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Last Updated on May 6, 2015, by eNotes Editorial. Word Count: 1699

In his new foreword, Sacks pays tribute to his mentor, the great Russian neurologist A. R. Luria, who founded the field of neuropsychology and created a rich new form of clinical biography. Luria spoke of the “classical” (analytic and reductionist) and “romantic” (holistic and existential) tendencies in medical science and...

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In his new foreword, Sacks pays tribute to his mentor, the great Russian neurologist A. R. Luria, who founded the field of neuropsychology and created a rich new form of clinical biography. Luria spoke of the “classical” (analytic and reductionist) and “romantic” (holistic and existential) tendencies in medical science and of how these approaches needed to be combined in the care of patients. In writing Awakenings, Sacks has tried to combine both approaches, to go beyond the clinical case histories of his patients to capture their interior lives, the subjective dimension of their imprisonment and sudden release with L-Dopa. From the poet W. H. Auden, his other mentor, Sacks discovered the value of parables and metaphors in conveying these experiences. In trying to combine what he calls the “biological” and the “biographical” dimensions of his patients’ afflictions, Sacks has transformed the medical narrative into a rich new literary genre, one full enough to encompass a precise clinical discussion of sleeping sickness and its development into parkinsonism; to include personal narratives of the awakenings of his twenty patients; and to offer clinical and philosophical perspectives on their affliction.

More than a collection of neurological case histories, Awakenings is a deeply moving testimony to the possibility of hope for people trapped by disease in strange and almost inconceivable worlds yet who are in other ways indistinguishable from their fellow human beings. As Sacks indicates in his new preface, his central concern is to show how his patients struggled to maintain their human identities under the most adverse circumstances, to show “what it was like to be human, to stay human, in the face of unimaginable adversities and threats.” As a physician, Sacks tried to understand his patients as people and not merely as pathological case histories, maintaining with them, in Martin Buber’s terms, an “I/Thou” and not an “I/It” relationship. His goal was to reveal his patients in the full emotional contexts of their lives, to depict the terrible isolation of a progressive, degenerative disease, the sudden awakening, years later, and the brief hopes and excruciating disappointments of L-Dopa therapy. Sacks pays tribute to the tremendous courage and fortitude of his patients, admitting that he often learned more from them than he could ever acknowledge. Through Sacks’s narrative depictions, each of his patients emerges as a real, unforgettable person with whom the reader identifies. The reader finds himself caring deeply about their fates and rediscovering the power of the imagination to awaken empathy and concern for others.

Even with his most severely disabled patients, Sacks conveys a sense of the personality, mannerisms, and dignity of each individual. Rose R., for example, was a lively and vivacious young socialite who was struck down by sleeping sickness at twenty-one and awakened twenty years later. At first, she seemed hyperactive and disoriented, unaware of the passage of time, but as she realized what had happened to her she relapsed into parkinsonism, overwhelmed with sadness at the knowledge of what she had lost. Miriam H. contracted sleeping sickness at twelve and suffered from progressive, degenerative parkinsonism for the next thirty-seven years, until she awoke at age fifty-five and began to create a new life for herself. One of the few patients who was able to tolerate the sustained use of L-Dopa, she now enjoys excursions outside the hospital, keeps a diary, reads voraciously, and is a terror at bingo. Not all patients, however, did as well. Leonard L., once a brilliant graduate student at Harvard University, was speechless and severely withdrawn until he was given L-Dopa, at which time a remarkable transformation took place. He awoke to a feeling of radiant good health and typed out a fifty-thousand-word autobiography in the three short weeks of recovery that he enjoyed until he suffered a violent relapse. Sacks writes that even in that short period of time, he learned more from Leonard L. than from any of his other patients.

As he studies these case histories of postencephalitic parkinsonism, the reader is shocked by the utter caprice of the original sleeping sickness epidemic, which started in 1916-1917, that struck Sacks’s patients in their childhood or early adulthood, irrevocably isolating them from their families. Every case was unique, every patient’s sense of loss was devastating, and every patient struggled to come to terms with the disease that had robbed him of the better part of his life. Each had a unique life history suddenly squelched, until the possibility of a “cure” was offered. As Sacks points out, the sense of health is so deep and innate that it was difficult for these patients to accept the fact of their illness. The transition from health to illness involves both a physical and a metaphysical change. The onset of their illness evoked in Sacks’s patients a deep sense of loss, along with a desperate hope of regaining that lost state of bliss. His patients felt cheated of their potential and they became frantic for reprieve, rescue, regeneration, or redemption. As the disease progressed, some patients lapsed into hopelessness and despair, while others felt a deep outrage at being swindled out of the best years of their lives; they yearned for a miracle, for the recovery of their health and of the years they had spent in limbo. Some clung to unrealistic hopes for a magical drug or an elixir that would cure them of their ailments. When the drug L-Dopa appeared in the 1960’s, it appeared to be such a cure. Researchers had discovered that the affected parts of the brain of parkinsonian victims were deficient in the nerve-transmitter dopamine. Early attempts to treat parkinsonian patients with minute doses of L-Dopa, however, were not successful. Then, in 1967, George Cotzias reported favorable results with dosage levels a thousand times greater than the dosages that had been used previously. As soon as he could, Sacks began to treat a group of severely afflicted patients at Mount Carmel, hoping for some improvement in their condition. The results were so startling and unpredictable, he was eventually led to reconsider the entire pathology of parkinsonism, since there was no effective way to adjust the medication to balance the drug’s benefits and its other, ravaging, effects.

Sacks soon discovered that administering L-Dopa to his patients created an “all-or-nothing” situation: The awakenings carried with them strange and paradoxical difficulties. Many of his patients alternated between moods of euphoric excitement, with strange arousals and many uncontrollable motor difficulties—tics, spasms, contortions, hysteria, and hallucinations—and devastating regressions into deep depressions and catatonic withdrawals. Sacks naturally wondered what was happening, and he was compassionate enough to empathize with his patients’ hope, excitement, frenzy, disillusionment, and despair. Sacks realized that the impact of parkinsonism was not merely on the motor functions; there was a corresponding mental slowness, or “stickiness of mind,” as though his patients’ thoughts were as slow and ponderous as their motions. He came to reject the mechanistic brain-mind dichotomy as untenable, as simply inadequate to describe the complex symptoms he witnessed. He also objected to the clinical reductionism of modern clinical neurology, which did not do justice to the complex reality of these patients. Sacks believed that the language of science was descriptively inadequate, that he needed a richer, more symbolic language. There was more than a chemical drama involved in his patients’ efforts to rebuild their lives after as much as forty years of isolation from the world.

As Sacks makes clear in “Perspectives,” the last part of his book, his experiences with his patients at Mount Carmel have forced him to rethink his entire concept of health and illness and to construct new formulations, based on the metaphysics of Gottfried Wilhelm Leibniz. He rejects mechanistic, Cartesian dualism, considering it responsible for the tendency among modern medical practitioners to deny the individual behind the disease and attempt to treat the disease alone. Sacks argues that in an irreducible way, the disease becomes the victim and the victim the disease; the symptoms cannot be separated from the suffering patient. One cannot launch an attack on the disease alone, he cautions, with total disregard for the responses of the patient. There are mental as well as physical landscapes of disease, terrains that cannot be mapped by the medical chart alone. “The work of healing, of rendering whole,” he reminds the reader, “is, first and last, the business of Love.” Repulsed by the dry clinical papers written about the response of patients to L-Dopa, devoid of any understanding of what it was like to suffer from postencephalitic parkinsonism, Sacks decided to write by example instead, to use rich, detailed case studies to convey the individual history of each patient. In these studies, disease and health seemed to exist in a perpetual conflict within each patient; thus, there was never any clear indication of how a patient would react to the medication. Although each person’s age, strengths, temperament, and past history contributed to his or her response, in general, Sacks was able to construct a paradigm of the disease in which he discusses the consequences of treatment with L-Dopa. In his third edition of Awakenings, he updates the postclinical responses of his original patients, indicating how they have fared since 1973.

The most analytical part of the book, “Perspectives,” contains a brilliant philosophical discourse on the nature of disease and health, followed by a discussion of the pattern of awakening, tribulation, and accommodation that Sacks witnessed among his patients. His epilogue contains a passionate appeal for a more profound and humane practice of medicine, one that will take fully into account the psychosomatic dimensions of disease, the individual psychic balance or inner harmony of each patient—which Sacks likens to a musical score, on tempo for the healthy patient but somehow tragically awry for the parkinsonian patient. Using another metaphor, he compares the parkinsonian victim to a chaos of broken clocks; the patient exists in a “relativistic delirium.” The epilogue concludes with “The Aftermath of Awakenings,” a brief update on each of the twenty patients and an appendix of electroencephalograms (EEGs) of his patients taking L-Dopa which shows the heightened electrical activity stimulated by the drug and the subsequent relapse into inactivity.

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