When Oliver Sacks first published Awakenings in 1973, he was largely ignored by his fellow neurologists. The reason often given to him was prosaic: Neurological case studies were not in the first person, did not involve the clinician's feelings, and were full of numbers and graphs. What he wrote wasn't clinical research, so it was beneath their notice.

The reason slightly less often given to him was that nobody believed him. Most of the patients first given L-DOPA had a conventional form of Parkinson's disease. PD is caused by a decline in dopaminergic neurons in a small region of the brain called the substantia nigra, and the body is so good at compensating for this that you don't even see symptoms until the substantia nigra is about 80% gone. It is progressive, and the course varies; it takes a good goddamn long time for most Parkinson's patients to degenerate to the state in which Sacks' encephalitis lethargica victims were when he first tried L-DOPA, and many of them will die of unrelated old person things before they ever get there. The catastrophic and unpredictable side effects seen in the Beth Abraham inmates wouldn't crop up in regular clinic patients for somewhere between 5-10 years and never, so when Sacks recounted what happened to his catastrophically-frozen inpatients, the general response was 'clearly ur doin it rong', and then everyone went on to other things.

One reason that seems to have been seldom if ever cited was that most neurologists would spend at least 25% of that book not knowing what the fuck Sacks was talking about.

Awakenings is not a proper neuropharmacological case study. Awakenings is not entirely about neuropharmacology. Sacks was prone to what I think most people see as digression -- all my long square-bracket inserts here are the closest I can come, in lazy Blogger HTML, to his habit of footnoting the bejeezus out of everything. Most of them are not simple bibliographic references, but lengthy asides about something he sees as closely related to the thing he's talking about in the main text. And when I say lengthy, I mean that when he was laid up in the hospital a few years after first writing the book, he passed the time by writing another load of footnotes for it that were a third again as long as the original text for inclusion in the second edition. The editor for the third edition said 'you cannot put 20k words of footnote into a book that was only 60k words to begin with, that is ridiculous, chop them out'. So for the fourth edition, issued after he had become a considerably more famous author, he very pointedly put them all back. This resulted in the 1990 edition of the book which has a section about a third of the way in, where he starts with a half-page footnote which rolls onto the next page and collides with the next note, rolling it onto the next page, and continues on in this fashion for thirteen pages, culminating with a leaf that has two lines of maintext at the top and is 100% footnote thereafter, and still splits two or three footnote lines off onto the verso side.

Many of these are comments on other patients whose stories aren't recounted in full in the main text, but many are not strictly neurological at all. He wanders into John Donne and Marcel Proust at points. That's reasonable; you can explain what you mean about Donne and Proust to someone unfamiliar with the original references by quoting relevant bits, which is what he does. It also works with a fair degree of success when he does it with Darwin. It works less well when he collides with Gottfried Leibniz and Georg Cantor; by the time you get into set theory and philosophy of mathematics, it's impossible to explain what you mean to a naïf without writing an entirely separate monograph on the subject. And then in trying to describe the pharmacological interactions and mechanics that must be producing the bizarre behavioral swings he was seeing in his patients, he gets into beginning quantum mechanics and Edward Lorenz, who at the time was still in the process of publishing his papers on non-deterministic flow, and was publishing them at MIT and in technical mathematics journals to boot.

[Sacks also added mini-monograph appendices to later editions for things he didn't feel he could adequately cover at the bottoms of other pages. He found an amenable mathematician in the late '80s, and the back of the 1990 edition has a ton of catastrophe-theory math. He doesn't give the equations there, but does reproduce a lot of rather pretty graphs tracing the behavior of functions in the same category as the ones that must govern the behavior of L-DOPA and dopamine function in the brain.]

There are not a lot of people cross-trained in neuropharmacology, ethnography, philosophy and history of science, linguistics, and cutting-edge meteorology. If my own life is any indication, the only way to do that is to cross-train yourself, because nowhere on Earth is there a sufficient concentration of polymaths to run a university program in it. If it hasn't happened in modern-day Boston, Weird Nerd Capital Of The World, believe me, it's not going to happen. Adding to the problem was that, while I recognized what he was describing was a non-linear deterministical system in 4+ dimensions with strange attractors, that was because I read it first in the mid-late 1990s, after having crammed my head full of things by Douglas Hofstadter and Martin Gardner -- in 1969-72, when Sacks was writing, chaos theory wasn't a thing yet.

There were a maximum of like five people on the entire planet who would have recognized everything in that book when it was originally published. There are probably a couple orders of magnitude more now, mainly because the internet has made it much easier to gain a conceptual familiarity with subjects in which one is not a highly-technical expert.

The only way to cope with that book would be to either be the sort of person whose brain peaceably edits out anything incomprehensible, and who therefore isn't bothered by not getting big chunks of the text, or to be the kind of person who responds to not getting things by finding a brief overview on Wikipedia, and then immediately going off to raid the public library. Sacks' body of work makes it obvious that he was the latter sort of person, and that this was in fact how he tripped over most of his projects. Most people, I suspect, are the former, and that is how they make it through life without going insane.

Technical fields of expertise seem to collect a high proportion of people who are intelligent enough to get through grad school, but lack either the capacity or the desire to acquire information on anything except their focus. They get angry when they run into things they don't understand, and deal with it by declaring anything outside their field to be not worth checking into. It's not restricted to Sacks' own putative field of medicine, but neurology is definitely a place where that happens.

I would guess from watching the frankly quite darling rambles that happened whenever Sacks was asked to speak publicly that he never really developed any detection routines for when he wandered across disciplinary boundaries, and consequently could never really put his finger on the point where people stopped having any clue what the fuck he was talking about. He thought all of the things he wrote about were aspects of one great interconnected whole, and I agree with him. Other people do not, and as far as I can tell, the main way they distinguish this 'interconnectedness' from things like schizophrenia is by discreetly checking to see if someone -- person or institution -- previously attested to as 'smart' is nodding like they're following along, or backing slowly away and reaching for their cell phone.

[The incredibly wide range of his analogical reasoning also makes me look at Sacks' work and go, "Ah. Here is a man who has taken a lot of drugs." Not that such feats of silhouette-matching between seemingly unrelated topics only happen when you're high, but Sacks plainly takes great joy in spotting them, and drugs are a known method of whacking yourself into a state of consciousness conducive to finding new ones. Plus, y'know, if anyone could actually be said to know what they were goddamn doing with recreational chemicals, it would be a neuropharmacologist.]

I do wonder if this rampant and persistent pattern-matchiness is either connected to or compensating for whatever goes wrong to produce things like prosopagnosia. The number of gestahlt-processing geniuses noted for being lousy at navigating cities and recognizing acquaintances out of context is suspiciously high.

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