Life, Death and the Whole Damn Thing

Oliver Sacks seeks for meaning in the chaos of neurological deficit. He has that in common with his patient Mr Thompson, one of two Korsakov amnesiacs described in The Man who Mistook His Wife for a Hat, who, says Sacks, ‘must seek meaning, make meaning, in a desperate way, continually inventing, throwing bridges of meaning over abysses of meaninglessness, the chaos that yawns continually beneath him’. Mr Thompson invents personal narratives over and over again with endless variation, but, according to Sacks, they fail to work ‘because they are confabulations, fictions, which cannot do service for reality while also failing to correspond with reality’.

Oliver Sacks does not trust fiction. Borges’s fictions, dripping with parables of memory and identity, are much admired by Sacks, but are not trusted to serve reality without a basis in documentary fact. ‘I have often wondered whether Borges’s Funes, so uncannily similar to Luria’s Mnemonist, may have been based on a personal encounter with such a mnemonist’, he muses in a footnote to Mr Thompson’s story. ‘Funes the Memorious’ is the story of someone inexplicable and astounding: ‘A circle drawn on a blackboard, a right triangle, lozenge – all these are forms we can fully and intuitively grasp; Ireneo could do the same with the stormy mane of a pony, with a herd of cattle on a hill, with the changing fire and its innumerable ashes, with the many faces of a dead man throughout a long wake.’

Oliver Sacks and the narrator of ‘Funes’ are in the same business of delineating the extraordinary, outlining the nearly unthinkable. The difference lies not only in the prose and the overtly fictional form in which Funes is presented, but in the moral tone of the narrator. Borges allows us to judge Funes’s tragedy for ourselves, presenting his case without pronouncing a final verdict on the condition of his soul. In the case-history which Dr Sacks provides of his patient Mr Thompson, he does not hold back from pronouncing him damned. Jimmie, the other Korsakov sufferer in the book, is granted a soul because he achieves short periods of concentration and repose during the hospital Mass: Mr Thompson is deemed ‘de-souled’ by his incapacity for quietness and fellow-feeling. Jimmie – with his occasional capacity for ‘genuine emotional relation’ – ‘can be redeemed’; he has the possibility of ‘salvation’ because he ‘is in despair’. There is, however, nothing redeeming in Mr Thompson, who is all ‘brilliant and brassy surface’, which may, Sacks acknowledges, obscure desperation, but only ‘a desperation he does not feel’.

Dr P., who mistakes his wife’s head for his hat, is compared to Zazetsky, the subject of Luria’s other great case, The Man with a Shattered World, and found wanting for his inability to recognise and despair over his visual errors. Dr P. ‘was not fighting, did not know what was lost, did not indeed know that anything was lost. But who was the more tragic, or who was more damned – the man who knew it, or the man who did not?’ Some of us, forced into such a formulation, might conclude the former, but it is Dr P. who is Sacks’ choice. This is not just a personal response on Sacks’s part, a private revulsion against the emotionally gutted condition of his patients: it is a judgment embedded in the philosophical soil of Nietzsche’s belief that ‘only great pain is the ultimate liberator of the spirit.’ Will ordinary pain not do?

It’s one thing to know, because you are a neurologist, that Mr Thompson is suffering from Korsakov’s psychosis and that Dr P. has a massive tumour or degenerative process in the visual parts of his brain: it is, I think, quite another to speculate on the condition of their souls. But that is the contradiction which Sacks fails to resolve, and it is, of course, largely for that reason that he is so read and admired in the literary world. Perhaps it is also the reason his books are almost invariably reviewed by writers and intellectuals rather than his fellow neurologists. He writes with the authority of a medical doctor not just of symptoms and diagnoses, but of intimations of immortality, and of the spiritual significance of remembrance of things past. He is read as a guru who can authenticate neurologically the art of Proust and the visions of Hildegard of Bingen, confirm the veridical aspects of Borges’s imagination, and reinforce our belief that salvation can be ours provided our brains are able to connect in the Forsterian way. He acts as the non-fictional conscience of imaginative art. The moral and spiritual diagnoses of his patients serve to reaffirm our metaphysical hankerings in much the same way that a recent television advertisement for medical insurance assured viewers, with a recital of the marvellous complexity of the human body and what it can do, that ‘you are amazing.’ Something about Sacks’s work similarly flatters his readers. (My God, we are extraordinary, look how interestingly wrong we can go.) After a thorough examination of the works of Oliver Sacks, you come away with the oldish thought that identity matters, as well as a new conviction that, along with good social relations, the purchase of a hard hat might be a useful hedge against soul death.

I don’t know whether in the weird world of neurology there is a condition that makes people profligate with footnotes, but if so Dr Sacks has it in spades. The text of the revised edition of Awakenings is practically doubled by its footnotes, and An Anthropologist on Mars is itself almost a stand-alone footnote to The Man who Mistook His Wife for a Hat. Many of the case-histories are similar to the cases in the earlier book or amplifications of them. Greg, ‘The Last Hippie’, a Krishna convert whose progressive brain tumour was mistaken by his fellow worshippers for special spiritual illumination, has a detachment from his illness similar to that of Jimmie, the Korsakov amnesiac. Jimmie’s memory came to a dead stop in 1946, while Greg’s arrested in 1970, late enough to permit a continuing devotion to the Grateful Dead – or rather the music the Grateful Dead played up to 1970. Sacks has the same spiritual concern for him that he had for Jimmie and Mr Thompson: ‘Given this radical lack of connection and continuity in his inner life, I got the feeling, indeed, that he might not have an inner life.’ For the Krishnas, when Greg was living with them, this detachment indicated an extreme of spiritual development, for Sacks it meant quite the opposite. Greg, I suppose, expressed no opinion either way, though he did enjoy the Dead concert to which Sacks took him, for as long as he could retain the memory of it.

Another Touretter stands in for Witty Ticcy Ray of The Man who Mistook His Wife, a surgeon, this time, instead of a musician. Sacks goes to stay with Dr Bennett and wonders at his capacity to perform tic-free operations while spending the rest of his time – which includes some hairy driving – ticcing up a storm. For Sacks, this is an example of the will, the inner life, shining through: the insistence on living a coherent life in spite of the demands disease makes on the personality. Bennett, and later Temple Grandin, a biologist suffering from autism, provide the metaphysically upbeat note to Sacks’s meditations on disease. Rather than merely seeing the difference between patients as what they can or cannot manage, Sacks offers a disease-as-personality theory. In Awakenings he states: ‘There is nothing alive which is not individual: our health is ours; our diseases are ours; our reactions are ours – no less than our minds or our faces.’ Our responses to illness, he says, are expressions of our nature, and, quoting Sir Thomas Browne, ‘things cannot get out of their natures.’ He puts this case to counter modern medicine’s inclination to reduce disease to the separate and mechanical, and it is a case that always needs reiterating, but his commitment to the notion that ‘diseases have a character of their own, but they also partake of our character’ does rather land the Mr Thompsons and Gregs of the neurologically deficient world in a mechanical hole. We would all applaud those who can overcome their disabilities, but it seems impertinent to consign those who are unable to do so – for whatever reason, biology or character (whatever that is) – to a spiritual wasteland. These latter Sacks declares to be ‘Humean beings’, on the grounds of Hume’s declaration that we are ‘nothing but a bundle or collection of different sensations, succeeding one another with inconceivable rapidity, and in a perpetual flux and movement’. The others, the fighters, as Sacks puts it, who have retained their sense of identity, are, I suppose, Homo sacksian.

Dr Sacks’s point in writing up his patients’ histories in the way he does is to liberate them from the loss of identity which occurs with the old-style medical description. He wants to present them, empathetically, in their totality, as persons rather than bundles of neurological symptoms. This is the current thinking, and a great improvement on cold medical authority, but if in their totality, which must include their disease, the patients have become depleted, it would seem decent to consider them more or less ill, rather than more or less persons. But then if your philosophical position is that illness takes its tone from character (again, whatever that is), I suppose the latter view follows logically. As someone free, so far as I know, from neurological insult, I’ll listen with interest to any judgment anyone fancies making about the state of my soul; but should I ever be in need of neurological attention, I think I would prefer my physician to confine himself to curing me or making me comfortable.

Of course, Dr Sacks, in his authorial hat, is writing books, not being a medical consultant, but there is a disturbing moment in his examination of Dr P., who is intact musically and abstractly, but so unwittingly damaged in his concrete apprehension of the world that he neither knows nor cares to distinguish his shoe from his foot. Dr Sacks was consulted by Dr P. and his wife on the advice of his optician that there was something wrong with his brain, not his eyes. The fact that the appointment with Sacks was made and kept suggests that someone, if not Dr P. himself, then his wife, recognised something was wrong and was worried about it. After the first examination and the pricking of Dr Sacks’s interest, he himself makes a visit to Dr P.’s house, in order to see him in his natural surroundings. He talks to Dr P., has tea with him and his wife, does a variety of tests and accompanies Dr P. on the piano as he sings Schumann. The tests tell nothing, he says, of Dr P.’s inner life, so he asks him to describe Anna Karenina. He finds that his patient can relate the plot and even the dialogue, but that his telling of the novel is ‘quite empty for him, and lacked sensorial, imaginal or emotional reality’. I’m not really sure what that means, with what kind of passionate involvement one is required to précis a novel, but it is clear from the two examinations that Dr P. is a very sick man. ‘Well, Dr Sacks,’ says Dr P, ‘you find me an interesting case, I perceive. Can you tell me what you find wrong, make recommendations?’ Sacks says that he can’t tell him what he finds wrong, but adds: ‘You are a wonderful musician, and music is your life. What I would prescribe, in a case such as yours, is a life which consists entirely of music. Music has been the centre, now make it the whole, of your life.’ That’s it; consultation over. We are not told how Dr P. or his wife responded to this and Sacks never saw them again, though it is not explained why he didn’t. Had I been the patient, I would have been left confused and deeply alarmed. The humanitarian part of the doctor’s role was performed with elegance, but what of his medical function as diagnostician and physician? Doubtless, something else happened here that Sacks does not write up, but it seems a curious lacuna.

Sacks suggests that one of the reasons some doctors strive for what they hope is an objective distance from their patients is to prevent their own ‘subjectivity’ from confusing the relationship. This is, we understand these days, a chimera, but it is interesting to see how a more open mutuality between patient and doctor might alter attitudes, though not necessarily for the benefit of the patient, who may find the doctor’s personal requirements an extra burden. Agreeing with Freud that a full life – inner and outer – consists of work and love, Sacks finds most disturbing those patients who are most detached, most emotionally deficient. So do we all. Those who cannot connect – that is, those with whom Sacks cannot make a human relationship, to whom he can only relate as physician – are condemned. The two-way relationship needs to work for Sacks to feel comfortable.

In the final essay of An Anthropologist on Mars, the autistic Temple Grandin is shown as a highly intelligent woman who has achieved an independent life as a biologist working primarily with cattle. Sacks visits her and she explains how her autism has prevented her from having the normal experiences from which social knowledge is constructed. As a result, she has to ‘compute’ the intentions and states of mind of others, ‘to try to make algorithmic, explicit, what for the rest of us is second nature’. Human interactions of a social and sexual kind she cannot ‘get’. She’s good with cows: ‘When I’m with cattle, it’s not at all cognitive. I know what the cow’s feeling,’ but it’s different with people and she has recognised her own needs by designing and building a ‘squeeze’ machine that holds her in a way that she cannot allow people to do. Sacks is very moved by Grandin, and impressed. He knows as a neurologist the emotional limits of autistic patients and the difficulties living holds for them, even if they are fortunate enough to be highly intelligent. ‘My work is my life,’ Grandin says. ‘There is not that much else.’ She took him to the airport at the end of the visit, and ‘suddenly faltered and wept’, saying that that she wanted to leave something behind her, to know that her life has had meaning. Sacks tells us, by way of ending both the essay and the book: ‘As I stepped out of the car to say goodbye, I said: “I’m going to hug you. I hope you don’t mind. ” I hugged her – and (I think) she hugged me back.’ The romantic in Sacks aches for relationship, even where its neuronal lack has, most heroically, been accommodated to. He will hug and wants to feel a reciprocation. Doubtless we all do, but this is the human Oliver Sacks trying to connect, rather than an equally human Dr Sacks respecting the existential reality of his patient. Moreover, the moment provides a moving conclusion to his story.

A story needs a conclusion whereas a case-history may not have one. In fact, stories have all kinds of needs that a case-history will not supply, and Sacks is insistent that he is writing the stories of his patients, not their cases. This is not intended to fudge fact and fiction, but to enlarge patients into people. On the other hand, he is describing people with more or less devastating illnesses – that is his raison d’être – and his explicit purpose is to generalise from these, usually unhappy, accidents of life and nature, to a greater understanding of the human condition. In Awakenings he states: ‘If we seek a “curt epitome” of the human condition – of long-standing sickness, suffering and sadness; of a sudden, complete, almost preternatural “awakening”; and, alas! of entanglements which may follow this “cure” – there is no better one than the story of these patients.’ He is offering life, death and the whole damn thing in the metaphor of his patients. And it is true that these patients and others show us what it is like, as he says, ‘to be human and stay human in the face of adversity’. But metaphors are not in fact descriptions of people in their totality. They are intentional, and consciously or unconciously edited tropes, not complete, contained narratives. I don’t know any kind of narrative, fictional or otherwise, that can present people in their totality, so perhaps it doesn’t matter, but Sacks is offering us people because of their sickness and the manner of their handling it. This is hardly an overturning of the medicalising tendency of doctors. And when we read these stories, as we do, to tell us more about ourselves, we read them as exaggerations of what we are, as metaphors for what we are capable of. Their subjects may not be patients as freaks, but they are patients as emblems. They are, as it were, for our use and our wonderment. Around their illness, the thoughts of Leibniz, Kant, Kierkegaard, Nietzsche and Proust are hoist like scaffolding, as if to stiffen their reality into meaning.

In The Island of the Colour-Blind Sacks the romantic is clearly visible, rather than merely inferred. It is a very different kind of book: two accounts of Micronesian island-hopping, based on a six-part television series to be broadcast this autumn. A fascination with islands following a childhood holiday on the Isle of Wight and reading boys’ adventure yarns, along with a Wellsian-cum-Darwinian fantasy of isolated mutation that results in a neurologically specialised population, is made concrete when he hears of a Pacific island with a colour-blind population. The Island of the Colour-Blind is a somewhat misleading title, as Pingelap turns out to have a population of 800, of whom 57 are congenitally colour-blind. The book parallels neither ‘The Country of the Blind’, nor The Voyage of the ‘Beagle’, but functions more as a travelogue of truncated dreams. This would be fine if it was written with self-conscious humour, but Sacks continually tries to redeem the minor key of the story with grand claims for what to the lay reader seems only a mildly interesting situation.

Colour-blindness – complete achromatopsia, seeing no colour at all, only degrees of luminosity that the colour-sighted would regard as grey, rather than the more common red-green colour-blindness – is also not new territory for Sacks. An Anthropologist on Mars included the somewhat Conan-Doyleishly entitled ‘Case of the Colour-Blind Painter’, who lost all sense of colour after a car accident. The condition was thoroughly described; the histology of achromatopsia was included as well as Goethe and Land’s investigation into colour vision. The narrative interest depended on the fact that Jonathan I. was a painter and on the detail of how he coped with a new life devoid of hue. Colourblindness, however intellectually interesting, does not have the same deep reverberations as the conscious/unconscious story of Awakenings, is hardly the ‘curt epitome’ of the human condition, as Sacks seems to acknowledge: ‘On the ultimate question – the question of qualia: why a particular sensation may be perceived as red – the case of Jonathan I. may not be able to help us at all.’

The minority population of achromats on Pingelap have a hard time of it. Not only do they see quite differently from the majority, and suffer, therefore, a degree of social stigma, but their condition carries with it an extreme sensitivity to light, so that they are only able to function fully in twilight and darkness. Although we lose the metaphor of the country of the blind, we do get quite a bit of medical information and develop a sympathy for their lot. Much of the story, however, is travelogue, as Sacks gathers about him a Norwegian achromat, Knut Nordby, an ophthalmologist friend, Bob Wasserman, and all their test equipment. (I presume he also had a film crew from the start, though they aren’t mentioned until he lands on Pingelap and we are told ‘the island children were fascinated not so much by our cameras as by the sound boom with its woolly muff, and within a day were making their own booms out of banana stalks and coconut wool.’)

There’s plenty to worry about, as well as plenty to learn about Oliver Sacks and his predilections. Spam, it seems, is devastating the eating habits of Micronesia: they love it, Sacks doesn’t, and frets anthropologically that their natural life is at risk as a result of American spam importations. ‘Having a sort of passion for monotony, I greatly enjoyed the unvarying meals on Pingelap, whereas Knut and Bob longed for variety ... But we were all revolted by the Spam which appeared with each meal – invariably fried; why, I wondered, should the Pingelapese eat this filthy stuff when their own basic diet was both healthy and delicious?’ This seems a minor problem compared to the fact that a good many of the islands Sacks and Co land on or pass over on their way are hush-hush American air-bases or have unbreathable air because of the usefulness of the atolls as nuclear testing sites. Still, I’m biased since I have a bit of a fondness for spam myself.

Sacks’s emotions are fully engaged on this journey. As he lands on Pingelap, children arrive to investigate. ‘I felt a wave of love – for the children, for the forest, for the island, for the whole scene ... I thought, I have arrived. I am here at last. I want to spend the rest of my life here – and some of these beautiful children could be mine.’ In fact he spends three weeks here and on other islands, meeting achromats, testing them and handing out sunglasses – a practical result of the doctors’ visit, since this simple device enables them to get out and see properly – in the way they can – during the day.

Another neurological mystery is found on Guam. A disease known as lytico-bodig, which has elements of both Parkinsons and motor neurone disease, is endemic and goes back in families to the beginning of the last century. Again, this is old Sacks territory. The variety of the symptoms and their late onset, as well as the Parkinsonian aspects, are reminiscent of his post-encephalitic patients in Awakenings. The situation presents a great challenge to the brain investigators who have yet to find the cause. It may be the result of a craving for the seeds of a particular cycad which is used by the locals as flour for tortillas and tamales. The seeds are poisonous unless lengthily prepared. It may also be the result of what seemed to be naturally very low calcium and magnesium levels. The mystery is never quite resolved, but it begins to look, by the end, as if the by now almost expected, and perhaps not very surprising, answer is that it’s the result of a combination of hereditary and environmental factors.

In any event, the affected families are suffering greatly, and Sacks visits them, observing and making tests. The disease seems to be self-limiting. No one born after 1960 appears to get it, and though this might be some comfort to the older generations, who know their children will be free of it, it’s a nuisance for the neurologists: ‘The disease is indeed dying out at last ... will the quarry, hotly pursued for forty years now, with all the resources that science can bring, elude them finally, maddeningly, by disappearing at the moment they are about to grasp it?’ There is no cure for the disease, as indeed, there seems to be no cure for much that neurology takes to be its concern. This is not the first time the locals have met neurologists. The doctor who lives on Guam and tries to make the lives of sufferers more comfortable says: ‘The patients ask us: “So what happened to those tests performed on us?” But we have no answers for them, because they are not our tests.’

There is much, towards the end of this book of the television series, on the nature of cycads, ancient palm-like plants that hark back to the Palaeozoic. Cycads are a passion of Oliver Sacks’s, and he writes of seeing them in their natural habitat in terms of the primeval sublime. Metaphors for the sublime come readily to Dr Sacks from out-of-the-way places and medical conditions, and perhaps the plethora of them in this book will work better in the visual medium of television, but after my rereadings of his other works, I began to long for someone to come along and fill instances of the mundane everyday with meaning. There must surely, I found myself brooding, be some significance in the ordinary.