Make your own free website on Tripod.com
Oliver Sacks's Awakenings: Reshaping Clinical Discourse
Copyright 1993 The Johns Hopkins University Press and the Society for Literature and Science. All rights reserved. This work may be used, with this header included, for noncommercial purposes within a subscribed institution. No copies of this work may be distributed electronically outside of the subscribed institution, in whole or in part, without express written permission from the JHU Press. This revolutionary publishing model depends on mutual trust between user and publisher.

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 [End Page 229] (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 [End Page 230] 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 [End Page 231] 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 [End Page 232] 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 [End Page 233] 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 [End Page 234] 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, [End Page 235] 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 [End Page 236] 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 [End Page 237] 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 [End Page 238] "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 [End Page 239] 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 [End Page 240] 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 [End Page 241] 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 [End Page 242] 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 [End Page 243] 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.

http://www.press.jhu.edu/journals/configurations/v001/1.2hawkins.html


Back to Subjects