A parable

Prompted by something or other I read, probably in the TLS or somewhere like that, I have been reading ‘Awakenings’ (reference 1), a big book in its time which was made into a big film. A book about Sacks’ use of a drug called L-dopa in the late 1960’s on a group of patients in a long-stay institution, mostly suffering from the long term effects of a bout of a now obscure disease called encephalitis lethargica (introduced at reference 2) – not that it was obscure at the time, that is to say following right on from the flu pandemic which started at the end of the first world war.

Towards the end, in the chapter called ‘Tribulations’, writing about the rather chaotic, bipolar consequences of taking this otherwise splendid drug, he made the striking observation that you cannot expect to control a complicated illness with one dimensional variation of a single drug. Cranking the dosage of a single wonder drug up and down, however carefully, cannot be expected to do everything. Which observation gave rise to the parable that follows.

The snap is taken from the Ordnance Survey map of a mountain – Beinn luthan Mhòr – to the north east of Blair Atholl, in the middle of the Scottish Highlands, a little to the east of where the River Tilt makes its turn to the west, and it is intended to represent a projection onto two dimensions of the state space of one of these patients.

The idea is that the more or less healthy bit of the patient’s world is represented by the more or less level space at the top of the mountain, here outlined in blue. What is left of the brain can more or less cope with the patient wobbling about inside this space, with some such wobbling suggested by the dotted black line. The normal ups and downs of daily life. But the wobbling can sometimes get too much for this brain and the patient tips off down one of the flanking slopes, down into the depths, perhaps of florid sexuality, despair or terror. From which extrication, that is to say rescue, can be difficult.

We suppose that we have four drugs working in this space: green, red, blue and brown, each pushing the patient in some direction or other. By controlling the dose one can control the speed of travel, but what one cannot do is change the direction of travel. So depending on the shape of the region of health, the patient’s state is more or less fragile. If, for example, one is in a thin bit of the region of health running north and south, and the drug of choice works east and west, things are going to be a bit tricky. I think that meta stable might be a bit of jargon which crops up in this context.

Another of Sacks’ points is that long term disease can do real damage to the brain, not easily repaired, damage which in my parable would be represented by the region of health shrinking, becoming smaller, perhaps more stretched out and fiddly, like one of those gerrymandered congressional districts in the USA. A region of health from which it is all too easy to fall – or to be pushed. With it not taking much of a push: perhaps a cross word from a fellow patient or a carer. Or not having the right sort of cake for tea. Or running out of cigarettes.

While the region of health of a healthy person is an extensive, sun-lit, upland plateau, with all the dangerous slopes a good way away. A person who has a sunny, relaxed life in consequence.

To deal with the rest of us, one needs a battery of wonder drugs, with each one covering one of the cardinal directions, and blood tests every hour, on the hour. Brain scans on Sunday mornings. Something which will perhaps be accomplished by an intelligent arm band by the time that I enter the field. I certainly hope so!

References

Reference 1: Awakenings - Oliver Sacks – 1973. Picador edition of 2012.

Reference 2: https://en.wikipedia.org/wiki/Encephalitis_lethargica. With reference 1 above being reference 6 herein.