people, that is, on deaf people as an ethnic group, rather than as individuals who have a medical problem. In some ways, though, this is an annoying book: there are simply too many, too lengthy footnotes. I see no reason why virtually all of the points raised in Sacks' so-called “imaginative excursions” couldn't have been integrated into the text. It would have made for a more enjoyable read.

SOURCE: Wiltshire, John. “Deficits and Enhancements: Reflections on the Writings of Oliver Sacks.” Cambridge Quarterly 20, no. 4 (1991): 304-21.

[In the following essay, Wiltshire provides a survey of Sacks's writings and attributes his success to his “capacity to turn deficits into wonders.”]

‘Neurology's Favourite Word is “Deficit”, denoting an impairment or incapacity of neurological function,’ writes Oliver Sacks at the opening of his very successful collection of case studies, The Man Who Mistook His Wife for a Hat: ‘loss of speech, loss of language, loss of memory, loss of vision, loss of dexterity, loss of identity and a myriad other lacks and losses …’ Much of the book's success (the title study has been made into a filmed opera) can be attributed to Sacks's capacity to turn deficits into wonders, to write about cases of sometimes extraordinary human loss in a way that reveals the scarcely visited reaches and capacities of the mind. Sacks's writing has interested a large general public in medical and neurological matters, for his books are entertainments which at the same time argue intensely and emotionally for the conviction that neither medicine nor neurology can be mechanical sciences, and that above all the experience of the individual patient is important. It is nearly twenty years now since ‘The Great Awakening’, the article which anticipated his most famous book Awakenings, was published in The Listener in 1972, and hailed by subsequent correspondents as ‘of truly breath-taking importance’ in its attempted synthesis of metaphysics, psychoanalysis and neurology.¹ The publication of his recent book, Seeing Voices,² which is also a study of people commonly accounted defective, the deaf, but which for much of the time takes the author beyond his medical speciality, is an opportunity to survey the whole body of his writing, for in its mixture of history, medical exposition, and passionate advocacy, this book reveals in an extreme way some of the problems and personal endeavours which seem to underlie his work, and which make it too, I believe, sometimes implicitly, a fascinating commentary on the medical world.

Throughout his writings Sacks has focused, more intently, and more imaginatively than any previous physician-writer, upon the life and experience of the individual patient. To recognize that each migraine sufferer has his or her own different constellation of symptoms, and different precipitating circumstances, that response to the same doses of the same drug will vary radically in different patients, was to put into question immediately some of the premises of functional, mechanistic neurology, and to emphasise the importance of what the French call the terrain, the constitution or receptivity of the patient. Sacks's interest in psychoanalysis, and his regard for Freud's case-histories (which he cites as models for his own), as well as his respect for the ‘romantic medicine’ of the Russian neurologist A. P. Luria, led him to believe that it was important, too, to tell the patient's story—that understanding and telling the patient's story is the right way both to practise medicine and to write it. ‘My own practice and orientation,’ as he described it in 1985, ‘though making use of whatever knowledge I may have as a neurologist and psychologist, has moved strongly towards that of the general practitioner, and strongly away from a medicine dominated by specialists.’ This movement away from interventionist and drug-based medicine has been accompanied by a shift to a more ‘popular’ style and focus in his writing.

In the Preface to Awakenings, and speaking of his hesitation about publishing the episode of medical history it recounts, Oliver Sacks writes of his patients that ‘it devolves on me to tell their story, since their story is unique, and there is no-one else to tell it.’ To argue that each patient's experience is unique, and to recognise that the brain does not work as an aggregate of separate functions but is in some way creative, even in response to damage and deficiency, is one thing: but to write medical narratives is another. ‘Telling the patient's story’ is the literary enterprise that Sacks embarks on in his three major books, Awakenings,A Leg to Stand On and The Man Who Mistook His Wife for a Hat, but if Freud is a model, he is also a warning. The doctor who undertakes to write his case study as a short story is vulnerable to the problems that beset Freud: for not only did his patients have desires and ambitions which they projected upon him, and which he was quick to recognise and perceive, but he in his turn had projects and fantasies which his patients unconsciously served, and these he only partially and belatedly recognised, and could not escape from. As in the now-notorious instance of the ‘Dora’ case history, Freud, in David Ellis's words, therefore ‘is drawn out from his security behind the couch to become as much an incitement to the reader's thought and curiosity as Dora herself.’³ The story of a patient cannot be told, in anything like completeness, without implicating the doctor who treats him or her, putting the position of the doctor at least to some extent in question—which happens to be peculiarly difficult to do consciously within the framework or format of the case history.

From his first book, Migraine: The Evolution of a Common Disorder in 1970 to Seeing Voices, Sacks has moved further and further away from the position and style of the professional physician addressing other professional physicians. As his work has evolved, so has his position changed, and his shift towards a more general approach (which involves, of course, a change of values and style) is marked by the continual revisions, cross references and allusions that occur among his books. Thus when the book on migraine was republished in 1985 it was as Migraine: Understanding a Common Disorder, much rewritten, so as to focus ‘more directly upon the patient himself’ with conclusions that are ‘broader, and deeper, and more personal’ but it is, in a way that is characteristic of Sacks's writing, incompletely rewritten, and incompletely reorientated towards the patient. The most striking new section concerns the horror of migrainous ‘scotoma’, ‘which may be felt not just as a failure of sight, but as a failure of reality itself’, an uncanny ‘hole in the world’, accompanied by a sense of violation, related partly through the striking first-person narration of a patient. This seems to reflect Sacks's nightmare experiences as recorded in A Leg to Stand On and to link up with some of the case-studies of Awakenings, though in neither edition of the migraine book is it disclosed that the writer was a migraine patient himself. The Listener article, ‘The Great Awakening’, followed a series of pieces in which Sacks and his professional colleagues commented upon various aspects of treatment of Parkinsonian patients by the so-called ‘wonder drug’ L-dopa, which were contributed to medical journals: there is much overlap of phrases and paragraphs between these articles and the later book Awakenings (1973), but also many omissions and changes of emphasis. The second edition of Awakenings (1976) partly documented in a great many footnotes Sacks's increasing bent towards what one might describe as the metaphysics of health and sickness; the third edition of 1982 includes much significant re-writing in the Introduction, a follow-up of surviving patients and an Epilogue. In October 1974, whilst on holiday in Norway, Sacks fell and badly damaged his leg and it was whilst convalescing from the surgery which followed this accident that (as I should guess) he wrote the footnotes for Awakenings. The story of this experience was told eventually: first in an article entitled ‘The Leg’ in the London Review of Books in 1982 and subsequently in A Leg to Stand On (1984). Thus the experiences of patienthood intervene between—and partially impact upon—the writings of the doctor. This rather intricate bibliographic history is interesting because it dramatises the ways in which Sacks's work has attempted to leap, span, and might be said in fact to be fractured by spanning, the two worlds of the professional doctor and the patient.

Sacks's early book on migraine is interesting because of its argument that migraine is simultaneously an organic and a functional illness, ‘a physical event which may also be from the start, or later become, an emotional or symbolic event.’ Both the physical and the symbolic must be treated by the physician, and therefore the specialist in migraine (and the book elaborately, even exhaustively, documents the author's claim to be such a specialist) must be, too, a kind of holistic psychotherapist, who understands the circumstances of the patient, and addresses, to some degree, the patient's emotional and family life. In the newly written parts of Migraine, Sacks expands on the concept of a ‘humane medicine’: ‘The Physician must indeed, have Authority; and the patient likewise, have Faith; there is not just technical but a moral relation between them …’ It is a measure not only of the direction that Sacks's convictions have taken but of the contrary direction of current American medical practice that such a position must now be affirmed in what look like quasi-transcendental terms.

Reading A Leg to Stand On takes one to the heart of the preoccupations and difficulties out of which—or so I imagine—his work both as a doctor and a writer springs. ‘The book may be regarded as a sort of neurological novel or short story, but one which is rooted in personal experience and neurological fact’, writes the author in the Preface; and perhaps ‘neurological novel’ is designed to allude to Freud's famous (and rather defensive) description of his case-studies as ‘short-stories’, as well as to suggest that this is a neurological story, not—however it may seem—a psychoanalytic one. A Leg to Stand On is an account of Sacks's descent into the underworld of patienthood, which is to put it a little melodramatically perhaps, but in a mode that reflects both the experience itself and the tone with which it is rendered. Speaking in the Preface of the paralysis of his leg, and the ‘abyss of bizarre, even terrifying effects’ into which injury plunged him, Sacks writes, ‘I found the abyss a horror, and recovery a wonder; and I have since had a deeper sense of the horror and wonder which lurk beneath life …’—a sense that as I've already suggested plays its part in the rewritten Migraine book.

High on a Norwegian mountain side, miles above the nearest village Sacks, a confident and vigorous climber, is cornered by a bull, flees from the encounter, falls and discovers his left leg crushed and useless beneath him. His account of the accident and of his reaction, his gathering his wits about him, and managing to strap the injured leg to his umbrella, and then begin the painful desperate slide back into the village thousands of feet below, is vividly and movingly told, and touches on a leitmotif which runs through all his work. ‘The organism, the nervous system, has an immense repertoire of “trick movements” and “back ups” of every kind … we would have no idea of the resources which exist in potentia, if we did not see them called forth as needed.’ The damage to his leg is so extensive that he is soon on the way to London, and an operation by a surgical specialist. He enters that ‘betrayal funnel’ which Erving Goffman memorably described as the lot of psychiatric patients—the process by which the person becoming an inmate of any hospital is, with their personal clothing and effects, insidiously stripped of identity, initiative and will. ‘I felt curiously helpless … and I thought, “Is this what ‘being a patient’ means?” Well, I have been a doctor for fifteen years. Now I will see what it means to be a patient,’ a reflection that occurs after Sacks has been refused his request for a spinal anaesthesia (‘For then I could see what was happening’).

One needs to remember the description of A Leg [A Leg to Stand On] as a ‘novel’, for there are some discrepancies of fact, and some omissions in the book as compared with the earlier article. In general the writing in the article is crisper, there is less attention to the patient's inner states, and the argument is rather more about medical politics and patient management. One of the most interesting divergencies between the two accounts occurs at this point, for the article includes a reminiscence that is omitted from the book:

I had asked to be put with the other patients in the ward. ‘You can't do that’, I was told. ‘You're a doctor. You must have a room of your own.’ But when I asked if it might be possible for the operation to be done under spinal anaesthesia, I was told that that too was out of the question. ‘Can't have patients watching their own surgery.’ Two years before, my mother, who was a surgeon herself, had had to have some major surgery. She had asked if this could be done under spinal anaesthesia, with an oblique mirror set up in such a way as to enable her to watch her own surgery. The surgeon, an old friend of hers, was delighted to comply—and she, in turn, took real delight in watching, and afterwards in describing to me, the ‘beautiful’ anatomy and the skill of the surgeon. Not only had she enjoyed, and, in a sense, ‘participated’ in the procedure, she had also avoided the terrors of uncontrol and passivity. I was deeply annoyed, though I said nothing, that this was not permitted to me.⁴

This mirror image and its omission might occasion multiple reflections. Such a simple, technological resolution of the dilemma of being a patient who is also a doctor is not available to Sacks himself. ‘The terrors of uncontrol and passivity’ are not merely those of a common or garden patient, but of a patient whose doctorhood might have been arrived at, it seems, partly as a defence against the invasion of just such fears.

The passage about the narrator's mother vanishes then from the final text, but she returns, obliquely, when, after his operation, he is visited by a reassuring maiden aunt. This visit follows an uncanny, nightmarish aftermath of the surgery, in which the narrator feels that he has lost his leg forever, and desperately, but unavailingly, seeks reassurance from the medical staff who visit him. In particular he expects attention and what he calls repeatedly, ‘authority’ from the surgeon. ‘What I could not do for myself in a hundred years, precisely because I was entangled in my own patienthood and could not stand outside it … he could cut across with a single stroke, with the scalpel of detachment, insight and authority.’ A Leg to Stand On, (63). But ‘Swan’, the surgeon, appears as the stock type of brisk, curt, unfeeling doctor who almost inevitably inhabits the pages of hospital patients' reminiscences (compare the technologically orientated and ruthless Dr P, for instance, in de Beauvoir's Une Mort Tres Douce) who has no time for his imaginative and demanding patient and who dismisses all Sacks's terrors:

‘Nonsense, Sacks,’ he said sharply and decisively. ‘There's nothing the matter. Nothing at all. Nothing to be worried about. Nothing at all!’

Since no mortal man could answer the demands that the helpless and desperate patient places upon him, Swan becomes a mythological being symbolising an uncaring medicine, whose callous dismissal of his patient's appeals speaks through even his Registrar. In response to Sacks's final desperate plea that ‘the leg doesn't feel right’, that it's ‘wooden, not flesh, lifeless, not mine’, the Registrar replies ‘Sacks, you're unique … I've never heard anything like this from a patient before’, (74) a reply that plunges the narrator into panic, into what he goes on to describe as ‘the hell of communication denied’ (77). There are moments in the book when the narrator imagines what Swan, as a private individual, might feel, and reflects on the falsity of their relationship (‘he [in] the role of the All-knowing Specialist, I [in] the role of the Know-nothing Patient’) but these are moments only, quickly wiped out by a further rejection. The reader reflects more sympathetically on the position of ‘Swan’, faced with this demanding patient who is moreover himself a famous neurologist, whose recent book (as he may well know) about patients has a great succes d'estime … but thoughts like these are not in the book. During his recovery, it is true, the narrator recovers some self-possession. ‘Although I knew, at some level, all the time, that he was a decent man, and so was I, … yet I couldn't shake off the nightmare feeling which had lain on me …’ Swan is glimpsed as just an ordinary human being, who cannot have any wish to play ‘ogre in my dream’ but the engulfing resentment persists—and is certainly strong still in ‘The Leg’. Swan remains a half-imagined and hated part-object, throughout the book—it is as if the narcissistic wounding that the surgeon has inflicted could never be healed over by adult revision. The narrator's aunt does seem to feel that there is something pathological in his reaction and she offers some advice:

‘… you mustn't expect too much from the surgeon … He'll have all sorts of limits—we all do. Professional limits, mental limits and emotional limits, most especially …’ She stopped, arrested by some recollection or reflection. ‘Surgeons are in a peculiar position,’ she said at last. ‘They face special conflicts. Your mother—’. She hesitated, scanning my face. ‘Your mother was a dedicated surgeon, and a very gentle sensitive soul, and it was sometimes difficult for her to reconcile her human feelings with her surgery. Her patients were very dear to her, but as a surgeon she had to see them as anatomical and surgical problems. Sometimes, when she was younger, she seemed almost ruthless … It was only later that she achieved a balance—that essential balance of the technical and the personal.’

(62)

‘In hospital one becomes a child again, a child with parents (parents who might be good or bad) and this might be felt as “infantalising” and degrading or as a sorely-needed nourishing,’ the narrator himself writes (128). A psychoanalytic reading would be bound to discover, I think, that behind the surgeon's mask lies a rejecting and wounding mother. Perhaps the mother-surgeon was herself excised from the text because her own achieved self-sufficiency was too threatening to this vulnerable and demanding patient. One wonders too whether Sacks is not himself more psychoanalytically sophisticated than his writing allows him to appear.

All this goes to explain why the narrator feels the experience of his surgery and patienthood (two different horrors but blended) as so terrible. Sacks gives a vivid and at times harrowing account of the effects of neurological damage on his sense of his leg, the horror that swept over him when he felt that his leg was no longer part of his body, the dread of future permanent disablement. But the deepest of all his fears is the fear of being what he calls ‘unmanned’: it is not, I think, simply the ‘terror of passivity’, of being a docile and vulnerable patient, not, so to speak, of being feminised, but of being less than a whole man. He gives vivid descriptions of putting his hand down under his cast and feeling the wasted leg, discovering that ‘the muscle lay motionless as a deflated balloon’ (39). There seems to be a link between the notion of manliness and the notion of being a doctor and neurologist. The horror of being unmanned is associated with the horror of being stripped of one's ‘active, masculine, ordering self, which I had equated with my science, my self-respect, my mind’ (79). The whole constellation of meanings comes closest to the articulate surface in the passage which dwells on the patient's forebodings about the ‘casting room’ where he is to be taken to have the plaster removed:

The very term ‘casting room’ had a grim and frightful resonance. Even the word ‘cast’ took on disquieting other meanings. I found unbidden images rising in my mind—of the Casting Room as a place where they cast and cast away; where new limbs and bodies were cast by the Caster, and old and useless ones were cast away. Such fancies kept bursting into my mind, and I could not dismiss them, absurd though they were.

(88)

It does not take much imagination to see that one of the meanings that is present but not made conscious here is ‘castrate’ (later there appears from nowhere a frightening ‘caster’ who wields a pair of shears) but the meaning that seems to subsume and envelope both this and the fear of being ‘cast away’ is indeed the fear of ‘losing caste’.

When in the magnificent chapter on his convalescence Sacks the neurologist is no longer separated from other patients, and shares his story with them, he discovers that the horrors he suffered were others' too. ‘I heard of hands and feet which felt “queer”, “wrong”, “strange”, unreal and uncanny, and again and again the phrase “like nothing on earth”’ (125). Thus Sacks is able to see his experience as representative and ‘exorcise the fearful words of the surgeon to me: you're unique!’ (It isn't in fact, as remembered here, the surgeon but, as reported earlier, his Registrar who says this—thus the blind panic of infantile rejection is enacted.) Now the discussion can be conducted in the stable, sober terms of science, and Sacks moves to draw conclusions from ‘the sense of reason's violation, and its fundamental importance’—importance, that is, to the phenomenology and epistemology of illness.

But, as I have tried to suggest, there are many indications in the book that the narrator's plight was indeed ‘unique’ and that, though the physiological aspects of his experience would be shared with other patients, its actual constituents had a good deal to do with his peculiar status as doctor, and in turn with his family romance, as the son of doctors. To say this is only to apply the argument of Sacks's own work to his case: for the theory of the Migraine text is carried out in Awakenings and The Man Who Mistook His Wife for a Hat, which are devoted to the recognition of the patient as an individual whose neurological condition or deficit is given a unique turn by the circumstances of their nature and history. The Man is devoted to cases of patients who show spectacular and even sensational losses (and corresponding enhancements) of mental capacities, and whilst a certain freak-show interest is sometimes apparent (as in the titles such as ‘The Disembodied Lady’), what Sacks, as doctor, is interested is the way his patients live through their conditions, sometimes with triumphant adjustment, sometimes with the generation of unique abilities. It is not a simple matter of compensation (though Sacks describes here, as in Seeing Voices, the plasticity of the brain, and the capacity of different areas or centres of the brain, if I have understood aright, to adjust to, and partly supplement, the loss of a capacity in another part). Christina, the ‘disembodied’ woman who has lost her sense of ‘proprioception’, her sense of her own body and its physical place in the world, who is, as she says, ‘pithed’, nevertheless resumes her life by teaching her other sense to do the work of the one she has lost. Other instances concern idiots sauvages—the twins of subnormal intelligence, for example, who nevertheless display astonishing calculating abilities. In the chapter called ‘The President's Speech’, Sacks relates the reactions of a group of brain-damaged patients to one of Ronald Reagan's television performances. The patients, though they had lost the capacity to follow sense and meaning, were perfectly alert to tone, gesture and inflection, and at Reagan's most solemn moments, they laughed. It is a classic demonstration that language is more than propositional, and a marvellous example of Sacks's power to make the strangest of instances contribute to our knowledge of the universals of the mind.

One reflects here upon another way in which Sacks has been influenced by psychoanalysis, for just as psychoanalysis is able to view perversions as ‘neosexualities’, performances staged by the individual as creative solutions to psychological conflicts, warding off the even greater danger of psychosis, so Sacks can view his patients' behaviours, however bizarre, as he did migrainous symptoms, as ‘inventions’, as creative solutions to human dilemmas.⁵ And, at its best, this creativity of the patient is matched by the enthusiasm, wonder and mythologising capacity of their doctor's writing, an enhancement of a different sort.

Awakenings is the story of ‘the lives and reactions of certain patients in a unique situation’, the surviving victims of the epidemic sleepy sickness (‘sleeping sickness’ in America and the text), encephalitis lethargica, which swept over Europe in the aftermath of the Great War. Such victims often recovered from the disease, or seemed to, but later, sometimes several decades later, they would start to experience jerky tic-like movements, forced and hurried gaits, or on the other hand, states of frozen immobility or blocking, which made normal work and life impossible and eventually led to their institutionalisation. (These states are called ‘Parkinsonian’ on analogy with Parkinson's disease, a neurological disorder or deficit which also causes tics and jerky movements.) In 1967, a year after Sacks took charge of a large group of such patients in a New York hospital, it was announced in the medical press that L-dopa, a natural precursor of dopamine, a substance in the brain in which Parkinsonian patients are deficient, had achieved significant therapeutic results in the treatment of the disease. (The drug is now, in combination with others, very widely and successfully used in the management of Parkinson's disease.) Trials were immediately undertaken to discover whether patients suffering from sleepy sickness would also benefit. In 1969 Sacks started to administer the drug to individual patients in his care. The effects were astonishing.

Patients were awakened from their sometimes decades-long torpor, immobility and half-life, to a sudden freedom of movement; patients who had been dumb and motionless for many years, suddenly burst into speech, or got up from their wheelchairs and walked across the ward; whilst the positive effects of the drug lasted, they could sing, dance or play the piano. Several, with Sacks's encouragement, began diaries of their experiences. The most startling case was reported by Sacks to The Lancet in June 1970:

A striking example of forced reminiscence induced by L-dopa was seen in the case of a 63-year-old woman who had had progressive postencephalitic parkinsonianism since the age of 18 and had been institutionalised in a state of almost continuous oculogyric ‘trance’, for 24 years. L-dopa produced, at first, a dramatic release from her parkinsonianism and oculogyric entrancement, allowing almost normal speech and movement. Soon there followed (as in several of our patients) a psychomotor excitement with increased libido. This period was marked by nostalgia, joyful identification with a youthful self, and uncontrollable upsurge of remote sexual memories and allusions. The patient requested a tape-recorder, and in the course of a few days recorded innumerable salacious songs, ‘dirty’ jokes and limericks, all derived from party-gossip, ‘smutty’ comics, nightclubs and music halls in the middle and late 1920s. These recitals were enlivened by repeated allusions to then-contemporary events, and the use of obsolete colloquialisms, intonations and social mannerisms irresistibly evocative of that by-gone flappers' era. Nobody was more astonished than the patient herself: ‘It's amazing’ she said, ‘I can't understand it. I haven't heard or thought of those things for more than forty years. I never knew I still knew them. But now they keep running through my mind.’ Increasing excitement necessitated a reduction of the dosage of L-dopa, and with this the patient, although remaining quite articulate, instantly ‘forgot’ all these early memories and was never again able to recall a single line of the songs she had recorded.⁶

This becomes the story of ‘Rose R’ in Awakenings. Although the book concerns a group of post-encephalitic patients treated with L-dopa, it is not an account of a ‘clinical trial’ in the strict sense, such as was carried out on 40 (anonymous) patients at Highlands Hospital in London in 1969.⁷ Instead it is presented as a series of individual case-studies, giving the life-story and response to the drug of each patient, a mode of presentation that responds to Sacks's conviction that ‘there were many other determinants of clinical state and behaviour besides localised changes in the brain’ and that the illness is ‘by no means a simple disease, but needed to be seen as an individual creation of the greatest complexity, determined not simply by a primary disease process … an illness in short, like neurosis or psychosis, a coming to terms of the sensitized individual with his total environment’ (20-21). The juxtaposition of different patients' individual stories graphically illustrates this, for the same disease had very different consequences for patients according to their family and circumstances, and more strikingly, the same drug produced startlingly different reactions, adjustments and outcomes (which is not to say that there were not a great many common elements). Thus Sacks's unfashionable belief that the constitution of the patient is as important as the viral invader or therapeutic agent is vindicated.

But the case-study by case-study presentation has other important effects. Each case is the story of the response of a separate patient to the drug, and screens out almost all of the factors (to use a medical metaphor) that are attributable to their social and communal world. It is not that the narrator is unaware of these factors—far from it—it is that his chosen mode of narration necessarily restricts the extent to which they can be given weight. ‘Screening out’ is thus not complete, but the hospital environment, and its fatal management decisions, is presented in a shadowy and allusive way, as when, for example, Sacks speaks of ‘the tragic, and sometimes hellish, darkness of the place’ (259).⁸ Many of the patients were obviously damaged by the institution, and by the various staff and management changes which occurred in the course of their treatment: in one case a patient who forms an attachment to a kindly physiotherapist relapses into psychosis when she is retrenched. The hospital itself, which is in the Bronx, is given a fictional location, name (‘Mount Carmel’) and history in Awakenings: what was, so one gathers, an enforcing milieu, is presented as a thinly sketched backdrop. One patient, ‘Margaret A’, for instance, who becomes tragically dependent upon the drug and ‘by 1970, would move not merely into exasperated Parkinsonianism and depression but with immediate stupor or coma if it was stopped for a day’ (147), attains ‘her former unbroken self’ when she is taken out once a month by a younger sister who comes up to New York for the purpose. ‘“I can't understand” her sister once said to me, “why Margaret is called crazy or broken or strange … She talked and laughed the way she used to in the old days, back in the twenties before she got ill … She goes mad in your madhouse because she is shut off from life”’ (149). Such moments are very telling, but the format, the design, and the narrational organisation of the book (which is, in effect, its medical ideology), by separating each life from the lives it was lived among, and from the economics that governed whatever life they had as a social group, allow one to forget the deleterious effect of the institution, as well as suppressing political, and medical-political implications.

The enhancement of patient individuality is accompanied by still other deficits. The role of the narrator-doctor is similarly distorted. In the Preface to Migraine Sacks speaks of the doctor's ‘magic of attention and interest’ and it is touchingly evident how, with his intense concern for these patients, his comparative youth, his vigour and enthusiasm, and his capacity for forming friendships, Sacks brought new hope to these sometimes abandoned people, even before treating them with the so-called miracle’ drug. When L-dopa does prove to have amazing powers, his patients become even more inclined to regard him as a saviour: when its disastrous later consequences become plain, they are caught in a tormenting love-hatred towards their doctor. ‘Sexuality, of course, was forbidden at Mount Carmel’, Sacks writes dryly. One of the recurrent dramas he relates has to do with the re-awakening of sexuality in his patients; but if sexuality was proscribed at Mount Carmel, it can scarcely, either, be given its due in the medical case-history. Sacks refers three times in the course of Awakenings to patients as ‘Sleeping Beauty’, leaving it to the reader alone to reflect that Sleeping Beauty was woken by a Prince: and by a kiss. The most arresting of the case-studies concern relationships between some patients and their nurse-mothers—intensely symbiotic and collusive entanglements of dependence and suppressed resentment which are observed acutely by the physician-narrator. But in fact these are triangular relationships in which the doctor makes a third in the sub-erotic triangle. ‘Lucy K’ is one such patient:

She was heavily and powerfully built, giving the impression of great physical strength clenched in restraint. She looked (like most post-encephalitics) much younger than her age—one could easily have supposed she was in her twenties, not her forties. Her bizarre ‘baby-doll’ appearance was accentuated by the immense pains her mother took to ‘prepare’ her every day. Miss K., when ‘prepared’, would sit in the hall rigid and motionless in her oversize chair, invested in an embroidered and ambiguous child's or bride's nightgown. Her jet-black hair would be heavily braided, and her face chalky-white from its coating of powder (she suffered from constant sweatings and sebarrhoea). Her dystonic, crippled hands (with fingers immovably flexed at the knuckles) were heavily ringed, and had long scarlet nails. Her inverted feet were daintily slippered. She looked like—I could never decide; like a clown, or a geisha, or Miss Haversham, or a robot. But most of all like a baby-doll, in the most absolute and literal sense of the words: a living reflection of her mother's mad whim.

The tragi-comic climax of ‘Lucy K’'s awakening drama comes when this patient, locked in a psychosis-like state for twenty years, responds to the doctor's magic of attention and interest:

That evening when I visited her alone (her mother had gone and the nurses had cooled down), I went over the examination again. In the course of this I said, ‘Will you give me your hand?’ and Miss K said, ‘Yes, yes, I'll give you my hand.’

She continued excited, elated, and very active the next day. When I did rounds in the evening, she took the initiative: ‘Dr Sacks!’ she said, her words tumbling over themselves in her excitement. ‘You asked for my hand. It's yours! … I want you to marry me and take me away. Take me away from this horrible place … And, promise—you'll never let her come near me again!’

(135)

Sacks has to explain that he is her doctor, nothing more. Lucy K reacts furiously and sinks into a rigid Parkinsonianism from which even massive doses of the drug do not shift her. Thus is pre-enacted, on this bizarre stage, the drama that was to take place between Sacks and Swan. ‘Frances D’, the patient whose case opens the book, is another instance of a woman whose awakening led, in Sacks's words, to a ‘tormenting transference-neurosis’. It is one of the lessons of psychoanalysis that there is no transference without counter-transference: but at the same time it is the function of the case-history format to give this truth minimum exposure, to deny the doctor's personal presence, and to shield him from any questioning or exposure of motives, even though, in Sacks's conception of medicine, relationships between doctors and patients are of great therapeutic importance.

Thus though Sacks attempts to tell the patient's own story and essays to reach, in many instances, the deepest secrets of his patient's ‘being’, he does this whilst reserving his authority, without surrendering his position, therapeutically and psychologically necessary, as doctor. This dilemma is reflected in the book's mixed and inconsistent styles. Awakenings, like Sacks's other books, is a patch-work of writing in different registers. Sometimes it is the impersonal style of a medical text-book, in which symptoms are separated from persons: ‘The clinical picture was completed by a number of spontaneous movements and hyperkineses. The muscles about the mouth exhibited puckering movements … there was occasional grinding of the teeth.’ Sometimes it veers into a highly subjective mode, a banalised version of interior monologue: ‘She was in a state of utter shock, horror and despair. What sort of a life would it be, if there were no natural recovery? What sort of a life, every move made by artifice?’ Sometimes, and most problematically, the style becomes intense, repetitious and even incantatory, striving to grasp and give definition to uncanny and profoundly disturbed inner states, as in this description of ‘Hester Y’:

… she did give the impression of an infinite remoteness. She seemed to dwell in some inimaginably (sic) strange, inaccessible ultimity, in some bottomless deep hole or abyss of being, she seemed crushed into an infinitely dense, inescapable state, or held motionless, in the motionless ‘eye’ of a vortex … She showed an infinite coercion or consent of behaviour—circular, effortless, ceaseless movement, which seemed still because its locus was infinitesimal in size. She was utterly still, intensely still, yet perpetually moving, in an ontological orbit contracted to zero.

(89)

All imagination could be construed as a desire to possess the other: but one sometimes has the feeling that this extension of clinical description is not so much responding to the alterity, the otherness of the patient's appearance, as bearing witness to a desire to blend with, or ultimately devour in language, her experience.

In these case-studies then, the convention of the omniscient narrator takes a peculiar turn. The stylistic instability and fracturing of this book makes it plain that there is no stable or fully reflective self-characterisation or self-positioning on the narrator's part. He is, of necessity, an important actor in the dramas he represents, the scenes he witnesses, and therefore human and fallible. But the narrational conventions, adopted without enough self-consciousness, continually propose him as invisible, all-seeing, always with hands clean. Perhaps this problem is only resolvable when the case-history convention is abandoned and the short-story mode frankly embraced, for then, as the ‘doctor stories’ of William Carlos Williams illustrate, it is possible to define the physician through a characterising voice—in Williams's case the tough, pragmatic, not over-sensitive idiom of the busy small town American G.P.—and so make manifest the partiality of the doctor's position. This puts the doctor's conscience full-square in the reader's attention, not just glimpsed from behind the couch or the consulting-room desk.

‘Lucy K’ is number 8 in the series of twenty case-histories. She is started on L-dopa belatedly, apparently at the insistence of her mother. By this time, ‘late in 1970’, Sacks's enthusiasm for the drug had waned. In fact, on 28 September 1970, Sacks and his colleagues at Mount Carmel published an important letter in the Journal of the American Medical Association (JAMA), headed ‘Long term effects of Levodopa in the severely disabled patient’ in which they wrote that, in contrast to other published reports, ‘we have observed that the period of benefit has been of limited duration and has been followed in all cases by adverse effects, the latter often progressive, sometimes serious, and occasionally dangerous’ (italics in the original).⁹ The narrational order of the cases in Awakenings is not their real-time or historical order. Three patients, ‘Margaret A’, ‘Robert O’ and ‘Hester Y’ were, for instance, according to their case notes, started on the drug on the same day, 7 May, 1967, but this fact is obscured by their position in the narrative chronology where, though Robert is fourth and Hester is fifth, Margaret A is ninth, and is preceded by Lucy K, who in fact was first given the drug something like eighteen months later. The first patient to be given the drug, ‘Leonard L’ in March 1969, with whom Sacks has the closest relation, is in fact the climactic example in the book. This reorganisation of chronology, partly in response one supposes to simple narrative choice (contrast, variety, climax) suspends the individual patients in a vacuum of non-historical time, just as the case-study format separated them from each other, and it plays an important part in the narrative enhancement of these historical events. The determination of this doctor to ennoble the experiences of his patients is conducted in a series of rhetorical gestures which transform failure and desperate misery into uplifting, even apocalyptic affirmations of human potentiality.

For in fact the sober words of the letter to the JAMA are illustrated by the cases presented. In this book called Awakenings, the patients who respond to L-dopa achieve a ‘high’, a brief period of greatly enhanced well-being and release, followed ‘in all cases’ by catastrophic ‘explosions’, often by uncontrollable and bewildering tics, delirium and madness—and Sacks gives some horrifying descriptions of the frenzied excitements and hallucinatory states to which patients were driven by the drug. In almost every instance it proved impossible to stabilise the patient on a modified dosage—in contrast to the true Parkinsonian case, who is included, for whom L-dopa is effective. The book ends with the case of ‘Leonard L’, ‘a man of most unusual intelligence, cultivation and sophistication … a man with an introspective and investigative passion which exceeded that of almost any patient I had ever seen’, who Sacks declares ‘has taught me more about Parkinsonianism, post-encephalitic illness, suffering, and human nature than all the rest of my patients combined.’ His position is designed, of course, as a tribute to a man who is seen, as various touches in the narrative indicate, as a hero, or rather as a martyr. Leonard L enjoys a sudden ‘conversion’ (Sacks's term) on the drug, ‘a mobility, a health and a happiness which he had not known in thirty years’ (193). Now able to tap at a typewriter, he begins a diary full of expressions of gratitude: ‘L-dopa is a blessed drug, it has given me back the possibility of life’, but this brief ecstasy is soon followed, as it was to be in other cases, by exorbitantly increased activity and erotomania, then hallucinations and psychoses, before the drug was stopped towards the end of July. Repeated trials only produced yet more desperate states. One can only say, I think, that the experiment—the experimentation—was not a success. And Leonard was running into trouble with L-dopa when other patients had yet to be started on the drug. Yet by placing his story at the climax of the book, by relying so much in the case-study on this patient's own words, and by communicating so much of his own admiration for him, Sacks succeeds in making the reader feel a sense of achievement, even of satisfactory resolution. In the chapter ‘The Aftermath of Awakenings’ added to the third edition, Leonard's intolerable subsequent history, including his ‘resurrection’ by the drug when almost a corpse, (‘this is a stinking miracle—obscene—a lot worse than Lazarus’ he cries with his new-found voice) and subsequent death when it is withdrawn at his request in 1981, is detailed. But the book now ends with an exchange of consoling letters between Sacks and Leonard's mother, whose love for, and perhaps need of, the patient unites them in grief and is made to signal a positive resolution and an endorsement of this physician's deep empathy for his patients. One can hardly suppress the feeling that it is the doctor who emerges, after all, as the hero.¹⁰

Awakenings is recalled briefly at the close of Seeing Voices when Sacks partakes in and reports a triumphant student strike at Gallaudet college for the deaf, a nostalgic return to the apocalyptic excitements of the sixties. But for the most part his latest book is an account of Sacks's investigation of a world rather remote from his medical speciality. Indeed, though announced as a voyage, as a personal discovery, much of the book, and perhaps the best part of the book, is a straightforward exposition of the history of the deaf in America, and of the nature of Sign language. It is, too, a piece of generous polemic, a passionate argument for the deaf to be educated in their own language, Sign. The most engrossing pages though, to my mind, are those, like the last pages of A Leg to Stand On, in which the author writes frankly as a medical authority about the neurological significance of the phenomena he has studied or experienced. Here he surveys a range of experiments and papers which show convincingly that Sign is not just a series of gestures, a poor replacement for speech. A deaf patient who sustains right hemisphere brain damage may not be able to believe in the existence of a left side of reality at all, but will Sign using left-hand space. Sign, Sacks argues, is thus a true language—it not only has a demonstrable grammar and syntax, but this grammar and syntax are recorded, as is all language ability, upon the left hemisphere of the brain. Sacks's demonstration of this is fascinating, and his vindication of Sign may well have the impact the book clearly intends to have upon the education of the deaf. But the author, one feels, yearns always to be something more than a neurological investigator. The book is an unsatisfactory, fractured mixture of reportage, scholarship, history and neurology, yet lacking the intense interest in, and relationship with, arresting individual patients of his own, that gives so much life to Oliver Sacks's earlier books.

As I write this commentary on Sacks's writing, Penny Marshall's film of Awakenings, starring Robin Williams as Sacks and Robert de Niro as Leonard L, is being screened,¹¹ and a fourth edition of Awakenings has just been published. It is an interesting story in itself, the success of this medical narrative. Beginning as an intellectually ambitious medical—philosophical commentary in the Listener in 1972, becoming a narrative or series of narratives in the subsequent book, through its various editions, a drama in Harold Pinter's version A Kind of Alaska, produced at the National Theatre in 1982, via a Yorkshire television documentary of 1973 (which includes footage of the original patients, including Leonard [Ed], filmed as they responded to L-dopa in 1969) and now to the Hollywood blockbuster: Sacks's writing clearly has had the power to excite thought and to compel emotion for many people. He has the gift of making specific patients and their deficits telling and often moving illustrations of neurological discoveries and human truths: this, with the obvious intensity of his sympathy and his passionate advocacy of a more humane medicine, goes far to explain the appeal of his writings. It is too simple, though, to notice merely that the success of his work reflects the general disillusionment with modern and technological medicine: for there is something more powerful and more positive in his appeal than this—the capacity, in spite of all the factitious intensities, the ‘infinite’ the ‘uncanny’ and the ‘utter’, which often makes his prose so tiresome, and in spite of the uneasy paternalism, and even bad faith, which sometimes disfigure his presentation of his patients, to discover in human sufferings, some of them new human sufferings, the result of modern initiatives in drugs and medicine, the occasions of parable and myth.

Notes

1. The Listener, 88, No. 2274, 26 October 1972, 521-524. There were letters over the next five issues. The quotation is from the correspondence column of 9 November, in which Frank Kermode also declares that ‘Dr Sacks is a writer of exceptional power.’ In this commentary I speak of ‘Sacks’, and occasionally of ‘the narrator’ in order to make clear that I am solely concerned with this author's writings. I am unqualified to comment on any aspect of his medical practice.

2. Seeing Voices, A Journey into the World of the Deaf, Picador, 1990, paperback £3.50.

3. David Ellis, ‘Freud's Dora’, The Cambridge Quarterly, Volume Nine, Number Three, 202-218, p. 214.

4. ‘The leg’, London Review of Books, 17-30 June, 1982, 3-5, p. 3.

5. ‘Neosexualities’ is the term of Joyce McDougall. See her Plea for a measure of abnormality, 1980, Theatres of the Body, 1989, etc.

6. ‘Incontinent nostalgia induced by L-Dopa’, The Lancet, 27 June, 1970, 1394.

7. D. B. Calne et al, ‘L-Dopa in Postencephalitic Parkinsonianism’, The Lancet, 12 April, 1969, 744-747.

8. A few further details about the hospital and the patients are given in Oliver Sacks's recent article, ‘Neurology and the Soul’, New York Review of Books, XXXVII, 18, 22 November 1990, 44-50. ‘In September 1969 a new hospital director abruptly dissolved the patient community, forbade visiting, and instituted a new, repressive regime’ (p. 46).

9. Journal of the American Medical Association, 213, 13, 28 September, 1970, 2270.

10. I have discussed Oliver Sacks's work so often with my colleague Dr Kay Torney, that I am not certain now which of these reflections were originally hers. This one, however, I am sure I do owe to her.

11. The review by John Ryle, ‘Muted Awakenings’ in the TLS, 15 March, 1991, makes some pertinent comparisons with the original book: ‘the truth is that, affecting though it is, well-acted and humane in intent, the film is bowdlerized …’

SOURCE: Weinraub, Judith. “Oliver Sacks: Hero of the Hopeless.” Washington Post 114 (13 January 1991): F1, F6.

[In the following essay, Weinraub investigates the origins of and the controversy surrounding Awakenings and discusses the impact of the cinematic adaptation on Sacks's life.]

“I had a dream about manganese the other night,” says Oliver Sacks, chortling over the idea. “I can't think of all the details, but I felt so good when I woke up.

“It was a dream about a stable mental object,” he continues with delight. “You know, people may come and go, but manganese is forever. Its electrons behave themselves. They've got Pauli's exclusion principle. They can't leave orbits. You know where you are with manganese.”

As a source of inspiration for dreams, the periodic table of elements isn't exactly standard. But for writer-neurologist Sacks, it's a natural.

A shy, burly Santa Claus of a man, Sacks, 57, is a consummate scientist, a compassionate clinician. He is also the model for the brilliant, caring doctor whose work with seemingly hopeless patients in a Bronx hospital for the chronically ill is described in the new movie Awakenings.

And today, huddled self-protectively at his desk in his office in a Greenwich Village apartment building, he is not at all comfortable with finding himself at the wrong end of a microscope. “Celebrity is not a word I use or a concept I'm very interested in,” he says.

He has been avoiding the spotlight all his life, preferring instead to define himself through his work with communities of outsiders: the strangely “frozen” post-encephalitic patients described in Awakenings; the neurologically damaged ones he detailed in The Man Who Mistook His Wife for a Hat; the deaf culture he wrote about in Seeing Voices. He works with them, studies them, and then, through his best-selling books, interprets their worlds to the world at large.

It is with these people whom society has shunted aside that Sacks is more at ease. An erudite, expressive man, he is not married. He lives alone. “I feel I don't have any identity,” he says simply. “I'm a resident alien, a kindly resident alien.”

So it was with considerable trepidation that Sacks approached the personal exposure involved—both for him and his patients—in seeing his 1973 book translated to the big screen. (He is the film's technical consultant. The screenplay was written by Steven Zaillian.) His book—essentially a compilation of case studies from the spring and summer of 1969—had been adapted many times before, as a documentary film, a radio drama, a stage play, a one-act play by Harold Pinter. But the idea of a flat-out commercial film with mega-movie-stars Robin Williams and Robert De Niro at first was disturbing.

“I was worried about the relation of fact to fiction—particularly the fictional me,” says Sacks, his voice still full of stammers and the accent of an upper-class English Jewish childhood. “I wondered very much if it was possible to act a neurological disorder.

“I finally decided that the plot and character and story were not quite my business but that representing neurological and medical and historical reality was. As long as I could imagine it, it was okay.”

In the fall of 1989 while the film was being shot, Sacks traveled to the Brooklyn set at 6:30 every morning before starting his ordinary workday. The company members took him to their hearts. “Oliver was invaluable,” says director Penny Marshall. “If we had any medical questions at all, I would turn to him and say, ‘Would this happen? Is this okay?’ and he'd say, ‘Well, maybe a little more like that.’ Robin and Bobby both loved talking to him. He was terrific.”

What allowed Sacks to relax a little was his decision not to allow his name to be used (his character, played by Robin Williams, is called Dr. Malcolm Sayer). And by Williams's ability to observe him unobtrusively, in order to incorporate some of the doctor's mannerisms in his performance. Says Sacks, “Robin was infinitely tactful and never gave me a feeling of watching me. I think he has created a credible, real person. Who is not me.”

NO HAPPY ENDINGS

“I wanted happy endings,” says Sacks wistfully.

They were not to be.

Sacks first discovered the patients whose poignant odyssey is chronicled in Awakenings in 1966 at Beth Abraham Hospital, a chronic care facility in the Bronx. Frozen in a variety of physically distorted, trancelike states for decades, they were all victims of an international outbreak of encephalitis lethargica (familiarly known as sleeping sickness) in the years after World War I. Thought to be retarded, mad or simply undecipherable medical puzzles, they had been stashed away, forgotten.

Young Sacks, Oxford- and UCLA-trained, saw a similarity in his patients' symptoms and those of Parkinson's disease, and was intrigued by the possibility of trying out L-dopa, a new drug that had been helpful to victims of Parkinson's. For two years he hesitated.

“Partly I didn't know what would come out of it—they were so complex physiologically,” he recalls. “And partly these patients had been so out of the world, so turned away from the world, I didn't know how bearable it might be for them. I didn't know what sort of Pandora's box would be let out.”

The hot New York summer of 1968 made his decision for him. There was no air conditioning, and many of them died. “I thought, Ollie, you'll spend a lifetime procrastinating and hesitating, and the rest of these poor patients will die.”

He administered the drug, first on one (played by De Niro), then gradually on the others, and found that, miraculously, it woke them up. But the awakenings were of limited durations. In some cases sooner, in others later, things started to go wrong and the L-dopa produced a tic-ridden manic behavior, even with reduced doses. When taken off the drug, the patients returned to their former state. And each one responded to the drug—and to its inevitable failure—differently.

Sacks was despondent. Between March and July, although his apartment was only 100 yards away, he spent 20-hour days at the hospital, trying to stabilize the patients. “I wondered what the hell had I got them into,” he says. “I couldn't understand the fluctuations and I didn't know what to do. I worried that I was doing something wrong.”

But those concerns were medical. It was the ethical side that really tormented him. The L-dopa experience had caused the patients great suffering. “Did I have the right to meddle,” he remembers asking himself.

The patients asked that question too. Says Sacks, “One or two of them said to me, you open the window and you raise unbearable hopes and prospects. And now you close it.”

TRAUMATIC CHILDHOOD

The reliability of science was what had attracted Sacks to it in the first place. As a child in London, he'd been separated from his family and sent away to boarding school to avoid the dangers of World War II. He rarely saw his parents or knew when he would see them next. To make matters worse, he remembers the couple who ran the school as “a disturbed pair, abusers.”

Whatever the impact of the situation (“I probably have something of a traumatic sort of blur about the period, which years of analysis haven't dissipated,” he says), he connects his desire for stability and predictability to the experience.

“All I can be certain of,” he recalls, “is that when I returned to London a month short of 10, I almost immediately developed a passion for science, and in particular for chemistry and the periodic table.”

And for numbers. Unlike the location of the first bubble in a boiling liquid or the variations in the flow of water from a tap, numbers were predictable. “As a child I would feel numbers as my friends,” he says. “They wouldn't deceive or slip away.”

His interests seemed natural to his parents, both doctors: his father, who had given up academic life to become the Yiddish-speaking general practitioner in London's East End in the 1920s, and his mother, a professor of anatomy who was the first woman to be allowed to join the Royal College of Physicians and Surgeons.

Sacks seems to share both parents' skills, the humanity of his father (who died last summer at 94 after having spent the previous four years making daily house calls via taxi), and the acuity of his mother (who died in 1972).

He refers to both as “medical storytellers.” His father, who he estimates probably saw more than 100,000 patients, could recall family medical tendencies for generations back. And his mother reveled in sharing her ideas. “She loved telling stories to everyone, the butcher, the milkman,” says Sacks. “She didn't have two forms of discourse. Whether it was the colleague or the gardener, the same sort of narrative was given to both.”

Sacks's destiny seemed fixed. By 1958, he had gotten his medical degree and was on his way to a series of internships. His father wanted him to join his practice. Not knowing quite what he was going to do next, Sacks found himself “between continents and between lives.” Then in 1960, he came to Canada and the United States for a holiday, and soon after he arrived sent home a one-word telegram: “Staying.”

He is not sure what he meant by it. “I wished not to belong, and I wished to belong,” he ventures. In any case, he had promised himself California. So, putting away “the soft European name of Oliver,” he headed west, where, embracing his legitimate middle name, he became Wolf Sacks, the “lycanthropic creature of the freeways.” Tall and lean, his hair slicked back, riding a motorcycle. For a time, he was an unofficial physician to a chapter of the Hell's Angels.

From the fall of 1960 until the summer of 1961, he was footloose. With the arrival of his green card (he'd applied for it when he came to America), he became employable, and continued along the neurological path that led him from California hospitals to the patients at Beth Abraham.

“It was a complete accident I went to work with post-encephalitics,” he says. “But we were made for each other.”

CRITICISM AND CHAOS

In the summer of 1970, in a letter to the Journal of the American Medical Association, Sacks published his findings on 60 patients he had maintained on L-dopa (sometimes on, sometimes off, sometimes combined with other drugs) for more than a year. The letter explained that all of the patients had done well at first, but then all of them got into trouble. He had found no easy way of controlling or predicting their reactions though the condition of many of them improved.

His letter caused a furor. An entire issue of JAMA was devoted to letters Sacks describes as “abusive.”

“I was publicly roasted,” he says. “I think a lot of my colleagues really felt threatened by notions of uncontrollability and unpredictability that reflected on their own power and reflected on the power of science.”

He was wildly upset. “I'm a genuine neurologist and observer,” he says. “And these were my patients. I cared for them, and I passionately wanted things to be right. And if they couldn't be right, I at least wanted them to be intelligible.” Sacks wrote to each of the respondents, asking them to come to the hospital and see the patients for themselves. None of them came.

Over the years, as he turned his attention to other subjects, he has continued to treat post-encephalitic patients. And continued to brood over the question of what went wrong.

And now a major motion picture has brought his work to the public. Does it give him a feeling of vindication?

It's a question he avoids answering directly. Instead he points to an international conference on Parkinson's that was held in Rome last summer. He was asked to open the conference by presenting his most recent theories on the subject, which have evolved from some of the concepts of contemporary chaos and catastrophe theory.

He describes his report as “an attempt to model many different factors simultaneously in a way somewhat similar to weather forecasting—weather forecasting itself being an interesting example of a kind of chaotic system,” he says. Factors such as “the absorption of L-dopa from the gut, the way L-dopa is treated in the blood-stream, the levels of dopa in the perceptors in the brain and an attempt to put everything together instead of trying to seek an increasingly elusive relation between just two things like dose and response.”

“What I did do was to introduce this chaos theory thing which tried to embrace what everyone was doing,” he says. “And I didn't want to do it in a retaliatory way. …”

“But myself, I'm rather pleased that 20 years later, in clumsy terms, I'm able to have an attempt at some sort of model or theory.”

Does he still feel a need to explain what happened?

“I think it needs to be explained,” he says. “But it is currently not in my power to go any farther than I have.”

Has he ever regretted using L-dopa in the first place?

“Not at all,” he says briskly. “I regret we didn't have it sooner. For many of my patients it made the difference between living and not living.”

RESIDENT ALIEN

Oliver Sacks really is a resident alien. He has maintained that legal status since he came to the United States in 1960. And since 1967, he has been based in New York, where he lives in a red-shingle house on City Island, a mostly working-class, water-front enclave of the Bronx. He spotted the house and its pleasant gazebo while he was swimming around City Island one day. (He is a champion swimmer.)

He hates the city. He loves open spaces, and the most he can do in New York is walk in the Botanical Gardens, which he tries to do every day.

“I don't know how I ended up in New York,” he says. “For years it didn't matter. I was absorbed in my work and thought, and I hardly noticed where I was.”

If he is no longer at home in England or New York or California, he is at home with his patients, whether they are deaf or neurologically damaged or Tourettic (he is hoping to get going on a “an endlessly incubated and procrastinated book on Tourette's syndrome”) or post-encephalitic.

“I wanted to be one of the patients, to be among them, to be both a participant and an observer,” he says of the group he awakened. “It has to do with community and identity. I wanted to know more and more what it was like to be them, to actually know what it felt like to have the sensations.”

It affected him with the deaf too. And with Touretters. “I'm an honorary Touretter, one of the few they can bear to be with.”

Not everyone welcomes him at first, this large, bespectacled, bearded man in a short-sleeved shirt and seer-sucker trousers—he gets overheated easily—looking for a group of patients to immerse himself in.

“I think originally the deaf community was quite suspicious,” he laughs. “Who is this weird person? Where does he come from? What does he want? What does he have up his sleeve? Well, I don't have any sleeves. And I don't want to do any more than try and understand them to some extent.”

“There are a million people with chronic neurological disease locked away in this country,” he says. “They are sort of dismissed and regarded as defective. But it isn't so. I've been in their world myself for a quarter of a century and I find it full of unexpected life and resource and courage and humor and just the sheer capacity to survive—and often without bitterness.”

A few years ago Sacks was introduced to a new post-encephalitic patient who had been brought to Beth Abraham. She had been in a state hospital for 45 years. “Somehow, and I don't know why,” he says, “I looked at her and I wanted to kiss her and embrace her because she was post-encephalitic. I thought, ‘you dear old thing.’”

What is there about these patients that attracts him so much? Why build his life around them?

“I'm not sure,” he says, venturing that his choices must have something to do with his ambivalence about belonging, and identity, and being an outsider, and his feeling that for him, his way is the safe way, the way he needs.

“And yet sometimes,” he says, “I have an image of myself as a little boy with my nose pressed against the window, looking in. I sometimes feel like a sort of Martian. But then I'm a resident alien, you see. Looking in.”

SOURCE: McRae, Murdo William. “Oliver Sacks's Neurology of Identity.” In The Literature of Science: Perspectives on Popular Scientific Writing, edited by Murdo William McRae, pp. 97-110. Athens: The University of Georgia Press, 1993.

[In the following essay, McRae traces the origins of Sacks's “neurology of identity,” a term given to his treatment of neurological patients as individuals.]

It is impossible not to respect and admire Oliver Sacks, successful neurologist and best-selling author of five books, one of them the basis for Penny Marshall's popular 1990 film Awakenings. Once himself a victim of neurological impairment, Sacks displays immense sympathy and compassion for his patients, many of whom have endured lives of unimaginable suffering. Stylistically and rhetorically vigorous, even audacious at times, his philosophically sophisticated prose contains a virtually encyclopedic range of allusions, not only to neurologists such as Henry Head or Hughlings Jackson, but also to philosophers and poets such as Gottfried Wilhelm von Leibniz, Pythagoras and René Descartes, John Donne and W. H. Auden. Perhaps most appealing, however, is his passionate rejection of the mechanistic and depersonalized ways in which traditional neurology views each patient. Sacks advocates instead a “neurology of identity,” superior to the neurological tradition because it would not regard each patient as a realization of some abstract neurological model (1985, xiv).

His conviction appears in Awakenings (1974), his first effort to supplant the neurological tradition, when he writes that “one must cease to regard all patients as replicas, and honor each one with individual attention, attention to how he is doing, to his individual reactions and propensities” (219). This stress on each patient's irreplicable individuality would bring Sacks eleven years later, in The Man Who Mistook His Wife for a Hat (1985), to contemplate a certain Dr. P., a musician who was unable to recognize concrete facial details as anything other than abstract, formal patterns. Sacks demonstrates his inclination to the use of tropes when he considers the significance of Dr. P., whose disorder is “an awful analogy … a warning and parable—of what happens to a science which eschews the judgmental, the particular, the personal” (19).

Since our culture locates human identity in the individual and unique, the irreplicable and particular, Sacks's various claims for the neurology of identity carry a powerful appeal. In spite of this, however, Sacks's repudiation of abstract and impersonal thinking should not blind us to the equally abstract and impersonal character of his own thinking. In the end, Sacks views his own patients, even himself when he is the patient, in ways that duplicate what he declares to be the conceptual, even ethical, fault in traditional neurology—its tendency to turn each patient into a replica of every other one.

One way to explain this duplication is to examine what Sacks describes as the Leibnizian and Pythagorean dimensions of his thought, both of which lead him to prefer the abstract over the concrete, thus to see the single empirical instance as a synecdoche for all other instances and for the form they realize. Since this preference means that Sacks thinks as traditional neurologists do, we might condemn him for being no less conceptually and ethically bankrupt than the tradition he scorns. That condemnation would be unfair, however, for Sacks cannot choose any other way to regard the patient. An explanation for why he cannot may be found in what Mikhail Bakhtin and Michel Serres have to say about dialogue, their term for the social character of language. Their comments are useful because they imply that scientific arguments are governed by the tendency, perhaps even the imperative, of regarding each concrete and particular datum tropically, as if it were a synecdoche for all the data, thus for the form they realize.

LEIBNIZIAN AND PYTHAGOREAN METAPHYSICS

Sacks indicts the neurological tradition by asserting that its founders—Henry Head, Hughlings Jackson, and C. S. Sherrington—always held to the false conviction that health “can be reduced to certain ‘factors’ or ‘elements’ … reduced to a level, something … titrated or topped-up in a mechanical way” (1974, 21). To this “Newtonian-Lockean-Cartesian view” (1974, 191) Sacks brings the perspective of Leibniz, whose God knows how every body in the universe “feels the effect of all that takes place” and thus can “read in each what is happening everywhere” (Leibniz 1948, 251). For Sacks, then, “health is infinite and expansive in mode, and reaches out to be filled with the fullness of the world” (1974, 196). This rejection of Cartesian mathematics, Newtonian physics, and Lockean psychology also means that a reformed neurology should try to comprehend each patient in terms of what Sacks calls Leibnizian “metaphysics,” which “makes no such [mechanistic, Newtonian-Lockean-Cartesian] reductions: its terms are those of organization or design” (1974, 21).

True enough, Sacks's critique of traditional neurology makes no use of strictly mechanistic paradigms.¹ But consider, for example, The Man Who Mistook His Wife for a Hat, in which Sacks organizes the study of neurological disease by dividing it into four abstract categories: “losses,” “excesses,” “transports,” and the “world of the simple.” There is something attractive, perhaps, in the way each category points to what Sacks claims to be an epistemological failing in traditional neurology. Thus, “losses” inquires into why the tradition can think of patients only in terms of their functional deficits; “excesses” and “transports” attempt, among other things, to explain why the tradition can never regard disease, paradoxically, as a sort of health; and “the world of the simple” examines how the mentally disabled often possess intellectual skills far in excess of those possessed by the mentally able.

Interesting though they are, however, the abstract character of these categories self-evidently betrays Sacks's emphasis on the unique. That is, the key terms of his metaphysics—organization and design—recapitulate the neurological tradition's way of thinking. Implicitly comparing his models with the tradition's, Sacks encourages traditional neurology to displace its mechanistic sense of organization and design with his universalizing one. Such a comparison sharpens his ability to characterize the tradition as reductive, but to make that comparison forceful he must also conversely presume that his competing notions of organization or design are more encompassing than those that shape the neurological tradition. In this respect, Sacks's move from the supposedly empirical reductions of Isaac Newton, John Locke, and Descartes to the expansive metaphysics of Leibniz is not unexpected.² Nonetheless, when he speaks out against reductive neurology, his elevation of metaphysics over reductiveness reverses the valuation of the particular over the abstract evident in his tropical description of Dr. P.

In other words, if thinking of each patient as a replica of the others is truly “to commit an epistemological solecism of the first order” (1974, 202), then the solecism is Sacks's as well, given his metaphysics of organization or design. Patterns displace particulars in Sacks's thought, which explains why he confesses to a lifelong Pythagorean enchantment with the formal properties of numbers. In A Leg to Stand On, his account of treatment for nerves severed in his left leg during a hiking accident, he describes the most formative intellectual experience of his childhood, when, in his family garden, he would gaze upon the sunflowers,

whose vast inflorescences fascinated me endlessly and showed me at five the Pythagorean mystery of the world. (For it was then, in the summer of 1938, that I discovered that the whorled florets were multiples of prime numbers, and I had such a vision of the order and beauty of the world as was to be a prototype of every scientific wonder and joy I was later to experience.)

(1984, 34)

The abstract and the computational are crucial for Sacks's life as a scientist, but this Wordsworthian memory also recalls how Sacks used the description of Dr. P., the analogy of a science that “becomes entirely abstract and computational” (1985, 19), to condemn the neurological tradition.

Given its universalizing power, the Pythagorean remains constant in Sacks's thought, appearing again in The Man Who Mistook His Wife for a Hat, in which he describes two clinical patients, John and Michael, twin autistic savants who possessed a “‘Pythagorean’ sensibility” of recognizing almost instantly, with no computational aids, any prime number upward of twenty digits (1985, 197). Their skill so reminded Sacks of himself as a childhood “number brooder” that he decided to locate a table of prime numbers in order to participate in their “numerical communion” (1985, 192), their conversing with each other by stating little more than prime numbers. Eventually Sacks was able to hold a sort of conversation with them, one whose sole content was his stating of a prime number and the twins' responding to him by stating an even larger one.

Although his account of this conversation possesses no small measure of charm—the doctor sprawled on the floor, entering with “great joy” (1985, 193) into the twins' number game—the foundation of that conversation was Sacks's reacting to the twins on the level of their abstract computational skills. The twins repeatedly claimed that they mentally “saw” (1985, 189) each prime number in their computational games, but what Sacks perceived was how one twin replicated the pleasure the other experienced when recognizing any prime. At the moment either twin saw any given prime, Sacks further regarded him to be intuitively and joyfully perceiving the pattern of all primes (numbers divisible only by themselves or by one).

Just as in his family's garden Sacks had seen the empirical part instantly disappear into the formal whole—the florets were multiples of prime numbers—so here, in conversation with the twins, what he saw was not a John or a Michael but a living prime number which said itself to another prime number in the replicable pattern of all primes. Replicating the other's computational skills, each twin for Sacks thus did not “merely live in a world of numbers, but in a world, in the world, as numbers” (1985, 203). Each twin finally occupied in Sacks's thought the place of a living number from a table of prime numbers, a part that realizes the formal pattern of the whole.

As these several examples indicate, Sacks often does conceive of the individual patient as a replica of other patients, their suffering evoking the model of their disease. No wonder that, in Awakenings, his account of treating postencephalitic parkinsonism with the drug L-DOPA, he describes each of his patients as if their disease totally absorbed their being: “from its first, infinitesimal, intimation or twinge, [the disease] could proceed by an infinite multitude of infinitesimal increments to an infinite, and then more infinite, and still more infinite, degree of severity … its ‘least part,’ so to speak, possessed (in infinitesimal form) the entire, indivisible nature of the whole” (1974, 78, n. 18). Making a universalizing, Leibnizian claim that the indivisible whole is realized in even the most infinitesimal instance, this passage turns on the infinitesimal standing in for the whole, in precisely the relationship of part to whole that defines the most common instances of synecdoche.³ This sort of thinking ultimately brings Sacks to insist that “one's total being, one's relation to the world, is in a sense present and represented in each and every part of the brain (or, at least, the cortex); and thus, that one's ontological organization is essentially microcosmic or monadic in kind” (1974, 201, n. 11).

These ontological claims in Awakenings join with assertions concerning the triadic sequence of “awakening, tribulation, accommodation,” which constitutes the metaphysical organization or design realized in the history of each victim of the disease. “It is in terms of this sequence,” Sacks argues, “that we can best discuss the consequences of L-DOPA” (1974, 196-97): the way that the drug first euphorically awakens the postencephalitic patient, eliminating his stupors, tics, and overwhelming muscular disorders, only to plunge him eventually into even more profound parkinsonian tribulations, from which there is no further release, only accommodation to the disease.

Through this sequence, Leibnizian universalism explicitly merges with the tropical in Sacks's thought, leading him to claim that other “metaphorical triads” or “allegorical sequences” could be used to characterize the progress of L-DOPA treatment: for example, the triads of “peace, war, truce”; or “first bliss, bliss lost, bliss regained”; or “at-homeness, departure, return” (1974, 197, n. 8). Sacks thus implies that the sequence “awakening, tribulation, accommodation” is part of some larger whole named by a sequence such as “peace, war, truce” or “at-homeness, departure, return.” We should recognize, however, that the reverse could also be maintained. Sequences such as “peace, war, truce” could be subsumed, for example, in the metaphorical triad “awakening, tribulation, accommodation.” This slipperiness of parts and wholes illustrates both how the whole can take the place of the part and how thoughts of the formal and not the empirical ultimately govern the operation of synecdoche. Indeed, this is precisely why all of the sequences Sacks adduces ultimately realize an even more abstract model—“the course of all our lives, and of history and culture” (1974, 197, n. 8).

I draw attention to Sacks's habits of thought not to quibble with him, and certainly not to gainsay his compassion, but to respond to the explicitly philosophical and rhetorical character of his arguments. Since his forceful advocacy of the neurology of identity rests on claims regarding how best to regard the individual patient, it is appropriate to ask whether he regards his own patients in terms of those claims. His Pythagorean and Leibnizian vision of the patient as one who constitutes the same organization or design as every other patient self-evidently moves Sacks some distance from claims for each patient's irreplicable uniqueness. Granted, Sacks must conceive of disease and human existence in these terms, for without them he could not articulate his personal understanding of organization or design. Even so, precisely because he conceives the patient to be monadic and not atomistic, interconnected with all others and not radically individuated, Sacks always insists that “the study of identity and disease cannot be disjoined” (1985, xiv): the patient's individual identity resides not in his particularity but in the abstract form of his disease.⁴ Instead of inappropriately charging Sacks with bad faith, however, we need to examine why he cannot choose some other way to regard the patient.

SERRES, BAKHTIN, AND THE DIALOGIC

When Sacks decries reductive and abstract thinking in the neurological tradition, he must envision himself engaging the tradition in a dialogue whose aim is to reform the way it conceives the patient. When we look at Sacks as a participant in such a dialogue, however, we see that little separates his way from the traditional way of thinking. To account for why this is ineluctably the case, we need to bring both Mikhail Bakhtin and Michel Serres into the conversation, for under the notion of the dialogic, both have thought deeply about the connection between language and rhetoric, on the one hand, and about single instances and formal wholes, on the other.

When Bakhtin thinks about dialogue, he emphasizes how the social dimensions of language guarantee individuality. Like Sacks, Bakhtin opposes the reductive; in his case, the reductions of the domineering, or monologic, “author who finds it easy to purge his work of speech diversity: he simply does not listen to the fundamental heteroglossia [diversity] inherent in actual language; he mistakes social overtones, which create the timbres of words, for irritating noises” (1981, 327). “A living human being,” Bakhtin consequently insists, “cannot be turned into the voiceless object of some secondhand, finalizing cognitive process. In a human being there is always something that … does not submit to an externalizing secondhand definition” (1984, 58).

When Sacks argues for uniqueness, he sounds much the same as Bakhtin, who tells us to pay attention to speech diversity in order to understand how identity cannot be submitted to an externalizing, secondhand definition. In fact, when Sacks first proposes the term neurology of identity, he expresses his own disdain for the typical medical case history, a kind of monologizing, externalizing, and secondhand definition of a human being, and advocates instead what might be called his own dialogic narrative principle: “we must deepen a case history to a narrative or tale” (1985, xiv) of individual suffering.⁵ Sacks's obedience to this principle, after all, seems to explain the way he organized both Awakenings and The Man Who Mistook His Wife for a Hat as collections of narratives about individual patients.

Unlike Sacks, however, Bakhtin does not imply that identity emerges in opposition to the collective. True enough, Bakhtin writes that a speaker's “word encounters an alien word and cannot help encountering it in a living, tension-filled interaction” (1981, 279), but this interaction does not mean that each verbal exchange pits the individual against the social. On the contrary, any word a speaker utters is so charged with social overtones that it “is half someone else's” (1981, 293). Speech marks no purely subjective, individual experience for Bakhtin; the “individual is a purely socioideological phenomenon … [and] the content of the ‘individual’ psyche is by its very nature just as social as is ideology,” he writes under Vološinov's name; “I give myself verbal shape from another's point of view, ultimately, from the point of view of the community to which I belong” (1973, 86).⁶ The social languages of a speaker's age group, social level, academic institution, profession, and even family are “forms for conceptualizing the world in words, specific world views” (1981, 291-92). Speakers utter nothing that is not thoroughly social, their expression in every respect at the moment of its utterance a particular reiteration of a socioideological point of view.

This is the point implied in an amusing, if delicately phrased, passage from Dostoevsky's Diary of a Writer, which Bakhtin cites at length in order to comment on “expressive intonation,” or the way connotation often exceeds denotation (1973, 103-4). Dostoevsky writes of one evening coming upon “six tipsy artisans” who seemed deeply engaged in a trivial, yet heated, debate. What made that debate so curious, however, was that the only word spoken was an “extremely laconic designation of a certain item, and nothing more”; that is, writes Dostoevsky, the indelicate reiteration of a “noun whose usage is forbidden in the company of ladies.” Twice Dostoevsky draws attention to this single word—“a certain noun, a noun, moreover, of utmost simplicity,” he says at one point; “just that one single word, just that one word alone,” he writes at another—in order twice to emphasize how “whole trains of reasoning,” a “whole train of thought,” can be evoked in but a single word.

Now, if it seems that the obscene conversation of six drunken Russians has no direct bearing on the ways Oliver Sacks conceives of his patients, recall, for example, the dialogue Sacks had with the autistic twins John and Michael; how he was able to communicate with them only when he regarded them as synecdoches for the formal pattern of all prime numbers. In the same way that John and Michael's conversation reveals their numerical “point of view,” so the single obscenity exchanged by Dostoevsky's interlocutors reveals their socioideological points of view. Indeed, Bakhtin understands that Dostoevsky could not recognize how each reiteration of the obscenity stood in for a point of view unless each utterance somehow recalled other expressions of that point of view. Similarly, Sacks could not conclude that the twins conversed in prime numbers unless he recognized how each number they spoke evoked the pattern of prime numbers.

Dostoevsky's story illustrates for Bakhtin how a single statement evokes a collective point of view, but not that any utterance expresses every point of view in “the Tower-of-Babel mixing of languages” (1981, 278) that is social dialogue. A speaker's utterance must remain selective to be heard; expression must exclude certain nuances of words, certain socioideological points of view, and yet include others. This is why Bakhtin conceives of dialogue as does Michel Serres, who writes that even when participants in a dialogue seem to disagree, “interlocutors are in no way opposed … they are on the same side, tied together by a mutual interest: they battle together against noise” (1982a, 67). And this is also why, though Sacks calls the neurological tradition into question, we sense how he is more fundamentally its dialogic ally, working with it against the “demon,” “the third man,” “the parasite”—all terms that Serres (1982b) uses elsewhere to define any mass of formless observations, any “noise,” which must be silenced if any dialogic, formal abstraction is to occur. Both Sacks and the tradition he condemns, yet therefore speaks to in a sort of dialogue, make use of an identical strategy for conceiving the patient: in Serres's terms, both “eliminate the empirical,” the individual and unique patient, and thereby “make a science possible” (1982a, 69).

Serres would insist that both Sacks and the tradition hope to format into useful data what would otherwise remain a mass of noisy, formless observations about patients. Sacks wants the tradition to realize a different form in the empirical, but not to ignore the formal altogether, since, as Serres puts it, the “first effort to make communication in a dialogue successful is isomorphic to the effort to render a form independent of its empirical realizations” (1982a, 69).⁷ In a sense, Sacks wants the tradition to allow the facts about patients to speak for themselves, but this can only occur when the empirical gives way to the formal. Only then do the facts seem to speak for themselves; only then may they be heard against the noise, which ceases to sound at the precise moment the facts take on their formal character. This is the very foundation of the concept of form, and of any effort to abstract the form from the data. When Sacks speaks against reductive thought, in other words, he is actively inviting the tradition to hear what he hears, to silence the noise by formalizing it.

Were Serres to read the works of Oliver Sacks, he would no doubt explain that Sacks's tendency to formalize is far from being an epistemological solecism, but is instead so essential that even when Sacks regards himself as a patient, as he does in A Leg to Stand On, he gazes upon himself in a formalizing way.⁸ Passionate and moving though it is, Sacks's narrative of his intense personal suffering perfectly illustrates Serres's point that to communicate is to “eliminate that which hides form” (1982a, 69), to render the form independent of its individual empirical realizations. The symmetry between dialogue and the discovery of form explains why the story of Sacks's treatment turns on his feeling excommunicated, both from his left leg, a lump of flesh that would not respond to his call, and from his physicians, who repeatedly assured him that he was unique.

What is initially remarkable about Sacks's narrative is the way he tells us that his left leg, whose nerves had been severed in a hiking accident, refused to communicate: “When I called to the muscle, there was no answer. My call was not heard, the muscle was deaf” (1984, 66). The silence of his uncommunicative leg meant he no longer could regard himself as a being unified through proprioception, or the way “the body knows itself, and has itself as ‘property’ … by virtue of a constant flow of incoming information, arising ceaselessly, throughout life, from the muscles, joints and tendons” (1984, 71). So profound was the tear in his being created by his uncommunicative leg that it left Sacks feeling that part of the “inner photograph” (1984, 75) of his body was missing, that the image of his body as a complete and unified whole had vanished.

Disturbing though it was, the proprioceptive terror that overcame Sacks in those awful days after his accident occurred because he defined proprioception as a sort of bodily colloquy that discovers a form—in this case, the unified body image. That unified image must extend even to the most infinitesimal part of the body if it can be lost in the uncommunicative, nonproprioceptive absence of any part. Sacks's response to his leg recalls the Leibnizian manner in which he regarded his L-DOPA patients, sensing their parkinsonism to extend to the least part of their being. Accordingly, when sensation returned to his leg at a moment when Mendelssohn's music unexpectedly came to mind, his sense of a complete and unified being, an “I” who was the expression of an organizing pattern, also returned, with equally Leibnizian force: “what appeared in this moment transcended the physical, but instantly organized and reorganized it into a seamless perfect Whole. … Grace, unbidden, appeared on the scene … and instantly coordinated, subordinated, all phenomena to itself” (1984, 150).

This moment of recovery suggests that Sacks could very well have delineated another triadic sequence—call it “communication, excommunication, communion”—to formalize his own experiences as a patient. His body's proprioceptive communication was disrupted by the excommunicative silence of his injured leg, but health began to return when his leg experienced a sort of communion with the bodily plenum. This triad could also join the others listed in Awakenings, as a way of stressing how Sacks's own suffering recapitulates the history of other patients: the twins John and Michael in their “numerical communion”; or the memory-impaired alcoholic, Jimmy G., who could nonetheless experience the “fullness and totality of Communion, the perfect alignment of his spirit and the spirit of the Mass” (1974, 36); or the parkinsonian Martin, for whom “communion with the music” of the church choir brought “absorption and animation, wholeness and health” (1974, 183); or even Sacks himself in the convalescent home, where sitting one September morning on a stone bench, like “Adam beholding the new world with wonder,” he felt “a perfect peace and communion lay upon the land” (1984, 174).

Just as Sacks's relationship with his nonproprioceptive leg was a failed dialogue, so also were his contacts with his physicians. When he attempted to explain his loss of body image, his surgeon felt that there was nothing to be alarmed about. Sacks writes that his surgeon “didn't even listen to me. He showed no concern. He doesn't listen to his patients—he doesn't give a damn” (1984, 105). Later, his surgeon's senior registrar spoke with him, assuring him, “Sacks you're unique. … I've never heard anything like this from a patient before” (1984, 106). But those assurances provoked Sacks's rage, a reaction quite unexpected from a neurologist who wants to institute the neurology of identity: “‘I can't be unique,’ I said, with anger, and rising panic. ‘I must be constituted the same way as everyone else! … you don't listen to what patients say, perhaps you're not interested in the experiences they have’” (1984, 106-7; emphasis added).

Sacks's convalescence further extended his feeling of being constituted no differently from other neurologically impaired patients. In convalescence, he learned that “my own experience, my ‘case,’ was far from unique. Almost every patient who had injury or surgery to a limb, and whose limb had then been casted, out of sight, out of action, had experienced some degree of alienation” (1984, 161; emphasis added). Again, there is no denying his great sympathy and compassion for his fellow patients, for he intimately recognized the terror and alienation they experienced, but it still remained for him that his fellow patients' identities resided not in their uniqueness but in the way each served as a synecdoche for an abstract form: the alienated, excommunicated, cast-out patient.

Throughout his arguments for a neurology of identity, Sacks faults a scientific way of thinking that is as fundamental to him as it is to the neurological tradition. This is why, regardless of his sympathy and compassion for patients, or the vigor of his style, or the intensity of his commitment to reform his profession, his efforts must be regarded with some caution, though not outright condemnation. Sacks's arguments repeatedly demonstrate that whenever the one instance is thought somehow to replicate the others (and this is fundamental to the Leibnizian and Pythagorean character of his intellect), there is consequently a tendency to regard each instance tropically, as a synecdoche for all other instances, and thus for the form, organization, or design they realize. To accept Sacks's indictment of reductive and abstract thinking without asking whether his own conceptual mechanics is fundamentally different would be to ignore how empirical science tries to understand each datum as an instance of an abstract form replicated in all the data.⁹ In the end, we may respect and admire his efforts, and we cannot condemn him out of hand, but Oliver Sacks never understands what Serres and Bakhtin implicitly do: synecdoche directs the traffic at the crossroads of science, rhetoric, and epistemology.

Notes

1. Elsewhere in this volume, Mary Ellen Pitts analyzes Sacks's rejection of mechanistic thought. I agree with Pitts that Sacks values the kinesthetic over the mechanistic; doing so is the source of his compassion for patients. Compassion does not necessarily guarantee the absence of abstract thinking, however.

2. In spite of his claims otherwise, there is an interesting symmetry between Sacks's ways of thinking and Newton's. In their survey of classical physics, Ilya Prigogine and Isabelle Stengers describe Newton's spatial dynamics in ways that could also characterize how Sacks maps his conceptual space: “any single state is sufficient to define the system completely. … Dynamics defines all states as equivalent: each of them allows all the others to be calculated” (1984, 60).

3. Synecdoche rather than metonymy names Sacks's dominant trope because his conception of the patient's status relies less on the metonymic “changing” or “substituting” of names than on the synecdochic “receiving together” of characteristics. Such a distinction is in keeping with Roman Jakobson's seminal meditations on the metaphoric and the metonymic. In cubism, for example, Jakobson observes that “the object is transformed into a set of synecdoches” (1971, 1114). As any cubist figure is the empirical realization of certain formal, geometric patterns, it synecdochically calls up all other cubist figures. Jakobson thus implies my point that synecdoche is the trope that realizes the formal in the empirical.

4. Elsewhere in Sacks, the fascination with abstract organization and design first surfaced in Migraine: Understanding a Common Disorder (1972, rev. 1985), in which his goal was “to trace the basic design or structure of migraine,” especially its five stages of “excitement,” “engorgement,” “prostration,” “resolution,” and “rebound” (120). The same fascination appears in Seeing Voices: A Journey into the World of the Deaf (1989), his most recent book, a study of the sign languages of the deaf, in which he writes that “the beauty of … [American] Sign … is like the beauty of theory in this way: that the concrete leads to the general, but it is through the general that one recaptures the concrete, intensified, transfigured” (123).

5. In his thematic survey of Sacks's oeuvre, William Howarth remarks on the “classical” and “romantic” in Sacks's writing to show how Sacks develops narrative forms that “establish a full ecology of healing, a view that emphasizes dynamic exchange, recurring cycles, the balance and integrated harmony of health” (1990, 119).

6. For an argument ascribing Vološinov's text to Bakhtin, see Holquist (1981).

7. For Serres, mathematics constitutes the most pronounced expression of this isomorphism of dialogue and scientific abstraction, for it is “an ideal republic which is the city of communication maximally purged of noise” (1982a, 68). No wonder, then, the Pythagorean in Sacks's thought, the way it conceives the autistic John and Michael, for example, to be synecdoches for the formal pattern of prime numbers.

8. I refer to Sacks's “gaze” in order to borrow from Michel Foucault's history of how the nineteenth-century birth of the clinical “gaze” reveals a tendency to regard the patient as a synecdoche. Like Serres, Foucault attends to the relationship between the formal and the empirical, on the one hand, and to the expression of that relationship, on the other. In the clinics of the nineteenth century, “the individual in question was not so much a sick person as the endlessly reproducible pathological fact to be found in all patients suffering in a similar way,” Foucault observes, and “to the exhaustive presence of the disease in its symptoms corresponds the unobstructed transparency of the pathological being with the syntax of a descriptive language: a fundamental isomorphism of the structure of disease and of the verbal form that circumscribes it” (1973, 97).

9. T. S. Kuhn also implies that a datum is a synecdoche for the form when he describes how “exemplars,” or a scientific “community's standard examples,” enable its members to acquire the community's “disciplinary matrix” (1977, 293-319). Kuhn adopted the terms exemplar and disciplinary matrix in response to criticism that he deployed the term paradigm in his Structure of Scientific Revolutions (1962, rev. 1970) in seemingly contradictory ways. But since paradigm involves a sort of merging of the formal and the empirical, it seems to me to indicate precisely how the empirical replicates the formal. If there is slippage in Kuhn's use of paradigm, it does not mark contradiction; indeed, labeling Kuhn contradictory misses the supplementary nature of his case; see McRae (1988).

References

Bakhtin, M. [V. N. Vološinov, pseud.] 1973. Marxism and the Philosophy of Language. Trans. L. Matejka and I. R. Titunik. New York: Seminar Press.

———. 1981. The Dialogic Imagination: Four Essays. Trans. C. Emerson and M. Holquist. Austin: Univ. of Texas Press.

———. 1984. Problems of Dostoevsky's Poetics. Trans. C. Emerson. Minneapolis: Univ. of Minnesota Press.

Foucault, M. 1973. The Birth of the Clinic. Trans. A. M. S. Smith. New York: Parthenon.

Holquist, M. 1981. The Politics of Representation. In Allegory and Representation: Selected Papers from the English Institute, 1979-80. Ed. S. J. Greenblatt. Baltimore: Johns Hopkins Univ. Press.

Howarth, W. 1990. Oliver Sacks: The Ecology of Writing Science. Modern Language Studies 20(4): 103-20.

Jakobson, R. 1971. The Metaphoric and Metonymic Poles. In Critical Theory since Plato. Ed. H. Adams. New York: Harcourt.

Kuhn, T. S. 1970. The Structure of Scientific Revolutions. 2d ed. Chicago: Univ. of Chicago Press.

———. 1977. The Essential Tension: Studies in Scientific Tradition and Change. Chicago: Univ. of Chicago Press.

Leibniz, G. W. von. 1948. The Monadology and Other Philosophical Writings. Trans. R. Latta. Oxford: Oxford Univ. Press.

McRae, M. W. 1988. The Paradigmatic and the Interpretive in Thomas Kuhn. Clio 17: 239-48.

Prigogine, I., and I. Stengers. 1984. Order out of Chaos: Man's New Dialogue with Nature. Toronto: Bantam Books.

Sacks, O. [1972] 1985. Migraine: Understanding a Common Disorder. Berkeley: Univ. of California Press.

———. 1974. Awakenings. Garden City, N. Y.: Doubleday.

———. 1984. A Leg to Stand On. New York: Summit.

———. 1985. The Man Who Mistook His Wife for a Hat and Other Clinical Tales. New York: Summit.

———. 1989. Seeing Voices: A Journey into the World of the Deaf. Berkeley: Univ. of California Press.

Serres, M. 1982a. Hermes: Literature, Science, Philosophy. Ed. J. V. Harari and D. F. Bell. Baltimore: Johns Hopkins Univ. Press.

———. 1982b. The Parasite. Trans. L. R. Schehr. Baltimore: Johns Hopkins Univ. Press.

SOURCE: Hawkins, Anne Hunsaker. “Oliver Sacks's Awakenings: Reshaping Clinical Discourse.” Configurations 1, no. 2 (spring 1993): 229-45.

[In the following essay, Hawkins describes Sacks's trajective approach to clinical experience found in Awakenings.]

THE METAPHOR OF TRAJECTIVE DISCOURSE

“My ideal doctor,” wrote the late Anatole Broyard, “would be my Virgil, leading me through my purgatory or inferno, pointing out the sights as we go. He would resemble Oliver Sacks, the neurologist who wrote Awakenings and The Man Who Mistook His Wife for a Hat. I can imagine Dr. Sacks entering my condition, looking around at it from the inside like a benevolent landlord with a tenant, trying to see how he could make the premises more livable for me. He would see the genius of my illness. He would mingle his daemon with mine: we would wrestle with my fate together.”¹ At first glance, Virgil and Sacks—Dante's imagined guide in the Divine Comedy and the very real twentieth-century physician—may seem an oddly assorted pair, but they are alike in that both poet and physician-writer can be seen as entering into the world of sin or sickness and accompanying the pilgrim or the patient through it.²

The fantasy of a physician accompanying a patient into the “Hell” of illness is an interesting one, and resonates with the method Sacks himself identifies in Awakenings as a “trajective” approach (p. 226).³ This approach is the result of Sacks's attempt to bring together the two kinds of narrative representation that he finds in clinical experience: the first, “an objective description of disorders, mechanisms, syndromes,” and the second, “more existential and personal—an empathic entering into patients' experiences and worlds” (p. xxxvi). Sacks returns to this view of clinical experience as composed of two different narrative components much later in the text, where he refers to two “types of discourse”: “identification,” which concerns diagnostically relevant information about a patient and uses the language of biomedical science, and “understanding,” an empathic knowledge about a patient, which uses descriptive language (p. 226). Sacks's idea of the two approaches appears to be greatly influenced by A. R. Luria's observations on romantic and classical science, which Sacks mentions (and even quotes) in his foreword to the 1990 edition of Awakenings (pp. xxxv-xxxvi). In The Making of Mind, Luria discusses at some length the distinction between classical and romantic science: a classical approach reduces phenomena to their elementary components and achieves understanding by means of abstract models, whereas a romantic approach will preserve the fullness of human reality, achieving understanding by means of an empathic identification with the patient's experience. This distinction is itself a reformulation of the two methodological approaches to science—the nomothetic and the idiographic. A nomothetic approach studies events and persons as examples of some general law: its aim is explanatory and its language is that of physiology and anatomy; the idiographic, on the other hand, studies events and persons as unique cases: its aim is understanding and its language is subjective or phenomenological.⁴

The two kinds of writing come together in the case histories that Sacks wrote in 1969 and that later became the “heart” as it were, of Awakenings—his collection of cases documenting the responses of patients with postencephalitic Parkinsonism to the drug levodopa (L-DOPA). What Sacks has done here is to combine both modes in a discourse that works “analogically, allusively … by images, similitudes, models, metaphors … [to] bridge the gulf between physician and patient” (pp. 225-226). Sacks describes his “trajective” approach as one that is “neither ‘subjective’ nor ‘objective’” and characterizes it as follows: “Neither seeing the patient as an impersonal object nor subjecting him to identifications and projections of himself, the physician must proceed by sympathy or empathy, proceeding in company with the patient, sharing his experiences and feelings and thoughts, the inner conceptions which shape his behavior” (p. 226). Sacks's trajective approach to clinical experience corresponds in many ways to the approach Broyard's “ideal doctor” would take—a doctor perceived as a fantasized Oliver Sacks “leading me through my purgatory or inferno. … entering my condition, looking around at it from the inside.”⁵

Central to the remarks of both Sacks and Broyard is the metaphor of the doctor as a traveler into the world of the patient. Sacks writes in Awakenings that the physician must become “a fellow traveller, fellow explorer, continually moving with his patients” (p. 225), and elsewhere he likens himself as a neurologist to an explorer of “the furthest Arctics and Tropics of neurological disorder.”⁶ The idea that serious illness can be likened to a different “world” with its own set of rules, routines, values, and goals appears again and again in the pathographies, or autobiographical accounts of illness, written by patients.⁷ A familiar example is Susan Sontag's elaborate (and often-quoted) description of illness as “an emigrat[ion] to the kingdom of the ill” at the beginning of Illness as Metaphor.⁸ Other pathographers use this notion of illness as a separate realm in more concrete ways. Kenneth Shapiro observes, “I exist in the world as most people see it, but I live in the world of the person with terminal cancer.”⁹ James L. Johnson sees his heart surgery as an occasion “to face squarely into death and make one of the most revolutionary journeys of my life … over and back.”¹⁰ Jory Graham uses this metaphor to criticize doctors for neglecting their patients' nonmedical needs: she perceives the failure to provide “safe conduct” for patients in their journey into the world of cancer and back as “the most serious shortcoming in cancer treatment today.”¹¹

Sacks himself, in a pathography written some years after Awakenings, uses the metaphor of illness as a journey into a separate world as the organizing construct of the book. In A Leg to Stand On, he describes his own experience as a patient recovering from a leg injury incurred while hiking. Though the injury is repaired by surgery, Sacks's recovery is complicated by a sense of proprioceptive impairment wherein he loses all feeling in the injured leg—even asserting that the leg no longer seems to “belong” to him—and by the fact that his physician refuses to acknowledge this disquieting sensation. Sacks quotes his doctor as telling him: “I can't waste time with ‘experiences’ like this. I'm a practical man. I have work to do.”¹² Searching for a way to formulate a sensation whose reality is denied by his physician, Sacks understands his recovery as a “pilgrimage” and “a journey of the soul,” alluding more than once to that other journey in the Divine Comedy. Here, the physician has become the patient, and in this sense he enters into the patient's world quite literally.

What is striking about Sacks's pathography is not only that he likens his slow recovery to Dante's journey through Hell, Purgatory, and Heaven, but that the original circumstances of the injury are so similar to the metaphorical frame in Dante's Divine Comedy. The Inferno begins with Dante trying to climb a mountain, confronting three beasts who force him back down, falling into despair, and then meeting Virgil, who helps him reach his goal. Sacks's injury occurs when he is climbing a mountain, comes upon a bull, turns and runs away from it, and then falls, tearing the quadriceps muscle in his thigh. The difference between the two pilgrimages is the absence, for Sacks, of any figure such as Virgil to act as companion and guide in the journey back to health. The refusal of Sacks's doctor to acknowledge his patient's subjective experience of proprioceptive impairment is, in effect, a refusal to enter the patient's world.

THE METHODOLOGY OF TRAJECTIVE DISCOURSE

The metaphor of the doctor as a traveler into the world of illness is the symbolic basis for Sacks's notion of trajective discourse. To understand how this notion functions, it may be helpful to turn from metaphor to methodology. Three different theoretical methods—from anthropology, social psychology, and literary theory—can help us better comprehend what Sacks means by a trajective approach to clinical experience.

Trajective discourse conforms to what ethnographer Clifford Geertz calls “thick description,” which seeks to “grasp and render … a multiplicity of complex conceptual structures, many of them superimposed upon or knotted into one another, which are at once strange, irregular, and inexplicit.”¹³ Such discourse requires that the physician be a kind of ethnographer of the world of illness, perceiving a patient not as a problem requiring a solution but as a complex phenomenal whole—a “multiplicity of configurations”—requiring “exploration,” or imaginative empathy, and understanding. Sacks's patients, severely crippled by Parkinsonism, are in many ways analogous to the strange and foreign cultures that the ethnographer studies. When used by either ethnographer or physician, thick description achieves an understanding of cultures or patients in their complexity, richness, and depth that, to use Geertz's words, “exposes their normalness without reducing their particularity.”¹⁴ Like thick description, trajective discourse is contextually grounded: it emphasizes as relevant to a patient history a sense of the character, life-history, important human relationships (with both family and staff), and personal values and goals of the individual patient. Thus Sacks includes as a necessary introduction to the account of his patients' response to L-DOPA a character-sketch of what they were like before the onset of Parkinsonism, a description of the ways in which the uniqueness of each of these individuals is expressed through or in spite of their disease, accounts of the nature of the important relationships in their lives—whether with a parent, a staff-person, or Sacks himself—and their interests, hobbies, and values.

The importance of a contextually grounded discourse is also central to Elliot Mishler's analysis of the dialectics of medical interviews. A social psychologist, Mishler has studied the medical interview as inherently structured around two voices—“the voice of medicine” and “the voice of the lifeworld”—each representing different normative orders.¹⁵ The “voice of medicine” refers to a technological bioscientific frame of reference wherein the meaning of events is based on abstract formulations of body structure and function, and the “voice of the lifeworld” refers to the psychological and sociocultural contexts that shape a patient's values, attitudes, and practices. Mishler perceives the routine medical interview as a discourse dominated and controlled by the voice of medicine—a kind of discourse where “patients' efforts to tell their stories and to provide a sense of their lived experience … are disrupted by physicians who ignore what they are saying and transform all content into the terms and the logic of the biomedical framework.”¹⁶ Sacks's experiment in the trajective approach to a medical history can be seen as conforming to Mishler's call for a discourse that attends and witnesses to lifeworld issues. Mishler urges a “[r]ecognition of the distinctive humanity of patients and respect for the contextual grounding of their problems in their lifeworlds.”¹⁷ Sacks tries to do just this in his histories. Thus he writes in his preface to the original edition: “I have … tried to preserve what is important and essential … the real and full presence of the patients themselves, the ‘feeling’ of their lives” (pp. xvii-xviii).

Very similar to Elliot Mishler's discussion of the relationship between the two voices in medical discourse is Mikhail Bakhtin's broader distinction between monologic and dialogic (or polyphonic) narrative. The typical medical history—the scientific, technological, disease-centered narrative of which Sacks is so critical—exemplifies Bakhtin's description of monologic discourse as “a monologically understood objectified world correlative to a single and unified authorial consciousness.”¹⁸ The medical history is monologic because it is controlled by a scientific ideology that focuses on the biochemical aspects of a disease and its treatment to the exclusion of the human being whose body harbors the disease so reified. To compare Awakenings to the conventional medical history is to trace a movement away from “authoritative discourse” and toward dialogism. As Michael Holquist defines it, “dialogization” takes place when a discourse “becomes relativized, de-privileged, aware of competing definitions for the same thing.”¹⁹ In the conventional medical history, the patient's subjectivity only rarely intrudes on the narrative. In Awakenings, however, Sacks consciously departs from the conventions of the medical history to try to present his patients as individuals—as “full-fledged subjects,” to use Bakhtin's description of character in polyphonic narrative.²⁰ Sacks does this by means of trajective discourse—a kind of discourse similar in many ways to Bakhtin's idea of dialogism. As we shall see, in his story of Frances D.'s illness and response to L-DOPA, Sacks renders Miss D.'s subjective experience by using direct quotations, by including as pertinent—and honoring—her wishes as to treatment, by explaining Parkinsonism as she experiences it, and by mentioning her ambivalent feelings about her doctor, Sacks, as well as the frustrations she undergoes in being confined to an institution.²¹

REFLECTION AND METAPHOR IN AWAKENINGS

The form of Sacks's cases in Awakenings is a greatly modified version of the standard medical history with its classic divisions into identifying information and chief complaint, past medical history, history of present illness, review of systems, and family and social histories. Sacks himself is aware of this issue of genre, and in the preface to the original edition of Awakenings he refers to his patient narratives as “extended case-histories or biographies” (p. xvii). He also calls the reader's attention to the book's “alternation of narrative and reflection” and “proliferation of images and metaphors” (p. xviii)—stylistic devices that have never been components of the standard medical history. At the outset, then, by his conscious inclusion of reflection and of image and metaphor, Sacks deviates markedly from the generic medical history in form and in content.

Both reflection and metaphor are necessary components of a trajective approach to clinical experience. Reflection implies that the ability to apprehend another's experience is something that unfolds over time: it is not an event, but a process whereby one comes to understand experience through thinking about it. There are several levels of reflection in Awakenings. One is Sacks's habit of introducing copious footnotes, most of which offer further thoughts on or elaborations of the issue discussed in the text. Thus he mentions Miss D.'s gnawing and biting compulsions, comparing them to other abnormally perseverative compulsions and discussing them as rooted in some phylogenetic, unconscious memory “from unimaginable physiological depths below the unconscious”; he then moves from these to other kinds of excitation that his patients experience at the height of their reactions to L-DOPA—sensations resulting in “menagerie noises … noises of almost unimaginable bestiality” (p. 55). Another way Sacks uses reflection is his habit of digressing on the meaning of a particular event for the patient who is experiencing it, often using the patient's own words. When Miss D.'s L-DOPA finally must be discontinued because of its many adverse effects, Sacks tries to provide the reader with a “thick description” of her response, a vivid realization of what this means in the context of her life. So he first describes her feeling of being “letdown” when the drug is withdrawn, and her disappointment in her doctor, Sacks, who could not prevent the escalation of side effects that forced her to discontinue L-DOPA; then her gradual disinvestment in hopes for a marked improvement in her condition, and her ambivalent feelings about Sacks; and finally an “accommodation” to the limits imposed on her by her illness, by the drug used to treat it, and by the institution where she would spend the rest of her life (pp. 54-58).

Sacks justifies his use of metaphor in these histories by his conviction that the phenomena to be described can be conveyed in no other way; metaphor here is not decorative, but necessary. He writes: “My aim is not to make a system, or to see patients as systems, but to picture a world … the landscapes of being in which these patients reside” (p. xviii). Metaphor and image are appropriate linguistic tools for realizing this aim, since these literary devices help us understand those things that are beyond our immediate experience by representing them analogically.

There are two modes of metaphorical discourse in Awakenings. The methodology of the book is itself conceived metaphorically: it is based on the author's “imaginative movement” into the patient's world in order to picture the “landscapes of being” that characterize the unusual experiences of these patients. But Sacks also uses metaphor in the particular images chosen to figure forth the inner reality of his patients' experiences. Of course the very language within which Parkinsonian symptoms are described is metaphorical: patients tend to “freeze” in movement or speech; a certain kind of facial immobility is referred to as a “staring attack”; the body tends to “jam” in particular postures. In trying to express a patient's response to the more grotesque and bizarre symptoms of Parkinsonism, Sacks mentions feelings of “intense and ‘inexplicable’ assaults on the citadel of the self” (p. 54). Attempting to reflect in his language Miss D.'s feelings about her compulsion to gnaw, bite, and gnash her teeth, Sacks resorts again to the metaphor of ontological landscape, seeing these oral voracities as “monstrous creatures from her unconsciousness and from unimaginable physiological depths … pre-historic and perhaps prehuman landscapes” (p. 55). Sacks here is elaborating on—“exploring,” to use his own image—her descriptions of her responses to these symptoms, which she has written about in a diary (p. 51). Even the title of the book is metaphoric, drawn from the world of folklore in its implicit allusion to characters like Rip van Winkle and Sleeping Beauty who awaken after sleeping for decades, and from the world of religion in suggesting an analogy with the spiritual “awakenings” that are a regular feature of religious conversion.

TRAJECTIVE DISCOURSE IN THE STORY OF FRANCES D.

Let us turn to one of Sacks's histories in Awakenings and see how it illustrates a trajective approach to clinical experience. The entire first paragraph of the story of Frances D. is a fine example of trajective discourse. Consistently linking the details of illness and an experiencing subject, Sacks “carries” the narrator (and the reader) into the world of the patient:

Miss D. was born in New York in 1904, the youngest and brightest of four children. She was a brilliant student at high school until her life was cut across, in her fifteenth year, by a severe attack of encephalitis lethargica of the relatively rare hyperkinetic form. During the six months of her acute illness she suffered intense insomnia (she would remain very wakeful until four in the morning, and then secure at most two or three hours' sleep), marked restlessness (fidgeting, distractible and hyperkinetic throughout her waking hours, tossing-and-turning throughout her sleeping hours), and impulsiveness (sudden urges to perform actions which seemed to her senseless, which for the most part she could restrain by conscious effort). This acute syndrome was considered to be “neurotic,” despite clear evidence of her previously well-integrated personality and harmonious family life.

(p. 39)

Sacks's narrative style is not the stark, objective, fact-laden style of the case history with its effaced narrator. On the other hand, this is not a floridly poetic attempt to characterize a patient and her experience. This is translucent prose; it is clear and quiet, though nonetheless full of tacit affect—a style that is informative but never intrusive.

Sacks does not begin his history of Francis D. with the traditional opening formula of a medical history: “a 65-year-old woman who presents with. …” Instead, he tells us, using the voice of the lifeworld, that she was born in New York in 1904 and that she was “the youngest and brightest of four children”—details for the most part irrelevant to her medical history, but important in reconstructing the context of her life before she became ill. In the second sentence, Sacks brings together the genres of medical history and clinical biography by introducing “the voice of medicine” within the larger frame of lifeworld issues. He emphasizes Miss D.'s intelligence by informing us that she was a “brilliant student,” then introduces the disease that was to change her life so drastically with a striking and yet understated verbal metaphor: “her life was cut across … by a severe attack of encephalitis lethargica.” These choices of verb and adjective highlight the pathos of this case while giving necessary clinical information (age of patient, date of onset, definition of precipitating illness). The long third sentence syntactically alternates the two voices of medicine and the lifeworld: each of her primary clinical symptoms is noted (e.g., “intense insomnia”), followed by a parenthetical description of the symptom as the patient experienced it (“she would remain very wakeful until four in the morning, and then secure at most two or three hours' sleep”). The discourse here is syntactically dialogic.

The paragraph concludes with a misdiagnosis, plus the evidence that proves the diagnosis wrong. This last sentence is structurally divided into two parts: the first tells us that her problems were thought to suggest a neurosis; the second part, in mentioning Miss D.'s “previously well-integrated personality and harmonious family life,” not only suggests the inaccuracy of that diagnosis but also reminds us once again of all that she has lost. By concluding the sentence (and the paragraph) not with the diagnosis but with the reference to personality and family life, Sacks firmly places Miss D. and her tragic story in the context of lifeworld issues rather than that of medicine. She is described “thickly,” as clinical symptoms and diagnosis are observed and explained (or challenged) by recourse to details from the lifeworld.

Other elements in the history of Frances D. illustrate Sacks's rhetorical strategy of imaginatively moving into the patient's world. One such strategy is simply to allow Miss D. her own voice. Early in the history, Sacks introduces a direct quotation from his patient: “I have various banal symptoms which you can see for yourself. But my essential symptom is that I cannot start and I cannot stop. Either I am held still, or I am forced to accelerate. I no longer seem to have any in-between states” (p. 40). Quotations such as this, in the patient's own words, emerge at various points in the narrative primarily to describe important symptoms or responses to treatment.²² Sacks observes that her description of her condition “sums up the paradoxical symptoms of Parkinsonism with perfect precision” (p. 40). Here the subjective formulation of the patient's experience replaces objective clinical description.

An even more striking rhetorical device occurs when Sacks describes Miss D.'s responses to the termination of L-DOPA: he tells the reader that he is going to “interrupt” his patient history “for her analysis of the situation” (p. 54). It is a statement that seems to embody perfectly Mishler's call for genuine dialogue between the voices of medicine and the lifeworld. Mishler describes the typical medical interview as dominated by the voice of medicine: when patients occasionally refer to the personal and social contexts of their problems, these function as interruptions in the flow of the discourse. Here, though, it is the physician himself who interrupts his own story so that we can hear the patient's voice. What follows is her description (in her own words) of “crashing” when the drug is suddenly withdrawn, of her sense of helplessness and outrage at the exacerbation of certain symptoms—in particular, certain violent appetites and passions resembling bestial regression—and of her ambivalent responses to her doctor, Sacks, who has given her L-DOPA.

The dialogic nature of the discourse in Awakenings includes the patient not only in describing symptoms and responses to treatment, but also in decision making. Miss D.'s wishes as to important decisions in the course of her treatment are, whenever possible, solicited and honored. On two occasions, Sacks wants to discontinue treatment, but does not do so in deference to her wishes. Sacks's two characters in the story—the physician and his patient—here exist as two independent consciousnesses, and their interaction is a matter not just of personal empathy but of pragmatic decision making. As discourse, then, the history embodies Bakhtin's notion of polyphonic narrative, which is characterized by a “plurality of independent and unmerged voices and consciousnesses. … a plurality of equal consciousnesses and their worlds which are combined here into the unity of a given event, while at the same time retaining their unmergedness.”²³

Not only is the patient rendered more “thickly” in Sacks's histories, but the physician is too. In the conventional case history the subjectivity of the author is ruthlessly extirpated. Here, though, the author's feelings and intuitions about his patient are allowed a place. At one point in his description of Frances D., Sacks mentions how her “candor, courage, and insight” help him understand more clearly her response to L-DOPA; at another, he describes “her mysterious reserves of health and sanity” as crucial in enabling her to deal with the limitations of treatment; and at the very end of the history, he characterizes her as “a superior individual” and a survivor of “an almost life-long character-deforming disease” who remains “a totally human, a prime human being” (pp. 53, 58, 67). Intuition, as well as emotional response, is legitimized in this trajective history; thus Sacks writes that, after he returned from vacation, “I felt what was happening with her, in a very fragmentary and inchoate way … but it was, of course, months and even years before my own intuitions, and hers, reached the more conscious and explicit formulations” (p. 57; emphasis in original).

Lastly, Sacks himself, the physician, makes several appearances in the narrative in his role as an important “actor” in the patient's drama of illness. For example, he includes as relevant information his taking a month's vacation, describing its disastrous impact on all his patients at a crucial time in their treatment. In another passage, searching for the cause of Miss D.'s oculogyric crisis, he realizes only when an observant nurse tells him that he, Sacks, is the stimulus of her crises. Examining why his presence should precipitate these crises, he comes to a better understanding of how a severely incapacitated patient might regard a physician who administers such a powerful drug. For Miss D., Sacks is “the equivocal figure who had offered her a drug so wonderful and so terrible in its effects” and the figure who disappears “at the height of her anguish” to go on holiday (pp. 56, 57). But Sacks does not introduce these comments just to characterize Miss D. more fully; rather, he goes further to reflect on their meaning for himself and his role as physician: L-DOPA, he concludes, “invested me … with all too much power over her life and well-being” (p. 56).

It seems appropriate to trajective discourse that the physician “enter” the patient's medical history—both as the object of his patient's feelings, and as a subject with feelings, intuitions, and his own lifeworld issues.²⁴ But Sacks is doing more than entering the patient's world. The doctor here becomes more than an epiphenomenon of the patient's consciousness. In so reflecting on his power as physician totally to transform a human life, for better or for worse, he provides a glimpse into the lived reality of the physician burdened with responsibility and choice, which renders the discourse truly polyphonic.

CONCLUSION

A sophisticated critical reading of Awakenings would tend to make much of the relationship between Sacks the author and Sacks the character. For we have become accustomed to fictions where the author distances himself from the narrator or the protagonist, obliquely exposing the shortcomings and deficiencies of a so-called hero or heroine. A critic who has thus learned always to second-guess hero or narrator might wonder whether Sacks the doctor is really manipulating his helpless patients, intruding into their private lives under the guise of sympathy, or exploiting their vulnerability for purposes of research or his own personal glory. But I believe such charges, in this instance, to be unfounded. Sacks exposes himself to suspicions like these by entering his own narrative instead of taking refuge in the safe anonymity of the conventional medical history, where the physician remains invisible and absent—his own feelings and his interaction with patients rigorously suppressed, his choices and decisions recorded as mere events. In contrast, Sacks's personal involvement involves risk, but this risk-taking seems of a piece with his genuine engagement with his patients—and his readers.²⁵

This engagement transforms the conventions of medical writing. Sacks excoriates the conventional discourse of neurology for its “‘objective’, styleless style” replete with “‘facts’, figures, lists, schedules, inventories, calculations, ratings, quotients, indices, statistics, formulae, graphs, and whatnot,” lamenting that “nowhere does one find … any residue of the living experience” (p. 230). Sacks's remarks here are typical of criticisms now leveled at the medical case history. Many commentators observe that the case report by its very structure not only conveys little genuine sense of patient experience but even validates a depersonalized and technological approach to patient care.²⁶ Practical suggestions for improvement or reform include William Donnelly's call for a description of the patient's understanding of his or her condition to be added at the end of the chart, Charles Freer's idea of “anecdotal diagnostic summaries” to be included in the problem list, and David Flood and Rhonda Soricelli's recommendation that the patient profile be expanded so as to include subjective data such as “ethnic and religious background …, occupation, hobbies, lifestyle, family structure and significant relationships.”²⁷ Kathryn Montgomery Hunter argues for an “enriched” history in which the doctor-narrator is recognized as “contextually conditioned”—that is, characterized by a history and a social context—and which acknowledges the “lived experience” of the patient.²⁸ It seems appropriate that Hunter should praise Sacks's histories (and Freud's too) as “set[ting] the standard for physicians' full empathetic and analytical narratives of illness and treatment.”²⁹

However, very real problems can arise when one tampers with the form of the medical history. The fate of David Barnard's essay “A Case of Amyotrophic Lateral Sclerosis” serves as an unfortunate example of what can happen when a physician allows her own feelings, motives, and lifeworld issues to enter a medical history.³⁰ Although the narrator of this case is not the physician but Barnard, a participant-observer, both come under fire—in an invited commentary by Erik Rabkin—for supposedly sacrificing the patient and his wife to the physician's need to be the self-sacrificing, humanitarian “heroine” of the story.³¹ An unfortunate result of Rabkin's attack has been to obscure what Barnard was trying to do in this unusual case history—namely, to present a patient's illness as “a meaningful event in the lives of both the physician and the patient.”³² And if critics of the medical history argue, as they now often do, that the self-effaced physician-narrator of the medical history is a stylized travesty of objectivity that condones as it enacts a depersonalized medical model, then attempts such as Barnard's to incorporate the physician's humanity into the medical history should be recognized for what they are—attempts to represent in narrative form elements actually present in the medical enterprise. Such elements include the recognition that a physician does have personal goals, values, and motives and that these inevitably affect the relationship with patients; the acknowledgement that there is no easy way to balance the need for emotional distance with the need for a compassionate and caring relationship with a patient; and the fact that physicians in the United States are trained to deal with acute, treatable conditions, whereas many of their patients have a chronic or terminal illness.

Sacks, like Barnard, intends his narratives to be imaginative reworkings of the medical case history. Sacks's “clinical tales” are meant to bring together the two modes of clinical approach—the nomothetic and the idiographic—and to blend the forms of discourse appropriate to each. Moreover, Sacks's aim in writing Awakenings was not so much to reform the medical history, which serves practical and legal functions, as it was to reconceive the relationship between doctor and patient.

It may be that attempts at reforming the medical history are misdirected. What needs reform is not so much the medical document as the way doctors and patients communicate with each other—or fail to do so. What Sacks offers the reader in Awakenings is not just a model for medical writing but a paradigm for actual medical practice. The twenty case histories that make up Awakenings record the trajectory of the physician's movement into lifeworld issues central to patients' experiences, situating the rhetoric of biomedicine within a discourse that can include intuitive appraisal, affective and relational dimensions, and, when appropriate, admission of failure or error. Such discourse situates the patient, not the disease, at the center of the medical enterprise, and its polyphonic narrative preserves the individuality of both patient and doctor. One can see why a patient like Broyard might have wished that Oliver Sacks had been his doctor.

Notes

1. Anatole Broyard, “Doctor Talk to Me,” New York Times Magazine, August 26, 1990, p. 36. This passage is slightly rephrased in Alexandra Broyard, ed., Intoxicated by My Illness and Other Writings (New York: Clarkson Potter, 1992), pp. 42-43.

2. Anne Hunsaker Hawkins, “Charting Dante: The Inferno and Medical Education,” Literature and Medicine 11:2 (1992): 200-215.

3. Oliver Sacks, Awakenings (New York: HarperCollins, 1990), p. 226 (further quotations from Awakenings will be from this edition and will be cited by page number within the text of my essay). The only reference to this term that I have been able to find in Eugen Rosenstock-Huessy's work is in Out of Revolution: Autobiography of Western Man (New York: Will Morrow, 1938; reprint Norwich, Vt.: Argo Books, 1969). Rosenstock-Huessy suggests here that the words “subject” and “object” be replaced by “traject” and “preject.” “Traject,” he writes, refers to human development by evolution, or “he who is forwarded in ways known from the past”; “preject” refers to development by revolution, or “he who is thrown out of this rut into an unknown future” (p. 747). It seems clear that Sacks is using the term “trajective” in a somewhat different sense.

4. A. R. Luria, The Making of Mind: A Personal Account of Soviet Psychology, ed. Michael and Sheila Cole (Cambridge, Mass.: Harvard University Press, 1979). Luria also wrote several extended case histories: The Mind of a Mnemonist, trans. Lynn Solotaroff (New York: Basic Books, 1968), and The Man with a Shattered World, trans. Lynn Solotaroff (New York: Basic Books, 1972). To some degree, Sacks's case histories in Awakenings, described by its author as “a book which tried to be both classical and romantic,” are modeled after those of Luria, which he praises as “the finest recent examples” of the genre (pp. xxxvi, 229). Debra Journet, in “Forms of Discourse and the Sciences of the Mind: Luria, Sacks, and the Role of Narrative in Neurological Case Histories,” Written Communications 7:2 (1990): 171-199, emphasizes the role of narrative in the case histories of Sacks and Luria, citing many of the important theorists associated with recent critical studies in narratology. For a discussion of Luria's two histories as a synthesis of the nomothetic and idiographic approaches to science, see Anne Hunsaker Hawkins, “A. R. Luria and the Art of Clinical Biography,” Literature and Medicine 5 (1986): 1-15. Jerome Bruner's paradigmatic and narrative modes of thought are yet another formulation of this same complementarity: the paradigmatic is concerned with general principles and its language is denotative; the narrative emphasizes particularity, “sacrifices denotation to connotation,” and uses figurative and metaphoric language (Actual Minds, Possible Worlds [Cambridge, Mass.: Harvard University Press, 1986], pp. 11-43).

5. Broyard, “Doctor Talk to Me” (above, n. 1), p. 36

6. Oliver Sacks, A Leg to Stand On (New York: Summit Books, 1984), p. 110.

7. For a full discussion of pathography, see Anne Hunsaker Hawkins, Reconstructing Illness: Studies in Pathography (West Lafayette, Ind.: Purdue University Press, 1993).

8. Susan Sontag, Illness as Metaphor (New York: Vintage, 1977), p. 3.

9. Kenneth A. Shapiro, Dying and Living: One Man's Life with Cancer (Austin: University of Texas Press, 1985), p. 130.

10. James L. Johnson, Coming Back: One Man's Journey to the Edge of Eternity and Spiritual Rediscovery (np: Springhouse, 1979), prologue.

11. Jory Graham, In the Company of Others (New York: Harcourt Brace Jovanovich, 1982), p. 66.

12. Sacks, Leg to Stand On (above, n. 6), p. 107.

13. Clifford Geertz, The Interpretation of Cultures (New York: Basic Books, 1973), p. 10. Dena S. Davis, “Rich Cases: The Ethics of Thick Description,” Hastings Center Report (July-August 1991): 12-17, is a superb application of Geertz's idea of thick description and Gilligan's care ethics to cases important for medical ethics. Sacks himself, in the 1990 edition of Awakenings, refers to Geertz's idea of thick description (p. xxxvii).

14. Geertz, Interpretation, p. 14.

15. Elliot G. Mishler, The Discourse of Medicine: Dialectics of Medical Interviews (Norwood, N.J.: Ablex, 1984); Elliot G. Mishler, Jack A. Clark, et al., “The Language of Attentive Patient Care: A Comparison of Two Medical Interviews,” Journal of General Internal Medicine 4:4 (1989): 325-335.

16. Mishler et al., “Language of Attentive Patient Care,” p. 332.

17. Mishler, Discourse of Medicine, pp. 192-193.

18. Mikhail Bakhtin, Problems of Dostoevsky's Poetics, trans. R. W. Rotsel (n.p.: Ardis, 1973), p. 6.

19. Michael Holquist, in glossary to The Dialogic Imagination: Four Essays by M. M. Bakhtin, ed. Holquist (Austin: University of Texas Press, 1981), p. 427.

20. Bakhtin, Problems of Dostoevsky's Poetics, p. 5.

21. It can be argued that because he does not, in some way, return the story of Miss D. to her for her corroboration, Sacks's writing cannot be said to be truly dialogic. Kathryn Montgomery Hunter, in Doctors' Stories: The Narrative Structure of Medical Knowledge (Princeton: Princeton University Press, 1991), emphasizes the need for the physician to return his or her medical interpretation of the patient's story to the patient for verification. Similarly, Nancy M. P. King and Ann Folwell Stanford, in an interesting essay on potential problems in the biopsychosocial model, observe that “a dialogic relationship” between doctor and patient requires corroboration of, if not collaboration in, the physician's explanation of a patient's problem or interpretation of a patient's story (“Patient Stories, Doctor Stories, and True Stories: A Cautionary Reading,” Literature and Medicine 11:2 [1992]: 185-199). Although the subject of King and Stanford's essay is the doctor-patient encounter, their creative and cautious use of Bakhtin's ideas of the monologic and the dialogic can be helpful in thinking about the medical history as well. My point is that the monologic and the dialogic can be seen as the two end points on a spectrum, with Awakenings positioned much closer to the dialogic than to the monologic.

22. We do not know whether these are reconstructions of actual dialogue, passages from this patient's diary (which Sacks indicates he has seen), or quotations wholly invented by Sacks. This seems to me a drawback in the book, and detracts from our sense that, throughout Awakenings, Sacks makes an exemplary effort to honor his patients' subjectivity.

23. Bakhtin, Problems of Dostoevsky's Poetics, p. 4 (emphasis in original).

24. Of course, physicians can become too involved in their patients' lives. An interesting example of this can be found in David Barnard, “A Case of Amyotrophic Lateral Sclerosis,” Literature and Medicine 5 (1986): 27-42 (discussed below). I am not suggesting here that a physician should abandon clinical distance. Too often, though, “clinical distance” in medicine is thought to refer to a stance that is dispassionate, objective, and emotionally uninvolved. Clinical distance should be seen as achieving a right balance between detachment and involvement, distance and intimacy.

25. In fact, Sacks the author does distance himself from Sacks the character in that the author's intention in writing Awakenings is to expose what I call “the myth of cure”: initially, the doctor who gives his patients L-DOPA embraces the myth of cure, but it is a myth that both he and his patients must renounce in the end. I explore this dimension of Awakenings in a paper entitled, “Oliver Sacks's Awakenings and the Myth of Cure,” presented at the 1992 MLA Convention in New York City for a Special Session on Literature and Medical Ethics.

26. See Joanne Trautmann Banks and Anne Hunsaker Hawkins, eds., Literature and Medicine 11:1 (1992), “The Art of the Case History.”

27. William J. Donnelly, “Righting the Medical Record: Transforming Chronicle into Story,” JAMA 260:6 (1988): 823-825; Charles B. Freer, “Description of Illness: Limitations and Approaches,” Journal of Family Practice 10:5 (1980): 867-870; David H. Flood and Rhonda Soricelli, “Development of Physician Narrative Voice in the Medical Case History,” Literature and Medicine 11:1 (1992): 64-83.

28. Hunter, Doctor's Stories (above, n. 21), pp. 166, 106.

29. Ibid., p. 164. Though Hunter goes on to observe that Sacks's histories “are not themselves usable models for much of medical care” because they are index cases and because only neurology and psychiatry require such full characterization, I think that she may be conceding too much (Doctors' Stories, p. 165; Kathryn Montgomery Hunter, “Remaking the Case,” Literature and Medicine 11:1 [1992], p. 173). The tendency to separate the disease from the person with the disease is precisely what so many—including Hunter—have been criticizing in contemporary, technological biomedicine.

30. In his reply to the comments of Rabkin and others, Barnard observes that “there are important respects in which ‘A Case of Amyotrophic Lateral Sclerosis’ [above, n. 24] is [the physician's] story and that it is precisely this side of the story that has been too often neglected by conventional case histories” (David Barnard, “A Case of Amyotrophic Lateral Sclerosis: A Reprise and Reply,” Literature and Medicine 11:1 [1992], p. 136). Barnard further comments that “this side of the story is the place of the patient's illness in the physician's life”—the way in which “the physician comes to play a role in his or her own existential drama, even while attempting to play an appropriate and helpful role in the patient's drama” (ibid.).

31. Eric Rabkin, “A Case of Self Defense,” Literature and Medicine 5 (1986): 43-53. In fact, as Barnard reminds us in “A Case of Amyotrophic Lateral Sclerosis: A Reprise and Reply,” his aim in writing the history was to use it as a teaching device to help medical students better appreciate the nontechnological aspects of physicians' responsibilities to their patients.

32. Barnard, “Reprise and Reply,” p. 134.

SOURCE: Beehler, Rodger. “Madness and Method.” Philosophy 68, no. 265 (July 1993): 369-88.

[In the following essay, Beehler finds similarities in the exploration of madness in Awakenings and R. D. Laing's The Divided Self.]

The daily practice of clinical medicine, or so it seems to me, demands theoretical and even ‘philosophical’ viewpoints, and precisely guides one to the viewpoints one needs. That medicine provides a philosophical education … is a delightful discovery; it seems to me strange that this is not more generally recognized.

—Oliver Sacks, 1982

I

The attention recently accorded to the writings of Oliver Sacks has once more recalled to a community wider than medical personnel the deeply-moving strangeness of human beings. I refer especially to Sacks' book The Man Who Mistook His Wife for a Hat, and to his earlier book Awakenings (which last has inspired a current commercial film of the same title).¹ A comparison that comes immediately to mind is R. D. Laing's work, which was widely read and discussed in the decade from, roughly, 1965 to 1975.²

Laing's and Sacks' writings give rise to questions of many different kinds about human experience, and about what we awkwardly refer to as ‘selfhood’. These include questions about their own proposed explanations of the conditions and experiences they seek to describe and understand. One question provoked by their works is how far a person's own agency contributes to those various states (ranging from mute immobility to violent predatory frenzy) that we collect under the vague and shifting expressions ‘psychosis’, ‘insanity’, ‘madness’, ‘mental illness’. It is this general question that frames the specific inquiry of my essay.

The book by Sacks that vividly presses this question on us is Awakenings. This records (over the span of its two editions) Sacks' engagement from 1967 to 1982 with a group of survivors of the 1917-1927 epidemic of encephalitis lethargica (‘sleepy sickness’) that afflicted five million people. Awakenings chronicles the response of twenty of these post-encephalitic survivors to the drug laevo-dihydroxyphenylaline (L-DOPA), a natural substance that acts to replace the nerve-transmitter dopamine in which the brains of post-encephalitic patients are deficient (31).

The consequences to Sacks' patients of L-DOPA treatment were greatly varied. One constant, however, was that virtually all suffered some kind of ‘tribulation’ after the initial period of ‘awakening’, even that minority who managed to achieve and sustain a viable condition of health on treatment with the drug. In discussing the possible causes of these tribulations, Sacks refers to the work with post-encephalitic patients of S. E. Jelliffe in the 1930s. Jelliffe's researches called attention to ‘the effects of the external environment’—‘the circumstances and vicissitudes of each patient's life’—on treatment (20). As interpreted by Sacks, Jelliffe's work revealed that ‘post-encephalitic illness could by no means be considered a simple disease, but needed to be seen as an individual creation of the greatest complexity, determined not simply by a primary disease-process, but by a vast host of personal traits and social circumstances: an illness, in short, like neurosis or psychosis, a coming-to-terms of the sensitized individual with his total environment’ (21).

In the concluding section of his book Sacks returns to the considerations touched on in the above passage, and asks of the persons treated with L-DOPA under his care: ‘Why did so many of our patients, after doing so well at first, spoil, “go bad”, move into all sorts of trouble?’ (231). He answers:

Clearly, they had in them the possibilities of great health: the most deeply ill were able to become deeply well for a time. Thereafter, apparently, they ‘lost’ this possibility, and in no case were able to retrieve it again; such at least is the case in all the Parkinsonian [including post-encephalitic] patients I have seen. … [W]hy, for example, should a patient who retained the possibility of ‘awakening’, through fifty years of the severest illness, ‘lose’ it, in a few days [or weeks], after receiving L-DOPA? One must allow … that their possibilities of continued well-being were actively precluded or prevented because they became incompossible with other worlds, with the totality of their relationships, without and within. In short, that their physiological or social situations were incompossible with continuing health, and therefore disallowed or displaced the first state of well-being, thrusting them into illness again.

(231, Sacks' emphases)

Sacks does not, notice, cite the patients' psychological ‘situation’ as an ‘incompossibility’ operating here. It is clear from the book, however, that he means to include it (perhaps intending the phrase ‘social situations’ to cover it). At the same time, his words ‘thrusting them into illness’ in this passage suggest a process acting upon these patients, to which they are subject, but in which they are not subjects: not agents. This seeming implication is in sharp contrast to Sacks' comments in more than one place concerning a patient, ‘Rose R.’, and to his comments, not only about Rose R. but about two other patients as well, in the following sentences. (All three patients figure, though in much watered-down and inaccurate depictions, in the recent film Awakenings.)

Lucy K. had spent the greater part of her life [including her years in hospital] in a state of symbiotic and parasitic dependence on her mother [who came every day to the hospital to tend her]; her mother was the most needed person in her life, and at once the most loved and most hated, and Lucy's illness and dependence, conversely, were the most important parts of her mother's life. Lucy K. had scarcely awoken on L-DOPA before she turned to me and demanded marriage, rescue, and removal from her mother; when I indicated that this was impossible, she fell back within hours into the depths of her sickness. Leonard L. had a similar if somewhat milder pathological relation with his mother [who also daily came to the hospital to tend him], and she, as we have seen, herself broke down when he got better; Leonard saw, all too clearly, that his mother's well-being was incompossible with his own well-being; and shortly after this he too relapsed. Perhaps the saddest case is that of Rose R., who ‘came to’ joyously to the world of 1926—and found that ‘1926’ no longer existed; the world of 1969, into which she awoke, was incompossible with the world of 1926, and so she went back to ‘1926’. In these three cases, the overall situation was pathological beyond remedy: the needs of these patients were incompossible with reality.

(232-3)

It would, I believe, be more accurate to say: ‘were judged by these patients to be incompossible with reality’. For the suggestion in Sacks' remarks is that an important part of the explanation of the relapse of these three patients is that each elected relapse. There was, in other words, method in their pathology or ‘madness’.—Not in the sense ordinarily given to this expression, which implies that ‘madness’ is feigned for a purpose, but in the sense that what caused the relapse of these patients into a pathological state was, at least in part, their choosing relapse in deliberate response to their experienced situation. Such an election would turn greatly on what each agent conceived and judged was possible or incompossible with reality.

My project in what follows is tentatively to explore this idea (to which Sacks' work gives some credence) that madness or allied pathological states may sometimes be chosen by a human being. (The word ‘sometimes’ is important here. It is no part of the hypothesis under consideration that this would be true in all cases.) I propose to explore this idea by examining in detail the condition of a young man named ‘David’ discussed by R. D. Laing in his most careful and important book The Divided Self.

Readers of Laing's The Divided Self will appreciate that the expression ‘there is method in his (or her) madness’ could be borrowed to characterize an aspect of Laing's explanation of the schizoid and psychotic states he discusses. Laing represents these as the outcome of strategies deliberately employed by afflicted persons in pursuit of certain desired benefits. However, this use of the expression would not capture the possibility I wish to investigate, since on Laing's theory (as we shall see) the final stages leading to psychosis, while outcomes of earlier choices, are not themselves exercisings of choice. They are unintended outcomes of earlier choices.

Yet if we attend closely to Laing's Divided Self we find in it some data that invite an understanding similar to that invoked by Sacks of Lucy K., Rose R., and Leonard L. Specifically, the condition of the young man David, as narrated by Laing, when construed against certain background facts that Laing puzzlingly ignores, may (I shall argue) plausibly be held to be compatible with the hypothesis under consideration.

If I am able to establish this conclusion in what follows, I shall in doing so reveal an important deficiency in the methodological procedure underwriting Laing's theory of psychosis. Readers will be aware that there are a great many competing theories purporting to explain the wide range of phenomena denoted ‘madness’ or ‘psychosis’ or ‘mental illness’. These extend dizzyingly from theories which explain these conditions as direct outcomes of abnormal brain configurations or chemical metabolic imbalances or genetically inherited viruses, through those which explain them as the outcome of destructive interpersonal or intrapersonal relations, to those (Thomas Szasz comes to mind) which claim that ‘madness’ in its myriad forms is a kind of malingering behaviour that ‘mental patients’ have learned to practice because it has a desired pay-off. We are still without the knowledge that would enable us finally to settle this controversy. But if we are ever to reach that knowledge (supposing it lies within the epistemic capacity of human beings, which it may not), we must—here, as elsewhere—be careful not to ground our candidate explanations solely on the criterion of what we find (or seem to find) intelligible; and we must strive to ensure that no rival explanation is proposable that is at least as intelligible, and more closely fits our data, than the one we proffer. Part of my intent in what follows is to show that Laing's work does not always meet these methodological requirements.

II

The basic explanatory concept in Laing's The Divided Self is ontological security. The concept refers to a human being's experiencing himself or herself as being-a-person—as having that kind of reality. According to Laing, persons who lack ontological security (who are ontologically insecure) are vulnerable to becoming psychotic if they employ certain interpersonal strategies as means of reducing or alleviating the anxiety and pain of their insecurity.

Central to Laing's theory is the following assumption:

A firm sense of one's own autonomous identity is required in order that one may be related as one human being to another. Otherwise, any and every relationship threatens the individual with loss of identity.

(44)

At the same time, Laing holds, to develop such a firm sense of one's own personal identity, other people must, from your earliest years, relate to you as to a person, receiving you and responding to you in ways that acknowledge your having a person's capacities, needs, and entitlements. Meanwhile, you, on your part, must disclose yourself to others—must let them be in touch with you, not with some ‘false representation’ of you. Otherwise, you cannot receive any confirmation of your reality by other persons. Yet a child who is not received by other persons in the above way may be drawn to deploy ‘social’ strategies that involve presenting just such a ‘false self’ to others.

Laing, in speaking of a person's ‘firm sense’ of ‘autonomous identity’, means to call attention to how a person's self-identity is importantly grounded in and affirmed by his or her experience of self-direction—of agency. Connected to this experience, according to Laing, is a person's experience of his or her reality as ‘embodied’.

Laing sometimes talks as though the sense of oneself as being a person and the sense of oneself as being embodied must both be achieved by a human being. In fact, it is at least as probable that though the first has to be achieved, the second is a kind of given, which must somehow be ‘lost’ before the ‘existential’ outcome that Laing terms ‘the disembodied self’ is reached.

On this view, a human infant begins with a primal ‘ontological’ sense of itself as being. Indeed there is evidence that a child in its early weeks tends to subsume the being of everything under his or her own being. The child must come to differentiate itself from what is not itself, while at the same time being confirmed in its being by what is not itself. The child needs both to be accepted in the kind of being it has, and allowed to ‘be’ that, while also coming itself to acknowledge and respect other persons' being. On Laing's theory, if acceptance and allowing of the child's being a person are not forthcoming from others, the child may contrive strategies of various kinds to deal with the situation. The most basic and generic of these strategies is for the child to comply with what other persons require of him or her, while disowning these compliant actions or inactions as ‘not self’. This stratagem, Laing argues, is fateful for the following reasons.

Despite the child's intentions, he or she is ‘in’ those compliant actions as their agent-subject, so it will be hard always to contrive and sustain the needed dissociation from that ‘outer self’. Meanwhile, by dissociating oneself from any action performed in public or potentially observable space and time, one dissociates oneself from what is grounded in the intersubjectively real. The content available for one's ‘inner’ self comes to be confined more and more to the ‘inner’ contents of one's own consciousness, with the result that what is available for contriving a sense of self becomes thinner and thinner. A parallel consequence is that there comes to be less and less any brake on irrationality in the thoughts, beliefs and feelings of the ‘inner’-dwelling ‘self’. A further related consequence is that the ‘self’ feels more and more ‘split’ off from his or her body, which comes to be identified with the ‘false self’ (or selves) that are enacted toward others. This false self or selves, nevertheless, are constituted of actions, which ineluctably involve kinesthetic and other kinds of sensation. Hence there is an experience of being increasingly ‘split off’ even from one's own subjectively experienced movements and sensations. As the child or young person feels more and more dissociated from anything that is experienced physiologically and psychologically as objectively real and communal (i.e., as intersubjective), his or her sense of isolation is further intensified, giving rise to increased anxiety and fear. The result is that a set of practices that was intended to reduce the threatening or oppressive character of what is ‘external’ to the self results (unintentionally) in magnifying the threat that is felt to proceed from everything outside the self.

What is worse, the parameters of what is felt as threatening are continually enlarged. In time, even one's own thoughts may come to be suspected as yet another intrusion upon oneself of the ideas and intentions of others. There is a terrible apprehension of one's being as more-and-more-controlled and less-and-less-controlling. The very experiences that are constitutive of being alive take on the character of visitations; of manifestations of another presence. The final consequence may be that the ‘inner self’ is extinguished, and succeeded by someone who is not the original self;—by one's parent, or Napoleon, or Joan of Arc, or by a continuum of persons or ‘voices’. A different possible outcome is that the original self is succeeded by ‘no one’. The final condition is one of extreme autism, the seeming absence of any presence.

These are the kinds of consequences Laing refers to by the expression ‘psychosis’. On Laing's theory, they are conceived as unintended outcomes of the afflicted persons' earlier strategies of compliance, dissociation, and so on. The final passage into psychosis is something that happens to a person, not something they elect.

I turn now to Laing's discussion in The Divided Self of the condition suffered by the young man identified as ‘David’.

III

To weigh Laing's conclusions regarding David, it is necessary to attend closely to the data that Laing presents about David's biography and experiences. I shall, therefore, quote these, where appropriate, from Laing's own account. All that Laing says in his book about David will, in the course of the discussion, be reported. When following these passages, the reader is advised to note (among other things) David's age at various stages, and to bear in mind the time and place of David's biography, which are Britain in the 1950s. (The Divided Self was first published in 1960, with a 1959 copyright, and the evidence suggests that Laing's meetings with David arose from Laing's work at one or other of the Glasgow Royal Mental Hospital in 1955, the Department of Psychological Medicine at the University of Glasgow in 1956, or the Tavistock Clinic of London in 1957-59.)

Laing introduces David as a ‘borderline’ case—someone whose condition verges on psychosis. David, he tells us, ‘was eighteen when I saw him. He was an only child whose mother had died when he was ten. Since then he had lived with his father’ (70). Laing's reference here to David's father might be taken to imply that while his mother was alive David did not live with both parents. Later testimony by the father (to which we shall come in a moment) suggests that he did.

Laing continues.

From grammar school [David] had gone to university to study philosophy. His father could not see the point of his son consulting a psychiatrist as there was nothing, in his view, for him to see a psychiatrist about. His tutor, however, was worried about the boy because he seemed to be hallucinated and acted in various somewhat odd ways. For instance, he attended lectures in a cloak, which he wore over his shoulders and arms; he carried a cane; his whole manner was entirely artificial; his speech was made up largely of quotations.

(70)

Laing next tells us that the ‘account’ given of David by his father ‘was very meagre’. In the father's view, David ‘had always been perfectly normal’, and his ‘present eccentricities were simply an adolescent phase’ (70). David, according to his father:

… had always been a very good child, who did everything he was told and never caused any trouble. His mother had been devoted to him. He was inseparable from her. He had been ‘very brave’ when she died and had done everything to help his father. He did the housework, cooked the meals, bought most of the food. He ‘took over’ from his mother or ‘took after’ her, even to the extent of showing her flair for embroidery, tapestry, and interior decoration. All this his father commended and spoke highly of.

(70)

This is as much as we learn from the father, whose report (as Laing relates it) leads one to conclude that prior to the death of David's mother, the father had little to do with the boy, and continued to have little to do with his son afterwards, except as the recipient of David's ‘help’. This would explain the father's having little to say about David other than that his son ‘was normal’, ‘had always been very good’, and ‘never caused any trouble’.

We now learn from Laing that when he first met with the eighteen year old David:

The boy was a most fantastic-looking character—an adolescent Kierkegaard played by Danny Kaye. The hair was too long, the collar too big, the trousers too short, the shoes too big, and withal, his second-hand theatre cloak and cane! He was not simply eccentric: I could not escape the impression that this young man was playing at being eccentric. The whole effect was mannered and contrived. But why should anyone wish to contrive such an effect?

(70)

Laing's answer to this question is that David is a classic case of an ontologically insecure person who has never achieved a firm sense of his own identity. Having resorted from an early age to a succession of ‘false selves’ presented to others, David now finds that his current false-self—sharply distinguished by David from his ‘own self’—threatens more and more to overwhelm him. As Laing describes David's state of being (all italics are Laing's):

His self was never [note the temporal adjective] directly revealed in and through his actions. It seemed to be the case that he had emerged from his infancy with his ‘own self’ on the one hand, and ‘what his mother wanted him to be’, his ‘personality’, on the other; he had started from there and made it his aim and ideal to make the split between his own self (which only he knew) and what other people could see of him, as complete as possible. He was further impelled to this course by the fact that despite himself he had always felt shy, self-conscious and vulnerable. By always playing a part he found he could in some measure overcome his shyness, self-consciousness, and vulnerability. He found reassurance in the consideration that whatever he was doing he was not being himself. Thus, he used that same form of defence which has been already mentioned: in an effort to mitigate anxiety he aggravated the conditions that were occasioning it.

(71)

Notice the assertion: ‘He found reassurance in the consideration that whatever he was doing he was not being himself’. This is the proposition on which Laing's explanation rests. It is also the one I shall try to show is problematic when set beside the evidence Laing himself presents to us.

Laing leaves unclear whether this proposition expresses David's reported relation to his own actions, or Laing's understanding of David's relation to his own actions. The proposition also does not distinguish between David's actions in the company of his mother from infancy to his commencing school (during which time ‘he was inseparable from her’), and David's actions in the company of others (including his father) since the time of his commencing school, and especially since age ten, following his mother's death.

Yet in the paragraph immediately before this important passage, Laing, in commenting on David's ‘playing at being eccentric’, declares: ‘He was indeed a practised actor, for he had been playing one part or another at least since his mother's death’ (70, my emphasis). This remark seems to suggest that David had not always (or even often) been ‘playing one part or another’ prior to his mother's death.

On the other hand, Laing's next sentence relates:

Before that [i.e., before his mother's death], he said, ‘I had simply been what she wanted’. Of her death he said, ‘As far as I can remember I was rather pleased. Perhaps I felt some sorrow; I would like to think so anyway’.

(70)

This report by David of being, up until her death, what his mother wanted him to be, Laing proceeds to emphasize:

Until his mother's death he had simply been what she wanted him to be. After her death it was no easier for him to be himself.

(70-71)

There is a suggestion here that David had perhaps hoped, or even expected, to find it easier to be himself now that his mother was dead. (We need not suppose that this was the whole of what he felt on her death.) If this were true, it would explain his being ‘rather pleased’ at her death.

Whatever the explanation of David's being ‘rather pleased’ at his mother's death, Laing's account of why David found it difficult to ‘be himself’ even after her death stresses throughout that while his mother was alive David ‘had simply been what she wanted’. This, Laing holds, led David to contrive a ‘schizoid’ organization of his being that now (at age eighteen) threatens to get out of control (73-74). As Laing represents David:

He had grown up taking entirely for granted that what he called his ‘self’ and his ‘personality’ were two quite separate things. He had never seriously imagined any other possibility, and he took it equally for granted that everyone else was constructed along similar lines. His view of human nature in general, based on his own experience of himself, was that everyone was an actor. It is important to realize that this was a settled conviction or assumption about human beings which governed his life. This made it very easy for him to be anything his mother wanted, because all his actions belonged only to a ‘false’ self, a self that acted according to her will, not his.

(71)

We find in these remarks Laing's diagnosis of the aetiology of David's difficulties. This diagnosis is summarized by Laing's already quoted claim that David ‘had emerged from his infancy with his “own self” on the one hand and “what his mother wanted him to be”, his “personality”, on the other’ (71).

It is roughly at this point in Laing's narrative that we are informed of the immediate difficulty that brought David to meet with Laing. But before turning to this difficulty, it is worth noticing that Laing leaves unclear precisely what periods of David's life are covered by such (supposedly) autobiographical reports as that ‘he had grown up’ taking for granted that his self and his personality were completely separate and ‘had emerged from his infancy’ not only living this distinction but assuming that everyone else did so too. Even if we assume that these are David's own descriptions of his past self-conscious states and actions (or Laing's accurate restatement of these), it is by no means clear that David meant these remarks to cover the whole of his life from birth. He may have meant them to cover only as far back as he can remember, or (what is altogether as plausible) only as far back as he can remember making this sense of his actions and his relation to others.

It is possible, in other words, that David's (purported) self-descriptions refer to a narrower time-frame than Laing's all-encompassing temporal attributions imply. In particular, it is not only possible but probable that David's self-descriptions refer only to his life from age six or seven—the age from which most people have the most accurate and extensive memories, and also the age from which many children (especially children raised in as sheltered a manner as David) begin to have extensive relations with persons outside their immediate family because of their commencing school. This probability, we shall see, is important in reckoning the possible implications of the data about David that we are given.

These data include the following specific and urgent difficulty that led to David's meetings with Laing:

All through his childhood he had been very fond of playing parts in front of the mirror. Now [at eighteen] in front of the mirror he continued to play parts, but in this one special instance he allowed himself to become absorbed into the part he played (to be spontaneous). This he felt was his undoing. The parts he played in front of the mirror were always women's parts. He dressed himself up in his mother's clothes, which had been kept. He rehearsed female parts from the great tragedies. But then he found he could not stop playing the part of a woman. He caught himself compulsively walking like a woman, talking like a woman, even seeing and thinking as a woman might see and think. This was his present position, and this was his explanation for his fantastic get-up. For, he said, he found that he was driven to dress up and act in his present manner as the only way to arrest the womanish part that threatened to engulf not only his actions but his even ‘own’ self as well, and to rob him of his much cherished control and mastery of his being. Why he was driven to play this role, which he hated and which he knew everyone laughed at, he could not understand. But this ‘schizophrenic’ role was the only refuge he knew from being entirely engulfed by the woman who was inside him, and always seemed to be coming out of him.

(72-73)

This passage forces on us two questions. The first is why David was driven to play this role. The second is why his condition is ‘borderline’—liable to pass into psychosis.

Laing's explanation of David's difficulty, as we have seen, is that David is an eighteen-year-old youth who has never become ontologically secure. From infancy his actions have constituted a ‘false-self system’ that is becoming more and more compulsively expressed and ‘quasi-autonomous’ (73). This system increasingly threatens David's tenuous and precarious sense of ‘his own self’, causing him to feel less and less an enacting agent and more and more acted upon. He experiences himself as increasingly in danger of ‘being entirely engulfed by this woman who was inside him, and always seemed to be coming out of him’ (73). Yet, throughout, David (according to Laing) distinguishes ‘this woman’ from ‘him’. It is his ‘own “self”’ that he regards this ‘womanish part’ as threatening ‘the existence of’ (73).

Now Laing, to repeat, presents David as not (yet) psychotic. Nevertheless, the manner in which Laing's theory would account for David's becoming psychotic is clear from the book. David would become psychotic when ‘the hidden shut-up self’, a self that increasingly experiences ‘a persistent haunting sense of futility’ and fear of being overwhelmed, is—perhaps suddenly and with little forewarning—supplanted (through some process we do not yet understand) by the ‘false-self’. In David's case, by ‘the woman who was inside him’.

As already remarked, such a passage into psychosis is conceived on Laing's theory as a development that the afflicted person passively suffers. While Laing stresses that psychotic persons are implicated in their condition because of their employing strategies at the very beginning that have unintentionally led to this result, the final stages of the process issuing in psychosis tend to be understood as developments to which these persons are passively subject.

I shall now propose a different hypothesis concerning David's condition and its possible outcome, one invoking the idea that psychosis or madness may sometimes be elected by a person. Before doing so, let me remark that Laing's account of David does strike a reader as, in outline, intelligible: the ‘devoted’ mother who, in fact, did not devote herself to nurturing an autonomous, healthy selfhood in her child, but rather left no place for her ‘inseparable’ child to become a person in his own right. That is an old, old story. What I shall now question is whether this story convincingly fits the facts Laing presents about David.

IV

Recall Laing's assertion that David ‘found reassurance in the consideration that whatever he was doing he was not being himself’ (71). This, as I have remarked, is the proposition on which Laing's explanation rests, and the one I shall try to show is challengeable by appeal to the data we have been given, and by appeal to certain commonplace facts of which we must take account.

First, there are facts making it probable—or, at the very least, possible—that the proposition does not hold of David's life from infancy until he went to school. Secondly, there are facts making it probable—or, at the very least, possible—that the proposition does not hold either of David's hours in front of mirrors, or of the ‘fantastic-looking character’ with whom Laing meets. Even if these probabilities cannot be conclusively established, the fact that they are (at the very least) compatible with the data we are given about David is enough to call in question Laing's explanation.

To begin at the first issue, Laing pictures David as being unable, from his earliest beginnings, to develop and affirm an authentic, autonomous self. ‘He had always been what his mother wanted him to be.’ As Laing portrays David, he is from the start in a ‘schizoid’ posture even in relation to his mother, distinguishing and opposing his ‘own self’ over against ‘what she wanted him to be’. This David compliantly was, we are told, so far as ‘actions’ (including, presumably, demeanour and expressions of feeling) are concerned. But David is never, as Laing portrays him, in these actions as authentic expressions of himself. His actions ‘belonged only to a “false self”, a self that acted according to her will, not his’ (71).

Yet despite this emphasis by Laing running throughout his portrayal of David at pages 70-73 of his book, when Laing returns to David's case some thirty pages later, he calls our attention to the following further facts (while at the same time reiterating his diagnosis):

Following his mother's death when he was ten, David began to display an extensive identification with her; he dressed up in her clothes in front of the mirror and kept house for his father just as his mother had done, even to the extent of darning his socks, knitting, sewing, doing embroidery, tapestry, selecting chair covers and curtains. Although it is quite obvious to an outside observer, to neither the patient nor his father was it apparent to what extent he had become his mother. It is also clear that in doing so the boy was complying with a wish on his father's part that had never been directly expressed and of whose existence his father was quite unaware. The false self [note the reiteration] of this schoolboy was already a most complex system by the time he was fourteen. He was unaware of the extent of his identification with his mother but he was intensely aware of his compulsive tendency to act in a feminine way and of his difficulty in shaking off the part of Lady Macbeth.

(101)

And who is Lady Macbeth? Two answers might be: a woman who plays an important part in a male coming to ruin, and a woman oppressed by apprehension about guilty disclosure.

I shall, however, ignore this literary (and ‘gender’) allusion (about which Laing says nothing more), since it is not needed to discern what is at least as plausible an account of David's situation as that given by Laing. Nor is any part of this later passage needed to arrive at this rival explanation. We have already been given enough information at pages 70-73. What this later passage does provide is further data that point even more insistently toward the question: what might go on in a boy who was ‘inseparable’ from his mother until going to school, and who, even after that, spent much of his time in her company, until he was ten years old?

One plausible answer, surely, is that, being virtually always in her company, David would from his earliest years be caught up in his mother's activities. It would be in and through these activities that he would be developing competences, and a sense of achievement. It would be in and through these activities that he would be developing standards of taste, of discrimination—standards of value and judgment. At the same time, it would be in and through these activities that David would be coming to experience affection, relationship, co-operation, commendation—self-expression.

This would explain how an adolescent boy can proceed, on his mother's death, to darn, knit, sew, do embroidery, weave tapestry, select chair covers and curtains (101), in addition to doing the housework, shopping, and cooking meals (70). David's proficiency at and inclination for these tasks and accomplishments is, when put beside everything else we are told, further evidence calling for the conclusion that Laing mis-states the situation when (in the page 101 passage quoted above) he asserts that neither David's father nor David himself was aware of ‘to what extent he had become his mother’. If we re-read the passage in which this remark occurs we find that Laing appears to have in mind the period ‘following his mother's death’ as the time when David ‘had become his mother’. Yet the data we are provided with, taken all together, make it at least as (if not more) probable that David already was very like his mother at the time of her death.

This probability is not upset by David's declaring to Laing that he ‘had always been what she wanted’. The seeming implication of these words is that David had never, while his mother was alive, been what he wanted. Yet it is by no means obvious that David's words establish this. In the first place, this remark may credibly be read as expressing an aspect of David's feelings now (at eighteen) about his interaction with his mother when she was alive. Now, when he looks back at having lived toward his mother what she invited and commended in him, he has an ambivalent and increasingly hostile relation to having done so, because he now suffers in ways that he senses are directly connected to that. Nevertheless, it is not only possible but even probable that, at the time, the child David often (or even virtually always) wanted to do what his mother wanted him to do. Furthermore, even if we grant, for the sake of argument, that at the beginning David unwillingly ‘was’ what his mother wanted him to be, it does not follow that he remained in that relation to being what she wanted. Human beings may often take up unwillingly or indifferently a routine of activity or interaction, and in time come to want to engage in those activities or interactions. They can come willingly and happily to do what at first they were disinclined or reluctant to do. Thus, even if, at the start, David was being what his mother alone wanted him to be, he could, through compliantly being that over time, have become what she wanted him to be. Henceforth, while being what she wanted him to be, he was also being what he was inclined to be.

I am arguing that the data we are given make it probable (or, at the very least, possible) that by the time of his mother's death when he was ten, David had become very like his mother. His having a sensibility and dispositions very like hers is who he was. I also wish to claim that it is probable that David recognized this, to the extent that an obviously intelligent and sensitive child can have self-knowledge.

But ‘who he was’ was also, from the time David was six or seven years old, a schoolboy, going to school (one guesses) either in Glasgow or London in the 1950s. Laing, who in so many ways is wonderfully alert to and thoughtful about the social context of self-hood, surprisingly overlooks the significance of this fact, which we find refracted in such a reported datum as this:

The whole organization of David's being rested on the disjunction of his inner ‘self’ and his outer ‘personality’. … The part he regarded himself as having been playing most of his schooldays [note the time reference] was that of a rather precocious schoolboy with a sharp wit, but somewhat cold. He said, however, that when he was fifteen he had realized that this part was becoming unpopular because ‘It had a nasty tongue’. Accordingly he decided to modify this part into a more likeable character, ‘with good results’.

(72)

This part played by David at school (and, one supposes, to neighbours, relatives, etc.) is what, at that time and place, would be seen by most persons as a notably ‘masculine’ character and demeanour. It is exactly the part that one would expect to be enacted by a boy who wished to deflect attention away from his real sensibility and nature because he feared ridicule or condemnation if he were to be himself.

Meanwhile, David, when alone at home, continues to act in front of the mirror women's parts ‘from the great tragedies’ (not, notice, from the great comedies), while dressed in his mother's—i.e., in female—clothes. The little Laing tells us about this still leads one to suspect that during David's first decade of childhood this activity involved his mother, either as participant or approving audience. (Just as one suspects that among the several present reasons for this dressing-up in his mother's clothes is that it is a clandestine summoning, in textures, smells, and visual recollections, of the presence of David's mother.) Now, however, at eighteen, David finds that more and more he cannot stop playing the part of a woman. He finds himself compulsively walking, talking, ‘even seeing and thinking as [he imagines] a woman might see and think’. This, Laing asserts, is the cause of the fantastic get-up David now goes about in, which Laing explains ‘as a way to arrest the womanish part that threatened to engulf him’ (72).

This, I submit, is a mistake. Laing overlooks the implication of what he himself singles out as the most striking feature of David's get-up: ‘withal, his second-hand theatre cloak and cane!’.

A theatre cloak is a long garment, worn about the shoulders and arms like a wrap, falling usually almost to ankle level, draping both torso and legs in cloth. It is, therefore, in many respects like a dress or gown. (Especially a dress or gown of the kind a female character from one of those plays might have worn,—and what a 1940s woman's dress would have looked and felt like, in the wearing, to a small boy playing roles in front of a mirror with his mother's encouraging participation or audience.) David's theatre cloak, when we examine it, is the closest David can come, not only visually but (most importantly) kinesthetically, to wearing a ‘female’ garment in public.

It may be, then, that, contrary to Laing's claim that ‘whatever he was doing he was not being himself’, David's ‘dressing up’ in his cloak is a covert expression of his ‘real self’. It is also almost certainly a covert (if attenuated) continuation of his mirror-playing, while being, at the same time, an overt attempt, not to ‘arrest’, but literally to cloak, any compulsive ‘walking like a woman’. (Just as David's speech ‘being mostly made up of quotations’ is also, at one and the same time, an overt attempt to camouflage any outbreaks of ‘talking like a woman’, and a covert continuation of his dramatic role-playing.) These facts present us with an answer to Laing's question quoted earlier: why should anyone wish to contrive such an effect?’ (70).

Laing represents David's trouble as being that this ‘woman’ with whom David does not identify keeps coming out of him. But an alternative view, at least as plausible as Laing's, is that David's trouble is that the ‘womanly’ sensibility and character that keep compulsively surfacing in him (which quite possibly include—he is eighteen—homosexual feelings) are recognized by him to be ‘his own self’, but he dreads the consequences of this being publicly recognized. It does not matter if David mistakes what those consequences would be. It is enough if he thinks them unbearable. Though if sexual inclinations figure in David's distress, it is worth recalling that overt expression of these in Britain in the 1950s could lead to imprisonment; and suspicion alone could lead to a variety of sometimes severe non-legal consequences.³ Still, it needs to be stressed that it is by no means necessary that David have homosexual desires for his dread of recognition to be intelligible. That males with notably ‘feminine’ sensibilities, tastes, and demeanour would meet with ridicule or contempt from many persons could be sufficient. All that is central to understanding the dynamic being posited here is that David shrinks from openly ‘owning’ who he is, but finds more and more that he cannot any longer keep from disclosing who he is.

I am arguing that if we attend to the data we are given, a conclusion compatible with the data but contrary to Laing's is credible. This is that David's difficulty is not that he has never developed a ‘self’, but that he cannot bring himself to express the self he has become. David, in other words, is, in a very real way, unable to accept who he is. (That it is other people's probable responses to his self which force on him this relation to himself does not change its content.) This fact about David's relation to himself is revealed both in David's trying to suppress ‘the woman inside him’, and in his representing that ‘woman’, to Laing, and to himself, as not himself. At one point Laing relates that David reported that ‘sometimes he played the part of himself (his own self); … he played at being himself’ (71). This is a way of distancing oneself from oneself—of striving to deny who one is by representing oneself to oneself as ‘just a role I'm playing’.

It is this last striving that, when taken together with David's increasingly compulsive ‘womanly’ behaviour, indicates (in my judgment) the gravity of his condition. The data we are given suggest that David is a person terrified of the consequences to him of others recognizing him to be the person he is. To be seen to be what (he believes) others will deem ‘a womanish’ person, bodes (he thinks) consequences of which he is terrified. At the same time, David finds he is increasingly unable not to be ‘a woman’. Thus, these consequences that he fears loom more and more as inescapable.

But these are consequences, notice, that he, David,—a male—fears. They are not consequences that a woman need fear.

If my reading of the data Laing gives us is correct, David is in a situation in which he must do one of three things. (1) He must contrive to live who he is sufficiently openly to achieve self-satisfaction, but without suffering intolerable consequences or debilitating fear. (2) He must fully and openly express who he is and bear whatever consequences attend his being recognized as who he is. Or (3) he must somehow contrive to avoid the consequences (of which he is terrified) that attend his compulsively expressing—and so being recognized as—who he is. We are not given enough information to judge which of these three outcomes it is probable that David will achieve. But we may discern how David might pursue the third option.

He might pursue it by electing to ‘become’ a woman—his mother, or Lady Macbeth, or Marie Antoinette, or Joan of Arc, or whoever. In becoming his mother, or some other woman, he, David, is now ‘safe’. For that woman is not prey to the fearful consequences that threatened him. In this way, David would avoid what he both fears, and reckons inescapable.

V

I have argued that R. D. Laing's once influential theory of psychosis invokes data which admit of a different explanation. That different explanation, I have suggested, is prima facie supported by some of Oliver Sacks' medical findings. Sacks, in a passage quoted at the very beginning of this essay, asserts (in words I deliberately omitted) that medicine not only ‘provides a philosophical education’, but ‘a better and truer one than any philosopher provides’ (Awakenings, 245). These (unargued) conceits by a humane and thoughtful investigator need not keep us from recognizing that the human realities clinical medicine seeks to understand and heal are ones that philosophy ought to take a close interest in. (Sacks himself goes on directly to assert that ‘Nietzsche, almost alone of philosophers, sees philosophy as grounded in our understanding (or misunderstanding) of the body [sic], and so looks to the ideal of the Philosophic Physician’ (245).)

Still, if philosophy ought to interest itself in pathology, medicine, in its turn, may find that philosophical reflection by non-medical (as much as by medical) investigators can throw light on the realities with which medicine grapples. In the present instance, the hard question, of course, is how a human being could will the supersession through time of his or her self-consciousness by a different conception and consciousness of self (even one lacking much coherence and viability). We may be helped to discover the processes at work here if—while continuing research into human neurophysiology and neuropsychology—we experiment with conceiving these processes on analogy with three common-garden-variety human activities: denial, day-dreaming, and dreaming.

Human beings are everywhere seen to deny unpalatable or threatening truths, and to practice systematically selective attention to the manifold features of reality. (Human possession of this capacity has probably been evolutionarily beneficial for the species up until the present. Though it is doubtful that it will continue to be so.) It is obvious that insistent desires and interests play a basic causal role in human beings' denial of unwanted truths and belief in wanted ‘truths’. Nothing is more ordinary than human beings finding it rational to believe, or do, or deny what, by disinterested epistemic standards, or by standards of different (often longer-term) interests, they would acknowledge it is irrational to believe, or do, or deny.

The familiar human activity of day-dreaming (or ‘fantasizing’) discloses human beings contriving to ‘enact’ a context and experience superseding that in which they are physically present; while in dreaming we encounter the everyday phenomenon of being ‘one's self’ in modes of experience, feeling, and capacity that exceed or contradict (or partially intersect with) intersubjectively experienced realities. These states are within the commonplace capacity of human beings, and they are (like all capacities) capable of considerable extension, development, and refinement. Thus there are persons who can contrive repeatedly to dream a desired dream, and who can remember minutely the detail of even very complex dreams, where the rest of us, who have not cultivated and honed our capacities in this domain of experience, can do little of the kind, and may find these others' exploits mysterious or even incredible.

Yet it is a familiar and much-proved human fact that many things may be done by intelligent effort, resolution and practice that otherwise will never come to be; as it is another familiar human fact that extreme situations call up (in some persons) extraordinary capacities. The situations of Sacks' patients, and of Laing's patient David (as David experienced it), were extreme, and it should not surprise us if the inhabitants of such situations (or some of them) came to be capable of ‘resolutions’ that lie outside the capacity of you and me in our greatly more fortunate situations. (What we do not need, we rarely come to be capable of.)

As for the logic of ‘electing madness’: if one judges that one is vulnerable to suffering a fearful and inescapable consequence, a consequence proceeding from or involving the intentional acts of others, there are, logically, at least two ways to proceed. One may seek to change the intentions of those others, thereby annulling the consequence. Or, one might try to cease being the kind of thing these others' negatively receive. (Is the rationality of this device, in cases like that of David, greatly different from seeking consolation in this inescapable vale of tears by striving to believe, against the overwhelming burden of empirical evidence, in another ‘heavenly’ world where the hurts and griefs of this world will be redressed and compensated?)

I can say no more about these analogies and rationalities here. But if they prove fruitful in trying to think about and investigate ‘madness’ (and I expect they have been proposed by others), this fact would partially reinstate Tennyson's (perhaps now indigestibly saccharine) tag about prayer. In so far as Tennyson had in mind ‘someone up there’ listening to and answering prayers, there are now few creditors among those whose work is inquiry (an important qualification). But prayer, of course, is a kind of activity—the (reverent) willing of an outcome (including, often, resignation to whatever does come about). To this extent, King Arthur's chronicler may have got a part of the story right. We may find, as we continue to probe that unlit territory that is ourselves, that more things are wrought by will than this world finds it comfortable to recognize.

Notes

1. Oliver Sacks, Awakenings, Second Edition (New York: E. P. Dutton, 1983); The Man Who Mistook His Wife for a Hat (New York: Summit Books, 1985). All page references to Awakenings in this essay are given in brackets following a quotation.

2. See, in particular, R. D. Laing, The Divided Self (London: Tavistock, 1960), and R. D. Laing and A. Esterson, Sanity, Madness and the Family (London: Tavistock, 1964). Both books were subsequently published by Penguin Books, and reprinted many times. All page references to The Divided Self in this essay are to the Penguin edition, given in brackets following a quotation.

3. It may be impossible, in our present, greatly freer, sexual environment, for persons born after 1950 to imagine the kinds of constraints sexuality was subject to then, in parts of Europe and North America. As an unregenerate heterosexual raised in the coils of Irish-German Roman Catholicism in Canada during the 1940s-1950s, it seemed much of the time as if this part of one's nature was calculated to cause nothing but grief, until finally precipitating one into hell. But when as a graduate student in Britain in the mid-1960s I observed the distress of acquaintances caught in a different inclination, it seemed at moments as if they were already in hell.

SOURCE: Diamond, Seymour. Review of Migraine, by Oliver Sacks. JAMA: The Journal of the American Medical Association 271, no. 6 (9 February 1994): 478.

[In the following review, Diamond deems the revised and expanded edition of Migraine a readable and insightful text.]

During the last five years, there has been a plethora of books published on headaches. This profusion is probably due to the multitude of investigations into headache as well as the extensive availability of newer therapies for cephalalgic patients. However, this revised and expanded edition of Oliver Sacks' Migraine is a welcome addition.

Dr Sacks' previous books, Awakenings and The Man Who Mistook His Wife for a Hat, have stimulated enormous lay interest in the neurological sciences. This revised edition of Migraine, although directed to a general readership, should be added to the library of any physician caring for headache patients. The author has produced a readable text that provides insight into, and knowledge of, a complex and poorly understood disorder.

The first two of five parts, “The Experience of Migraine” and “The Occurrence of Migraine,” similar to the previous edition, include simplified yet accurate descriptions of symptoms and intricacies. The author's discussion of migraine and its relationship to epilepsy may cause some confusion and unnecessary concern to the headache sufferer. Throughout the literature, headache experts find a limited relationship between migraine and any form of convulsive disorder. The disruptive aspects of migraine are depicted through the case histories and lengthy discussions of the migraine aura, premonitory symptoms, and autonomic symptoms of the attacks. In particular, the discussion of the premonitory symptoms and features distinct from the aura will give the practitioner a better understanding of migraine characteristics usually ignored by the average physician during the headache history.

One negative feature that surfaces throughout the case histories is the excessive focusing on the psychological aspects of migraine, thus deterring from the relevance of this material. Also, some sufferers may find this overemphasis demeaning. Another area of confusion lies in the description of cluster headache, which the author labels as migrainous neuralgia. Because “cluster headache” is the accepted term, clarification of “migrainous neuralgia” should be provided in the glossary.

Both the professional and lay reader may find the material in part 3, “The Basis of Migraine,” difficult and plodding. This topic is highly theoretical and controversial. The complexity of the subject is enigmatic for most physicians, including the research neurologist. The updated part 4, “Therapeutic Approaches to Migraine,” is an endeavor to be welcomed by both lay and physician readers. The section on methysergide indicates that this drug is commonly used, a misleading supposition. Discussion of other serotonin drugs, such as sumatriptan, is neglected, an omission that limits the scope of this section.

The final section, “Migraine as a Universal,” is superb, and the chapter “Migraine Aura and the Hallucinatory Constants” will entrance the physician reader. The text and illustrations refer to almost all the important descriptions in the literature of these phenomena. In this chapter, the contributions of Airy, Gower, Lashely, Tissot, and others are all described in an organized, understandable fashion. Of particular interest are the allusions to the migrainous visions of the Abbess Hildegard of Bingen in 1180 CE. These visions resulted in her tapestries, which personify a migraine aura. Personally, I have used some of the excellent illustrations included in the previous editions of this book in my lectures and writings on migraine hallucinations and the history of migraine. This revised edition contains color plates of the aura as well as migraine art, items not included in the previous edition. The section on the history of migraine is probably the most comprehensive and enjoyable that I have encountered.

The physician reader will find this text a readable and interesting discussion of an often misunderstood subject. It is rare that a book on headache written primarily for the sophisticated lay reader can satisfy the needs and interests of the physician by presenting essential and new concepts. Migraine is enhanced by the absorbing writing, which renders it a must read for the neurologist, pain specialist, or any physician involved in the management of chronic headache. Oliver Sacks has contributed a fascinating depiction of a disorder that in some way affects the lives of nearly 20٪ of the population. I highly recommend this book for anyone interested in the complex subject of migraine. Until a writer surfaces to do it better, Oliver Sacks is peerless in his description of migraine headaches.

SOURCE: Kohn, Marek. “Voyages to Inner Space.” New Statesman & Society 8, no. 340 (17 February 1995): 49.

[In the following review of An Anthropologist on Mars, Kohn praises Sacks's case histories of patients suffering from neurological afflictions as poignant and insightful.]

Already, the most frequently asked question about Dr Sacks' new collection of case studies [An Anthropologist on Mars] appears to be whether the title is biographical or autobiographical. The obsession with the doctor at the expense of the patient is retrograde. Like any author, Sacks sees his own vision in his subjects. But he is essentially contemplative, which transforms the traditional air of mastery that pervades the doctor-patient relationship in most physicians' prose. He is at his best with Temple Grandin, an animal scientist who writes about her autism. They meet as equals; scientists of autism both, since Grandin is the nearest a person gets to being a dispassionate observer of herself.

Yet Grandin cares passionately about the welfare of cattle, having worked on the humane design of slaughterhouses. She is preoccupied with understanding human emotion—hence the book's title, which is in fact her own self-description. Like many autistics, she identifies with the Star Trek character Data, the android whose deepest longing is to become human. Some of her lines are uncannily like Data's; it is not surprising to learn that Sacks is a Trekkie too.

Most of Sacks' subjects have limited insight into their condition. The other autistic person in this collection is Stephen Wiltshire, the British boy famous for his intricate and accomplished drawings. His capacity for understanding is limited not just by his youth but by a level of intellectual performance that gains him just 52 points on a verbal IQ test. In the case of the figure Sacks calls “the last hippie”, lack of insight is the defining characteristic of his condition. Unfortunately, perhaps tragically, Greg's fellows in the Hare Krishna temple he had entered in the late 1960s took his increasing detachment from the world as a sign of spiritual progress. In fact, it was a symptom of the ravages of a brain tumour, which left Greg blind, largely immobilised, and incapable of retaining memories from the period after his illness. His insistence that he was still sighted appears not as denial, in the conventional sense of repression, but a self-papering over its own fissures at a fundamental cognitive level: a more flagrant case of the neglect that people sometimes manifest towards parts of themselves after strokes. Sacks takes him to hear the Grateful Dead, his favourite group, play Madison Square Garden. Greg sings along and insists he can see Pigpen, a member of the group who had died nearly 20 years before.

It is one of the most poignant stories Sacks has ever written, with disturbing undertones that suggest a profoundly pathological character to the 1960s counterculture. As writing, it has beauty, power and resonance; but two questions remain. One is that of its biographical truth. Of course Sacks' accounts are not the whole, only story. Sometimes this leaves an uneasy feeling, such as when we learn that Stephen Wiltshire's father was killed, but read not a word about his mother. I suspect that one of the reasons for omission is the degree to which Sacks identifies with his subjects. He seems to write about them as he might wish to be written about himself; similarly, he seems to feel an obligation to respect the privacy of significant others.

The other question is that of whether, as well as being uplifting and astonishing, Sacks' cases offer any fresh insights into the nature of consciousness. Are they just too far out to be of scientific utility? In fact, bizarre cases have long enjoyed a privileged place in medical textbooks. Sacks cites the most celebrated, that of Phineas Gage, who lived to tell of how a yard-long iron bar was blown clean through his skull, albeit with a less agreeable personality than before.

Sacks' method is sometimes represented as little more than a reminder that there are real people behind the case histories. This does no justice to the subtleties or ambition of his project, an exploration of a synthesis between different ways of knowing. “Neither a biological nor a psychological nor a moral-social viewpoint is adequate; we must see Tourette's not only simultaneously from all three perspectives,” he writes, “but from an inner perspective, an existential perspective, that of the affected person.”

His comments on Tourette's puckish and scatological syndrome stand for his work as a whole. What becomes possible under these terms is not a conventional progress from hypothesis to conclusion, but a continuous engagement of insight.

SOURCE: Chidley, Joe. “The Case of the Quirky Neurologist.” Maclean's 108, no. 11 (13 March 1995): 60-1.

[In the following favorable assessment of An Anthropologist on Mars, Chidley contends that Sacks “skillfully bridges the chasm between diagnosis and literature, blending sometimes highly clinical observations of neurological disorders with a profound thoughtfulness for the person affected.”]

Oliver Sacks, distinguished neurologist and best-selling author, is having trouble deciding what to have for lunch. The doctor strokes his bushy beard and hems and haws as he looks over the room-service menu of the Toronto hotel where he is staying while promoting his latest book, An Anthropologist on Mars. Rather dejectedly, he settles for a club sandwich. But the thought process—looking for the right thing to satisfy his craving—clearly fascinates him. Without prompting, he describes his reaction when, almost 20 years ago, he was laid up in a London hospital with a leg injury and a friend brought him a smoked trout. “It not only put me into ecstasy,” Sacks recalls, “but I also had the feeling that really much of my misery in the hospital was due to an unconscious yearning for a smoked trout. Indeed, perhaps my whole life was accreted about this previously unrecognized yearning.” He pauses—another hem and a haw—and adds: “I felt the same with regard to [Danish philosopher Soren] Kierkegaard when I read him for the first time.” His eyes suddenly light up. “There must be something about hitting the spot,” he beams. “When the spot is hit, there's this strange feeling that it was waiting to be hit.”

Sacks is not being flip. An immensely well-read and soft-spoken man, the 61-year-old New York City-based neurologist likes to quote E. M. Forster's axiom, “Only connect.” And it is possible to see his medical and writing career as an ongoing attempt to do just that—with his patients, with his readers and, perhaps, with himself. In books such as Awakenings (1974)—made into a 1990 movie starring Robin Williams as Sacks—The Man Who Mistook His Wife for a Hat (1986) and now An Anthropologist on Mars (Knopf), he has revived the case study as a popular literary form. He skilfully bridges the chasm between diagnosis and literature, blending sometimes highly clinical observations of neurological disorders with a profound thoughtfulness for the person affected. The search for the “spot,” the vital, if mysterious, connection of doctor and patient, mind and body, is central to his work.

And An Anthropologist on Mars is his best book to date. In it, Sacks relates seven case studies, all of them previously published in The New York Review of Books or The New Yorker. With unfailing empathy and a seemingly encyclopedic knowledge of the latest neurological theory, he describes the struggles and triumphs of a New York painter who suddenly becomes completely color-blind, or achromatopsic; a onetime hippie whose memory ends in 1969; a British Columbia surgeon with Tourette's syndrome, which can cause its sufferers to move and curse unpredictably; a man whose sight is restored after 40 years of blindness, but who still cannot see; an artist who paints only visions of the Italian village he left as a young man 50 years ago; a British autistic teenager who creates stunning architectural drawings from memory; and an intellectually gifted scholar and engineer whose autism prevents her from engaging in complex human emotions such as love. An Anthropologist on Mars is a neurological travel book, a geography not only of the mind, but of the human spirit.

Perhaps one of the reasons for Sacks's facility with neurological “abnormality”—a term he uses infrequently and reluctantly to describe the people he writes about—is the fact that he is such a singular character himself. He is notoriously shy. A bachelor, he lives alone in a house on New York's City Island. He says he is celibate. Yet he is given to odd passions: his love of ferns and of swimming, for instance, verge on the fanatical. In person, he seems almost overwhelmingly diffident, a demeanor that belies his imposing frame, all six-feet and 200-plus pounds of it. And on the subject of his authorial career, he is self-deprecating. “I don't actually know what I'm doing,” he says. “And I prefer not to know what I'm doing. I even feel it may be dangerous.”

Still, storytelling and medicine are both part of his family legacy. His father, Samuel, and mother, Elsie, were both physicians—as are his three older brothers. While growing up in prewar London, Sacks quickly learned the narrative approach to medicine from his parents. “Telling is in my blood,” he says. “It was so with my parents, who liked telling their medical experiences—and to all and sundry, in a rather incontinent way.”

As a child, Sacks recalls, he was fascinated by travel literature, including Charles Darwin's descriptions of the Galápagos Islands. And after receiving his medical training at Oxford in 1958, he decided to write about his own wanderings. One of his first books was a travel journal of Canada, titled Canada 1960. “I spent several months here, sort of between the past and the future, not quite knowing which way life would go,” he recalls.

Life took him to the United States, where he studied at the University of California in Los Angeles before becoming an instructor in neurology at Albert Einstein College of Medicine in New York City (he is now a professor of clinical neurology there). But travel remains his passion—he recently visited the so-called Island of the Color-blind, Pingelap, where genetic achromatopsia is rampant. “I also regard neurology itself as a form of travelling, both for the person and for the explorer,” he says. “These are other lands, the lands of achromatopsia, autism, migraine, with their own customs and assumptions.”

In An Anthropologist on Mars, the traveller Sacks plays a vital role in the seven stories. He is at times heartwarmingly subjective—as when he describes how flying in a plane piloted by the surgeon with Tourette's syndrome made him somewhat anxious—and given to flights of philosophical fancy. “Could one be an artist without having a ‘self’?” he wonders in Prodigies, about the precocious autistic artist Stephen Wiltshire. And bit by bit, he reveals his own fascination—perhaps even identification—with his subjects. At the end of his story about Temple Grandin, an autistic professor of animal science at Colorado State University whose intellectual prowess more than makes up for her emotional deficit, Sacks writes: “I said, ‘I'm going to hug you. I hope you don't mind.’ I hugged her—and (I think) she hugged me back.”

Sacks's unique strength as a writer is that he tries to get inside not only his subjects' heads, but also their lives. “Something which was important to me as a medical student,” he recalls, “was an old man, dying of uremia and delirious, about whom the doctors said, ‘Don't waste your time with him—it's all nonsense.’ But I listened to him by the hour and found it fascinating. I had the feeling of a whole life in figures and landscapes. It was like being privy to a dream.” With endless curiosity, Sacks does the same thing in Anthropologist—listening to the disorder and to the person.

Not surprisingly, he is ambivalent about the current rage for pharmaceutical solutions to complex psychological problems. He freely admits experimenting with drugs in the 1960s. “I'm glad I did, and glad I stopped, and glad I didn't kill myself,” he says. On the other hand, he adds, “I'm the only person I know not on Prozac. And God knows I need it more than any of them.” Why? “I get down, I get melancholy. I think how worthless and meaningless it all is.” Sacks sees an analyst twice a week, but has said he is unlikely to turn to Prozac. “I think it's a very important antidepressant for people who are unhappy,” he acknowledges. “But the cosmetic use, or the notion that we could all be reconfigured and happier and this and that—I think this may bypass some of the crucial experiences of living, and the sufferings and complexities that go with it.”

Sacks does his thinking in swimming pools. An avid swimmer—and competitive weightlifter—in university, he now gets wet twice a day, for as much as two hours in total. “I feel I belong in the water—I feel we all belong in the water,” he says. “It's a rather solitary activity, in a way. Even if there are two or three people in the same lane, you're always independent from them.” He does much of his reading, meanwhile, in the bathtub, where he often dozes off. “All my paperbacks,” he confesses, “have been in the bath.”

Sacks's enthusiasms and eccentricities are famous. He is a huge fan of Star Trek: The Next Generation, and recently visited the set in Los Angeles. “Oh, yes, I have a picture of myself with [the android character] Data,” he gushes. Typically, the memory leads him off on a tangent. “I thought that seeing the gimcrack scenery of the set would spoil the illusion for me, but it didn't. I'm completely taken in by theatrical illusion. With the film Kind Hearts and Coronets, people asked me, ‘Did you recognize Alec Guinness in all eight roles?’ And I said, ‘No, I didn't recognize him in a single one!’” Sacks lets out a roaring laugh. “I'm the ideal theatregoer, because I'm an idiot.”

There is something childlike, too, about Sacks's concern for living things. Like ferns, for instance. He rather dislikes flowering plants—“modern and vulgar and new and trendy, and they've only been around 100 million years.” But to him, ferns are “paradisal—I think of the Garden of Eden as looking somewhat like the Australian or New Zealand forest, with its tree ferns. I like the idea of this individual, unashamed, gallant, sensible group of plants that developed in its own way—they're really great survivors.” He has a similar passion for cephalopods—the invertebrate family that includes squids, cuttlefish and octopuses, several of which he has kept as a hobby. “You don't have to have a backbone,” he says, “to be interesting and intelligent.”

Sacks speaks with admiration of the subjects in Anthropologist, all of whom he regards as friends. But he seems particularly fascinated with Mr. I., the New York painter struck with color-blindness. Faced with the prospect of a cure—I.'s color-blindness is linked to a dysfunction of a small and little-understood part of the brain known as V4—the artist refused. He had come to terms with his new way of seeing, preferring black and white to color.

As he gazes at a vase of red and yellow roses sitting nearby, luminous in the sunlight filtering through the hotel-room window, Sacks utters a characteristic “Umm,” then adds: “I find myself looking at the color of these flowers, and imagining a blood vessel suddenly pinching off in V4, the flowers greying out.” He pauses. “I think what one does have seems so much more precious when it seems more precarious.”

SOURCE: Hunter, William. “Your Friendly Neighborhood Neurologist: Dr. Oliver Sacks and the Cultural View of Physicians.” Journal of Popular Culture 28, no. 4 (spring 1995): 93-102.

[In the following essay, Hunter analyzes the dichotomy of the nurturing doctor/doctor as authority figure in Sacks's work.]

Hold the physician in honor for he is essential to you, and God it was who established his profession. From God, the doctor has his wisdom, thus God's creation work continues without cease. He who is a sinner toward his Maker will be defiant toward his doctor.

(Unknown)

The above lines found on a sampler in a doctor's office in the Midwest (Katon 1) demonstrate a longstanding cultural view of physicians in the United States. Because of the level of education they have completed and their role in the life and death decisions of their patients, doctors have enjoyed a level of trust and respect which has been displayed on few other careers. Doctors have also been trained to look upon themselves with a great deal of pride and belief in their own powers and abilities. In contemporary history, however, this superior position has caused physicians to be viewed not as servants of God, but as cold, impersonal technicians who refuse to concern themselves with the human interests of their patients. This shift in cultural attitudes has forced the medical profession to seek to alter their depiction in the popular culture. They have attempted to demonstrate a caring, nurturing side of the medical profession. The question remains however, how much of this new view of doctors is real and how much is illusory?

One example of the dichotomy between the way doctors are trained to behave toward their patients and the new ethics being espoused by the medical profession is Dr. Oliver Sacks. In Sacks' work we see the creation of a caring, fatherly doctor who seems to be as interested in his patients as human beings as he is in their particular disease. A close examination of his work, however, demonstrates that Sacks, in the very same stories in which he glorifies his patients, is constructing a matrix in which he maintains all power and authority.

Before we talk about Sacks specifically, it is important to better understand this conflict in the medical community between nurturing and authority. For centuries, the physician has appeared as an almost godlike figure who stands at an emotional distance from his subjects. The creation of this distance begins in the medical training process. Beginning students are starting what is often a lifelong dream of healing the sick, but because of the intense studies that lie ahead of them (four years of medical school and up to eight years of residency), they are encouraged to become less empathetic towards their patients (Zabarenko 39). They are urged by the instructors and teachers to become callous towards the sight of human suffering.

It is not uncommon for medical students … to experience occasional feelings of faintness at the sight of blood, to suffer a spell of anxiety while observing an amputation … Where such effective disruptions persist, the student will be handicapped not only in learning many aspects of basic medical science, but in mastering the general intrusiveness and aggression needed for medical work.

(Zabarenko 37-38)

The role of the medical school is to provide information, and often, this is learned more effectively with an absence of empathy. For even in the eighteenth century, the “acquisition of practical training which is dominated by the theme of social usefulness, was left almost entirely to private initiative” (Foucault 48). With the huge volume of technical information necessary in modern medicine, such tasks as dealing with grieving relatives and effective bedside manner are left to the individual physician. In today's medicine, a study of the concepts of self and ideal self among medical students discovered that they “see themselves as significantly less loving than they would ideally like to be” (Rein 370).

Another significant block to the creation of a caring doctor is the extensive use of cadavers in the early phases of medical training. The work creates a pattern of dealing with patients who are nonsensitive, can't speak, and feel no pain (Zabarenko 40). The cadaver becomes a first patient and this has an effect on a doctor's view of life and death.

The possibility of opening up corpses immediately, thus reducing to a minimum the latency period between death and the autopsy, made it possible for the last stage of pathological time and the first stage of cadaveric time almost to coincide … Death is now no more than the vertical absolutely thin line that joins, in dividing them, the series of symptoms and the series of lesions.

(Foucault 141)

In the mind of the medical student, death becomes as beneficial to the learning process as life.

The creation of the callous, uncaring physician is also ensured by the enormous amount of skill and knowledge to be comprehended. This has forced modern medical training to divide itself into two groups: one dominated by power and authority, and one dominated by nurturing (Zabarenko 74), and “[while] nursing education traditionally reinforces the ability to be loving, medical education has not” (Rein 372). Medical training has been geared to create powerful, authority figures capable of processing information derived from their observations and sustaining life with their judgments. Yet it has failed to create doctors who care for, or about, the physical or psychological suffering of their patients. Modern medicine, which Michel Foucault dates from 1707, has created doctors who through their own education are taught to see patients as cases rather than people. They have been trained to view their patients without empathy for their suffering, to pay no attention to the degree of pain felt, to often create more pain in order to bring about a definitive cure, to remove themselves from the ‘human level’ of medical care in order to study the pattern of symptoms, and to cure the cause of the disease. This separation, combined with the mystique surrounding the medical profession, has developed a modern physician who may maintain his/her role of authority by degrading or even dehumanizing his/her patients.

An additional element in more contemporary medicine which has created a distance between patient and doctor is the increased use of technology in the field. In 1910, Abraham Flexner studied medical education for the Carnegie Foundation and claimed that scientific instruction was deplorably lacking. This report became the basis for a restructuring of medical education which highlighted the view of doctor as scientist (Babbie 17). Flexner felt that a doctor should view his patient from a stance which allowed objective observation based on scientific expectations. He described this physiological laboratory as a “wholesome discipline” because “it banishes from [a doctor's] mind metaphysical principles, such as vital force, depression etc.” (Flexner 63).

Flexner's study resulted in medical schools shifting the focus of their programs from tutelage to scientific, laboratory studies. Of the ＄90 million spent on medical school construction in 1963-64, more than ＄58 million was spent on research facilities (Babbie 18). Doctors have come to see themselves as technicians dealing with broken machines, rather than individuals treating patients. It is no longer their function merely to heal disease but to diagnose a problem and prescribe the correct field of technology that can correct it. Eric Cassell writes

It is not surprising that a generation of physicians should have come to power for whom the scientific and technologic aspects of physicianship represented not part of being a doctor, but all of medicine and its practice incarnate … For hundreds of years, the power of physicians had come from their specialized knowledge and their status.

(23)

Medicine has come to be viewed as a warehouse of technical knowledge to which only doctors have gained access. This perception alters the role of the physician in two very distinct ways. Most clearly, it removes the responsibility from the doctor and places it upon technology. If a patient is lost, it is only because technology hasn't advanced far enough to have saved him. On another level, however, this increase in technology also provides the doctor with unlimited authority as ruler of the technology which promotes health. This view combined with Flexner's view of the human body as “an infinitely complicated machine” (63), allows the physician to hold total authority over the symptoms, suffering and recovery of his/her patient. “Once the physician gains control, he assumes power to make decisions on behalf of the patient, often imposing personal values and ideologies on what are moral and social decisions” (Preston 73).

The culmination of these elements is that physicians have developed a stereotype among the popular culture of being unfeeling, distant and cold. While this cultural position provided them with additional authority for centuries, over the last 20 to 30 years, several elements have caused the medical profession to attempt to recreate their popular image.

One important shift in the medical profession was internal. Several elements of medicine became interested in a stronger definition of medical ethics. “In 1966, Henry Beecher demonstrated the failure of investigators to protect the interests of their patients in several major projects. His work is frequently cited as a landmark denoting the start of the present interest in bioethics” (Cassell 26). Beecher's article in The New England Journal of Medicine complains that medical research methodology allows for “increasing employment of patients as experimental subjects when it must be apparent that they would not have been available if they had been truly aware of the uses that would be made of them (1354). Beecher concluded that of 100 studies using human subjects published in a reputable journal in 1964, 12 of them appeared to be unethical (1355).

Though this increase in bio-ethics would appear to be a result of an increased view of humanity in the medical profession, it was co-existent with a shift in the patient community's awareness of their own role in medicine. “While there was a day when patients, and even health volunteers would assume that investigators were appropriate ones to decide whether new procedures should be tried … today that naivete is rapidly disappearing” (Veatch 209).

This shift in a patient's willingness to implicitly trust their doctor can also be seen as a result of the confusion which attended 1960s America. This period in our history brought about a new sense of individualism which created a stronger sense of a patient's abilities to make decisions regarding their own health care. The 1960s, and the anti-Vietnam struggle which continued into the 1970s, created an anti-authority fever which altered our belief and trust in medical professionals (Haug 17).

In addition, with the decline of infectious disease which a doctor is able to clearly diagnose and treat, and the increase in chronic disease, which is beyond a doctor's ability to cure and are often subjects of disagreement among physicians (Haug 32), patients see the limits of medical science and the humanity of their family physician. This shift in the patient's understanding has also been influenced by the higher level of education of the general public. Power comes from the ability to understand knowledge. In recent years, patients have been more willing to question their doctor's authority as they have demonstrated a stronger understanding of this knowledge (Haug 19). A literature has developed which serves no other purpose but to educate the public about medical practices and issues, thus providing them with a sense of empowerment.

These two factors: a greater sense of bio-ethics and a generational shift concerning authority have forced doctors to alter their behavior in dealing with patients. They have constructed a model more empowering to their patients. The Beneficence Model contains four basic axioms.

1. Both doctor and patient must be free to make informed decisions and to act as moral agents.

2. Physicians have the greater responsibility in the relationship because of the inherent inequality of information and power between themselves and those who are ill.

3. Physicians must be persons of personal moral integrity

4. Physicians must respect and comprehend moral ambiguity yet not abandon the search for what is right and good in each decision.

(Pellegrino 34-35)

What is even more important than doctors following this model is that doctors make this model a part of the culture. By placing this model in the popular culture, doctors will be able to increase their ability to attract patients and patient trust. This entrance into the popular culture can be seen in such films as The Doctor and Doc Hollywood, both of which demonstrate an unfeeling doctor learning to understand the suffering of his patients.

Another example of a caring, feeling doctor entering into the popular culture is Dr. Oliver Sacks whose medical writings have become popular among general readers of fiction, and have even been made into a very popular film, Awakenings. A close reading of Sacks' writing, however, demonstrates that while he does present himself as a fatherly, beneficent physician, there is also a level in which Sacks is working to maintain control and present himself as superior to the patients he works with.

Sacks explains his work as demonstrating a doubleness which occurs in him as a physician and as a writer.

I feel myself a naturalist and a physician both; and that I am equally interested in diseases and people; perhaps, too, that I am equally, if inadequately, a theorist and dramatist, as equally drawn to the scientific and the romantic, and continually see both in the human condition of sickness—animals get diseases, but only man falls radically into sickness.

(vii)

This statement stands in direct contrast to the role of doctor depicted by Flexner, who called for doctors to treat humans as consisting of animal tissue devoid of the interests of humanity. Sack's purpose in writing, however, is to dispel Flexner's image of doctors. He describes his admiration and interest in his patients and uses the case studies to introduce the reader to his patients as individuals as well as examples of illness.

Another important factor in Sacks' depiction of his doctor character appeared in his work A Leg to Stand On. Sacks describes an incident in which his knee was injured in a mountain climbing accident, and he was forced to assume the role of patient. It was during his lengthy recovery that Sacks learned many of the problems with the doctor/patient relationship. “Both of us, in a sense, were forced to play roles—he the role of the All-Knowing Specialist, I the role of the Know-Nothing Patient” (106). The callousness of the medical professionals toward Sacks seems to have altered his own perception of patients. His moral concerns derived from this experience are then presented in his case studies in The Man Who Mistook His Wife for a Hat (Budge 135).

There is, however, a third rationale for Sacks' recording of these case studies. It is interesting to note the audience Sacks has chosen for his work. Rather than working within medical journals, Sacks is writing for a popular audience. His purpose then must be not influencing other medical professionals, but changing the views of the larger audience's perception of physicians. The caring doctor character becoming part of the popular culture works to alter our views of doctors in general, thereby improving physician's position in society. The primary purpose of Sacks' writing, therefore, is to create an image in the popular culture of a medical professional who is empathetic, involved and loving, who understands and appreciates the suffering of his patients.

The highlighted feature of Sacks' work is to present case studies of a selection of his patients. These allow his readers to better understand them as people. The patient characters he creates are fascinating, noble individuals, fully capable of living with the neurological disorders that face them. Two clear examples are Dr. P., a “musician of distinction, well-known for many years as a singer, and then, at the local School of Music, as a teacher” (8), and Martin, a mentally retarded adult who despite his mental limitations had memorized more than 2000 operas (187). “Much of the books success … can be attributed to Sacks' capacity to turn deficits into wonders, to write about cases of sometimes extraordinary human loss in a way that reveals the scarcely visited reaches and capacities of the mind” (Wiltshire 304). One entire section of this work even goes so far as to describe a series of maladies which actually improve the lives of the sufferers.

Ray, for example, after taking Halodol to overcome Tourette's Syndrome misses the life he lived with his variety of tics and streams of obscenities.

During working hours, and working week, Ray remains ‘sober, solid, square’ on Halodol … He is slow and deliberate in his movements and judgements, with none of the impatience, the wild improvisations and inspirations. Even his dreams are different in quality; straight wish-fulfillment,’ he says, ‘with none of the elaborations, the extravaganzas, of Tourette's. He is less sharp, less quick in repartee, no longer bubbling with witty tics and ticcy wits … but [he] would take himself off [Halodol], and let fly, at weekends.

(100-01)

The relationship between the patient and disease is very peculiar in Sacks in that none of his patients really seem to suffer. They work, they question, they adapt, but they all overcome. Dr. P, for example, a renown musician who has lost nearly all of his abilities to recognize the visual world, can find solace in his music. Dr. P is then able to overcome the difficulties he faces from his neurological disorder by relying on the one aspect of his life that he truly loves.

This aspect of Dr. P is very important because, as has been discussed above, modern medicine is faced with a growing number of maladies that it is unable to cure. During the course of Sacks' text he is only able to ‘heal’ one of his patients. The remainder continue to live as best they can within their disorder; at best, Sacks helps them cope. His selection of patients then must work to downplay his failures in returning his patients to normal. By selecting the patients who are strong enough to deal with their problems, he is able to describe individuals without creating a sense of pity. Rather, we, as readers, see them as admirable souls who find their true nobility only after having developed the disease.

The most dominant figure in the text, however, is not one of the patients, but Oliver Sacks. Why does he play such a large role in the stories he tells? Whereas he develops very little in the way of therapy, medicinal or surgical curatives, why is his presence so dominant in the text? Even though he does discuss a series of fascinating individuals, the strongest link that forms the book is the forceful presence of Oliver Sacks.

One movement Sacks makes to increase his importance in the text is to shift his function as doctor from healer to interpreter. Since Sacks is not able to reverse the effects of the neurological illnesses of his patients, he makes diagnosis his prime function. While the previous physicians have generally mislabeled and misunderstood his patients, he alone has the ability to name the disease. Sacks is able to demonstrate his power and knowledge by examining the variety of mental tics and awkward mannerisms and giving them a name.

A great deal of Sacks presentation of his own character is built upon the creation of a figure as noble as the patients he discusses. Like a number of his patients, Sacks has a great appreciation and understanding of art. He plays the role of musician (12), literary scholar (119) and religious and art critic (166), and, like a number of his readers, he truly cares about the humanity of his patients. But while Sacks is able to hold his own on such topics with his patients and readers, he alone has control of the medical knowledge contained in the tales. Sacks maintains his role as professional neurologist by holding on to his community's vocabulary. Sacks uses distinct neurological terms such as astrocytoma (153), parietal and occipital lobes (12) and proprioceptive deficit (46), none of which he defines for his non-medical audience. This element of medical knowledge serves as his authority over his patients, but it also works to maintain a very important distance between author and reader. We may have been invited into his world, but we must know that it is a world we will never understand as well as Sacks.

The key element of the work which demonstrates Sacks' power in relationship to his patients, and to his readers, is his role as story teller. It is in this role that he has total control. He tells his patients' stories because they are unable to tell them themselves. Sacks' book contains a repeated crisis in his patients, not only of visual and spatial coordination, but in the function of narrative itself, which is either stopped in time, presented in a wildly unintelligible manner or missing altogether (Rose 238). Sacks then steps in to pick up the narrative which his patients are unable to tell and no one else would be able to truly understand.

The duality Sacks discusses is more severe than even he seems to realize. In his role as writer he is committed to creating patients of distinction who are given an equal voice in their own treatment, yet in his role as doctor he has been trained to maintain control and authority over his patient's stories as well as their treatment. In this view, the writing of Oliver Sacks serves to demonstrate the current split in how physicians are viewed in our contemporary culture. While voices both inside and outside of the field have called for a greater sense of humanity in the treatment of patients, at the same time, medical training and the responsibilities of practice have required a strong commitment to distant objectivity and complete authority.

Works Cited

Babbie, Earl R. Science and Morality in Medicine. Berkeley: U of California P, 1970.

Beecher, Henry K. “Ethics and Clinical Research.” New England Journal of Medicine 274.24 (1966): 1354-60.

Budge, Alice, and Emil Dickstein. “The Doctor as Patient.” Literature and Medicine 7 (1988): 132-37.

Cassell, Eric J. The Nature of Suffering. New York: Oxford UP, 1991.

Flexner, Abraham. Medical Education in the United States and Canada. 1910. Washington, D.C.: Science & Health Publications, 1960.

Foucault, Michel. The Birth of the Clinic. Trans. A.M. Sheridan Smith. New York: Vintage, 1973.

Katon, Wayne, and Arthur Kleinman. “Doctor-Patient Negotiations and Other Social Science Strategies in Patient Care.” The Relevance of Social Sciences for Medicine. Dortricht Holland: D. Reidel, 1981.

Pellegrino, Thomas. The Clay Pedestal. New York: Charles Scribner's Sons, 1981.

Rein, Ingrid. “Medical and Nursing Students: Concepts of Self and Ideal Self.” Journal of Personality Assessment 41.1 (1977): 368-74.

Rose, Jacqueline. “The Man Who Mistook His Wife for a Hat or A Wife Is Like an Umbrella—Fantasies of the Modern and Postmodern.” Universal Abandon. Ed. Andrew Ross. Minneapolis: U of Minnesota P, 1988: 237-50.

Sacks, Oliver. A Leg to Stand On. New York: Summit, 1984.

———. The Man Who Mistook His Wife for a Hat. New York: Harper Perennial Library, 1990.

Veatch, Robert M. The Patient as Partner. Bloomington: Indiana UP, 1987.

Wittshire, John. “Defects and Enhancements: Reflections on the Writings of Oliver Sacks.” The Cambridge Quarterly 20.4 (1991): 304-21.

Zabarenko, Ralph, and Lucy Zabarenko. The Doctor Tree: Developmental Stages in the Growth of Physicians. Pittsburgh: U of Pittsburgh P, 1978.

SOURCE: Sacks, Oliver, and David Lazar. “An Interview with Oliver Sacks: Above All, the Paradox.” Ohio Review 54 (1995): 109-18.

[In the following interview, Sacks discusses his interest in disease and treatment, his writing process, and the influence of W. H. Auden on his life and work.]

[Lazar]: One thing that comes up in your work over and over again for me is the shadow of Martin Buber. In much of what you talk about and much of what you seem to reach for in Awakenings and elsewhere, there is a kind of hook between you and the patient, and between the patient and himself or herself, and between you and the audience. There is a kind of play with the I-You relationship, and even the I-Thou relationship at its most secondary and most metaphysical.

[Sacks]: I used to read a lot of Buber once. My bookshelves are strewn with fossils of past passions. Mr. Buber is no exception; I don't think I've gone to it in ten or fifteen years. To begin at the wrong end, which is sort of what I'm writing about, I don't know to whom or for whom I write. And for me, the primary writing is always in notebooks, like this one here, although I don't keep conventional journals. My journeys are documented after, which generates the journal quality of some of my books. Which is what I have done sort of lifelong. Although I call these notebooks, they are not notes. I never look at them, no one else looks at them. They are not published—except under freaky circumstances when, two or three years ago, a journal called Antaeus wrote to me about their issue devoted to notebooks and journals and asking did I keep these, which I had done nonstop since I was about eight or whatever. It so happened that their phone call reached me when I was in Alabama, at Tuscaloosa, which made me go back and pull out a journal I had done about Alabama as a thirty-year-old. So I sent around my travel packet along with a faded photo. When Susan Sontag saw that, she said this isn't a journal, this is very elaborated, cooked-up. So I showed her the original and she said, well perhaps it is, perhaps some of the elaboration does come in at the time.

Your journal tends to be more cooked than raw?

Well, you see, a lot of it is in fact just thinking, like this. Yesterday I wrote a bit of a journal at the airport, as I was about to go through the checkpoint: “I saw a strange figure, figurine, which I first thought was a doll and then a little corpse, seated upright and motionless, tiny in an airport wheelchair. Child-like size proportions, a fleshless beaked nose, cataract eyes, wizened lips, extreme old age. His little bald head covered by a black kerchief. Progeria, a rare terrible disorder of some children, which turns them in a year or two of hideous acceleration of the aging process into tiny wizened creatures ready for the grave. The skin ages, the voice becomes high and piping, the heart and the internal organs atrophy, the joints stiffen, the bones become fragile, the eyes become dim, the ears fill up with debris. Total atrophy comes last, including, fearfully almost at last, a deep awareness of what's happening. How does the child feel shriveled up like that?”

How does the child feel, and feel about his fate?

It has always seemed to me the most terrible fate possible, more than any deformity or terminal disease or whatever. When I was eight, I saw in Trench's Differential Diagnosis a photo of Progeria, and it has haunted me now for fifty years, and though I had never seen the condition before, I recognized it instantly from that photo fifty years ago, and I wonder why did it horrify me? For extreme age, I thought of a thousand-year old guru like a shriveled child or a monkey. Above all, the paradox: the outrageous conjunction of childhood and age.

Progeria has always seemed to me to be the innocent side of the Sibyl of Cumae, who aged when she asked for eternal life.

Oh yes! I was trying to think of the mythological character who asked for eternal life, Tithonus?

Yes, Tithonus did. “The Gods themselves. …” Don't you think that especially the more one writes the more one gets into a habit of writing? We see this in Cheever's journals, the more he writes in the journals, the closer we see him circling certain truths about himself. They take on a kind of imperative. Or perhaps it's as Montaigne says, “One writes.” And the more one writes the more one writes.

A healthy Midwestern breakfast. Everything looks thicker and finer and brighter, more 1940's. Innocent, like a sort of wizened Progeria. Is your recorder on? The last time I was in Ohio, I was in Akron and I was put up in a converted silo in the Quaker Oats Factory. Are they still in operation?

Oh yes, who knows what conglomerate owns them now though.

Oatmeal. Or rather “Oak-meal” as it became, a strange epithet with a Tourettic friend with whom I was traveling, who pronounced it “oak-meal.” So yes, back to what you were saying, it is a spontaneous jotting, but in a way, it's a rather formed style, even though Susan Sontag didn't believe it.

When I first published something in the New York Review of Books, called “The Lost Mariner,” Bob Silvers was curious and I guess suspicious, but he said can I see your original notes. I said sure, and I brought them in and he was startled at how close they were both in substance and style to the printed thing, except some parts of the journal were fresher and better, and he said put that in instead. I kept a journal as well for Awakenings—well, not a journal, but notes. Occasionally emotion gets me going and I'm afraid I write in the car quite a lot. I have whole journals that are written in a funny angle. I've tried using a tape recorder, but the written rather than the spoken word makes a lot of difference, a neurological difference as well. But for me there has been one exception, although no one ever commented on it so maybe it's not too obvious: the first nine cases in Awakenings were written from dictation. At that time I had a head-and-neck injury, in '72, and couldn't hold a pen, so a young sort of shorthand typist came along, a sort of Scheherazade in reverse, and I would lie down in my neck brace and would get myself into a sort of dreamlike state, and I would tell stories and I was telling them to her. In a way this was a sort of I-Thou thing, sort of thinking aloud in that relaxed state and her transcribing, and there was something about her attention that sort of guided me, that she would come back to the next day. That was the only time I ever did that—because of the physiological necessity, which I couldn't do anything about.

And do you see the difference between the first nine cases and the rest?

Yes, the first nine are more elaborate, the sentences are longer. There's more reflection. But I don't know if there's a deep difference.

It's interesting: think about James dictating his last three novels and think of those sentences being spoken; it's especially difficult to conceive of in the U.S., since we thrive on short, clipped sentences. For me, I think the hearing of my actual voice would be a great distraction to dictation.

I can't imagine speaking in those paragraph-sentences. When Julie Innis and I were driving in from the airport, we saw a vulture and I said it reminded me of a writer, and she said yes, she had written something once about the writer as a vulture. We were very much on the same wavelength.

Kinship. The question of journals and using them in your work and their relationship to the essay and the case study is interesting because your persona in your essays is very distinct, while at the same time you really keep the focus on the subject—the literal subject as person, more than the subject as idea. You don't talk much about yourself.

Incidentally, another form I suppose is important for me is letter writing. And I think the letter-writing mode comes from something different from the journal one. I've sometimes found that a flurry of letters can turn into a book-length piece, which is sort of a letter to everyone. But specifically, in “RickyTickyJay” the narrative part was a letter which I'd written to a publisher who wrote back and said he liked reading about James—his name was not really James, I had, of course, changed his name because it reminded me of a certain tick he had when he would say “rickytickyjay,” he would do it with a sort of jay-like swoop and a toss of his head, identifying himself with a bluejay—I suppose I should have put that in.

When I read Montaigne, I feel in many of the essays there is the sense of important Other out there, frequently la Boetie. I think that's a crucial part of the genre, that speaking to a larger audience out of a singular one, using the epistolary form.

I remember a late reading of Auden at the “Y” in New York. On the one hand, and I was too young to have known this, it was sort of an odd formal performance; at the same time it was highly personal, so that the man on one side would think “he was speaking to me.” No he wasn't! He was speaking to me! And everyone there felt he had been individually addressed.

Auden seems like an important influence and friend for you. How did you meet?

I had seen him and listened to him, but not dared to approach him when he was a professor of poetry at Oxford, and then in '67 a friend of his had sort of a dinner party and knew Auden pretty well and invited me around. The first time I just looked at him with awe, I don't think I said anything! We were very formal; for a long while, I used to say “Mr. Auden” and he would say “Dr. Sacks” and it was a year or two before we got on. I don't know if you read the thing I wrote about Auden in the Stephen Spender tribute. But he did become a, what word to use, one wants to use a word like “wise old” and then I remember how mischievous and child-like and naughty—an unexpected antinomian—how reckless and outrageous he was. I got a strange letter the other day from the wife, the widow of a psychoanalyst; she said something about her husband “the late doctor. …” How he would have hated being called the “late”! So even though it's been twenty years now, the “late” Mr. Auden seems belied, since all I can remember was he was quite the heretic. I used to see him quite a bit at tea-time. He'd get a bit drunk. At tea-time, he'd sit on a volume of the OED and you never knew which way the conversation was going to go. I'm not much a reader or rememberer of poetry, but for some reason, I know all of Pope by heart. There is something about Pope's sort of zaniness and surrealistic imagery which I think is like Auden. His father was one of the pioneer survivors that helped confirm encephalitis in England. Auden was specifically interested in this and once came along with me on rounds. And I think it was sort of generic in a way to dedicate the book to him as his doctor, though I wasn't his doctor. I think Awakenings would have been more like Migraine and less audacious in getting out of the medical form if not for Auden.

With each edition of Awakenings, the notes and the digressions expand until, frankly, the latest edition is almost a collage. I mean that in a perfectly complimentary way. Essayists have frequently had the urge to produce a kind of collage, a collection that would go from aphorism to narrative to meditation. One sees that in analytic studies very strongly as well, no?

Yes, well the new Migraine is going to be twice as long, with a whole part five in it, with a foreword and an afterword and color plates.

In that, you're like Auden who used to revise so insistently and strangely.

I never know what to revise. I think one of the things I wanted to straighten out in Awakenings was what was an earlier voice from what was a later voice. But one might say “In science, who cares?!”

I think it's pretty clear. I think the notes that you added and the digressions are distinct. The later editions are much more dense and metaphysical, so the difference in voice is clear.

I'm never through with a subject. There is something about coming back which I like. Now in part five of Migraine, which was sketched twenty-five years ago, I've begun to deal with some of the stranger visual hallucinations which people can get. There was an article on the alteration of the scotoma. I wrote a long long letter to the editor saying it was a lovely article but beyond the one phenomenon which the author described, there are all these other examples which took us into very strange territory for which no existing neurological principle was anecdotal. One needed some theory of the sort of mass action, a sort of huge change across the entire field of neurons. The editor wrote back and said he liked my letter, he thought it was nice “But it's too long. Can you either shorten it or turn it into an article?” Impossible! Dear Sir, in response to your letter twenty-one years ago, please find enclosed article. But specifically, I can't quite say it was in my mind, but it was somewhere cooking. And then last summer, I saw the most amazing exhibit of Migraine Art in San Francisco, about a hundred paintings by people of their visual hallucinations. And this clicked with other things I had seen about some of the strange forms one can see: chaotic systems, weather systems, turbulence, chemical systems. And I was speaking with a friend of mine who was working with neuron networks and he had seen similar things now being simulated on the neuron network on the whole. And I think they may be understandable in terms of self-organization, a sort of Chaos Theory, which of course did not exist twenty years ago. So it's very nice to be able to say that what I could not properly deal with in 1967, I can deal with now in 1992. The book is now more complete! But I've gotten away from your original question about I-Thou which I would like to talk about.

Oh, that's fine. Actually I'll bring back Buber for a second because there is that sense of manifold possibility in Buber and the manifold beingness, that runs, it seems to me, throughout your work as well—that split or that tension between disability and possibility that gets examined in the case studies, especially in Awakenings. It seems that many of your additions to Awakenings point in this direction, that limitation turns into a kind of window of possibility.

For the patient or the thinker?

More for the thinker for its metaphysical implications.

I got a letter a few days ago from a man with Tourette's Syndrome, who at one point wondered why he witnesses his Tourette's as his Tourette's Syndrome, that Tourette's Syndrome can generally act as an unexpected window into human nature. And at one point he says he is no longer just an afflicted one, saying instead, “I am a window.” It's nicer than saying “I am a camera.”

In A Leg to Stand On, your Judaism emerges just a bit and you use a slightly Talmudic approach to both subject and self.

That was the most difficult thing to write; it took years and years. I remember when I made the first draft it was 300,000 words, which was cut down to 58,000. It wasn't so much that the other quarter-million were bad, it was just too much. But specifically, at one point or another in writing some of the early stuff, I had become fascinated by Kabbalah, I'd been reading Gershom Scholem.

I thought, especially in Awakenings but elsewhere too, about your fascination with departure and return, quite mystical in places.

I am a compulsive tidier and I am a compulsive untidier, a chaos maker. I don't know whether the Jewishness of the Leg [A Leg to Stand On] book isn't a sort of fake and generally just the appearance of religiousness. But perhaps it was to some extent from another time. I did sort of read a lot of Psalms then, and they did sort of speak to my condition.

What about music? Music comes up over and over again in your work, literally and metaphorically.

Music is an important part of personality, very much so for patients—my patients, for all patients—but especially neurological patients who have lost some of the temporal order. Music helps them gain that order, a window or a guide, or whatever, to past worlds and identities. Toscanini was furiously ambivalent about music, wasn't he? He used to get furious at its inexplicable power, the fact that it could pull him out of control and make him weep. But he didn't want to weep, didn't know what he was weeping about.

One of my favorite essays about music is the Charles Lamb essay, “A Chapter on Ears.” Do you know that? I'd love to see what you'd think about it because there is all this fear and terror, a fear of madness which is not all that surprising for Lamb, but seems very focused on instrumental music, wordlessness. He starts in that perfectly whimsical Charles Lamb fashion by saying, “I have no ear. No, don't mistake me, I have the actual ear …” and then ends in a kind of essayistic chaos. It's really quite extraordinary. He quotes Burton all over the place.

When John Stuart Mill had his breakdown, he became afraid that melodies were exhaustible.

I was just at a very high-powered neurosurgeons' conference. I was very glad that it ended up with a concert. We'd tried desperately to answer questions verbally and intellectually for three days with the answer in the music constantly before us. How can it be so? It would seem to be so.

Es muss sein. Of course the answer is in the possibility of saying how it is so, because that would be turning it into the kind of verbal analysis that couldn't resolve itself to begin with, and that music can approach.

It is the strangest of the arts. It does seem to ask questions and interrogate constantly in a way that visual art doesn't.

Beethoven's great question, “Must it be,” seems to run throughout music, especially to run throughout chamber music. I think, perhaps, it's one of your questions, too.

I wonder if music forms any way back or way out or way into the world of art for Gary Greg [subject of a Sacks study, published in New York Review of Books]?

Do you think it might?

I haven't really been able to really think; I've had a very distracted couple of months. I haven't been able to sort of start and get right to it.

Too much in demand? People think of you as one of our essential humanists.

[Laughs] Yes, well I'm grateful, I suppose, but I do get tired of that fucking humanist label. In any case, about that question, I could give you an answer later.

SOURCE: Diamond, Jared. “Outcasts of the Islands.” New York Review of Books 44, no. 4 (6 March 1997): 15-18.

[In the following essay, Diamond finds The Island of the Colorblind an insightful and well-written “account of patients with two neurological disorders but also of island plants, islands as laboratories of plant and animal evolution, and many other aspects of islands.”]

1.

In 1964, while studying bird evolution on the tropical Pacific island of New Guinea, I happened to set up camp among a tribe known as the Fore. I soon found my attention drawn away from birds to a human tragedy unfolding around me. Many of the tribespeople, children as well as adults, were limping on crutches, or unable to control their facial muscles, or lying semiparalyzed in their huts. When I asked what was wrong, their healthy relatives answered with the single word “kuru,” as if no more explanation were needed. Kuru, the Fore way of death, is now internationally notorious as a neurological disease, always fatal, and confined to that one tribe living in a group of mountain valleys only a few hundred square miles in extent.

As I proceeded through the New Guinea highlands in search of birds, every ten or twenty miles I passed into the territory of a different tribe, each with its own language, its own culture—and its own disease or genetic anomaly. The second tribe that I encountered had many albinos; the third, the world's highest incidence of leprosy; and others had high frequencies of male pseudohermaphroditism, or of a disorder making the skin resemble that of a crocodile, or of misshapen red blood cells. Scientists have learned that each such local condition stems from various combinations of local infectious agents, adaptations, and genes.

While these pathologies may at first seem to be nothing more than exotic diseases confined to faraway peoples, they have proved enormously influential in the development of medical science, for two reasons. First, for physicians, New Guinea's mountain valleys harbor so many locally distinct human populations that the resulting range of entrenched diseases rivals that of Europe and the United States, with their much larger but more homogeneous human populations. Some of those diseases first recognized in New Guinea turned out to provide decisive insights into more widespread conditions—notably kuru, which has been the best model for understanding Creutzfeldt-Jakob disease, mad cow disease (alias bovine spongiform encephalopathy), and possibly Alzheimer's disease. Second, for evolutionary biologists, New Guinea's human populations allow us to study processes of evolution and genetic change under conditions much more relevant to ourselves than the usual animal population studies cited in any textbook of biology.

Two such diseases on other tropical Pacific islands are subjects of the latest book by the distinguished neurologist and author Oliver Sacks. Both diseases have a known or possible genetic basis: achromatopsia (complete color blindness) on Pingelap, and lytico-bodig (a highly variable neurological disorder) on Guam. Dr. Sacks is already deservedly admired for previous successful books (e.g., Awakenings, An Anthropologist on Mars, The Man Who Mistook His Wife for a Hat) distinguished by beautifully written, poignant studies of individuals with neurological diseases, and by Dr. Sacks's ability to bring himself and his readers into the unusual states of mind of his patients. The current book, based on two visits by Dr. Sacks to Pingelap and Guam and two neighboring islands, is in a similar mold. But The Island of the Colorblind contains much more, because the species of ferns and cycads confined to those islands restimulated Dr. Sacks's childhood interest in plants, especially since one theory of lytico-bodig attributes the disease to the effects of eating poisonous cycad seeds. Hence Dr. Sacks's new book is an account of patients with two neurological disorders but also of island plants, islands as laboratories of plant and animal evolution, and many other aspects of islands.

The small atoll of Pingelap lies in the Pacific 180 miles from the volcanic island of Pohnpei, which in turn lies 2,200 miles east of the Philippines and 1,200 miles northeast of New Guinea. Dr. Sacks was drawn to Pingelap because fifty-seven of its seven hundred human inhabitants suffer from a hereditary form of colorblindness termed achromatopsia. About one third of the remaining inhabitants carry one gene for achromatopsia without reporting symptoms. From Pingelap, which he visited with an ophthalmologist friend, Dr. Sacks went on to study a remote village of Pingelap émigrés on Pohnpei.

Our eyes contain four types of light receptors, termed rods and cones. Rods function under conditions of dim light and give us our nighttime white/grey/black world view without color, while the three types of cones function under daylight conditions of bright light and contain three different pigments that respond differently to lights of different colors (different wavelengths). What most so-called colorblind Americans and Europeans suffer is in fact just the lack of one of those three cone types; they are unable to distinguish red from green but have no other impairment of vision or color perception. In contrast, Pingelap achromatopes have no cones at all, only rods, so that they experience a colorless world like that experienced by the rest of us at night. In bright light the rod pigments become bleached out, and cone vision takes over for us “normals”—but not for Pingelap achromatopes. Hence while their condition is often loosely described as complete colorblindness, Dr. Sacks makes clear from his interviews with people on Pingelap that the much more disabling consequence for them is that they are dazzled by daylight and literally blinded by bright sunlight.

Achromatopsia is not confined to Pingelap but occurs throughout the world. For example, Dr. Sacks visited Pingelap in the company of a Norwegian scientist, Knut Nordby, himself an achromatope, who established instant rapport with Pingelap achromatopes because he at last found himself in a society with many people sharing his condition, and they at last saw an outsider coping successfully with a condition identical to theirs. En route home from Pingelap, Dr. Sacks stopped in Berkeley to visit Frances Futterman, an achromatope who has established a worldwide achromatopsia network. But Nordby, Futterman, and other achromatopes outside Pingelap are very rare cases in their own societies.

How did achromatopsia become so disproportionately common on that one tiny, remote island? The probable answer that Dr. Sacks suggests depends on the genetics of achromatopsia and the history of Pingelap. Achromatopsia exemplifies what geneticists term an autosomal recessive disease. Recall that we inherit two copies of most of our genes, one from our father and one from our mother. If you inherit a normal gene for cone light receptors from either of your parents, that one copy suffices for you to make cones in your eyes. Only if you receive a defective mutant gene from both parents and thus have no normal copy of the gene for cone production do you lack the capacity to make cones. But the gene for achromatopsia is very rare everywhere except on Pingelap, and thus it is even rarer to find a marriage in which both the man and the woman happen to have one copy of the achromatopsia gene. In addition, by the laws of genetics—so-called recessive inheritance—only one quarter of the children of such a marriage inherit the defective gene from both parents and end up as achromatopes. That is, throughout most of the world the achromatopsia gene is rare, marriages between two people carrying the genes are much rarer, and achromatopic offspring of such marriages rarer yet.

Pingelap history is unusual in exemplifying what evolutionary biologists describe as the “founder effect.” The flat, low-lying island was completely inundated in 1775 by a typhoon that killed 90 percent of the population outright; most of the immediate survivors were then gradually killed by starvation. The population of a thousand was thus reduced to only about twenty, probably including just about half a dozen adult women in their reproductive years and half a dozen adult men, one of whom happened to be the hereditary chief (titled the nahnmwarki), whom one might expect to have sired more than a merely proportional share of the resulting children. Within a few decades the twenty survivors bred their numbers back to a hundred, but the first achromatopic children were born in the fourth generation after the typhoon, and within a few more generations the frequency of such children rose to its present level of somewhat under 10 percent of the population. Pingelap genealogies suggest that the nahnmwarki himself was the source of the achromatopsia gene transmitted to all current gene-bearers on Pingelap. Probably the gene was formerly present but rare on Pingelap as elsewhere in the world, so that asymptomatic gene carriers—people with just one copy of the gene—rarely happened to marry. Only when the typhoon reduced the adult male population to the gene-carrying nahnmwarki and a few other men of lower status was Pingelap repopulated with a newly founded, inbred population containing many gene carriers, who inevitably often ended up marrying and producing achromatopic children.

The founder effect, which Sacks briefly describes, is a phenomenon of widespread importance in evolutionary biology, because the populations of most animal and plant species are divided into small effective breeding populations or are periodically reduced to small populations by environmental accidents like Pingelap's typhoon. While evolutionary biologists usually deduce principles from animal studies and apply those principles to humans, the reverse is true for the founder effect, because human beings are unique among animal species in being all individually named and inordinately concerned with recording their genealogies. That makes it possible to trace some locally frequent genetic traits back to one or a few founding ancestral individuals. For instance, hexadactyly—six-fingered dwarfism—is exceptionally common in the Amish population of Lancaster County, Pennsylvania—not because something about Lancaster County makes a sixth finger uniquely useful there, but because the few original founders of the Lancaster Amish population included a certain Mr. Samuel King and his wife, at least one of whom happened to carry the gene for hexadactyly. Again, a genetic condition called osteodental dysplasia, in which all one's teeth fall out by the age of twenty, is uniquely common in the so-called Cape Colored population of South Africa, not because South Africans don't need teeth but because a polygamous dysplasic immigrant named Arnold, assisted by his seven wives, propelled the gene to high frequencies in the recently founded population.

It is only through lucky chance that geneticists studying continental populations were able to trace the operation of the founder effect among the Lancaster Amish and the Cape Coloreds. In contrast to populations of remote islands, most continental populations are divided into large political units with extensive genetic homogenization, tending to eliminate any original concentrations of a local gene that are due to founder effects. Such effects for human populations are clearest on islands and on those few parts of the continents not homogenized in the last thirteen thousand years. Until about thirteen thousand years ago, all humans on Earth were divided into small local populations of hunter-gatherers, probably each with its own “private” genes, like Pingelap and its achromatopsia. Since then, continental human populations have undergone three successive waves of genetic homogenization. The first was the expansion of the territory of the earliest farmers at the expense of the hunter-gatherers, erasing much pre-existing gene diversity over wide areas. Examples include the expansion of Bantu farmers over sub-Saharan Africa beginning around five thousand years ago, the expansion of Austronesian farmers over the Philippines and Indonesia beginning around six thousand years ago, and perhaps the expansion of farmers bringing Indo-European languages to Europe around ten thousand years ago.

The second wave of homogenization began around five thousand years ago with the formation of political states, which promoted intermarriage among a state's people. The third wave is now the one following airplanes and Coca-Cola across oceans and large land masses, and producing genetic melting pots on Hawaii and elsewhere. That is, human genetic diversity must have been much higher in the past than at present, as new populations were constantly being founded and expanding to carry their private genes over small local areas. Pingelap and New Guinea are thus far more important to geneticists than their tiny fraction of the world's population would suggest, because they show us our genetic landscape as it used to be. For a long time now, the global trend has been toward mixing populations. But the world's peoples still have a long way to go before all human populations become coffee-colored and share similar gene frequencies.

Nonetheless, the founder effect acting alone is not the sole possible explanation for achromatopsia's high frequency on Pingelap. Another, more speculative possibility involves what geneticists term a “balancing selective advantage”: perhaps achromatopsia carries with it some subtle advantage offsetting its obvious disadvantage of impaired vision in bright light. The genetic literature is full of examples of “bad” genes with “good” effects, especially genes for autosomal recessive diseases like achromatopsia.

The best-understood example is the sickle-cell gene common in black Africans and in their African-American descendants. That gene causes our red blood pigment, hemoglobin, to be synthesized in an altered form, resulting in red blood cell oxygen levels below normal. Individuals “homozygous” for the sickle-cell gene—that is, with two copies of it, one inherited from one's mother and the other from one's father—produce only sickle-cell hemoglobin and lack normal hemoglobin. Those homozygous individuals end up with low red blood cell oxygen concentrations tending to cause a blood disease, which was often fatal before modern medicine and still can be today. But individuals with only one copy of the sickle-cell gene—so-called heterozygotes, who are much more numerous than the homozygotes—develop only mildly low red blood cell oxygen concentrations, not so low as to make them sick but still low enough to damage malaria parasites during their life-cycle stage within red blood cells.

As a result, in tropical areas of Africa where malaria is the most dangerous infectious disease, sickle-cell heterozygotes have some inherited resistance to malaria and survive even better than do homozygous “normal” individuals producing only normal hemoglobin. The mild selective advantage to the numerous heterozygotes offsets the severe disadvantage to the less numerous sickle-cell homozygotes. The offsetting, of course, is not in the sense of a moral balance whereby some people must die for the good of their relatives, but in the sense of a balancing selection that prevents the sickle-cell gene from being eliminated by natural selection and maintains it in malarial areas of Africa.

Dr. Sacks describes a possible such advantage for achromatopsia under Pingelap conditions, though he abstains from speculating that it could contribute to Pingelap's high frequency of achromatopsia. He mentions that achromatopic homozygotes on Pingelap are reported as seeing better than normal people under dim-light conditions at dusk and dawn and on moonlit nights. Specifically, the achromatopes are outstandingly successful at night fishing because they can detect fish underwater in dim light. That's a vital skill for an island population heavily dependent on fish for protein. And as night fishers, Sacks writes, “the achromatopes are preeminent; they seem able to see the fish in their dim course underwater, the glint of moonlight on their outstretched fins as they leap. …” Hence I found myself wondering whether heterozygotes carrying the gene for achromatopsia might also have somewhat better night vision than normal people, without the homozygotes' debilitating impairment of poor day vision. If the heterozygotes thus were somewhat more successful than normal individuals at catching fish and thus attracting marriage partners and feeding their children, they could enjoy an advantage in traditional Pingelap society. In that case, Pingelap achromatopsia would exemplify a founder effect subsequently amplified by natural selection.

Here again isolated little Pingelap may illustrate an evolutionary phenomenon (balancing selection) of worldwide importance, with sickle-cell hemoglobin being only one among myriads of human examples. Dr. Sacks describes one related example, involving the genes that let us store carbohydrate as fat and that may thereby precipitate diabetes in adults. Those fat storage genes are disadvantageous to most readers of these pages—i.e., people whose Western life style includes high sugar intake and low physical activity—because they may thereby end up overweight and diabetic. But fat storage genes could be highly advantageous to people with a spartan life style: if you are especially efficient at storing the occasional high-carbohydrate meal as fat, you will be less likely to starve under the more usual conditions of marginal food supply. Just imagine how Pacific islands must have been originally discovered and populated by long, open-ocean canoe voyages into the unknown. At the end of such a voyage, few of the canoe's starting passengers might still be alive, and those alive would tend to be the ones who had had the most body fat at the outset. Under the conditions of the traditional vigorous life of Pacific islanders, they would then face a negligible risk of diabetes; but their risk would swiftly increase if they adopted Western habits, a tragedy now being observed among so many Pacific island populations. For instance, on Nauru Island, whose phosphate mines support the most affluent population of Pacific islanders, who shop in supermarkets and are freed from the hard work of farming and fishing, more than half of all adults surviving to the age of sixty end up diabetic.

That balancing of natural selection in adults who may be susceptible to diabetes involves a complex genetic basis. But other genetic diseases familiar by name to readers of this review may involve the balancing of natural selection by the same simple mechanism as that conceivably operating in Pingelap achromatopsia. The cystic fibrosis gene, which is the most common deleterious gene in people of Northern European origins, may have risen to its otherwise puzzling high frequency by protecting heterozygous carriers of the gene against the risk of bacterial diarrheas (formerly the leading killer of infants), while causing the fatal or debilitating condition of cystic fibrosis in homozygotes. The Tay-Sachs gene so common in people of Eastern European Jewish origins may have reached those frequencies by protecting heterozygotes against tuberculosis (formerly a big risk to city-dwellers, as most Eastern European Jews were), even though homozygotes all succumbed in childhood to a fatal disease.

2.

The other neurological disease discussed by Dr. Sacks is lytico-bodig, recently widespread among the native Chamorro population of the Pacific island of Guam. Today, Guam is a melting pot of Filipinos, Spaniards, and other immigrants, but the original inhabitants who greeted Magellan on his voyage of circumnavigation were the Chamorros, a largely Micronesian people.

Lytico-bodig is a doubly puzzling disease. First, its symptoms vary so much that Chamorros call one form lytico and another form bodig, raising some question whether two separate diseases or just one variable disease are involved. The forms range from a paralysis resembling amyotrophic lateral sclerosis (ALS, or Lou Gehrig's disease) to Parkinsonism and dementia. Second, the cause of lytico-bodig remains debated. Its confinement to Guam's Chamorro population might initially make one suspect yet another genetic disease, like achromatopsia. Indeed, the history of the Chamorro population suggests a founder effect as on Pingelap, because 99 percent of the original population died in the Spanish colonial era from massacres and infectious diseases, leaving only 1 percent to refound the modern Chamorro population. But a genetic theory is difficult to reconcile with the mysterious decline in frequency of new lytico-bodig cases over the last four decades. A competing theory discussed by Sacks involves seeds of wild cycad plants, which are nutritious but contain a substance that has severe toxic effects if it is not carefully removed during preparation of the seeds. Perhaps the recent and now waning lytico-bodig epidemic is a legacy of the Chamorros' temporary heavy dependence on cycads for food during the Japanese military occupation in World War II. Still other theories invoke a postulated mineral imbalance (too little calcium and magnesium, too much aluminum) or a so-called slow virus.

Whereas Pingelap achromatopsia has attracted little notice from the outside world, medical scientists have devoted much attention to the Chamorros' lytico-bodig, because it has long been clear that lytico-bodig could be far more than an exotic disease of one remote Third World population. Many features of lytico-bodig are reminiscent of the kuru that I encountered among New Guinea's Fore people: variable neurological symptoms; confinement to one human population and absence from other populations living in the same environment; tendency of symptoms to run in families; and very long latency for the disease to express itself. Chamorros who leave Guam to settle in California may come down with lytico-bodig forty years later, long after their presumed infection in Guam, if indeed an infectious agent is involved at all. While it remains unknown how the postulated agent was transmitted among Chamorros, we now know that kuru among the Fore is due to a very slow-acting infectious agent formerly transmitted between Fores through endo-cannibalism—the eating of dead relatives. Kuru transmission stopped with the end of Fore cannibalism in 1959, but the consequences to Fore children alive at the time of the last cannibalistic feasts are still emerging today, in the form of new cases of kuru appearing in adults now in their forties. The mysterious waning of cases of lytico-bodig thus analogously suggests the disappearance, around 1952, of some other mode of transmission on Guam.

The medical and scientific insights gained from studying kuru and, potentially, lytico-bodig are enormous. As for the medical insights, at the time that I was working in the Fore area in the 1960s, many medical researchers guessed that kuru was the result of some environmental condition (some toxin?) unique to the Fore area, or possibly was genetic. An infectious agent seemed an unlikely explanation because of kuru's often very long latency, so much longer than that of most other acknowledged infectious diseases. But Dr. Carleton Gajdusek of the National Institutes of Health received a Nobel Prize for his epochal demonstration that kuru did involve a very slow-acting infectious agent. He inoculated kuru brain extracts into chimpanzees, which proceeded to develop a kuru-like degenerative condition years later. This was a scientific discovery made against great odds: almost any other scientist except Gajdusek would have lost patience and given up long before the chimpanzees developed symptoms.

Kuru (and perhaps lytico-bodig) now proves to be a human analog of long-latency neurodegenerative diseases previously known in animals, including sheep and mink. Creutzfeldt-Jakob disease is another kuru-like human disease that is widespread throughout the world but rare everywhere. Hence the Fore kuru epidemic may well derive from just one original case of Creutzfeldt-Jakob disease, which would have immediately died out elsewhere but was transmitted among the Fore by endo-cannibalism. While readers of this review may dismiss kuru and lytico-bodig as exotic conditions for which they are not at risk, they certainly should be worried about their risk for some other conditions that may be caused by related agents, such as Alzheimer's disease, multiple sclerosis, and Parkinsonism. Oliver Sacks found that some of the patients he saw reminded him of the victims of post-encephalitic Parkinsonism that he described in Awakenings. And many European readers are justifiably terrified by their risk of contracting mad cow disease (BSE, or bovine spongiform encephalopathy), which is caused by an agent very similar to the agent of kuru (and perhaps lytico-bodig).

The BSE agent was transmitted to cows whose feed was partly made up of infected sheep carcasses. In at least fifteen well-attested cases, fatal BSE has now been transmitted to Europeans (mostly British) who ate infected beef. No one can predict whether those cases herald the beginnings of a European epidemic of long-latency BSE, one that will extend over the next forty years, like the kuru and lytico-bodig epidemics.

These are the possible medical implications, but there are equally huge scientific implications. Gajdusek described kuru as a slow virus disease, although he was not able to isolate a responsible virus. He merely made that inference because he knew that the infectious agent was so small that it passed through very fine filters, and the only then-known infectious agents so small were viruses. But growing evidence now suggests that the agent could be a peculiarly folded form of a widespread and normally innocuous protein called a prion, which is found on the surface of some brain cells and which may affect the normally folded protein molecules nearby, causing the formation of destructive clots in the brain. This hypothesis, formulated by Dr. Stanley Prusiner of the University of California at San Francisco, was long rejected as heretical by many other scientists, because it violated some of the most basic accepted tenets of biology.

If the hypothesis does prove to be true, it will in my opinion be the most astonishing discovery by molecular biologists since Watson's and Crick's discovery of DNA structure in 1953. Until now we have been assuming that a protein's three-dimensional structure is uniquely determined by its sequence of amino acid building blocks that supposedly specify how the protein will fold up. But if Prusiner is correct (and his conclusions are still being hotly debated), prion proteins can assume different folded configurations, specified by some factors other than the amino acid sequence itself. Furthermore, while all the genetic information specifying protein structure is supposedly contained in nucleic acids (especially DNA), Prusiner argues, equally heretically, that the form in which protein is folded can also contain such information. It is thus no understatement to say that diseases of those two tropical Pacific island peoples, the Fore and the Chamorros, are revolutionizing our understanding of medicine and biology.

In short, the two medical subjects of Dr. Sacks's book are important and fascinating. His book also deals with much interesting material about plants, and has short discussions of a wide variety of other engrossing topics. The book contains the vivid and sensitive descriptions we have come to expect from Dr. Sacks's previous books, especially when he brings us close to the minds and lives of patients with achromatopsia or lytico-bodig. Here, for example, he describes a patient afflicted with bodig:

I was told he had “man-man”—the Chamorro word for staring blankly into space—though this was not a blank staring, a staring at nothing, but an almost painfully engrossed, wistful staring, staring out at the children who played in the road, staring at the occasional passing cars and carts, staring at the neighbours leaving for work each morning, and returning late in the day. Jesus sat on his porch, unblinking, unmoving, motionless as a tortoise, from sunrise till midnight (except on the rare days when high winds or rain lashed across it), forever gazing at a constantly varying spectacle of life before him, an enraptured spectator, no longer able to take part. …

We had been told that Jesus might pass the whole day with scarcely a word. And yet he spoke well, even volubly, when we engaged him in conversation; though, it soon became apparent, he waited for our questions. He could respond quite readily, but could not initiate a sentence. Nor, it seemed, a movement either—he might sit totally motionless for hours, unless something or someone called him to move. I was again strongly reminded of my post-encephalitic patients and how they were crucially dependent on the initiative of others, calling them to speech or action. I tore a page out of my notebook, balled it up, and threw the balled paper at Jesus. He had been sitting, seemingly incapable of movement, but now his arm shot up in a flash, and he caught the paper ball precisely. One of his little grandsons was standing by, and his eyes widened with astonishment when he saw this. I continued playing ball, and then asked Jesus to throw the ball at his grandson, and then to another child, and another. Soon we had the entire family playing ball, and akinetic Jesus, no longer akinetic, kept it going between us all. The children had not realized that their “paralyzed” grandfather could move by himself at all, much less that he could catch a ball, aim it accurately, bluff, throw it in different styles and directions, and improvise a fast ball game among them.

In its format, The Island of the Colorblind is unusual, and is best described as a two-tiered mosaic of loosely related chunks. At the top tier, the book consists of five chapters: one organized around Dr. Sacks's travel to Pingelap, one each around his observations of achromatopes on Pingelap and Pohnpei, one around lytico-bodig on Guam, and one on the island of Rota near Guam. The two diseases are unrelated to each other except for the fact that they afflict peoples of remote Pacific islands; and the chapter on Rota says nothing about diseases but instead describes Rota's ferns, cycads, and other plants. The book concludes with a fifty-eight-page section of notes, longer than four of the five chapters: ninety-four mini-essays, averaging about one half page each, on diverse other subjects that arose from Dr. Sacks's trips and that interested him, such as the lives of various botanists, coconut crabs, Darwin's views about seed dispersal, the effects of golf course construction on Rota, the evolution of bananas, and Micronesian languages.

Each of the five chapters itself is a finer-scaled mosaic, shifting abruptly between diseases, plants, and other subjects. For instance, the thirty-six-page chapter on Pohnpei progresses through the following sequence of topics, devoting slightly under three pages to each: the archaeological ruins at Nan Madol; the human geography of Pohnpei; observations of achromatopic children; the experience of Knut Nordby and his siblings as achromatopes; island bats; medical care on Pohnpei; a description of Pohnpei's capital; the colonial history of Pohnpei; ethnobotany; forest plants; Dr. Sacks's experience of becoming stoned on a hallucinogen called sakau; reflections on Pingelap; and the encounter with Frances Futterman in Berkeley that I earlier mentioned.

How well does this patchwork format succeed? My guess is that different readers will react quite differently. For me, the resulting book is frustrating. While the material is intrinsically fascinating, I found my own fascination to derive more from what I already knew about the subjects than from what Dr. Sacks says about them. Many subjects are discussed too briefly for the text to be adequately informative. That problem applies to the treatments even of the two main subjects, achromatopsia and lytico-bodig. Far too little explanation is devoted to the “founder effect,” to autosomal recessive diseases, and to slow viruses or prions to set these two diseases within a larger frame of understanding.

There are also specific problems with using these two diseases as the focus of a book. Dr. Sacks's main motive for his visit to Pingelap, as reflected in his choice of the book's title, was to experience an “island of the colorblind.” In Dr. Sacks's words, he wondered whether Pingelap would be

a culture where the entire concept of color might be missing, but where, instead, other forms of perception, of attention, might be amplified in compensation …, an entire achromatopic culture with its own singular tastes, arts, cooking, and clothing—a culture where the sensorium, the imagination, took quite different forms from our own, and where “color” was so totally devoid of referents or meaning that there were no color names, no color metaphors, no language to express it; but (perhaps) a heightened language for the subtlest variations of texture and tone, all that the rest of us dismiss as “grey.”

Such a society would indeed be interesting. But Pingelap proved not to be such a society. More than 90 percent of its population has normal color vision, and even for the relatively few achromatopes, poor vision in bright light is a more important consequence than lack of a color sense. Lytico-bodig similarly proves to be a somewhat unsatisfying focus: while a slow virus or prion seems to me the most plausible cause, other possible causes have not been ruled out, and the question may ultimately remain unresolvable because the disease is now disappearing spontaneously. Hence the book's overall shape is a travelogue of two separate trips that interested Dr. Sacks a lot, and that exposed him to many interesting subjects, about many of which he has produced accounts or notes ranging in length from half a page to dozens of pages; but these accounts, although often beautifully observed, are not woven into a coherent, satisfying book.

I should, however, reiterate my admiration for Dr. Sacks's prose. At a time when it is essential that the public have some understanding of medicine and science, few physicians and scientists are able and willing to explain their subjects well to the general reader. Among those few, Dr. Sacks is pre-eminent in his broad interests, engaging prose, powers of observation, and ability to bring himself and the reader close to another person's mind. Despite my reservations, many readers will enjoy his new book, just as many listeners enjoy Beethoven's Fourth Symphony although it is overshadowed by his other symphonies. But Dr. Sacks has set high standards, and by those standards he can do better. I hope that, in his next book, he will use his impressive talents more effectively to produce a more cogently constructed work.

SOURCE: Hanlon, David. Review of The Island of the Colorblind and Cycad Island, by Oliver Sacks. Contemporary Pacific 11, no. 1 (spring 1999): 270.

[In the following review, Hanlon argues that “despite the charm of much of its narrative and the fluidity of its prose, Island of the Colorblind remains little more than another travel account of life in the Pacific that reduces indigenous peoples to the category of observed and controlled subjects.”]

Oliver Sacks, professor of neurology at Albert Einstein College of Medicine and author of several popularly acclaimed books, has written an account of his travels to Micronesia [The Island of the Colorblind]. He describes his book as a “very personal, idiosyncratic, perhaps eccentric view of the islands, informed in part by a lifelong romance with islands and island botany” (xii). It certainly is that. Sacks recounts two trips to the region, though the exact dates of these journeys remain unclear. The first, to Pingelap via Pohnpei, both islands being in the Eastern Caroline group, appears to have taken place in late 1993; the second trip, to Guam and the Northern Mariana Islands, may have occurred in 1994. Confusion over the exact location in time of these trips is of lesser concern, however, than the intellectual, literary, and colonial genealogies informing Sacks' narrative and his representations of various Micronesian peoples.

Lifelong interests in islands, island botany, and neurological disorders provide the immediate motivation behind the trips. Sacks visits Pingelap to observe a community among whose members exists an unusually large percentage of people suffering from congenital color blindness or achromatopsia. Man of science that he is, Sacks wonders what kinds of heightened and compensatory sensitivities achromatopic people develop in lieu of color. His interest in Guam centers on a neurological disease endemic to the island and called by the Chamorro people lytico-bodig. The disease manifests itself in two forms. There is sometimes lytico, a progressive physical paralysis resembling the motor neuron disease, amyotrophic lateral sclerosis. On other occasions, there develops bodig, a degenerative disease similar to parkinsonism and sometimes accompanied by dementia.

In the early 1950s, 10 percent of all adult Chamorro deaths were attributed to lytico-bodig; the prevalence of the disease in this period was one hundred times greater on Guam than on the North American mainland. In some areas of Guam, specifically the village of Umatac, the incidence of the disease was four hundred times greater than in North America. The cause of lytico-bodig on Guam has been the subject of considerable investigation by neurological scientists the world over. Foreign researchers have considered a variety of genetic and environmental factors, the most persistent suspect being a starch extract from the fruit of the cycad tree that is most often served in the form of tortillas. Called fadang, this popular food was consumed in great quantities by the Chamorro people until the mid 1950s. The decline in its consumption over the last four decades parallels a dramatic drop in the incidence of lytico-bodig, thus sustaining for some a belief in cycasin toxicity as the source of the disease.

In many ways, Island of the Colorblind is more about Oliver Sacks' own past than late-twentieth-century Micronesian realities. I am reminded of Anthony Pagden's point about the ways in which otherness is so often understood in terms of the self and the self's world. There is a consciously articulated personal history that precedes and informs Sacks' encounter with Micronesians. Fragmented memories of an English childhood visit to the Isle of Wight, supplemented by stories from his parents, create in Sacks' mind the idea of an island as a special, remote, mysterious, attractive, and frightening place. Bouts with visual migraines as a youth invite speculation on what life might be like in a totally colorless world. The works of Arthur Conan Doyle, H G Wells, Herman Melville, and Robert Louis Stevenson add to the fascination with islands. Later intellectual engagements with the works of Charles Darwin, Alexander yon Humboldt, and Alfred Russell Wallace add a Victorian veneer to Sacks' parallel interest in the primitive and the natural. Within the Pacific, Arthur Grimble's A Pattern of Islands, David Stanley's Micronesia Handbook, and Paul Theroux's The Happy Isles of Oceania serve as Sacks' personal travel books.

A literary lineage such as this helps explain the touristic, highly romanticized nature of Sacks' writing and his fascination with what he perceives to be the more exotic aspects of life in the islands. Sacks recounts his participation in a fishing expedition during his last night on Pingelap, an expedition that took place under a magnificent star-filled sky, upon an ocean lit up by the bioluminescence of tiny protozoan creatures. The megalithic ruins of Nan Madol, a series of artificial islets linked by watery channels just off the southeastern coast of Pohnpei proper, stir Sacks with their enormity; he finds their abandonment and emptiness uncanny. And there is his highly erotic walk in a primordial forest of cycad trees on Rota, the island closest to Guam in the Northern Mariana chain.

This fascination with the exotic and erotic dimensions of seascapes and landscapes does not preclude more poignant moments of encounter during the course of Sacks' travels. Knut Nordby, a vision researcher at the University of Oslo and an achromat himself, accompanied Sacks to Pingelap. His status as a fellow sufferer, observes Sacks, allowed him an immediate, intense, and deep bond of fellowship with the color-blind members of the Pingelap community. There is the gift of a visor to a young boy living in the Pingelapese village of Mand on Pohnpei. With his hypersensitive achromotopic eyes now shielded from the sun's blinding glare, the boy runs toward the shore yelling gleefully, “I can see! I can see!” On Guam, Sacks writes of Dr John Steele's unceasing devotion to his patients in the village of Umatac and of the physician's continuing struggle to find the cause and a cure for lytico-bodig. Even more moving are accounts of the quiet dignity of Chamorro victims of the disease—people such as Jose and Estella, the Commissioner, Juan, Tomasa, Roque, Euphrasia, Felipe, and Jesus—and of the loving care, attention, and support given them by the members of their extended families.

What compromises this otherwise sympathetic series of personal portraits is Sacks' failure to name fully the victims of the disease. Indeed, we know these people only by their disease and their first names. Researchers and doctors, on the other hand, are fully named, and their theories and findings minutely detailed, while Chamorro understandings of the disease are devalued quickly and simply as “folk neurology.” This privileging of the foreign as enlightened, scientific, and exceptional shows itself in Sacks' description of the effects of sakau, an intoxicating drink made from the roots of the pepper plant (Piper methysticum). Chronic consumption of sakau helps explain for Sacks the lethargic pace of life on Pohnpei; his own consumption of the drug, however, leads to a vision of James Joyce's “heaventree of the stars hung with humid nightblue fruit” (88).

There are other problems with the text. Sacks accepts uncritically the written ethnographies and histories of the islands he visits. At other times, he invents his own. The principal town of Kolonia on Pohnpei is described as unchanged from the 1830s; more accurately, Kolonia was not built until 1887 by the Spanish colonial government and, along with the whole island, has changed considerably over the more than 110 years and three separate colonial regimes since. Far more disturbing than any simple historical error is the attention Sacks gives to the travel writer Paul Theroux's very irresponsible, wrong, and harmful ideas on the link between canned luncheon meat and cannibalism. Sacks muses recklessly, if inconclusively, about Theroux's theory that Pacific Islanders' alleged modern-day fondness for Spam and corned beef reflects the earlier and widespread practice of cannibalism in the region. It's an unfortunate, very sad digression from his account of life on Pingelap.

Despite the charm of much of its narrative and the fluidity of its prose, Island of the Colorblind remains little more than another travel account of life in the Pacific that reduces indigenous peoples to the category of observed and controlled subjects. Writing of his travels after returning home to New York, Sacks admits to the ways in which reflecting and remembering contribute to a reinvented experience. Memories of personal interactions and cultural differences become more romantic, fanciful, and creative in the retelling. I would add the word colonizing to this confessed litany of textual affectations. Inadvertently perhaps, Island of the Colorblind offers images of Micronesia and Micronesians that draw from and add to the histories of colonization in the area.

SOURCE: Cassuto, Leonard. “Oliver Sacks: The P. T. Barnum of the Postmodern World?” American Quarterly 52, no. 2 (June 2000): 326-33.

[In the following essay, Cassuto explores Sacks's representation of the disabled, arguing that he tends to imbue his case studies with aspects of the freak show.]

The historic problem in representing disabled people's lives has always been the control of that representation. When others speak for the disabled, they often point the way to the freak show and the medical theater, two arenas of human objectification. The freak show, which flourished well into the twentieth century, depended on the spectacular mystification of disability; promoters exhibited disabled people as wondrous creatures of stupefying difference. Medical discourse has been fairly credited with killing off the freak show by rendering its fantastic displays in prosaic terms as medical anomalies.¹ But in place of the freak show's alienating presentations, medicine has substituted a different kind of objectification, reducing disabled people to case studies of their “defects” and turning them into props in a theatrical display of pathology. Typically, contemporary narratives of disabled lives treat the freak show and the medical case study as Scylla and Charybdis—the author usually designs a course to avoid them, often seeking to repudiate one or both along the way. Within this conventionally straitened genre, Oliver Sacks is a one-man countertrend. Rather than setting a course between the freak show and the case study, he has combined aspects of both. And, as I will suggest, his still-evolving methodology has become increasingly collaborative within these parameters.

.....

Sacks's project becomes clearly visible in his second book, Awakenings, the account of his work in the late 1960s and early 1970s with a sanitarium population of people who were paralyzed by a strain of encephalitis during and after the 1918 influenza epidemic.² When Sacks (who is a neurologist) gave his group of post-encephalitics L-DOPA, a dopamine replacement therapy which was an experimental drug, the patients “woke up” in dramatic fashion, startling doctors with their sudden vitality.³ The result was a kind of joyful bedlam in the chronic ward. Patients who had been silently cohabiting for decades could suddenly speak to each other, and to their loved ones. Sacks says that everyone “was caught up with the emotion, the excitement, and with something akin to enchantment, even awe” (xxiv). I want to emphasize the collective nature of this experience. As Sacks puts it in a long footnote, “there were fifty ‘awakenings’” at one time, leading to “a camaraderie” where “they discovered, they delighted in, each other as people. … There was communal health, all that summer … and an elation of shared hope” (65). The decline also happened in concert: “Every setback in a patient aroused fear in the others … fear and helplessness spread like a contagion through the ward” (65). In sum, “I did not have fifty, isolated, insulable patients; I had a community which was like a single living organism” (66).

Given this collectivity, how revealing is the way that Sacks organizes his material in his book. Following some prefatory remarks on the circumstances of the situation (the disease, the drug, and so forth) and the uniqueness of what is to follow, he presents twenty consecutive individual case studies of his most memorable patients, including observations of physical appearance and some of their more fantastic disease- and drug-aided behaviors. (An example: before L-DOPA, there was a patient who would have “counting crises,” where she would have to count to a number like 95,000, or raise 15 to the seventh power, before she could sleep [131]; after L-DOPA, she was at one point able to speak five hundred words a minute without missing a syllable [136].) Clustered together in the middle of the book, these case studies represent, in Sacks's words, “the true and unassailable centre of Awakenings” (xxxiv).

A comparison of the layout of the book with the architecture of a typical freak show yields some striking structural similarities. The talker outside the tent would tout the show, promising thrills from the oddities inside, coaxing the customer through the entrance. Once inside, the viewer would encounter individual freaks on raised platforms, lined up next to each other in rows, surrounded by props. Spectators would move down the line from one freak to the next, watching short performances, listening to monologues, buying pamphlets and cartes de visite.

The parallels are clear; Sacks has structured Awakenings like a freak show with himself as impresario. By splitting the community into a sequence of individual cases in his written presentation, Sacks has not only enabled the creation of a freak show but also—in an amazing paradox—he has at the same time brought his work under the formal umbrella of western science, the worldview that has received most of the credit (and justifiably so) for ending the freak show. That is, Sacks has conceived a freak show in all its fabulous strangeness, and he has done it in the very discourse that colonized, medicalized, and finally demystified that strangeness.

.....

The most prominent form of this medical discourse has long been the case study. “I have always regarded [case studies] with especial affection,” writes Sacks (xxxiv). As a doctor, he would have a long familiarity with them. Case histories are one of the oldest staples of the western medical profession. As a genre with tendentiously objective connotations, the case study became the primary vehicle by which scientifically-based medical practice turned the freak into a medical narrative.⁴ The longer case studies in Awakenings follow this familiar format. Sacks tells each story in clinical divisions: first a thumbnail biographical sketch, then a portrait of the patient with disease before the L-DOPA trial, then a section entitled “course under L-DOPA,” followed by a compressed account of what happened over the following few years. Yet within these technically named sections are remarks like this observation of Mrs. Y's tics, which proliferated, each in distinct regular rhythm, when she was on L-DOPA: “When Mrs. Y is merrily ticcing, she gives the impression of a clockshop gone mad, with innumerable clocks all ticking and chiming in their own time and tune” (108). Such wild juxtapositions with the non-human steer the clinical narrative trajectory toward territory colonized by P. T. Barnum.

By creating freaks within a clinical setting that is supposed to discourage that possibility, Sacks is writing narratives of wonder at a time when wonder is hard to come by. These wonder narratives wind up creating a uniquely collaborative space within which disabled people can express themselves—rather than closing one off. Stephen Greenblatt calls wonder “ravishment … an overpowering intensity of response [to] … something amazing. … [It is] a primary or radical passion that precedes, even escapes, moral categories. … When we wonder, we do not yet know if we should love or hate the object at which we are marveling; we do not know if we should embrace it or flee from it.”⁵ Rosemarie Garland Thomson has described freak narrative as the result of linking the narrative of pathology to the narrative of wonder—but by explaining the amazing, science has made wonder a scarce commodity in the western world and deprived this equation of its most crucial element.⁶Awakenings was about wonder from the first. The book began for Sacks with letters he wrote about his patients to The Lancet “that allowed me to convey the wonder of the clinical experience” (xxxi).

Sacks conveys this sense of wonder from within science by focusing not on what we know—the accepted basis for scientific exposition—but on what we don't know. Science generally claims to have “solved” the freak, with the doctor playing the role of hero/detective, and with disability as the “crime.” Sacks works against this implicit crime narrative; he generates wonder by downplaying the detective's ratiocinative skill and spotlighting his limitations—and his liminality. From Poe's Auguste Dupin and Doyle's Sherlock Holmes forward, the detective acts as a kind of narrative bridge between two social constructions: the “normal” (what is understood and organized) and the “peculiar” (what isn't categorized, and which is sometimes dangerous). Both Dupin and Holmes are peculiar themselves, and their eccentricities help them in their work. Sacks also acknowledges his own unusual life in his writing to the point where he makes himself into a kind of a freak, a process that he calls attention to in his third book, A Leg to Stand On (New York: Summit Books, 1984), where he turns himself into a case study.⁷ Sacks the odd wonder writer does the opposite of what a detective does: his self-appointed task is to take us to the edge of what we know, and peer off into the chaos on the border.⁸

Through his rhetorical stance and untraditional practice over the course of his writing career, Sacks ultimately brings together the two uses of the case study: the medical and the literary (the “cases” in crime and mystery stories) to create a collaborative space, a community of freaks that eventually comes to include himself. He is, he says, looking for “an approach, a language, which is adequate for the subject” (233), and concludes that he must “found or refound a romantic science” (287). This romantic medicine privileges difference and emphasizes personal connection. From Awakenings forward, Sacks's career has followed a trajectory that aims at this goal. Deviating from a straight medical model, he deconstructs the concept of “freak” and the genre of the case study. Borrowing from both the medical model and the freak show, he deviates from the first while trying—with increasing success—to avoid the distancing objectification of the second.

This is a risky project that has taken some time to find its shape. Awakenings shows Sacks trying to find places for many different voices, and some of the shorter case studies in the book clearly fall short of his humanistic ideal. Similarly, The Man Who Mistook His Wife for a Hat (New York: Summit Books, 1985) spotlights weird conditions rather than people. But Sacks has more recently moved toward a more collaborative model, explicitly shifting the case study away from the traditional medical narratives of pathology and toward an account where the condition is an inextricable part of the person. This impulse is present in Sacks's early writing (he shows how the Parkinsonian conditions of the Awakenings subjects all represent unique expressions of individual identity), but his later work calls special attention to it. Sacks's work in this decade has given sympathetic voice to some who cannot speak for themselves (like the autistic artistic prodigy Stephen in An Anthropologist on Mars), but he also helps to amplify the voices of those (like the well-known autistic professor Temple Grandin, another subject in Anthropologist) who can—and do—tell their own stories.

.....

If early freak shows turned on the axis of group identity—a testing of the boundaries of what Thomson calls the “normate” and a reinforcement of “us” against “them”—then Sacks's contemporary freak displays erode the boundaries and definitions of each individual human self and the labels such as “normal” and “pathological” that people use to categorize them.⁹ The Parkinsonian symptoms that Sacks's patients display in Awakenings are not “disease” in any sense that we are accustomed to using that word; as Sacks shows, they are intertwined with the patients' personalities, beliefs, and desires. Each set of symptoms and each set of responses to the drug are also unique—as are the patients' opinions of L-DOPA. One remarked after his tumultuous trial with the drug, “I'll stay myself, and you can keep your L-DOPA” (219). But another credits the drug with making him “feel like a man again” (164). Following this thread into Sacks's later work, we encounter cases where there is no disease to isolate nor any cure to search for. Instead, Sacks narrates the lives of people who just are—in wondrous ways. For example, in “To See and Not to See,” a case study from Anthropologist of a man who regains his sight in middle age after being blinded at age three, Sacks shows that seeing is done by the brain as well as the eyes, and thus it has a learned, experiential component—with the result that the recovery of lost sight can be an extremely disorienting experience rather than a “cure.” Similarly, Franco Magnani, another Anthropologist subject, paints scenes of his childhood village that he sees in trancelike states that arise—Sacks deduces—from epileptic seizures. But this diagnosis does not prompt any medical action, as the “affliction” is seen by Magnani as a gift, a part of his identity that he has no desire to change.¹⁰

Through his subjects, Sacks explores “what it was like to be human, to stay human, in the face of unimaginable adversities and threats” (xxviii). It's up to each reader to decide whether he meets this goal, but in judging his motives, I think Sacks uses the wonder he creates in order to appreciate the people he writes about—and in doing so, he offers the most important acknowledgement of the humanity of his subjects. It is this unusual celebration of human dignity that separates Sacks from Barnum and his contemporaries.

Sacks also separates himself from his fellow doctors. Unlike traditional medical narratives, Sacks's case studies call attention to his own authorial presence in between the subject and the reader; over the years this presence has grown increasingly less medical. Most of the subjects in Anthropologist are not patients, for example, and Sacks visits them in their native places, becoming more a travelling spectator than a doctor. Two of Sacks's recent books, Seeing Voices and Island of the Colour-Blind, focus on communities rather than individuals, as does his recent PBS television series, The Mind Traveller. The series shows especially clearly how Sacks has shifted his presentation even as he preserves the original essence of his project. Taken as a whole, this evolution shows how wonder has become a basis in Sacks's work for reframing medical discourse as an inclusive conversation—he breaks down the fences around the role of “doctor” to involve other people instead of keeping them out.

This educated involvement is the ultimate goal of the spectacle. Sacks's work argues that people will want to stare, and the best way to counter this desire is not to forbid it but to shape and direct it, to make the gaze into a mutual look, a meeting of two worlds. It is reasonable to hope for a time when this desire will be surpassed—when disability will be part of the range of human difference, not a state that makes people uncomfortable. If desensitization does some day replace wonder, perhaps we will recall Oliver Sacks as a catalyst of that change. By emphasizing community and collaboration, his work provides a bridge across the border separating two worlds. Paradoxically, it is a freak show that emphasizes the sensibility of disability.

Notes

1. For a fuller elaboration of this argument, see Robert Bogdan, Freak Show: Presenting Human Oddities for Amusement and Profit (Chicago: Univ. of Chicago Press, 1988).

2. Awakenings (1973; New York; Vintage, repr. 1990); future citations will be given parenthetically within the text. Though able to think, the patients in Awakenings were basically frozen in trancelike states by extreme Parkinsonian symptoms, some for as long as fifty years. Sacks calls them “ontologically dead,” and “living statues” (14-15). There are some notable exceptions to the deathlike condition of extreme Parkinsonism, however. For example, there is a case of a Parkinsonian who would sit motionless—for days on end—until she was thrown three or more oranges. She would then catch them and start to juggle (she could handle as many as seven objects) for up to half an hour. But if she dropped one or was interrupted, she would become motionless again (10).

3. Unfortunately, the recovery proved short-lived for most of them, as in a matter of couple of months they relapsed in fantastic and unpredictable ways.

4. The case study emerged as the dominant medical narrative at around the same time that medical practice became professionalized (in the period 1880-1920). For more on the standardization and incorporation of the medical profession, see Paul Starr, The Social Transformation of American Medicine (New York: Basic Books, 1982). For an extensive analysis of the case study, see Kathryn Montgomery Hunter, Doctors' Stories: The Narrative Structure of Medical Knowledge (Princeton, N.J.: Princeton, Univ. Press, 1991).

5. Stephen Greenblatt, Marvelous Possessions: The Wonder of the New World (Chicago: Univ. of Chicago Press, 1995), 16, 17, 20.

6. See Rosemarie Garland Thomson, “From Wonder to Error: A Genealogy of Freak Discourse in Modernity,” in Freakery: Cultural Spectacles of the Extraordinary Body, ed. Rosemarie Garland Thomson (New York: New York Univ. Press, 1996), 1-23.

7. For differing accounts of A Leg, see G. Thomas Couser, Recovering Bodies: Illness, Disability, and Life Writing (Madison, Wisc.: Univ. of Wisconsin Press, 1997), 186-89; Arthur W. Frank, The Wounded Storyteller: Body, Illness, and Ethics (Chicago: Univ. of Chicago Press, 1995), 118; and Anne Hunsaker Hawkins, Reconstructing Illness: Studies in Pathography (West Lafayette, Ind.: Purdue Univ. Press, 1993), 82-87.

8. Sacks has written about his eccentricities and discussed them in interviews. For details, see, for example, Tom Shakespeare's review of Sacks's Anthropologist on Mars in Disability and Society 11 (spring 1996): 137-39; and Kirk Johnson's interview of Sacks: “Looking Inward, Understanding Strange Worlds,” New York Times 23 Oct. 1996, sec. C, p. 6.

9. Thomson describes the normate as the figure opposed to the disabled person “through which people can represent themselves as definitive human beings” in Extraordinary Bodies: Figuring Physical Disability in American Literature and Culture (New York: Columbia Univ. Press, 1997), 8.

10. Oliver Sacks, An Anthropologist on Mars (New York: Knopf, 1995), 108-87.

SOURCE: Sacks, Oliver, and Tracy Cochran. “Oliver Sacks: In Search of the Truth of Being.” Publishers Weekly 248, no. 40 (1 October 2001): 32-3.

[In the following interview, Cochran identifies the search for truth as the central concern of Sacks's writings.]

At first, the famous neurologist and author Oliver Sacks hangs back like a shy animal. It is Kate Edgar, his down-to-earth editor and assistant, who strides across the common area of a bright suite of offices in downtown Manhattan, greeting PW and gently insisting that we take her green fleece jacket to swaddle ourselves against the blasting air-conditioned cold of Sacks's own office. Sacks watches from a distance.

Dressed in a green T-shirt and khakis, his 68-year-old body looks robust and powerful, yet the man inhabiting the rugged frame looks as earnest and as excruciatingly vulnerable as Robin Williams's portrayal of him in the movie version of his 1973 book Awakenings, which chronicled the brief chemical resurrections of an extraordinary group of people who had spent decades frozen in trance-like states following bouts with sleeping sickness.

In light of recent events, it is relevant to note up front that the sensitivity and intense attentiveness that are so visible in Sacks are gifts that were greatly shaped by the trauma of war. Suddenly, it is easier to understand why Sacks, who was born in London in 1933 and received his medical training at Oxford, chose to believe the nurses at Beth Abraham Hospital in the Bronx when they reported that there were feeling and thinking individuals buried beneath drastic parkinsonian symptoms that made the post-encephalitic patients seem to be the living dead. Sacks, a consulting neurologist, decided to administer L-dopa, a drug proven effective in treating Parkinson's, to try to bring these people back partly because he remembered what it was like to be six years old and shipped out of London with his 11-year-old brother to escape the bombing. In his new memoir, Uncle Tungsten: Memories of a Chemical Boyhood, published this month by Knopf, Sacks relates that after years of beatings by a sadistic headmaster, years of loneliness and fear, his brother Michael broke down.

“This is something I don't go into [in the new book] but when my brother Michael had his breakdown and became psychotic, one of the things he said was, don't call this a disease. It is my struggle, my world, my attempt to find meaning,” says Sacks.

Sitting across from PW at a big, blond-wood desk in a bright office, he speaks softly and in rapid bursts of thought.

“Let me show you something.”

He jumps up abruptly and leads PW into the office kitchen to point out a cupboard blazoned with little illustrations of great chemists from the last three centuries. Just as in his memoir, Sacks rushes to counterbalance his pain with the seemingly indestructible order of science, especially prequantum chemistry. In 1945, when Sacks encountered a vast representation of the periodic table at the just reopened Science Museum, he declared it the most beautiful thing he had ever seen. It was evidence of a divine order that “was neither arbitrary nor superficial, but a representation of truths which would never be overturned. …”

Sacks admits that there is tenacity in him, a drive to investigate and not to be turned away until he has found the deeper truths, the person, under the disease. Awakenings was declared a masterpiece of medical writing by W. H. Auden, winning comparisons to the writings of the great Russian neurologist A. R. Luria and to Sigmund Freud because it brought the case study to the level of art. Literary and beautifully described, Sacks's portraits conveyed truths that were greater than a sum of symptoms. In Awakenings, as in his other books, including the bestselling The Man Who Mistook His Wife for a Hat (1985), An Anthropologist on Mars (1995) and most recently The Island of the Colorblind (1996), Sacks “makes housecalls at the far borders of human experience” to send back exquisitely detailed reports about our drive and the capacity to be individuals in the face of impersonal and seemingly insurmountable forces.

Along with Auden, Sacks credits both his parents as sources of inspiration; both were doctors and great storytellers. His father made house calls, and an essay pressed upon PW in the course of our interview describes how Sacks virtually co-wrote Awakenings with his dying mother. She would lie in bed and listen and ask questions as he told the stories of his brave and unique patients.

“‘That doesn't ring true,’” she would say,” Sacks remembers, telling PW that he would rethink and rework until he heard her say, “Now it rings true.”

Back home from his hellish boarding school, the city of London itself became a teacher. As the bombs fell and familiar landmarks and beloved sights disappeared, Sacks developed a passion for journal keeping and for photography.

“Such documentation was, in part, forced on me by the war, the wholesale way in which seemingly permanent objects were destroyed or removed,” he writes in the book.

This documenting marked the beginning of what would be an abiding interest in perception, memory and identity. The disappearance of things also increased his need to study old books and fossils and old things of all sorts. He still loves and surrounds himself with primitive things, elemental things, invertebrates rather than vertebrates, ferns, minerals, metals.

When we comment on a shelf of books by his friend, the marine biologist and artist Richard Ellis, Sacks jumps up and races out of his office and returns with two rubber-toy versions of the giant squid prepared for display in the Museum of Natural History by Ellis (little toy cephalopods also adorn the bathroom).

“I like this idea of the truth of being,” he says, echoing a phrase PW comes up with for the way he obviously delights in physical things, objects and in the sense of physical movement. He still swims two hours a day, and even when he isn't making his house calls all over the globe (he is leaving for Guadaloupe the next day), he is in movement.

“I need the physical,” he says. When he was an intern in California, he lifted weights, owned a motorcycle and hung out with the Hell's Angels.

“I used to travel immensely on the Norton,” Sacks reminisces. “I would leave UCLA on Friday afternoon and go to the Grand Canyon, traveling 900 miles on Route 66. It was that feeling of your hair blowing back. … It was, as you say, embodied.”

And now there is the swimming. As he put it in an essay in the New Yorker, there is a joy, “an essential rightness about swimming, as about all such flowing and, so to speak, musical activities.”

Writing, surprisingly, is not always a joyous flowing activity for the productive Sacks. Indeed, he has destroyed or lost so much work that Kate now copies everything before it leaves the office.

Writing his first book, Migraine, was a battle outwardly as well as inwardly. When he wrote it in 1967, his then boss literally locked up the manuscript, threatening Sacks that he would never work in neurology in the States again if he presumed to publish. Even his father, to whom he had gone for counsel, warned Sacks not to cross this powerful man.

“I think my father was a man who combined, as I do, great timidity with great courage,” offers Sacks.

In September of 1968, however, unwilling to be bullied into silence, Sacks gave himself 10 days to reconstruct the book, or, he vowed, he would kill himself. The book flew out in nine days of nearly round-the-clock work. After Sacks dropped it off at Faber & Faber, he walked through the British Museum, filled with the feeling that he had made something, “something outside myself which could no longer be destroyed by me or anyone else.”

Waiting at home in London to be interviewed on the day a glowing review appeared in the London Times, Sacks remembers, his father came into his room “pale and shaking, at seven in the morning, saying, in a horrified tone, ‘You're in the papers.’”

“For years I automatically substituted the word ‘publish’ with ‘punish,’” says Sacks. “For whatever reason, both my parents had the feeling that one ought to lie low.”

When Oliver Sacks was 14 years old, his mother, a general surgeon and professor of anatomy who moved her practice to gynecology and obstetrics in the 1930s, arranged with a colleague, a professor of anatomy at the Royal Free Hospital in London, that he should be inducted into human anatomy by dissecting the body of a 14-year-old girl.

“Some of the girl had been dissected already, but there was a nice, untouched leg I could start on,” Sacks writes in his memoir.

It took Sacks a month to dissect the leg. There were moments when Sacks could share his mother's feeling for how beautifully the organism was put together. Most of the time, however, his appreciation for the intellectual and aesthetic pleasure his mother took in anatomy was obliterated “in the horror of the dissection.” Worst of all, “the feeling of the dissecting room spread to life outside—I did not know if I would ever be able to love the warm, quick bodies of the living after facing, smelling, cutting the formalin-reeking corpse of a girl my own age.”

“I don't think there was anything sadistic or perverse,” he tells PW. “I think that she was carried away by enthusiasm and by love for her youngest and perhaps brightest son. I think she somehow wanted me to join her, and there was a failure of empathy or an identification, a forgetting that I was a fragile boy.”

Still, it gives one pause to consider A Leg to Stand On, a book wrenchingly difficult to complete. Published in 1984, it is an account of a 1976 mountaineering accident that left Sacks's knee twisted and badly damaged. Even after surgery repaired the ligaments and tendons, the leg still felt alien and detached. Sacks had lost the inner sense of his own limb. Significantly, Sacks found he could write that book only as he swam. He would emerge dripping from a lake to scribble every half hour or so, until he had produced a manuscript of 300,000 words or so, written in running ink. He submitted it to his editor at Summit, Jim Silberman, who fortuitously hired Kate Edgar to convert it to typescript.

Asked if he writes with his mother or his father in mind now, he concedes that this “is a really interesting question.”

“I don't consciously have anyone in mind,” he says, “though it astonishes and moves me when people come up to me and say, ‘I became a medical student because of you.’ So it's not just mother but also them.”

A bit later he adds that Auden and Luria were important father figures, adding that he still looks for father figures, although he is a “father figure if not a grandfather figure” himself.

“There is the paradox that you can find father figures and mother figures that are younger than yourself,” he says with a kindly smile. “Which is what you do because it is what you have to do.”

This simple statement acquires a special resonance after the recent attacks in New York and Washington, merging with Sacks's image of falling in love as a boy with one of the “giant barrage balloons which floated overhead in wartime London, looking like vast aerial sunfish, with their plump, helium-filled bodies and trilobed tails. They were made of an aluminized fabric, so they gleamed brilliantly when the sun's rays hit them. They were attached to the ground by long cables, which (it was thought) could entangle enemy warplanes, prevent them from flying too low. The balloons were our giant protectors as well.”

Sacks admits that he does like to write with people nearby, with the background music of cheery conversation at a cafe or with Kate Edgar and the others working in the next room.

“I do have a fear of disappearing,” he says softly.

SOURCE: Perutz, M. F. “Growing up among the Elements.” New York Review of Books 48, no. 17 (1 November 2001): 46-8.

[In the following essay, Perutz regards Uncle Tungsten as an enjoyable and accessible memoir of Sacks's life and love of science and learning.]

London's Science Museum in South Kensington was closed during the Second World War. When it reopened in 1945, the twelve-year-old Oliver Sacks discovered there the periodic table of the chemical elements. They were written in large letters on a wall, with samples of each element or one of its compounds attached to each name. That night Oliver could hardly sleep for excitement. To a boy who was already a keen amateur chemist, the revelation that the apparently disconnected properties of the elements could be fitted into a logical system gave the first sense of the power of the human mind. Sacks writes:

In that first, long, rapt encounter in the Science Museum, I was convinced that the periodic table was neither arbitrary nor superficial, but a representation of truths which would never be overturned, but would, on the contrary, continually be confirmed, show new depths with new knowledge, because it was as deep and simple as nature itself. And the perception of this produced in my twelve-year-old self a sort of ecstasy, the sense (in Einstein's words) that “a corner of the great veil had been lifted.”

This sounds a little precocious for a twelve-year-old, but it reminded me of my own excitement when, as a student, I read Linus Pauling's just-published book The Nature of the Chemical Bond. It transformed the empirical edifice of chemistry that I had been required to memorize into a science that could be understood, because it was based on fundamental properties of atoms, their sizes and charges, and the configurations of their electron shells, based on the new quantum mechanics.

The discoverer of the periodic system was the Russian chemist Dmitry Ivanovich Mendeleev. The romantic story of Mendeleev's early career made him one of Sacks's heroes. He was born in a small town in Siberia in 1834, the youngest of fourteen children. His father, the head of the local high school, went blind shortly after his birth and died not many years afterward. Dmitry's mother recognized the boy's outstanding talents and walked with the fourteen-year-old thousands of miles to Moscow to enroll him at the university there, only to learn that as a Siberian he was ineligible for admission. The same happened in St. Petersburg, but there she finally found him a place in the Pedagogical Institute to train as a teacher.

Despite those setbacks, Mendeleev became professor of chemistry at the Institute of Technology in St. Petersburg at thirty, and four years later professor at the university there. In the same year, aged thirty-five, he published the periodic table as part of his monumental Principles of Chemistry.¹ Mendeleev had begun by ordering the eighty-one elements known at his time in sequence according to their atomic weights. He noticed that many of their chemical properties were repeated at regular intervals, which led him to order them into horizontal rows and vertical columns. He placed the two lightest elements, hydrogen and helium, at either end of the first row, followed by two rows of eight elements, like two octaves of musical chords, followed by three rows of eighteen. This left some vacant places where Mendeleev predicted new elements, which were later found.

There are profound physical reasons underlying the order, the periodicities, of Mendeleev's table, but it took another fifty years before Niels Bohr, one of the greatest physicists of all time, discovered them. Oliver Sacks must have already absorbed an astonishing amount of chemical knowledge to have become so excited on seeing the table for the first time. Sacks calls the Principles the most delightful and vivid chemistry text ever published. Mendeleev's romantic, magisterial, Victorian introduction sets the tone:

In comparing the science of the past, the present, and the future, in placing the particulars of its restricted experiments side by side with its aspirations after unbounded and infinite truth, and in restraining myself from yielding to a bias towards the most attractive path, I have endeavoured to incite in the reader a spirit of inquiry which, dissatisfied with speculative reasonings alone, should subject every idea to experiment, to encourage the habit of stubborn work, and to excite a search for fresh chains of evidence to complete the bridge over the bottomless unknown.

Sacks writes [in his Uncle Tungsten] that he devoured Mendeleev's classic, but I wonder if he really absorbed its 1,168 pages.

Oliver Sacks's parents were both doctors living in a large, comfortable brick house in northwest London. His father was an expansive, outgoing man. Like the young Lewis Thomas in The Youngest Science,² Oliver sometimes went along on his father's Sunday morning house calls. Sacks writes:

He loved doing housecalls more than anything else, for they were social and sociable as well as medical, would allow him to enter a family and home, get to know everybody and their circumstances, see the whole complexion and context of a condition. Medicine, for him, was never just diagnosing a disease, but had to be seen and understood in the context of patients' lives, the particularities of their personalities, their feelings, their reactions.

… I loved to see him percuss the chest, tapping it delicately but powerfully with his strong stubby fingers, feeling, sensing, the organs and their state beneath. Later, when I became a medical student myself, I realized what a master of percussion he was, and how he could tell more by palpating and percussing and listening to a chest than most doctors could from an X-ray.

Unlike Lewis Thomas's father, he did not tell his son how little he was able to do for most of his patients at a time before antibiotics became generally available. At home his father spent his leisure with ancient Hebrew texts rather than The Lancet or The New England Journal of Medicine, which might have kept his medical knowledge up-to-date.

Oliver's mother, a teacher of medicine, was the sixteenth of eighteen children, which provided him with about a hundred cousins, mostly living in London. The family was exceptionally gifted, and Oliver writes that his uncles and aunts were as good as a reference library. Uncle Yitzak was a radiologist, Uncle Abe a physicist, Uncle Dave a chemist, mineralogist, and metallurgist, Auntie Len an amateur botanist who told Oliver that God thinks in numbers, and this may have led to his early fascination with prime numbers. Uncle Dave ran a factory making tungsten filaments for electric light bulbs, hence the nickname that gave Sacks's book its title. Oliver never knew his youngest uncle, because he had become an outcast, a nonperson whose name was never spoken again after he married a Gentile, a shiksa. Each year, Oliver's father told his family that he was off to Wales on a slimming cure; he would return tanned, invigorated, but not much slimmer. It was only after his death that Sacks found the ticket stubs showing that he had in fact secretly visited his excommunicated brother in Portugal. Home was also a venue for meetings of Zionists, but their bullying manners turned Oliver into an enemy of Zionism, evangelism, and politicking of every kind for life.

Oliver describes his mother as intensely shy, a woman who retreated into silence or her own thoughts on social occasions, but an exuberant performer with her students (of surgery, anatomy, or histology?—Sacks does not say). He believes that she was drawn into medicine because it was part of natural history or biology and writes that she had a love of structure extending from plants to human anatomy. When Oliver was only eleven, she had him dissect malformed, stillborn babies. At fourteen she took him to the dissecting hall of the anatomy school of the Royal Free Hospital for Women and told him to dissect the leg of a fourteen-year-old girl. It was his first encounter with a corpse, and he spent a month on the task. He writes:

I lacked my mother's powers of visualization, her strong mechanical and engineering sense, but I loved it when she talked of the foot and drew, in rapid succession, the feet of lizards and birds, horses' hooves, lions' paws, and a series of primate feet. But this delight in understanding and appreciating anatomy was lost, for the most part, in the horror of the dissection, and the feeling of the dissecting room spread to life outside—I did not know if I would ever be able to love the warm, quick bodies of the living after facing, smelling, cutting the formalin-reeking corpse of a girl my own age.

Oliver's fascination with chemistry began as an escape from the aftermath of his traumatic school experiences during and after the war. His life at home had been happy until the war broke out in September 1939, when he was six years old; but then the government, fearful of immediate, devastating German air raids, decreed the evacuation of women and children from London. As a doctor, Oliver's mother had to stay, so she sent Oliver and his elder brother Michael to a small boarding school in the Midlands that had just been set up. It was headed by a master who, faced with his new responsibilities, soon turned into a sadistic, avaricious monster. He beat many of the boys. Oliver included, almost daily. When he beat Oliver so hard that his cane broke, he sent the bill for a new one to his parents. He fed the boys on a diet of turnips and coarse beets grown for cattle. Sacks writes:

The horribleness of the school was made worse for most of us by the sense that we had been abandoned by our families, left to rot in this awful place as an inexplicable punishment for something we had done.

He felt trapped without hope, without recourse, forever. Yet on their rare visits, his parents noticed nothing. At home his mother had said a prayer with him before she kissed him goodnight, but here Sacks replaced his childhood religion with a raging atheism, a fury with God for not existing, not taking care, for allowing the war with all its horrors to occur.

When the school finally closed because most other parents had withdrawn their children, Oliver and Michael's parents sent them to another boarding school where the bullying drove Michael insane. Sacks does not say whether he ever recovered. Oliver withdrew into a world of fantasy, telling the other nine-year-olds, not unreasonably, that his parents had thrown him out as a small child and that he had been brought up by a she-wolf. The parents finally realized that he was on the brink and took him home to London, where he recovered.

Despite those haunting experiences, I found no hint of resentment of his parents in Sacks's book. On the contrary, he writes affectionately about them both, and the only mild criticism he allows himself is a remark that “they were intensely sensitive to the suffering of their patients, more so, I sometimes thought, than to those of their children.”

To make Oliver more sociable and teach him practical skills, they enrolled him in the Cub Scouts, but it was a failure. The fires he laid never started to burn and the tents he pitched invariably collapsed. One day the scoutmaster told the boys to bake disks of unleavened bread, and bring them to the next outing. When he found the flour tin empty, Oliver, ever resourceful, discovered some cement outside, made it into a paste, flavored it with garlic, shaped it into an oval disk, and baked it in the oven. When he tempted the unsuspecting scoutmaster with that delicacy he cracked a tooth, and Oliver was expelled.

He turned to chemistry instead, and Uncle Tungsten became his teacher. He showed Oliver how to make tungsten metal by smelting tungsten ore with charcoal. The ore was named scheelite after its eighteenth-century Swedish discoverer, Karl Wilhelm Scheele. His uncle told Oliver that Scheele had been an apothecary who worked all on his own, cared nothing for money, and just explored chemistry for its own sake. This made Oliver want to become a chemist and to discover a new mineral that would be named Sacksite.

His uncle told Oliver that the tungsten filaments made in his factory had been invented after many years of experiment that began with the observation that lime shone brightly in a gas flame. Lime was soon used to light theater stages, hence the figurative term “limelight” that has survived after the real lime lights have long been forgotten. The Austrian inventor Carl Auer von Welsbach (not a German, as Sacks writes) replaced them with fabrics impregnated with a mixture of cerium and thorium oxides. They produced a brilliant glow and were soon used for domestic and street lighting. Oliver used to watch the lamplighters go round the streets with their long poles lighting one gas light after another, as my own children did.

Oliver's first London school concentrated on Greek and Latin. He writes that

this did not matter, for it was my own reading in the library that provided my real education, and I divided my spare time, when I was not with Uncle Dave, between the library and the wonders of the South Kensington museums, which were crucial for me throughout my boyhood and adolescence.

The museums, especially, allowed me to wander in my own way, at leisure, going from one cabinet to another, one exhibit to another, without being forced to follow any curriculum, to attend to lessons, to take exams or compete. There was something passive, and forced upon one, about sitting in school, whereas in museums one could be active, explore, as in the world. The museums—and the zoo, and the botanical garden at Kew—made me want to go out into the world and explore for myself, be a rock hound, a plant collector, a zoologist or paleontologist. …

One gained entrance to the Geological Museum, as to a temple, through a great arch of marble flanked by enormous vases of Derbyshire blue-john, a form of fluorspar. The ground floor was devoted to densely filled cabinets and cases of minerals and gems. There were dioramas of volcanoes, bubbling mudholes, lava cooling, minerals crystallizing, the slow processes of oxidation and reduction, rising and sinking, mixing, metamorphosis; so one could get not only a sense of the products of the earth's activities—its rocks, its minerals—but of the processes, physical and chemical, that continually produced them.

Oliver liked the minerals' personal names like wollastonite, montmorillonite. Entrance to all the museums was free, and in the 1940s it was still safe for a young boy to travel across London by underground on his own.

At home Oliver repeated the experiments that led the French eighteenth-century chemist Antoine Lavoisier to disprove phlogiston, the substance that was supposed to be given off by inflammable substances on burning, and to discover that it is the combination with the oxygen in the air that makes them burn. One of Oliver's favorite books was Mary Elvira Weeks's Discovery of the Elements,³ which ranged from the prehistoric discoveries of copper and iron to Otto Hahn, Fritz Strassmann, and Lise Meitner's discovery of nuclear fission in 1939. It gave details of the methods used for each element and short biographies of their discoverers. Oliver read how on October 6, 1807, the twenty-eight-year-old English chemist Humphry Davy had the idea of using a battery to pass an electric current through crystals of potash and saw for the first time tiny lumps of metallic potassium forming at one of the battery's terminals. A few days later, passage of a current through crystals of soda led Davy also to the discovery of metallic sodium. Oliver could repeat these experiments. At the Science Museum his mother showed him the miner's lamp named after Davy, designed to prevent the flame from igniting explosive mixtures of gases in underground mines, and she also showed him the improved version of the lamp named after her father, Marcus Landau. Sacks writes:

It was Davy's personality that appealed to me—not modest, like Scheele, not systematic, like Lavoisier, but filled with the exuberance and enthusiasm of a boy, with a wonderful adventurousness and sometimes dangerous impulsiveness—he was always at the point of going too far—and it was this which captured my imagination above all.

Another of Oliver's favorites was a short volume that looked like a prayer book: Chemical Recreations by John Griffin, published in Glasgow in 1825. Its introduction is even more uplifting than Mendeleev's:

If we consider Chemistry purely as a science, we shall find no study better calculated to encourage that generous love of truth which confers dignity and superiority on those who successfully pursue it. No science holds out more interesting subjects of research, and none affords more striking proofs of the wisdom and beneficence of the Creator of the universe. Chemistry is a science that is founded entirely upon experiment: and no person can understand it unless he performs such experiments as verify its fundamental truths. The hearing of lectures, and the reading of books, will never benefit him who attends, to nothing else; for Chemistry can only be studied to advantage practically; chemical operations are in general, the most interesting that could possibly be devised. Reader! What more is requisite to induce you to MAKE EXPERIMENTS?

The book taught Oliver how to make a battery by putting down alternate plates of zinc and copper inter-leaved with moist paper, and how to make a balloon out of a turkey's stomach filled with hydrogen gas, as well as a chemical chameleon from salts of manganese. He learned several ways of preparing invisible ink and found the chapter on combustion and detonation especially appealing.

Oliver succeeded in making his own photographic emulsions by suspending silver chloride in gelatin and spreading it on a glass plate, and his own batteries by sticking rods of copper and zinc into raw potatoes. After reading a chapter on “The Smells We Dislike,” Oliver prepared hydrogen sulfide and selenide, two evil-smelling and toxic gases that made his parents' house barely habitable, but instead of forbidding further experiments, they equipped his room with a glass-fronted, ventilated cupboard that extracted the smells into the open air. He also loved setting off explosions in the garden, and showing the wonders of chemistry to others helped him to overcome his shyness.

Uncle Dave had specimens of many of the rare heavy metals and the ores from which they are mined: platinum, palladium, osmium, tantalum, “given its name because its oxide was unable to drink water, i.e., to dissolve in acid,” after Tantalus, who suffered agonies of thirst in hell because water retreated from him whenever he tried to drink it. Uncle Dave also told him that some of these heavy metals acted as catalysts of chemical reactions, meaning that they accelerate them many thousandfold without undergoing any perceptible change themselves. For instance, a platinum wire instantly ignited an otherwise stable mixture of oxygen and hydrogen and made it explode.

Uncle Tungsten apparently failed to tell him that catalysis is the chemical secret of life. Nearly all chemical reactions in living cells need catalysts to make them work, and nearly all catalysts are proteins, complex molecules made of thousands of atoms. Each of the thousands of reactions is catalyzed by a protein that exists specifically for that single purpose. Coding for these proteins is the main function of genes. That much was known when Oliver became an amateur chemist; but proteins were black boxes, and their amazing catalytic powers were a mystery. Solving that mystery was the challenge that inspired my own research.

Uncle Dave had a cathode ray tube in his attic. When he pumped the air out of it, wired its two metal plates to an induction coil, and put them under electric tension, a miniature aurora borealis lit up between them. He told Oliver about Wilhelm Konrad Röntgen, the German physicist who one day covered such a cathode ray tube with black cardboard and saw crystals nearby lighting up brightly in the darkened room. This was his first glimpse of the X-rays whose discovery made him famous. Sacks writes that Röntgen told only his wife about his observation, but I could find no evidence for this. According to her he would arrive late and ill-tempered for meals, speak not a word, and hurry back to his lab immediately afterward. He told no one, because he realized that any one of the many physicists who experimented with cathode rays at the time could have repeated his observation in an afternoon if his secret had leaked out before publication established his priority. Röntgen was the first recipient of the Nobel Prize for Physics just one hundred years ago.

Sometime after Oliver had studied Mendeleev's principles, he asked his uncle for the reason underlying the strange periodic arrangement of Mendeleev's table. Uncle Dave told him about Niels Bohr, the Danish genius who brought together the periodic table. Max Planck's discovery of the quantum, Rutherford's discovery of the atomic nucleus, and the already well-known characteristic spectral lines of hydrogen, and from them was able to form a satisfying, unified theory of the atom. Bohr proposed that the rows of the table represented successive shells of negatively charged electrons spinning around the positively charged atomic nucleus like planets round the sun. These shells become filled with electrons one by one as the nuclear charge rises: up to two electrons in the first shell, then up to eight in each of the next two shells, and up to eighteen in the remaining ones, matching the two atoms in the first period, eight in each of the next two periods, and eighteen atoms in the remaining ones in Mendeleev's table. That revelation sent Oliver back to the Science Museum once more, thrilled that the table now made physical as well as chemical sense, but it also made Oliver wonder what need there was for experiments now that theory had become so powerful. He writes:

I had dreamed of becoming a chemist, but the chemistry that really stirred me was the lovingly detailed, naturalistic, descriptive chemistry of the nineteenth century, not the new chemistry of the quantum age, which, so far as I understood it, was highly abstract and, in a sense, closer to physics than to chemistry. Chemistry, as I knew it, the chemistry I loved, was either finished or changing its character, advancing beyond me.

From this point, chemistry seemed to recede from my mind—my love affair, my passion for it, came to an end.

Parental expectations made him turn to medicine and he became a successful neurologist, but he must now feel that his world has turned full circle, since mental illnesses are increasingly recognized as chemical disorders of the brain and modern diagnostic tools rest on quantum physics.

According to Edmond de Goncourt, originality in literature consists in making something extraordinary out of something ordinary. What could have been more ordinary than the Sacks's huge, rambling, Edwardian house, the sitting room with its dilapidated, comfy chairs for general use (dilapidated not because his parents were poor, but because they were too busy to notice or didn't care); the drawing room with its elegant uncomfortable Chinese chairs for sabbath gatherings of uncles, aunts, and cousins; the library, sacred to the children for their father's Hebrew texts; and the surgery which they were forbidden to enter, with its shelves of medicines? Yet Sacks's vivid description delights the imagination like a lovingly painted Dutch interior, and it sets the stage for his actors: Father and Mother; the affectionate and a little limited Auntie Birdie, who lived with them; Aunt Lina, who blows her nose in the tablecloth at meals and whose sharp-eyed judgment of people he likens to Keynes's description of Lloyd George; the formidable Aunt Anna, more English than the English and more Jewish than the Zionists, whose orthodoxy is offended by little Oliver riding his bicycle on a sabbath; Uncle Dave, whose hands are stained black with tungsten; and the whole family whose tongues are black from munching charcoal biscuits against wind. I know them all now and feel as though I had lived in their house.

Sacks transforms himself into the wide-eyed, playful, eager, mischievous, and indefatigably questioning boy to whom chemistry has become at once a toy and a window to the miracles of the natural world. Such is his precocity, performing sophisticated experiments and developing an understanding far beyond his age, and so numerous and minute are the details of Sacks's reconstruction that I wondered if this impressionable boy, shaped by his uncles and aunts, might not also have been reshaped somewhat by Uncle Oliver, his present self. Does Sacks really recognize himself in him or would he be, as François Jacob writes of himself as a schoolboy, almost “a stranger,” hard to recognize if he met him in the street? “Like a bird contemplating the shell he has just broken out of, saying, ‘Me? In there? Never!’”⁴ To the reader the answer does not really matter, because Sacks has treated us to an enjoyable and very human story and to a painless and readable introduction to the elements of chemistry and atomic physics, enhanced by his long, erudite footnotes.

Notes

1. Dmitry Mendeleev, Principles of Chemistry, translated by George Kamensky and Thomas H. Pope (London: Longman, Green and Co., 1905).

2. The Youngest Science: Notes of a Medicine Watcher (Oxford University Press, 1984).

3. Easton, Pa.: Journal of Chemical Education, 1945.

4. François Jacob, The Statue Within (Basic Books, 1988), p. 15.

SOURCE: Christ, Mary. “Oliver Sacks's Science Project.” Book, no. 19 (November-December 2001): 48.

[In the following essay, Christ offers a brief profile of Sacks's life and literary career.]

A man walks into a bar carrying a spectroscope. The punch line? There isn't one—this is just a typical Friday night for Oliver Sacks, world-famous neurologist. “They have all sorts of interesting fluorescent lights,” says Sacks, who had wandered into a pub near his office in lower Manhattan. He has carried the pocket spectroscope—a device for observing the color breakdown of light—since childhood. “Within ten minutes I had everyone talking about spectroscopy instead of sex,” he laughs. “An achievement!”

His enthusiasm for science is contagious, and it shows elsewhere—in his book sales, for one. Sacks, the author of highly readable and affecting case studies of the brain, such as The Man Who Mistook His Wife for a Hat and An Anthropologist on Mars, is well on his way to doing for neuropathology what Stephen Hawking has done for physics and what Carl Sagan did for astronomy. Bearded and bespectacled at age sixty-eight, he has now written a memoir: Uncle Tungsten: Memories of a Chemical Boyhood, just released from Alfred A. Knopf.

Sacks is lucky to have made it to memoir-writing age. He grew up in postwar London, and by the time he was a fifteen-year-old schoolboy he had torched, detonated and poisoned his way through the periodic table of elements in his own homemade lab. “We all got away with a lot,” he admits, reminiscing about the chemical exploits he and his contemporaries pulled off as young scientists. “A colleague I know in Australia has burns all up and down his leg, and another one was deafened by a hydrogen explosion.”

So it's not surprising that Sacks counts among his heroes a number of swashbuckling chemists (Humphry Davy, Marie Curie, Dmitri Mendeleev) who gave their lives, and sometimes limbs, to science. Uncle Tungsten is as much a paean to these explorers as it is a personal remembrance. The title character is the author's Uncle Dave, an early manufacturer of tungsten lightbulbs (tungsten is the metal with the highest melting point) and one of eighteen children raised by Sacks' science-mad maternal grandfather. Sacks himself was pushed to pursue medicine; he regularly accompanied his father, a motorcycle-driving doctor, on house calls. He dissected his first cadaver at fourteen and eventually became a bit of a motorcyclist himself—even riding with the Hells Angels during his days as a student at UCLA.

But he also seems to have learned much from his mother. “My mother was like the ancient mariner,” Sacks says. “She would sort of capture people and, for hours, she would invent very elaborate stories. … When I came to this country, I had a sort of crisis in a way—I sort of wondered where I should live and what I should do and if I should be a writer. But then I also decided that while I might have a bit of talent, I had nothing to write about. Medicine came to my rescue this way.”

THE ACCIDENTAL TOURIST

In addition to a talent for storytelling, Mother Sacks also passed down a curious affection for ferns. Sacks has belonged for eight years to the American Fern Society, a century-old Smithsonian-based fan club of 900 backyard botanists and serious scholars, some of whom Sacks joined on a recent expedition to southern Mexico. The journey will yield a book: Oaxaca Journal, due out from National Geographic Directions next March.

“Without entirely intending to, I kept the journal,” Sacks says. “The first pages were written on the flyleaf in the cover of a book I was reading until a fellow passenger, seeing this, pulled out a yellow pad.” It will be “a little book, a baby book” of some 190 pages, and an informal study of ancient Mexico. “There's been all sorts of things [that came out of there], from chocolate to rubber to tomatoes, which I have turned into little essays,” Sacks says. “Actually, the research on chocolate caused me to put on quite a lot of weight.”

As if studying Mexican ferns, writing about the brain and tending to patients aren't enough to keep him busy—not to mention the occasional Hollywood project (Sacks was the basis for Robin Williams' role in Awakenings and wrote the story behind At First Sight, starring Val Kilmer)—the good doctor is just starting work on a new assignment. A week after this interview, Sacks left for the Caribbean island of Guadeloupe, where a strange neurological disease has taken hold. Like Guam's mysterious illness described by Sacks in 1996's The Island of the Colorblind, the Guadeloupe disease is attributed to eating a plant—in this case a plant called a soursop. “Maybe I'll eat some of it,” Sacks muses.

“Or maybe not.”

SOURCE: Gross, John. “The Man Who Fell in Love with a Table.” Spectator 287, no. 9047 (29 December 2001): 30-1.

[In the following review, Gross views Uncle Tungsten as an insightful memoir and a noteworthy achievement.]

When Oliver Sacks was a boy, one of his teachers wrote in an end-of-term report: ‘Sacks will go far if he does not go too far.’ Certainly the young Oliver didn't do things by halves. The great passion of his boyhood was chemistry, which he pursued with an astonishing energy; but that still left room for a swarm of lesser passions, from music to photography. Any one of them would have taken up a large slice of an ordinary boy's spare time.

Sacks's parents were doctors—his mother a gynaecologist, his father a GP—and from the outset there was an assumption that the future author of Awakenings and The Man Who Mistook His Wife for a Hat would follow in their footsteps. But there were broader scientific traditions in the family as well. Thanks to a remarkable autodidact grandfather, most of Sacks's many uncles and aunts on his mother's side had had some kind of scientific education. A number of them, along with some of his cousins, became scientists or mathematicians themselves, and as his own interest in science flowered he could rely on the encouragement of a formidable family support-system. There was Auntie Len, for instance, ‘my botanical aunt’, and Uncle Dave, ‘my chemical and mineralogical uncle’, and Uncle Abe, a scientist-businessman whose achievements ranged from devising an improved method of ‘pearling’ light-bulbs to taking part in the invention of Marmite. (When Oliver became interested in astronomy, Abe was ready to hand: he had a small observatory on the roof of his house.)

The most important of these mentors was Dave, the ‘Uncle Tungsten’—it was a family nickname—from whom Sacks's memoir takes its title. Dave ran a firm which made light-bulbs with filaments of tungsten wire, but his fascination with the metal, and with metals and rocks in general, went far beyond commercial considerations. Oliver, from his early years, was fascinated by metals himself—by their feel, their colour, everything about them. He turned to Dave for guidance, and embarked on the long voyage of exploration which the memoir chronicles.

While Dave offered expertise, Sacks also owed a great deal to the liberal attitudes of his parents. They allowed him to rig up his own laboratory, and endured the sometimes messy or malodorous results. He spent his pocket money on samples from chemical supply houses and works of popular science—often battered Victorian volumes, which he writes about with affection. He was left free to haunt the Science Museum in South Kensington, where at the age of 12 he experienced a memorable epiphany—his first sight of the giant periodic table of the elements on display there, ‘the most beautiful thing I had ever seen’. (He was uncertain, he adds, whether the source of the beauty was simplicity, coherence, rhythm, inevitability—‘or perhaps it was the symmetry, the comprehensiveness of every element firmly locked into its place, with no gaps, no exceptions, everything implying everything else’.)

There are moments, reading the book, when you are tempted to conclude that he was essentially the product of his environment. How could an extended family like the one he describes have failed to produce an Oliver Sacks sooner or later? But to believe that would be to reckon without the quality of his response—its ardour, its breadth, its humour. At almost every stage, even as a boy, he seems to have set what he was doing in its human context. He was especially interested in the history of science, and at least half Uncle Tungsten is given over—though not at one stretch—to an idiosyncratic account of the development of chemistry, with brilliant sketches of Boyle, Lavoisier, Davy, Dalton, Mendeleyev and other key personalities.

These pages reveal a powerful gift for popularisation, but they are not quite what you expect from a childhood memoir. There is bound to be a suspicion that if he is putting a lot of science in, he is leaving a lot of himself out.

He does in fact tell us a good deal about his non-scientific life. His writing is pointed enough for him to convey extended impressions of his parents, and other significant figures, within a few pages. He is also well aware that science partly served as a refuge from the blows which ordinary existence could inflict, and he leaves no doubt as to what the heaviest of those blows was. At the beginning of the war, when he was six, he was packed off for safety's sake to a small boarding school. It was run by a sadistic wretch (though his parents failed to realise what was going on), and he endured four years of misery. No wonder he later took so much pleasure in The Jungle Book, a consoling fantasy which had its origins in another childhood scarred by cruelty and apparent parental indifference.

Sacks doesn't dwell at length on the boarding-school episode and its emotional fall-out. He doesn't have to. There is anger in Uncle Tungsten, implicit rather than paraded. But there is also anger overcome. If unhappiness was one of the forces that propelled him towards science, it soon counted for less than his enthusiasm and curiosity. He arrived at what was surely a balanced (and on the whole sympathetic) view of his parents. The qualities which eventually made him an outstanding writer emerged undamaged: insight, drive, a sense of drama, a love of life (for all that can be said against it), a feeling for what makes people what they are. He was to go far—and his memoir not only reveals some of the sources of his achievement, it is part of that achievement itself.

SOURCE: Kadanoff, Leo P. “The Elements of an Education.” Science 295, no. 5554 (18 January 2002): 448.

[In the following favorable review of Uncle Tungsten, Kadanoff asserts that “readers, from practicing scientists to intellectually curious high school students, can expect to appreciate the colorful life story recounted, the interesting person revealed, and the excellent history of chemistry retold.”]

Oliver Sacks is a physician, scientist, and author known for his fascinating stories of people coping with amazing neurological disabilities. In Uncle Tungsten, he recounts his scientific boyhood in Britain during the period around World War II. Sacks was born into a large and close-knit family, and he was surrounded by relatives who made science both their work and their hobby. This memoir focuses on the traumas of his separation from family during the war, his fears of insanity, and the redemption he achieved through throwing himself into scientific studies. As Sacks tells his own personal and scientific life story, he also recounts the histories of his family and of the science of chemistry.

The early part of the book describes young Oliver's extensive and foolhardy chemical experiments. In a home basement laboratory, he acquaints himself with the properties of the different chemical elements by the classic processes of mixing and boiling, exploding and burning, and feeling and tasting and smelling. He is aided and abetted by a supportive family, especially his many uncles practicing science and engineering. The “Uncle Tungsten” of the title had created a firm that produced incandescent bulbs with tungsten filaments, and which he ran as businessman, inventor, and scientist. He and his nephew are both particularly taken with the properties of metallic tungsten. This uncle provides not only encouragement for chemical investigations, but also metallic samples, chemical reagents, and scientific instruments. Supportive parents—both are quite thoughtful physicians—provide lab space, a very necessary exhaust hood, and apparently inexhaustible patience. In this way, our young scientist-to-be becomes acquainted with most of the chemical elements and many of their more dramatic chemical properties.

Oliver Sacks badly needs his world of chemistry. He finds much of his boyhood surroundings insupportably oppressive. During the bombing of London, the Sacks children were sent away to country schools where Oliver found sadism, loneliness, and an awful sense of abandonment. So upon returning home, he throws himself into science to escape a world that he has found to be largely intolerable.

The book's climax comes between chapters 15 and 16. At the end of chapter 15, Michael—the author's closest sibling—becomes psychotic and delusional. Oliver believes this illness to be the result of their shared wartime experiences and thinks that he is going the same way himself. But then, at the beginning of chapter 16, he enters the Science Museum in South Kensington, London, which had been closed during the war. There he encounters the museum's giant periodic table, which covers an entire wall at the top of the stairs. He realizes at once that the table enables him to order and organize the knowledge gained in his basement lab and from visits to his uncle's factories. For the first time, Sacks was able to feel not only the richness and diversity of the chemical world, but also science's capacity for giving structure to the results of experience. For a young man at wit's end, this organizing experience hit with all the force of being born again. In the book he recollects, “Seeing the table, ‘getting’ it, altered my life. … it was real, a key to the universe.”

Consequently, in 1945 Sacks extends his interest from the practical chemistry of the laboratory to the books of the museum library. He begins to learn about the history of chemistry. From his first point of reference, Mendeleev and the periodic table, he reaches back to older organizing principles in chemistry, particularly to Dalton's atomic theory. This autobiography presents Sacks's memories of learning the chemistry of 1945, but recounts this process with his wisdom and experience as of 2001. For example, he can say of Sir Humphry Davy (1778-1829) that “it was Davy's personality that appealed to me … filled with the exuberance and enthusiasm of a boy, with a wonderful adventurousness and sometime dangerous impulsiveness—he was always at the point of going too far—and it was this which captured my imagination above all.” Of course, it is exactly these qualities in Sacks which make this book, and his other writings about science, exciting and unique.

Readers, from practicing scientists to intellectually curious high school students, can expect to appreciate the colorful life story recounted, the interesting person revealed, and the excellent history of chemistry retold. But please, dear parents, don't encourage your children to try the experiments, and don't think that Uncle Tungsten provides a primer for raising young scientists.