taking place in two realms. In England, Peter begins to have short, unpredictable spells of altered consciousness and hallucinations. Peter is evaluated by Dr Frank Reeves, played by Roger Livesey. Ultimately brain surgery is performed to save Peter's life. Meanwhile, in Heaven, the supervisor angels are quite disturbed that this pilot did not arrive at his proper destination and they dispatch a Heavenly conductor, Marius Goring, to pick him up. It is this angel that visits Peter in his spells of altered consciousness. During his final spell on the operating table, Peter appeals this decision of death before a Heavenly tribunal and, happily for all, Peter wins his case in both realms.
A CASE HISTORY OF COMPLEX PARTIAL SEIZURES
This is not a medical film, but rather a fantasy of love and the interplay of American and English cultures. Yet this film depicts clinical details in such an accurate way that a clinician might diagnose the probable site of the lesion.
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Details gleaned from the story reveal a clinical history (Table 1) as well as a description of the spell (Table 2). These details permit the formation of a differential diagnosis.
- Diagnosis proposed by physician in the film: "chronic adhesive arachnoiditis (from concussion two years earlier) affecting the olfactory nerve." Dr Reeves says he saw this condition at the l'Hopital de la Pitie in Paris.
- Diagnosis proposed by this author: Recent concussion resulting in increased intracranial pressure and complex partial seizures probably due to an epidural haematoma or a subacute subdural haematoma. Because the neurological examination elicits a left superior quadrantanopsia suggesting damage to the visual fibres in Meyer's Loop, the site of injury is most likely the right temporal lobe.
THE STORY BEHIND THE STORY
As World War II drew to a close, British public officials became concerned that co-operative relationships between Britain and America would deteriorate under the strain of post-war complications. Jack Beddington, Minister of Information, approached Michael Powell and Emeric Pressburger in 1944 to ask them to make a film that would depict those close relationship between the two countries 2.
Powell and Pressburger produced a number of films during an intense period of unique collaboration in which both shared responsibilities and credits for writing directing and producing. Their films include, 49th Parallel (1941), One of Our Aircraft is Missing (1942), The Life and Death of Colonel Blimp (1943), A Canterbury Tale (1944), I Know Where I'm Going (1945) and later, Black Narcissus (1947), and The Red Shoes (1948).
Pressburger had found a newspaper account of an English airman who had actually survived a fall from a plane into the sea. Together Powell and Pressburger developed the fantasy of a pilot claimed by both Heaven and Earth, with the intent of making both realms as real as possible.
Powell sought out the advice of his brother-in-law, Mr. Joseph P. Reidy, a plastic surgeon. Mr. Reidy was busy collaborating in the care of injured British and American airmen at Stoke Mandeville Hospital with Dr Hugh Cairns, Professor of Neurology, Oxford 3. In Mr. Reidy's personal correspondence he stated, "He (Cairns) would deal with the brain injuries and I would deal with the external cover" 4. Mr. Reidy provided medical references as well as the idea
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Table 1: Case history
Peter Carter: 27 year old right handed man
Lecturer at Cambridge in Poetry; Master Bomber, RAF four years;
No significant illnesses, no psychiatric history;
Two years previous to admission: concussion with no sequellae;
Past six months: right fronto-temporal headaches, eating and drinking more;
Most recent injury: fall of undetermined distance into sea.
Events prior to coming to surgery: (times are approximate)
Hour 0: Unconscious for an unknown period of time. When awakens on beach there is little or no evidence of retrograde amnesia since he is able to recognize a woman's voice he has heard just before the fall. Able to run, walk, and talk without apparent problems.
Hour 6: First 'spell' lasting less than a minute.
Transient reduction in left field of vision.
Hour 30: (day 2): Aura. Examined by physician. Has developed a permanent left superior quadrantanopsia.
Becoming slightly anxious.
Hour 54 (day 3): Second 'spell' awakening patient from sleep. Increasing weakness, apprehension, headache and confusion.
Hour 78 (day 4): Third 'spell'. Insomnia, other symptoms increasing. Possible dilated right pupil and possible Babinski on left.
Hour 84: Fourth 'spell' during surgery.
Table 2: Description of spell
Stereotyped, unpredictable, lasts from seconds to a minute. Level of consciousness is not directly tested by onlookers. Always begins with a smell of fried onions. Sometimes accompanied by hearing a stereotyped musical phrase. Spell evolves so rapidly that the patient cannot call for help although he tries to do this.
Then time seems frozen to the patient. Has a complex visual/aural hallucination which has repeating thematic elements of impending death.
Postictally, has headache and confusion. May walk about. Is pale and diaphoretic. Has lingering feeling of apprehension.
for a neurological condition which could produce hallucinations in a psychiatrically normal man. Michael Powell later wrote that among the medical texts he had consulted, one stated in part "increasing pressure in the brain can produce highly organized hallucinations, comparable to an experience of real life, a combination of vision, hearing and of ideas ..."
5. He also found a line in a text which helped him shape the concept of the film: "This illusion can take place in space but not in time" 5. This phrase took hold of Powell's imagination and later was included in a speech made by the Heavenly Conductor, as well as becoming a major theme in Mr. Powell's autobiography 2. Powell made extensive medical notes and integrated them into the script. He may have made hospital rounds with an unnamed British neurologist 5.
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Mr. Reidy could not recall whether he specifically suggested complex partial seizures as the condition that could provide the dramatic device connecting angels and men 4, yet the choice of seizures is a perfect dramatic device, allowing a person to have unusual experiences that others do not share. While Powell does not refer to the spells as seizures, he does portray them accurately and without trivialization. The story does not require such accuracy and yet he provides it, even thought at accuracy is invisible to most viewers. This transparent accuracy was a deliberate artistic choice in many of Powell's films. He believed that by the addition of details such as these, the audience would be subconsciously drawn further into the story without knowing exactly why 2.
A NEUROLOGICAL TALE
This film contains a portrait of a physician with neurological training arriving at a diagnosis of complex partial seizures.
The physician, Frank Reeves is described as a country doctor, educated in Edinburgh, and having been published in Brain. We are introduced to him as he is looking over his village through a camera obscura mounted in his attic. He mentions that he has come to several diagnostic conclusions while observing his patients at a distance. The move depicts a neurological history and examination that reveals to the audience Peter Carter's visual field defect. His field of vision is shown through the lens of the camera on the screen. The meaning of this detail cannot be discerned unless one has neurological training. Some critics noticed the neurological details, but misinterpreted them. One critic stated that he believed the detail of 'fried onions' to be a dramatic touch:
"In each film of Powell's this romantic urge sports a different livery- co-existing with the everyday and with an only mildly pusillanimous humour - the Heavenly Messenger is always heralded by the smell of fried onions ... 6"
There is a depiction of 'seizure monitoring' in Dr Reeves' home, which many contemporary epileptologists will recognize. Peter is brought to Dr Reeves' home for continuous observation and instructed to reach for a bell at the bedside
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when he notices the onset of the next episode of the odour of onions. Moreover, the film contains an apt description of the unpredictability of both seizures and Heavenly Messenger: "The messenger will return in his own time".
The operating room is the setting for some other interesting touches. Those who conduct continuous EEG monitoring during epilepsy surgery will recognize that spike and wave activity can take place during surgery. Peter has a spell during his operation and is seen to rise out of his body to observe himself and the surgery. In the film the Earthly realm is shown in technicolor while Heaven is shown in black and white. Powell wrote that the operating room makes a perfect bridge between the two, because most colour in the room is covered by white drapery and gowns 2. Powell added a further humorous touch when he reveals to the audience in the last scene of the film that the Judge of the Heavenly Tribunal is also Peter Carter's neurosurgeon.
Most intriguing is an event in the film which may be accidental or deliberate. The scene in which Pete Carter is examined by Frank Reeves takes place in a military club recreation area. Nearby, soldiers practice a scene from "A Midsummernight's Dream". Felix Mendelssohn's "Incidental Music for a Midsummernight's Dream" is playing in the background. The choice of this music may be only to echo the romantic story, but there is another interesting epilepsy connection. Sir Victor Horsley performed the first epilepsy surgery with Hughlings Jackson in attendance in 1886. Sir Victor Horsley's grandfather was a close friend of Mendelssohn and Mendelssohn may have first performed this work in the elder Horsley home 7.
HOW DID POWELL AND PRESSBURGER DEVELOP THEIR NEUROLOGICAL EXPERTISE?
This question can only be answered in part.
- Powell used as dialogue in the film some statements from texts he had consulted. For example, he had Dr Reeves say, "... highly organized hallucinations comparable to an experience of real life, a combination of vision, hearing, and ideas ...." 1
- Emeric Pressburger, a Hungarian who had fled to England as World War II approached, had read a 1939 non-fiction account, Journey 'Round My Skull, by the Hungarian writer Frygers Karinthy 8, 9.
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In it, Karinthy recounted his experiences with a brain tumour, what seem to be complex partial seizures and surgery by the Swedish neurosurgeon Herbert Olivecrona. Several passages seem reminiscent of images or ideas in the film (a) Karinthy recounts attending an amateur film festival where he sees a film of the Boston neurosurgeon Harvey Cushing performing brain surgery for epilepsy; (b) Karinthy's seizures had symptoms that included hearing a characteristic sound - a train. Later as the tumour grew, he heard "an unseen hurdy gurdy grinding out a tune which I heard only as I walked"; (c) One chapter, entitled "Death Tempts Me", describes a visit from a doctor that later proves to be a hallucination; (d) Karinthy's brain surgery was performed with Karinthy being awake and one part of one chapter describes his out-of-body experience "like a sequence from a film" of rising up from the operating table and moving around to observe Olivecrona operating.
The complete answer about the source of medical information may never be known. Powell's widow, Thelma Schoonmaker Powell, says that the extensive notes Michael Powell took may have been discarded 10. She mentioned that, when attending retrospective film seminars, people often would approach Mr. Powell to say that he had described a condition similar to something that they had experienced. Kim Hunter stated that after the film came out and she was hospitalized with appendicitis, she recalled the doctors and nurses commenting on how accurate the operating room scenes were 11.
We can only wonder whether Powell read any of the early descriptions of dreamy states first identified by Hughlings Jackson 12 in the late 1880s and subsequently by Gowers 13, Crichton-Brown 14, Kinnier Wilson 15 and others. Jackson specifically wrote about seizures with thematic elements of impending death 16. Some questions remain unanswered. What texts provide the lines of dialogue that shaped this film? Who was the neurologist neurosurgeon who provided Powell with medical advice and from which hospital? Eric Warman produced a book of the film in 1947, which included surgical details only a practicing physician could easily know. Who was the person who assisted Eric Warman with his book of the film 17? Were Powell and Pressburger influenced by the fictional literature concerning epilepsy and Heaven, including Dostoevsky's The Idiot 18, or Washington Irving's biography of Mohammed 19?
[Steve's Note: There appear to be two statues of Mohammed on the stairway. But we, quite correctly, never see his image. We only see the name on the plinth. I say there are two because the name is seen twice, and in the time between the two sightings the staircase would have moved past quite a few statues.]
The most pleasant part of this film though is what we hope for all persons who have seizures; that they will achieve control over the seizures and that they will be loved by someone who looks through the seizures into the person's heart.
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ACKNOWLEDGEMENTS
The author appreciates the generous assistance of Mr. J. Reidy, Mrs. Thelma Schoonmaker Powell and Elaine Wyllie MD in the preparation of this paper.
REFERENCES
- Pressburger, E. and Powell, M. A Matter of Life and Death. Great Britain, J. Arthur Rank, 1946.
- Powell, M. A Life in Movies. New York, Alfred A. Knopf, 1987.
- Reidy, J. Burns II. Skin cover for full-thickness skin loss. British medical Journal 1950; 2: 1030-1033.
- Reidy, J. Personal Communication, 1990.
- Badder, D. Powell and Pressburger: the war years. Sight and Sound 1979; 1:8-12.
- Durgnat, R. Durgnat on Powell and Pressburger. In: Powell, Pressburger and Others (Ed. I. Cristie). London, British Film Institute, 1978: pp. 79-104.
- Taylor, D. One hundred years of epilepsy surgery: Sir Victor Horsley's contribution. In: Surgical Treatment of Epilepsies (Ed. J. Engel, Jr.). New York, Raven Press, 1987: pp.7-11.
- Karinthy, F. A Journey 'Round My Skull. New York, Harper and Bros., 1939.
- Ian Cristie. British Film Institute. Personal communication, 1991.
- Thelma Schoonmaker Powell. Personal communication, 1991.
- Kim Hunter. Personal communication, 1991.
- Jackson, H. Epileptic attacks with a warning of a crude sensation of smell and with the intellectual aura (dreamy state) in a patient who had symptoms pointing to gross organic disease of the right temporo-sphenoidal lobe. Brain 1899; xxii: 534-549.
- Gowers, W. The Hughlings Jackson Lecture. Brain 1910; 21:303-326.
- Crichton-Brown, J. The Cavendish Lecture on dreamy mental states. Lancet 6 July 1895; 1-5 and 13 July 1895; 73-75.
- Wilson, S. The psychical components of temporal (uncinate) epilepsy. Modern Problems in Neurology. London, Edward Arnold and Co., 1928: pp. 51-75.
- Greenberg, D., Hochberg, F. and Murray, G. The theme of death in complex partial seizures. American Journal of Psychiatry 1984; 141: 1587-1589.
- Warman, E. A Matter of Life and Death. London, World Film Publications, 1946.
- Temkin, O. The Falling sickness, 2nd edition. Baltimore, John Hopkins Press, 1971; pp.370-395.
- Irving, W. Life of Mahomet. New York, E.P. Dutton and Co., 1911.
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