Excerpts from "Awakenings"

by Oliver Sacks

I. Prologue:

Pages 3 - 11

In 1817, Dr James Parkinson, a London physician, published his famous Essay on the Shaking Palsy, in which he portrayed, with a vividness and insight that have never been surpassed, the common, important, and singular condition we now know as Parkinson's disease.

Isolated symptoms and features of Parkinson's disease - the characteristic shaking or tremor, and the characteristic hurrying or festination of gait and speech - had been described by physicians back to the time of Galen. Detailed descriptions had also appeared in the non-medical literature - as in Aubrey's description of Hobbes's 'Shaking Palsy'. But it was Parkinson who first saw every feature and aspect of the illness as a whole, and who presented it as a distinctive human condition or form of behaviour5.

It is true, in a sense, that Parkinson had many 'predecessors' (Gaubius, Sauvages, de la Noe, and others) who had observed and classified various 'signs' of Parkinsonism. But there was a radical difference between Parkinson and these men - perhaps more radical than Parkinson himself allowed or admitted. Observers of Parkinsonism, before Parkinson himself, had been content to 'spot' various characteristics (in much the same way as one 'spots' trains or planes), and then to arrange these characteristics in classificatory schemes (somewhat as a butterfly-spotter, or would-be entomologist, might arrange his specimens according to colour and shape). Thus Parkinson's predecessors were entirely concerned with 'diagnosis' and 'nosology'- an arbitrary, pre-scientific diagnosis and nosology, based entirely on superficial characteristics and relationships: the Zodiacal charts of Sauvages and others represent a sort of pseudo-astronomy, first attempts to come to grips with the unknown. Parkinson's own initial observations were also made 'from the outside' so to speak, from seeing Parkinsonians in the streets of London, inspecting their peculiarities of motion from a distance. But his observations were deeper than those of his predecessors, deeper rooted and more deeply related. Parkinson resembles a genuine astronomer, and London the field of his astronomical observations, and at this stage, through his eyes, we see Parkinsonians as bodies-in-transit, moving like comets or stars. Soon, moreover, he came to recognize that certain stars form a constellation, that many seemingly unrelated phenomena form a definite and constant 'assemblage of symptoms'. He was the first to recognize this 'assemblage' as such, this constellation or syndrome we now call 'Parkinsonism'.

This was a clinical achievement of the first magnitude, and Parkinsonism was one of the first neurological syndromes to be recognized and defined. But Parkinson was not merely talented - he was a man of genius. He perceived that the curious 'assemblage' he had noted was something more than a diagnostic syndrome - that it seemed to have a coherent inner logic and order of its own. that the constellation was a sort of cosmos ... sensing this, he now realized that inspection-on-a-distance, however acute, was insufficient if he wished to understand its nature; he realized it was necessary to meet actual patients, to engage them in clinical and dialogic encounter. With this he adopted an entirely different stance and concurrently with this a quite different language. He ceased to see Parkinsonians as remote objects in orbit, and saw them as patients and fellow human beings; he ceased to use diagnostic jargon, and used words indicative of intention and action; he ceased to see Parkinsonism as 'an assemblage of symptoms' and now thought of being-Parkinsonian as a strange form of behavior, a peculiar and characteristic mode of Being-in-the-World. Thus Parkinson. compared to his predecessors, was a radical, a revolutionary, in two different ways: first in establishing a genuine empiricism - a science of 'facts' and their interrelations; second. in making a still more radical move in intellectual mid-course, by moving from an empirical to an existential position.

Between 1860 and 1890, working amid the large population of chronically ill patients at the Salpetriere in Paris, Charcot filled in the outline which Parkinson had drawn. In addition to his rich and detailed characterizations of the illness. Charcot perceived the important relations of Parkinson's disease and those of depression, catatonia, and hysteria: indeed, it was partly in view of these striking relationships that Charcot called Parkinsonism 'a neurosis'.

In the nineteenth century, Parkinsonism was almost never seen before the age of fifty, and was usually considered to be a reflection of the degenerative process or defect of nutrition in certain 'weak' or vulnerable cells; since this degeneration could not actually be demonstrated at the time, and since its cause was unknown, Parkinson's disease was termed an idiosyncrasy or 'idiopathy'. In the first quarter of this century, with the advent of the great sleeping-sickness epidemic (encephalitis lethargica), a 'new' sort of Parkinsonism appeared, which had a clear and specific cause: this encephalitic or post-encephalitic Parkinsonism6, unlike the idiopathic illness, could affect people of any age, and could assume a form and severity much graver and more dramatic then ever occurred in the idiopathic illness. A third great cause of Parkinsonism has been seen only in the last twenty years, and is an unintended (and usually transient) consequence or 'side-effect' of the use of phenothiazide and butyrophenone drugs - the so-called 'major tranquillizers'. It is said that in the United States alone there are two million people with Parkinsonism: a million with idiopathic Parkinsonism or Parkinson's disease; a million with drug-induced Parkinsonism; a few hundred or thousand patients with post-encephalitic Parkinsonism - the last survivors of the great epidemic. Other causes of Parkinsonism - coal-gas poisoning, manganese poisoning, syphilis, tumours, etc. - are excessively rare, and are scarcely likely to be seen in a lifetime of practice by the ordinary physician.

Parkinson's disease has been called the 'shaking palsy' (or its Latin equivalent - paralysis agitans) for some centuries. It is necessary to say at the outset that the shaking or tremor is by no means a constant symptom in Parkinsonism, is never an isolated symptom, and is often the least problem which faces the Parkinsonian patient. If tremor is present, it tends to occur at rest and to disappear with movement or the intention to move7, sometimes it is confined to the hand, and has a characteristic 'pill-rolling' quality or (in Gower's words) a quality 'similar to that by which Orientals beat their small drums'; in other, and especially in post-encephalitic patients, tremor may be extremely violent, may affect any or every part of the body, and tends to be increased by effort, nervousness, or fatigue.

The term 'post-encephalitic' is used to denote symptoms which have come on following an attack of encephalitis lethargica, and as a direct or indirect consequence of this. The onset of such symptoms may be delayed until many years after the original attack.

There are many actors, surgeons, mechanics, and skilled manual workers who show severe Parkinsonian tremor at rest, but not a trace of this when they concentrate on their work or move into action.

The second commonly mentioned symptom of Parkinsonism, besides tremor, is stiffness or rigidity; this has a curious plastic quality - often compared to the bending of a lead pipe - and may be of intense severity8. It must be stressed, however, that neither tremor nor rigidity is an essential feature of Parkinsonism; they may both be completely absent, especially in the post-encephalitic forms of disease with which we shall especially be concerned in this book. The essential features of Parkinsonism, which occur in every patient, and which reach their extremest intensity in post- encephalitic forms of disease, relate to disorders of movement and 'push'.

The first qualities of Parkinsonism which were ever described were those of festination (hurry) and pulsion (push).

Festination consists of an acceleration (and with this, an abbreviation) of steps, movements, words, or even thoughts - it conveys a sense of impatience, impetuosity, and alacrity, as if the patient were very pressed for time; and in some patients it goes along with a feeling of urgency and impatience, although others, as it were, find themselves hurried against their will9. The character of movements associated with festination or pulsion are those of quickness, abruptness, and brevity. These symptoms, and the peculiar 'motor impatience' (akathisia) which often goes along with them, were given full weight by the older authors: thus Charcot speaks of the 'cruel restlessness' suffered by many of his patients, and Gowers of the 'extreme restlessness . . . which necessitates ... every few minutes some slight change of posture.' I stress these aspects - the alacrity and pressure and precipitation of movement - because they represent, so to speak, the less familiar 'other side' of Parkinsonism, Parkinsonism-on-the-boil, Parkinsonism in its expansile and explosive aspect, and as such have peculiar relevance to many of the 'side-effects' of L-DOPA which patients exhibit.

It was observed by Charcot, and is observed by many Parkinsonian patients themselves, that rigidity can be loosened to a remarkable degree if the patient is suspended in water or swimming (see below the cases of Hester Y., Rolando P., Cecil M., etc.). The same is also true, to some extent, of other forms of stiffness and 'clench' - spasticity, athetosis, torticollis, etc.

Thus festination ('scelotyrbe festinans') is portrayed by Gaubius in the eighteenth Century: 'Cases occur in which the muscles, duly excited by the impulses of the will, do then, with an unbidden agility, and with an impetus not to be repressed, run before the unwilling mind.'

The opposite of these effects - a peculiar slowing and difficulty of movement - are more commonly stressed, and go by the general and rather uninformative name of 'akinesia'.

There are many different forms of akinesia, but the form which is exactly antithetical to hurry or pulsion is one of active retardation or resistance which impedes movement, speech, and even thought, and may arrest it completely.

Patients so affected find that as soon as they 'will' or intend or attempt a movement, a 'counter-will' or 'resistance' rises up to meet them. They find themselves embattled, and even immobilized, in a form of physiological conflict - force against counter-force, will against counter-will, command against countermand.

For such embattled patients, Charcot writes: 'There is no truce'- and Charcot sees the tremor, rigidity, and akinesia of such patients as the final, futile outcome of such states of inner struggle, and the tension and tiredness of which Parkinsonian patients so often complain as due to the pre-emption of their energies in such senseless inner battles. It is these states of push and constraint which one patient of mine (Leonard L.) would always call 'the goad and halter10 The appearance of passivity or inertia is deceiving: an obstructive akinesia of this sort is in no sense an idle or restful state, but (to paraphrase de Quincey) '... no product of inertia, but ... resulting from mighty and equal antagonisms, infinite activities, infinite repose. "

Analogous concepts are used by William James, in his discussion of 'perversions' of will (Principies, 2, xxvi). The two basic perversions delineated by James are the 'obstructive' will and the 'explosive' will; when the former holds sway, the performance of normal actions is rendered difficult or impossible; if the latter is dominant, abnormal actions are irrepressible. Although James uses these terms with reference to neurotic perversions of the will, they are equally applicable to what we must term Parkinsonian perversions of the will:

Parkinsonism, like neurosis, is a conative disorder, and exhibits a formal analogy of conative structure.

At this point we must introduce a fundamental theme which will re-appear and re-echo, in various guises, throughout this book. We have seen Parkinsonism as sudden starts and stops, as odd speedings and slowings. Our approach, our concepts, our terms have so far been of a purely mechanical or empirical type: we have seen Parkinsonians as bodies, but not yet as beings ... if we are to achieve any understanding of what it is like to be Parkinsonian, of the actual nature of Parkinsonian existence (as opposed to the parameters of Parkinsonian motion), we must adopt a different and complementary approach and language.

We must come down from our position as 'objective observers', and meet our patients face-to-face; we must meet them in a sympathetic and imaginative encounter: for it is only in the context of such a collaboration, a participation, a relation, that we can hope to learn anything about how they are. They can tell us, and show us, what it is like being Parkinsonian - they can tell us, but nobody else can.

Indeed we must go further, for if - as we have reason to suspect - our patients may be subject to experiences as strange as the motions they show, they may need much help, a delicate and patient and imaginative collaboration, in order to formulate the almost-unformulable, in order to communicate the almost incommunicable. We must be co-explorers in the uncanny realm of being-Parkinsonian, this land beyond the boundaries of common experience; but our quarry in this strange country will not be 'specimens', data, or 'facts', but images, similitudes, analogies, metaphors - whatever may assist to make the strange familiar, and to bring into the thinkable the previously unthinkable. What we are told, what we discover, will be couched in the mode of 'likeness' or 'as if', for we are asking the patient to make comparisons - to compare being-Parkinsonian with that mode-of-being which we agree to call 'normal'.
All experience is hypothetical or conjectural, but its intensity and form vary a great deal: thus patients able to achieve some detachment, or patients only partially or intermittently affected, will describe their experiences in metaphorical terms; whereas patients who are continually and completely engulfed by their experience will tend to describe it in hallucinatory terms.... Thus, images such as 'Saturnian gravity' are used with great frequency by patients. One patient (Helen K.) was asked how it felt to be Parkinsonian: 'Like being stuck on an enormous planet,' she replied. I seemed to weigh tons, I was crushed, I couldn't move.' A little later she was asked how she had felt on L-DOPA (she had become very flighty, volatile, mercurial): 'Like being on a dotty little planet', she said. 'Like Mercury - no, that's too big, like an asteroid! I couldn't stay put, I weighed nothing, I was all over the place. It's all a matter of gravity, in a way - first there's too much, then there's too little. Parkinsonism is gravity, L-DOPA is levity, and it's difficult to find any mean in between.' Such comparisons are also used, in reverse, by patients with Tourette's (Sacks, 1981, reprinted in Sacks, "The Man Who Mistook His Wife for a Hat", Summit Books, New York, 1985).

In some patients, there is a different form of akinesia, which is not associated with a feeling of effort and struggle, but with one of continual repetition or perseveration: thus Gowers records the case of one patient whose limbs '... when raised remained so for several minutes, and then slowly fell' - a form of akinesia which he correctly compares to catalepsy; this is generally far more common and far more severe in patients with post-encephalitic forms of Parkinsonism11.

Arrest (akinesia) or profound slowing (bradykinesia) are equally evident in other spheres - they affect every aspect of life's stream, including the stream of consciousness. Thus, Parkinsonism itself is not 'purely' motor - there is, for example, in many akinetic patients, a corresponding 'stickiness' of mind or bradyphrenia, the thought stream as slow and sluggish as the motor stream. The thought stream, the stream of consciousness, speeds up in these patients with L-DOPA, often speeding too far, into a veritable tachyphrenia, with thoughts and associations almost too fast to follow. Again, there is not merely motor, but a perceptual inertia in Parkinsonism: a perspective drawing of a cube or a staircase, for example, which the normal mind perceives first this way and then that, in alternating perceptual configurations or hypotheses, may be absolutely frozen in one configuration for the Parkinsonian; it will unfreeze as he 'awakens' and may then be thrust, with the continuing stimulation of L-DOPA, in the opposite direction, with a near-delirium of perceptual hypotheses alternating many times a second.

These characteristics - of impulsion, of resistance, and of perseveration - represent the active or positive characteristics of Parkinsonism. We will later have occasion to see that they are to some extent interchangeable, and thus that they represent different phases or forms or transformations of Parkinsonism. Parkinsonian patients also have 'negative' characteristics - if this is not a contradiction in terms.

Thus some of them, Charcot particularly noted, would sit for hours not only motionless, but apparently without any impulse to move: they were, seemingly, content to do nothing, and they lacked the 'will' to enter upon or continue any course of activity, although they might move quite well if the stimulus or command or request to move came from another person - from the outside. Such patients were said to have an absence of the will - or 'aboulia.'

Other aspects of such 'negative' disorder or deficiency in Parkinsonian patients relate to feelings of tiredness and lack of energy, and of certain 'dullness' - an impoverishment of feeling, libido, motive, and attention. To a greater or less degree, all Parkinsonian patients show alteration of 'go', impetus, initiative, vitality, etc., closely akin to what may be experienced by patients in the throes of depression13.

A special form of negative disorder, not described in the classical literature, is depicted with Hester Y. (see pp. 111 - 112 of "Awakenings").

Thus Parkinsonian patients suffer simultaneously (though in varying proportions) from a pathological absence and a pathological presence. The former cuts them off from the fluent and appropriate flow of normal movement (and - in severe cases - the flow of normal perception and thought), and is experienced as a 'weakness', a tiredness, a deprivation, a destitution; the latter constitutes a preoccupation, an abnormal activity, a pathological organization, which, so to speak, distends or inflates their behaviour in a senseless, distressing, and disabling fashion. Patients can be thought of as engorged with Parkinsonism - with pathological excitement ('erethism') - as one may be engorged with pain or pleasure or rage or neurosis. The notion of Parkinsonism as exerting a pressure on the patient seems to be supported, above all, by the phenomenon of kinesia paradoxa which consists of a sudden and total (though transient) disappearance or deflation of Parkinsonism - a phenomenon seen most frequently and most dramatically in the most intensely Parkinsonian patients14

Thus one may see such patients, rigid, motionless, seemingly lifeless as statutes, abruptly called into normal life and action by some sudden exigency which catches their attention (in one famous case, a drowning man was saved by a Parkinsonian patient who leapt from his wheelchair into the breakers). The return of Parkinsonism, in circumstances like these, is often as sudden and dramatic as its vanishing: the suddenly 'normal' and awakened patient, once the call-to-action is past, may fall back like a dummy into the arms of his attendants.

Dr Gerald Stern tells me of one such patient at the Highlands Hospital in London who was nicknamed 'Puskas' after the famous footballer of the 1950s. Puskas would often sit frozen and motionless unless he were thrown a ball; this would instantly call him to life, and he would leap to his feet, swerving, running, dribbling the ball, with a truly Puskas-like acrobatic genius. If thrown a matchbox he would catch it on the tip of one foot, kick it up, catch it, kick it up again, and in this fashion, juggling the matchbox on one foot, hop the entire length of the ward. He scarcely showed any 'normal' activity; only this bizarre and spasmodic super-activity, which ended, as it started, suddenly and completely.

There is another story of the post-encephalitic patients at Highlands. Two of the men had shared a room for twenty years, but without any contact or, apparently, any feeling for each other; both were totally motionless and mute. One evening, while doing rounds, Dr Stern heard a terrific noise coming from this room of perpetual silence. Rushing to it with a couple of nurses, he found its inmates in the midst of a violent fight, throwing each other around and shouting obscenities. The scene, in Dr Stern's words, was 'not far short of incredible - none of us ever imagined these men could move.' With some difficulty the men were separated and the fight was stopped. The moment they were separated, they became motionless and mute again - and have remained so for the last fifteen years. In the thirty-five years they have shared a room, this is the only time they 'came alive.'

This mixture of akinesia and a sort of motor genius is very characteristic of post-encephalitic patients; I think of one such, not at Mount Carmel, who sits motionless until she is thrown three oranges (or more). Instantly she starts juggling them - she can juggle up to seven, in a manner incredible to see - and can continue doing so for half an hour on end. But if she drops one, or is interrupted for a moment, she suddenly becomes motionless again. With another such patient (Maurice P.), who came to Mount Carmel in 1971, I had no idea that he was able to move, and had long regarded him as 'hopelessly akinetic,' until, one day, as I was writing up my notes, he suddenly took my ophthalmoscope, a most intricate one, unscrewed it, examined it, put it together again, and gave a stunning imitation of me examining an eye. The entire 'performance,' which was flawless and brilliant, occupied no more than a few seconds.

Less abrupt and complete, but of more therapeutic relevance, is the partial lifting of Parkinsonism, for long periods of time, in response to interesting and activating situations, which invite participation in a non-Parkinsonian mode. Different forms of such therapeutic activation are exemplified throughout the biographies in this book, and explicitly discussed on P. 59, and in an Appendix: Parkinsonian Space and Time, P. 339.

It is scarcely imaginable that a profound deficiency can suddenly be made good, but it is easy to conceive that an intense pressure might suddenly be relieved, or an intense charge discharged. Such conceptions are always implicit, and sometimes explicit, in the thinking of Charcot, who goes on, indeed, to stress the close analogies which could exist between the different forms or 'phases' of Parkinsonism and those of neurosis: in particular Charcot clearly saw the formal similarity or analogy between the three clearly distinct yet interchangeable phases of Parkinsonism - the compliant-perseverative, the obstructive-resistive, and the explosive-precipitate phases - with the plastic, rigid, and frenzied forms of catatonia and hysteria. These insights were reinforced during the 1920s, by observation of the extraordinary amalgamations of Parkinsonism with other disorders seen in the encephalitis epidemic. They were then completely 'forgotten', or thrust out of the neurological consciousness. The effects of L-DOPA - as we shall see - compel us to reinstate and elaborate the forgotten analyses and analogies of Charcot and his contemporaries.

II. Footnotes from "Frances D."

Pages 60 - 64

"This power of music to integrate and cure, to liberate the Parkinsonian and give him freedom while it lasts ('You are the music / while the music lasts', T.S. Eliot), is quite fundamental, and seen in every patient. This was shown beautifully, and discussed with great insight, by Edith T., a former music teacher. She said that she had become 'graceless' with the onset of Parkinsonism, that her movements had become 'wooden, mechanical - like a robot or doll', that she had lost her former 'naturalness' and musickness' of movement, that - in a word - she had been 'unmusicked'. Fortunately, she added, the disease was 'accompanied by its own cure'. I raised an eyebrow: 'Music', she said, 'as I am unmusicked, I must be remusicked.' Often, she said, she would find herself 'frozen', utterly motionless, deprived of the power, the impulse, the thought, of any motion; she felt at such times 'like a still photo, a frozen frame' - a mere optical flat, without substance or life. In this state, this statelessness, this timeless irreality, she would remain, motionless-helpless, until music came: 'Songs, tunes I knew from years ago, catchy tunes, rhythmic tunes, the sort I loved to dance to.'

With this sudden imagining of music, this coming of spontaneous inner music, the power of motion, action, would suddenly return, and the sense of substance and restored personality and reality; now, as Edith T. put it, she could 'dance out of frame', the flat frozen visualness in which she was trapped, and move freely and gracefully: 'It was like suddenly remembering myself, my own living tune.' But then, just as suddenly, the inner music would cease, and with this all motion and actuality would vanish, and she would fall instantly, once again, into a Parkinsonian abyss.

I am often asked what music can serve to awaken such patients, and what precisely is going on at such times. Rhythmic impetus has to be present, but has to be 'embedded' in melody. Raw overpowering rhythm, which cannot be so embedded, causes a pathological jerking, it coerces instead of freeing the patient, and thus has an anti-musical effect. Shapeless crooning ('slush', Miss D. calls this), without sufficient rhythmic/motor power, fails to move her - either emotionally or motorically - at all. One is reminded here of Nietzsche's definition regarding the pathology of music: here he sees, first and foremost, 'degeneration of the sense of rhythm'. 'Degenerate' music sickens and forces, 'healthy' music heals and frees. This was precisely Miss D.'s experience: she could never abide 'banging' or slush', and required a firm but 'shapely' music.

Would any music, then, provided it was firm and shapely, serve to get Frances D. going in the right way? By no means. The only music which affected her in the right way was music she could enjoy; only music which moved her 'soul' had this power to move her body. 'She was only moved by music which moved her.' The 'movement' was simultaneously emotional and motoric, and essentially autonomous (this distinguishing it from passive jerkings and pathology).

Equally striking, and analogous, was the power of touch. At times when there was no music to come to her aid, and she would be frozen absolutely motionless in the corridor, the simplest human contact could come to the rescue. One had only to take her hand, or touch her in the lightest possible way, for her to 'awaken'; one had only to walk with her and she could walk perfectly, not imitating or echoing one, but in her own way. But the moment one stopped she would stop too.

Such phenomena are very commonly seen in Parkinsonian patients, and usually dismissed as 'contactual reflexes'. Miss T.'s interpretation, and indeed her experience, seemed to be of a more existential, and indeed 'sacramental', type: 'I can do nothing alone', she said. 'can do anything with - with music or people to help me. I cannot initiate, but I can partake of all this. The moment you go away I am nothing again.'

Kant speaks of music as 'the quickening art' , and for Edith T. this is literally, vitally, true. Music serves to arouse her own quickness, her living-and-moving identity and will, which is otherwise dormant for so much of the time. This is what I mean when I speak of these patients as 'asleep', and why I speak of their arousals as physiological and existential 'awakenings', whether these be through the spirit of music or living people, or through chemical rectification of deficiencies in the 'go' parts of the brain.

... A brief allusion to some of Miss D.'s methods may be made. In her long years of illness, she had observed her own propensities and symptoms with a minute curiosity, and had devised many ingenious ways of reducing, overcoming, or circumventing these. Thus, she had various ways of 'defreezing' herself if she chanced to freeze in her walking: she would carry in one hand a supply of minute paper balls of which she would now let one drop to the ground; its tiny whiteness immediately 'incited' or 'commended' her to take a step, and thus allowed her to break loose from the freeze and resume her normal walking pattern. Miss D. had found that regular blinking, or a loud-ticking watch, or horizontal lines or marks on the ground, etc., similarly served to pace her, and to prevent the incontinent hastenings and retardations which otherwise marred her ambulation. Similarly in reading, or talking, she learned to emphasize certain words at set intervals, which would serve to prevent verbal hurry, stuttering, impaction, or freezing. In these and a thousand and one other ways, Miss D. - by herself, with me, with other patients, and with an increasingly intrigued staff of nurses, physiotherapists, speech-therapists, etc. - filled many productive and enjoyable hours exploring and playing with endless possibilities of self- and mutual help. Such methods are discovered or devised by all gifted postencephalitic and Parkinsonian patients, and I have learned more from such patients than from a library of volumes.

Ed W. is a highly gifted young patient with 'ordinary' Parkinson's disease, who often finds himself 'frozen', 'paralysed', in his chair, and unable to stand. Unable, that is, to start directly. But he has discovered methods of standing - indirectly. He might at first make a slight movement of the eyes (nothing else would be possible); Then perhaps a certain movement of the neck; then perhaps an infinitesimal leaning to one side. He has to go through an exceedingly complex motor sequence, which to a large extent he must improvise or re-invent each time, in order to reach a point where - suddenly, and almost explosively - he is able to stand up. He cannot reach this point without the long sequence; but having reached it, he suddenly finds he knows to stand up.

The moment he has stood up, he forgets what he has done - the knowledge of how-to-stand only being present in the moment of standing, the knowledge being contained in the act. But the knowledge of how-to-stand can immediately lead to other knowledge - of how-to-walk, how-to-dance, how-to-jump, whatever. This motor knowledge, this knowledge of how-to-act, is not known, explicitly, to any of us; it is implicit knowledge, like the knowledge of language or grammar. What seems highly characteristic of Parkinsonism is the loss of access to implicit knowledge, to built-in motor programmes - and in fact that access can sometimes only be regained by a 'trick'.

Many of the symptoms and features of Parkinsonism, especially 'freezing', are due to getting stuck in a Parkinsonian 'world', or rather in a Parkinsonian emptiness, or vacuum, or unworld ('I freeze in empty spaces', as Lilian T. says in the documentary film 'Awakenings'). This stuckness depends in part on a stuckness, or paralysis, or entrancement of attention - on there being, indeed, no proper object for attention. The 'cure' for this (if it is possible) is to redirect attention back to the real world (which is full of objects, proper objects for attention). Sometimes it is sufficient for another person to say 'Look!', 'Look at that!', or 'Look over there!' to release the transfixed attention, to disimprison the patient from his spellbound, albeit empty, Parkinsonian attention and allow him once again to move freely in the real world. Sometimes the patient can do this for himself - employing his ingenuity, his cerebral cortex, to bypass the subcortical transfixion of attention, to compensate for the subcortical emptiness of attention. This requires the intervention of consciousness and effort (acts which are normally done 'naturally' and unconsciously can no longer be done, in Parkinsonism, without conscious intervention) - in particular, the fixing of attention on a real object or percept or image. This is beautifully show in the film of Ivan, and described by Ivan Vaughan in his book. Ivan is able to run several miles - if he can get started. Instead of concentrating on the first step (which increases his freezing) he must divert his attention onto something else - anything, a leaf, a perceptual object; he touches a leaf, and, magically, this serves to 'release' him. Similarly, Ivan may not be able to get up in the morning, by direct willpower; but he has a tree painted on the bedroom wall by his bed. He looks at this, imagines climbing it, using its branches to get himself going; and by doing this he is enabled to climb out of bed.

The mode of Awakenings is largely biographic - it presents the reactions of individuals receiving L-DOPA. But these individuals, of course, were not isolated; they were all part of a large post-encephalitic community, and very sensitive to, and sometimes very influenced by, others' reactions.

This sensitivity, this influence, went in different directions. It led first, in the spring and summer of 1969, to a state of shared delight and joy. There was not one 'awakening', there were fifty 'awakenings', at this time, fifty individuals emerging from the decades-long isolation their illness had imposed on them, suddenly and miraculously finding themselves back in the world and alive, surrounded by fifty other Rip van Winkles or Sleeping Beauties.

A camaraderie speedily developed among them - all of them had lived in the same tunnel or dungeon, all of them were now out in the bright light of day. Suddenly released, they fell to dancing and talking together: some of the most charming scenes in the documentary film of Awakenings show the newly-awakened patients dancing, enjoying life, convivial, together. They discovered, they delighted in, each other as people - where hitherto they had only been contiguous statues on a ward. They shared their memories, their tragedies, their perplexities, their new hopes. They delighted in each other's daily-increasing health and vitality, and strengthened each other in the resolve for a new life. Thus there was not just individual, there was communal health, all that summer, and a peculiar excitement, and an elation of shared hope. This reached a height when Aaron E. left the hospital: 'Perhaps all of us can hope to leave it now as well!'

But then in September, there came tribulations of all sorts. Some of this was due to the treacherous 'side-effects' of L-DopA, the very limited stability of their own nervous systems when excited; some to'harsh changes occurring in the hospital at this time (see n. 39, P. 53); and some, no doubt, to their own regressive needs. But what was also all too clear, in the close medium of the ward, was how despondency, and side effects,' would spread from one Person to another. Everyone, in that summer, was encouraged by everyone eise - optimism and hope spread like a contagion. Whereas now every setback in a Patient aroused fear in the others, every discouragement discouraged the others - fear and helplessness spread like a contagion through the ward. These patients, above A others, were highly impressionable, not only psychically, but somatically as well - the 'somatic compliance' of whichjelliffe liked to speak. (Such an almost hypnoid impressionability, and tendency to mimesis, here, is biologically as well as psychologically determined; it is characteristic of all the diencephalic syndromes.)

The fear of fluctuations, the fear of tics, seemed to play a part in actually precipitating tics and fluctuations. And as the patients got past the critical point, and advanced further and further along the path of instability, psychic influences became more potent than ever. Happiness, freedom, good relationships stabilised them; stress, isolation, boredom destabilised them: all of these became quite as potent as L-DOPA. Thus the atmosphere of the ward, its mood, became all-important - I did not have fifty isolated, insulable patients; I had a community which was like a single organism.


Pages 339 - 348

Frances D. (like half a dozen other highly articulate post-encephalitic patients under my care) has often depicted for me the strange and deeply paradoxical world in which she lives. These patients describe a fantastical-mathematical world remarkably similar to that which faced 'Alice'. Miss D. lays stress on the fundamental distortions of Parkinsonian space, on her peculiar difficulties with angles, circles, sets, and limits. She once said of her 'freezing': 'It's not as simple as it looks. I don't just come to a halt, I am still going, but I have run out of space to move in ... You see, my space, our space, is nothing like your space: our space gets bigger and smaller, it bounces back on itself, and it loops itself round till it runs into itself.'

We may first take a brief historical look at notions of 'space'. An essential difference (one might almost say, the essential difference) between the philosophies of Newton and of Leibniz hinges on their differing notions and uses of the word 'space' - the Newtonian concept of 'motion' versus the Leibnizian one of 'action'. For Newton space and time were absolutes - absolute media in which motion occurred; they were not hypotheses (Hypotheses non fingo), or, as we would say now, frames-of-reference. For Leibniz, in contrast, 'space' and 'time,' and all such notions of continuity and extension, were simply ways of speaking, ways of picturing and measuring the size of actions: they were concrete and actual, not absolute and abstract, i.e. they were convenient (or conventional) constructions or 'models,' figurative language (albeit of a very special sort). (These essentially relativistic concepts of Leibniz are fully spelled out in his correspondence with Clark - a correspondence interrupted only by Leibniz's death, and not published until many years later.) The notion of 'space' as a way of speaking and looking at the world, rather than as a Euclidean or Newtonian absolute, was revived by Gauss in his famous papers on the possible curvatures of possible spaces, and then by the great Russian geometers in their 'alternative geometries.' These, then, combined with Maxwellian dynamics, were the intellectual antecedents of Einstein's thought, his notions of coordinate systems in motion relative to each other, of the possibility of countless, individual, variable space-times ...

Let us now come to practical examples, familiar and unfamiliar, of 'personal space' and 'personal time', which indicate how our judgements and our actions may be at variance with the abstract measure of clocks and rulers, or the judgements and actions of other human beings. First, a familiar and universal example, which all of us have experienced when impatient, hurried, or 'pressed for time': 'a watched pot never boils', as the old saying has it - if we are impatiently awaiting its boiling, it seems to take 'unduly long', and we may feel that the very watches we wear have become unreliable; again, if we are hurrying to catch a bus or train, the distance we must traverse seems 'unduly long', and the time we have 'unduly short'.

Thus we may experience illusions (or misleading conjectures) about space-time when we are hurried or festinant; and equally we may have illusions when dawdling or procrastinant. Now let us examine Parkinsonian behaviour in this light, concerning ourselves especially with illusions of scale. I have had letters from Frances D., and other Parkinsonian patients, which showed singular (and often comic) disparities of scale: I remember one such letter from Frances D., of which the first page was in a perfectly formed but microscopic hand (so small I needed a magnifying-glass to decipher it), while at the start of the second page (which was in normally sized script) she had written: I see that what I wrote yesterday was far too small, although I didn't see this at the time. Today I have borrowed a ruler and ruled lines on this page, and I will use the lines to guide my writing, so that I don't inadvertently make it tiny again.' Other letters from Frances D., and certain other patients, were sometimes marked by enormous (though perfectly shaped and formed) writing, and this too would be done in seeming ignorancie of its abnormal magnitude153 Similar disturbances were common in speech: most Parkinsonian patients tend to speak softly, and often to do so without knowing they are doing so; but if asked to ' speak up', they may find no difficulty in raising their voices; on the other hand Cecil M., who had 'megaphonia', habitually spoke in a Brobdingnagian voice, and felt everyone around him was speaking too softly (I should add that his hearing was perfectly normal - it was his judgement of sounds which showed aberrations).

lf one observes Parkinsonians with sufficient minuteness - for example in the act of writing- one may say that there are indeed changes of scale, but that these consist of sudden, incalcalable jumps: within a coupie of seconds, for example, there may be a dozen such 'jumps' - so what we observe is not, in fact, a continuously warped metric, but an infinitely stranger twitching metric; not a smooth geometrical or topological transform, but a sudden algebraic or statistical one.

Again, in walking, one may see 'microambulation' ('marche a petits pas') in Parkinsonian patients; if such patients measure themselves against regular marks or clocks, or the framework of dimensions around them, or against the movements of other persons whom they take to be 'normal', they may perceive (and perhaps correct) their own tiny steps; but this may not happen, or may be prevented from happening - the patient may be engrossed in his own scale of walking, and fail to realize that either the walking or the scale is 'wrong'. Parkinsonian patients often make 'macro-' or 'micro-gestures' - gestures of the right sort, but on the wrong scale (too large, too small, too fast, too slow ... ); these they may perform completely unwittingly, unaware that the gesture is inappropriate in scale. I am often able to show a beautiful example of such 'kinetic illusions' when I demonstrate Aaron E. (a deeply Parkinsonian, but not post-encephalitic, patient) to my students:

'Mr E.,' I say, 'would you be kind enough to clap your hands steadily and regularly - thus?'

'Sure, doc,' he replies, and after a few steady claps is apt to proceed into an incontinent festination of clapping, culminating in an apparent 'freezing' of motion.

'There, doc!' he says, turning to me with a pleased smile. 'Didn't I do it nice and regular, just like you asked me?'

'Gentlemen!' I say to the students. 'You be the judges. Did Mr E. clap his hands steadily and regularly, as he says?'

'Why, of course not!' exclaims one of the students. 'His movements kept getting faster and faster, and smaller and smaller - like tbis!'

At this point Mr E. leaps to his feet in indignation: 'What do you mean?' he cries to the student. 'What do you mean by saying my movements got faster and smaller - in that crazy way you did it yourself? My movements were perfectly regular and stable - like tbis!'

Festinant clock, warped by Parkinsonian pressure,- lilliputian handwtiting, unwarped but minute. Both were felt as 'normal' by tbe patient, tbougb only truly normalised by L-DOPA.

And, concentrating fiercely, totally absorbed in his own activity, he falls once again into the grossest festination.

This demonstration (when it works! and this depends on how much Mr E. is enclosed in his own frame-of-reference, versus how much he can stand outside it and make comparisons and corrections) is - in the charming idiom of my New York students - 'mind blowing', 'mind boggling', 'wild!', 'out of sight!'

It is, indeed, literally shocking, because of the clarity with which it shows that what Aaron E. clearly perceives in others, he cannot perceive in himself-, that he may use a frame-of-reference (or coordinate-system, or way of judging space-time) which departs from 'the normal' in an ever-increasing and accelerating way; and that he may be so enclosed within his own (contracting) frame-of-reference, that he is unable to perceive the contracting scale in his own movements.

Thus, the curious 'dialogue' between Mr E. and the students comes to resemble an imaginary Einsteinian dialogue between people in lifts (or frames-of-reference) which are moving or accelerating relative to each other; and the entire demonstration provides the clearest manifestation of relativity in action, the clearest vindication of Frances D.'s insights when she speaks of different 'spaces', and says:

'... my space, our space, is nothing like your space.'

Such a demonstration certainly establishes that individuals may have varying experiences of space and time - and (a point continually stressed by Richard Gregory) that their experiences are themselves hypotheses or conjectures. It does not, by itself, show that the false conjectures of Aaron E. are of a relativistic kind, rather than of a simpler kind, involving simple visual or kinaesthetic or motor illusions.

We are all subject to the latter - as shown by the 'queer feeling' (or continually violated delusion of motion) we may experience if we walk on an escalator which has stopped. Patients with cortical apraxias and agnosias are especially liable to misperceptions (misconjectures) of this sort, and so too, for a while, are patients who have sustained peripheral injuries (e.g. an injury which has de-activated, hence de-realised, a leg or a foot): such patients may make individual misjudgements, or a series of these, with regard to the size of individual objects, especially meaningless, geometrical objects like steps, because of an uncertainty or deficiency in their own inner scales, secondary to a mutilation or distortion in part of their body image, of their own biological measuring-apparatus . . . But such errors, which all of us are prone to when faced with new motor tasks (skiing, pole-vaulting, riding bicycles, etc.) are different in kind from Parkinsonian misjudgement.

I vividly remember, from my first month with these patients, the following event in 1966. As I was writing notes at my desk, I perceived through the open door Seymour L. careering down the corridor; he had been walking pretty normally, and then, suddenly, was accelerated, festinant, precipitated. I thought he was going to fall flat on his face. He recovered himself, however, and was able to proceed without further incident to the nursing station near my desk. He was obviously in a rage, and a panic, and bewildered: 'Why the hell do they leave the passage like that?' he spluttered.

'What do you mean, Mr L.?' the nurse rejoined. 'What's wrong with the passage? It's no different from usual.'

'No different from usual!' Seymour shouted, going red in the face. 'It's got a bloody great hole in it - they been excavating or something? I'm walking along, minding my business, and the ground suddenly falls away from my feet at this crazy angle, without reason. I was thrown into a run, lucky I wasn't thrown flat on my face. And you say there is nothing wrong with the passage?'

'Mr L.,' the nurse replied. 'You're not making sense. I assure you the passage is perfectly normal.'

At this point I got up, agog at the whole thing, and suggested to Mr L. and the nurse that we walk back together, to find out about the 'excavation.' Seymour walked between us, unconsciously attuning his pace to ours, and we walked the length of the passage together without any incident - and without any hint of festination or precipitation.

This absence of incident left Seymour confounded. 'I'll be damned,' he said. 'You're perfectly right. The passage is quite level. But' - he turned to me, and spoke with an emphasis and a conviction I have never forgotten- 'I could have sworn it suddenly dipped, just as I said. It was because it dipped that I was forced into a run. You'd do the same if you felt the ground falling away, in a steep slope, from under your feet! I ran as anyone would run, with such a feeling. What you call 'festination' is no more than a normal reaction to an abnormal perception. We Parkinsonians suffer from illusions!'154

Such illusions of space are common in Parkinsonism - this was well understood a century ago. Thus Michael Foster, in the 1883 edition of his Textbook of Physiology (London: Macmillan), writes:

Persons who have experienced similar forced movements as a result of [basal gangliar] disease report that they are frequendy accompanied, and seem to be caused by disturbed visual or other sensations; thus when they suddenly fall forward they say they do so because the ground in front of them appears to sink away beneath their feet.

The Parkinsonian - unlike the cortical apraxic-agnosic - understands perfectly well what is meant by a 'foot'; he has in no sense lost his ideas of dimension. What we observe, however, is that all his space-time judgements are pushed out of shape,

Frances D.'s ability to climb stairs in a regular and controlled fashion, which stood in the most dramatic contrast with her irregular and uncontrollable tendencies to hurry or freeze in her walking, is an example of the use, and indeed the necessity, of external means to activate Parkinsonian patients, and to regulate or control their activity.

  1. Such direct methods of activation and regulation - direct in that they concern themselves directly with the actual behavioural and experiential disorders of Parkinsonism, and not with its chemical or anatomical substrate - are of fundamental importance, both theoretically and practically, in helping us to understand, and through understanding to help, Parkinsonian patients.
  2. Such direct methods are discovered, or can be learned (and should be learned!) by all Parkinsonian patients, by their friends and relatives, by their physicians and nurses, by all who come into close contact with them; they are easy, and often delightful, to leam;
  3. they can make a literally vital difference to the lives of Parkinsonian patients; and they form an essential complement to the use of L-DOPA155.

See also n. 45, p. 6o and n. 47, p. 63.

The central problem in all Parkinsonian disorders is passivity - passivity and pulsivity, i.e. inertia - as the central cure for them all is activity (of the right kind).

The essence of this passivity lies in peculiar difficulties of self-stimulation, and initiation, not in the capacity to respond to stimulation.

This means, in the severest cases, that the patient is totally unable to help himself, although he can very easily be helped by other people, or other means, outside himself; in less severe cases (as Luria has never ceased to stress) the Parkinsonian patient can help himself in a limited fashion, by using his normal and active powers to regulate his pathological or 'de-activated' onwn.

The problem, then, is to provide a continual stimulus of the appropriate kind - and if we can achieve this we can recall Parkinsonians from inactivity (or abnormal activity) into normal activity, and from the abyss of unbeing into normal being. 'Quis non agit non existit' (writes Leibniz); when the Parkinsonian is not active he does not exist - when we recall him to activity we recall him to life.

We may use alternative terms, and say that the problem of activation is one of order or organisation, of finding forms of order or organisation which will combat the specific disorders and disorganisations which constitute Parkinsonism.

We observe of Parkinsonians that either they fail to move at all, or they move wrongly, and that the wrongness of their movements is a wrongness of scale - their movements are too large or too small, too fast or too slow. Thus what the Parkinsonian needs, and what we must give him, is measure (or metric), so that he can overcome his peculiar deficiencies or distortions of measuring (his 'ametria' and 'dysmetria').

What is a measure - and how do we measure? We create and use two sorts of measure: measures that are abstract, absolute, and formal (measuring-sticks and pendulums, rulers and clocks, the C.G.S. measures of engineering and physics); or measures that are concrete, actual, and active - measures that relate to our environment and ourselves. ('Man is the measure of all things', said da Vinci.) Both come together, for example, in the concept of 'a foot', which was at first a living, practical measure, based on the size of a human foot, and then a precise and abstract measure, the distance between two marks on a rigid, lifeless rod.

So, in the most general terms, we find that ametric-dysmetric Parkinsonian patients can be activated and regulated, ordered and organised, by either sort of measure: by regular marks in a conventional, formal (and linear) space-time, e.g. stairs, steps painted on the ground, clocks, metronomes, and devices that count in a simple, regular, and orderly manner; or by co-action and co-ordination with a concrete, living activity or agent. Thus, in the case of Miss D., the chalking of regular lines on the ground enabled her to walk stably, but like a puppet or robot; but taking her arm, and strolling with her, enabled her to stroll like a normal human being. The first form of treatment is kinetic, the second mimetic. The first is directed to the scale of motion, the second to the shape of action. Parkinsonism, at its severest, presents itself as an akinetic amimia (as opposed to certain cortical disorders which are amimic akinesias). Since right mimesis entails right kinesis, whereas kinesia per se entails only itself, the best form of therapy is mimetic, kinetic therapy constituting a second best - a prosthetic or algorithmic substitute (like a wooden leg, or an artificial pace-maker).

Thus Hester would rush and dart when alone in a room, but move at a more 'normal' pace if she were moderated by other things or other people; similarly Miriam would only speed up in her speech when she 'forgot' the presence of others, when she was, as it were, enveloped in monology. At such times, they felt they were moving and talking 'normally', i.e. they suffered a sort of tachyscopic illusion which blinded them to their own tachykinesia and tachyphemia. Could not such a tendency and such an illusion be countered by the introduction of a commensurate resistance or retardation in the medium of their movements, or a commensurate illusion of 'bradyscopy'? Such measures do work, in a limited way: thus Hester's tendency to walk too fast was moderated if she had to walk uphill (as it was aggravated if she had to walk downhill); it was also moderated if she thought she was walking uphill (when, in reality, she was walking on the level). Indeed she once asked me if it might not be possible to make a special pair of glasses for her which would distort appearances so that all the level corridors would seem to her to be going uphill. (I was unsure whether this would be ontologically possible, let alone optically possible.)

We have repeatedly referred to the usefulness of steps, lines, ticks, clocks, routines, pacings, etc. - scales, measures, series, patterns, disposed in a fixed and regular and conventional space-time. All of these can provide (in Luria's terminology) 'syntagms' or 'algorithms' for the structuring and coordination of experience and behaviour; they provide (again in Luria's terms) 'logico-grammatical' or 'quasispatial' paradigms or schemes.

All of us (by 'us' l mean human animals, as opposed to non-human animals, who are so admirably guided by their own, biological 'clocks' and 'scales') require and use artificial, abstract, conventional measures - standards - of this sort, standards for consensus and communication. The Parkinsonian, who is 'far out', whose behaviour has become so different from, so incommensurable with, ordinary conduct, stands in special need of such formalities and conventions; but he also stands in special peril from them. A subtle and sensible balance is needed, a propriety of relation, so that the Parkinsonian patient can have the mechanical and the systematic at his service, witbout himself becoming enslaved to them.

Complementary to the artifices and algorithms which can so help Parkinsonian patients is the real world, infinite in variety, aspect, and depth, infinitely concrete, infinitely metaphorical, infinitely formal yet infinitely expressive, infinitely ordered yet infinitely free. The real world, whether in Nature or Art or social relationship, is - finally - the only thing which can give the Parkinsonian (which can give any of us) that fullness, ease, and spontaneity of action which constitutes happiness, health, freedom, and life.

The true ideal would be the restoration of a 'natural' rhythm and movement, the 'kinetic melody' (in Luria's term) natural and normal to each particular patient: something which would not be a mere scheme or diagram or algorithm of behaviour, but a restoration of genuine spaciousness and freedom.

The art of 'handling' Parkinsonian patients, learned by sensitive nurses and friends - assisting them by the merest intimation or touch, or by a wordless, touchless moving-together, in an intuitive kinetic sympathy of attunement - this is a genuine art, which can be exercised by a man or a horse or a dog, but which can never be simulated by any mechanical feedback; for it is only an ever-changing, melodic, and living play of forces which can recall living beings into their own living being.

Such a subtle, ever-changing play of forces may also be achieved through the use of certain 'natural' devices, which intermediate, so to speak, between afflicted patients and the forces of Nature. Thus while severely affected Parkinsonians are particularly dangerous at the controls of motorcars and motorboats (which tend to amplify all their pathological tendencies), they may be able to handle a sailing boat with ease and skill, with an intuitive accuracy and 'feel'. Here, in effect, man-boat-wind-wave come together in a natural, dynamic union or unison; the man feels at one, at home, with the forces of Nature; his own natural melody is evoked by, attuned to, the harmony of Nature; he ceases to be a patient - passive and pulsive - and is transformed to an agent - active and free.


pages 233 - 234

Leibniz's 'optimum', health, is an allusion to the greatest fullness of relationship possible in a total world-manifold, the organization with the greatest richness and reality. Diseases, in this sense, depart from the optimum, for their organization or design is impoverished and rigid (although they have frightening strengths of their own). Health is infinite and expansive in mode, and reaches out to be filled with the fullness of the world; whereas disease is finite and reductive in mode, and endevours to reduce the world to itself.

Health and disease are alive and dynamic, with powers and propensities and 'wills' of their own. Their modes of being are inherently antithetical: they confront one another in perpetual hostility - our 'Internal Militia', in Sir Thomas Browne's words. Yet the outcome of their struggle cannot be pre-determined or pre-judged, any more than the outcome of a chess game or tournament. The rules are fixed but the strategy is not, and one can learn to outplay one's antangnist, Sickness. In default of health, we manage, by care, and control, and cunning, and skill, and luck.

Health, disease, care - these are the most elemental concepts we have, the only ones adequte to bear the discussion. When we give L-DOPA to patients, we see

It is in terms of this sequence - Awakening ... Tribulation ... Accommodation - that we can best discuss the consequences of L-DOPA.

... The 'dark' side of patients' awakenings: page 55

For a certain time, in almost every patient who is given L-DOPA, there is a beautiful, unclouded return to health; but sooner or later, in one way or another, almost every patient is plunged into problems and troubles. Some patients have quite mild troubles, after months or years of good response; others are uplifted for a matter of days - no more than a moment compared to a life-span - before being cast back into the depths of affliction.

No simple statement can be made as to which patients get into most trouble first, nor can any firm prediction be made as to how and when trouble will present itself. But it is reasonable to say that patients who were in the greatest trouble originally -whether their troubles were neurological, emotional, socioeconomic, or whatever- tend (other things being equal) to get into the greatest trouble on L-DOPA.

Pages 262-263
... [As to tribulations as side-effects of L-DOPA: These] must be seen as a summoning of possible natures, a calling-forth of entire latent repertoires of being. We see an actualization or extrusion of natures which were dormant, which were 'sleeping' in posse, and which perhaps might have been best left in posse. The problem of 'side-effects' is not only a physical but a metaphysical problem: a question of how much we can summon one world, without summoning others, and of the strengths and resources which go with different worlds.

Why did so many of our patients, after doing so well at first, spoil, 'go bad', move into all sorts of trouble? Clearly, they had in them the possibilities of great health: the most deeply ill patients were able to become deeply well for a time. Thereafter, apparently, they 'lost' this possibility, and in no case were able to retrieve it again; such, at least, is the case in all the Parkinsonian patients I have seen. But the notion of 'losing' a possibility in such a way is difficult to comprehend, on both theoretical and practical grounds: why, for example, should a patient who retained the possibility of 'awakening', through fifty years of severest illness, 'lose' it, in a few days, after receiving L-DOPA? One must allow, instead, that their possibilities of continued well-being were actively precluded or prevented because they became 'incompossible' with other worlds, with the totality of their relationships, without and within. In short, that their physiological or social situations were incompossible with continuing health, and therefore disallowed or displaced the first state of well-being, thrusting them into illness again.

The descent into illness, once started, may proceed by itself, moving incontinently further by innumerable visious circles, positive feedbacks, chain-reactions - first a 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 ... (John Donne)

Tribulation ... Accommodation

(pages 263 - 267)

version: 16 November 2015
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Joachim Gruber