AWAKENING
from: "Awakenings" (a Film Version of this Book)by Oliver Sacks
Virtually all patients with true Parkinsonism show some sort of 'awakening' when given L-DOPA.
Patients with 'pseudo-Parkinsonism' (e.g. Parkinsonian-like pictures associated with disease of the cortex - a not uncommon situation in elderly patients) show virtually no awakening at all. 1 drew attention to this in 1969 (see Sacks, 1969) and suggested at this time that trial with L-DOPA might thus be useful in distinguishing such patients from true Parkinsonians.
The aetiology of the Parkinsonism, in itself, is not of significance in modifying reactions to L-DOPA: thus toxic Parkinsonism, associated with manganese or carbon monoxide poisoning, may respond well to L-DOPA. Among my own patients who have done well when given L-DOPA have been three who suffered from syphilitic Parkinsonisra (Wilson's 'syphilitic mesencephalitis') associated with tabes.
This is true of all but three (Robert 0., Frank G., Rachel I.) of the patients described in this book, and of all but a score of the two hundred Parkinsonian patients to whom I have given L-DOPA.
A few patients may fail to show awakening on L-DOPA and instead be thrust into deeper illness; moreover, the response may be quite different at different times in a single patient.
In general - though this is not always the case - awakening is most profound and most rapid in patients with the severest disease, and may be virtually instantaneous in patients with 'imploded' (or 'black hole') types of Parkinsonism- catatonia (e.g. Hester Y.). In patients with ordinary Parkinson's disease, awakening may be extended over a matter of days, although it usually reaches its zenith within two weeks or so. In post-encephalitic patients, as our case- histories have shown, awakening tends to be much prompter and more dramatic; moreover, post-encephalitic patients, in general, are much more sensitive to L-DOPA, and may be awakened by a fifth or less of the doses required for 'ordinary' patients.
An 'ordinary' patient may be in excellent (behavioural) health apart from his Parkinsonism, and this itself may be mild, and of relatively short duration; for such a patient, therefore, getting well or awakening chiefly consists in a reduction or apparent abolition of his Parkinsonism; there are other aspects to awakening, even in such patients, but these are much more readily studied in profoundly and chronically disabled post-encephalitic patients, who suffer from a great number of disabilities in addition to Parkinsonism.
Such a 'global' awakening was indeed unintelligible in relation to the prevailing notions of neuroanatomy in 1969 - notions which saw the 'motor,' the 'perceptual', the 'affective', and the 'cognitive' as residing in separate and noncommunicating compartments of the brain. But anatomy has been revolutionised in the past twenty years, most especially by Walle Nauta, who has shown that all these supposedly-separate compartments of brain function are richly interconnected and in continual communication; only with this new neuroanatomy does one understand how the motor, the sensory, the affective, the cognitive, can - and indeed must - go together (see Nauta, 1989; Sacks, 1989).
Certain feelings are invariably experienced during a profound awakening, and are described by patients in figurative terms very similar to those which an 'outside' observer would invoke. The sudden relief of Parkinsonism, catatonia, tensions, torsions, etc., is experienced as a deflation or detumescence, a sudden relief of an internal pressure; patients often compare it to passing flatus, eructation, or emptying of the bladder. And this is exactly how it looks to an external observer: the stiffness or spasm or swelling disappears, and suddenly the patient is 'relaxed', and at ease. Patients who comment on the 'pressure' or 'force , of their Parkinsonism, etc., are clearly not speaking in physical terms, but in ontological or metaphysical terms which correspond to their experience. The terms of 'pressure' or 'force' indicate something about the organisation of illness, and give a first inkling of the nature of ontological or 'inner' space in these patients; and in all of us.
This return-to-oneself, resipiscence, 'rebirth', is an infinitely dramatic and moving event, especially in a patient with a rich and full self, who has been dispossessed by disease for years or decades (e.g. Hester Y.). Furthermore, it shows us, with wonderful clarity, the dynamic relation of sickness to health, of a 'false self' to the real self, of a disease-world to an optimum-world.
The automatic return of real being and health, pari passu with the drainage of disease, shows that disease is not a thing-in-itself, but parasitic on health and life and reality: an ontological ghoul, living on and consuming the grounds of the real self. It shows the dynamic and implacable nature of our 'internal rnilitia'; how opposed forms of being fight to possess us, to dispossess each other, and to perpetuate themselves.
This reciprocity between health and sickness is quite apparent even in the absence of L-DOPA.
One sees, in practice, again and again,
Thus, two years ago, I had occasion to see an old lady who, the day before falling and breaking her hip, had been 'full of life,' and had shown not the least sign of Parkinsonism (or none that was recognized); the following day, when I saw her, she was in some pain, but - more significantly - had suffered, and showed, an existential collapse, a sense that she was 'finished' and that death was near, a draining away of her vitality and da-sein; now, in addition to looking half-dead, she was deeply Parkinsonian; three days later, she 'was herself once again' - she felt full of life and no longer showed the least trace of Parkinsonism. She has continued in excellent health since this time, and has not again shown any manifest Parkinsonism. I have no doubts, however, that it is there (in potential, in propensity, latent, dormant, in posse), and will again come to the forefront if her health, her real-being, is injured or lost.
That a return to health or resipiscence is possible, in these patients with half a century of the profoundest illness, must fill one with a sense of amazement - that the potential for health and self can survive, after so much of the life and structure of the person has been lost, and after so long and exclusive an immersion in sickness. This also is of major importance, not only therapeutically, but theoretically as well.
Such awakenings may be compared to so-called 'lucid intervals'. At such times - despite the presence of massive functional or structural disturbances to the brain - the patient is suddenly and completely restored to himself.
Again, there is described, and I have seen, the sudden 'sobering' effect of illness, tragedy, bereavement, etc., on profoundly deteriorated, 'burnt-out,' hebephrenic schizophrenics; such patients - who may have been 'decomposed' into a swarm of mannerisms, impulsions, automatisms, and mocking 'selflets' for decades - may come together in a moment faced with an overwhelming reality.
But one need not look for such far-out examples.
Many neuropsychologists, pre-eminently Lashley, have spent their lives 'in search of the Engram': the work of Lashley, in particular, has conclusively shown how individual skills and memories may survive massive and varied extirpations of the brain. Such experimental observations, like careful and thoughtful clinical observations (most notably those of Luria, as set out in The Man with a Shattered World), indicate
Note (I990): Such a dynamic, biological concept of consciousness as reflecting ever-shifting 'global mappings' in the brain, ceaseless relatings of current perceptions to past mappings, has been articulated with great force recently, by Gerald Edelman.
One observes this, again and again, at the height of toxic, febrile, or other deliria: sometimes the person may be recalled to himself by the calling of his name; then, for a moment or a few minutes, he is himself, before he is carried off by delirium again. In patients with advanced senile dementias, or pre-senile dementias (e.g. Alzheimer's disease), where there is abundant evidence of all types regarding the massive loss of brain structure and function, one may also - very suddenly and movingly - see vivid, momentary recalls of the original, lost person. (There may be brief, sudden normalisations of an otherwise profoundly abnormal EEG in these tantalisingly lucid moments: compare figure I, P. 328.)
All of us have experienced sudden composures, at times of profound distraction and disorganization; sudden sobriety, when intoxicated; and - especially as we grow older - sudden total recalls of our past or out childhood, recalls so complete as to be a re-being.
All of these indicate that one's self, one's style, one's persona exists as such, in its infinitely complex and particular being; that it is not a question of this system or that, but of a total organisation which must be described as a self. Style, in short, is the deepest thing in one's being. An extraordinary example of this is provided by a number of letters which I once saw, written by Henry James when he was in a terminal, extremely febrile, pneumonia delirium: these letters show clear evidences of delirium, but their style is unmistakably and uniquely that of Henry James, and indeed, of 'late' Henry James.
They show, instead,
that one's ontological organisation, one's entire being - for all its multiplicity, all its shimmering, ever-shifting succession of patterns (Hume's bundle of perceptions', Proust's 'collection of moments') - is nevertheless a coherent and continuing entity, with a historical, stylistic, and imaginative continuity, with the unity of a life-long symphony or poem.
If we are to understand the quality of awakening, and of the awakened state -health- we must depart from the physiological and neurological terms which are generally used, and heed the terms which patients themselves tend to use. Currently used neurological and neuro-physiological terms have reference to alterations of energy-level and energy-distribution in the brain; we must also use energetic and economic concepts, but in a radically different way from the way in which they are generally used.
We have already spoken (n. 31, p. 30) of the two schools in classical neurology - the holists and topists, or, in their own vernacular - the 'lumpers' and 'splitters'.
Holists refer to the 'total energy' of the brain as if this were something uniform, undifferentiated, and quantifiable. They speak, for example, of arousal and activation, of increased activity in an activating-system - an increase which can be defined and (in principle) measured by counting the total number of impulses which pass up this system. In more idiomatic terms, it is said that patients are 'turned on' or 'switched on' by L-DOPA. The limitation, and finally, the unreality, of such terms is that they are purely quantitative, and that they speak of magnitudes without reference to qualities. In reality, one cannot have magnitudes destitute of quality. Al though patients do speak of feeling more energy, more 'pep', more 'go', etc., they clearly distinguish the qualities of pathology and health: in the words of one patient awakened by L-DOPA - 'Before I was galvanized, but now I am vivified',Topists, by contrast, envisage a mosaic of different 'centres' or 'systems', each imbued with a different kind of energy; they see energy as parcelled or partitioned in innumerable packages, all of which are 'correlated' in some mysterious way. Thus, patients on L-DOPA may be given a 'vigilance-rating', a 'motility-rating', an 'emotivity-rating', etc., and correlation-coefficients established between these. Such notions are completely alien to the experience of the patient, or to that of a sympathetic observer who feels with his patients. For nobody is conscious of their 'emotivity', for example, as distinct from their 'vigilance': one is conscious only of feeling alive, attentive, aware - and of the total, infinite character of one's attention and awareness. To break up this unity into isolated components is to commit an epistemological solecism of the first order, as well as to be blind to the feelings of one's patients.
Awakening consists of a change in awareness, of one's total relation to one's self and the world. All post-encephalitic patients (all patients), in their individual degrees and ways, suffer from defects and distortions of attention: they feel, on the one hand, cut-off or withdrawn from the world, on the other hand immersed, or engrossed, in their illness. This pathological in-turning of attention on itself is particularly marked in cataleptic forms of illness, and is beautifully illustrated by a cataleptic patient who once said to me 'My posture continually yields to itself. My posture continually enforces itself. My posture is continually suggesting itself. I am totally absorbed in an absorption of posture.'
Awakening, basically, is a reversal of this: the patient ceases to feel the presence of illness and the absence of the world, and comes to feel the absence of his illness and the full presence of the world.
Instinctively and intuitively all patients use certain metaphors again and again. Thus, there are the universal images of rising and falling, which come naturally and automatically to every patient: one ascends to health and happiness and grace, and one descends to depths of sickness and misery. But a dangerous confusion can also arise: there are enticing ascensions and 'fraudulent heights' of mania, greed, and pathological excitement; and although these are quite different from the solid elevation of health, yet they may be confused with and .'compensate' for it. Another universal metaphor is that of light and darkness: one emerges from the darkness and dimness of disease, into the clear light of health. But sickness has brilliance and false lights of its own.
He becomes (in D. H. Lawrence's words) 'a man in his wholeness wholly attending'.
Thus the awakened patient turns to the world, no longer occupied and preoccupied by his sickness. He turns an eager and ardent attention on the world, a loving and joyous and innocent attention, the more so because he has been so long cut-off, or 'asleep'. The world becomes wonderfully vivid again. He finds grounds of interest and amazement and amusement all round him - as if he were a child again, or released from gaol. He falls in love with reality itself.
Reunited with the world and himself, the entire being and bearing of the patient now changes. Where, previously, he felt ill at ease, uncomfortable, unnatural, and strained, he now feels at ease, and at-one with the world. All aspects of his being - his movements, his perceptions, his thoughts, and his feelings - testify simultaneously to the fact of awakening. The stream of being, no longer clogged or congealed, flows with an effortless, unforced ease: there is no longer the sense of 'ca ne marche pas', or stoppage inside.
This partly mechanical, partly infernal, sense of inner stoppage, or of a senseless, maddening going-which-goes-nowhere, so typical of Parkinsonism and neurosis, is nowhere better expressed than in D. H. Lawrence's last poems and letters.
. . . going, yet never wandering, fixed yet in motion,
Men that sit in machines
among spinning wheels, in an apotheosis of wheels,
sit in the grey mist of movement which moves not,
and going which goes not,
and being which is not.
the kind of hell that is real, grey and awful
the kind of hell grey Dante never saw ...
There is a great sense of spaciousness, of freedom of being. The instabilities and knife-edges of disease disappear, and are replaced by poise, resilience, and ease.
These feelings, variously coloured by individual disposition and taste, are experienced, with greater or less intensity, by every patient who becomes fully awakened from the use of L-DOPA. They show us the full quality - the zenith of real being (so rarely experienced by most 'healthy' people); they show us what we have known - and almost forgotten; what all of us once had - and have subsequently lost.
This sense of a return to something primal, to the deepest and simplest thing in the world, was conveyed to me, most vividly, by my patient Leonard L. 'It's a very sweet feeling', he said (during his own so-brief awakening), 'very sweet and easy and peaceful. I am grateful to each moment for being itself . . . I feel so contented, like I'm at home at last after a long hard journey. just as warm and peaceful as a cat by the fire'. And this was exactly how he looked at that moment -
. . . Like a cat asleep on a chair, at peace, in peace,
and at one with the master of the house, with the mistress,
at home, at home in the house of the living,
sleeping on the hearth, and yawning before the fire.Sleeping on the hearth of the living world
yawning at home before the fire of life
feeling the presence of the living God
like a great reassurance
a deep calm in the heart a presence
as of the master sitting at the board
in his own and greater being,
in the house of life.D.H. Lawrence, "Pax"