I had a sense of horror—and, in part, of guilt. Was it not I who had introduced Karl to drugs? Was I, to some extent, responsible for this shattering of a once-noble human being? I did not see Karl again. I heard, in the 1980s, that he was ill with AIDS and had gone back to Germany to die.
—
While I was doing my residency at UCLA, Carol Burnett, my friend from Mount Zion, had returned to New York for her residency in pediatrics. When I moved to New York, we resumed our friendship; we would often go to Barney Greengrass (“the Sturgeon King”) for a smoked-fish brunch on Sunday mornings. Carol had grown up on the Upper West Side, had grown up going to Barney Greengrass, and she had picked up her fluent, idiomatic Yiddish from listening to the Yiddish nattering which filled the shop and restaurant on Sunday mornings.
In November of 1965, I was taking huge doses of amphetamines every day and then, unable to sleep, huge doses of chloral hydrate, a hypnotic, every night. One day, sitting in a café, I started to experience hallucinations of the wildest sort, which came on suddenly, as I described in Hallucinations:
As I was stirring the coffee, it suddenly turned green, then purple. I looked up, startled, and saw that a customer paying his bill at the cash register had a huge proboscidean head, like an elephant seal. Panic seized me; I slammed a five-dollar note on the table and ran across the road to a bus on the other side. But all the passengers on the bus seemed to have smooth white heads like giant eggs, with huge glittering eyes like the faceted compound eyes of insects—their eyes seemed to move in sudden jerks, which increased the feeling of their fearfulness and alienness. I realized that I was hallucinating, that I could not stop what was happening in my brain, and that I had to maintain at least an external control and not panic or scream or become catatonic, faced by the bug-eyed monsters around me.
When I got off the bus, the buildings around me were tossing and flapping from side to side, like flags blowing in a high wind. I called Carol.
“Carol,” I said, as soon as she picked up, “I want to say good-bye. I’ve gone mad, psychotic, insane. It started this morning, and it’s getting worse all the while.”
“Oliver!” Carol said. “What have you just taken?”
“Nothing,” I replied. “That’s why I’m so frightened.” Carol thought for a moment, then asked, “What have you just stopped taking?”
“That’s it!” I said. “I was taking a huge amount of chloral hydrate and ran out of it last night.”
“Oliver, you chump! You always overdo things,” Carol said. “You’ve given yourself the DTs.”
Carol sat with me, nursed me, anchored me, through the four days of my delirium, when waves of hallucination and delusion kept threatening to engulf me; she was the only stable point in a chaotic and shattered world.
The second time I called her in a panic was three years later, when I started, one evening, to feel a little dizzy, lightheaded, and strangely excited for no reason. I could not sleep and was alarmed by seeing little patches of my skin changing color before my eyes. My landlady at the time was a brave and charming old lady who had battled for years with scleroderma, a very rare disease which gradually hardens and shrinks the skin, causing deformities of the limbs and sometimes necessitating amputations. Marie had had this for more than fifty years; she told me proudly that she was the longest-surviving case known to the medical profession. In the middle of the night, when bits of my skin seemed to change texture, becoming hard and waxy, I had a sudden, piercing insight: I too had scleroderma, “galloping scleroderma.” I had never actually heard of such a thing; scleroderma is usually the most indolent of diseases. But there is always a first case of this or that, and I thought I too would surprise the profession, as the world’s first case of acute scleroderma.
I phoned Carol, and she came to see me, black bag in hand. She took one look at me—I had a high fever and was covered in blisters—and said, “Oliver, you idiot, you’ve got chicken pox.”
“Have you examined anyone with shingles lately?” she continued. Yes, I told her. I had examined an old chap at Beth Abraham with shingles just fourteen days earlier. “Experientia docet,” Carol said. “Now you know, and not just because the textbooks say so, that shingles and chicken pox come from one and the same virus.”
Brilliant, witty, generous Carol, fighting juvenile diabetes in herself, as well as prejudices against women and blacks in her profession, rose to become a dean at Mount Sinai and in this capacity was critical, for many years, in ensuring that women physicians and physicians of color were respected and treated equitably. She never forgot the episode with the surgeons at Mount Zion.
—
Drugging had increased when I started in New York, fueled in part by the soured love affair with Karl and in part by the fact that my work was going badly and my sense that I should not have opted for research in the first place. By December of 1965, I had started to call in sick, missing work for days at a time. I was taking amphetamines constantly and eating very little; I lost so much weight—nearly eighty pounds in three months—that I could scarcely bear the sight of my emaciated face in the mirror.
On New Year’s Eve, I had a sudden lucid moment in the midst of an amphetamine ecstasy, and I said, “Oliver, you will not see another New Year’s Day unless you get help. There has to be some intervention.” I felt there were very deep psychological troubles underlying my addiction and self-destructiveness and that unless these were addressed, I would always return to drugs, and sooner or later do myself in.
A year or so earlier, when I was still in Los Angeles, Augusta Bonnard, a friend of the family’s who was herself a psychoanalyst, had suggested that I go and see someone. I went reluctantly to see the psychoanalyst she recommended, a Dr. Seymour Bird. When he asked, “Well, what brings you here, Dr. Sacks?” I snapped, “Ask Dr. Bonnard—she referred me.”
I was not only resistant to the whole business; I was stoned most of the time. One may be very glib and facile on amphetamines, and things seem to proceed with miraculous rapidity, but it all blows away, leaving no imprint.
It was utterly different at the beginning of 1966 when I myself sought out an analyst in New York, knowing that I would not survive without help. I was suspicious of Dr. Shengold at first, because he was so young. What experience of life, what knowledge, what therapeutic power, I thought, could I find in someone scarcely older than myself? I soon realized that this was someone of very exceptional caliber and character, someone who could pierce my defenses and not be deflected by my glibness, someone who felt I could tolerate and profit from intensive analysis and the intense and ambiguous feelings that transference involved.
But Shengold insisted from the start that this would only work if I gave up drugs. Drugging, he said, put me beyond the reach of analysis; he could not continue to see me unless I stopped using them. Bird might also have thought this, but he never really said it, whereas Shengold hammered it home every time I saw him. I was terrified by the idea of being “out of reach” and even more terrified that I would lose Shengold. I was still half-psychotic at times from the amphetamines I had not yet kicked. Thinking of my schizophrenic brother, Michael, I asked Shengold if I too was schizophrenic.
“No,” he answered.
Was I then, I asked, “merely neurotic”?
“No,” he answered.
I left it there, we left it there, and there it has been left for the last forty-nine years.
—
Nineteen sixty-six was a grim year as I struggled to give up drugs—grim too because my research was going nowhere and I was realizing that it would never get anywhere, that I did not have what it took to be a research scientist.
I would continue to seek satisfaction in drugs, I felt, unless I had satisfying—and, hopefully, creative—work. It was crucial for me to find something with meaning, and this, for me, was seeing patients.
As soon as I started clinical work in October of 1966, I felt better. I found my patients fascinating, and I cared for them. I sta
rted to taste my own clinical and therapeutic powers and, above all, the sense of autonomy and responsibility which I had been denied when I was still a resident in training. I had less recourse to drugs and could be more open to the analytic process.
I had one more drug high or mania in February of 1967, and this—paradoxically and unlike all my previous highs—took a creative turn and showed me what I should and could do: to write a worthwhile book on migraine and perhaps other books after this. It was not just a vague feeling of potential but a very clear, focused vision of future neurological work and writing which came to me when I was high but then stayed with me.
I never took amphetamines again—despite sometimes-intense longings for them (the brain of an addict or an alcoholic is changed for life; the possibility, the temptation, of regression never go away). And with this, I was no longer out of reach, and analysis could get somewhere.
Indeed I think it saved my life many times over. Back in 1966, my friends did not think I would make it to thirty-five, and neither did I. But with analysis, good friends, the satisfactions of clinical work and writing, and, above all, luck, I have, against all expectations, made it past eighty.
I still see Dr. Shengold twice a week, as I have been doing for almost fifty years. We maintain the proprieties—he is always “Dr. Shengold,” and I am always “Dr. Sacks”—but it is because the proprieties are there that there can be such freedom of communication. And this is something I also feel with my own patients. They can tell me things, and I can ask things, which would be impermissible in ordinary social intercourse. Above all, Dr. Shengold has taught me about paying attention, listening to what lies beyond consciousness or words.
—
It was a huge relief to me when, in September of 1966, I stopped laboratory work and started seeing real patients at a headache clinic in the Bronx. I thought my chief concern would be headache and little else, but I soon found that the situation could be far more complex, at least in patients with so-called classical migraine, which could provoke not only intense suffering but a huge range of symptoms, almost an encyclopedia of neurology.
Many of these patients would tell me that they had seen their internists or their gynecologists or their ophthalmologists or whatever but had not received proper attention from them. This gave me a feeling of what seemed wrong with American medicine, that it consisted more and more of specialists. There were fewer and fewer primary care physicians, the base of the pyramid. My father and my two older brothers were all general practitioners, and I found myself feeling not like a super-specialist in migraine but like the general practitioner these patients should have seen to begin with. I felt it my business, my responsibility, to enquire about every aspect of their lives.
I saw one young man who had “sick headaches” every Sunday. He described the scintillating zigzags he saw before the headache, so it was easy to make a diagnosis of classical migraine. I told him we had medications for this and that if he put an ergotamine tablet under his tongue as soon as he started to see the zigzags, this might serve to abort the attack. He phoned me up in great excitement a week later. The tablet had worked, and he had no headache. He said, “God bless you, Doctor!” and I thought, “Gosh, isn’t medicine easy?”
The following weekend, I did not hear from him, and, curious to see how he was getting along, I phoned him. He told me in a rather flat voice that the tablet had worked again, but he then made a curious complaint: he was bored. Every Sunday for the previous fifteen years had been devoted to migraines—his family would come, he was the center of attention—and now he missed all of that.
The week after, I got an emergency phone call from his sister saying that he was having a severe attack of asthma and was being given oxygen and adrenaline. There was a suggestion in her voice that it was perhaps my fault, that I had somehow “rocked the boat.” I called on my patient later that day, and he told me that he had had attacks of asthma as a child but that these had later been “replaced” by migraine. I had missed this important part of his history by attending only to his present symptoms.
“We can give you something for the asthma,” I suggested.
“No,” he replied, “I’ll just get something else.…
“Do you think I need to be ill on Sundays?”
I was taken aback at his words, but I said, “Let’s discuss it.”
We then spent two months exploring his putative need to be ill on Sunday. As we did, his migraines got less and less intrusive and finally more or less disappeared. For me, this was an example of how unconscious motives may sometimes ally themselves to physiological propensities, of how one cannot abstract an ailment or its treatment from the whole pattern, the context, the economy of someone’s life.
Another patient at the headache clinic was a young mathematician who also had Sunday migraines. He would start to get nervous and irritable on Wednesday, and this would become worse by Thursday; by Friday, he could not work. On Saturday he felt tormented, and on Sunday he would have a terrible migraine. But then, towards the afternoon, the migraine would melt away. Sometimes as a migraine disappears, the person may break out in a gentle sweat or pass pints of pale urine; it is almost as if there is a catharsis at both physiological and emotional levels. As the migraine and the tension drained out of this man, he would feel himself refreshed and renewed, calm and creative, and on Sunday evening, Monday, and Tuesday he did highly original work in mathematics. Then he would start getting irritable again.
When I gave this man medication and cured him of his migraines, I also cured him of his mathematics, disrupting this strange weekly cycle of illness and misery followed by a transcendent sort of health and creativity.
No two patients with migraine were the same, and all of them were extraordinary. Working with them was my real apprenticeship in medicine.
—
The head of the migraine clinic was a man of some eminence called Arnold P. Friedman. He had written a good deal on the subject, and he had run this clinic—the first of its kind—for more than twenty years. I think Friedman took a shine to me. He thought I was bright, and I think he wanted me to be a sort of protégé. He was friendly towards me, and he arranged for me to do more clinics than everyone else and to be paid slightly more. He introduced me to his daughter, and I even wondered whether he thought of me as a potential son-in-law.
And then there came a strange episode. I would meet with him on Saturday mornings and tell him about interesting patients I had seen during the week, and on one Saturday early in 1967 I told him about a patient who did not develop a headache after the scintillating zigzag that begins many migraines but had severe abdominal pain and vomiting instead. I said that I had seen a couple of other patients like this, who had apparently switched from headache to abdominal pain, and that I wondered whether one should exhume the old Victorian term “abdominal migraine.” When I said this, Friedman suddenly became a different man. He turned red and shouted, “What do you mean, talking about ‘abdominal migraine’? This is a headache clinic. The word ‘migraine’ comes from hemi-crania! It means a headache! I will not have you talk about migraines without a headache!”
I drew back, amazed. (This was one of the reasons why in the very first sentence of the book I later wrote, I emphasized that headache is never the sole symptom of a migraine—and why the second chapter of Migraine was entirely devoted to forms of migraine without a headache.) But that was a small explosion. The bigger one came in the summer of 1967.
I have described in Hallucinations how, in February of 1967, in an amphetamine-induced epiphany, I read Edward Liveing’s 1873 book, On Megrim, from cover to cover and resolved to write a comparable book, a Migraine of my own, a Migraine for the 1960s, incorporating many examples from my own patients.
In the summer of 1967, after working in the migraine clinic for a year, I went back to England for a holiday, and to my own great surprise I proceeded to write a book on migraine over the course of a couple of weeks. It spilled out suddenly, witho
ut conscious planning.
I sent a telegram to Friedman from London, saying that somehow or other a book had just gushed out and that I had taken it to Faber & Faber, a British publisher (which had published a book of my mother’s), and that they were interested in publishing it.3 I hoped Friedman might like the book and write a foreword. He sent a return telegram, saying, “Stop! Hold everything.”
When I came back to New York, Friedman did not look at all friendly; he looked rather disturbed. And he almost tore the manuscript of the book out of my hands. Who did I think I was to write a book on migraine? he demanded. What presumption! I said, “I’m sorry, it just happened.” He said that he would send the manuscript out for review, to someone very high up in the migraine world.
I was very taken aback by these reactions. A few days later, I saw Friedman’s assistant photocopying my manuscript. I didn’t pay much attention to this, but I noted it. About three weeks later, Friedman gave me a letter from the reviewer, from which all identifying characteristics of the sender had been removed. It was a letter lacking any real, constructive critical substance but full of personal and often envenomed criticism of the book’s style and its writer. When I said this to Friedman, he replied, “On the contrary, he is absolutely right. This is what your book consists of; it’s basically trash.” He went on to say that he would not in future allow me access to any of my own notes on the patients I had seen, that everything would be locked up. He warned me not to think of going back to the book, saying that if I did, he would not only fire me but see that I never got another neurological job in America. At that time, he was chairman of the headache section of the American Neurological Association, and it would indeed have been impossible for me to get another job without his recommendation.