Author: Oliver Sacks
This book is an exhilarating excursion into the world of some the most intriguing neurological disorders. The main theme linking the stories is the detailed narrative of each case study. The author’s trademark is his ingenious capacity for probing beneath the superficial diagnosis to reveal the wider impact of the disease on his patients. His abiding objective is to unravel the real person behind the diagnostic label, and to use this to make a difference to their lives. He expounded on this when he said ‘I am equally interested in diseases and people…constantly my patients drive me to question, and constantly my questions drive me to patients’ (page xxi). Arguing that the medical case history does not reveal the real person, he uses his narrative style ‘to restore the human subject at the centre’, thereby tightly connecting the study of disease with the study or neurology of identity (page xxii). He went to great lengths to justify his preference for narrative, saying ‘historically, as narratives-we are each of us unique’ (page 117). In this, the author, a renown neurologist, follows in the footsteps of his declared role models, Alexander Luria, Paul Broca, and Hughlings Jackson.
Many of the stories in the book focus on people with rare and striking neurological disorders, and they reflect both the complexity and the vulnerability of the brain. The man who mistook his wife for a hat, for example, is ‘a musician of distinction‘ who suddenly lost the ability to recognise faces, and ‘saw faces where there were no faces to be seen’ (page 9). Describing what he said ‘was the strangest mistake I had ever come across’, the author related how the musician also astonishingly mistook his foot for his shoe (page 11). However, rather than focus on the negative aspect of the case, the author characteristically emphasised the positives, telling the musician ‘I can’t tell you what I find wrong…but I’ll say what I find right‘ (page 19). Instead of envisaging his patients as victims, he preferably depicts them as heroes, martyrs, and warriors (page xxiii). He repeatedly painted them as extraordinary people who are seeking and finding ways of overcoming their challenging handicaps.
One of the most touching stories in the book is of Jimmy, the Lost Mariner. He suffers with Korsakoff syndrome and has an ‘extreme and extraordinary loss of recent memory‘, which meant he was apt to forget anything he sees or hears within seconds (pages 25 and 29). But even with this profoundly disabled patient, the author emphasised that ‘a man does not consist of memory alone but also has feeling, will, sensibilities, and morality‘, and it is through these ‘that you may find ways to touch him’ (page 36). And touch him the author did, illustrating that ‘however great the organic damage…there remains the undiminished possibility of reintegration by art, by communion, by touching the human spirit: and this can be preserved in what seems at first a hopeless state of neurological devastation’ (page 42). Rather than project gloomy forecasts, the author consistently argues that even the most superficially hopeless cases have redeeming aspects, if only those charged with caring for them bother to look.
Perhaps the most insightful of all the narratives is that of Rebecca. This is a young lady who is seemingly a ‘mass of handicaps and incapacities‘. But observing her outside of the clinical setting, in touch with nature, the author found that ‘at some deeper level there was no sense of handicap or incapacity, but a feeling of calm and completeness‘ (page 189). He reflected on how his neurological assessments ‘had given me no hint of her positive powers, her ability to perceive the real world…as a coherent, intelligible, poetic whole‘ (page 190). Her case made him realise the inadequacy of relying entirely on routine clinical assessments which he says ‘only show us deficits, they do not show us powers‘. He lamented that ‘we are far too concerned with ‘defectology‘, and far too little with ‘narratology‘ (pages 191-193). A similarly insightful case is of Jose, the supposedly ‘hopelessly retarded’ autistic, who the author touched and set on the path of recovery through drawing (page 225-226).
Many of the stories in the book are strikingly rare, for example the calculator savant twins. Some of the disorders are however well-recognised neurological diseases which the author ingeniously furnished with refreshingly unique perspectives and insights. An example is his positive perspective on phantom limbs, pointing out their importance to the success of artificial limbs; he said ‘the disappearance of a phantom may be disastrous, and it’s recovery, it’s reanimation, a matter of urgency’ (page 71). Another example is his constructive approach to people with aphasia. He noted that it is difficult to tell lies successfully to a person with this disorder because ‘he cannot grasp your words, and so cannot be deceived by them; but what he grasps he grasps with infallible precision, namely the expression that goes with the words.. which can never be simulated or faked, as words alone can’ (page 86). Other disorders which received the book’s insightful viewpoints include musicogenic epilepsy, migraine, and sensory neuronopathy.
A theme that ran throughout the book is the author’s disdain for formalistic neurology. He argued that the split of neuroscience at the turn of the century resulted in ‘a soulless neurology and a bodiless psychology’. He said ‘traditional neurology, by its mechanicalness, its emphasis on deficits, conceals from us the actual life which is instinct in all cerebral functions…such as imagination, memory, and perception‘. Formalistic neurology, he went further, conceals from us the very life of the mind‘ (page 93). He brilliantly illustrated this with several examples such as when he distilled the ‘advantages’ of Tourette syndrome (page 103). In many places, the author’s approach is quite unconventional, such as when he advocated the practice of ‘street neurology‘ or ‘naturalistic neurology‘- the practice of observing patients in the real world, ‘wholly given over to the spur and play of every impulse‘ (page 128).
This book highlights the humanity that underlies sincere clinical practice. By emphasising the central place of the person who has the disease, the author harkens to the kind of passionate curiosity that typifies great doctors. All the stories serve to remind physicians to reach out and understand what really makes their patients tick. It is particularly noteworthy that the author views his patients as heroes, preferring to focus on their abilities and how to overcome their limitations. The author however relied on a narrow range of selected sources which he cited repeatedly. The lessons he projects are also largely subjective, with only the occasional reference to detailed research evidence. These criticisms aside, this is a book worthy of its fame.
The book’s focus on narrative rather than case histories is particularly relevant in today’s healthcare where technology threatens to erode the human aspect of the doctor-patient interaction. The book rightly places the patient at the centre of medicine, and the author excellently demonstrates, through all his narratives, how this may be done in practice. This is an excellent book and I recommend it to all doctors.
Publisher, Place, Year: Picador Classic, London, 1986
Number of Chapters: 24
Number of Pages: 261
Star Rating: 5