Oliver Sacks's Awakenings: Reshaping Clinical Discourse
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Anne Hunsaker Hawkins
The Pennsylvania State University - College of Medicine
The Metaphor of Trajective Discourse
"My ideal doctor," wrote the late Anatole Broyard,
"would be my Virgil, leading me through my purgatory or inferno,
pointing out the sights as we go. He would resemble Oliver Sacks, the
neurologist who wrote Awakenings and The Man Who Mistook His
Wife for a Hat. I can imagine Dr. Sacks entering my
condition, looking around at it from the inside like a benevolent
landlord with a tenant, trying to see how he could make the premises
more livable for me. He would see the genius of my illness. He would
mingle his daemon with mine: we would wrestle with my fate together."
1 At first glance, Virgil and
Sacks--Dante's imagined guide in the Divine Comedy and the very
real twentieth-century physician--may seem an oddly assorted pair, but
they are alike in that both poet and physician-writer can be seen as
entering into the world of sin or sickness and accompanying the
pilgrim or the patient through it. 2
The fantasy of a physician accompanying a patient into
the "Hell" of illness is an interesting one, and resonates with the
method Sacks himself identifies in Awakenings as a
"trajective" approach
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(p. 226). 3 This
approach is the result of Sacks's attempt to bring together the two
kinds of narrative representation that he finds in clinical
experience: the first, "an objective description of disorders,
mechanisms, syndromes," and the second, "more existential and
personal--an empathic entering into patients' experiences and
worlds." (p. xxxvi). Sacks returns to this view of clinical
experience as composed of two different narrative components much
later in the text, where he refers to two "types of discourse":
"identification," which concerns diagnostically relevant information
about a patient and uses the language of biomedical science, and
"understanding," an empathic knowledge about a patient, which uses
descriptive language (p. 226).Sacks's idea of the two approaches
appears to be greatly influenced by A. R. Luria's observations on
romantic and classical science, which Sacks mentions (and even quotes)
in his foreword to the 1990 edition of Awakenings (pp.
xxxv-xxxvi). In The Making of Mind, Luria discusses at some
length the distinction between classical and romantic science: a
classical approach reduces phenomena to its elementary components and
achieves understanding by means of abstract models, whereas a romantic
approach will preserve the fullness of human reality, achieving
understanding by means of an empathic identification with the
patient's experience. This distinction is itself a reformulation of
the two methodological approaches to science--the nomothetic and the
idiographic. A nomothetic approach studies events and persons as
examples of some general law: its aim is explanatory and its language
is that of physiology and anatomy; the idiographic, on the other hand,
studies events and persons as unique cases: its aim is understanding
and its language is subjective or phenomenological. 4
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The two kinds of writing come together in the case
histories that Sacks wrote in 1969 and that later became the "heart"
as it were, of Awakenings --his collection of cases documenting
the responses of postencephalitic Parkinson's patients to the drug
levodopa (L-DOPA). What Sacks has done here is to combine both modes
in a discourse that works "analogically, allusively...by images,
similitudes, models, metaphors... [to] bridge the gulf between
physician and patient" (pp. 225-226). Sacks describes his
"trajective" approach as one that is "neither 'subjective' nor
'objective"' and characterizes it as follows: "Neither seeing the
patient as an impersonal object nor subjecting him to identifications
and projections of himself, the physician must proceed by sympathy or
empathy, proceeding in company with the patient, sharing his
experiences and feelings and thoughts, the inner conceptions which
shape his behavior" (p. 226). Sacks's trajective approach to clinical
experience corresponds in many ways to the approach Broyard's "ideal
doctor" would take--a doctor perceived as a fantasized Oliver Sacks
"leading me through my purgatory or inferno.... entering my
condition, looking around at it from the inside." 5
Central to the remarks of both Sacks and Broyard is the
metaphor of the doctor as a traveler into the world of the patient.
Sacks writes in Awakenings that the physician must become "a
fellow traveller, fellow explorer, continually moving with his
patients" (p. 225) and elsewhere he likens himself as a neurologist
to an explorer of "the furthest Arctics and Tropics of neurological
disorder." 6 The idea that
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serious illness can be likened to a different "world" with its own
set of rules, routines, values, and goals appears again and again in
the pathographies, or autobiographical accounts of illness, written by
patients. 7 A familiar example
is Susan Sontag's elaborate (and often-quoted) description of illness
as "an emigrat [ion] to the kingdom of the ill" at the beginning of
Illness as Metaphor. 8
Other pathographers use this notion of illness as a separate realm in
more concrete ways. Kenneth Shapiro observes, "I exist in the world
as most people see it, but I live in the world of the person with
terminal cancer." 9 James L.
Johnson sees his heart surgery as an occasion "to face squarely into
death and make one of the most revolutionary journeys of my
life...over and back." 10
Jory Graham uses this metaphor to criticize doctors for neglecting
their patients' nonmedical needs: she perceives the failure to provide
"safe conduct" for patients in their journey into the world of
cancer and back as "the most serious shortcoming in cancer treatment
today." 11
Sacks himself, in a pathography written some years
after Awakenings, uses the metaphor of illness as a journey
into a separate world as the organizing construct of the book. In A
Leg to Stand On, he describes his own experience as a patient
recovering from a leg injury incurred while hiking. Though the injury
is repaired by surgery, Sacks's recovery is complicated by a sense of
proprioceptive impairment wherein he loses all feeling in the injured
leg--even asserting that the leg no longer seems to "belong" to
him--and by the fact that his physician refuses to acknowledge this
disquieting sensation. Sacks quotes his doctor as telling him: "I
can't waste time with 'experiences' like this. I'm a practical man. I
have work to do." 12
Searching for a way to formulate a sensation whose reality is denied
by his physician, Sacks understands his recovery as a "pilgrimage"
and "a journey of the soul," alluding more than once to that other
journey in the Divine Comedy. Here, the physician has
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become the patient, and in this sense he enters into the patient's
world quite literally.
What is striking about Sacks's pathography is not only
that he likens his slow recovery to Dante's journey through Hell,
Purgatory, and Heaven, but that the original circumstances of the
injury are so similar to the metaphorical frame in Dante's Divine
Comedy. The Inferno begins with Dante trying to climb a
mountain, confronting three beasts who force him back down, falling
into despair, and then meeting Virgil, who helps him reach his goal.
Sacks's injury occurs when he is climbing a mountain, comes upon a
bull, turns and runs away from it, and then falls, tearing the
quadriceps muscle in his thigh. The difference between the two
pilgrimages is the absence, for Sacks, of any figure such as Virgil to
act as companion and guide in the journey back to health. The refusal
of Sacks's doctor to acknowledge his patient's subjective experience
of proprioceptive impairment is, in effect, a refusal to enter the
patient's world.
The Methodology of Trajective Discourse
The metaphor of the doctor as a traveler into the world
of illness is the symbolic basis for Sacks's notion of trajective
discourse. To understand how this notion functions, it may be helpful
to turn from metaphor to methodology. Three different theoretical
methods--from anthropology, social psychology, and literary theory-can
help us better comprehend what Sacks means by a trajective approach to
clinical experience.
Trajective discourse conforms to what ethnographer
Clifford Geertz calls "thick description," which seeks to "grasp
and ren-der...a multiplicity of complex conceptual structures, many of
them superimposed upon or knotted into one another, which are at once
strange, irregular, and inexplicit." 13 Such discourse requires that the physician be a
kind of ethnographer of the world of illness, perceiving a patient not
as a problem requiring a solution but as a complex phenomenal whole--a
"multiplicity of configurations"-- requiring "exploration," or
imaginative empathy, and understanding. Sacks's patients, severely
crippled by Parkinsonism, are in many ways analogous to the strange
and foreign cultures that
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the ethnographer studies. When used by either ethnographer or
physician, thick description achieves an understanding of cultures or
patients in their complexity, richness, and depth that, to use
Geertz's words, "exposes their normalness without reducing their
particularity." 14 Like
thick description, trajective discourse is contextually grounded: it
emphasizes as relevant to a patient history a sense of the character,
life-history, important human relationships (with both family and
staff), and personal values and goals of the individual patient. Thus
Sacks includes as a necessary introduction to the account of his
patients' response to L-DOPA a character-sketch of what they were like
before the onset of Parkinsonism, a description of the ways in which
the uniqueness of each of these individuals is expressed through or in
spite of their disease, accounts of the nature of the important
relationships in their lives-whether with a parent, a staff-person, or
Sacks himself--and their interests, hobbies, and values.
The importance of a contextually grounded discourse is
also central to Elliot Mishler's analysis of the dialectics of medical
interviews. A social psychologist, Mishler has studied the medical
interview as inherently structured around two voices--"the voice of
medicine" and "the voice of the lifeworld"--each representing
different normative orders. 15 The "voice of medicine" refers to a
technological bioscientific frame of reference wherein the meaning of
events is based on abstract formulations of body structure and
function, and the "voice of the lifeworld" refers to the
psychological and sociocultural contexts that shape a patient's
values, attitudes, and practices. Mishler perceives the routine
medical interview as a discourse dominated and controlled by the voice
of medicine--a kind of discourse where "patients' efforts to tell
their stories and to provide a sense of their lived experience...are
disrupted by physicians who ignore what they are saying and transform
all content into the terms and the logic of the biomedical
framework." 16 Sacks's
experiment in the trajective approach to a medical history can be seen
as conforming to Mishler's call for a
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discourse that attends and witnesses to lifeworld issues. Mishler
urges a " [r]ecognition of the distinctive humanity of patients and
respect for the contextual grounding of their problems in their
lifeworlds." 17 Sacks's
tries to do just this in his histories. Thus he writes in his preface
to the original edition: "I have...tried to preserve what is
important and essential...the real and full presence of the
patients themselves, the 'feeling' of their lives" (pp. xvii-
xviii).
Very similar to Elliot Mishler's discussion of the
relationship between the two voices in medical discourse is Mikhail
Bakhtin's broader distinction between monologic and dialogic (or
polyphonic) narrative. The typical medical history--the scientific,
technological, disease-centered narrative of which Sacks is so
critical--exemplifies Bakhtin's description of monologic discourse as
"a monologically understood objectified world correlative to a single
and unified authorial consciousness." 18 The medical history is monologic because it is
controlled by a scientific ideology that focuses on the biochemical
aspects of a disease and its treatment to the exclusion of the human
being whose body harbors the disease so reified. To compare
Awakenings to the conventional medical history is to trace a
movement away from "authoritative discourse" and toward dialogism.
As Michael Holquist defines it, "dialogization" takes place when a
discourse "becomes relativized, de-privileged, aware of competing
definitions for the same thing." 19 In the conventional medical history, the
patient's subjectivity only rarely intrudes on the narrative. In
Awakenings, however, Sacks consciously departs from the
conventions of the medical history to try to present his patients as
individuals--as "full-fledged subjects," to use Bakhtin's
description of character in polyphonic narrative. 20 Sacks does this by means of trajective
discourse--a kind of discourse similar in many ways to Bakhtin's idea
of dialogism. As we shall see, in his story of Frances D.'s illness
and response to LDOPA, Sacks renders Miss D.'s subjective experience
by using direct quotations, by including as pertinent--and
honoring--her wishes as to treatment, by explaining Parkinsonism as
she experiences it, and by mentioning her ambivalent feelings about
her doctor,
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Sacks, as well as the frustrations she undergoes in being confined to
an institution. 21
Reflection and Metaphor in Awakenings
The form of Sacks's cases in Awakenings is a
greatly modified version of the standard medical history with its
classic divisions into identifying information and chief complaint,
past medical history, history of present illness, review of systems,
and family and social histories. Sacks himself is aware of this issue
of genre, and in the Preface to the original edition of
Awakenings he refers to his patient narratives as "extended
case-histories or biographies" (p. xvii). He also calls the reader's
attention to the book's "alternation of narrative and reflection"
and "proliferation of images and metaphors" (p. xviii)--stylistic
devices that have never been components of the standard medical
history. At the outset, then, by his conscious inclusion of reflection
and of image and metaphor, Sacks deviates markedly from the generic
medical history in form and in content.
Both reflection and metaphor are necessary components
of a tra-jective approach to clinical experience. Reflection implies
that the ability to apprehend another's experience is something that
unfolds over time: it is not an event, but a proces s whereby
one comes to understand experience through thinking about it. There
are several levels of reflection in Awakenings. One is Sacks's
habit of introducing copious footnotes, most of which offer further
thoughts on or elaborations of the issue discussed in the text. Thus
he mentions Miss D.'s gnawing and biting compulsions, comparing them
to other abnormally perseverative compulsions and discussing them as
rooted in some phylogenetic, unconscious memory "from unimaginable
physiological depths below the unconscious"; he then
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moves from these to other kinds of excitation that his patients
experience at the height of their reactions to L-DOPA--sensations
resulting in "menagerie noises...noises of almost unimaginable
bestiality" (p. 55). Another way Sacks uses reflection is his habit
of digressing on the meaning of a particular event for the patient who
is experiencing it, often using the patient's own words. When Miss
D.'s L-DOPA finally must be discontinued because of its many adverse
effects, Sacks tries to provide the reader with a "thick
description" of her response, a vivid realization of what this means
in the context of her life. So he first describes her feeling of being
"letdown" when the drug is withdrawn and her disappointment in her
doctor, Sacks, who could not prevent the escalation of side effects
that forced her to discontinue L-DOPA; then her gradual disinvestment
in hopes for a marked improvement in her condition, and her ambivalent
feelings about Sacks; and finally an "accommodation" to the limits
imposed on her by her illness, by the drug used to treat it, and by
the institution where she would spend the rest of her life (pp.
54-58).
Sacks justifies his use of metaphor in these histories
by his conviction that the phenomena to be described can be conveyed
in no other way; metaphor here is not decorative, but necessary. He
writes: "My aim is not to make a system, or to see patients as
systems, but to picture a world...the landscapes of being in which
these patients reside" (p. xviii). Metaphor and image are appropriate
linguistic tools for realizing this aim, since these literary devices
help us understand those things that are beyond our immediate
experience by representing them analogically.
There are two modes of
metaphorical discourse in Awakenings. The methodology of the
book is itself conceived metaphorically: it is based on the author's
"imaginative movement" into the patient's world in order to picture
the "landscapes of being" that characterize the unusual experiences
of these patients. But Sacks also uses metaphor in the particular
images chosen to figure forth the inner reality of his patients'
experiences. Of course the very language within which Parkinsonian
symptoms are described is metaphorical: patients tend to "freeze" in
movement or speech; a certain kind of facial immobility is referred to
as a "staring attack"; the body tends to "jam" in particular
postures. In trying to express a patient's response to the more
grotesque and bizarre symptoms of Parkinsonism, Sacks mentions
feelings of "intense and 'inexplicable' assaults on the citadel of
the self" (p. 54). Attempting to reflect in his language Miss D.'s
feelings about her compulsion to gnaw, bite, and gnash her teeth,
Sacks resorts again to the metaphor of
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ontological landscape, seeing these oral voracities as "monstrous
creatures from her unconsciousness and from unimaginable physiological
depths...pre-historic and perhaps prehuman landscapes" (p. 55). Sacks
here is elaborating on--"exploring," to use his own image--
her descriptions of her responses to these symptoms, which she
has written about in a diary (p. 51). Even the title of the book is
metaphoric, drawn from the world of folklore in its implicit allusion
to characters like Rip van Winkle and Sleeping Beauty who awaken after
sleeping for decades, and from the world of religion in suggesting an
analogy with the spiritual "awakenings" that are a regular feature
of religious conversion.
Trajective Discourse in the Story of Frances D.
Let us turn to one of Sacks's histories in
Awakenings and see how it illustrates a trajective approach to
clinical experience. The entire first paragraph of the story of
Frances D. is a fine example of trajec-tive discourse. Consistently
linking the details of illness and an experiencing subject, Sacks
"carries" the narrator (and the reader) into the world of the patient:
Miss D. was born in New York in 1904, the
youngest and
brightest of four children. She was a brilliant student at high school
until her life was cut across, in her fifteenth year, by a severe
attack of encephalitis lethargica of the relatively rare
hyperkinetic form. During the six months of her acute illness she
suffered intense insomnia (she would remain very wakeful until four in
the morning, and then secure at most two or three hours' sleep),
marked restlessness (fidgeting, distractible and hyperkinetic
throughout her waking hours, tossing-and-turning throughout her
sleeping hours), and impulsiveness (sudden urges to perform actions
which seemed to her senseless, which for the most part she could
restrain by conscious effort). This acute syndrome was considered to
be "neurotic," despite clear evidence of her previously
well-integrated personality and harmonious family
life. (p. 39)
Sacks's narrative style is not the stark, objective, fact-laden style
of the case history with its effaced narrator. On the other hand, this
is not a floridly poetic attempt to characterize a patient and her
experience. This is translucent prose; it is clear and quiet, though
nonetheless full of tacit affect--a style that is informative but
never intrusive.
Sacks does not begin his history of Francis D. with
the traditional opening formula of a medical history: "a 65-year-old
woman who presents with...." Instead, he tells us, using the voice of
the lifeworld, that she was born in New York in 1904 and that she was
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"the youngest and brightest of four children"--details for the most
part irrelevant to her medical history, but important in
reconstructing the context of her life before she became ill. In the
second sentence, Sacks brings together the genres of medical history
and clinical biography by introducing "the voice of medicine" within
the larger frame of lifeworld issues. He emphasizes Miss D.'s
intelligence by informing us that she was a "brilliant student,"
then introduces the disease that was to change her life so drastically
with a striking and yet understated verbal metaphor: "her life was
cut across...by a severe attack of encephalitis lethargica."
These choices of verb and adjective highlight the pathos of this case
while giving necessary clinical information (age of patient, date of
onset, definition of precipitating illness). The long third sentence
syntactically alternates the two voices of medicine and the lifeworld:
each of her primary clinical symptoms is noted (e.g., "intense
insomnia"), followed by a parenthetical description of the symptom as
the patient experienced it ("she would remain very wakeful until four
in the morning, and then secure at most two or three hours' sleep").
The discourse here is syntactically dialogic.
The paragraph concludes with a misdiagnosis, plus the
evidence that proves the diagnosis wrong. This last sentence is
structurally divided into two parts: the first tells us that her
problems were thought to suggest a neurosis; the second part, in
mentioning Miss D.'s "previously well-integrated personality and
harmonious family life," not only suggests the inaccuracy of that
diagnosis but also reminds us once again of all that she has lost. By
concluding the sentence (and the paragraph) not with the diagnosis but
with the reference to personality and family life, Sacks firmly places
Miss D. and her tragic story in the context of lifeworld issues rather
than that of medicine. She is described "thickly," as clinical
symptoms and diagnosis are observed and explained (or challenged) by
recourse to details from the lifeworld.
Other elements in the history of Frances D. illustrate
Sacks's rhetorical strategy of imaginatively moving into the patient's
world. One such strategy is simply to allow Miss D. her own voice.
Early in the history, Sacks introduces a direct quotation from his
patient: "I have various banal symptoms which you can see for
yourself. But my essential symptom is that I cannot start and I
cannot stop. Either I am held still, or I am forced to accelerate. I
no longer seem to have any in-between states" (p. 40). Quotations
such as this, in the patient's own words, emerge at various points in
the narrative primarily to describe important symptoms or responses
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to treatment. 22
Sacks observes that her description of her condition "sums up the
paradoxical symptoms of Parkinsonism with perfect precision" (p. 40).
Here the subjective formulation of the patient's experience replaces
objective clinical description.
An even more striking rhetorical device occurs when
Sacks describes Miss D.'s responses to the termination of L-DOPA: he
tells the reader that he is going to "interrupt" his patient history
"for her analysis of the situation" (p. 54). It is a statement that
seems to embody perfectly Mishler's call for genuine dialogue between
the voices of medicine and the lifeworld. Mishler describes the
typical medical interview as dominated by the voice of medicine: when
patients occasionally refer to the personal and social contexts of
their problems, these function as interruptions in the flow of the
discourse. Here, though, it is the physician himself who interrupts
his own story so that we can hear the patient's voice. What follows is
her description (in her own words) of "crashing" when the drug is
suddenly withdrawn, of her sense of helplessness and outrage at the
exacerbation of certain symptoms--in particular, certain violent
appetites and passions resembling bestial regression, and of her
ambivalent responses to her doctor, Sacks, who has given her L-DOPA.
The dialogic nature of the discourse in
Awakenings includes the patient not only in describing symptoms
and responses to treatment, but also in decision making. Miss D.'s
wishes as to important decisions in the course of her treatment are,
whenever possible, solicited and honored. On two occasions, Sacks
wants to discontinue treatment, but does not do so in deference to her
wishes. Sacks's two characters in the story--the physician and his
patient--here exist as two independent consciousnesses, and their
interaction is a matter not just of personal empathy but of pragmatic
decision making. As discourse, then, the history embodies Bakhtin's
notion of polyphonic narrative, which is characterized by a "
plurality of independent and unmerged voices and
consciousnesses.... a plurality of equal consciousnesses and
their worlds which are combined here into the unity of a given
event, while at the same time retaining their unmergedness." 23
Not only is the patient rendered more "thickly" in
Sacks's histories, but the physician is too. In the conventional case
history the subjectivity of the author is ruthlessly extirpated. Here,
though, the
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author's feelings and intuitions about his patient are allowed a
place. At one point in his description of Frances D., Sacks mentions
how her "candor, courage, and insight" help him understand more
clearly her response to L-DOPA; at another, he describes "her
mysterious reserves of health and sanity" as crucial in enabling her
to deal with the limitations of treatment; and at the very end of the
history, he characterizes her as "a superior individual" and a
survivor of "an almost life-long character-deforming disease" who
remains "a totally human, a prime human being" (pp. 53, 58, 67).
Intuition, as well as emotional response, is legitimized in this
trajective history; thus Sacks writes that, after he returned from
vacation, "I felt what was happening with her, in a very
fragmentary and inchoate way...but it was, of course, months and even
years before my own intuitions, and hers, reached the more conscious
and explicit formulations" (p. 57; emphasis in original).
Lastly, Sacks himself, the physician, makes several
appearances in the narrative in his role as an important "actor" in
the patient's drama of illness. For example, he includes as relevant
information his taking a month's vacation, describing its disastrous
impact on all his patients at a crucial time in their treatment. In
another passage, searching for the cause of Miss D.'s oculogyric
crisis, he realizes only when an observant nurse tells him that he,
Sacks, is the stimulus of her crises. Examining why his presence
should precipitate these crises, he comes to a better understanding of
how a severely incapacitated patient might regard a physician who
administers such a powerful drug. For Miss D., Sacks is "the
equivocal figure who had offered her a drug so wonderful and so
terrible in its effects" and the figure who disappears "at the
height of her anguish" to go on holiday (pp. 56, 57). But Sacks does
not introduce these comments just to characterize Miss D. more fully;
rather, he goes further to reflect on their meaning for himself and
his role as physician: L-DOPA, he concludes, "invested me...with all
too much power over her life and well-being" (p. 56).
It seems appropriate to trajective discourse that the
physician "enter" the patient's medical history--both as the object
of his patient's feelings; and as a subject with feelings, intuitions,
and his own lifeworld issues. 24 But Sacks is doing more than entering the
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patient's world. The doctor here becomes more than an epiphenomenon of
the patient's consciousness. In so reflecting on his power as
physician totally to transform a human life, for better or for worse,
he provides a glimpse into the lived reality of the physician burdened
with responsibility and choice, which renders the discourse truly
polyphonic.
Conclusion
A sophisticated critical reading of Awakenings
would tend to make much of the relationship between Sacks the author
and Sacks the character. For we have become accustomed to fictions
where the author distances himself from the narrator or the
protagonist, obliquely exposing the shortcomings and deficiencies of a
so-called hero or heroine. A critic who has thus learned always to
second-guess hero or narrator might wonder whether Sacks the doctor is
really manipulating his helpless patients, intruding into their
private lives under the guise of sympathy, or exploiting their
vulnerability for purposes of research or his own personal glory. But
I believe such charges, in this instance, to be unfounded. Sacks
exposes himself to suspicions like these by entering his own narrative
instead of taking refuge in the safe anonymity of the conventional
medical history, where the physician remains invisible and absent--his
own feelings and his interaction with patients rigorously suppressed,
his choices and decisions recorded as mere events. In contrast,
Sacks's personal involvement involves risk, but this risk-taking seems
of a piece with his genuine engagement with his patients--and his
readers. 25
This engagement transforms the conventions of medical
writing. Sacks excoriates the conventional discourse of neurology for
its "'objective', styleless style" replete with "'facts', figures,
lists, schedules, inventories, calculations, ratings, quotients,
indices, statistics, formulae, graphs, and whatnot," lamenting that
" nowhere does one find...any residue of the living
experience" (p.230). Sacks's remarks here are typical of criticisms
now leveled at the medical case history. Many commentators observe
that the case report by its very structure not only conveys little
genuine sense of patient experience but even validates a
depersonalized and technological approach
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to patient care. 26
Practical suggestions for improvement or reform include William
Donnelly's call for a description of the patient's understanding of
his or her condition to be added at the end of the chart, Charles
Freer's idea of "anecdotal diagnostic summaries" to be included in
the problem list, and David Flood and Rhonda Soricelli's
recommendation that the patient profile be expanded so as to include
subjective data such as "ethnic and religious background...,
occupation, hobbies, lifestyle, family structure and significant
relationships." 27 Kathryn
Montgomery Hunter argues for an "enriched" history in which the
doctor-narrator is recognized as "contextually conditioned"--that
is, characterized by a history and a social context--and which
acknowledges the "lived experience" of the patient. 28 It seems appropriate that
Hunter should praise Sacks's histories (and Freud's too) as "set
[ting] the standard for physicians' full empathetic and analytical
narratives of illness and treatment." 29
However, very real problems can arise when one tampers
with the form of the medical history. The fate of David Barnard's
paper "A Case of Amyotrophic Lateral Sclerosis" serves as an
unfortunate example of what can happen when a physician allows her own
feelings, motives, and lifeworld issues to enter a medical history. 30
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Although the narrator of this case is not the physician but Barnard, a
participant-observer, both come under fire--in an invited commentary
by Erik Rabkin--for supposedly sacrificing the patient and his wife to
the physician's need to be the self-sacrificing, humanitarian
"heroine" of the story. 31
An unfortunate result of Rabkin's attack has been to obscure what
Barnard was trying to do in this unusual case history--namely, to
present a patient's illness as "a meaningful event in the lives of
both the physician and the patient." 32 And if critics of the medical history argue, as
they now often do, that the self-effaced physician-narrator of the
medical history is a stylized travesty of objectivity that condones as
it enacts a depersonalized medical model, then attempts such as
Barnard's to incorporate the physician's humanity into the medical
history should be recognized for what they are--attempts to represent
in narrative form elements actually present in the medical
enterprise. Such elements include the recognition that a physician
does have personal goals, values, and motives and that these
inevitably affect the relationship with patients; the acknowledgement
that there is no easy way to balance the need for emotional distance
with the need for a compassionate and caring relationship with a
patient; and the fact that physicians in the United States are trained
to deal with acute, treatable conditions, whereas many of their
patients have a chronic or terminal illness.
Sacks, like Barnard, intends his narratives to be
imaginative reworkings of the medical case history. Sacks's "clinical
tales" are meant to bring together the two modes of clinical
approach--the nomothetic and the idiographic--and to blend the forms
of discourse appropriate to each. Moreover, Sacks's aim in writing
Awakenings was not so much to reform the medical history, which
serves practical and legal functions, as it was to reconceive the
relationship between doctor and patient.
It may be that attempts at reforming the medical
history are misdirected. What needs reform is not so much the medical
document as the way doctors and patients communicate with each
other--or fail to do so. What Sacks offers the reader in
Awakenings is not just a model for medical writing but a
paradigm for actual medical practice. The twenty case histories that
make up Awakenings
[End Page 244]
record the trajectory of the physician's movement into lifeworld
issues central to patients' experiences, situating the rhetoric of
biomedicine within a discourse that can include intuitive appraisal,
affective and relational dimensions, and, when appropriate, admission
of failure or error. Such discourse situates the patient, not the
disease, at the center of the medical enterprise, and its polyphonic
narrative preserves the individuality of both patient and doctor. One
can see why a patient like Broyard might have wished that Oliver Sacks
had been his doctor.
Anne Hunsaker Hawkins is
Associate Professor
of Humanities at the Pennsylvania
State
University College of Medicine. She has coedited an issue of Literature
and
Medicine on the
medical case history and is the author of Reconstructing Illness:
Studies in
Pathography
(1992) and Archetypes of Conversion: The Autobiographies of Augustine,
Bunyan,
and
Merton (1985).
Endnotes
1. Anatole Broyard, "Doctor
Talk to Me," New York Times Magazine, August 26, 1990,
p. 36. This passage is slightly rephrased in Alexandra Broyard, ed.,
Intoxicated by My Illness and Other Writings (New York:
Clarkson Potter, 1992), pp. 42-43.
2. Anne Hunsaker Hawkins,
"Charting Dante: The Inferno and Medical Education,"
Literature and Medicine 11:2 (1992): 200-215.
3. Oliver Sacks,
Awakenings (New York: HarperCollins, 1990), p. xxxvi
(further quotations from Awakenings will be from this
edition and will be cited by page number within the text of my essay).
The only reference to this term that I have been able to find in Eugen
Rosenstock-Huessy's work is in Out of Revolution: Autobiography
of Western Man (New York: Will Morrow, 1938; reprint Norwich,
Vt.: Argo Books, 1969). Rosenstock-Huessy suggests here that the words
"subject" and "object" be replaced by "traject" and "preject"
"Traject," he writes, refers to human development by evolution, or
"he who is forwarded in ways known from the past"; "preject,"
refers to development by revolution, or "he who is thrown out of this
rut into an unknown future" (p. 747). It seems clear that Sacks is
using the term "trajective" in a somewhat different sense.
4. A. R. Luria, The
Making of Mind: A Personal Account of Soviet Psychology, ed.
Michael and Sheila Cole (Cambridge, Mass.: Harvard University Press,
1979). Luria also wrote York: Basic Books, 1968), and The Man
with a Shattered World, trans. Lynn Solotarofft
several extended case histories: The Mind of a Mnemonist,
trans. Lynn Solotaroff (New (New York: Basic Books, 1972). To some
degree, Sacks's case histories in Awakenings, described
by its author as "a book which tried to be both
classical and romantic," are modeled after those of Luria, which he
praises as "the finest recent examples" of the genre (pp. xxxvi,
229). Debra Journet, in "Forms of Discourse and the Sciences of the
Mind: Luria, Sacks, and the Role of Narrative in Neurological Case
Histories," Written Communications 7:2 (1990): 171-199,
emphasizes the role of narrative in the case histories of Sacks and
Luria, citing many of the important theorists associated with recent
critical studies in narrativity. For a discussion of Luria's two
histories as a synthesis of the nomothetic and idiographic approaches
to science, see Anne Hunsaker Hawkins, "A. R. Luria and the Art of
Clinical Biography," Literature and Medicine 5 (1986):
1-15. Jerome Bruner's paradigmatic and narrative modes of thought are
yet another formulation of this same complementarity: the paradigmatic
is concerned with general principles and its language is denotative;
the narrative emphasizes particularity, "sacrifices denotation to
connotation," and uses figurative and metaphoric language
(Actual Minds Possible Worlds [Cambridge, Mass.: Harvard
University Press, 1986], pp. 11-43).
5. Broyard, "Doctor Talk to
Me" (above, n. 1), p. 36.
6. Oliver Sacks, A Leg
to Stand On (New York: Summit Books, 1984), p. 110.
7. For a full discussion of
pathography, see Anne Hunsaker Hawkins, Reconstructing Illness:
Studies in Pathography (West Lafayette, Ind.: Purdue University
Press, 1993).
8. Susan Sontag, Illness
as Metaphor (New York: Vintage, 1977), p. 3.
9. Kenneth A. Shapiro,
Dying and Living: One Man's Life with Cancer (Austin:
University of Texas Press, 1985), p. 130.
10. James L. Johnson,
Coming Back: One Man's Journey to the Edge of Eternity and
Spiritual Rediscovery (NY: Springhouse, 1979), prologue.
11. Jory Graham, In the
Company of Others (New York: Harcourt Brace Jovanovich, 1982),
p. 66.
12. Sacks, Leg to Stand
On (above, n. 6), p. 107.
13. Clifford Geertz,
The Interpretation of Cultures (New York: Basic Books,
1973), p. 10. Dena S. Davis, "Rich Cases: The Ethics of Thick
Description," Hastings Center Report (July-August 1991):
12-17, is a superb application of Geertz's idea of thick description
and Gilligan's care ethics to cases important for medical ethics.
Sacks himself, in the 1990 edition of Awakenings, refers
to Geertz's idea of thick description (p. xxxvii).
14. Geertz,
Interpretation, p. 14.
15. Elliot G. Mishler,
The Discourse of Medicine: Dialectics of Medical
Interviews (Nor-wood, N.J.: Ablex, 1984); Elliot G. Mishler,
Jack A. Clark, et al., "The Language of Attentive Patient Care: A
Comparison of Two Medical Interviews," Journal of General
Internal Medicine 4:4 (1989): 325-335.
16. Mishler et al. "Language
of Attentive Patient Care," p. 332.
17. Mishler, Discourse
of Medicine, pp. 192-193.t
18. Mikhail Bakhtin,
Problems of Dostoevsky's Poetics, trans. R. W. Rotsel
(n.p.: Ardis, 1973), p. 6.
19. Michael Holquist, in
glossary to The Dialogic Imagination: Four Essays by M. M.
Bakhtin, ed. Holquist (Austin: University of Texas Press,
1981), p. 427.
20. Bakhtin, Problems
of Dostoevsky's Poetics, p. 5.
21. It can be argued that
because he does not, in some way, return the story of Miss D to her
for her corroboration, Sacks's writing cannot be said to be truly
dialogic. Kathryn Montgomery Hunter, in Doctors' Stories: The
Narrative Structure of Medical Knowledge (Princeton: Princeton
University Press, 1991), emphasizes the need for the physician to
return his or her medical interpretation of the patient's story to the
patient for verification. Similarly, Nancy M. P. King and Ann Folwell
Stanford, in an interesting essay on potential problems in the
biopsychosocial model, observe that "a dialogic relationship"
between doctor and patient requires corroboration of, if not
collaboration in, the physician's explanation of a patient's problem
or interpretation of a patient's story ("Patient Stories, Doctor
Stories, and True Stories: A Cautionary Reading," Literature
and Medicine 11:2 [1992]: 185-199). Although the subject of
King and Stanford's essay is the doctor-patient encounter, their
creative and cautious use of Bakhtin's ideas of the monologic and the
dialogic can be helpful in thinking about the medical history as well.
My point is that the monologic and the dialogic can be seen as the two
end points on a spectrum, with Awakenings positioned much
closer to the dialogic than to the monologic.
22. We do not know whether
these are reconstructions of actual dialogue, passages from this
patient's diary (which Sacks indicates he has seen), or quotations
wholly invented by Sacks. This seems to me a drawback in the book, and
detracts from our sense that, throughout Awakenings,
Sacks makes an exemplary effort to honor his patients' subjectivity.
23. Bakhtin, Problems
of Dostoevsky's Poetics, p. 4 (emphasis in original).
24. Of course, physicians can
become too involved in their patients' lives. An interesting example
of this can be found in David Barnard, "A Case of Amyotrophic Lateral
Sclerosis," Literature and Medicine 5 (1986): 27-42
(discussed below). I am not suggesting here that a physician should
abandon clinical distance. Too often, though, "clinical distance" in
medicine is thought to refer to a stance that is dispassionate,
objective, and emotionally uninvolved. Clinical distance
should be seen as achieving a right balance between
detachment and involvement, distance and intimacy.
25. In fact, Sacks the author
does distance himself from Sacks the character in that the author's
intention in writing Awakenings is to expose what I call
"the myth of cure": initially, the doctor who gives his patients
L-DOPA embraces the myth of cure, but it is a myth that both he and
his patients must renounce in the end. I explore this dimension of
Awakenings in a paper entitled, "Oliver Sacks's
Awakenings and The Myth of Cure," presented at the 1992
MLA Convention in New York City for a Special Session on Literature
and Medical Ethics.
26. See Joanne Trautmann
Banks and Anne Hunsaker Hawkins, eds., Literature and
Medicine 11:1 (1992), "The Art of the Case History."
27. William J. Donnelly,
"Righting the Medical Record: Transforming Chronicle into Story,"
JAMA 260:6 (1988): 823-825; Charles B. Freer,
"Description of Illness: Limitations and Approaches," Journal
of Family Practice 10:5 (1980): 867-870; David H. Flood and
Rhonda Soricelli, "Development of Physician Narrative Voice in the
Medical Case History," Literature and Medicine 11:1
(1992): 64-83.
28. Hunter, Doctors'
Stories (above, n. 21), pp. 166, 106.
29. Ibid., p. 164. Though
Hunter goes on to observe that Sacks's histories "are not themselves
usable models for much of medical care" because they are index cases
and because only neurology and psychiatry require such full
characterization, I think that she may be conceding too much
(Doctors' Stories, p. 165; Kathryn Montgomery Hunter, and
"Remaking the Case," Literature and Medicine 11:1
[1992], p. 173). The tendency to separate the disease from the person
with the disease is precisely what so many--including Hunter-- have
been criticizing in contemporary, technological biomedicine.
30. In his reply to the
comments of Rabkin and others, Barnard observes that "there are
important respects in which 'A Case of Amyotrophic Lateral Sclerosis'
[above, n. 24] is [the physician's] story and that it is
precisely this side of the story that has been too often neglected by
conventional case histories" (David Barnard, "A Case of Amyotrophic
Lateral Sclerosis: A Reprise and Reply," Literature and
Medicine 11:1 [1992], p. 136). Barnard further comments that
"this side of the story is the place of the patient's illness in the
physician's life"--the way in which "the physician comes to play a
role in his or her own existential drama, even while attempting to
play an appropriate and helpful role in the patient's drama" (ibid.).
31. Eric Rabkin, "A Case of
Self Defense," Literature and Medicine 5 (1986): 43-53.
In fact, as Barnard reminds us in "A Case of Amyotrophic Lateral
Sclerosis: A Reprise and Reply," his aim in writing the history was
to use it as a teaching device to help medical students better
appreciate the nontechnological aspects of physicians'
responsibilities to their patients.
32. Barnard, "Reprise and
Reply," p. 134.
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