Ceci n’est pas un chapeau

The Man Who Mistook His Wife for a Hat

Charcot and his pupils, who included Freud and Babinski as well as Tourette, were among the last of their profession with a combined vision of body and soul, ‘It’ and ‘I’, neurology and psychiatry. By the turn of the century, a split had occurred, into a soulless neurology and a bodiless psychology…

Oliver Sacks, renown New York neurologist and author of The Man Who Mistook His Wife for a Hat, attempts to reconcile this split, both in his practice and through his writing. And this is the very reason I find his work so compelling – without losing sight of the chemical imbalances and neural damage underlying the disorders described in his writing, he treats his patients holistically – as a system of flesh, bones, electricity and chemistry, beliefs, values and fears, family and community members, loved ones, history, symbols and wonder.

In one of the chapters of The Man Who Mistook His Wife for a Hat, Sacks describes how he spent 3 months analysing all the implications – psychological, social, economical – of treatment with haloperidol (a dopamine antagonist) for a patient with Tourette’s syndrome, “Witty Ticcy Ray”. He did this in weekly sessions with Ray and in the end they came up with an unconventional but satisfactory solution that was best for Ray (controlling Tourette’s during the week with medication, and letting it run its course on weekends). I find this so inspiring – this process of working with each individual patient, recognising the unique ways in which a disorder might affect them, and tailoring treatment to suit them, rather than making them fit a rigid and generic treatment regimen.

I also find fascinating the way in which disorders can become more or less accommodated or integrated within an individual’s personality and life – especially with chronic disorders. They become part of the person, altering who they are – which is why, in cases like Ray’s, simply “taking the disorder away” was impossible and disastrous for Ray’s sense of self, which was partly based on Tourette’s.

Sacks never loses a sense of wonder in what he encounters; disorders don’t only cause deficits, but can also cause excesses (of energy, mood, movement, reflexes, thought) and can be productive in a Foucauldian sense, contributing to identity (subjectivity) production. However, Sacks also always preserves empathy for his patients – they never become mere “subjects” or “curios”.

Sometimes I feel this is a lost art (at least in the Western biomedical model) – treating the disorder (symptoms and underlying causes), but also treating the patient – as a complete person enmeshed in a larger network, where both the internal and external workings rely on delicate and complex sets of balances. Homeostasis needs to be maintained, or restored, both inside and outside the body. Sacks seems to have an intuitive understanding of this, and I think anyone who works in any sort of healthcare profession (especially mental health!) would get a lot out of his writing.

Sacks, O. (1986). The Man Who Mistook His Wife for a Hat. London: Picador