There was a time when detailed case histories, including direct quotations from patients’ accounts of their own experiences, formed a significant part of the medical literature.
There was a time when detailed case histories, including direct quotations from patients’ accounts of their own experiences, formed a significant part of the medical literature. French doctors of the 19th century were particularly adept at writing such case histories; the lucidity of their prose, as of their thought, was exemplary. Indeed, French medical prose of the 19th century was often as good as that of Flaubert.
But the extended case history has gone out of medical fashion, as being too anecdotal and therefore unscientific. Now that we have so many diagnostic blood tests and imaging techniques, as well as powerful therapeutic procedures, the mere phenomenology of illness does not interest us very much; indeed it seems almost a waste of valuable time to elicit it. Yet a large percentage of avoidable medical mistakes are caused by doctors’ failure to take a proper history or to take much notice of what patients tell them.
There is therefore something rather old-fashioned about Oliver Sacks’s books, with their rich clinical material, use of patients’ words, and leisurely description of symptoms. Dr Sacks is clearly no technophobe or neurological Luddite who declines to take advantage of the startling technical progress of the last few years; but he is also not the kind of doctor whose first inclination is to put a patient straight away into the latest scanner in the hope that a diagnosis, prognosis and therapeutic regime will emerge all by itself, like a sausage out of a sausage machine. It is possible for technology to become a substitute for thought and a slayer of empathy.
Sacks, by contrast, takes an interest in that difficult but sacrosanct being, the whole person, to whom practically all doctors genuflect in theory but in practice ignore. He does not hesitate, for example, to observe his patients at home because he knows that circumstances alter symptoms, and much of clinical value is to be learnt from how patients react in different situations. Of course, this implies a degree of professional independence that most doctors nowadays do not enjoy whatever health system they work in; he seems like a figure from a past when medicine was still truly a liberal profession, a past to which there will be no return.
His latest volume is a series of case studies, mostly but not entirely about the faculty of vision and its loss. As usual, Sacks draws wider lessons from his cases, often of a rather optimistic nature. His patients who, for neurological reasons, lose one faculty seem often to be able to compensate by developing or improving another, sometimes to such an extent that the original damage seems almost a blessing in disguise. Certainly it is true that people often triumph over adversity by means of adaptation, both physiological and psychological; but there is in this reassuring message a danger that the sense of the tragic will be lost, and thereby unrealistic hopes and expectations raised. There is a fine line to be drawn between fatalism born of laziness or ignorance of possibilities, and refusal to look painful reality in the face, thereby rendering it all the more painful in the end.
Sacks’s medical practice has been predominantly among the elderly, into which category he now himself fits; he continues to practise at the age of 77, which is reassuring to those of us who fear inactivity and uselessness in old age. A considerable proportion of the book is taken up by an account of his own loss of vision in one eye because of a tumour that developed in it.
His reaction to the diagnosis of a tumour (a melanoma) is that of a very frightened layman. His years of medical practice do not protect him in the slightest from fear, even when his specialist assures him that melanomas of the eye rarely metastasise and therefore do not often kill. But what, he thinks, if I am the one unlucky person out of a hundred? In this, Sacks is no different from the great majority of people, for whom statistics offer cold comfort at best.
When his specialist delays treatment over the Christmas period by three weeks, with the assurance that such a delay will not make any difference to the evolution of the tumour, and then things turn out worse than anticipated, Sacks’s first thought is that the delay was responsible. One almost expects to learn that he has instituted a lawsuit against his specialist (who was once a student of his).
In other words, Sacks’s long and honourable medical career, all his technical knowledge and worldly success, his musical and other cultivation, have not been sufficient to assuage his own primal fear of death. Perhaps only religious belief could have done that, but he long ago lost any religious belief that he might have had, and he cannot persuade himself of the truth of something only because it would be comforting to believe it to be true. There is a rawness to his existential fear that is painful to read, and could not have been easy to admit.
The clinical stories in this volume, apart from his own, are not perhaps among the most absorbing — which for many people probably means the most bizarre — that he has related in his books. But, as ever, he manages artfully to combine the particular with the general so that the reader does not ever have the impression that he is reading a mere treatise, and he remains a master narrator. Sacks always manages to satisfy two appetites at the same time: that for the freakish, and that for knowledge.