by Oliver Sacks
Oliver Sacks
An Anthropologist on Mars
1995
Neurological patients, Oliver Sacks once wrote, are travellers to unimaginable lands. An Anthropologist on Mars offers portraits of seven such travellers—including a surgeon consumed by the compulsive tics of Tourette’s syndrome unless he is operating; an artist who loses all sense of color in a car accident, but finds a new sensibility and creative power in black and white; and an autistic professor who cannot decipher the simplest social exchange between humans, but has built a career out of her intuitive understanding of animal behavior. These are paradoxical tales, for neurological disease can conduct one to other modes of being that—however abnormal they may be to our way of thinking—may develop virtues and beauties of their own. The exploration of these individual lives is not one that can be made in a consulting room or office, and Sacks has taken off his white coat and deserted the hospital, by and large, to join his subjects in their own environments. He feels, he says, in part like a neuroanthropologist, but most of all like a physician, called here and there to make house calls, house calls at the far border of experience. Along the way, he shows us a new perspective on the way our brains construct our individual worlds. In his lucid and compelling reconstructions of the mental acts we take for granted—the act of seeing, the transport of memory, the notion of color—Oliver Sacks provokes anew a sense of wonder at who we are.
The universe is not only queerer than we imagine, but queerer than we can imagine.
J.B.S. Haldane
Ask not what disease the person has, but rather what person the disease has.
(attributed to) William Osler
Acknowledgments
First, I am deeply grateful to my subjects: “Jonathan I.”, “Greg F.”, “Carl Bennett”, “Virgil”, Franco Magnani, Stephen Wiltshire, and Temple Grandin. To them, their families, their friends, their physicians and therapists, I owe an infinite debt.
Two very special colleagues have been Bob Wasserman (who was my co-author on the original version of “The Case of the Colorblind Painter”) and Ralph Siegel (who has been a collaborator in other books)—we formed a sort of team in the cases of Jonathan I. and Virgil.
I owe to many friends and colleagues (more than I can enumerate!) information, help, and stimulating discussion. With some there has been a close, continual colloquy over the years, as with Jerry Bruner and Gerald Edelman; with others only occasional meetings and letters; but all have excited and inspired me in different ways. These include: Ursula Bellugi, Peter Brook, Jerome Bruner, Elizabeth Chase, Patricia and Paul Churchland, Joanne Cohen, Pietro Corsi, Francis Crick, Antonio and Hanna Damasio, Merlin Donald, Freeman Dyson, Gerald Edelman, Carol Feldman, Shane Fistell, Allen Furbeck, Frances Futterman, Elkhonon Goldberg, Stephen Jay Gould, Richard Gregory, Kevin Halligan, Lowell Handler, Mickey Hart, Jay Itzkowitz, Helen Jones, Eric Korn, Deborah Lai, Skip and Doris Lane, Sue Levi-Pearl, John MacGregor, John Marshall, Juan Martinez, Jonathan and Rachel Miller, Arnold Modell, Jonathan Mueller, Jock Murray, Knut Nordby,
Michael Pearce, V.S. Ramachandran, Isabelle Rapin, Chris Rawlence, Bob Rodman, Israel Rosenfield, Carmel Ross, Yolanda Rueda, David Sacks, Marcus Sacks, Michael Sacks, Dan Schachter, Murray Schane, Herb Schaumburg, Susan Schwartzenberg, Robert Scott, Richard Shaw, Leonard Shengold, Larry Squire, John Steele, Richard Stern, Deborah Tannen, Esther Thelen, Connie Tomaino, Russell Warren, Ed Weinberger, Ren and Joasia Weschler, Andrew Wilkes, Harvey Wolinsky, Jerry Young, Semir Zeki.
Many people have shared their knowledge and expertise in the field of autism with me, including, first and foremost, my good friend and colleague Isabelle Rapin, Doris Allen, Howard Bloom, Marlene Breitenbach, Ginger Clarkson, Uta Frith, Denise Fruchter, Beate Hermelin, Patricia Krantz, Lynn McClannahan, Clara and David Park, Jessy Park, Sally Ramsey, Bernard Rimland, Ed and Riva Ritvo, Mira Rothenberg, and Rosalie Winard. In relation to Stephen Wiltshire, I must thank Lorraine Cole, Chris Marris, and above all, Margaret and Andrew Hewson.
I am grateful to innumerable correspondents (including the now-unknown correspondent who sent me a copy of the 1862 Fayetteville Observer), some of whom are quoted in these pages. Many of these explorations, indeed, started with unexpected letters or phone calls, beginning with Mr. I.’s letter to me in March 1986.
There are places, no less than people, that have contributed to this book, by providing shelter, calm, stimulation. Foremost among them has been the New York Botanical Garden (and especially the now-dismantled fern collection), my favorite place for walking and thinking; the Lake Jefferson Hotel and its lake; Blue Mountain Center (and Harriet Barlow); the New York Institute for the Humanities, where some of the testing of Mr. I. was done; the library at the Albert Einstein College of Medicine, which has helped me track down many sources; and lakes, rivers, and swimming pools everywhere—for I do most of my thinking in the water.
The Guggenheim Foundation very generously supported my work on “A Surgeon’s Life” with a 1989 grant for research on the neuroanthropology of Tourette’s syndrome.
Earlier versions of “The Case of the Colorblind Painter” and “The Last Hippie” were published in The New York Review of Books, and of the other case histories in The New Yorker. I have been privileged to have worked with Robert Silvers at the NYRB, and John Bennet at The New Yorker, and the staff of both publications. Many others have contributed to the editing and publication of this book, including Dan Frank and Claudine O’Hearn at Knopf, Jacqui Graham at Picador, Jim Silberman, Heather Schroder, Susan Jensen, and Suzanne Gluck. Finally, someone who has known all the subjects in this book, and has helped to give it impetus and shape, has been my assistant, editor, collaborator, and friend, Kate Edgar.
But to return to where I started—for all clinical studies, however widely they adventure, or deeply they investigate, must return to the concrete subject, the individuals who inspired them, and whom they are about. So to the seven people who have trusted me, shared their lives with me, given so deeply of their own experience—and who, over the years, have become my friends—I dedicate this book.
Preface
I am writing this with my left hand, although I am strongly right-handed. I had surgery to my right shoulder a month ago and am not permitted, not capable of, use of the right arm at this time. I write slowly, awkwardly—but more easily, more naturally, with each passing day. I am adapting, learning, all the while—not merely this left-handed writing, but a dozen other left-handed skills as well: I have also become very adept, prehensile, with my toes, to compensate for having one arm in a sling. I was quite off balance for a few days when the arm was first immobilized, but now I walk differently, I have discovered a new balance. I am developing different patterns, different habits—a different identity, one might say, at least in this particular sphere. There must be changes going on with some of the programs and circuits in my brain—altering synaptic weights and connectivities and signals (though our methods of brain imaging are still too crude to show these). Though some of my adaptations are deliberate, planned, and some are learned through trial and error (in the first week I injured every finger of my left hand), most have occurred by themselves, unconsciously, by reprogrammings and adaptations of which I know nothing (any more than I know, or can know, how I normally walk). Next month, if all goes well, I can start to readapt again, to regain a full (and “natural”) use of the right arm, to reincorporate it back into my body image, myself, to become a dexterous, dextral human being once again.
But recovery, in such circumstances, is by no means automatic, a simple process like tissue healing—it will involve a whole nexus of muscular and postu
ral adjustments, a whole sequence of new procedures (and their synthesis), learning, finding, a new path to recovery. My surgeon, an understanding man who has had the same operation himself, said, “There are general guidelines, restrictions, recommendations. But all the particulars you will have to find out for yourself.” Jay, my physiotherapist, expressed himself similarly: “Adaptation follows a different path in each person. The nervous system creates its own paths. You’re the neurologist—you must see this all the time.”
Nature’s imagination, as Freeman Dyson likes to say, is richer than ours, and he speaks, marvellingly, of this richness in the physical and biological worlds, the endless diversity of physical forms and forms of life. For me, as a physician, nature’s richness is to be studied in the phenomena of health and disease, in the endless forms of individual adaptation by which human organisms, people, adapt and reconstruct themselves, faced with the challenges and vicissitudes of life.
Defects, disorders, diseases, in this sense, can play a paradoxical role, by bringing out latent powers, developments, evolutions, forms of life, that might never be seen, or even be imaginable, in their absence. It is the paradox of disease, in this sense, its “creative” potential, that forms the central theme of this book.
Thus while one may be horrified by the ravages of developmental disorder or disease, one may sometimes see them as creative too—for if they destroy particular paths, particular ways of doing things, they may force the nervous system into making other paths and ways, force on it an unexpected growth and evolution. This other side of development or disease is something I see, potentially, in almost every patient; and it is this, here, which I am especially concerned to describe.
Similar considerations were brought up by A.R. Luria, who, more than any other neurologist in his lifetime, studied the long-term survival of patients who had cerebral tumors or had suffered brain injuries or strokes—and the ways, the adaptations, they used to survive. He also studied deaf and blind children as a very young man (with his mentor L.S. Vygotsky). Vygotsky stressed the intactness rather than the deficits of such children:
A handicapped child represents a qualitatively different, unique type of development—If a blind or deaf child achieves the same level of development as a normal child, then the child with a defect achieves this in another way, by another course, by other means—, and, for the pedagogue, it is particularly important to know the uniqueness of the course along which he must lead the child. This uniqueness transforms the minus of the handicap into the plus of compensation.
That such radical adaptations could occur demanded, Luria thought, a new view of the brain, a sense of it not as programmed and static, but rather as dynamic and active, a supremely efficient adaptive system geared for evolution and change, ceaselessly adapting to the needs of the organism—its need, above all, to construct a coherent self and world, whatever defects or disorders of brain function befell it. That the brain is minutely differentiated is clear: there are hundreds of tiny areas crucial for every aspect of perception and behavior (from the perception of color and of motion to, perhaps, the intellectual orientation of the individual). The miracle is how they all cooperate, are integrated together, in the creation of a self. 1
1. This, indeed, is the problem, the ultimate question, in neuroscience—and it cannot he answered, even in principle, without a global theory of brain function, one capable of showing the interactions of every level, from the micropatterns of individual neuronal responses to the grand macropatterns of an actual lived life. Such a theory, a neural theory of personal identity, has been proposed in the last few years by Gerald M. Edelman, in his theory of neuronal group selection, or “neural Darwinism.”
This sense of the brain’s remarkable plasticity, its capacity for the most striking adaptations, not least in the special (and often desperate) circumstances of neural or sensory mishap, has come to dominate my own perception of my patients and their lives. So much so, indeed, that I am sometimes moved to wonder whether it may not be necessary to redefine the very concepts of “health” and “disease”, to see these in terms of the ability of the organism to create a new organization and order, one that fits its special, altered disposition and needs, rather than in the terms of a rigidly defined “norm.”
Sickness implies a contraction of life, but such contractions do not have to occur. Nearly all of my patients, so it seems to me, whatever their problems, reach out to life—and not only despite their conditions, but often because of them, and even with their aid.
Here then are seven narratives of nature—and the human spirit—as these have collided in unexpected ways. The people in this book have been visited by neurological conditions as diverse as Tourette’s syndrome, autism, amnesia, and total colorblindness. They exemplify these conditions, they are “cases” in the traditional medical sense—but equally they are unique individuals, each of whom inhabits (and in a sense has created) a world of his own.
These are tales of survival, survival under altered, sometimes radically altered, conditions—survival made possible by the wonderful (but sometimes dangerous) powers of reconstruction and adaptation we have. In earlier books I wrote of the “preservation” of self, and (more rarely) of the “loss” of self, in neurological disorders. I have to come to think these terms too simple—and that there is neither loss nor preservation of identity in such situations, but, rather, its adaptation, even its transmutation, given a radically altered brain and “reality.”
The study of disease, for the physician, demands the study of identity, the inner worlds that patients, under the spur of illness, create. But the realities of patients, the ways in which they and their brains construct their own worlds, cannot be comprehended wholly from the observation of behavior, from the outside. In addition to the objective approach of the scientist, the naturalist, we must employ an intersubjective approach too, leaping, as Foucault writes, “into the interior of morbid consciousness, [trying] to see the pathological world with the eyes of the patient himself.” No one has written better of the nature and necessity of such intuition or empathy than G.K. Chesterton, through the mouth of his spiritual detective, Father Brown. Thus when Father Brown is asked for his method, his secret, he replies:
Science is a grand thing when you can get it; in its real sense one of the grandest words in the world. But what do these men mean, nine times out of ten, when they use it nowadays? When they say detection is a science? When they say criminology is a science? They mean getting outside a man and studying him as if he were a gigantic insect; in what they would call a dry impartial light; in what I should call a dead and dehumanized light. They mean getting a long way off him, as if he were a distant prehistoric monster; staring at the shape of his “criminal skull” as if it were a sort of eerie growth, like the horn on a rhinoceros’s nose. When the scientist talks about a type, he never means himself, but always his neighbour; probably his poorer neighbour. I don’t deny the dry light may sometimes do good; though in one sense it’s the very reverse of science. So far from being knowledge, it’s actually suppression of what we know. It’s treating a friend as a stranger, and pretending that something familiar is really remote and mysterious. It’s like saying that a man has a proboscis between the eyes, or that he falls down in a fit of insensibility once every twenty-four hours. Well, what you call “the secret” is exactly the opposite. I don’t try to get outside the man. I try to get inside.
The exploration of deeply altered selves and worlds is not one that can be fully made in a consulting room or office. The French neurologist François Lhermitte is especially sensitive to this, and instead of just observing his patients in the clinic, he makes a point of visiting them at home, taking them to restaurants or theaters, or for rides in his car, sharing their lives as much as possible. (It is similar, or was similar, with physicians in general practice. Thus when my father was reluctantly considering retirement at ninety, we said, “At least drop the house calls.” But he answered, “No, I’ll keep the hous
e calls—I’ll drop everything else instead.”)
With this in mind, I have taken off my white coat, deserted, by and large, the hospitals where I have spent the last twenty-five years, to explore my subjects’ lives as they live in the real world, feeling in part like a naturalist, examining rare forms of life,—in part like an anthropologist, a neuroanthropologist, in the field—but most of all like a physician, called here and there to make house calls, house calls at the far borders of human experience.
These then are tales of metamorphosis, brought about by neurological chance, but metamorphosis into alternative states of being, other forms of life, no less human for being so different.
New York O.W.S.
June 1994
1. The Case of the Colorblind Painter
Early in March 1986 I received the following letter:
I am a rather successful artist just past 65 years of age. On January 2nd of this year I was driving my car and was hit by a small truck on the passenger side of my vehicle. When visiting the emergency room of a local hospital, I was told I had a concussion. While taking an eye examination, it was discovered that I was unable to distinguish letters or colors. The letters appeared to be Greek letters. My vision was such that everything appeared to me as viewing a black and white television screen. Within days, I could distinguish letters and my vision became that of an eagle—I can see a worm wriggling a block away. The sharpness of focus is incredible. BUT I AM ABSOLUTELY COLOR BLIND. I have visited ophthalmologists who know nothing about this color-blind business. I have visited neurologists, to no avail. Under hypnosis I still can’t distinguish colors. I have been involved in all kinds of tests. You name it. My brown dog is dark grey. Tomato juice is black. Color TV is a hodge-podge…
