MY mother and her 17 brothers and sisters had an Orthodox upbringing — all photographs of their father show him wearing a yarmulke, and I was told that he woke up if it fell off during the night. My father, too, came from an Orthodox background. Both my parents were very conscious of the Fourth Commandment (“Remember the Sabbath day, to keep it holy”), and the Sabbath (Shabbos, as we called it in our Litvak way) was entirely different from the rest of the week. No work was allowed, no driving, no use of the telephone; it was forbidden to switch on a light or a stove. Being physicians, my parents made exceptions. They could not take the phone off the hook or completely avoid driving; they had to be available, if necessary, to see patients, or operate, or deliver babies.
We lived in a fairly Orthodox Jewish community in Cricklewood, in Northwest London — the butcher, the baker, the grocer, the greengrocer, the fishmonger, all closed their shops in good time for the Shabbos, and did not open their shutters till Sunday morning. All of them, and all our neighbors, we imagined, were celebrating Shabbos in much the same fashion as we did.
Around midday on Friday, my mother doffed her surgical identity and attire and devoted herself to making gefilte fish and other delicacies for Shabbos. Just before evening fell, she would light the ritual candles, cupping their flames with her hands, and murmuring a prayer. We would all put on clean, fresh Shabbos clothes, and gather for the first meal of the Sabbath, the evening meal. My father would lift his silver wine cup and chant the blessings and the Kiddush, and after the meal, he would lead us all in chanting the grace.
On Saturday mornings, my three brothers and I trailed our parents to Cricklewood Synagogue on Walm Lane, a huge shul built in the 1930s to accommodate part of the exodus of Jews from the East End to Cricklewood at that time. The shul was always full during my boyhood, and we all had our assigned seats, the men downstairs, the women — my mother, various aunts and cousins — upstairs; as a little boy, I sometimes waved to them during the service. Though I could not understand the Hebrew in the prayer book, I loved its sound and especially hearing the old medieval prayers sung, led by our wonderfully musical hazan.
Oliver Sacks, Casting Light on the Interconnectedness of Life
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Oliver Sacks in 2001.CreditAndrea Mohin/The New York Times
It’s no coincidence that so many of the qualities that made Oliver Sackssuch a brilliant writer are the same qualities that made him an ideal doctor: keen powers of observation and a devotion to detail, deep reservoirs of sympathy, and an intuitive understanding of the fathomless mysteries of the human brain and the intricate connections between the body and the mind.
Dr. Sacks, who died on Sunday at 82, was a polymath and an ardent humanist, and whether he was writing about his patients, or his love of chemistry or the power of music, he leapfrogged among disciplines, shedding light on the strange and wonderful interconnectedness of life — the connections between science and art, physiology and psychology, the beauty and economy of the natural world and the magic of the human imagination.
In his writings, as he once said of his mentor, the great Soviet neuropsychologist and author A. R. Luria, “science became poetry.”
In books like “Awakenings,” “The Man Who Mistook His Wife for a Hat” and “An Anthropologist on Mars,” Dr. Sacks — a longtime practicing doctor and a professor of neurology at the New York University School of Medicine — gave us case studies of patients whose stories were so odd, so anomalous, so resonant that they read like tales by Borges or Calvino. A man, with acute amnesia, who loses three decades of his life and lives wholly in the immediate present, unable to remember anything for more than a minute or two. Idiot savant twins, who can’t deal with the most mundane tasks of daily life but can perform astonishing numerical tricks, like memorizing 300-digit numbers or rattling off 20-digit primes. A blind poet who suffers from — or is gifted with — extraordinarily complexhallucinations: a milkman in an azure cart with a golden horse; small flocks of birds wearing shoes that metamorphose into men and women in medieval clothes.
SCIENCEBy POH SI TENG1:59Dr. Oliver Sacks, Explorer of the Brain
Dr. Oliver Sacks was a neurologist and best-selling author who explored the brain’s strangest pathways. His work touched Hollywood, theater, even opera, and his legacy lasts in the stories he told.
By POH SI TENG on Publish DateAugust 30, 2015. Photo by Sara Krulwich/The New York Times.Watch in Times Video »
Dr. Sacks depicted such people not as scientific curiosities but as individuals who become as real to us as characters by Chekhov (another doctor who wrote with uncommon empathy and insight). He was concerned with the impact that his patients’ neurological disorders had on their day-to-day routines, their relationships and their inner lives. His case studies became literary narratives as dramatic, richly detailed and compelling as those by Freud and Luria — stories that underscored not the marginality of his patients’ experiences, but their part in the shared human endeavor and the flux and contingencies of life.
Those case studies captured the emotional and metaphysical, as well as physiological, dimensions of his patients’ conditions. While they tracked the costs and isolation these individuals often endured, they also emphasized people’s resilience — their ability to adapt to their “deficits,” enabling them to hold onto a sense of identity and agency. Some even find that their conditions spur them to startling creative achievement.
In fact, Dr. Sacks wrote in “An Anthropologist on Mars,” illnesses and disorders “can play a paradoxical role in bringing out latent powers, developments, evolutions, forms of life that might never be seen or even be imaginable in their absence.” A young woman with a low I.Q. learns to sing arias in more than 30 languages, and a Canadian physician with Tourette’s syndrome learns to perform long, complicated surgical procedures without a single tic or twitch. Some scholars believe, Dr. Sacks once wrote, that Dostoyevsky and van Gogh may have had temporal lobeepilepsy, that Bartok and Wittgenstein may have been autistic, and that Mozart and Samuel Johnson could have had Tourette’s syndrome.
In his later books, Dr. Sacks increasingly turned to chronicling his own life — from his deep love of chemistry as a boy in “Uncle Tungsten,” to his experiments with L.S.D. and amphetamines in “Hallucinations,” to his coming of age as a young man and as a doctor in “On the Move.” It was a life as eclectic and adventurous as his intellectual pursuits, taking him from medical school in England to a stint as a forest firefighter in British Columbia to medical residencies and fellowship work in San Francisco and Los Angeles. He held a weight-lifting record in California, and on weekends, sometimes drove hundreds of miles on his motorcycle, from California to Las Vegas or Death Valley or the Grand Canyon.
Animated by a self-deprecating sense of humor and set down in limber, pointillist prose, Dr. Sacks’s autobiographical accounts are as candid and searching as his writings about his patients, and they suggest just how rooted his compassion and intuitive understanding — as a doctor and a writer — were in his youthful feelings of fear and dislocation. He tells us about the lasting shock of being evacuated from London as a boy during the war, and being beaten and bullied at boarding school. The rest of his life, he writes, he would have trouble with the 3 B’s: “bonding, belonging, and believing.”
He also writes about the frightening psychotic episodes of his schizophrenic brother, Michael, and his own feelings of shame for not spending more time with him — and his simultaneous need to get away. Science, with its promise of order and logic, provided a refuge for young Oliver from the chaos of his brother’s madness, and medicine promised both family continuity (his father was a general practitioner; his mother, a surgeon) and a way to study and try to understand brain disorders like Michael’s.
Dr. Sacks once described himself as a man with an “extreme immoderation in all my passions,” and his books pulsate with his “violent enthusiasms” and endless curiosity: his fascination with ferns, cephalopods, jellyfish, volcanoes, the periodic table — for all the marvels of the natural world; as well as his passion for swimming, chemistry, photography and perhaps most of all, writing. Known as Inky as a child, he began keeping journals at the age of 14. For the shy boy, writing was a way to connect with the world, a way to order his thoughts; and he kept up the habit throughout his life, amassing nearly a thousand journals, while using his books and essays to communicate to readers the romance of science and the creative and creaturely blessings of being alive.
Inclined to living “at a certain distance from life,” Dr. Sacks writes that he unexpectedly fell in love — “(for God’s sake!) I was in my 77th year” — with the writer Bill Hayes, which meant relinquishing “the habits of a lifetime’s solitude,” like decades of meals that consisted mostly of cereal or sardines, eaten “out of the tin, standing up, in 30 seconds.”
In February, Dr. Sacks wrote in an Op-Ed essay in The New York Times about learning that he had terminal cancer and had just months to live. “I cannot pretend I am without fear,” he wrote. “But my predominant feeling is one of gratitude. I have loved and been loved; I have been given much and I have given something in return; I have read and traveled and thought and written. I have had an intercourse with the world, the special intercourse of writers and readers.
“Above all, I have been a sentient being, a thinking animal, on this beautiful planet, and that in itself has been an enormous privilege and adventure.” His patients have lost an erudite and compassionate doctor. The world has lost a writer of immense talent and heart, a writer who helped illuminate the wonders, losses and consolations of the human condition.
The author and neurologist has died, aged 82. This Radio 3 programme is from 2013.
BBC.IN
Oliver Sacks has died. A longtime contributor to The New York Review, he wrote in our pages earlier this year about illness and recovery.
A General Feeling of Disorder by Oliver Sacks
On Monday, February 16, I could say I felt well, in my usual state of health—at least such health and energy as a fairly active eighty-one-year-old can hope to enjoy—and this despite learning, a month earlier, that much of my...
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Newcastle Beach, New South Wales, Australia, 2000; photograph by Trent Parke
1.
Nothing is more crucial to the survival and independence of organisms—be they elephants or protozoa—than the maintenance of a constant internal environment. Claude Bernard, the great French physiologist, said everything on this matter when, in the 1850s, he wrote, “La fixité du milieu intérieur est la condition de la vie libre.” Maintaining such constancy is called homeostasis. The basics of homeostasis are relatively simple but miraculously efficient at the cellular level, where ion pumps in cell membranes allow the chemical interior of cells to remain constant, whatever the vicissitudes of the external environment. More complex monitoring systems are demanded when it comes to ensuring homeostasis in multicellular organisms—animals, and human beings, in particular.
Homeostatic regulation is accomplished by the development of special nerve cells and nerve nets (plexuses) scattered throughout our bodies, as well as by direct chemical means (hormones, etc.). These scattered nerve cells and plexuses become organized into a system or confederation that is largely autonomous in its functioning; hence its name, the autonomic nervous system (ANS). The ANS was only recognized and explored in the early part of the twentieth century, whereas many of the functions of the central nervous system (CNS), especially the brain, had already been mapped in detail in the nineteenth century. This is something of a paradox, for the autonomic nervous system evolved long before the central nervous system.
They were (and to a considerable extent still are) independent evolutions, extremely different in organization, as well as formation. Central nervous systems, along with muscles and sense organs, evolved to allow animals to get around in the world—forage, hunt, seek mates, avoid or fight enemies, etc. The central nervous system, with its sense organs (including those in the joints, the muscles, the movable parts of the body), tells one who one is and what one is doing. The autonomic nervous system, sleeplessly monitoring every organ and tissue in the body, tells one how one is. Curiously, the brain itself has no sense organs, which is why one can have gross disorders here, yet feel no malaise. Thus Ralph Waldo Emerson, who developed Alzheimer’s disease in his sixties, would say, “I have lost my mental faculties but am perfectly well.”
By the early twentieth century, two general divisions of the autonomic nervous system were recognized: a “sympathetic” part, which, by increasing the heart’s output, sharpening the senses, and tensing the muscles, readies an animal for action (in extreme situations, for instance, life-saving fight or flight); and the corresponding opposite—a “parasympathetic” part—which increases activity in the “housekeeping” parts of the body (gut, kidneys, liver, etc.), slowing the heart and promoting relaxation and sleep. These two portions of the ANS work, normally, in a happy reciprocity; thus the delicious postprandial somnolence that follows a heavy meal is not the time to run a race or get into a fight. When the two parts of the ANS are working harmoniously together, one feels “well,” or “normal.”
No one has written more eloquently about this than Antonio Damasio in his book The Feeling of What Happens and many subsequent books and papers. He speaks of a “core consciousness,” the basic feeling of how one is, which eventually becomes a dim, implicit feeling of consciousness.1 It is especially when things are going wrong, internally—when homeostasis is not being maintained; when the autonomic balance starts listing heavily to one side or the other—that this core consciousness, the feeling of how one is, takes on an intrusive, unpleasant quality, and now one will say, “I feel ill—something is amiss.” At such times one no longer looks well either.
As an example of this, migraine is a sort of prototype illness, often very unpleasant but transient, and self-limiting; benign in the sense that it does not cause death or serious injury and that it is not associated with any tissue damage or trauma or infection; and occurring only as an often-hereditary disturbance of the nervous system. Migraine provides, in miniature, the essential features of being ill—of trouble inside the body—without actual illness.
When I came to New York, nearly fifty years ago, the first patients I saw suffered from attacks of migraine—“common migraine,” so called because it attacks at least 10 percent of the population. (I myself have had attacks of them throughout my life.2) Seeing such patients, trying to understand or help them, constituted my apprenticeship in medicine—and led to my first book, Migraine.
Though there are many (one is tempted to say, innumerable) possible presentations of common migraine—I described nearly a hundred such in my book—its commonest harbinger may be just an indefinable but undeniable feeling of something amiss. This is exactly what Emil du Bois-Reymond emphasized when, in 1860, he described his own attacks of migraine: “I wake,” he writes, “with a general feeling of disorder….”
In his case (he had had migraines every three to four weeks, since his twentieth year), there would be “a slight pain in the region of the right temple which…reaches its greatest intensity at midday; towards evening it usually passes off…. At rest the pain is bearable, but it is increased by motion to a high degree of violence…. It responds to each beat of the temporal artery.” Moreover, du Bois-Reymond looked different during his migraines: “The countenance is pale and sunken, the right eye small and reddened.” During violent attacks he would experience nausea and “gastric disorder.” The “general feeling of disorder” that so often inaugurates migraines may continue, getting more and more severe in the course of an attack; the worst- affected patients may be reduced to lying in a leaden haze, feeling half-dead, or even that death would be preferable.3
I cite du Bois-Reymond’s self- description, as I do at the very beginning of Migraine, partly for its precision and beauty (as are common in nineteenth-century neurological descriptions, but rare now), but above all, because it is exemplary—all cases of migraine vary, but they are, so to speak, permutations of his.
The vascular and visceral symptoms of migraine are typical of unbridled parasympathetic activity, but they may be preceded by a physiologically opposite state. One may feel full of energy, even a sort of euphoria, for a few hours before a migraine—George Eliot would speak of herself as feeling “dangerously well” at such times. There may, similarly, especially if the suffering has been very intense, be a “rebound”after a migraine. This was very clear with one of my patients (Case #68 in Migraine), a young mathematician with very severe migraines. For him the resolution of a migraine, accompanied by a huge passage of pale urine, was always followed by a burst of original mathematical thinking. “Curing” his migraines, we found, “cured” his mathematical creativity, and he elected, given this strange economy of body and mind, to keep both.
While this is the general pattern of a migraine, there can occur rapidly changing fluctuations and contradictory symptoms—a feeling that patients often call “unsettled.” In this unsettled state (I wrote in Migraine), “one may feel hot or cold, or both…bloated and tight, or loose and queasy; a peculiar tension, or languor, or both…sundry strains and discomforts, which come and go.”
Indeed, everything comes and goes, and if one could take a scan or inner photograph of the body at such times, one would see vascular beds opening and closing, peristalsis accelerating or stopping, viscera squirming or tightening in spasms, secretions suddenly increasing or decreasing—as if the nervous system itself were in a state of indecision. Instability, fluctuation, and oscillation are of the essence in the unsettled state, this general feeling of disorder. We lose the normal feeling of “wellness,” which all of us, and perhaps all animals, have in health.
2.
If new thoughts about illness and recovery—or old thoughts in new form—have been stimulated by thinking back to my first patients, they have been given an unexpected salience by a very different personal experience in recent weeks.
On Monday, February 16, I could say I felt well, in my usual state of health—at least such health and energy as a fairly active eighty-one-year-old can hope to enjoy—and this despite learning, a month earlier, that much of my liver was occupied by metastatic cancer. Various palliative treatments had been suggested—treatments that might reduce the load of metastases in my liver and permit a few extra months of life. The one I opted for, decided to try first, involved my surgeon, an interventional radiologist, threading a catheter up to the bifurcation of the hepatic artery, and then injecting a mass of tiny beads into the right hepatic artery, where they would be carried to the smallest arterioles, blocking these, cutting off the blood supply and oxygen needed by the metastases—in effect, starving and asphyxiating them to death. (My surgeon, who has a gift for vivid metaphor, compared this to killing rats in the basement; or, in a pleasanter image, mowing down the dandelions on the back lawn.) If such an embolization proved to be effective, and tolerated, it could be done on the other side of the liver (the dandelions on the front lawn) a month or so later.
The procedure, though relatively benign, would lead to the death of a huge mass of melanoma cells (almost 50 percent of my liver had been occupied by metastases). These, in dying, would give off a variety of unpleasant and pain-producing substances, and would then have to be removed, as all dead material must be removed from the body. This immense task of garbage disposal would be undertaken by cells of the immune system—macrophages—that are specialized to engulf alien or dead matter in the body. I might think of them, my surgeon suggested, as tiny spiders, millions or perhaps billions in number, scurrying inside me, engulfing the melanoma debris. This enormous cellular task would sap all my energy, and I would feel, in consequence, a tiredness beyond anything I had ever felt before, to say nothing of pain and other problems.
I am glad I was forewarned, for the following day (Tuesday, the seventeenth), soon after waking from the embolization—it was performed under general anesthesia—I was to be assailed by feelings of excruciating tiredness and paroxysms of sleep so abrupt they could poleaxe me in the middle of a sentence or a mouthful, or when visiting friends were talking or laughing loudly a yard away from me. Sometimes, too, delirium would seize me within seconds, even in the middle of handwriting. I felt extremely weak and inert—I would sometimes sit motionless until hoisted to my feet and walked by two helpers. While pain seemed tolerable at rest, an involuntary movement such as a sneeze or hiccup would produce an explosion, a sort of negative orgasm of pain, despite my being maintained, like all post-embolization patients, on a continuous intravenous infusion of narcotics. This massive infusion of narcotics halted all bowel activity for nearly a week, so that everything I ate—I had no appetite, but had to “take nourishment,” as the nursing staff put it—was retained inside me.
Another problem—not uncommon after the embolization of a large part of the liver—was a release of ADH, anti-diuretic hormone, which caused an enormous accumulation of fluid in my body. My feet became so swollen they were almost unrecognizable asfeet, and I developed a thick tire of edema around my trunk. This “hyperhydration” led to lowered levels of sodium in my blood, which probably contributed to my deliria. With all this, and a variety of other symptoms—temperature regulation was unstable, I would be hot one minute, cold the next—I felt awful. I had “a general feeling of disorder” raised to an almost infinite degree. If I had to feel like this from now on, I kept thinking, I would sooner be dead.
I stayed in the hospital for six days after embolization, and then returned home. Although I still felt worse than I had ever felt in my life, I did in fact feel a little better, minimally better, with each passing day (and everyone told me, as they tend to tell sick people, that I was looking “great”). I still had sudden, overwhelming paroxysms of sleep, but I forced myself to work, correcting the galleys of my autobiography (even though I might fall asleep in mid-sentence, my head dropping heavily onto the galleys, my hand still clutching a pen). These post-embolization days would have been very difficult to endure without this task (which was also a joy).
On day ten, I turned a corner—I felt awful, as usual, in the morning, but a completely different person in the afternoon. This was delightful, and wholly unexpected: there was no intimation, beforehand, that such a transformation was about to happen. I regained some appetite, my bowels started working again, and on February 28 and March 1, I had a huge and delicious diuresis, losing fifteen pounds over the course of two days. I suddenly found myself full of physical and creative energy and a euphoria almost akin to hypomania. I strode up and down the corridor in my apartment building while exuberant thoughts rushed through my mind.
How much of this was a reestablishment of balance in the body; how much an autonomic rebound after a profound autonomic depression; how much other physiological factors; and how much the sheer joy of writing, I do not know. But my transformed state and feeling were, I suspect, very close to what Nietzsche experienced after a period of illness and expressed so lyrically in The Gay Science:
Gratitude pours forth continually, as if the unexpected had just happened—the gratitude of a convalescent—for convalescence was unexpected…. The rejoicing of strength that is returning, of a reawakened faith in a tomorrow and the day after tomorrow, of a sudden sense and anticipation of a future, of impending adventures, of seas that are open again.
Epilogue
The hepatic artery embolization destroyed 80 percent of the tumors in my liver. Now, three weeks later, I am having the remainder of the metastases embolized. With this, I hope I may feel really well for three or four months, in a way that, perhaps, with so many metastases growing inside me and draining my energy for a year or more, would scarcely have been possible before.
1
Antonio Damasio and Gil B. Carvalho, “The Nature of Feelings: Evolutionary and Neurobiological Origins,” Nature Reviews Neuroscience, Vol. 14 (February 2013). ↩
2
I also have attacks of “migraine aura,” with scintillating zigzag patterns and other visual phenomena. They, for me, have no obvious relation to my “common” migraines, but for many others the two are linked, this hybrid attack being called a “classical” migraine. ↩
3
Aretaeus noted in the second century that patients in such a state “are weary of life and wish to die.” Such feelings, while they may originate, and be correlated with, autonomic imbalance, must connect with those “central” parts of the ANS in which feeling, mood, sentience, and (core) consciousness are mediated—the brainstem, hypothalamus, amygdala, and other subcortical structures. ↩
