Awakenings

Neurologist Oliver Sacks recounts the extraordinary true story of a group of patients who survived the worldwide epidemic of encephalitis lethargica, a mysterious viral brain illness commonly known as the sleeping sickness, which erupted in the winter of 1916–17 and raged for a decade before vanishing in 1927. The epidemic took or ravaged nearly 5 million lives. A third of those affected died during the acute phase, succumbing to comas so deep they could not be roused or to states of insomnia so fierce they could not be sedated. Many who survived appeared to recover, only to develop devastating neurological problems years or decades later, most commonly a severe form of Parkinsonism characterized by profound immobility, speechlessness, and withdrawal. By the 1930s, thousands of these survivors had been consigned to chronic hospitals and asylums, where they were largely forgotten.

Sacks opens with a prologue surveying the medical background. He traces the history of Parkinson's disease from James Parkinson's landmark 1817 essay through the later elaborations of the French neurologist Jean-Martin Charcot, describing the illness's cardinal features: tremor, rigidity, and disorders of movement and impulse. Parkinsonian patients experience two opposing forces simultaneously: pathological absence, a loss of fluent movement and initiative, and pathological presence, an abnormal internal pressure that distends and distorts behavior. Sacks explains that post-encephalitic Parkinsonism tends to be far more severe and strange than ordinary Parkinson's disease, involving not only motor arrest but also catatonia, involuntary movements, compulsions, and complex crises combining many symptoms at once. He stresses that these illnesses cannot be understood in purely mechanical terms; they are shaped by each patient's constitution, personality, and circumstances.

Sacks arrived at Mount Carmel Hospital in New York in 1966, where about 80 post-encephalitic patients remained. Nearly half sat immersed in states of pathological "sleep," virtually speechless and motionless, requiring total nursing care. The hospital itself had deteriorated from a warm, community-oriented facility into a rigid, impersonal institution. Between 1966 and 1969, Sacks worked to form the patients into a self-governing community and to reestablish human connections. Progress was real but limited against the crushing weight of illness and decades of isolation.

In the late 1950s, researchers established that Parkinsonian brains lacked the neurotransmitter dopamine, a chemical messenger essential for normal movement. Attempts to replenish it with small doses of L-DOPA, a precursor that the brain converts into dopamine, repeatedly failed until Dr. George Cotzias reported dramatic success with massive oral doses in 1967. Sacks emphasizes the almost religious fervor that surrounded L-DOPA as a supposed miracle drug and the danger of mistaking a chemical intervention for a metaphysical cure. Cost and caution delayed its use at Mount Carmel until March 1969.

The central portion of the book presents 20 extended case histories, each tracing the arc from long illness through awakening and its aftermath. Frances D., who had maintained a career, social life, and sharp intelligence despite decades of progressive Parkinsonism, initially responded well to L-DOPA with improved voice, posture, and mobility. Within weeks, however, she developed respiratory crises, compulsive chewing, freezing episodes, and escalating distress. Attempts to find the right dose proved futile: Raising L-DOPA triggered one type of crisis; lowering it triggered another. After a catastrophic 60-hour episode combining respiratory spasm, rigid "jamming," and extremes of anguish, the drug was stopped, and she plunged into a state far worse than before. Over the following years, she achieved a hard-won accommodation on modest, intermittent doses, actively managing her symptoms through ingenious self-devised strategies and sustained by music, which could instantly dissolve her obstructive states.

Rose R., once a vivacious young woman who flew across the country, attended parties, and sketched, was struck by the sleeping sickness in 1926 at age 21. She spent the next 43 years virtually motionless at Mount Carmel, her face unlined, looking decades younger than her age. When L-DOPA awakened her in 1969, she poured out songs, jokes, and references all dating to 1926, feeling that she was still 21. She knew intellectually that it was 1969, but emotionally she inhabited her last year of real life. Within weeks, her state deteriorated into tics, blocking (a sudden inability to continue movement or speech), and total motor arrest. Subsequent trials produced diminishing returns; the extraordinary sense of inhabiting 1926 never recurred. Sacks concludes that the half-century gap between her felt age and her actual age constituted an anachronism she could not bear.

Leonard L., completely speechless and nearly motionless since his late 20s, communicated only by spelling out messages on a letter-board, yet served as the hospital librarian and wrote brilliant book reviews. He described his existence using passages from Dante, speaking of "a bottomless darkness and unreality." On L-DOPA, he experienced a total return to health: He walked, talked, and read Dante's Paradiso with tears of joy, feeling "a sense of health amounting to Grace." His abundance soon tipped into grandiosity and mania. He developed insatiable desires frustrated by institutional life, typed a 50,000-word autobiography in a final burst of coherent creation, and then fragmented into hallucinations, violent oscillations, and psychosis. After the drug was stopped, he reflected on the experience: "It was wonderful, terrible, dramatic, and comic. It is finally sad, and that's all there is to it."

Other histories illustrate the range of responses. Magda B., virtually speechless and motionless for decades, achieved one of the smoothest sustained recoveries, regaining her identity as a cultured Viennese woman and reconnecting with her family. Hester Y., frozen for over 20 years, "exploded" into activity within seconds but then oscillated between extreme states up to 200 times daily, yet maintained extraordinary equanimity. Rolando P., who had been ill since infancy, gained dramatic mobility but died after losing his mother and a beloved physiotherapist. Ida T., rigid and mute for 48 years, burst into Yiddish folk songs and was eventually reunited with a long-lost daughter. Maria G. enjoyed a single beautiful week of recovery before fragmenting into escalating furies. Rachel I., whose cognition had been further compromised by dementia, destabilized uncontrollably on L-DOPA and died weeks later.

In a concluding section titled "Perspectives," Sacks frames these experiences as a three-part sequence: Awakening, the initial return to health; Tribulation, the relapse into compounding difficulties; and Accommodation, the hard-won achievement of a livable balance. He rejects the term "side-effects" as misleading, arguing that all responses to L-DOPA form an organized whole. The tipping of well-being into excess reveals an underlying deficit; the system enters a vicious cycle of escalating excitation and catastrophic recoil, and the middle ground of normality progressively shrinks. Yet Sacks insists that patients can learn to navigate their turbulent states through rest, ingenuity, music, environmental modifications, and above all through meaningful human relationships. L-DOPA is a necessary chemical prerequisite, but it is never sufficient alone.

In an epilogue written in 1982 and a postscript from 1990, Sacks provides follow-ups on each patient. Most have died, though a significant number achieved enduring, stable awakenings. He argues for a medicine that goes beyond pharmacology, combining rational physiological treatment with an "existential" medicine that uses art, music, and human presence to call forth the patient's own latent will and autonomy. He describes how music can instantaneously normalize both the clinical state and the brain-wave patterns of deeply afflicted patients, and how the presence of another person can enable movement that no drug can achieve. Appendices discuss the history of the sleeping sickness, advances in understanding the dopamine system, the distorted perceptual "space" of Parkinsonian patients, the application of chaos theory to the unpredictable oscillations observed on long-term L-DOPA, and the various dramatic adaptations of Awakenings for stage and screen.