pt: Is the impulse to heal not the most interesting aspect of medicine for you?
os: I want to do something, if I can. Even with incurable, advancing neurological disease there are always things to be done, adaptations to be made. But curiosity or some exploring impulse, wanting to understand what life is about, may be a stronger, safer motive.
pt: In your most recent book, An Anthropologist on Mars, one car bumps another car, causing a man to lose his color vision--not just any man, but an artist who dwells in the world of color. Life sounds awfully fragile.
os: Well, it is and it isn't. When I was in Boston yesterday, I visited a writer who all but died after eating a red snapper in Florida and getting ciguatera poisoning. I saw a patient a couple of years ago who was on his way to lunch with a colleague, walking down Fifth Avenue, when a gust of wind blew a glass table off a 30th floor balcony. The glass smashed on the way down and sent an arrow of glass straight into the back of his brain.
Having said that, I'm also impressed by how tough and resilient we are. Perhaps more than any other species on.the earth. We live in all possible climes. We survive concentration camps and starvation and heat and cold. I have a heightened sense both of the fragility and of the toughness of it.
pt: What strikes me is how exotic all of the people in your book are, their disorders. How on earth do you find them? You don't just call Bizarre Central for the latest talent.
os: If, as you say, I have some adventures into the exotic, this is only for part of the time. i still go to hospitals and see my regular patients. I've been at the same hospital in the Bronx for 29 years. But the phone rings, the mailman comes. People contact me.
pt: Surely you don't pursue every one. Which do you select, and on what basis?
os: Certain things attract me, conditions which are deep, complex, strange, like autism and Tourette's syndrome, especially if the people who have them are in touch with the impact of this on their thoughts and feelings and can be articulate. But when I got a call about Virgil--I never thought I would run into something like this--someone who had been virtually blind from birth and who had, in fact, just been given sight. And who then ran into trouble. Virgil is not too articulate. He is not a remarkable man. But he's in a remarkable situation. Not just in a Barnum and Bailey way, but remarkable in the illumination it may give into brain and mind and life and being a person. It is the remarkable which captures my attention.
pt: Do you have a wish list of disorders you would love to have fall into your lap?
os: Yeah. Since you've put it that way. At the moment, I'm seeing a number of people who were born totally color blind. But there is something else which is extremely rare. I know of a patient in Germany who has motion blindness. She may see a cow or a person clearly, but as soon as they move, they vanish then reappear for her.
Sometimes she is stuck in a freeze frame, so that in pouring tea or coffee there may be a solid motion or spout, like a glacier coming out, and then suddenly, a big puddle, as she moves from one stuck frame to another, a few seconds later. I would love to speak with this woman and spend time with her. We take color for granted, how much more do we take motion?
pt: What sorts of illumination will you find in this kind of exploration?
os: One takes the visual world for granted, and you have to see someone who can't put it together, like Virgil, or in whom it has been taken apart, like people who have had strokes or head injuries, to realize the miraculous way it's all put together. It teaches something about how the brain works--how it's not at all like a camera, but everything is analyzed, prepared, correlated, and synthesized to give an image in the brain--and also about the way people cope and survive in different ways. For me it's always both, the neurological and human sides. I'm concerned with how people hold together in the .face of disaster. That's the theme of Mars.
pt: You've taken some of the most forgotten creatures in our society, the residents of the back wards in the state hospitals, and made them into neurological stars. What kind of a trick are you playing on us?
os: Well, I am surprised myself at what has happened. When I came to this country, I was looking for space, including medical space. In England, things are tighter, more rigid, more hierarchical. I thought that in the interstices, in chronic hospitals, I could hide and do my thing, whatever my thing was. These neglected, forgotten people in the back ward were often very conscious of being neglected and forgotten. To some extent, the Awakenings patients explicitly or implicitly said, "Tell our story, and validate our lives; bring some sense or meaning to this fate." I did tell their stories. I don't know if that's any sort of trick at all.
pt: No, but it's not what we had been thinking of as the material of great stories. And that's the totally overlooked and devalued part of medicine.
os: Yeah. It didn't used to be so overlooked. The whole emphasis has moved not just from back wards, but from individual cases very much towards statistical series.
pt: It seems to me that your book could never have been written by an American, because Americans are so much more focused on the norm, and the English have maintained a tolerance of eccentricity.
os: You are libeling your own people. I don't think it's an English or American thing. Although, I have to say there is an interesting movement back to individual case histories. What I'm doing, perhaps, is somewhat more than a case history; it becomes biography. Perhaps it's just that I don't know when to stop.
I remember once, back in '69, when I was first using L-dopa, at that time an experimental drug. A former professor of mine said, "Sacks, how many patients do you have on L-dopa?" And I said, "I've got three patients, sir." He said "Gee, Ollie, I've got three thousand patients." And I said, "Yes, sir, but I know a thousand times as much with each patient as you do?'
pt: In reading Oliver Sacks, one begins to see disorder not just as a disease but as a challenge. These patients appear to be in distress. Most doctors would throw antidepressants or antianxiety agents at them and you don't. You let the condition take another course, suggesting that such drugs might be interrupting some other kind of important process, a process of adaptation.
os: I'm not anti drug. How could Awakenings have happened if I had been anti drug? I'm not against intervention. In my early book, Migraine, I talk about all sorts of interventions. But I also say that just to throw down a medication and then continue rushing around may, in a sense, defeat the purpose, because the migraine is partly saying, "Hey, stop, take it easy."
The color-blind artist first came to me in a medical way. He said, "What's happened? I can't get any sense out of anyone. I've been to a neurologist, an ophthalmologist. I tried to get hypnotized. I wondered if it was hysterical. No one has told me anything. What's going on? Can you help?"
My first function was to do various tests and to say, "Well, you seem to have knocked out these two small areas of the brain--V3 and V4--pretty completely. I don't know whether there will be any spontaneous recovery. There is nothing I can do to bring about spontaneous recovery. In the meanwhile, let's try and get you living again." He was wild at that time, potentially suicidal.
He felt that all the meaning and the joy had drained out of his art and his life. When a possible intervention later came up which might have reeducated parts of his brain to see color, he said, "I would have loved it at first, but now I don't want it."
pt: Here's someone in acute distress. Many people might have attempted to allay it with something like Prozac. Does that interfere with the creative adaptation to illness you're ultimately interested in?
os: He allayed some of the distress with gin. But there was a state of anxiety and depression which was rooted in reality.
Some things I could reassure him about. I was able to say, "No, this is not hysteria. Your unconscious is in no sense culpable. It is a genuine misfortune, but it is not factitious. It is real, but also, it's happened, and there's no reason it should happen again." I don't think I withheld what he needed.
pt: You said, his anxiety was rooted in reality. That suggests that some are and some aren't, there are some you would help with drugs and some you wouldn't.
os: Absolutely. But I'm pricked by your question. I'm not in the line of trying to withhold what may be needed.
pt: I'm not suggesting you're trying to withhold what's needed. Many people would have said, "Okay, you're agitated, here is a blast of Prozac," but you, instead, tried to contain him with information, reassurance, and somehow gave him the envelope in which he could make an adaptation, not go off some deep end.
os: Right. Okay.
pt: The people that you write about are clearly at odds with the world in some way. Are you at odds with the world in the same ways, say, as Temple Grandin [the autistic professor of animal behavior] ?
os: I don't know if she is at odds with the world. She has, so to speak, a funny angle. I'm driven very much by curiosity and the wish to understand. In some ways, I'm rather narrow. I don't get a daily newspaper. I imagine that I will hear what's going on. I never vote either.
pt: You're not a citizen.
os: No, I'm a resident alien. However, I didn't vote in England, where I could vote.
os: In fact, I'm not terribly interested. I don't think I have to be terribly interested.
If this was Nazi Germany in 1935, I would either have to know what was happening or lose my life, but rightly or wrongly, I don't feel in any particular danger. I don't feel the relevance. Besides, there are many activists around.
I'm eccentric. I don't have much social life. I don't go out much. I'm on the shy side and I don't entirely feel rooted or at home or that I belong anywhere. I don't think I ever have. The term "eccentric" means "off center;" whereas "abnormal" means "away from normal," and what I'm interested in, both in my patients and myself, is seeing whether one can establish a different center. I think a life has to be centered, but I think it doesn't have to be the same center.
The color-blind artist was able to recenter himself in a world of black and white. Temple centered herself in the realm where she has strong, strange powers and sympathies, and minimizes contact with the collegial and social world she doesn't understand and can't manage. She is not trying to be normal, but finding the richest life possible for her as an autistic person. She has a different center.
pt: Do we all have this drive to center our lives?
os: There's a balance between this and the rules and regulations, norms and traditions, conventions and orthodoxies which say, "You should do this and be this and be that." We need the traditions and conventions; they support us. Yet we mustn't be imprisoned by them.
I remember some time ago, a former chief of mine, before I'd published much, was concerned because I wasn't on the academic register, climbing up. He said, "Sacks, I'm worried about you. You don't have any position:" And I said, "Oh, yes I do;" and he said, "What?" And I said, "I have a position in the heart of medicine."
He said, "That's a lot of rhetoric." This has to do with being a little eccentric. My medical life is certainly different from the lives of many doctors, and yet, it may have its own center.
pt: It requires a great deal of confidence to be able to say, "I'm going to center my life there, and screw the position."
os: Yes. At one level, I'm timid and hesitant and have low self-esteem and all that. The other side is stubbornness and tenacity and audacity, even chutzpah.
I do think one needs to find one's own center. Otherwise you never fully become an individual. One has to become attuned to the way one thinks, the way one feels, the structure of one's psyche, the health of one's body. One needs to find the sort of mind one has. It's very crucial in education.
pt: This is the decade of the brain. Are there things that you want us to know about the brain and how it works that we won't get from a neurophysiology text?
os: Yes. The brain is in the person and the brain is in the body and the brain and the body are personal, and the person moves about in the world. Neurophysiology and cognitive psychology are reductionist, and need to be, in the sense that they study simplified situations.
The study of the individual has to come back and has to be central. It will never be outmoded. I think there's a definite danger, with this decade-of-the-brain stuff, that we may go ape over the genome project and the latest in neurophysiology. A Nobel Prize, for example, is never given for clinical work. It's always given for lab work. Lab work is crucial, and this is where the great discoveries are made. Yet it's going to be different when we come to the nature of consciousness.
pt: Of course, that's my next question.
os: This is not a simple thing to crack,if, indeed, it can be cracked at all. Neuroscience is inching up to some of the simpler forms of at least perceptual synthesis, which is a precursor of consciousness and the way, say, the visual world is put together. I don't know whether what you call "red" is the same as what I call "red," and perhaps I can never know. There is a privacy and a completeness that can never be breached, never be shared, which is a sorrow, in a way.
pt: Sure, we all reconstruct reality inside our own heads, but on the other hand, we both know that you're wearing a yellow shirt, correct?
os: No. All right, yes. That's simply a general consensus. But we're not transparent, and, we're mediated through language and through gesture.
pt: Well, if you had to place your bet on consciousness, how would you describe it?
os: Obviously, one has to go through to levels of integration far above the molecular, far above the individual neuron. One is dealing with the integrated activity of countless millions of neurons and probably a form of communication between them which is like a thousand simultaneous voices. Its complexity is unimaginable, indescribable, and at the moment quite uninvestigatable. There's perceptual consciousness, which a cat has, to make a scene imbued with recognizability, salience, meaning, value, threat, promise.
Then there's this higher-order consciousness, which involves the explicit concept of self, or so-called theory of mind, and of history. It partly requires language, although much can occur in the absence of language, and which is pretty much peculiar to our species.
Our culture beats on us constantly, and we see this most clearly in the occasional wild child, the wolf boy, who has been lost in the woods. The human without culture is not a viable creature. Our nervous systems need culture as much as they need chemicals. Without language and culture, we are like headless monsters.
pt: The culture tunes our neurons. . . .
os: Right, and so the biological and the cultural are woven in us together from the very start, from the first days of life. This is why a pure view of physiology is not sufficient. It has to take in the whole world.
PHOTOS: Oliver Sacks
Photographs by GRAHAM HABER