Outpouchings

It could be said that Oliver Sacks put neuropathology on the literary map. His first book Awakenings, about the stunning effects of the drug L-Dopa on patients afflicted with a form of Parkinsonism, attracted considerable critical acclaim from the literary world, and ‘inspired’ Harold Pinter’s rather ponderous play A Kind of Alaska. Sack’s second book A Leg to Stand On was similarly well-received. He has published a number of short pieces in this journal, as well as in its elder American sibling, several of which are reprinted in the present collection, along with 12 previously unpublished pieces. (His book Migraine seems to have excited rather less popular interest, no doubt because it is a less popular kind of book.) Yet the scientists of the nervous system do not seem to have been similarly impressed. When I asked a colleague in neuro-anatomy what he thought of Sack’s work he said he had never heard of him, and the neuroscientists I consulted who had heard of him were not inclined to attach any scientific importance to his writings. Unanimity between the two cultures is not perhaps to be expected, but in the present case the reason for this asymmetry of esteem lies deeper than mere difference of interest. The problem is that it is quite unclear what Sacks is doing. For whom is he writing? What kind of writing is it? Is it intended as sober science or fanciful fiction? What is its relation to an orthodox text of neuropathology? Can it really be taken seriously? Literary people seem tolerant of such uncertainties, but those concerned to discover the literal truth will want them clarified.

Sacks’s pocedure is to describe as winningly as possible the case-histories (or segments thereof) of various patents with whom he has had personal contact. These are, as it were, recreated before our eyes, like entries in a doctor’s diary, rather than being set down once all the data are in. They have tension, surprise, realistic dialogue, resolution, tragic dénouements, touches of humour, epiphanies. The cases are divided into four categories: ‘Losses’, ‘Excesses’, ‘Transports’, ‘The World of the Simple’. Here are some samples from each category. The man who mistook his wife for a hat was a distinguished musician, learned and charming, who had, through damage to his visual cortex, lost the ability to recognise familiar things despite being quite capable of seeing them; he couldn’t associate the visual appearance of things with their proper function or identity. Thus he mistook his foot for his shoe, his wife’s head for his hat (he tried to put her head on his), and he would Puzzle verbosely over ordinary things like gloves (‘a continuous surface, infolded on itself. It appears to have five outpouchings, if this is the word’). These failures of recognition may have stemmed from a total loss of the concepts in question or from an inability to apply them to what is seen – it is unclear. Sacks characteristically throws no light on the question, though his data seem to suggest the latter alternative. Instead of approaching the matter in a coolly analytical frame of mind, he prefers to burble on about the ‘intuitive, personal, comprehensive and concrete’ nature of judgment, suggesting that the patient has lost this capacity and then observing (inconsistently) that his judgment was ‘in all other spheres ... prompt and normal’.

The Lost Mariner, victim of alcoholically-induced Korsakov’s syndrome, can keep things in his memory only for a matter of seconds and has a retrograde amnesia stretching back thirty years. He has vivid memories of his life before the age of 19 and thinks this to be his present age. He is shocked by his appearance in the mirror, with which Dr Sacks brutally confronts him, and (we may presume) has often been so shocked in the last thirty years, each time having the shock erased within seconds. Naturally, his life was one of bewilderment and confusion. Witty Ticcy Ray suffers from Tourette’s Syndrome, which is characterised by an excess of nervous energy producing ‘tics, jerks, mannerisms, grimaces, noises, curses, involuntary imitations and compulsions of all sorts, with an odd elfin humour and a tendency to antic and outlandish kinds of play’. Ray could not hold down a job (or the job could not hold him down) and his social behaviour was found unacceptable, but he exploited his motor mania in jazz drumming and table tennis, at both of which (we are told) he excelled. Sacks put him on Haldol, which initially induced virtual catatonia but later levelled out, bringing him to near motor normality. Now he could keep a job and not upset his friends, but he felt that his tic-free self was less exciting than his old Tourettic self; he had from an early age built his life and personality around his affliction. The solution was to take Haldol during the working week but go cold turkey at the weekend, thus allowing his old manic and excitable self to re-emerge. This odd inversion of the usual drug-taker’s schedule apparently led to a more balanced and satisfying life for Ray.

A case of transportation is provided by Stephen D., a medical student constantly high on cocaine and amphetamines: he dreamt he was a dog with a dog’s olfactory gift, and when he woke up he retained the heightened sense of smell. Now he could smell people’s emotions, recognise his friends by their aroma, find his way around New York City with his nose. Three weeks later he reverted, with mixed feelings, to olfactory normal. He had known what it is like to be a dog. The Twins, retarded, misshapen, undersized, severely myopic, nevertheless have remarkable powers of computation, earning them regular television appearances. Say any date during the next forty thousand years and they will tell you instantly on what day of the week it falls. They can remember 300 digit numbers, where most of us are taxed to the limit by seven. They can generate six-figure primes at will and are not defeated by the task of going up to ten figures. Yet their IQs are a mere 60 and they cannot even perform elementary addition and subtraction. They seemed, Sacks reports, to see numbers and to read off their properties without performing calculations. When they were separated ‘for their own good’, they lost their mathematical powers and the enjoyment they derived from their exercise.

All this is very striking and remarkable, like strange tales from a fabulous foreign land. Sacks relates his case-histories with great vividness and obvious compassion. The book is a fascinating read all right. But doubts assail one on almost every page. There is, first, the question of Sack’s prose style. It has been lavishly praised by some critics (‘beautifully written’). Lush, belletristic, edifying, competent – this is the best I could say for it. For the most part it is embarrassingly over-lyrical gushing, pretentious and sentimental. Try saying this out loud with a straight face:

  ‘Watch Jimmie in chapel,’ they said, ‘and judge for yourself.’

  I did, and I was moved, profoundly moved and impressed, because I saw here an intensity and steadiness of attention and concentration that I had never seen before in him or conceived him capable of. I watched him kneel and take the Sacrament on his tongue, and could not doubt the fullness and totality of Communion, the perfect alignment of his spirit with the spirit of the Mass. Fully, intensely, quietly, in the quietude of absolute concentration and attention, he entered and partook of the Holy Communion. He was wholly held, absorbed, by a feeling. There was no forgetting, no Korsakov’s then, nor did it seem possible or imaginable that there should be; for he was no longer at the mercy of a faulty and fallible mechanism – that of meaningless sequences and memory traces – but was absorbed in an act, an act of his whole being, which carried feeling and meaning in an organic continuity and unity, a continuity and unity so seamless it could not permit any break.

This passage is entirely typical of the kind of windy rhapsodising with which Sacks embellishes the bare (and sufficiently eloquent) facts of each case. There is a constant straining for cosmic significance, and with it a disturbingly self-regarding messianic fervour. A.R. Luria is quoted with cloying reverence, and big names are dropped to no apparent effect save that of intellectual pretentiousness (Wittgenstein, Frege, Nietzsche, Schopenhauer et al.). He is much too fond of the wistful ‘...’ The result is that the patients and their plight are eclipsed by their doctor’s desire for what he imagines to be a fine phrase.

More seriously, perhaps, there is the question of credibility. Sacks himself describes these pieces as ‘tales and fables’ prompted by what he has observed in clinical practice. He says that he has changed ‘names and some circumstantial details ... for reasons of personal and professional confidence, but my aim has been to preserve the essential “feeling” of their lives.’ Is that all he has preserved? one wants to ask. A novelist could say the same yet would be making up more than mere names and ‘circumstantial details’. What are we to make of the dialogue, for instance? There is no claim that his conversations with patients were tape-recorded, or that he wrote down what was said straight after, or indeed that such conversations ever took place. To what extent has Sacks invented stretches of dialogue for dramatic purposes? And was he really as ill-informed about some of these cases as he seems to have been, or is it that he is feigning initial ignorance in order to create in the reader the thrill of discovery? Does he ever exaggerate the bizarre deficits and excesses he describes for greater literary effect? More fundamentally, did all of this really happen, and how does it stand in relation to Harold Pinter’s play? Are questions of literal truth beside the point?

I myself suspect that the genre to which these ‘stories’ belong is that of the dreaded ‘drama-documentary’ – that art-form which blends fact and fiction in a way that defies evaluation under either aesthetic or scientific criteria. Fictionalised fact cannot be criticised for being bad art, since it is intended as a report of fact. It is a genre in which you have no idea where you are and what you are supposed to be up to. It should be discouraged. Sacks wants his case-histories to contribute towards a more humanistic neurology – no doubt a laudable aim – but neurology won’t listen until it is told whether it is being offered data or drama. There is, of course, room for, and an honourable tradition in, medical (including psychiatric) case-histories, but these are characteristically objective and impersonal in style, and the authors are quite clear that the circumstantial details have not been made up. There is a fine line between legitimate interpretation and over-imaginative reading-into, and I am not convinced that Sacks has kept on the right side of it, or even intended to.

Putting aside the issue of genre, what positive value do these studies have? They certainly serve to remind us, especially the doctors among us, that patients are people too – that illness, however caused, and especially illness of the brain, has significance in the life of a person. This of course is a truism, but it seems necessary to keep on saying it in the face of the forces of ‘depersonalisation’. More theoretically, they compellingly demonstrate the fact, unwelcome as it is, that everything about the mind, from the sensory-motor periphery to the inner sense of self, is minutely controlled by the brain: if your brain lacks certain chemicals or gets locally damaged, your mind is apt to fall apart at the seams. What we call ‘the mind’ is in fact made up of a great number of sub-capacities, and each of these depends upon the functioning of the brain. It begins to seem a miracle that the system doesn’t break down more often.

When it comes to theory, however, Sacks’s studies yield little of consequence. He makes no effort to put his data into a systematic theoretical framework; indeed, the book contains remarkably little on the mechanisms of brain function. He offers us no philosophical account of the mind-brain relation, despite the importance of this question for his general theme of the dependence of mind on brain: is he a Cartesian dualist, an identity theorist, an epiphenomenalist, or what? His occasional references to Hume’s theory of the self are naive at best. He seems to think that Hume regarded us as unconnected bundles of sensations possessed of no principle of unity: in fact, Hume claimed that the unity comes from precisely the sorts of connection which are missing in Sacks’s pathological cases. It is therefore quite misleading of him to claim that Hume’s theory fits those pathological cases but not us normals. Or is it that he is simply using Hume’s theory as a loose literary metaphor? The problem of genre again.

It might be said that Sacks is not out to give a scientific or philosophical theory of the phenomena he reports: rather, he is providing the theorist with raw data to work with. But this is hard to square with Sacks’s casual unconcern about the data assembled by other researchers. Uncomfortably often he appends a postscript in which it is observed that there is in fact a large (but uncited) literature on the syndrome he has just been describing. Then why publish further data of the same kind, unless he has made some new observations? The answer must be that he thinks he has, not new data, but new descriptions of old data – more dramatic descriptions. So, again, what he is doing is not science.

So I return to the question of what sort of book this is supposed to be. I fear that the answer must be this: it is a coffee-table book for the scientifically shy to dip into and amaze themselves and their friends. It has all the fascination – morbid and humanitarian – of a lurid text on medical pathology, with the bonus that it is easy reading. There is, of course, a place for coffee-table books – on the coffee table with the colour-supplements – but they should not be confused with genuine science (or genuine literature). Above all, such writing should not be greeted by the non-scientific world as science at last Getting Somewhere, becoming Relevant, shedding its bogus Claims to Objectivity. This attitude is in its way as philistine as the obverse philistinism commonly attributed to scientists vis-à-vis the arts.

Sacks suggests that ‘classical neurology’ needs to be supplemented with modes of description which address the person as a psychological being. This is a very familiar plaint which was most vigorously urged in the Sixties by R.D. Laing and others in respect of medically-based psychiatry. It is part of the general question of the relationship between the psychological sciences and the kind of understanding of people we find in novelists and biographers. This is a very hard question. The problem, not addressed by Sacks, is how this integration is to be achieved – indeed, whether it can be achieved at all. It seems that we have two distinct and distinctive modes of thinking here which refuse to fit neatly together. To solve this problem we need to do some hard thinking about the relationship between mind and brain, the nature of science, and the viability of our ordinary notions of what a person is in the face of the scientific facts. Pious pleas for neurology to ‘take account’ of the fact that human brains house human minds will not result in any progress with these questions.

Perhaps a more radical thesis lurks in the background, if not of Sacks’s mind, then of the minds of his admirers. This is the idea that ‘classical neurology’ provides the wrong approach to the psychological disorders here described; that it should be replaced, not supplemented. We must treat the patient as a person (not as a machine) and forget about physical causes altogether. This attitude (which I do not attribute to Sacks) makes a fundamental mistake. The proposal, in effect, is to treat Sacks’s patients in the kind of way psychoanalysis treats its patients. That is, we should address ourselves to the psychological basis of the disorder and work on it, in collaboration with the patient, in order to change his unhealthy psychic structure. This is a mistake because the whole point of neuropathological disorders is that they do not have psychological causes or an intelligible psychological history: they have brute physical causes, such as head injury. Herein resides the peculiar difficulty of bringing together neuropathology and a personal view of the patient: for the person is prone to massive psychological changes the causes of which are entirely impersonal. By all means let us remember that these patients are people, but let us also not forget that their psychological problems do not lie at the personal level (as the problems addressed by psychoanalysts do). There is thus a clear sense in which these people must be treated as machines – for the simple reason that the brain is a machine and hence is prone to the breakdowns that are the lot of all machines. In this respect the brain obeys the same laws as the body; and the mind wholly depends upon the brain. No doubt this is a harsh and disturbing truth, amply and harrowingly demonstrated by the results of brain malfunction, but it is a truth that cannot be dodged. There is thus no prospect of a fully personalised neuropathology.

And what of the consequences of neuropathology for the immortality of the soul? Pretty bleak, it would seem. For consider what becomes of the parts of mind that are lost upon various kinds of brain damage. They can scarcely be supposed to survive as separate bits, waiting for the other mental parts to join them when the damage is complete; they must simply go out of existence. Suppose now the damage is progressive, so that the several components of mind are successively lost. What happens to the last bit? It can hardly survive on its own, an incomplete yet immortal mental fragment. If parts of the mind depend for their existence upon parts of the brain, then the whole of the mind must so depend too. Hence the soul dies with the brain, which is to say it is mortal. This may be thought an irresistible conclusion anyway, of course, but it is gratifying to see it proved by philosophical neuropathology. Or is it that only the souls of those whose brains are destroyed in one go are immortal? This seems hardly fair.