Andrew M.H. Alexander

“Like a jellyfish through a tea-strainer:” Oliver Sacks on being an anti-quantitative outsider

November 2024

I’ve been reading Oliver Sacks’s collected Letters. To my surprise, I’ve found unexpected resonance in how Sacks describes what it feels like to be an outsider in one’s profession, and, even more surprisingly, in the specific reasons he’s an outsider.

In the late 1960s, Sacks did the work that first brought him recognition (later described in Awakenings). In his hospital was a ward of patients who had been more-or-less comatose for decades; Sacks used a novel pharmaceutical treatment to effectively bring them back to life. Despite this medical miracle-work, “In the last 2-3 years, I have mostly experienced unwelcome, and misunderstanding, and antagonism from other neurologists, which (as you know) made me more than a little paranoid.”1. Expanding on this a few months later, he writes:

Perhaps my experience has been an atypical one; perhaps I have been provocative, or sought alienation; but the positive experience with the Listener article, like the five years of negative experience which preceded it, persuade me that it is all-but-impossible to have any real and fruitful dialogue in Medicine and medical circles (especially the barren neurological ones to which I belong), whereas there is obviously a mass of real, alive people outside Medicine who will listen to me, and with whom I can enjoy the delight (the necessity) of real converse, what (if I remember correctly) Dr. Johnson called “a streaming of mind.”2

That letter was to W.H. Auden—one of the people outside medicine who had begun to take notice of his writing. The Listener was a British general-interest newsmagazine, in which Sacks had written a popular-audience version of his experience with these patients. Writing to his brother, he describes how

… the article obviously hit the right spot in an appreciative and responsive audience; there has been a lovely public dialogue and exchange of letters, following it; and I have been enjoying a mild but definite celebrity … [it] gave me a lovely feeling of welcome and warmth and understanding and appreciation, and has shown me that in the future I can most hope to appeal to a cultivated general audience, and as for my fellow neurologists, they can go to blazes (neurology has been dead, imaginatively and fundamentally, for half a century anyhow).3

When he finally published the book-length narrative of this clinical experience, Awakenings, the response was similar. Sacks describes how he had faced

… so many years of non-recognition, rejection, getting nowhere, being nothing, etc. The sort of rejection is interesting, but perhaps not entirely surprising: I write a book about the central problems in Medicine (at least, these are as close to the book’s centre as anything could be in an essentially centreless book), and everyone seems to be fascinated by it except my own profession, my colleagues, my “set,” who have managed to cold-shoulder it (and me) entirely … 4

All of this reflectiveness comes only after his writing has started to bring him recognition outside of medicine. Earlier, he’s far less articulate about his frustrations. There are grumblings here and there about his colleagues and his boss, but that’s about it. From a letter to his parents in 1969:

[Sacks’s boss] still wants to get everyone involved with these patients—Dr. X and Dr. Y and Mr. A and Miss B—in his stupid American concept of a Big Deal and a Multidisciplinary Approach, etc. I try to ignore all this and arrogate the patients to myself. I am a superb clinical observer, and I neither want nor need anyone’s help. I find more and more that if I am to accomplish anything it is necessary to regard virtually everyone about be as either stupid or hostile obstructions to my own activities. I am not impolite, but I have to go my own way. Dependence on other people is lethal for me—for my work, for my self-image, for even the possibilities of independent existence. 5

It’s tragic to read that in comparison to what he later writes to Auden, about how he’s finally realizing there’s “a mass of real, alive people outside Medicine who will listen to me, and with whom I can enjoy the delight (the necessity) of real converse.” When he’s alienated from his colleagues, he’s convinced that he has to be a loner. Once he starts engaging with people who get what he’s doing, he realizes “the necessity of real converse.” Perhaps it’s true that to develop and maintain his method of medicine, he needed to keep himself separate from his colleagues—the isolation being both necessary and tragic.

From a letter to his dad (also a physician) in 1974:

I was also particularly pleased by that Editorial in the British Clinical Journal (do you know who the editor is, by the way?). It has been the first generous and genuine response from the profession; I wrote to tell him how grateful I was. Because there is no doubt that Awakenings has been received by my colleagues, on the whole, with a mixture of hostility, bewilderment, and mean-ness—just the mixture which has so confined me since [his then-boss] Arthur Friedman, 1967, and even years before this. It is so paradoxical that the last people to grant one a proper recognition are so often one’s colleagues and fellow-workers in a subject.6

Two years later, despite all Awakenings’ accolades, he’s still hurting. To a fellow physician, after an apparently spirited dinner party, he writes:

If I was unduly sharp or rude that evening. I apologize; and I must ask you to remember, in extenuation, that I am someone who has been silenced for the past seven years, by the pressures and powers of professional disapproval. … [lengthy apology for his style of medicine, and the copious evidence he has of its effectiveness] … I am honest, I am brilliant, I have made the best observations—and yet, damn it!—I find myself, I have found myself, these last seven years, virtually “unpublishable” in the Professional Press. By 1971, it was clear to me that almost anything I wrote would be rejected out-of-hand by most Medical Editors. In December 1970 I had found myself “attacked”—by [many colleagues]: attacked in a way which impugned my veracity and sanity. I wrote personally, and civilly, to all of these colleagues, inviting them to see me, and my patients, at “Mount Carmel”—none of them even had the courtesy to reply.

Continuing, Sacks references the editorial in the British Medical Journal that he had mentioned to his dad in that letter two years prior:

A single brave medical editor—just one!—representing (and this is significant) general practitioners and not specialists, wrote a remarkable editorial in which he spoke of “the strange mutism” of the Profession in response to a book of outstanding importance, and one which was aimed and lodged at the very Heart of Medicine. 7

That the editor used the word “mutism” was deliberate: the technical term for the coma-like state of Sacks’s patients in Awakenings was akinetic mutism.

Why was Sacks an outsider?

Professional success can breed not just admiration or imitation, but also envy. The institutional and social pressure to conform and not innovate is real and can be strong. Intellectually, I’ve known this for years; on a gut level, it’s only recently that I’ve come to feel it.

Plus, Sacks seems to have just been a weird dude.

What Sacks writes about in his letters, though, which resonates with me just as much as those first three points do, is his frustration with the culture of quantification and systematization in medicine. Patients aren’t people; they’re numbers on a chart and inputs to a treatment algorithm. In one letter to a friend, he rails against

the folly of this sort of “objective” examination which replaces human judgment by stereotyped questionnaires … In some very fundamental sense, when all the gradings and rating and testings and measurements have been done, and all the test-sheets and schedules filled up, the very flesh of the subject has escaped, like a jellyfish through a tea-strainer.8

“Like a jellyfish through a tea-strainer:” what an arresting and vivid image. It comes from his description of a visit to a neurologist colleague (and distant cousin). He likes the guy on a personal level, but his style of medicine is the opposite of Sacks’s:

I went to see Caine … whom I found to be very bright, eager, but essentially pedestrian. That’s a mean word to use after his receiving me so pleasantly, and giving me an afternoon of his time, and letting me sit in on his Parkinson clinic, and arranging a visit to Highlands for me, and showing me an advance copy of his book (which came out a few days ago). Seeing Caine, sitting through his clinic, and reading his book, were also highly significant experiences for me, for they brought into the sharpest focus the antithesis of two styles. He sat in his clinic, alert, neat, quick, with a pile of ruled test-sheets in front of him, rapidly reducing his patients to test-scores and paying (unless I do him an injustice) almost no attention to them as people: tremor 3, rigidity 2 1/2, akinesia 4, next patient please, etc. I was irresistibly reminded of Henry James’ impression of Ellis Island, of the immigrants “appealing and waiting, marshaled, herded, divided, subdivided, sorted, sifted … an intendedly ‘scientific’ feeding of the mill,” and of the folly of this sort of “objective” examination which replaced human judgment by stereotyped questionnaires … In some very fundamental sense, when all the gradings and rating and testings and measurements have been done, and all the test-sheets and schedules filled up, the very flesh of the subject has escaped, like a jellyfish through a tea-strainer. … 9

Today someone with Sacks’s or my views might call the attitude we oppose scientism. But Sacks isn’t writing today, with our culture of being “data-driven” and “evidence-based.” He’s writing in the 1960s and 1970s. I had always assumed that scientism was a novel/contemporary philisophical problem; perhaps it’s a perennial one.

“There is, these days, such a Gradgrindian insistence on definitions and enumerations and ‘facts,’” Sacks writes:

It has taken me years and years—far longer than I like to think—to learn to listen to [patients], and to try and feel my way into the nature of their experiences … one must gain impressions and stick to impressions, and not try to reduce them to formulae and facts. All patients are naturally poets: they try to express their experiences into images and metaphors, and we “experts” try to squash these back into “symptoms” and “signs.”10

“All patients are naturally poets,” and so a physician must be a poet as well:

I am sure that a wholly different mode of description can be used, must be used, in place of those horrid test-figures with their derivative graphs and statistics. The classical mode of description is narrative. I see no way of picturing the innumerable influences and factors involved except in a narrative. Can you imagine Domney or Jarndyce reduced to a few figures and diagrams? I think there is something almost inhuman about the mechanical intelligence which has taken over so much scientific and medical writing: it is reasonably enough to describe physical and chemical and simply physiological processes, but cannot possible indicate the repertoire of higher behaviour. I was reading Hard Times a couple of weeks ago and find myself thinking of Caine’s approach (which is the accredited and almost universal approach to patients, and mode of presenting data) as pure Gradgrind. You were good enough to use the word Oslerian of one of my Lancet letters: I assure you that I was not indulging in deliberate archaism, but using the only mode of presenting the data which could begin to do justice to it.11

Gradgrind is a character in Dickens’ Hard Times whose name, according to Wikipedia, “is now used generically to refer to someone who is hard and only concerned with cold facts and numbers.” Gradgrind was a teacher—now we’re vibrating Andrew’s fundamental frequencies. In a separate letter, Sacks writes:

I have been struggling for years towards a means of expression which does no violence, or not too much violence, to clinical observations; I felt strangled by the sort of “objective,” dead language usually used by neurologists, which is the only language most of us approve or allow; I felt a great need to express myself and my “data” in a wholly different way and to a wholly different audience 12

That’s from a letter to the literary critic Frank Kermode—again, one of the many prominent people whose correspondence and validation he starts to receive after the extra-professional success of Awakenings.

Awakenings launched Sacks’s literary career, won the British equivalent of a Pulitzer Prize, and was eventually made into a movie starring Robin Williams as Sacks. The movie came out in 1990—the year after Williams played another innovating iconoclast, the prep-school teacher in Dead Poets Society. Williams’s character, Mr. Keating, is loved by his students, disliked by his colleagues, and eventually fired. From the hospital where he treated the Parkinsonian patients in Awakenings, Sacks, too, was fired. He spent the rest of his career as an independent physician. For many years (as evidenced in the next decade of letters) he barely scraped by on book royalties and Medicaid reimbursements.

  1. OS to Marcus Sacks, 30 Dec 1972, pp214-16↩︎

  2. OS to W.H. Auden, 31 March 1973, pp223-4↩︎

  3. OS to Marcus Sacks, 30 Dec 1972, pp214-16↩︎

  4. OS to Thom Gunn, 13 January 1974, p255↩︎

  5. OS to Elsie and Sam Sacks, 17 May 1969, p153-4↩︎

  6. OS to Sam Sacks, 3 March 1974, p260↩︎

  7. OS to Paul S. Papavasiliou, 30 March 1976, p306↩︎

  8. OS to Paul Turner, 12 September 1970, pp182-3↩︎

  9. OS to Paul Turner, 12 September 1970, pp182-3↩︎

  10. OS to Frank Kermode, 24 November 1972, p210-11↩︎

  11. OS to Paul Turner, 12 September 1970, pp182-3↩︎

  12. OS to Frank Kermode, 24 November 1972, p210-11↩︎