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| Dr. Oliver Sacks |
My third year in medical school I fell in love with Neurology. It had been a fickle year: I had fallen in love with obstetrics and gynecology, the first "clinical" rotation of the year, then internal medicine. I was like the girl who can't say no; I just loved every rotation.
But Neurology really hooked me.
The chairman of the Department of Neurology, Fred Plum, was as intimidating as he was famous, the author of several widely read textbooks, he believed in teaching by embarrassment and he did rounds every morning at precisely 10 AM, working his way down the forty bed ward, listening the precisely formulated presentations of each new patient, delivered by the terrified third year medical student who had evaluated the patient the day or night before.
I had heard about these "horror shows" from my brother, who preceded me at the same medical school five years earlier and still broke into a cold sweat at the mention of Dr. Plum's name.
But I had loved neuroanatomy, one of the few courses I really got into during the first two "preclinical" basic science years, and Neurology was basically neuroanatomy in action. If you knew where the tracts ran in the brain and from the brain down the spinal cord, it all made sense. There was order and precision there.
Of course, there were parts of the brain which were still not understood, black boxes with functions still unclear. Even basic functions like memory were not as simple as the textbooks suggested.
I was very lucky to pull for my resident the most stellar of all Dr. Plum's housestaff: Kathy Foley. Dr. Plum did not approve of women in medicine because they would likely have children and they would place those children at least as high on their list of priorities as they put Neurology, and for Dr. Plum nothing should be higher on anyone's list than Neurology. To be made chief resident on Dr. Plum's service Kathy had to be simply head and shoulders above all the other residents, which she was (figuratively speaking--she was only a wisp of a woman, physically.)
When my turn came to present a patient, Kathy had prepped me so thoroughly, I sailed through the presentation, although it was a complicated case with some unexplained findings. Plum, who usually interrupted the student after the first sentence listened quietly, his face clouding, looking as if he had just swallowed a sour pickle whole, and he allowed me to finish without a single interruption. He asked me the very questions Kathy had predicted he would ask, which, of course, I answered just as she directed.
Dr. Plum was very annoyed. He had not been able to skewer or flay the medical student. Every finding I reported was demonstrable at the bedside; the formulation of the case, the localization of the patient's brain tumor to his parietal lobe was on the mark. He turned to Kathy and said, "This is just a little too perfect. Has anyone prepped this student?" Kathy met his glare with her pale, icy blue eyes and said, "No,sir. Certainly not."
"Well, Dr. Foley," I told her later. "You are going straight to Hell after that bald face lied."
Unsmiling, she said, "That's what you go to confession for. Besides, he is not a normal man."
So, I loved Neurology, and I always read Oliver Sacks, the British neurologist who writes occasional pieces for The New Yorker, and this week's (April 27) is a doozy.
I've had this odd connection with Dr. Sacks, which has built since I first read, The Man Who Mistook His Wife for A Hat. I loved that book and couldn't stop talking about it until my partner finally said, "You know, my father knows Oliver--they were at the VA together in the Bronx. He's an odd duck." And he is. He has prosopagnosia, the inability to recognize faces, and he has lived a celibate life, not friendless, but nun like, monk like, something I did (for only three years) but it's a mode of existence I have to remind myself to avoid, an affliction I see as a personal possibility.
Sacks also has metastatic melanoma, one of my personal night howls ever since my internship stint at Memorial/Sloan Kettering, and worse yet, his began in his eye, another personal nightmare, and very atypically, it metastasized from there. And yet, he is still churning out pieces for the New Yorker .
What particularly struck me about the case he describes is that it involves the frontal lobes. The frontal lobes, when I was in medical school, were often described as "silent." It wasn't clear exactly what they did. Of course, "frontal lobotomy" was that old, misguided procedure they used on Jack Nicholson in "One Flew Over the Cuckoo's Nest" to render him pacified. Just cut the connections between frontal lobes and the rest of the brain and you get this tractable, joyless lump of humanity, hardly fit to be called a human being.
Spaulding Gray, the subject of Sack's article, suffered an injury to his frontal lobe in a car accident, and he became severely depressed, lost his creativity and descended into despondence.
We knew, even back when I was a third year student, the frontal lobes had something to do with personality, with taste, with inhibition of behavior. Patients who were loquacious, capricious were often described as "frontal lobey" but everyone knew this was all very vague.
When my own mother was found to have metastatic disease in her frontal lobes and these were resected, I asked my friend, who had been in on the surgery, what the frontal lobes did and how she would be affected. He didn't know. "They're kind of silent, you know." I thought I had noted subtle changes in her tastes before the surgery. She had always had impeccable taste in clothes, but in the months leading up to the surgery, with her frontal lobes presumably already involved by mets, she sent me swimming trunks she had purchased for me which were so garish I thought it was a joke.
Mr. Gray was treated with electroshock therapy (EST) at Payne Whitney, the psychiatric unit at The New York Hospital, where I had been asked to "clear" patients for EST when I was a medical resident. It's a pretty medieval approach to depression, but I had to admit, seeing the patients before and after EST, I was, despite my bias, astonished by the change in some of them, who went from inert lumps to relatively responsive and cheerful people, at least for a while.
But that's where we are, or were in the years Mr. Gray got treated, sending electric current through the skull to the entire brain, treating parts like the frontal lobes, which are still mysterious, in a way for which we cannot explain a mechanism of action.
I wondered how Dr. Sacks got permission to tell Mr. Gray's story. Presumably, the family gave permission. Sacks has been accused of being "The doctor who mistook his patients for a literary career." I have been accused of the same thing. But that smacks of sour milk to me. Opening up the real world of disease and patients and doctors to the general public has been, overall, salutary, not simply show boating for doctors. From real life shows like "New York Med" to the fictional "ER" a more realistic depiction of what doctors face and what patients endure has provided more benefit than risk to the general public, and to the public health.
I hope Dr. Sacks has a few more articles in him, and more time before his disease claims him.
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