Monday, November 5, 2007

The Listener

As Oliver Sacks observes the mind through music, his belief in a science of empathy takes on new dimension.

By Jonah Lehrer in Seed Magazine. Click Here for article.

In 1974 Oliver Sacks was climbing a mountain in Norway by himself. It was early afternoon, and he had just begun his descent when a slight misstep sent him careening over a rocky cliff. His left leg was "twisted grotesquely" beneath his body, his limp knee wracked with pain. "My knee could not support any weight at all, but just buckled beneath me," he wrote in A Leg to Stand On. Sacks began to "row" himself down the mountain, sliding on his back and pushing with his hands, so that his leg, which he'd splinted with his umbrella, was "hanging nervelessly" in front of him. After a few hours, Sacks was exhausted, but he knew that if he stopped he would not survive the cold night.

What kept Sacks going was music. As he painstakingly descended the mountain, he began to make a melody out of his movements. "I fell into a rhythm," Sacks writes, "guided by a sort of marching or rowing song, sometimes the Volga Boatman's Song, sometimes a monotonous chant of my own. I found myself perfectly coordinated by this rhythm—or perhaps subordinated would be a better term: The musical beat was generated within me, and all my muscles responded obediently...I was musicked along." Sacks reached the village at the bottom of the mountain just before nightfall.

A long convalescence followed, as he tried to regain the use of his injured leg, but the nerves in his limb had been severely damaged. When Sacks tried to walk, he was forced to consciously calculate his movements, to think before each step.

Once again, Sacks was saved by the sudden appearance of song. As he was struggling with physical therapy—and growing increasingly frustrated—his mind was inexplicably filled with the resonant strings of Mendelssohn's Violin Concerto. "In the moment that this inner music started," Sacks recounts, "the leg came back. With no warning, no transition whatever, the leg felt alive, and real, and mine." Sacks would later describe his vivid hallucinations of the Concerto as a kind of miracle, in which the music "descended like grace," reminding him of his own "kinetic melody." The song had restored him to himself.

I'm sitting in Oliver Sacks's office in New York City's Greenwich Village. Bookshelves are cluttered with neurological texts and periodic-table paraphernalia, so that a rod of tungsten (his favorite element) sits next to the collected works of William James. The air conditioner is perpetually set on high, its wheeze so loud that it drowns out the noises of city and street. This is where Sacks writes, at a desk facing the window by the air conditioner, on long yellow sheets fed into a manual typewriter. "I like the clacking of the keys," he says. "I can't write without that sound."

Sacks's latest book is Musicophilia, an exploration of the musical mind. As in his previous works, such as An Anthropologist on Mars, or The Man Who Mistook His Wife for a Hat, Sacks describes a series of ordinary people transformed by their extraordinary neurological conditions. He writes, for instance, of Tony Cicoria, who, after being struck by lightning, suddenly developed an insatiable obsession with Chopin's piano music. Before the accident, Tony had been a respected surgeon, with little interest in classical music. But now he insisted on spending all of his spare time practicing the piano. He even began composing his own pieces, "giving form to the music continually running in his head." Sacks also describes the case of Martin, who developed uncanny musical talents after contracting meningitis as a child. While the affliction impaired many aspects of Martin's mind, it left him with a limitless auditory memory. And then there's Mrs. C., who was besieged by musical hallucinations after becoming deaf. She couldn't stop hearing Christmas carols.

But Musicophilia is not just a collection of neurological case studies. There is an unexpected thread running through the book. That thread is Sacks's life. Even as he explores the neurology of music, Sacks returns, again and again, to stories from his own past, almost as if he's rediscovering them. There are the famous patients from Awakenings, who were unfrozen by the sound of music. There are the musical hallucinations of his mother, who, at the age of 70, was temporarily seized by patriotic songs from her childhood. And there's the tale of Sacks's own musical healing so that at times it feels like a memoir told through the prism of music. In Musicophilia, Sacks is both a sensitive observer and a subject. As usual, his own story is inseparable from the stories of his patients.

"I had no intention of writing a book devoted to music," Sacks says. "I'm not a musician or an expert on music...but this book found me. I began to revisit all of these older stories and present them in an explicitly musical light. That's the way writing is sometimes. One doesn't know what story one is telling until the story is told."

At first glance, music seems like an unlikely theme for Sacks. He's hard of hearing, and has to turn down his beloved air conditioner during our conversation. There's also something distinctly unmusical about Sacks's movements. He is charmingly clumsy, and his fingers are constantly fumbling with things, be it a mug of tea or that rod of tungsten. Sacks bears the scars of numerous falls, and says that he's so accident-prone his friends were convinced he wouldn't make it past the age of 30. It's hard to imagine his hands playing a piano (which, very occasionally, they do).

And yet, Sacks has always been enthralled by music. One of his earliest childhood memories is the sound of his mother singing Schubert Lieder in the drawing room. As a teenager, he spent endless hours "trembling" to Mozart symphonies, transfixed by feelings he couldn't comprehend.

Music has also played a crucial role in Sacks's work as a neurologist. In his writings, he uses music as a metaphor for his unusual approach to medicine. He cites a Novalis aphorism—"Every disease is a musical problem; every cure is a musical solution"—in several books, usually when discussing the therapeutic powers of music. But it's clear that Sacks also believes in a deeper, less literal connection between medicine and music, which is why Musicophilia reads like a retrospective. Music encapsulates two of the most essential aspects of his work: listening and feeling. The art form is the model for his method. As a doctor, Sacks is exquisitely attentive, not just to the symptoms, but also to the person. He treats each patient like a piece of music, a complex creation that must be felt to be understood. Sacks listens intensely so that he can feel what it's like, so that he can develop an "intuitive sympathy" with the individual. It is this basic connection, a connection that defies explanation, that allows Sacks to heal his patients, letting them recover what has been lost: their sense of self.

Of course Sacks is still a neurologist, intimate with the folds of the brain and the advances in neuroscience toward understanding our relationship with music. He knows that how we experience music is just an emanation of the temporal lobe, a side effect of neural electricity. But Sacks remains most interested in what anatomy lessons alone can't explain. "There is also a certain danger here," he observes. "A danger that the art of observation may be lost, and the richness of the human context ignored."

Sacks relays in Musicophilia, for example, the case of Dr. P, the infamous patient who mistook his wife for a hat. Dr. P's surreal condition left him unable to perceive objects and people, so that he was "lost in a world of lifeless abstractions." One of the most telling lines in the case history comes at the end, when Sacks is presenting his formal clinical diagnosis: "a massive tumor or degenerative processes in the visual parts of the brain." That single sentence, an ambiguous afterthought, is Sacks's sole nod to "classical, schematic neurology." Instead of looking for the physical source of the illness, Sacks immerses himself in the life of the patient. He describes Dr. P's experiences as a music teacher and the ways in which the sound of music eases his sensory confusion. (In order to get dressed, Dr. P had to sing to himself.) When Dr. P asks Sacks what's wrong with his brain, Sacks replies, "I can't tell you what I find wrong, but I'll say what I find right. You are a wonderful musician, and music is your life. What I would prescribe is a life which consists entirely of music." It's an astonishing prescription, wholly focused on preserving Dr. P's tenuous identity. This is what Sacks tries to treat: not the disease, not even the brain afflicted by it, but the person. Any science of the mind that "neglects the personal," Sacks says, "misses out on our most essential aspect." Although he meticulously follows the latest advances in neuroscience and applies that knowledge to his patients, Sacks is ultimately guided by his sympathetic instincts, his uncanny ear for the consonances and dissonances of being. "We underestimate the power of listening," Sacks says. "It is by listening to our patients that we can discover their humanity. It is the only way to grasp what they are going through."

Sacks was not always such a sympathetic character. Empathy was an epiphany for him, a late revelation. Long before Sacks was a famous neurologist, he was a struggling writer. After he received his medical degree from Oxford, Sacks decided to wander the world. He began, in 1960, with America. His parents thought his trip was just a brief vacation, but once he arrived, Sacks sent them a one-word telegram: "Staying." He traveled across the continent by motorcycle, racking up more than 10,000 miles on an "erratic, zigzag" journey. He fought wildfires in British Columbia and hitchhiked across Alabama with a trucker named Mac. He called himself "Wolf."

At the time, Sacks despaired of ever becoming a doctor. In a journal entry written in the summer of 1960, Sacks confessed that medicine wasn't his chosen profession. "Others chose it for me," he wrote. "Now I only want to wander and write. I think I shall be a logger for a year." While Sacks rarely talks about these years of his life—"They remain a bit of a mystery, even to me," he says—excerpts from his immense travel journals, which he reads aloud to me in a vintage British accent, provide a window into his development, both as a writer and as a person. Many of the entries resemble early Kerouac, filled with odes to the open road and vaguely mystical encounters with nature. His prose is loose yet lucid. And yet, this isn't the writing of the Oliver Sacks the world knows. Something is different.

Sacks had begun sending his journals to his friend Thom Gunn, a British poet living in San Francisco. While Gunn enjoyed Sacks's acutely observed travelogues, he found parts of the journals to be a "little nasty," full of "sarcasms and grotesqueries." Gunn would later write Sacks a letter in which he confided that, after reading Sacks's early prose, he had "despaired of your [Sacks] ever becoming a good writer...I found you so talented, but so deficient in one quality—call it humanity, or sympathy, or something like that."

In 1961, after a year on the road, Sacks finally "settled down" and began an internship at Mount Zion Hospital in San Francisco. After completing a residency at UCLA, he moved to the Bronx and got a job in New York working in a neuropathology lab at the Albert Einstein College of Medicine. "I was awful at bench science," Sacks says. "Truly awful. I think the final straw was when I dropped some food into the ultracentrifuge. They said to me, 'Sacks, get out, you're a menace. Go see patients: You won't be able to do much harm to them.' That's when they sent me to Beth Abraham."

Beth Abraham was a chronic hospital, an asylum for patients for whom there was no cure. In this hopeless place, Sacks ended up working with the most hopeless patients. He was drawn to the "sleeping sickness" ward, filled with people who had been locked in a Parkinsonian trance for decades. An aftereffect of the 1920s encephalitis epidemic, the disease left the patients in an "ontological death," numb to everything around them.

Sacks was deeply moved by these frozen patients. "It was the experience of Beth Abraham that changed me," he says. "It was where I really came alive, almost for the first time in twenty years. I didn't just care for these patients. I lived with these patients." There was no medical treatment for sleeping sickness, and Sacks had nothing to offer the patients but unconditional kindness. "All I wanted was to give them a sense of being people again," he says, "to let them forge human relationships again, even if it was only with me."

In 1969 Sacks began a 90-day clinical study of L-DOPA, a new drug that was heralded as a miracle cure for Parkinson's patients. One group of his patients received the drug, while the other group received a placebo. The effects were immediate and profound. There was an "astonishing, festive 'awakening,'" as the L-DOPA patients suddenly emerged from their timeless limbo.

But the drug wasn't a cure. After a few months of treatment, Sacks's patients began to develop serious side effects, as their diseased brains adjusted to the increased levels of dopamine. And then, one by one, the patients began to sink back into their restless sleep. The "miracle" was temporary.

The following summer, Sacks sent a letter to The Journal of the American Medical Association, documenting the tragic results of his clinical study. His short letter provoked a storm of criticism. Some neurologists declared that the side effects never occurred, and that L-DOPA really was a cure. Others assailed Sacks for being "against L-DOPA" and for not properly controlling his study.

In his defense, Sacks wrote a detailed report describing the personal experiences of his patients, but every major medical and neurological journal rejected it. That's when Sacks realized the problem wasn't L-DOPA; it was the way medicine treated the mind. Modern neurology had become a hard science, a subject of mechanical circuits and anatomical anomalies. Treating patients meant fixing their matter. But Sacks had become acutely aware of what such brute materialism left out. It treated symptoms, not people, and had lost a sense of basic human empathy. The same quality that Thom Gunn had found lacking in Sacks's journals, Sacks now found lacking in modern medicine.

The inability to publish a medical article led Sacks to explore a new kind of medical writing. He was initially inspired by the work of A.R. Luria, a Soviet neurologist who had published two extended case histories that boldly merged clinical descriptions with, as Sacks puts it, "an empathic entering into patients' experiences and worlds." (When Sacks first read Luria's work, he assumed it was fiction.) "When I began writing," Sacks says, "I realized that I was going against the trend. Few doctors wrote case histories anymore. But I had been moved by these patients—I suppose I had fallen in love with them, you might say—and so I needed to tell their stories."

In the summer of 1972, Sacks returned to London, renting a small flat on the edge of Hampstead Heath. He had grown close to W.H. Auden, the British poet who occasionally visited Sacks at Beth Abraham. Auden encouraged Sacks to "transcend medical writing, to find some radically new and very personal form." And so, with Luria as his model and Auden as his mentor, Sacks wrote Awakenings, the story of his patients' experiences on L-DOPA. The prose poured out of him, and he wrote most of the book in just a few weeks. It was a strange composition, equal parts neurology and biography, filled with erudite digressions into dopamine, Leibniz, and the perception of time. The science of the disease was delicately interwoven with descriptions of his "intense sense of fellow-feeling" for the patients. Sacks had found his form.

The book was greeted with high literary acclaim and scientific disdain. (Auden declared it a "masterpiece.") "There was one particular review which stung me greatly," Sacks says now. "It said 'Dr. Sacks is clearly imaginative, and he's invented a set of impossible patients.'" Other doctors were dismissive of Sacks's admission of empathy. What kind of neurologist fell in love with his patients?

The work, however, has outlived the criticism: Sacks's writerly form is now its own literary genre. It's easy to take his originality for granted, to forget how unlikely it is that a book about neurological disorders would become a bestseller, or that a bearded neurologist would become a cultural icon. Sacks has used the broken brain as a point of entry into the mind, so that readers learn about the perception of colors from a color-blind painter, or about the structure of memory from a man who has none. But the real lesson of Sacks's work goes far beyond the confines of scientific knowledge. His case histories are essays in empathy, sincere attempts to enter into the experience of someone else, to know the individual and not just the disease. Sacks wants the kind of knowledge that can be known only through love, through listening.

Eighteen months ago, Sacks noticed a looming shadow in his field of vision. The darkness was ocular melanoma, a rare type of eye cancer. The cancer slowly spread, and Sacks felt his sight recede. As a neurologist, he is morbidly fascinated by his own condition and keeps detailed notes on all of his visual problems. "My scotoma [blind spot] is Australia-shaped," Sacks says, "about thirty degrees across. It's almost like a window, and there are constantly hallucinations inside it. Just this morning I was staring at my clock radio and saw a crowd of tiny people inside it."

Sacks shows me his "melanoma journals"—"Melanoma is such a lovely word," he remarks—which are full of rough sketches of his visual sensations. There is one drawing that shows a torso with a scratched-out face, just a slew of horizontal lines. "That's my first horrified sketch of when I couldn't see my own head," Sacks says. "I looked in the mirror one morning, and there was just a shadow there." Sacks is also fascinated by how his mind compensates for the blind spot, automatically "filling in" the new void in his senses. "If I wait for a few moments," he says, "The form just creeps in from the periphery, like ice crystallizing. And then I look away, and the scotoma returns."

There is something deeply poignant about watching Sacks deal with his decaying sight. It's as if he's become a character from one of his books, bewildered by his own brain. He can't help but continually interrupt himself in conversation, remarking on the strangeness of what he's just experienced. His desk is littered with typewritten pages about his blind spot, which he struggles to type since he can't see the keys. "I've always had a great fear of losing central vision. Especially in the past few weeks, it seems to get worse each day," Sacks says. "But now I've come to a deal with the melanoma. If it takes my vision and leaves me my life, that's okay with me."

In his books, Sacks often describes his patients in heroic terms, as they struggle to maintain their identity in the face of disease. Sacks is no exception. The illness hasn't diminished his charming eccentricities. He remains obsessed with the periodic table, ferns, and cephalopods. He swims every day. When Sacks is talking about something that excites him, his voice slips into a slight stammer, as his mouth struggles to keep up with his thoughts. Although he calls his shyness a "disease," he is as exuberant as ever, eager to celebrate the world and its wonders.

Music brings out this romantic side of Sacks, providing him with a deep sense of comfort as cancer erodes his sight. He tends to get passionate about particular pieces of music and will listen, almost exclusively, to the same song or symphony for weeks at a time. Sacks revels in the mysteriousness of music and likes to quote Schopenhauer on its "inexpressible easy to understand and yet so inexplicable."

One of the final stories in Musicophilia is that of Clive Wearing, an English musician and musicologist who was struck by a severe brain infection that decimated his memory. As a result, Clive lives inside brief parentheses of time, just a few seconds long. "Desperate to hold on to something," Sacks writes, "Clive started to keep a journal. But his journal entries consisted, essentially, of the statements 'I am awake' or 'I am conscious,' entered again and again every few minutes."

The only thing that comforts Clive is music. When he is playing the piano, Clive is suddenly "himself again." A Bach prelude can't recover his past, but it does allow him to be fully immersed in the present tense. He can share, if only for a moment, the emotions of the melody. The music is a "bridge across the abyss," a temporary relief from the terrifying loneliness of his amnesia.

Sacks relays numerous similar stories of musical healing—in many instances, an awareness of music is a person's last awareness. "I have seen deeply demented patients weep or shiver as they listen to music," Sacks writes. "Once one has seen such responses, one knows that there is still a self to be called upon, even if music, and only music, can do the calling." He likes to quote a shard of a T.S. Eliot poem: "We are the music while the music lasts." For Sacks, the line is literally true. He knows that music is often the final means of human connection, our closing form of comfort. It is what we have when we have nothing else.