Wednesday, January 02, 2013

The Top Of My Head, Part X - A View On Some Writings By Oliver Sacks

 (Warning - please note this essay deals with extremely adult themes)

As those readers who have stuck with me all the way through this project from the beginning will attest, I have relied heavily upon the writings of Oliver Sacks. Given that their author seems so dedicated to the raising of awareness of neurology through literature, it therefore seems only fair to express one's own views upon those works of his that I have read as wholly as I can.

Without any shadow of doubt the most famous neurologist in the world, Dr. Sacks has achieved this status by publishing a number of what might be termed 'crossover' books, effectively popular books on neurological themes, usually based on case studies. I have read two of these, 'Awakenings' and 'The Man Who Mistook His Wife For A Hat'.

'Awakenings' describes how, in 19659, he treated a group of post-encepahalitic Parkinsonians with L-DOPA at a New York hospital which he named 'Mount Carmel', and the sequelae they suffered. The real name of 'Mount Carmel' was Beth Abraham, a discovery made within moments of starting to peruse Dr. Sacks's entry in my local library's copy of 'Who's Who' (it's also on the web).

Some of the observations he makes in that book are, as I have noted elsewhere, extremely acute.  In particular, his observations on what he describes as the 'infinite' nature of Parkinsonian illness and the Parkinsonian's disrupted relationship with space are bang on the money. His description of the Parkinsonian's need for medical advice is also extremely acute. If nothing else, his aim in wishing to depart from what he describes as the 'styleless style' of much writing on neurology is a worthy one - the inaccessibility of most medical literature reinforces the impression that medicine is the property of medics, which it most certainly is not. Yet he had a few patients at Beth Abraham in whose histories he perhaps left a little too much of himself - and those parts that he left lying around sometimes seem very revealing indeed.

It should not be forgotten that Dr. Sacks did not isolate L-DOPA, nor was he the first to envisage its possibilities. That was the work of Dr. George Cotzias and his colleagues. Nor was he the first to describe some of the effects that L-DOPA could produce in those to whom it was administered - the 'involuntary foot stamping', or 'pawing of the ground', he described as being exhibited by 'Rolando' in 'Awakenings', first published in 1973, had earlier been described by Drs. Krasner and Cornelius in the British Medical Journal of 21st November 1970.

'Leonard L', a Harvard graduate, then in his mid-40's, whose Parkinsonism had rendered him speechless and immobile, and whose only means communication was a letter board upon which he would tap with a single finger, was the first patient to whom Dr. Sacks administered L-DOPA. Dr. Sacks seems to have had a very great deal of sympathy for Leonard's plight; their relationship perhaps having been cemented by Leonard's description of himself as being like 'Rilke's 'Panther'', perhaps a meeting of two literary minds. His description of Leonard's case is quite unusual amongst those narrated in that book in that, in the fourth edition at least, he provides no information either on Leonard's ethnic origins nor indeed upon when, if ever, he developed encephalitis lethargica. He is described as being 'post-encephalitic', but no mention is made of when he suffered the actual illness, only that he started to become unwell after the death of his father when he was six.  Leonard's immobilised description of Beth Abraham as a 'human zoo' might have given some indication of the presence of some emotional problems, but the difficulties he suffered on L-DOPA were immense.

Over the course of several months' treatment with L-DOPA, Leonard became psychotic, passing from total disability to awakening to benign wellness to exorbitance to hyperlibido to eventually requiring to be placed in a punishment room - a raw deal, I thought, given that he was being punished by the hospital authorities for a decline in behaviour which was the consequence of a reaction to a drug which he had been administered under their aegis. Even with the L-DOPA alternative amantadine, Leonard never recovered, and died in 1981.

As I have said frequently, I am not a doctor, but there are some aspects of Leonard's case that puzzle me, not the least of which is, of all things, the size of his hands.

Dr. Sacks describes Leonard's hands as having been very small, dystrophied from lack of use; yet in her rather marvellous little book 'Diaghilev and Friends', Joy Melville described the hands of Vaslav Nijinsky as having been similarly small and underdeveloped; and Nijinsky, once dubbed 'the fly catcher' because his mouth was always open, was a chronic and almost lifelong schizophrenic.

Could Leonard have been schizophrenic?

(At this point, I must confess that ballet is an art from about which I desire to know a great deal more than I do. As long as we have ballet, we can call ourselves civilised. This interest was sparked by Andy Wilson's marvellous BBC film 'Riot at The Rite', a dramatisation of the notorious riot which occurred at the premiere of 'The Rite of Spring' in 1913, starring Adam Garcia as Nijinsky and Alex Jennings as Diaghilev. In her book, Melville describes how Nijinsky had a range of movement well beyond that of other dancers - perhaps a description of that capacity for odd movement described by Dr. Sacks in two of his Parkinsonian patients, one a former racing driver, the other a former boxer? Nijinsky's original choreography for 'The Rite of Spring' was lost within a few years of the premiere, but if his opening poses were recreated accurately in 'Riot at The Rite', then the knock knees, inwardly pointing toes and shoulders sloping into stoop suggest a classic Parkinsonian posture). 

I had been wondering about this for a while even before I read this essay describing Robert De Niro's portrayal of 'Leonard Lowe' in the 1990 movie of 'Awakenings', a movie I must confess I've never seen. Schizophrenia thrives in families, and Leonard's relationship with his mother was unhealthily close - at one point, Dr. Sacks describes the two of them as being in love with each other, and that Leonard's mother had a need for him to be ill; when he was well, the relationship just did not function. There can be no doubt that Leonard was extremely 'divided', the bookish devotee of Rilke and T. S. Eliot also quite validly being the hyperlibidinous, and habitually hallucinating, fantasist of cannibalism.

That the question of whether Leonard was schizophrenic is not canvassed in 'Awakenings' seems like something of a missed opportunity, if only because it might have shed some light on the question of whether Parkinsonism and schizophrenia can exist in the same patient in a way in which Parkinsonism and Tourettes cannot; and if that is the case, whether Tourettes and schizophrenia can also similarly co-exist in the same patient.

Given the quirks of schizophrenogenic families, it would also be interesting to note whether there was anything else about his father's death, other than the bald fact of his death, which so traumatised Leonard that it might have led to him becoming disabled him for life. 

Yet it is in the case of 'Ida T' that Dr. Sacks seems to reveal most of himself; through a glass, darkly. 

'Ida' was originally Polish. Bedridden for years by the time Dr. Sacks began to treat her, she was then bald, her head was covered in sebum and she weighed 400 pounds - he describes her as being 'seal-shaped'. Yet under the influence of L-DOPA Ida achieved the most remarkable transformation, getting up, walking, singing, making contact with a daughter who had been told she was dead and never for one moment stopping being grateful to Dr. Sacks for having medicated her by subterfuge. It is in his description of her priorities after her awakening that Dr. Sacks gives us a glimpse of what perhaps his own priorities as far as the writing of 'Awakenings' might have been. 

At Page 178 of the fourth edition of 'Awakenings', he wrote (with his italics), 

"To celebrate her 'awakening', Mrs T. announced in a stentorian voice that she wanted a quart of chocolate ice-cream with each meal every day, and 'a big olive-oil enema -but big!"

To the best of my recollection, my knowledge and my belief, this is the only reference which Dr. Sacks makes in 'Awakenings' to any of his patients having suffered from bowel difficulties. This is in marked contrast to the very sensitive treatment given to this subject by Gilbert Obiafor Onuaguluchi is his previously cited work 'Parkinsonism'. Toiling away in the lazaretto at Stobhill Hospital in Glasgow, where he did that groundbreaking work on the use of the EEG on Parkinsonians which Dr. Sacks was later more than happy to cite, Professor Onuaguluchi noted that all his patients suffered from bowel difficulties resulting in acute constipation, best relieved by enemas of either olive oil or warm soapy water. 

It may be the case that a discussion of his patients' bowel movements, or indeed their lack thereof, might have been deemed inappropriate in a book designed for the mass market. Yet while I may be completely incorrect, I can't help but think that the mention of the 'but big!' might have been intended to be slightly comic, an attempt to turn poor, horribly afflicted Ida, a patient who for all I know he might have found personally disgusting yet who was also the recipient of so much affection from her nurses, into something of a figure of fun. 

If that was the case, if that was his intention, then the nature of Dr. Sacks's motives might have become a little clearer; that instead of being interested in narrating his patients' histories for their sake, he would instead be one of that class of authors, like Thomas Cranmer with the English Reformation, like P. J. O' Rourke with right-wing politics, of whom it can be fairly said that they have attached themselves to an activity or cause not for its own sake but for the opportunities it provides them with to create literature. In the case of Dr. Sacks, the activity is neurology; for it seemed important to him to tell the world that poor Ida wanted an olive-oil enema, without explaining why. 

This is a very slightly different criticism to that offered by Tom Shakespeare when he wrote that Dr. Sacks was 'the man who mistook his patients for a literary career'. That would suggest that at some point the practice of medicine has been more important than the creation of literature. Both might be equally important, but the thing you have to remember about cause-barnacled litterateurs is that the opportunity to write about the cause is always at least as important as the cause itself. 

And the difficulty with creating literature for its own sake is that those addicted to it, like P. J. O' Rourke, indeed perhaps even like Oliver Sacks, can never stop. They will write and write and write even as the soil is being thrown over their coffins, their pathological compulsion to vomit out words, to talk and talk and talk always, always getting the better of them. As it certainly gets the better of Oliver Sacks, when he finishes the story of Ida on Page 179 by writing that,

"In the last year there have been some complications from the continued use of L-DOPA - some return of her rigidity and stuttering, etc. But, all considered, she is still doing incredibly well considering she was dead for forty-eight years". 

But Ida, all bald, ravenous,Yiddish-folk-song-bawling, just off the boat, four hundred Polish pounds of her, was never 'dead'. She had always been triumphantly alive, just unable to express it. For a person so deprived of normal living for so long to be described by their doctor as having been dead when they were clearly anything but dead seems, in my opinion, to be grossly disrespectful.

This need to talk leads him down some other strange paths. In one of his more excitable moments, Leonard suggested the establishment of a brothel service in Beth Abraham. When this was automatically rebuffed, he began to play with himself, in Dr. Sacks' words, 'fiercely, freely and with little attempt at concealment'. Yet the extent of Leonard's mania was such that it led Dr. Sacks, in a perhaps unguarded footnote, to speculate on just what might have happened had he been permitted to set up such a service - a totally fruitless line of thinking, given that I imagine the American Medical Association would never have permitted it, never mind the hospital authorities.

He is a very well-read man, for sure. The pages of 'Awakenings' are peppered with quotes from Kant, and Donne, and Eliot. Yet like all the rest of who like reading I'm sure he knows that he's not as well-read as he'd like to be - if he were, he might have known that the expression 'Cupid's Disease', an expression of which he admits ignorance while treating 'Natasha' in 'The Man Who Mistook His Wife For A Hat', is recorded on Page 236 of George R. Stewart's classic science fiction novel 'Earth Abides', first published in 1949. 

Yet the achievement that is 'Awakenings' is one that can't be taken away from Dr. Sacks. Filmed in 1990, it's also been adapted for radio, and one of his case histories, that of 'Rose R', was adapted by Harold Pinter into a one act play entitled 'A Kind Of Alaska', which premiered at the National Theatre in October 1982, with Judi Dench in the role of 'Deborah' (the real 'Rose R' choked to death on a chicken bone one night in 1979). It was with a little wry amusement that I noted Dr. Sacks's footnote at the bottom of Page 371-

"At its most recent (1989) performance in London, Pinter himself played the part of the doctor"

Pinter himself? My word!

If it is the case that Oliver Sacks considers neurology to be a vehicle for the creation of literature, then although his medical ethics might be intact (a question which has sometimes been the subject of debate.pdf), then it is only fair to suggest to readers that that desire to create literature is the prism through which will Oliver Sacks writes about neurology, and that they will be experiencing his literary skills just as much as they will be receiving his knowledge of neurology. Neurology is not unlike plumbing; there are some things in life you just cannot make interesting no matter how hard you try, and they are usually the things in respect of which substance is always more important than style. 

The body of the essays is now complete. Only the epilogue now remains to be written, and that will hopefully appear in a few days time. 

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