The Man Who Mistook His Wife for a Hat

THE OPEN MIND
“The Man Who Mistook His Wife For A Hat”
Host: Richard D. Heffner
Guest: Dr. Oliver Sacks
VTR: 2/7/87

Heffner: I’m Richard Heffner, your host on The Open Mind. I suppose it’s not really all that strange that only when diminished in some major part, to some noticeable degree, do we begin really to appreciate the abundance and strength of our natural endowment, only when physically or psychologically we are individually in deficit can we, do we, appreciate fully enough nature’s bounty: how rich it is to be human, to have about us all our faculties.

But the eminent neurologist, Dr. Oliver Sacks, has made those deficits his life’s study, and as a skilled essayist, too, has time and again interpreted for us something of what it means, humanly speaking, to be in deficit…and, by contrast, of course, what an extraordinary gift human mind and body are.

Now all of Oliver Sacks’ “neuro-histories” have been acclaimed; he has been described as “poetically gifted”, one of the great clinical writers of the 20th Century. And now that there is a soft cover edition, too, of The Man Who Mistook His Wife For A Hat, I want to ask him – from his clinical studies or contributing the them – what vision is it of human life, of human purposefulness, that informs his medical work and his continuing efforts to reach and to teach his ever larger and more enthralled readership. Dr. Sacks, that really, as I re-read The Man Who Mistook His Wife For A Hat, I had to ask myself, “What is it that informs Sacks’ picture of the nature of human nature”?

Sacks: That’s a big question to start with. But as I, I feel in some ways that we are insufficiently grateful for what we have, that we take everything for granted. And in health, everything is given to us. We think, say, visually, that the world is given to us in all of its richness of color and depth and movement and form and meaning and you have to have someone like Dr. P. who sees, but sees without sense. A patient I’m seeing at the moment, who sees, but sees without color, suddenly lost all sense of color to realize what a miracle is performed by the brain in putting things together. I think some sort of, although I seem to write about disorder, I think some sort of lyrical feeling for the, for the organism and for being alive and for the brain is involved. And I suppose the other thing is this sense of the immense resilience and resourcefulness of patients and people who’ve lost faculties of one sort or another and how coping is much too mild a word; transcending is a little too ethereal, but my interest is in survival. And survival in the face of the strangest sort of neurological disorders.

Heffner: Of course, as I look back, starting most recently with The Man Who Mistook His Wife For A Hat, to the other books, Migraine, The Awakenings book originally, then A Leg To Stand On, your book about your own deficit, when you went mountain climbing and didn’t do quite so well in the face of a bull, and injured yourself severely. I thought to myself, “This man must be so full of a sense of deficit, must be so full of a sense of the evil that occurs to us, the damages that we do to ourselves, that he couldn’t maintain this optimistic, buoyant personality”, and yet you do.

Sacks: Well, I think there’s a fundamental difference between the sort of things which nature does to us and the sort of things which other people may do to us. And I see again and again that patients can take the hurts of nature with a sort of equanimity. People can get used to blindness or paralysis; they can’t get used to being ill-treated. When, and I don’t get, well sometimes I think when people first see some of these patients, and on the whole I tend to work in chronic hospitals with some of the sickest patients, the first vision may be, may be a very dismal one and even one of horror. But then I think one has a very strong sense of the people as survivors. I can’t bear to see a place where there is any negligence and cruelty; I think that’s entirely different…then there’s moral agency at work, but somehow the indifference of nature, I think does, does make it bearable.

Heffner: You use the word “coping” and I can’t help but ask, “Why do we cope and how do we cope?” What, what inner mechanism is there that enables us to?

Sacks: One somehow wants to use a common phrase like “the will to live”.

Heffner: But then I’d ask you what it means.

Sacks: I know that it can take a beating and sometimes I think after a massive stroke or massive heart attack, something about the will to live may, you know, my not be there for a while and the person may need to be sort of carried, tenderly. But then it reasserts itself. It has to do with, it certainly has to do with caring.

Heffner: You mean other people’s caring for us?

Sacks: Other people’s caring for us. And also our caring for ourselves. But there were some famous studies some years ago of an orphanage in Mexico where the children had every sort of hygienic and mechanical care, but no human care. All of them died by the age of three. The will to live didn’t seem to be established there. I think that caring and being cared for is, is quite essential.

Heffner: Now in a society in which, and this has been said at this table may times, medical care is provided for larger and larger numbers of people and perhaps better medical care, scientifically speaking, but is provided without that human touch you’re talking about, what does the future hold for us?

Sacks: Well, I think…well the present position is very, is one of paradox because technology, neuroscience have risen meteorically. Things are possible now which couldn’t have been imagined ten years ago and God knows what will be possible by the turn of the century. But, but human care, I think, has taken something of a beating. I mean, people come in with a headache now and they’re sent for a CAT scan straight away. When the first thing one should do is to listen. Listening is the beginning of medicine and attention. Physicians themselves also are beginning to suffer from this lack of human contact. There’s talk about “burn-out”, boredom, which there never used to be a few years ago. I think there has to be some sort of revolution bringing back the human to go with the high tech.

Heffner: Where does that take place? How could it take place? I can understand standing at the barricades and carrying a flag, but I don’t understand how it would happen in your field.

Sacks: Well, I think it largely has to happen with individuals. Say with individual doctors who, who do stand on, on either side of the barricade who will listen intensely to their patients. Who will try and imagine what it’s like to be the patient and at the same time who can call on all the technology and all the new concepts. It doesn’t seem to me an impossible thing. It seems to be a crucial thing.

Heffner: Well, again, going back to the, to the matter of “coping” and you say it doesn’t seem to you to be an impossible thing.

Sacks: Yes.

Heffner: I have to wonder whether the crucial nature of it, as you just characterized it, doesn’t perhaps, forgive me…blind you to maybe the impossibility of coping with this today, given numbers and given this technological advance.

Sacks: Well, I’ve, I don’t’ think that time and busyness are sort of adequate excuses. I remember a former Chief of mine, who, in his Friday afternoon clinics, he might see fifty patients, in his outpatient clinic. Now, true, these were all people he’d seen before, but somehow in thirty seconds or in sixty seconds, he would concentrate so much, that they would, they’d feel themselves the only person in the world. And, I think that a great intensity of care and concentration is possible in a short time. But I agree it’s very difficult and I suppose there’s the same problem in education, where there’s a question of a sort of mass, mass training versus individual tutoring.

Heffner: Well, Dr. Sacks, last week, at this table, I discussed this question of education and you’re quite correct, the same matter of quantity versus quality surfaced. But I find it, as a teacher, I shouldn’t say this, but as a teacher I find it much more crucial in the area of medicine. And I just wonder whether there is a force at work now, in the medical schools for instance, that would tend to institutionalize the concerns that you’ve expressed and the solutions, if I may call them that, that you offer? The time.

Sacks: I, I think there are some changes which are coming in now. It’s realized that students have to spend time with patients and that this can’t be hurried, that things can’t be sort of passively learned by lectures. I think it’s also realized that something like an apprenticeship, which sounds so, so medieval, in a way is still, is still necessary. I think again there is something of a concern in the medical literature which, for individual case histories; twenty years ago it had become almost impossible to publish an individual case history. And everyone said we’ve got to have a series, tell us what happened with fifty patients, you have to have double-blinds, double-blind series, or whatever. I think the feeling is now coming back that a single patient, studied with enormous detail can illuminate a great deal and, I think some sort of respect for the individual, whether it’s the patient or the student, is on the way back. But it’s, but there are also forces going in the other direction.

Heffner: You used the word “apprentice” before…”apprenticeship”…you said something almost as medieval as that. What, why do you say that?

Sacks: I think there are many things which can’t be taught, but which can only be learned. And they can only be learned by being in the proximity of someone who is, who is experienced or who is a master or whatever.

Heffner: Then you don’t mean “medieval” in a pejorative sense.

Sacks: No.

Heffner: I thought there was a note of that, that you were almost apologetic.

Sacks: No. It’s almost a sort of nostalgic sense. No. At one time when I had been asked to grade medical students, which is something I hate, I don’t like the idea of grading generally, I would say, “Look, I can’t set him an exam. Let him come to me for a month. Let me see him in all sorts of situations. Let me see how he conducts himself. How he learns, how he interacts with patients. Then I’ll have some idea of what sort of person he is. And also some idea of what sort of a doctor he might be”. But what I’m asking for really is: let him be an apprentice for a while. And the answer was partly, of course, “We have three hundred students a year, that’s not possible”. But, yet I still think it should be possible.

Heffner: Gets back to the question of numbers, then.

Sacks: Yes.

Heffner: Quality and quantity. Is, is the neurological work that you do, do you find in it a growth, a pattern of change over the years? We do know so much more now, technically. But is there a qualitative change about the neurological work that you do, that you could identify?

Sacks: I think there’s…when I was a resident we had a journal club which met every week, which discussed the latest…everything was the latest. There was very little sense of history, of what had once been observed or thought or said. I think the sense of history and of medical tradition and specifically what superb powers of clinical observation and description there were in the last century, especially the last third of the last century, I think this is coming back. And re-inspiring people. I know for myself, say, that when I wrote my first book on migraine, a book on migraine, written in the 1860s, was absolutely crucial to me. In many ways it was sort of absurdly old-fashioned, but in terms of just description, an accurate description can never be obsolete. And accurate description, I think, reached a great high point in the last century and has since declined. I think this has been rather generally realized, and coming back into medical education.

Heffner: You know, again going back to your word “coping” which certainly surfaces again and again in your books, I wondered, as I read The Man Who Mistook His Wife For A Hat and went back over the other books again, whether this case by case example of coping leads you to feel differently than other physicians might, other scientists might about our capacity now not only to manipulate genetic content, but perhaps our responsibility to take life at the end, which is such, in a sense, the antithesis of an involvement with the human coping mechanism. I mean, how do you, how do you find yourself responding to those physicians who look for, not…they don’t welcome…but look for, of necessity, the right, the authority, to be involved more in euthanasia?

Sacks: Well, I think first that there’s a tendency to, to medicalize birth and death and sort of just see them as medical events which occur in a hospital and without much, necessarily without much human content. The situation now is changing in an unprecedented way because we have the power to maintain a sort of life in people who are brain dead and really have no possibility of consciousness. It’s a terribly difficult question because, because where is one to stop? I think that certainly patients themselves, especially elderly and chronically ill patients, should be able to express, and strongly, their feeling that after a particular point they don’t want any more heroic endeavors made or any further resuscitations.

Heffner: Would you accept their conclusion?

Sacks: Personally, I would. But I, I’ll say that this may in a sense be theoretical because I don’t, myself, carry this sort of life and death responsibility.

Heffner: But you are a medical person, observing what is going on in this field, in this field of concern, and you must have some very visceral responses to it, too. As a citizen as well as a physician.

Sacks: Yes. Well, I…yes I certainly have visceral responses but that responses start in one’s own family. There’s a very favorite Aunt of mine, I describe her a little bit in A Leg To Stand On who had a wonderful life until the age of eighty-six. And she was full of good activity until that age. She then had to have some surgery and everything went wrong. And, and she said very plainly, that so far as she was concerned it was not worth continuing life on these terms. I t would be a misery to her and a burden for everyone else. And she therefore declined to eat. A psychiatric opinion was sought. But the psychiatrist said, “This is the sanest person I know. And she’s an adult. Let, you know…if this is what she wants to do”. And I think I think clearly that was a responsible decision on her part. But equally clearly one’s got to protect people against sort of, sort of self-destructive things.

Heffner: And the mechanism must be what? Of protecting, of permitting? Autonomy and of protecting against whatever it is you want to protect us against?

Sacks: I’m hopefully bringing everything up to the level of rational discussion and openness.

Heffner: But again I raise the question of what the mechanism must be in the medical field, in the medical profession. The psychiatrist who said your Aunt was the sanest person there? A board, a group of physicians? How are we going to make this incredible decision as we go into the future? And it’s going to come up more and more. More of us are living longer and longer. And clearly we’re going to be affected by that. What would you do?

Sacks: Well, I, I confess I haven’t thought, thought a good deal on this.

Heffner: Has the medical profession generally? And that really is the question.

Sacks: Yes. The medical profession generally, I think is, is very exercised by this and the, the problem is mounting. I think above all, the question of establishing limits is so difficult.

Heffner: What do you think the major questions that, that we must answer, we must face, that come before medicine today are, in what areas do we find the most difficult ones? Obviously, in this question of making the determination whether someone may choose to live or die.

Sacks: Well, first and foremost, I think there needs to be a renewed respect for the patient’s experience. The patient has to be listened to. He has to be allowed to express as fully as he can, his own situation. Both his medical situation and his human situation. And, that door of listening and attending has been partly closed. That’s got to be opened. I think if that door is opened, a great deal else will follow.

Heffner: But haven’t physicians said generally that “We need not listen”? I don’t mean that, but “We need to present an authority figure. We need to be those who know to start with, in order best to serve the patient”.

Sacks: Well, there are different sorts of knowledge and the patient has his experience. We have our expertise, but I think there needs to be more of a sort of collaboration. I describe this in a story which is, if you want metaphorically as well as literally called On The Level. I describe here an old man, in his nineties, very bright, with severe Parkinson’s disease, who tends to lean to one side. He doesn’t know it, but other people comment on this. And I ask if I can take a videotape of him. And he looks at this and his mouth…

Heffner: He hadn’t believed it before…

Sacks: He hadn’t believed it, no, no. And he thought people were pulling his leg, joking. And he was amazed when he saw it but said, “sure, they’re right, they’re right”. And then he thought. He said “Is there a sort of censor in the brain which will normally tell you if you’re on the level or tilted?” and I…and he said, “and could this be affected in me? Is it affected in Parkinson’s disease?’ and I sort of said yes, yes. And then he thought and I call this the therapeutic moment, and it was sort of very, very moving. In that moment he thought about things and he made a suggestion. He said, “If this level in the brain isn’t working, or if I can’t make use of it, would it be possible to make an external level, he used to be a carpenter, so something like a bubble-level, or a spirit level, which would be attached to the spectacles and which I could sue to monitor my walking?” And I said I thought that was a very, it sounded bizarre, but it was also, I thought a brilliant idea. Anyhow, it was made and first of all he was sort of, was rather cross-eyed and sort of gazing at this thing and then it became automatic, like looking at the instruments of his car and it worked very well. Now this really is a lovely example of a sort of collaboration between patient and physician. Obviously, there are many situations in which that’s not possible, but there are other situations in which it is possible.

Heffner: You’re talking then about artistry, aren’t you? You’re really talking about creative artistry, the connection between the physician and the patient. You’re not talking about science here, are you?

Sacks: Well, science was involved here.

Heffner: The science of listening?

Sacks: The science of listening. But also a precise delineation of certain mechanisms which are necessary to control body posture and orientation.

Heffner: No, I meant your relationship to the patient. Yes, his carpentry skills…

Sacks: Yes.

Heffner: …lead him to want that level…

Sacks: Yes.

Heffner: …available to himself…but I’m talking about the doctor’s contribution.

Sacks: There certainly perhaps, there needs to be an access of authority and faith. But it’s, it’s got to be of an adult sort. I think there’s great danger in sort of infantalizing patients. I had some experience of that myself when I was a patient. I think one may not know what being a patient involves unless one becomes one oneself. And in particular I then found it very difficult to communicate my own condition or talk back. But, yes, certainly listening is an art. It’s almost a sort of feeling and certainly intuition is involved.

Heffner: Dr. Sacks, it’s been such a pleasure for me to talk with you and to listen to you as I’ve sort of listened to these wonderful books and to the experiences and I guess I can only say that I hope that what goes into these individual tales, is what can be breathed into medicine generally. But I’m less of an optimist than you are. Thank you so much for joining me today.

Sacks: It’s been a pleasure. Thank you.

Heffner: And thanks, too, to you in the audience. I hope you’ll join us again next time. And if you care to share your thoughts about today’s program, today’s subject, please write to THE OPEN MIND, P.O. Box 7977, FDR Station, New York, NY 10150. For transcripts send $2.00 in check or money order. Meanwhile, as an old friend used to say, “Good night and good luck”.

Continuing production of this series has generously been made possible by grants from: The Rosalind P. Walter Foundation; The M. Weiner Foundation of New Jersey; The Mediators and Richard and Gloria Manney; The Richard Lounsbery Foundation; Mr. Lawrence A. Wien; Pfizer, Inc.; The New York Times Company Foundation.