At the risk of sounding grandiose and overserious, I have to say that I found Awakenings to be an important reminder of human frailty and of the inscrutable power of nature. I felt the temptation, again and again, to identify with the post-encephalitic patients. And I do believe that there’s an element of the universal in their stories. One can see their constellations of symptoms printed in miniature within oneself. Dr. Sacks’s patients make one heedful of the mysterious, extreme, and sometimes terrifying potentialities of the human mind.
I suspect that, in tomorrow’s discussion, concern will be voiced about Dr. Sacks’s approach to the case history--about his style and voice, about the strong presence of his personality and his idiosyncrasies in the studies, about the boldness of some of his assertions, about his willingness to go beyond the outward and observable to the inward and intuitive. I would argue that what one may misconstrue as strange and excessive in the histories is in fact essential to the work of doctors, especially those, like psychiatrists and neurologists, who aim to treat the mind. And it is essential to all of us who seek to study and understand the mind. How often I’ve gone to my physician with a nebulous complaint, with the feeling that something is wrong and only a rough assemblage of seemingly unrelated symptoms as data from which the doctor can make deductions. Either I’m hysterical, or there is a kind of data to which the doctor’s ears and eyes are insensible. That is the data that Sacks takes into account, and that is principally what distinguishes these case histories.
A secondary distinction of his writing and clinical work is care. Care need not be sentimental, invasive, warm or fuzzy. Care cannot, however, be alive and energetic between doctor and patient, if their relationship is sterile and unequal. I want medical implements and facilities to be sterile, but my relation to the doctor and his to me ought to be based on sympathy and equality. Sacks understands that statistics and models and infinitesimally precise adjustments in the dosage of medications, though helpful, can never be adequate substitutes for humane sensitivity and thoughtful judgment, for humane consideration of the whole experience of the patient and of the patient as a whole person. I do not want to minimize the necessity of rigorous science and empirical data, but I want to emphasize the importance of generating abstract possibilities from those data with the aid of intuition and creativity, the importance of shifting one’s gaze from the specific to the universal and then back.
In the extremity of these patients’ situations the common substrate of human mental life is exposed. Sacks speaks in impassioned tones of Frances D.’s “releases or exposures or disclosures or confessions of very deep and ancient parts of herself, monstrous creatures from her unconscious and from unimaginable physiological depths below the unconscious, pre-historic and perhaps prehuman landscapes whose features were at once strange to her, yet mysteriously familiar, in the manner of certain dreams,” of “entire behaviours, entire repertoires, of a most primitive and prehuman sort.” He writes, “What we see here are genuine ancestral instincts and behaviours which have been summoned from the depths, the phylogenetic depths which all of us still carry in our persons.” This is Jung’s collective unconscious. According to Jung, and according to Sacks, we hold the same explosive potentialities.
But these case histories also reveal how thoroughly individual we all are. Consider the endless range of patients’ particular experiences of Parkinson’s, and the infinite variability of their responses to L-DOPA. How much of what we call individuality has a biological basis in the brain? That’s the first question I hope to explore tomorrow. Another pressing question has to do with Sacks’s hints and gestures as to what these cases might tell us about the use of psychoactive medications generally. He repeatedly suggests, alarmingly, that patients’ patterns of response to L-DOPA mirror the brain’s standard response to chemical interference in the form of medication (see p. 252). If Sacks is right, what does this augur for the multitudes who daily take medications for ADHD, depression, anxiety, sleeping troubles, etc.? Need we be afraid?
I apologize for the length of my post--I just really loved Sacks--and promise to be more succinct next time.
Tuesday, January 27, 2009
Monday, January 26, 2009
Stark Dualities
I was struck by the theme of dramatic contrasts – embodied both in the environment and in the patients themselves - that came up throughout the book. In the section “Life at Mount Carmel” Sacks offers a romanticized picture of what the hospital once was, painting an idealized picture of a devoted staff and a pleasant surrounding countryside, before using the words “fortress or prison” to express what he felt the place had become. He admits that some staff members still exhibit a genuine affection, and his more profound point is that the institution is inevitably a melding of forces of good and evil. He states, “The hospital, in short, is a singular mixture, where freedom and bondage, warmth and coldness, human and mechanical, life and death, are locked together in perpetual combat” (25). He describes it as a place of constant contradiction, irresolvable in that the nature of an institution is impersonal, structured, and rigid, but the reality of the people that live and work there is one of human individuality, irregularity, and compassion. In his note on that page Sacks points out that “The coercions of institutions call forth and aggravate the coercions of their inmates: thus one may observe, with exemplary clarity, how the coerciveness of Mount Carmel aggravated neurotic and Parkinsonian tendencies in post-encephalitic patients; one may also observe, with equal clarity, how the ‘good’ aspects of Mount Carmel – its sympathy and humanity – reduced neurotic and Parkinsonian symptoms.” As I read the case studies the stark duality of the disease seemed prominent in most of the patients, as well as the impact environmental factors had, in conjunction with L-DOPA, on their awakenings.
One example is in the case of Frances D., who returned from a day-trip to the country, Sacks says, “in a most radiant mood, and exclaimed: ‘What a perfect day – so peaceful – I shall never forget it! It’s a joy to be alive on a day like this…It this is what L-DOPA can do, it’s an absolute blessing!’” (51). It was the drug that gave her the ability to control her movement again, but the change in her environment elicited her elated mood and new appreciation for being alive. Once back in the hospital, however, her uplifted mind and body collapsed into a peril equally as dramatic as her ecstatic state. Sacks states, “The following day saw the onset of the worst and most protracted crisis of Miss D.’s entire life,” and goes onto describe her physical torment that made up that crisis. It is as though once Frances D. had experienced the highest joys life could offer, her body felt the need to respond with equal negative force.
Hester Y. embodied another kind of harsh contrast in reaction to L-DOPA. While slow and largely motionless without the drug, once under its influence her movements became uncannily quick. In a note Sacks states, “It Mrs. Y., before L-DOPA, was the most impeded person I have ever seen, she became, on L-DOPA, the most accelerated person I have ever seen” (103). He goes on to describe her extremely accelerated reaction time, where she would catch a ball, count to ten, and throw it back, all in a split second. She did this, Sacks says, “without realizing she did it so fast.” Although the drug freed her limbs from their stupor, it accelerated not only her physicality but her mental actions to the extreme opposite end of the spectrum.
These kinds of harsh dualities seem to be a fundamental aspect of the sleeping-sickness and the effects of L-DOPA. Sack’s work highlights not only the of uncomfortable incongruity of institutions and this particular illness, but it also demands that we reflect upon the irresolvable contradictions we all face in our environments, and how we then embody them in our behavior.
One example is in the case of Frances D., who returned from a day-trip to the country, Sacks says, “in a most radiant mood, and exclaimed: ‘What a perfect day – so peaceful – I shall never forget it! It’s a joy to be alive on a day like this…It this is what L-DOPA can do, it’s an absolute blessing!’” (51). It was the drug that gave her the ability to control her movement again, but the change in her environment elicited her elated mood and new appreciation for being alive. Once back in the hospital, however, her uplifted mind and body collapsed into a peril equally as dramatic as her ecstatic state. Sacks states, “The following day saw the onset of the worst and most protracted crisis of Miss D.’s entire life,” and goes onto describe her physical torment that made up that crisis. It is as though once Frances D. had experienced the highest joys life could offer, her body felt the need to respond with equal negative force.
Hester Y. embodied another kind of harsh contrast in reaction to L-DOPA. While slow and largely motionless without the drug, once under its influence her movements became uncannily quick. In a note Sacks states, “It Mrs. Y., before L-DOPA, was the most impeded person I have ever seen, she became, on L-DOPA, the most accelerated person I have ever seen” (103). He goes on to describe her extremely accelerated reaction time, where she would catch a ball, count to ten, and throw it back, all in a split second. She did this, Sacks says, “without realizing she did it so fast.” Although the drug freed her limbs from their stupor, it accelerated not only her physicality but her mental actions to the extreme opposite end of the spectrum.
These kinds of harsh dualities seem to be a fundamental aspect of the sleeping-sickness and the effects of L-DOPA. Sack’s work highlights not only the of uncomfortable incongruity of institutions and this particular illness, but it also demands that we reflect upon the irresolvable contradictions we all face in our environments, and how we then embody them in our behavior.
Tangible Metaphors
What struck me the most about the cases presented throughout “Awakenings” was the unmistakably metaphoric nature of each post-encephalitic and/or Parkinsonian symptom exhibited by the patients. Sacks himself underscores this out numerous times (most frequently in his extensive footnotes), as he relates the rapid L-Dopa-induced oscillations between akinesis and akathesis to “the ‘stationary states’ and quantal ‘jumps’ postulated of atoms and electronic orbits” (Sacks 111). In his own terminology, such behaviors suggest both “macro-quantal states” (in cases of hyperkinetic activity) as well as “micro-relativistic states” (in cases of catatonically warped or retarded activity).
If the analogies to physics continue, an even greater linkage can be seen between the critical (yet usually unattainable) balance between L-Dopa administration and behavioral outcome—the elusive balance point of the proverbial pin to which so many of his patients make reference. Even beyond the Newtonian principles of spatial improbability (outlined by Sacks’s footnotes, p. 201) is the same physicist’s well-known concept of gravity: one that has long been paraphrased as what goes up must go down. Certainly, this is the case for the post-encephalitic patients undergoing L-Dopa chemical therapy. In the majority of cases presented by Sacks, the more rapid an individual’s ascension to activity, the more rapid their descent or decline. One need only recall the case of Leonard P., who flew into egomaniacal delusions, wherein he envisioned the staff at Mount Carmel “…set[ting] up a sort of a evangelical lecture-tour, so that he could exhibit himself all over the States and proclaim the Gospel of Life according to L-Dopa” (210). Even before the reduction of his L-Dopa, Leonard was observed to fall into states of “rapid exhaustions or reversals of response…profound exhaustion, associated with severe recrudescence of Parkinsonian and catatonic immobility and rigidity” (215). The words of Frances D. prove equally pertinent, inasmuch as she described such psychophysiological symptoms as “…a vertical take-off…I’d gone higher and higher on L-Dopa – to an impossible height. I felt I was on a pinnacle a million miles high…And then…I crashed…I was buried a million miles deep in the ground” (201).
An even more intriguing correlation can be seen with various laws of thermodynamics. As the second law of thermodynamics predicts, any isolated system (i.e. an ecosystem, a cell, an organism) moves spontaneously toward states of greater entropy (with entropy being the amount of disorder in a given system). Simply put, disorder always increases – and the attempt to create order in any system only increases the disorder in surrounding systems. (A basic example would be the heat energy given off by a cell as it synthesizes a polypeptide to more efficiently carry out cellular functions: by burning energy from food to use to its own advantage, the cell inevitably increases the disorder of its surrounding environment as surrounding atoms are displaced by increasing temperatures). Such an event is grossly manifested by the results of L-Dopa administration in post-encephalitic patients: a predisposition to an increasingly degenerative disease is already present, which can only increase in its levels of disorder. Such necessity is exacerbated (if not precipitated by) the introduction of L-Dopa, originally intended to induce order, but actually invoking disorder as it chemically alters dopaminergic functioning in such afflicted individuals. Though a temporary respite may be experienced in the first few months of L-Dopa treatment, the ultimate effect of the drug’s administration is to disadvantageously alter isolated systems which had already been poorly-functional in the first place. Evidence of this can be found in patients’ sensitizations to the drug, as well as intensification of tics, psychosis, bipolarity, dystonias, and other ‘side-effects,’ though Sacks argues for the abolishment of this term. Sacks even acknowledges this truth, explaining that “all patients, then, move into trouble on L-Dopa…” (246).
Most importantly, however, metaphors resonating from post-encephalitic symptoms are more significant in the way they reflect and represent the personal lives of each patient. Though each behavior pattern may be undeniably linked to an external phenomenon (such as Newtonian laws of gravity or the Laws of Thermodynamics), true revelations are present in the manner by which they personify private conflicts (either concerning a relationship to a friend, family member, or hospital staff; or regarding a
Many times, the myriad symptoms (catatonic freezings, echolalia, hallucinations, voracious appetites, dystonia, etc.) seem to be non-verbal articulations on the part of the patient. Such ‘reactions,’ in a sense, have an uncanny connection to events in the patients’ lives and seem, in most cases, to be a physical manifestation of a response the patients cannot bring themselves to vociferate. It is no wonder, for instance, that various symptoms were exaggerated in response to the loss of family members or loved ones or (i.e. Margaret A., who suddenly developed encephalitis lethargica after the death of her father; Ida T., who developed a “sudden onset of impatience, irritability, impetuosity, increased appetite, and a violent temper” characteristic of the more hyperactive and psychotic end of the post-encephalitic spectrum after the death of her husband. Also: Rolando P. who, following a “cessation of [his mother’s] visits [experienced] a severe emotional crises; and Lucy K. who “imploded again, contracted herself to an intransigent point, infinitely withdrawn” after Dr. Sacks’ refusal to marry her).
Sacks, in his Perspectives section, speaks of the need for a different language that can better describe the plight of patients, a language which circumvents the dehumanizing and depersonalizing route of quantitative data and cold, mechanical analysis. In all actuality, the physical behavior of his patients seems to be just that: a language that cannot be tied down by statistics, that cannot be understood through an abstract mathematical model. A language that communicates more coherently and directly through physical metaphors representing internal emotional/psychological states. As Sacks sums up, “the person [or patient] shows forth in all his reactions, in a continual disclosure or epiphany of himself; he is always enacting himself in the theatre of his self” (259). If this is true, then the enactment of one’s internal world cannot be ruled out as an underlying force of post-encephalitic symptoms. The metaphoric nature of the disease becomes evident, and the behavioral responses both on and off of L-Dopa take on significantly more meaning: a meaning which eludes statistical categorization, as well as predictability.
If the analogies to physics continue, an even greater linkage can be seen between the critical (yet usually unattainable) balance between L-Dopa administration and behavioral outcome—the elusive balance point of the proverbial pin to which so many of his patients make reference. Even beyond the Newtonian principles of spatial improbability (outlined by Sacks’s footnotes, p. 201) is the same physicist’s well-known concept of gravity: one that has long been paraphrased as what goes up must go down. Certainly, this is the case for the post-encephalitic patients undergoing L-Dopa chemical therapy. In the majority of cases presented by Sacks, the more rapid an individual’s ascension to activity, the more rapid their descent or decline. One need only recall the case of Leonard P., who flew into egomaniacal delusions, wherein he envisioned the staff at Mount Carmel “…set[ting] up a sort of a evangelical lecture-tour, so that he could exhibit himself all over the States and proclaim the Gospel of Life according to L-Dopa” (210). Even before the reduction of his L-Dopa, Leonard was observed to fall into states of “rapid exhaustions or reversals of response…profound exhaustion, associated with severe recrudescence of Parkinsonian and catatonic immobility and rigidity” (215). The words of Frances D. prove equally pertinent, inasmuch as she described such psychophysiological symptoms as “…a vertical take-off…I’d gone higher and higher on L-Dopa – to an impossible height. I felt I was on a pinnacle a million miles high…And then…I crashed…I was buried a million miles deep in the ground” (201).
An even more intriguing correlation can be seen with various laws of thermodynamics. As the second law of thermodynamics predicts, any isolated system (i.e. an ecosystem, a cell, an organism) moves spontaneously toward states of greater entropy (with entropy being the amount of disorder in a given system). Simply put, disorder always increases – and the attempt to create order in any system only increases the disorder in surrounding systems. (A basic example would be the heat energy given off by a cell as it synthesizes a polypeptide to more efficiently carry out cellular functions: by burning energy from food to use to its own advantage, the cell inevitably increases the disorder of its surrounding environment as surrounding atoms are displaced by increasing temperatures). Such an event is grossly manifested by the results of L-Dopa administration in post-encephalitic patients: a predisposition to an increasingly degenerative disease is already present, which can only increase in its levels of disorder. Such necessity is exacerbated (if not precipitated by) the introduction of L-Dopa, originally intended to induce order, but actually invoking disorder as it chemically alters dopaminergic functioning in such afflicted individuals. Though a temporary respite may be experienced in the first few months of L-Dopa treatment, the ultimate effect of the drug’s administration is to disadvantageously alter isolated systems which had already been poorly-functional in the first place. Evidence of this can be found in patients’ sensitizations to the drug, as well as intensification of tics, psychosis, bipolarity, dystonias, and other ‘side-effects,’ though Sacks argues for the abolishment of this term. Sacks even acknowledges this truth, explaining that “all patients, then, move into trouble on L-Dopa…” (246).
Most importantly, however, metaphors resonating from post-encephalitic symptoms are more significant in the way they reflect and represent the personal lives of each patient. Though each behavior pattern may be undeniably linked to an external phenomenon (such as Newtonian laws of gravity or the Laws of Thermodynamics), true revelations are present in the manner by which they personify private conflicts (either concerning a relationship to a friend, family member, or hospital staff; or regarding a
Many times, the myriad symptoms (catatonic freezings, echolalia, hallucinations, voracious appetites, dystonia, etc.) seem to be non-verbal articulations on the part of the patient. Such ‘reactions,’ in a sense, have an uncanny connection to events in the patients’ lives and seem, in most cases, to be a physical manifestation of a response the patients cannot bring themselves to vociferate. It is no wonder, for instance, that various symptoms were exaggerated in response to the loss of family members or loved ones or (i.e. Margaret A., who suddenly developed encephalitis lethargica after the death of her father; Ida T., who developed a “sudden onset of impatience, irritability, impetuosity, increased appetite, and a violent temper” characteristic of the more hyperactive and psychotic end of the post-encephalitic spectrum after the death of her husband. Also: Rolando P. who, following a “cessation of [his mother’s] visits [experienced] a severe emotional crises; and Lucy K. who “imploded again, contracted herself to an intransigent point, infinitely withdrawn” after Dr. Sacks’ refusal to marry her).
Sacks, in his Perspectives section, speaks of the need for a different language that can better describe the plight of patients, a language which circumvents the dehumanizing and depersonalizing route of quantitative data and cold, mechanical analysis. In all actuality, the physical behavior of his patients seems to be just that: a language that cannot be tied down by statistics, that cannot be understood through an abstract mathematical model. A language that communicates more coherently and directly through physical metaphors representing internal emotional/psychological states. As Sacks sums up, “the person [or patient] shows forth in all his reactions, in a continual disclosure or epiphany of himself; he is always enacting himself in the theatre of his self” (259). If this is true, then the enactment of one’s internal world cannot be ruled out as an underlying force of post-encephalitic symptoms. The metaphoric nature of the disease becomes evident, and the behavioral responses both on and off of L-Dopa take on significantly more meaning: a meaning which eludes statistical categorization, as well as predictability.
Startingly Alive
I am thankful to Elizabeth for having us read the prologues because they clearly and concisely provide much needed information about the history of, among other things, Parkinsonism, the Sleeping Sickness epidemic and about Sacks himself. Reading his at times hectic style in his additions and footnotes to the original ‘Great Awakening’ text prepares one for what is to come—accounts and explanations chock full of detail—detail one would have to know some history to fully comprehend. The many facts and elucidations Sacks includes in his first thirty pages truly pulled me in and made me want to get to the case studies as soon as possible so I could begin to read about the several different effects and manifestations he mentions in the prologue. I found myself questioning many of his statements. For example, I was very surprised and still baffled by the fact that the Mount Carmel ‘awakening’ is the only existing account of its kind. I am not sure if I understand the initial hostile reactions to Sacks observations by the medical community of the time. Was this simply because his finding seemed “beyond credibility”? I imagine there had to be some fear and excited apprehension on both the part of the author and the profession with the instance of such a monumental discovery like that of a ‘miracle drug’.
Sacks honest enthusiasm for what he was witnessing and studying is humbling. “What excited me was that the spectacle of the disease was never the same with two patients.” Here Sacks refers to the “wonderful panorama of the phenomena” that he saw in the post-encephalitic patients. I also thought that his writing style and possibly his inspiration in much of his research are apparently very influenced by his elders and contemporaries such as Ibsen, Cotzias and predominantly Luria. I think Luria’s “Romantic Science” study is what may possibly characterize much of Oliver Sack’s life and work. The “combination of intellectual power and human warmth’ is very much present in his case studies and descriptions of patient, doctor, attendant relations. The great promise of L-DOPA and the consequent threat for the patients is truly a perverse case in point of the resilience and strength of will and humanity. The way Sacks describes the many unique side effects and symptoms of the disorder is truly dynamic in that he describes certain ones in medical language—yet still being accessible for a wider audience—and explains these characteristics with a very specific tone in mind. On the other hand, in describing other outcomes he expresses great empathy for the patients and their most impenetrable states. “Unimaginable solitude”, he writes, “perhaps the least bearable of all.”
Sacks honest enthusiasm for what he was witnessing and studying is humbling. “What excited me was that the spectacle of the disease was never the same with two patients.” Here Sacks refers to the “wonderful panorama of the phenomena” that he saw in the post-encephalitic patients. I also thought that his writing style and possibly his inspiration in much of his research are apparently very influenced by his elders and contemporaries such as Ibsen, Cotzias and predominantly Luria. I think Luria’s “Romantic Science” study is what may possibly characterize much of Oliver Sack’s life and work. The “combination of intellectual power and human warmth’ is very much present in his case studies and descriptions of patient, doctor, attendant relations. The great promise of L-DOPA and the consequent threat for the patients is truly a perverse case in point of the resilience and strength of will and humanity. The way Sacks describes the many unique side effects and symptoms of the disorder is truly dynamic in that he describes certain ones in medical language—yet still being accessible for a wider audience—and explains these characteristics with a very specific tone in mind. On the other hand, in describing other outcomes he expresses great empathy for the patients and their most impenetrable states. “Unimaginable solitude”, he writes, “perhaps the least bearable of all.”
Sunday, January 25, 2009
Oh, sweet humanity.
In my opinion, the case of Frances D. yielded its most fascinating insights in the footnotes. I was particularly intrigued by what Sacks referred to as the “second awakening”, ie the surfacing of primal human urges and characteristics over the course of taking L-DOPA, and the description of the mitigating effects that things like human contact, music, and internal rituals had on patients’ side-effects. These two happenings seem strangely intertwined, though they are intrinsically opposed (indeed, an unintentional Parkinsonian reference), that is, one having to do with the arrival of adverse reactions to L-DOPA and the other with combating those reactions. However, though they address opposing sides of the same issues, they both belong to the same sort of sub-element that subtly pervades all of Sacks’ observations; the innate humanness of his patients. Both the involuntary teeth-gnashing and the normalizing effect of a human touch are very human tendencies, albeit from very different sides of the spectrum. Sacks refers to the former as “genuine ancestral instincts and behaviours which have been summoned from the depths, the phylogenetic depths which all of us still carry in our persons” (Sacks 55-56), while the latter is a more familiar phenomenon that one does not necessarily associate with disease. Clearly, these are two very different descriptions of human behavior. Nevertheless, they both refer to a part of the person not affected by drugs, though the drugs may activate it. The strength of the primitive behaviors is such that they are uncontrollable and totally involuntary, while on the other side the strength of willpower and self-manipulation is such that it can raise a frozen man from a wheelchair. How different are these types of power? How different are their sources? Are they simply varying manifestations of the same thing? These are questions I found myself considering after reading the case of Frances D, and other case studies. I admire Sacks for deliberately permeating his book with reminders of humanity shown from all sides, and not simply attributing all successes and failures to interactions between the disease and the drug. Though obviously, discussions on human vitality caused by L-DOPA are also necessary; such as in the cases of Magda B and Rose R, which saw tremendous increases in personality and vivacity after the patients started on the drug. However, the unavoidable adverse effects were often worse than the original symptoms, creating an anguished impasse for the patient. I often found myself torn, while reading these cases, as to whether I myself would continue taking the drug. The vivacity granted by it is no small thing, yet I have difficulty imagining a life in those circumstances in the first place, which makes me an unfit judge. The most frightening part about their conditions was that it did not affect distinct parts of the body or the mind, but rather settled over the entire being like a fog. Within the fog a person may find clear patches through which they may speak, move, or think, but these patterns were unpredictable and thus unreliable. Their seemed to be no respite from full disability. So however brief the remission was, it was uplifting to know that a happy interlude existed between periods of crushing illness; that the patients could feel human once more.
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