On the Move: A Life

by Oliver Sacks

  Whether as a result of the insulin comas or a natural process of resolution, Michael returned from the hospital three months later, no longer psychotic but deeply shaken, feeling he might never hope to lead a normal life. He had read Eugen Bleuler’s Dementia Praecox; or, The Group of Schizophrenias while in hospital.

  Marcus and David had enjoyed a day school in Hampstead, a few minutes’ walk from our house, and Michael was glad now to continue his education there. If he was changed by his psychosis, this was not immediately apparent; my parents chose to think of it as a “medical” problem, something from which one could make a complete recovery. Michael, however, saw his psychosis in quite different terms; he felt it had opened his eyes to things that he had never previously thought about, in particular the downtroddenness and exploitation of the world’s workers. He started reading a communist newspaper, The Daily Worker, and going to a communist bookshop in Red Lion Square. He devoured Marx and Engels and saw them as the prophets, if not the messiahs, of a new world era.

  By the time Michael was seventeen, Marcus and David had finished medical school. Michael did not want to become a doctor, and he had had enough of school. He wanted to work—were workers not the salt of the earth? One of my father’s patients had a large accounting business in London and said he would be happy to have Michael as an accounting apprentice or in any other capacity he wanted. Michael was quite clear about the role he would like to have; he wanted to be a messenger, to deliver letters or packages that were too important and urgent to be left to the post. In this, he was absolutely meticulous; he would insist on putting whatever message or packet he was entrusted with directly into the hands of its designated recipient and no one else. He loved walking around London and spending his lunch hours on a park bench, if the weather was nice, reading The Daily Worker. He once told me that the seemingly humdrum messages he delivered might have hidden, secret meanings, apparent only to the designated recipient; this was why they could not be entrusted to anyone else. Though he might appear to be an ordinary messenger with ordinary messages, Michael said, this was by no means the case. He never said this to anyone else—he knew it would sound bizarre, if not mad—and he had begun to think of our parents, his older brothers, and the entire medical profession as determined to devalue or “medicalize” everything he thought and did, especially if it had any hint of mysticism, for they would see it as an intimation of psychosis. But I was still his little brother, just twelve years old, not yet a medicalizer, and able to listen sensitively and sympathetically to anything he said, even if I could not fully understand it.

  Every so often—it happened many times in the 1940s and early 1950s, while I was still at school—he became floridly psychotic and delusional. Sometimes there was warning of this: he would not say, “I need help,” but he would indicate it by an extravagant act, such as flinging a cushion or an ashtray to the floor in his psychiatrist’s office (he had been seeing one since his initial psychosis). This meant, and was understood to mean, “I’m getting out of control—take me into hospital.”

  At other times, he gave no warning but would get into a violently agitated, shouting, stamping, hallucinated state—on one occasion, he hurled my mother’s beautiful old grandfather clock against a wall—and at such times my parents and I would be terrified of him. Terrified, and deeply embarrassed—how could we invite friends, relatives, colleagues, anyone, to the house with Michael raving and rampaging upstairs? And what would their patients think? Both my parents had their medical offices in the house. Marcus and David also felt reluctant about inviting their friends into (what sometimes seemed to be) a madhouse. A sense of shame, of stigma, of secrecy, entered our lives, compounding the actuality of Michael’s condition.

  I found it a great relief when I took weekends or holidays away from London—holidays which, besides everything else, were holidays from Michael, from his sometimes intolerable presence. And yet there were other times when his native sweetness of character, his affectionateness, his sense of humor, shone out again. At such times, one realized, even when he was raving, that the real Michael, sane and gentle, was there underneath his schizophrenia.

  —

  When, in 1951, my mother learned of my homosexuality and said, “I wish you had never been born,” she was speaking, though I am not sure I realized this at the time, out of anguish as much as accusation—the anguish of a mother who, feeling she had lost one son to schizophrenia, now feared she was losing another son to homosexuality, a “condition” which was regarded then as shameful and stigmatizing and with a deep power to mark and spoil a life. I was her favorite son, her “mugwump” and “pet lamb,” when I was a child, and now I was “one of those”—a cruel burden on top of Michael’s schizophrenia.

  —

  The situation changed for Michael and for millions of other schizophrenics, for better and worse, around 1953, when the first tranquilizer—a drug called Largactil in England, Thorazine in the United States—became available. The tranquilizers could damp down and perhaps prevent the hallucinations and delusions, the “positive symptoms” of schizophrenia, but this could come at great cost to the individual. I first saw this, shockingly, in 1956 when I came back to London after my months in Israel and Holland and saw that Michael was bent over and walked with a shuffling gait.

  “He’s grossly parkinsonian!” I said to my parents.

  “Yes,” they said, “but he’s much calmer on the Largactil. He’s gone a year without a psychosis.” I had to wonder, however, how Michael felt. He was distressed at the parkinsonian symptoms—he had been a great walker, a strider, before—but even more upset by the mental effects of the drug.

  He was able to continue at his job, but he had lost the mystical feeling that gave depth and meaning to his messengering; he had lost the sharpness and clarity with which he had previously perceived the world; everything seemed “muffled” now. “It is like being softly killed,” he concluded.2

  When Michael’s dose of Largactil was reduced, his parkinsonian symptoms subsided, and, more important, he felt more alive and regained some of his mystical sensibilities—only to explode, a few weeks later, into florid psychosis again.

  In 1957, by now a medical student myself, interested in brain and mind, I phoned Michael’s psychiatrist and asked if we could meet. Dr. N. was a decent, sensitive man who had known Michael since his initial psychosis nearly fourteen years earlier, and he too was disturbed by the new, drug-related problems he was encountering with many of his patients on Largactil. He was trying to titrate the drug, to find a dosage which would be just enough but not too much or too little. He was, he confessed, not entirely hopeful here.

  I wondered whether systems in the brain concerned with the perception (or projection) of meaning, significance, and intentionality, systems underlying a sense of wonder and mysteriousness, systems for appreciation of the beauty of art and science, had lost their balance in schizophrenia, producing a mental world overcharged with intense emotion and distortions of reality. These systems had lost their middle ground, it seemed, so that any attempt to titrate them, damp them down, could tip the person from a pathologically heightened state to one of great dullness, a sort of mental death.

  Michael’s lack of social skills and of ordinary day-to-day aptitudes (he could scarcely make a cup of tea for himself) demanded a social and “existential” approach. Tranquilizers have little or no effect on the “negative” symptoms of schizophrenia—withdrawal, flattening of affect, etc.—which, in their insidious, chronic way, can be more debilitating, more undermining of life, than any positive symptoms. It is a question of not just medication but the whole business of living a meaningful and enjoyable life—with support systems, community, self-respect, and being respected by others—which has to be addressed. Michael’s problems were not purely “medical.”

  —

  I could, I should, have been more loving, more supportive, while I was back in London, in medical school; I could have gone out with Michael to restauran
ts, films, theaters, concerts (which he never did by himself); I could have gone with him on visits to the seaside or the countryside. But I didn’t, and the shame of this—the feeling that I was a bad brother, not available to him when he was in such need—is still hot within me sixty years later.

  I don’t know how Michael would have responded had I shown more initiative. He had his own severely controlled and limited life and disliked any departure from it.

  His life, now that he was on tranquilizers, was less turbulent but, it seemed to me, increasingly impoverished and constricted. He no longer read The Daily Worker, no longer visited the bookshop in Red Lion Square. He had once had a certain feeling of belonging to a collective, sharing a Marxist perspective with others, but now, as his ardor cooled, he felt increasingly solitary, alone. My father hoped that our synagogue might provide moral and pastoral support, a sense of community, for Michael. He had been quite religious as a youth—after his bar mitzvah, he wore tzitzit and laid tefillin daily and went to shul whenever he could—but here too his ardor had cooled. He lost interest in the synagogue, and the synagogue, with its diminishing community—more and more of London’s Jews were emigrating or assimilating and intermarrying in the general population—lost interest in him.

  Michael’s general reading, once so intense and omnivorous—had not Auntie Annie left her entire library to him?—dwindled dramatically; he ceased to read books almost completely and looked at newspapers only desultorily.

  I think that despite, or perhaps because of, the tranquilizers, he had been sinking into a state of hopelessness and apathy. In 1960, when R. D. Laing published his brilliant book The Divided Self, Michael had a brief resurgence of hope. Here was a physician, a psychiatrist, seeing schizophrenia not as a disease so much as a whole, even privileged mode of being. Although Michael himself sometimes called the rest of us, the non-schizophrenic world, “rottenly normal” (great rage was embodied in this incisive phrase), he soon tired of Laing’s “romanticism,” as he called it, and came to regard him as a slightly dangerous fool.

  When I left England on my twenty-seventh birthday, it was, among many other reasons, partly to get away from my tragic, hopeless, mismanaged brother. But perhaps, in another sense, it would become an attempt to explore schizophrenia and allied brain-mind disorders in my own patients and in my own way.

  1. I have written of the school, and its effects on us, in much more detail in Uncle Tungsten.

  2. Years later, when I worked at Bronx State Hospital, I was to see gross motor disorders, and hear similar mental complaints, from hundreds of schizophrenic people who had been slugged with heavy doses of drugs like Thorazine or a then-new category of drugs called butyrophenones, such as haloperidol.

  San Francisco

  I had arrived in San Francisco, a city I had dreamed of for years, but I had no green card, and therefore I could not be legally employed or earn any money. I had kept in touch with Michael Kremer, my neurology chief at the Middlesex (he had been all in favor of my skipping the draft; “a complete waste of time now,” he said), and when I mentioned my thoughts of going to San Francisco, he suggested that I look up his colleagues Grant Levin and Bert Feinstein, neurosurgeons at Mount Zion Hospital. They were pioneers in the art of stereotactic surgery, a technique that allowed one to insert a needle directly and safely into small, otherwise inaccessible areas of the brain.1

  Kremer had written to introduce me, and when I met Levin and Feinstein, they agreed to take me on informally. They suggested that I help evaluate their patients before and after surgery; they could not give me a salary, since I had no green card, but they kept me going with $20 notes. (Twenty dollars was a lot at the time; an average motel cost about $3 a night, and pennies were still used in some parking meters.)

  Levin and Feinstein said they would find me a room to live in in the hospital in a few weeks, but in the interim, having very little money, I arranged to stay at a YMCA; there was a large residential Y, I heard, in the Embarcadero, opposite the Ferry Building. The Y looked shabby, a little dilapidated, but comfortable and friendly, and I moved into a little room on the sixth floor.

  Around 11:00 p.m., there was a soft knock on my door. I said, “Come in”; the door was not locked. A young man put his head round the door and, seeing me, exclaimed, “Sorry, I’ve got the wrong room.”

  “Don’t be too sure,” I answered, hardly believing what I was saying. “Why don’t you come in?” He looked uncertain for a moment and then came in, locking the door behind him. This was my introduction to life at the Y—a continual opening and shutting of doors. Some of my neighbors, I observed, might have five visitors in a night. I had a peculiar, unprecedented feeling of freedom: I was no longer in London, no longer in Europe; this was the New World, and—within limits—I could do what I wished.

  A few days later, Mount Zion said it had a room available for me, and I moved into the hospital—none the worse for my fling at the Y.

  —

  I spent the next eight months working for Levin and Feinstein; my official internship at Mount Zion would not begin until the following July.

  Levin and Feinstein were as different from each other as could be imagined—Grant Levin unhurried and judicious, Feinstein passionate and intense—but they made a fine complementary pair, like my neurological chiefs Kremer and Gilliatt in London (and my surgical chiefs Debenham and Brooks at the Queen Elizabeth Hospital in Birmingham).

  I had been fascinated by such partnerships even as a boy; in my chemical days, I read about the partnership of Kirchhoff and Bunsen and how their very different minds, together, were indispensable for the discovery of spectroscopy. I had been fascinated, at Oxford, by reading the famous paper on DNA by James Watson and Francis Crick and learning how different the two men were. And while I was toiling away at my uninspired internship at Mount Zion, I was to read about another seemingly improbable and incongruous pair of researchers, David Hubel and Torsten Wiesel, who were opening up the physiology of vision in the wildest, most beautiful way.

  Besides Levin and Feinstein and their assistants and nurses, the unit employed an engineer and a physicist—there were ten of us in all—and the physiologist Benjamin Libet often visited.2

  One patient in particular stayed in my mind, and I wrote to my parents about him in November of 1960:

  Do you remember a Somerset Maugham story about a man who had a spell cast on him by some jilted Island girl, and developed a fatal hiccup? One of our patients, a postencephalitic coffee baron, has had a hiccup for six days following operation, intractable to all the usual and some very unusual measures, and I fear may go the same way unless we block his phrenic nerves or something. I suggested bringing in a good hypnotist: I wonder if this will work? Have you any experience of this as a major problem?

  My suggestion was viewed skeptically (I had doubts about it myself), but Levin and Feinstein agreed to call in a hypnotherapist; nothing else had worked. To our amazement, he was able to get the patient “under” and then to give him a posthypnotic command: “When I snap my fingers, you will wake up and no longer have hiccups.”

  The patient woke up, free from hiccups, and they never recurred.

  —

  Though I had kept a journal in Canada, I stopped once I had arrived in San Francisco and did not resume till I was on the road again. I continued, however, to write long, detailed letters to my parents, and in February of 1961 I wrote of seeing two of my idols, Aldous Huxley and Arthur Koestler, at a conference at UCSF:

  Aldous Huxley gave a tremendous after dinner speech on Education. I had never seen him before, and was amazed by his height and cadaverous emaciation. He is almost blind now, and blinks his pebble like eyes constantly, as well as screwing up his fists in front of them (this puzzled me, but I think now it was to secure some pinhole vision): he has long corpse like hair floating back, and a dun skin very loosely, very inaccurately, covering the bony contours of his face. Leaning forward, in intense concentration, he somewhat resembled Vesalius�
�� skeleton in meditation. However, his marvelous mind is as good as ever, served by a wit, a warmth, a memory and an eloquence that brought everyone to their feet more than once…. And finally Arthur Koestler, on the creative process, a wonderful analysis so poorly audible and presented that half his audience walked out. Koestler, by the way, looks a little like Kaiser, a little like all the Hebrew teachers in the world, and speaks just like them [Kaiser, our Hebrew teacher, had been a familiar figure in the house from my earliest days]. Americans don’t get lined, whereas Koestler’s litvuk face was ostentatiously lined, seamed with great furrows of anguish and intelligence which seemed almost indecent in that smooth faced assembly!

  Grant Levin, my genial and generous boss, had procured tickets for all of us in the neurosurgical unit to attend a conference called “The Control of Mind,” and he frequently distributed tickets to musical, theatrical, and other cultural events in San Francisco, a rich diet which made me love the city more and more. I wrote to my parents of seeing Pierre Monteux with the San Francisco Symphony Orchestra:

  He was conducting (always just one beat behind the orchestra, I felt), and the programme included Berlioz’ Symphonie Fantastique (the execution scene always reminds me of that grisly Poulenc opera); “Till Eulenspiegel”; Debussy’s “Les Jeux” (tremendous, could have been written by the early Stravinsky) and some minor nonsense by Cherubini. Monteux himself is almost ninety now, and has a wonderful pearlike shape, bobbing and waddling along, and a melancholy French moustache, somewhat like Einstein’s. The audience went mad over him, partly I think out of appeasement (they hissed at him sixty years ago), and partly their faddy rather patronising mythomania, by which great age alone becomes a recommendation. However, I admit it is exciting to think of the uncomputable rehearsals and first nights, the crushing failures, the heavenly successes, the tumbling billions of notes which must have run through that old brain in his ninety years.