Two brains: few authors have influenced the popular imagination of mental illness as much as Sacks
Ask a philosopher to name the most influential philosophical essay of the last half-century and there’s a good chance he will choose Thomas Nagel’s 1974 paper “What Is It Like to Be a Bat?” The point of Nagel’s argument is not that there is anything especially exciting about bats’ mental lives, but simply that there is no way for a human being to understand how bats—or, for that matter, any other creature—experience the world. What would it be like to know the world not through light and colour, but through sound and echo? The answer cannot be found by opening up a bat’s skull and measuring the electrical pulses in its tiny brain.
Nagel’s argument suggests there is an irreducible gulf between the human brain and the human mind. The mind may be created by the brain but there is no way to deduce the nature of consciousness from even the most complete neural map. The old mind-body problem, which bedevilled Descartes in the 17th century, does not disappear even in an age of neurological wizardry like our own. “Without consciousness,” Nagel writes, “the mind-body problem would be much less interesting. With consciousness it seems hopeless.”
The only way to find out what it’s like to be a bat would be to ask a talking bat. But what if you could find a human being whose consciousness, whose experience of the world, was so radically different from the norm that he is in some sense inhuman, or superhuman? What if a human brain, through some disease, stroke, or injury, produced a qualitatively different kind of mind, yet left its possessor still human enough to tell the world—with the help of an interpreter—what his world felt like?
Oliver Sacks has spent his career serving as that kind of interpreter—a literary ambassador to the far countries of neurological otherness. In his books, we have met a pair of twins who instinctively “see” the most complex mathematical facts, but are unable to add or subtract; a woman so trapped in her own paralysed mind that she does not experience the passage of time; a man who cannot recognise anything he sees, from a glove to a face, though his eyes work perfectly. His new book, Hallucinations, also journeys into the outer reaches of human consciousness, focusing on the hallucinatory experiences of otherwise ordinary people.
Sacks, who will turn 80 next year, has been a practicing neurologist in the New York area for almost half a century, though he was born and raised in London. He has taught generations of students and cared for countless patients in nursing homes. The diseases and symptoms he has seen must be familiar to many other neurologists. But only Sacks has had the literary ability and philosophical curiosity to take his cases out of the consulting room and reveal their deeper, more universal interest.
That interest is not just philosophical, of course. It is primarily human, and the dramatic appeal of Sacks’s stories can be gauged by the number of playwrights and filmmakers they have inspired. Harold Pinter’s play A Kind of Alaska grew out of Sacks’s classic Awakenings, which was itself turned into a movie starring Robin Williams; most recently, the story has inspired Will Self’s novel Umbrella, shortlisted for the Man Booker prize, in which the Sacks figure is a doctor called Zack Busner. Christopher Nolan’s film Memento, a thriller about a man incapable of forming long term memories, seems clearly indebted to Sacks’s case study “The Lost Mariner” from his bestselling 1987 book The Man Who Mistook His Wife for a Hat. After Sacks wrote about her in An Anthropologist on Mars (1995), the high-functioning autistic Temple Grandin became famous in her own right, and was the subject of a 2010 biopic starring Claire Danes.
Both directly and indirectly, then, few writers have exercised as much influence as Sacks on the popular imagination of mental health and illness. Which does not mean that readers look to Sacks for a scientific education. As some critics have noted, he seldom spends much time tracing the precise aetiology of a patient’s disease, and he has little to say about cutting-edge research in neurology. Writers like Eric Kandel, in his recent The Age of Insight, or Antonio Damasio, in books like Descartes’ Error (1994) and Self Comes to Mind (2010), do more to explain just how the brain creates the mind.
What interests Sacks, rather, is phenomenology: close descriptions of what it is actually like to live with dysfunctions of the brain. As he has written, “there were always two books, potentially, demanded by every clinical experience: one more purely ‘medical’ or ‘classical’—an objective description of disorders, mechanisms, syndromes; the other more existential and personal—an empathic entering into patients’ experiences and worlds.” The title of An Anthropologist on Mars was taken from Temple Grandin’s description of herself, trying to work out the subtle signals that govern most ordinary human communication. But Sacks was justified in appropriating it for himself, for the mental worlds he writes about are deeply alien to the average reader.
In Hallucinations, Sacks reveals how he first discovered his calling: on an amphetamine trip. Sacks writes candidly about how, in the mid-1960s, he embarked on a voyage of pharmaceutical discovery. This was hardly unique at the time; what made Sacks unusual is that he was led to drugs less by generational instinct than by literary influence and scientific curiosity. As a student, he had read the classics of drug literature: De Quincey and Baudelaire and Aldous Huxley. By the time he was 30, Sacks was well equipped as a doctor both to procure drugs and to combine them. On one occasion, he writes, “I developed a pharmacologic launchpad consisting of a base of amphetamine (for general arousal); LSD (for hallucinogenic intensity); and a touch of cannabis (for a little added delirium).”
But the trip that really mattered came in February 1967, when Sacks, in an amphetamine rush, read through a 500-page book about migraines by a Victorian doctor named Edward Liveing. Here, he realised, was the kind of writing he wanted to do: “I loved Liveing’s humanity and social sensitivity,” the immediacy with which he conjured his patients’ lives. “Who,” Sacks recalls asking himself, “could be the Liveing of our time? A disingenuous clutter of names spoke themselves in my mind… And then a very loud internal voice said, ‘You silly bugger! You’re the man!’”
Maybe Sacks needed to be high to allow himself such an immodest claim, but it turned out to be justified. Sacks’s first book would in fact be a study of migraines, from which he himself suffers. But it was Awakenings, his 1973 book, that introduced the world to what would become his signature style.
Starting in the mid-1960s, Sacks began to treat a group of survivors of the epidemic of encephalitis lethargica, or “sleepy sickness,” that swept the globe after the first world war. Forty years on, they had descended into a Parkinson’s disease so severe as to be almost unimaginable: catatonic, motionless, bodies wrenched into impossible contortions. Then, in a transformation Sacks describes in practically religious terms, these patients were brought back to life by the drug L-DOPA, which supplied their brains with the neurotransmitter dopamine. “I was seeing such things,” Sacks recalled in an introduction to a later edition of Awakenings, “as had never, perhaps, been seen before—and which, in all probability, would never be seen again.”
But if that suggests a Hollywood story of miraculous cure, it is misleading. When they first tried the drug, in the summer of 1969, Sacks’s patients did indeed seem to rise like so many Lazaruses. But soon many patients had gone from one extreme to the other. Instead of immobility, patients now suffered from unstoppable movements, tics, agitation and insomnia. Some refused to go on with L-DOPA, preferring catatonia to mania; others resigned themselves to a life of violent oscillations.
There was, Sacks came to understand, no cure for what his patients had. At first he believed that if the dose of L-DOPA could be precisely calibrated, it would be possible to avoid its negative “side effects.” But the very idea of side effects, he came to realise, was an illusion. In a system as intricate as the human brain, the introduction of a powerful drug was inherently chaotic.
This realisation led Sacks to doubt the conventional understanding of health and sickness he had learned in his medical training. As he wrote in Awakenings: “We rationalise, we dissimulate, we pretend: we pretend that modern medicine is a rational science, all facts, no nonsense, and just what it seems.”
His approach to L-DOPA and its effects made him something of a pariah among neurologists. His papers on the subject “elicited vehemently censorious, even violent, rejections, as if there were something intolerable in what I had written. This confirmed my feeling that a deep nerve had been struck, that I had somehow elicited not just a medical, but a sort of epistemological, anxiety—and rage.”
This professional rejection led him to turn Awakenings into a call to arms, whose real subject is not just L-DOPA but the shortcomings of a mechanistic model of neurology. To fully understand a patient’s experience, Sacks argued, it’s necessary to think empathetically and biographically, not just biologically. The loss we experience in illness is not simply a matter of bodily function: our “sense of what is lost, and what must be found, is essentially a metaphysical one. If we arrest the patient in his metaphysical search, and ask him what it is that he wishes or seeks, he will not give us a tabulated list of items, but will say, simply, ‘My happiness,’ ‘My lost health,’ ‘My former condition,’ ‘A sense of reality.’”
What the experiences of Awakenings taught Sacks was that neurological illness could only be fully understood by imagining the altered “sense of reality” that it brought to its victims. Some of the book’s most powerful and horrifying passages are its evocations of the subjective experience of severe Parkinson’s; what it feels like from the inside. In the case of “Rose R” it seemed that the disease had literally stopped her perception of time. “Waking up” in 1969, she still felt as though it were 1926, her last year of health before encephalitis lethargica claimed her. What did it feel like to spend 43 years trapped in timelessness, thinking about nothing? Rose R explained that it was like looking at a map.
“Everything I do is a map of itself, everything I do is a part of itself,” she told Sacks. “Every part leads into itself... I’ve got a thought in my mind, and then I see something in it, like a dot on the skyline. It comes nearer and nearer, and then I see what it is—it’s just the same thought I was thinking before. And then I see another dot, and another, and so on... Once I get going I can’t possibly stop. It’s like being caught between mirrors, or echoes, or something.”
If Sacks’s physical descriptions of his patients often evoke Dante, this passage beats anything in Kafka. Here is a “sense of reality” as alien to most of us as a bat’s, but explained in such a way that we can almost grasp it—a task that ordinarily belongs to fiction. No wonder Sacks’s way of writing about the lived experience of illness, cultural and imaginative as well as biological, has proved immensely influential on later writers, including classics of the medical literature genre like Anne Fadiman’s The Spirit Catches You and You Fall Down (1997) and Rebecca Skloot’s The Immortal Life of Henrietta Lacks (2010).
Sacks’s tendency to see a patient as a life rather than a case comes from his parents, both of whom were doctors. As a child, he writes in his 2010 book The Mind’s Eye, “a lot of the dinner-table conversation was inevitably about medicine, but the talk was never just about ‘cases.’ A patient might present as a case of this or that, but in my parents’ conversation, cases became biographies, stories of people’s lives as they responded to illness or injury.”
Reading his 2001 memoir Uncle Tungsten, however, it becomes clear that Sacks’s childhood prepared him for his adult career in other, less happy ways as well. The central trauma of his childhood, he writes, came in 1939, when he was evacuated from London and sent to the country. In Sacks’s case, this meant a school, Braefield, which he remembers as a nightmare of sadism and deprivation. Writing about these events some 60 years later, it is clear that he has not fully recovered from them. When his older brother Michael began to exhibit psychotic symptoms, Sacks writes: “I became terrified of him, for him, of the nightmare which was becoming reality for him, the more so as I could recognise similar thoughts and feelings in myself, even though they were hidden, locked up in my own depths. What would happen to Michael, and would something similar happen to me, too? It was at this time that I set up my own lab in the house, and closed the doors, closed my ear, against Michael’s madness.”
Science, then, was a refuge against suffering and mental chaos for Sacks. While he is a character in most of his essays, Sacks is highly reticent when it comes to his personal life; you can read his books and come away knowing virtually nothing about his feelings towards sex, politics, or religion. But it is noteworthy that, as a neurologist, Sacks’s own specialty brought him into the closest possible contact with mental disorder. He has managed to remain in touch with his nightmares in a way that is often productive for writers.
Most of Sacks’s cases, however, are not as flatly nightmarish as those in Awakenings. Rather, what interests him is the way that neurological disorders create their own worlds—worlds that are different from our own, and usually worse, but not without their own integrity. He is fond of quoting Ivy McKenzie’s formulation: “The physician is concerned... with a single organism, the human subject, striving to preserve its identity in adverse circumstances.” Thus Temple Grandin, though she can’t understand most human emotions, is able to build a successful career on her close empathy with animals. The work of the autistic savant Stephen Wiltshire, who is able to make incredibly accurate drawings of buildings after a single viewing, “may never develop, may never add up to a major opus, an expression of a deep feeling or theory or view of the world”; but, Sacks insists, “his vision is valuable... precisely because it conveys a wonderfully direct, unconceptualised view of the world.”
This insistence on finding the humanity in the most damaged individuals can lead, in Sacks’s work, to an occasional saccharine note—an insistence on finding a redemptive message even in cases of mere casualty. There is also the danger of voyeurism, of allowing the reader to thrill to the weirdness of some of his case studies. This happens most often in The Man Who Mistook His Wife for a Hat, where some cases read like the kind of “cases” Sherlock Holmes solves. In that book, “The Man Who Fell Out of Bed” deals with a man who is convinced that his leg does not belong to his body; that it is a strange limb placed in his bed as some sort of cruel practical joke. The denouement of the story, italics and all, seems like pure Edgar Allan Poe: “But—and at this point his conversational manner deserted him, and he suddenly trembled and became ashen-pale—when he threw it out of bed, he somehow came after it—and now it was attached to him.”
Sacks’s most adventurous and consequential work deals with people who, like Nagel’s bat, inhabit a profoundly foreign world. By contrast, Hallucinations, his new book, is lighter, almost frolicsome at times, because it deals with otherwise ordinary people who merely take brief holidays from reality. Drugs are probably the most popular way to do this—as the word “trip” suggests—but Sacks covers a range of other hallucinogenic conditions as well. These can be as trivial as hypnagogic visions or voices, experienced as you fall asleep, and as exotic as Charles Bonnet Syndrome (CBS), in which a totally blind person begins to see images.
Most of the time, Sacks points out, it is easy for us to tell when we are hallucinating: the images we see are just that, images, without the tangible and emotional presence of real objects. The more philosophically interesting cases in Hallucinations are those where reality itself seems altered, in such a way that it is impossible—for the patient, and maybe for the doctor as well—to separate symptom from true perception.
In epilepsy, for instance, seizures are often preceded by hallucinatory states. For Dostoevsky, one famous sufferer, these moments seemed to offer a connection to the divine: “I felt heaven was going down upon the earth and that it had engulfed me,” he wrote. “I have really touched God.” Such religious feelings are common among epileptics. Sacks cites a paper arguing that Joan of Arc’s visions are best understood as epileptic symptoms, and in his first book he wrote that the visions of the medieval saint Hildegarde von Bingen matched common migraine symptoms. He is very hesitant, however, to take the next step and assert that this means religious experience itself is a kind of hallucination: “To speak of a biological basis and biological precursors of religious emotion says nothing of the value, the meaning, the ‘function’ of such emotions, or of the narratives and beliefs we may construct on their basis.”
Even so, the implications of Sacks’s work for metaphysics are unmistakable. His case studies point to the conclusion that there is no such thing as a simple objective reality. What we call objectivity is really the consensus of all similarly constructed minds; of all healthy brains. Sacks’s stories can thus be read as footnotes to Kant, who first demonstrated that we can never know the noumenon, the thing in itself, but only the phenomenon, the thing as it presents itself to our particular kind of mind. Autism, Parkinson’s and other brain conditions can so fundamentally alter one’s experience of the world as to create a wholly different reality, one which is no less real to those who experience it. It takes a doctor and writer as intrepid as Oliver Sacks to guide us through those strange, and strangely human, worlds.
