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Logo of bmjThis ArticleThe BMJ
BMJ. 2007 June 2; 334(7604): 1169.
PMCID: PMC1885331
Medical Classic


Charlotte Allan, foundation year 1 doctor, Leeds General Infirmary

In 1969 levodopa (L-dopa) was hailed as a miracle drug that would cure parkinsonism. Sacks's book Awakenings is a series of extraordinary case reports describing how patients trapped by parkinsonism were re-awakened by levodopa after decades of stupor and inertia.

After the first world war, an epidemic of encephalitis lethargica started in Vienna and spread across the world. Many of those who survived developed a range of postencephalitic syndromes. Oliver Sacks worked at Mount Carmel, an institution outside New York, which had 80 patients with intractable, post-encephalitic parkinsonian syndrome. It affected all aspects of behaviour and trapped patients within themselves, often for decades. For patients such as Miriam H, who developed parkinsonism at the age of 12, levodopa was a miracle drug that released her from physical immobility at the age of 49.

Levodopa had dramatically different effects between patients and within the same patient. Despite being titrated slowly, the effects of levodopa were unpredictable and random. Leonard L, when started on levodopa, returned to a happiness he “had not felt for thirty years.” Yet six weeks later he developed exaggerated sensitivity to the drug and even with tiny doses had uncontrollable side effects. Even when the drug was prescribed carefully, the complexity of the brain made taking it anything but straightforward, and for some patients it was a nightmare rather than a fairytale awakening.

For many patients psychological, environmental, and emotional factors seemed to have a profound effect on the efficacy of levodopa. Miron V initially had an excellent response, but then became violently unstable. However, when he resumed work at a cobbler's workshop, his mood stabilised; he became cheerful and continued to be well while taking levodopa. Even when the responses to the drug were positive, patients were not always able to cope with the consequences. Rose R was struck by sleeping sickness at the age of 21 and awoke in 1969 to find her world of 1926 had vanished. She remained rooted in the 1920s and, as if the time gap was beyond her comprehension, stopped responding to levodopa.

Sacks talks with humanity and a deep sense of concern about all his patients. He makes clear that treating them required far more than giving them a new drug. Although levodopa was not always successful, the long term relationship Sacks had with his patients was crucial for them and their families. Awakenings is an important reminder that healing is a complex art and that the notion that one pill can cure disease remains a fantasy.

Awakenings captures readers' imagination with the fairytale notion of returning to life after decades blighted by parkinsonism. It has not only been published as a book but has also inspired a radio play, a stage play, and a film. Although there were many problems with levodopa, it leaves us wondering what seemingly impossible conditions may yet find a cure. And it inspires us to remember that despite life changing medical advances, the art of healing remains of fundamental importance.

Articles from The BMJ are provided here courtesy of BMJ Publishing Group