Oliver Sack's Awakenings: Reshaping Clinical Discourse

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 (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

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...