Oliver Sacks



Pages 263 - 267


The descent into illness, once started, may proceed by itself, moving incontinently further by innumerable vicious circles, positive feedbacks, chain reactions - a first strain causing other strains, a first breakdown other breakdowns, perversion summoning perversion, with the dynamism and ingenuity which is the essence of disease:

Diseases themselves hold Consultations, and conspire how they may multiply, and join with one another, and exalt one anothers force ...


In this spiral of deterioration, the need for illness joins hands with the liability to illness, that conjoint perversion which is pathological propensity. The first of these, necessarily, must be a major factor in the lives of some of our most deeply disabled and deeply regressed patients, whose illness has been the main part of their lives. In such patients, the sudden removal of illness will leave a hole, so to speak, a sudden existential vacuum, which needs to be filled and filled quickly with real life and activity, before pathological activity is sucked back again to fill it. The perverse need for illness - both in patients themselves, and sometimes in those who are close to them - must be a major determinant in causing relapse, the most insidious enemy of the will-to-get-better:

BURNLEY: "How does poor Smart do, Sir, is he likely to recover?'

JOHNSON: 'It seems as if his mind has ceased to struggle with the disease; for he grows fat upon it.'


Whenever ... advantage through illness is at all pronounced, and no substitute for it can be found in reality, you need not look forward very hopefully to influencing (it) through your therapy.


It is certain that the compensation of disease, and the destitutions of 'external' reality, can only be a part of the matter; but they are a part which we are well-placed to study, and sometimes to modify.

Such considerations can hardly be avoided, for instance, with regard to Lucy K., Leonard L. and Rose R., Lucy K. had spent the greater part of her life in a state of symbiotic and parasitic dependence on her mother; her mother was the most needed person in her life, and at once the most loved and most hated, and Lucy's illness and dependence, conversely, were the most important parts of her mother's life. ... Leonard L. had a similar if somewhat milder pathological relation with his mother, and she, as we have seen, herself broke down when he got better; Leonard saw, all too clear, that his mother's well-being was incompossible with his own well-being; and shortly after this he too relapsed. Perhaps the saddest case is that of Rose R., who 'came to' joyously to the world of 1926 - and found that '1926' no longer existed; the world of 1969, into which she awoke, was incompossible with the world of 1926, and so she went back to '1926'. In these cases, the overall situation was pathological beyond remedy: the need of these patients were incompossible with reality. In other patients -most clearly exemplified by Miron V. - a much happier situation eventually resulted, the 'side-effects' of L-DOPA being greatly reduced by the establishment of good feelings and relations, of central securities which had lapsed in their lives.

Thus, finally, we come to the only conclusion we can: that patients on L-DOPA will always do as well as their total circumstances will allow; that altering their chemical circumstances may be a prerequisite to any other alteration; but that it is not, in itself, enough. The limitations of L_DOPA are as clear as its benefits, and if we hope to reduce the one and increase the other we must go beyond L-DOPA, beyond all purely chemical considerations, and deal with the person and his being-in-the-world.


Or to take arms against a sea of trouble

And by opposing end them?

It is characterisitic of many neurologists (and patients) that they mistake intransingence for strength, and plant themselves liek Canutes before advancing seas of trouble, defying their advance by the strngth of their will. Or, like Podsnaps, they deny the sea of trouble which is rising all around them: 'I don't want to know about it; I don't choose to discuss it; I don't admit it!' Neither defiance nor denial os of the least use here: one takes arms by learning how to negotiate or navigate a sea of troubles, by becoming a mariner in the seas of one's self. 'Tribulation' dealt with trouble and storm; Accomodation' is concerned with weathering the storm.

The trouble experienced are not ordinary trouble, and the weapons which are needed are not ordinary weapons:

Weapons for such combats are not to be forged at Lipara; Vulcan's Art does nothing in this internal militia ...


The weapons of use in the tribulations of L-DOPA are those we all use in conducting our lives: deep strengths and reserves, whose very existence is unsuspected; common sense, forethought, caution, and care; special vigilance and wiles to combat special dangers; the establishment of right relations of all sorts; and, of course, the final acceptance of what must be eccepted. A good part of the tribulations of patients (and their physicians) comes from unreal attempts to transcend the possible, to deny its limits, and to seek the impossible: accomodation is more laborious and less exalted, and consists, in effect, of a painstaking exploration of the full range of the real and the possible.

Accomadation lacks the glamour of Awakening. It lacks its sudden, spontyaneous, 'miraculous' quality. It does not come 'of itself' - easily and effortlessly. It is earned, worked for - with infinit effort and courage and trouble. It does not reflect some local change in the basal ganglia, and can in no sense be regarde as localized process: it is an achievement of character, of negotiation, in its widest possible sense. What is achieved in this way, with work and difficulty, is secure and enduring - unlike the facile 'flash' of 'awakening', which goes, as it comes, too easily, too quickly ... The qualities of the first DOPA-awakening are essentially those of innocence and jpy - like an anomalous return to earliest childhood: the 'awakened' in this sense, irrespective of their age, come to resemble the 'once-born' of whom William James speaks. tribulation is an ordeal, a dark night of the soul, which challenges to the utmost those who must face it. A number are broken and fail to survive; others endure and are forged by their suffering. These survivors - the 'accomodated' - have (in James's words) 

'drunk too deeply of the cup of bitternee ever to forget its taste, and their redemption is into a universe two storeys deep.' 

These then are the 'twice-born', who after bitter division, physilogical and social, finally achieve a real reunion, a reconciliation of the depest and stablest kind.

... Some of the patients described in this book -Rose R., Rolando P., Leonard L., etc. - were never able to achieve a 'satisfactory'  ccomodation, and were forced either to cease taking  L-DOPA altogether or to accept a very miserable modus vivendi.

version: 16 November 2015
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Joachim Gruber