by Oliver Sacks
Kremer, on the other hand, was intuitive in the extreme; I remember him once making a diagnosis on a newly admitted patient as soon as we entered the ward. He spotted the patient thirty yards away, clutched my arm excitedly, and whispered “Jugular foramen syndrome!” in my ear. This is an exceedingly rare syndrome, and I was astonished that he could identify it, across the length of the ward, at a glance.
Kremer and Gilliatt made me think of Pascal’s comparison between intuition and analysis in the opening of the Pensées. Kremer was preeminently intuitive; he saw everything at a glance, often more than he could put into words. Gilliatt was primarily analytic, looking at phenomena one at a time but seeing in depth the physiological antecedents or consequences of each.
Kremer’s sympathy or empathy was very remarkable. He seemed to read his patients’ minds, to know intuitively all their fears and hopes. He observed their movements and postures like a theater director with his actors. One of his papers—a favorite of mine—was called “Sitting, Standing, and Walking.” It showed how much he observed and understood even before doing a neurological exam, even before the patient opened his mouth.
In his Friday afternoon outpatient clinics, Kremer might see thirty different patients, but each one claimed his intense, undivided, and compassionate attention. He was much loved by his patients, and all of them spoke of his kindness, of how they found his very presence therapeutic.
Kremer remained interested and often actively involved in the lives of his housemen long after they had moved on to other jobs. He advised me about going to America, gave me some introductions, and twenty-five years later wrote me a thoughtful letter after reading A Leg to Stand On.6
I had less contact with Gilliatt—we were both, I think, quite shy—but he wrote to me when Awakenings came out in 1973 and invited me to call on him in Queen Square. I found him far less terrifying now, with an intellectual and emotional warmth I would never have suspected. The following year, he invited me again, to show the documentary film of my Awakenings patients there.
I was sad when Gilliatt died of cancer—he was still relatively young and very productive when it hit him—and when Kremer, who was so sociable and so loved conversation and who continued to see patients long after his “retirement,” was rendered aphasic by a stroke. Both influenced me, in good but very different ways: Kremer to be more observant and intuitive; Gilliatt to think always of the physiological mechanisms involved. More than fifty years later, I remember them both with affection and gratitude.
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My pre-med studies in anatomy and physiology at Oxford had not prepared me in the least for real medicine. Seeing patients, listening to them, trying to enter (or at least imagine) their experiences and predicaments, feeling concerned for them, taking responsibility for them, was quite new to me. Patients were real, often passionate individuals with real problems—and sometimes choices—of an often agonizing sort. It was not just a question of diagnosis and treatment; much graver questions could present themselves—questions about the quality of life and whether life was even worth living in some circumstances.
This hit me very hard when I was a houseman at the Middlesex and Joshua, a young man and fellow swimmer, was admitted to the medical unit with odd and puzzling pains in his legs. A tentative diagnosis was made from some blood tests, and, pending further tests, he was allowed to spend the weekend at home. On Saturday night, while he was enjoying himself at a party with a crowd of young people, including some medical students, one of the students asked Joshua why he had been admitted to hospital. He said he didn’t know but had been given some pills. He showed the bottle to his questioner, who, seeing “6MP” (6-mercaptopurine) on the label, blurted out, “Christ, you must have acute leukemia.”
When Joshua came back from his weekend leave, he was in a desperate state of mind. He asked if the diagnosis was certain, what treatments could do, what lay in store for him. A bone marrow test was done, confirming the diagnosis, and he was told that while medication might give him a little more time, he would go downhill and die within a year, perhaps sooner.
That afternoon, I saw Joshua climbing over the railings of the balcony; our ward was on the second floor. I rushed over to the railings and pulled him back, saying whatever I could about life being worth living, even with such a condition. Reluctantly—the moment of decision had passed—Joshua let himself be persuaded back into the ward.
The strange pains quickly grew more severe and began to affect his arms and trunk as well as his legs. It became apparent that these were caused by leukemic infiltrations of the sensory nerves as they entered the spinal cord. Pain medication was of no use, though he was put on ever-stronger opiates, by mouth and injection, and finally heroin. He started to scream with pain, day and night, and at this juncture the only recourse was to give him nitrous oxide. As soon as he came round from the anesthesia, he started screaming again.
“You shouldn’t have pulled me back,” he said to me. “But I guess you had to.” He died, racked with pain, a few days later.
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It was not easy, or safe, to be an open or practicing homosexual in the London of the 1950s; homosexual activities, if detected, could lead to harsh penalties, imprisonment, or, as in Alan Turing’s case, chemical castration by the mandatory administration of estrogen. Public attitudes were, on the whole, as condemnatory as the law. It was not easy for homosexuals to meet; there were some gay clubs and gay pubs, but these were constantly watched and raided by the police. There were agents provocateurs everywhere, especially in public parks and public lavatories, trained to seduce the unwary or ingenuous and bring them to destruction.
Though I made visits to “open” cities like Amsterdam as often as I could, I dared not seek any sexual partners in London, the more so as I was living at home, under my parents’ vigilant eyes.
But in 1959, when I was doing house jobs in medicine and neurology at the Middlesex, I had only to walk down Charlotte Street and cross Oxford Street, and I was in Soho Square. A little farther—down Frith Street—and I would find myself in Old Compton Street, where everything was for rent or sale. Here, at Coleman’s, I could get my favorite Havana cigars; a Bolivar “torpedo” could last a whole evening, and I would treat myself to one on special, festive occasions. There was a delicatessen which sold a poppy seed cake of a succulence, a lusciousness, I have never tasted since, and there was a little newspaper and confectionery shop with sexual advertisements posted in its windows, advertisements discreetly ambiguous—anything else would have been dangerous—but unmistakable in meaning.
One such was from a young man who said that he loved motorbikes and motorbike gear. He gave his first name, at least a name, Bud, and a phone number. I dared not linger, much less make a note of his advertisement, but my then-photographic memory absorbed it in an instant. I had never answered an advertisement, or thought of doing so, in my life, but now, after nearly a year of abstinence—I had not been to Amsterdam since the previous December—I decided to phone the enigmatic “Bud.”
We chatted on the phone, circumspectly, talking mostly about our motorbikes. Bud had a BSA Gold Star, a big 500 cc single with dropped handlebars, and I had my 600 cc Norton Dominator. We arranged to meet at a motorbike café and go for a ride from there. We would recognize each other by our bikes and our kit: leather jackets, leather pants, leather boots and gloves.
We met, shook hands, admired each other’s bikes, and then took off for a ride around south London. Born and bred in northwest London, I was lost in south London, so Bud led the way. I thought he looked very gallant, a knight of the roads, riding his motor-steed, clad in black leather.
We went back to his apartment in Putney for dinner—a rather bare apartment, with very few books but a lot of motorbike magazines and motorbike gear. There were photographs of motorcycles and motorcyclists all over the walls and (this I had not expected) some beautiful underwater photographs which Bud had taken; his other passion, besides motorcycling, was scuba diving. I ha
d been initiated into scuba diving while I was at the Red Sea in 1956, and so here was another avocation we shared (quite an unusual one in the 1950s). Bud had a lot of diving gear, too; this was before the days of wet suits and neoprene, and one wore dry suits of heavy rubber.
We had a beer and then, quite suddenly, Bud said, “Let’s go to bed.”
We made no attempt to find out more about each other; I knew nothing about Bud, his work, or even his last name, and he knew as little about me, but we knew (intuitively, unerringly) what we wanted, how we could pleasure ourselves and each other.
There was no need to say afterwards how much we had enjoyed our encounter, how much we wanted to meet again. I was about to go to Birmingham for a six-month house job in surgery, but this was a problem easily dealt with. I could shoot down to London on my bike on Saturdays to spend the night at home with my parents, but I could arrive early and spend the afternoon with Bud first, and the following morning we could go for a ride together. I loved our rides on crisp Sunday mornings, especially if I stowed my own bike and rode pillion with Bud, so closely jammed together we sometimes felt like a single leather animal.
I was in a state of uncertainty about my own future at this time: my house jobs would come to an end in June of 1960, and I would then be eligible for the draft (my call-up had been postponed through the years of studenthood and internship).
I said nothing while I was ruminating on this, but in June I wrote to Bud, saying that I would be leaving England for Canada on my birthday, July 9, and might not return. I did not think this would affect him very much; we had been motorcycle buddies and bed buddies but, I thought, nothing more. We never spoke about any feelings for each other. But Bud sent me a passionate, painful letter in reply; he felt desolate, he said, had sobbed when he received my letter. I felt stricken when I received his letter and realized, too late, that he must have fallen in love with me and that now I had broken his heart.
1. In a notebook I kept at the time, I indicated my intention to write five novels (including the motorcycle one), as well as a memoir on my chemical boyhood. I never wrote the novels, but forty-five years later I wrote the memoir, Uncle Tungsten.
2. My examiner in zoology when I had taken the Higher School Certificate exam in 1949 was the great zoologist J. Z. Young, who had discovered the giant nerve axons of squids; it was investigation of these giant axons a few years later which led to our first real understanding of the electrical and chemical basis of nerve conduction. Young himself spent every summer in Naples, studying the behavior and brain of the octopus. I wondered whether I should try to work with him, as Stuart Sutherland, my contemporary at Oxford, was now doing.
3. In the United States, this would have been called an internship; in England, interns are referred to as housemen, and residents as registrars.
4. This was indeed impressive, though my mother, I could not help thinking, had become a consultant at the age of twenty-seven.
5. Valentine Logue, their neurosurgical colleague on the ward above, used to ask junior physicians if they saw anything “wrong” about his face, and only then would we realize that there was something odd about his eyes: one of his pupils was much larger than the other. We speculated endlessly as to why this was so, but Logue never enlightened us.
6. Kremer wrote:
I was asked to see a puzzling patient on the cardiology ward. He had atrial fibrillation and had thrown off a large embolus giving him a left hemiplegia, and I was asked to see him because he constantly fell out of bed at night for which the cardiologists could find no reason.
When I asked him what happened at night he said quite openly that when he woke up in the night he always found that there was a dead, cold, hairy leg in bed with him which he could not understand but could not tolerate and he, therefore, with his good arm and leg pushed it out of bed and naturally, of course, the rest of him followed.
He was such an excellent example of this complete loss of awareness of his hemiplegic limb but, interestingly enough, I could not get him to tell me whether his own leg on that side was in bed with him because he was so caught up with the unpleasant foreign leg that was there.
I quoted this passage of Kremer’s letter when I had occasion to describe a similar case (“The Man Who Fell out of Bed”) in The Man Who Mistook His Wife for a Hat.
Leaving the Nest
As a boy, reading novels by Fenimore Cooper and watching cowboy films, I had formed a romantic view of America and Canada. The rugged open spaces of the American West portrayed in John Muir’s books and Ansel Adams’s photographs seemed to promise an openness and freedom and an ease which England, still recovering from the war, lacked.
As a medical student in England, my military service had been deferred, but as soon as I finished my house jobs, I was due to report for duty. I did not like the idea of military service much (although my brother Marcus had enjoyed it, and his knowledge of Arabic got him posted to Tunisia, Cyrenaica, and North Africa). I had signed up for an attractive alternative, doing a three-year stint as a doctor in the Colonial Service, and I had elected to do my three years in New Guinea. But the Colonial Service itself was shrinking, and its medical service option came to an end just before I finished medical school. Obligatory military service itself was due to end just months after my enlistment date in August.
The feeling that an attractive, exotic posting in the Colonial Service was no longer possible and the fact that I would be one of the very last conscripts infuriated me and was another factor in making me leave England. Nonetheless, I felt that I had, in some sense, a moral duty to serve. These conflicting feelings drove me, when I arrived in Canada, to volunteer for the Royal Canadian Air Force. (I was entranced by a line of Auden’s, about the airman’s “laughter in leather.”) Service in Canada, a Commonwealth country, would have been accepted as equivalent to military service in England, an important consideration if I returned to England.
There were other reasons to escape England, as my brother Marcus had done ten years earlier when he went to live in Australia. Large numbers of highly qualified men and women left England in the 1950s (in the so-called brain drain), for professions and universities were crowded in England, and (as I saw when I did my neurology internship in London) brilliant and accomplished people could get stuck for years in subservient roles, never enjoying autonomy or responsibility. I thought that America, with a medical system far more capacious and far less rigid than that in England, would have room for me. I was also moved, as Marcus had been, by a feeling that there were too many Dr. Sackses in London: my mother, my father, my older brother David, an uncle, and three first cousins, all competing for space in London’s crowded medical world.
I flew to Montreal on July 9, my twenty-seventh birthday. I spent a few days there, staying with relatives, visiting the Montreal Neurological Institute, and making contact with the RCAF. I wanted to become a pilot, I told them, but after some tests and interviews, they said that with my background in physiology I would be best placed in research. A very high-up officer, a Dr. Taylor, interviewed me at length and invited me to spend an evaluatory weekend with him. At the end of this, sensing my ambivalence, he said, “You are clearly talented, and we would love to have you, but I am not sure about your motives for joining. Why don’t you take three months to travel, think about things. If you still want to join up then, contact me.”
I was relieved by this; I had a sudden sense of freedom and lightheartedness and decided to make the most of my three-month “leave.”
I set out to travel across Canada and, as always when traveling, kept a journal. I wrote only brief letters to my parents while I was moving across Canada, and I did not get a chance to write to them more fully until I got to Vancouver Island. There I composed an enormous letter to them, detailing my travels.
Trying to summon a picture of Calgary, of the Wild West, for my parents, I let my imagination loose; I doubt if the real Calgary was quite as exotic as I portrayed:
Calgary has just
finished its annual “stampede,” and the streets are full of loafing cowboys in jeans and buckskins, sitting the long days out with their hats crushed over their faces. But Calgary also has 300,000 citizens. It is a boom town. Oil has brought a huge influx of prospectors, investors, engineers to it. The Old West life has been overwhelmed by refineries, and factories, and by offices and skyscrapers…. There are also tremendous fields of uranium ore, gold and silver, and the base metals, and you can see little packets of gold dust passed from hand to hand in the taverns, and men made of solid gold behind their tanned faces and filthy overalls.
Then I went back to the joys of traveling:
I took the Canadian Pacific Railroad to Banff, roaming excitedly in the train’s “scenic dome.” We passed from the boundless flat prairies through the low spruce-covered foothills of the Rockies, climbing gently all the time. And gradually the air became cooler, and the scale of the country more vertical. The hillocks grew to hills, and the hills to mountains, higher and jaggeder with each mile we progressed. We puffed punily in the floor of a valley, and snowcapped mountains soared tremendous about us. The air was so clear that one could see peaks a hundred miles away, and the mountains beside us seemed to be rearing over our very heads.
From Banff, I went deeper into the heart of the Canadian Rockies. I kept a particularly detailed journal here, and later I reworked it for a piece I called “Canada: Pause, 1960.”
CANADA: PAUSE, 1960
