doi:10.1093/brain/awv280
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DORSAL COLUMN
Book Review
One is always nearer by not keeping still
In an article entitled My Own Life published by the New
York Times in its 19 February 2015 issue Oliver Sacks
announced to his many fans and admirers that at the age
of 81 his luck had finally run out. The rare ocular melanoma, which he had written about in his book The Mind’s
Eye and that had left him blind in one eye for the last few
years had spread to his liver. In the spring of this year
when I visited him at his home in Greenwich Village, he
was still writing furiously. His desk was covered with
metals and crystals. He told me that the steely grey beryllium (element 4) rectangle reminded him of his Elysian
childhood while his bismuth (element 83) sample sparked
optimism for a future he feared he was unlikely to ever see.
He also described how he had been moved one night while
visiting the country by the celestial beauty of a sky peppered with stars.
During his admission to hospital for a hepatic embolization he had lapsed briefly into stupor, but with characteristic curiosity he later recorded his delirium. He told me
that his liver now closely resembled a wodge of
Emmentaler. He then showed me his notebook where for
an hour or so his script had become spidery and uncharacteristically small and we speculated whether manganese
atomic number 25 might be the culprit. The chemotherapeutic beads allowed him to rebound and have several
months of health. He was able to see his memoir published,
to make a farewell visit to England, and to continue his
daily swims. I later learned that he had requested to be
wheeled out to look at the heavens in the hours before
his death.
On the Move, the most autobiographical of his 13 books,
can be read as a prequel to the poignant New York Times
letter where he wrote ‘This does not mean I am finished
with life’. ‘On the contrary. . . I feel intensely alive’.
From Uncle Tungsten we had already learned a great
deal about his precocious passion for chemistry. Uncle
Dave who owned a factory in Farringdon that manufactured light bulbs and filaments of fine tungsten wire had
introduced him to the cold beauty of metals, while Abe—
Dave’s older and more mathematically minded sibling—
ON THE MOVE: A LIFE
By Oliver Sacks, 2015
London: Picador
ISBN: 978-1-4472-6404-0
Price: £20
had introduced him to the thrill of penetrating rays and
spectroscopy. Uncle Dave’s cabinet and a series of increasingly dangerous and smelly experiments carried out in his
home laboratory brought the Periodic Table to order. His
mother, the surgeon Muriel Elsie Landau showed him how
if one threw a pinch of salt on the stove the flame turned a
brilliant yellow. At the age of 11, he would sit engrossed in
classical 19th century chemistry texts in the Science
Library, oblivious of the passage of time. The permanence
and stability of elements served as a stabilizing force.
To the relief of his parents, chemistry eventually fell away
to be replaced by marine biology. At St Paul’s he was told
he was a menace in the laboratory; the school curriculum
and some indifferent teaching had rendered a holy subject
utterly profane. This had led to his classmate and friend
Jonathan Miller proclaiming one day, ‘Our love of science
is utterly literary’. Then in 1997, a chemist friend, the
Nobel laureate Roald Hoffmann, sent him a chunk of tungsten in the post. His cherished and all but buried ‘erection
of the mind’ re-erupted into Uncle Tungsten. The symbols
of permanence he had counted on in his childhood had
returned to console him in old age.
Sacks’ father, Samuel had toyed briefly with a career in
neurology before electing for the ‘more real and alive’
Received August 28, 2015. Accepted August 28, 2015
ß The Author (2015). Published by Oxford University Press on behalf of the Guarantors of Brain. All rights reserved.
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Book Review
world of general practice. He worked as Henry Head’s
house officer at The London Hospital when the great
man’s career was being brought to a premature close by
Parkinson’s disease and had been impressed by his chief’s
erudition. Sammy Sacks later told his son that he felt
Head’s handicaps had made him more sensitive to his patients’ predicaments. Sometimes Head’s morbid propelling
force made him career down the ward, requiring the nursing sister to break his fall before he crashed into a wall.
When Oliver expressed difficulty imagining what it must
have been like to live and work with the shaking palsy,
his father, who would often imitate the diseases he treated
out of empathy not unkindness, stopped in the middle of
the Essex Road and broke into a festinant trot. Sammy
Sacks continued to do house calls well into his nineties
and had become part of Whitechapel folklore when I was
doing my house jobs.
Sacks has also previously related how as a child he had
been evacuated with his older brother Michael to a boarding school in the small village of Braefield. The years spent
at what he called his own terrifying Dotheboys Hall left
permanent scars. The headmaster was a flagellomaniac and
the 6-year-old Sacks was tormented and bullied by his
classmates. Mathematics saved him, numbers became his
most reliable friends, and during botanizing school holidays
spent with his Auntie Len in Cheshire he came to frame
them in a magical secret garden. When he eventually returned to London at the age of 10, the absolute certainty of
his imaginary world of prime numbers was replaced by
new waking excitements for rare earths, Davy’s electric
fish and the blaze of halogens. Two of his brothers
Marcus and David were already at medical school while
Michael, his more dreamy 15-year-old brother, had returned from Clifton College with a diagnosis of
schizophrenia.
At the age of 12 a perceptive schoolmaster had written in
his report, ‘Sacks will go far if he does not go too far’. At
St Paul’s he came under the mesmerizing spell of Sidney
Pask, a biology teacher who expected an undivided commitment by his pupils to his subject. Sacks along with his
equally enthusiastic classmate friends Jonathan Miller and
Eric Korn rose to the challenge. All three accompanied
Pask on weekend plant-hunting trips, spent evenings studying at the Natural History Museum with him and in the
school holidays visited the marine biology facility at
Millport in the Firth of Clyde. There Korn became enamoured with sea cucumbers, Miller with bristled worms, and
Sacks acquired his lifelong love of cuttlefish and squid.
It had been preordained from birth that Sacks would
become a doctor and his mother, an obstetric surgeon
took him just after his 14th birthday to the Royal Free
Hospital where under the supervision of the Professor of
Anatomy he was encouraged to dissect the corpse of a 14year-old female. Sacks’ mother had already brought malformed stillbirths to the family home and demonstrated
infantile human anatomy to her 11-year-old son. In contrast to the halcyon domiciliary visits where he
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accompanied his father to the East End on Sunday mornings these well-intentioned but distressing lessons designed
to lure him into a career in surgery turned him away from
medicine.
At Oxford University he was poor at factual exams involving yes or no answers but could spread his wings with
essays. In anatomy finals he came next to bottom and then
after five pints of beer he impulsively entered for the
Theodore Williams Prize where he wrote continuously for
2 hours on one of the seven mandatory questions. A few
weeks later he was notified that he had won and was presented with his award by Le Gros Clark, the distinguished
Oxford anatomist.
In On the Move we also learn of his childhood longing
for superhuman power and ease of movement, that first
manifested through dreams of flying, then a love of horse
riding and finally to motor biking on the open highway.
Not long after his 18th birthday he started to frequent the
Ace Café on the North Circular bypass going on ‘burn ups’
with the ‘ton-up’ boys on his Norton Dominator
(‘Dommie’) but wishing all the time he had a more powerful Vincent. During his subsequent neurology residency at
Mount Zion hospital in San Francisco he would slip away
to race with fellow bikers down the sunset strip heading for
Stinson Beach or Bodega Bay. During the day he was working hard in the hospital and studying for his Boards exams
but as dusk fell he metamorphosed into a night rider. He
would think nothing of heading out on Friday night on his
BMW to arrive at the Grand Canyon 500 miles away in
time to watch the sun come up. The bike and rider became
one invisible entity and one feels his palpable freedom of
being at one with his BMW in every sentence (Fig. 1). The
importance of propulsion to his life is also reflected in the
Figure 1 Oliver Sacks on his new BMWR60 in Greenwich
Village 1961. By kind permission of Dr Sacks. Photograph taken by
Douglas White.
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title of this book that is borrowed from a poem about
motorcyclists written by his friend Thom Gunn.
After completing his medical degree at the Middlesex
Hospital, Sacks worked for Dr Richard Asher in the
Medical Observation Unit at Park Royal. In Cold Storage,
an essay published some years later, he described his personal
recollection of Asher’s celebrated Rip van Winkle case, ‘Uncle
Toby’ who had been suspended in a sort of hibernation for
many years due to untreated myxoedema. Treatment with
thyroid extract had woken him up but ironically ignited a
dormant lung cancer. Asher’s teaching where he had questioned the wisdom of giving naturally occurring hormones
without considering their total effect on the person had returned to haunt Sacks during his time at Beth Abraham hospital. It is of interest to recall that Asher, whom he held in
high esteem, did not feel appreciated within his profession,
perhaps because his wit was confused with frivolity, and his
clarity of expression mistaken for a lack of depth.
In 1959, Sacks was appointed Senior House Officer in
Neurology back at his alma mater and began working for
Michael Kremer and Roger Gilliatt. Kremer was genial and
suave with a twisted smile. Gilliatt on the other hand was
beetle-browed, defensive and irritable. At the bedside
Gilliatt was methodical, painstaking and analytical insisting
his house officer wrote down his findings whereas Kremer
seemed to work by reading his patients’ minds. Kremer was
kind and courteous and had all the time in the world for
his patients, juniors and nurses. Gilliatt, on the other hand,
was a neurophysiologist who seemed to find patients a
strain. In a recent memoir published in Practical
Neurology Sacks expresses gratitude to this ‘brilliant but
almost comically incongruous pair’. Kremer would later
write a glowing letter of recommendation for him when
he decided to pursue a career in neurology in California.
Sacks’ earlier book Hallucinations had already drawn
readers to his propensity for recreational drug experimentation but there are further disclosures in On the Move
including a description of his year’s dependency on amphetamines (an ‘empty ecstasy’) and his trips to inner space
with morning glory seeds during his time in San
Francisco and Los Angeles:
‘Some of my Muscle Beach friends had urged me to try getting
stoned on Artane, which I only knew as an anti-Parkinsonian
drug. “Just take twenty tablets,” they said, “you’ll still be in
partial control”’.
It took a move to New York to work in a headache clinic,
support and advice from a trusted female friend and psychoanalysis to set him straight.
His exploits on Los Angeles’ Muscle Beach where he
mingled with six-pack hunks and briefly held the
Californian State squat lifting record are also described
in detail (there are supporting photographs inside the
book of a toned Sacks pumping iron in Speedos). He
also describes his ‘wipe out’ while surfing on Venice
Beach that fortunately left him with a dislocated shoulder
Book Review
rather than a broken neck. During this exciting sojourn in
this strange world of strong men he seriously considered
writing a book about the people, scenes and events that he
had encountered. As he got older 6-hour swims, an exercise also favoured by his father, became his preferred way
of keeping fit. Continuous powerful movement through
the water also had the effect of calming the shooting
stars exploding in his head. He describes how when in
the water without fear or fret his literary brain would
fire up and whole paragraphs would swim through his
mind. He describes his brushes with lion’s mane jellyfish
and how he was almost cut in half by a boat where the
East River meets the Long Island Sound close to his City
Island home.
On the Move also provides Sacks with a chance to put
the record straight. In 1970 while working at Beth
Abraham Hospital in the Bronx he wrote several letters
to The Lancet describing the effects of L-DOPA on a
group of long-stay patients with postencephalitic parkinsonism including the phenomenon of incontinent nostalgia. Under pressure from the medical director who saw
little point in adding to the correspondence section of a
limey journal, he was then pressured to write up his overall experience with L-DOPA in 60 patients for JAMA
where he cautioned of the potential dangers of the drug
in severely handicapped patients. The entire correspondence in the letters section of the next edition was devoted
to highly critical and vituperative responses to his article
questioning his accuracy of observation and intimating
that even if true he should not have published because it
would negatively impact on the atmosphere of optimism
necessary for a positive L-DOPA response. No right of
reply was permitted by the Editor. Sacks had cast doubt
on predictability itself and needed to be censored. Much
more distressing though was when the sister of Rose R.,
one of his patients, held up the New York Daily News
that had reprinted one of his letters to The Lancet verbatim complaining, ‘Is this your medical discretion?’
This made clear to him the potential perils relating to
what can and what cannot be written even in medical journals. Sacks now felt trapped in that he knew he had something of importance to say but if he were to remain faithful
to his experiences he would inevitably forfeit medical ‘publishability’ and the acceptance of his colleagues:
‘I felt this most keenly when a long paper I had written about
the postencephalitics and their responses to L-DOPA was rejected by Brain, the oldest and most respected journal of
neurology.’
If he were to write the detailed case histories of his patients he would need to obtain their unconditional consent
and disguise their identity and the institution (Beth
Abraham became Mount Carmel) where they were resident. W. H. Auden gave him particularly good advice in
the planning phase for his intended book. ‘You’re going to
Book Review
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have to go beyond the clinical. . .Be metaphorical, be mystical, be whatever you need.’
When Awakenings was published in 1973 it was reviewed positively in the newspapers and by the literary
magazines and was awarded the Hawthornden prize for
imaginative literature. Richard Gregory who had reviewed
the book for The Listener sent an early copy to Alexander
Luria who replied:
In 1976 Sacks received a letter from one of the medical
students at the Middlesex Hospital called Jonathan Cole
asking whether he might come to New York and spend
his 2-month elective in his department. He added how
much he had enjoyed Awakenings and how he had already
done a year of research in sensory neurophysiology at
Oxford. Sacks who now no longer had a salaried post at
Beth Abraham replied with some embarrassment:
My dear Dr Sacks,
I received Awakenings and have read it at once with great delight. I was ever conscious and sure that a good clinical description of cases plays a leading role in medicine, especially in
Neurology and Psychiatry. Unfortunately, the ability to describe
which was so common to the great Neurologists and
Psychiatrists is lost now perhaps because of the basic mistake
that mechanical and electrical devices can replace the study of
personality. Your excellent book shows, that the important
tradition of clinical case studies can be revived and with a
great success. Thank you so much for the delightful book!
A.R. Luria
Dear Mr. Cole,
I thank you for your letter of February 27 and am sorry to be
so long in replying.
My delay in replying is because I don’t know what to reply.
But here, roughly is my situation:
I don’t have a Department.
I am not in a Department.
I am a gypsy, and survive-rather marginally and precariouslyon odd jobs here and there.
Despite acclaim from his poet friends—Auden who wrote
that he had enjoyed the book but suggested he add a glossary and Thom Gunn who wrote telling him that his sympathy was literally the organizer of his style and it was that
alone which had enabled him to be so inclusive, receptive
and varied in his writing—he was disappointed to see that
unlike his first book Migraine that had received praise from
his peers, a ‘strange mutism’ lasting more than a year prevailed in the medical press. Eventually a few short and
lukewarm reviews trickled in and amongst them was one
he found particularly galling:
‘This is an amazing book, the more so since Sacks is talking
about non-existent patients in a non-existent hospital, patients
with a non-existent disease, because there was no worldwide
epidemic of sleepy sickness in the 1920s.’
The word had gone out that Sacks had let fantasy get the
better of objectivity, a cardinal sin in medicine. His integrity had been called into question. ‘Sacks is a fraud’ could
be heard echoing through the corridors of the world’s prestigious neurological institutes or ‘Sacks that treacherous
paperback writer who mistook his patients for bestselling
books’. With the full support and active encouragement of
some of his patients a brilliant documentary was made by
Duncan Dallas at Yorkshire Television and broadcast in
England in 1974. The prodigal son may not have been
telling fibs but the closed shop of British neurology had
still not forgiven him. To his great surprise the person
who had terrified him most during his training, Roger
Gilliatt his old boss, was the first to offer an olive branch
inviting him to lecture and show the film at a Grand Round
at Queen Square. His other ally was William Gooddy who
had written the foreword for his first book Migraine and
now wrote congratulating him on the publication of
Awakenings.
The young student was not deterred and eventually travelled to New York where he followed his hero on peripatetic rounds to the Little Sisters of the Poor nursing home,
grim residential ‘manors’ and the long-stay wards at Beth
Abraham. Several years later Sacks had the satisfaction to
learn that his one and only medical protégé had become a
Consultant Neurophysiologist and a medical writer. At the
time Jonathan Cole was fixing up his imaginative elective I
was working at the Middlesex Hospital and visiting the
Highlands Hospital in Enfield to study the last surviving
postencephalitic patients. Gerald Stern, Donald Calne and
the Medical director at Highlands, Joseph Sharkey had conducted a double blind trial with L-DOPA on 40 patients in
1968 and reported in The Lancet that half the L-DOPAtreated patients had shown a striking improvement, but involuntary movements and psychiatric disturbances had
occurred in the first few weeks limiting its long term use
in some. Only one patient was still on DOPA 8 years later
and Gerald Stern and I felt a trial of bromocriptine was
worth a try in 10 of the patients.
By the time it was decided to proceed with a feature film
of Awakenings in 1989 all the patients at Beth Abraham
had died but nine of the patients at Highlands were still
alive. Robert De Niro who would play Leonard L. in the
film insisted on coming to London with Sacks to try to
understand better what he was expected to play. It was
on this visit to London that I first met Oliver and learned
first-hand about his ongoing interest in the dynamic interplay of motion and emotion.
Sacks has always been the outsider denigrated by the
medical establishment for his oddness and naivety, his
limited number of peer-reviewed publications, his nonformulaic vivid narratives and his exploitation of the
exotic. He was a physician without a post who has done
no clinics or ward rounds for many years and came over to
neurologists more like a psychiatrist. By his own admission
he has also often been self-destructive and dangerously impulsive. The fact that he had spent much of his career
seeing incurable patients in ‘bins’ also unfairly counted
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against him. Some neurologists even disliked the way he
was always in the frame in his books.
Aspirant British neurologists of his generation were often
reminded by their chiefs to never be seen running on duty.
They were expected to be effete, clubbable, cerebral and
graceful. His face blindness, wildly associative mind and preternatural sensitivity presented insurmountable obstacles to a
run of the mill neurology career. . .
Sacks is also an unrepentant hero worshiper. The ‘innocent Victorian naturalists’ Darwin, Wallace, Bates and
Spruce are ever present in his writing as he quests for
new epiphanies. In On the Move his interactions with his
living heroes are as instructive and lively as the case histories of his earlier works. We learn how flushed with excitement he became after Gerald Edelman had managed to
explain to him his theory of neural Darwinism in which
consciousness may be explained on the basis of natural
selection between competing neuronal galaxies. After a science conference in San Diego Frances Crick took him by
the shoulders and sat him down next to him saying, ‘tell me
stories’. Sacks later wrote to Crick saying that for him the
dinner had been a little like sitting next to a nuclear reactor. After copious correspondence over several years largely relating to visual science Sacks was in awe at how
Crick had made the jump from physics to life sciences so
efficiently. There is also a delightful passage about his
friendship with the natural historian Stephen Jay Gould
who read out a poem he had written at Sacks’ 65th
birthday:
One legg’d, migrain’d, colour blinded
Awak’ning on Mars, and hat-minded
Oliver Sacks
Still lives life to the max
While his swimming leaves dolphins behinded.
At 18 Sacks’ father had asked him straight out if he liked
boys more than girls, a question he answered truthfully but
begged him not to tell his mother. The next day his mother
called him an abomination and said ‘I wish you had never
been born’.
‘Her words haunted me for much of my life (Sacks
writes), and played a major part in inhibiting and injecting
with guilt what should have been a free and joyous expression of sexuality.’
There are further remarkable throwaway narratives
describing homosexual encounters in Amsterdam and at
Hampstead Ponds to be followed by 35 lovelorn years totally devoted to the study of his patients. In a moment of
deep insight Sacks writes, I had fallen in love—and out of
love—and, in a sense, was in love with my patients. There
is also a late chapter describing how he found true love for
the first time in his late 70s with his partner Billy.
Oliver Sacks has done more than anyone else to explain
the workings of the diseased brain to a general readership.
He has risked losing his own mind to determine what
goes on inside the human brain. His narratives always
Book Review
emphasize the importance of compassion and kindness in
medicine and remind us that healing is an art. In his hands
deficits become gifts and hopelessness is transformed into
optimism. His work has not only inspired countless young
people to embark on careers in medicine but has also permeated culture at large, so that people now use the term
‘Oliver Sacks-like’ when they are describing odd and interesting maladies that require our compassion and understanding. Despite his natural diffidence, his university
lectures attract many hundreds of undergraduates from
arts and science faculties. He has become a semi-reluctant
celebrity and arguably the best known neurologist on the
planet. Neurophilics transfixed by the connections between
brain science and culture regard him as their leader. His
writing has also inspired and fertilized the work of a wide
array of scientists researching in subjects ranging from the
mechanics of visual and auditory perception to the workings of memory and consciousness itself.
From America he wrote to his parents that he hoped he
could repay their benevolence by leading a fairly happy and
useful life. It seems that he has kept his promise but On the
Move also explains why he would never have fitted into the
highly judgmental and elitist world of post-war British
neurology and why even today he is denigrated by many
academics. Like Luria and Freud before him he has elevated the case history into literature and in so doing has
become a Poet Laureate of Medicine. He is also in the
tradition of Sir Frederick Treves, The London Hospital surgeon who rescued the Elephant Man from the showman’s
freak show. There is almost a spirituality about some of his
writing. ‘Each of us constructs and lives a narrative, this
narrative is us, our identities’, he once wrote. His copious
patient notes compiled over many decades and his hundreds of journals and notebooks are the word hoard that
inform his clinical tales.
In On the Move Sacks has deliberately allowed the
mask of the bookish Jewish atheist to slip revealing a
wolf (his middle name), an intriguing Easy Rider with
film star looks, a vain novelty seeker who has shot
heroin and dropped acid and a muscle bound traveller
for ever on the move in search of adventure. William
Burroughs, my own tormenting angel of light would
have approved of this gonzo badass’s long journey. He
is a field worker who is fascinated by individuals with
exceptional weaknesses and strengths and how these specific deficits have affected their lives. To understand and
appreciate Oliver Sacks needs some imagination and a
little understanding.
Oliver Sacks passed away on 30 August 2015.
Andrew Lees
The National Hospital, Queen Square,
London WC1N3BG
E-mail: [email protected]
Advance Access publication September 15, 2015