Awakenings

"The turning point for Sacks as a writer was to read A.R. Luria’s (the Russian ur -neuropsychologist) Mind of a Mnemonist in 1968. Those 160 pages served as an exemplar not only for Awakenings but for everything he was to write… by emulating Luria’s skill at “combining the classical and the romantic, science and storytelling.” His publishers Faber & Faber were not interested but with the acclaim of W.H. Auden, Duckworth published the book in 1973. An accessible non-fiction account of his sleeping-sickness/post-encephalitic Parkinson’s patients at the fictional ‘Mount Carmel’ hospital in imaginary ‘Bexley-on-Hudson’, with an eye for clinical detail lost since the great 19th-century neurological case narratives of Hughlings Jackson, Awakenings sold 5 million copies worldwide. Popular acclaim can be the kiss of death for scientific gravitas— the so-called ‘Sagan effect’—and Sacks was pigeonholed as a popular science writer by the academic neurology establishment, never receiving his due as an accomplished clinical neuroscientist. Sacks, a neurologist without university support for most of his career, was arguably the foremost neurologic belle-lettrist of his generation. Poignantly and meticulously he set down the case histories of 20 of his patients at Beth Abraham Hospital in the North Bronx. These patients had post-encephalitic Parkinsonism brought on by von Economo’s encephalitis which raged worldwide in 1916 and 1917 and “took or ravaged the lives of nearly five million people before it disappeared, as mysteriously and suddenly as it had arrived, in 1929.” Sacks, writing with unmatched descriptive and almost novelistic power, portrayed his wards “as insubstantial as ghosts, and as passive as zombies”; von Economo compared them to “extinct volcanoes.” Through Sacks’ widened eyes we bear witness to the responses of these patients to “a remarkable new ‘awakening drug’ L-dopa (L-3,4-dihydroxyphenalanine)—a metabolic precursor of the neurotransmitter dopamine, which is severely depleted by the degeneration of dopaminergic neurons in the substantia nigra of Parkinson’s disease patients. The first patient Sacks introduces is Frances D., a 65-year-old woman who had contracted encephalitis lethargica fifty years earlier. For the most part, she recovered and had a successful career as a legal secretary until her mid-forties when she developed “a more sinister set of symptoms” – alternating between freezing and hurrying of her movements and speech – typical of the dopamine depletion that is the signature of Parkinsonism. Increasingly incapacitated, she was admitted for chronic care to ‘Mount Carmel’ (Beth Abraham) in 1969, and over the course of 33 pages Sacks describes the therapeutic journey of his patient of “superior intelligence,” doubled up posture and “humorous eyes” in an expressionless face, beginning with initiation of 0.5 gm of L-dopa on 25 June, 1969. It is a very rough ride for patient and doctor alike written with a jarring admixture of dispassionate clinical detail and Miss D.’s “astonishment, rage, and terror” at the vicissitudes of her clinical course. In 1973 Awakenings was without precedent and Sacks’ voice helped to confirm my nascent interest in neurology as a third-year medical student. Sacks treated over 200 patients at Mount Carmel and, in the pages after Frances D., there are 19 more case reports “of our most complex sufferings and disorders of being.” As an academic outsider, Sacks’ formal scientific communications (“of the lives and responses of these patients which have no real precedent in the history of medicine”) were given short shrift by medical journals. He chose instead the larger canvas of this book of case histories of patients he treated for almost seven years. They transcended pathography and, he wrote, “composed a strange sort of Odyssey, through the deepest and darkest oceans of being.” The sense of wonder about the human neurologic condition is all-too-often dulled by the daily workflow of diagnosis and treatment. Oliver Sacks’ oeuvre is a powerful restorative for the fascination that starts us out in the practice of the field of applied human biology called, simply, ‘medicine.’ Or as in Osler’s epigram used by Sacks to open The Man Who Mistook His Wife for a Hat : “To talk of diseases is a sort of Arabian Nights entertainment.” Clinical neuroscience is a relatively young science. Although we’ve come a long way since the jousts of Cajal and Golgi in 1906, we’re still wrestling with the marvelous complexity of the 86 billion neurons we carry inside our heads. Looking backward from the dawn of neuroscience recognizable to current practitioners, neurons and glia begat synapses and neurotransmitters like dopamine, which begat action potentials. Then local circuits led to distributed networks subserving language, vision, emotion, memory, and anon. “And anon” is pointed at the neural correlates of consciousness—reverberating thalamocortical circuits? Crick’s claustrum? everything (panpsychism)? We’re still a long way from finding the neuroscience Holy Grail that unlocks David Chalmers’ ‘hard problem’ of consciousness ! As an English major going to medical school in the 1970s, psychiatry exerted a strong humanistic attraction for me. Neurology had been approaching many of the questions posed by psychiatry but neurology advanced as the tools of physiology were refined and the ‘wiring diagrams’ of neuroanatomy jumped from the pages of anatomy atlases to the images generated by CT and MRI neuroimaging. Some of my teachers practiced “neuropsychiatry”—an amalgam rarely encountered today—but the two fields remain inextricably linked. Every U.S. board-certified neurologist is granted his or her bona fides by the American Board of Psychiatry and Neurology. The adventure of exploring the science of the brain and treating its disorders was irresistible and persuasively abetted by Cajal, Cushing, Penfield, Kandel, and Sacks. I keep an open mind to the dualism of Penfield but I fervently hope for a resolution of the explanatory gap between mind and brain. We shall see."

"I must have first read this book in the early eighties, and found it – like a lot of Sacks’s writing – absolutely fascinating. Not just because of the philosophical and scientific perspectives that he is involved in, but because of his involuntary self-characterisation. I used some of Sacks’s modes and mannerisms quite shamelessly as one of the sources for my character Zack Busner, who is a repeat presence in my fictions. So in a way the seeds of Umbrella were planted here, many years ago. It was a real phenomenon, first identified in 1917 in Vienna – a pandemic of brain disease, inflammations in the lining of the brain, that spread at the end of the First World War. It affected as many as five or 10 million people worldwide. A third completely recovered after an attack. A third either suffered sleep agrypnia – where you can’t sleep at all until you die, horribly, after some days – or went into comas and died. The final third seemed to recover only to suffer further attacks months or years later, many of which resulted in long-term comas. When Oliver Sacks went to work at the Highlands hospital in Brooklyn in the late sixties, he found victims of this third moiety of patients still alive on long-stay psychiatric wards. Around the same time, the drug L-DOPA was developed with various applications in mind, one of which was for Parkinsonian patients – a neurological disease related to encephalitis lethargica. Sacks had the idea of trying L-DOPA on these post-encephalitics, with rather spectacular and flamboyant results – hence the title of his book, Awakenings . They awoke, very dramatically, from these comas. Many of them were able to very lucidly describe what it had been like. They experienced a strange kind of ebullience, and initially seemed to exhibit considerable well being. But then they developed an exaggeration of the many little ticks, foibles and palilalia – the repetition of phrases – that had afflicted them in a muted way during this long-term torporous state. These in turn become flamboyant and extreme, until in the case of some of the patients Sacks had to withdraw the medicine, and they lapsed back into even worse and more catatonic states. All sorts of things. For a start there is the straightforward, Rip van Winkle thing of having people who are out of the world for almost half a century, and then reintroducing them to it. But more it was the physical things that happened to them, the extremity of the symptoms. Many of them exhibited almost savant-like capabilities – an ability to speak at incredibly quick levels, an ability to make calculations very fast. It seemed to be akin to what happens with certain other kinds of neurological damage that gives people extraordinary mental powers at the same time as terrible mental and physical deficiencies. But mostly it was the ticks and jerks, and the way that Sacks writes about them, which triggered in me the idea that their bodies were responding to machinery in some way. There was a metronomic quality to these repetitive movements. It all began just at the end of the First World War, which was a watershed for industrialisation and the coming era of technology in civilisation. The war was an assembly line of death, and out of it came this illness, in which the individual human body seems to be caught up in a mechanistic frenzy. That was what most struck me."