A Leg to Stand On
Page 1
Oliver Sacks
A LEG TO STAND ON
Dr. Oliver Sacks spent more than fifty years working as a neurologist and writing books about the neurological predicaments and conditions of his patients, including The Man Who Mistook His Wife for a Hat, Musicophilia, and Awakenings. The New York Times referred to him as “the poet laureate of medicine,” and over the years, he received many awards, including honors from the Guggenheim Foundation, the National Science Foundation, the American Academy of Arts and Letters, the American Academy of Arts and Sciences, and the Royal College of Physicians. His memoir On the Move was published shortly before his death in August 2015.
www.oliversacks.com
ALSO BY OLIVER SACKS
Migraine
Awakenings
The Man Who Mistook His Wife for a Hat
Seeing Voices
An Anthropologist on Mars
The Island of the Colorblind
Uncle Tungsten
Oaxaca Journal
Musicophilia
The Mind’s Eye
Hallucinations
On the Move
Gratitude
The River of Consciousness
Everything in Its Place
FIRST VINTAGE BOOKS EDITION, SEPTEMBER 2020
Copyright © 1984 by Oliver Sacks
Afterword copyright © 1993 by Oliver Sacks
Foreword copyright © 2020 by Kate Edgar
All rights reserved. Published in the United States by Vintage Books, a division of Penguin Random House LLC, New York. Originally published in hardcover in the United States by Summit Books, a division of Simon & Schuster, Inc., New York, in 1984, and subsequently published by HarperPerennial, a division of HarperCollins Publishers, New York, in 1993.
Vintage and colophon are registered trademarks of Penguin Random House LLC.
The Library of Congress has cataloged the Summit Books edition as follows:
Name: Sacks, Oliver, 1933–2015.
Title: A leg to stand on / Oliver Sacks.
Description: New York : Summit Books, c1984.
Identifier: LCCN 84008497
Subjects: LCSH: Sacks, Oliver, 1933–2015. | Neurologists—England—Biography. | People with disabilities—England—Biography.
Classification: LCC RC339.52.S23 A35 1984 | DDC 362.4/3/0924 B
LC record available at https://lccn.loc.gov/84008497
Vintage Books Trade Paperback ISBN 9780593311004
Ebook ISBN 9780593311011
Cover design by Linda Huang
Cover illustration: leg © Aaltazar/Getty Images
www.vintagebooks.com
ep_prh_5.6.0_c0_r0
To the memory of A. R. Luria
Contents
Foreword by Kate Edgar
Preface
Acknowledgements
ONE The Mountain
TWO Becoming a Patient
THREE Limbo
FOUR Quickening
FIVE Solvitur Ambulando
SIX Convalescence
SEVEN Understanding
Afterword (1993)
Annotated Bibliography
Foreword
by Kate Edgar
When I first began working with Oliver Sacks, in 1982, it was to help him put the finishing touches on “the Leg book,” as he often called it. I was a young editor, freelancing, and his publisher had sent me a manuscript for part of the book. It was covered with crossings-out and densely packed handwriting which was nearly indecipherable. On top of that, the pages were sometimes blotchy, as if they had been caught in the rain. It was not until I got to know Oliver better that I found out why. He adored swimming, he told me, and on summer weekends, he often rented a tiny room near a lake in the Catskills. Swimming helped him shape the flow of ideas, and he would keep a pen and a sheaf of paper by the edge of the lake so that, if a paragraph suddenly came to him while he was in the water, he could rush out, dripping, to write it down.
Oliver, clearly, was unlike anyone I had ever met, in many ways, and this book was my immersion into his world.
* * *
—
With his first two books, Migraine and Awakenings, he had begun to develop what he called case histories, or clinical tales. Deeply influenced by the nineteenth-century neurologists (whom he talked about and quoted almost as if they were personal friends), his case histories were novelistically rich, compassionate, and not without a sympathetic humor. These portraits were profoundly insightful and humane, never losing sight of the person, the individual, behind the “syndrome.”
A Leg to Stand On, his third book, is also a case history, but his own case history, following a serious injury which nearly cost him his life. Here he meditates on the meaning of illness and recovery, and on the complexities of the doctor-patient relationship. He, the physician, is now the patient, and he chronicles this in exquisitely evocative, intimate, moment-by-moment detail—including the frustration and sometimes despair of not being believed by his own doctors.
Much more than any of his other books, perhaps, Leg reveals Oliver as a poet and philosopher, no less than a physician. He invokes philosophers from Arendt and Nietzsche to Kant to interrogate the existential problems of nothingness, and one can feel, too, how deeply he has imbibed the poetry of John Donne, T. S. Eliot, and the Psalms. The language he uses in Leg is lush, sometimes eccentric, but always highly original. Like Sir Thomas Browne, he pushes the English language to its extreme, drawing upon obscure words, or making up his own phrases when he needs to (“kipperish euphoria,” for instance, to describe the aftermath of a particularly delectable breakfast). He loves to play with repetitions and permutations; one can almost hear the OED entries echoing in his mind. Sometimes he calls upon a soaring, rhythmic poetry that almost demands to be put into stanzas, like this opening sentence of the “Quickening” chapter:
Throughout these twelve, endless yet empty days the leg itself had not changed a jot; it remained entirely motionless, toneless, senseless, beneath its white sepulchre of chalk.
His rendering of scenes and dialogue in the hospital is often wryly comic, bringing to mind other literary heroes of his, like Dickens, Chekhov, or Conan Doyle. He even slips in a little reference to his beloved Star Trek, by naming one of the nurses after George Takei’s character, Sulu.
Oliver’s fondness for Star Trek went hand in hand with his love of H. G. Wells and many other science fiction writers, as well as his admiration for the travel narratives of the great nineteenth-century explorers and naturalists like Darwin, Humboldt, and Wallace. He felt that the best neurologists, too, were natural historians and describers, and, in the chapter called “Limbo,” he writes:
I had explored many strange, neuropsychological lands—the furthest Arctics and Tropics of neurological disorder. But now I decided—or was I forced?—to explore a chartless land. The land which faced me was No-land, Nowhere.
Exploring this abyss of nothingness and the travails of patienthood, and eventually returning to health and understanding, Oliver emerges newly grounded, more deeply comprehending of his own patients. This is evident in the essays that came together in The Man Who Mistook His Wife for a Hat—essays that he had begun to publish during the years in which he was writing A Leg to Stand On. As he writes in the final chapter, “Understanding,”
I could now open myself fully to the experiences of my patients, enter imaginatively into their experiences and be accessible and “hospitable” in these regions of dread. I would listen to patients as never before—to their stammered half
-articulate communications as they journeyed through a region I knew so well myself.
Even thirty-five years later, Leg still has a feeling of urgency to it, especially as it lays the groundwork for a neurology which can do justice to “the richness and density of experience,…its personeity, its ever-changing flow of experience, of history, of becoming.”
Preface
Thom Gunn has written powerfully of the “occasions” of poetry. Science has its occasions no less than art: sometimes a dream-metaphor, like Kekulé’s snakes; sometimes an analogy, like Newton’s apple; sometimes a literal event, the thing-in-itself, which suddenly explodes into unimagined significance, like Archimedes’s “Eureka!” in his bath. Every such occasion is a eureka or epiphany.
The occasions of medicine are provided by sickness, injury, patients. The occasion of this book was a peculiar injury, or at least an injury with peculiar effects, resulting from an accident on a mountain in Norway. A physician by profession, I had never found myself a patient before, and now I was at once physician and patient. I had imagined my injury (a severe but uncomplicated wound to the muscles and nerves of one leg) to be straightforward and routine, and I was astonished at the profundity of the effects it had: a sort of paralysis and alienation of the leg, reducing it to an “object” which seemed unrelated to me; an abyss of bizarre, and even terrifying, effects. I had no idea what to make of these effects and entertained fears that I might never recover. I found the abyss a horror, and recovery a wonder; and I have since had a deeper sense of the horror and wonder which lurk behind life and which are concealed, as it were, behind the usual surface of health.
Deeply disturbed and puzzled by these singular effects—the central resonances, so to speak, of a peripheral injury—and the absence of adequate reassurance from my own doctor, I wrote to the eminent neuropsychologist A. R. Luria in Moscow. In the course of his reply he wrote: “Such syndromes are perhaps common, but very uncommonly described.” When I recovered from my injury and returned to being a doctor, I found that this was indeed the case. Over the years I investigated some hundreds of patients, all with singular disorders of body-image and body-ego which were neurologically determined and essentially similar to my own. I discuss this work and its implications in outline in the last chapter of this book.
Thus many themes are interwoven here: the specific neuropsychological and existential phenomena associated with my injury and recovery; the business of being a patient and of returning later to the outside world; the complexities of the doctor-patient relationship and the difficulties of dialogue between them, especially in a matter which is puzzling to both; the application of my findings to a large group of patients, and the pondering of their implication and meaning—all this leading, finally, to a critique of current neurological medicine, and to a vision of what may be the neurological medicine of the future.
This last did not come till several years later. Its occasion was a long train-ride from Boston to New York, when I read Henry Head’s great Studies in Neurology (1920): his journey so similar to my own, from the examination of the effects of a cut nerve in himself to the most general concepts of body-image and body-music. My final chapter was written on a mountain in Costa Rica, completing the odyssey begun on that fateful mountain in Norway.
Except in the last chapter the material is not presented systematically. The book may be regarded as a sort of neurological novel or short story, but one which is rooted in personal experience and neurological fact, such as Luria has given us in The Man with a Shattered World, and his other “neurographies.”
In all this I was greatly assisted and encouraged by Luria, with whom I had the privilege of an intimate correspondence from 1973 until his death in 1977. In the course of our correspondence he wrote: “You are discovering an entirely new field….Please publish your observations. It may do something to alter the ‘veterinary’ approach to peripheral disorders, and to open the way to a deeper and more human medicine.” To the late A. R. Luria, the pioneer of a new and deeper medicine, I dedicate this book in grateful memory.
O.W.S.
London & New York
September 1983
Postscript, September 1993
There are occasions of seeing for the first time, of revelation, of insight, and occasions of seeing again, of resonance and of recollection. This whole, sometimes traumatic, experience of 1974 was “locked up” for me until an incident which occurred five years later, when I was holidaying in the northern island of Manitoulin. Here, one day, I saw a monstrous sow—the famous giant sow of Manitoulin—resting in a field with a new litter of piglets. Fascinated, perhaps provocatively, I called to the sow, shouted at her as she was feeding her young. With an alacrity terrifying in so vast an animal, she jumped to her feet and charged towards me. Her huge sow face seemed to me, in my panic, as she got closer, to grow huger and huger, finally to occupy the entire universe. This terrifying, quasi-hallucinatory enlargement brought back to me my meeting with the bull in Norway. I returned to my cabin and wrote a short piece, “The Sow,” and then, without lifting my pen from the paper, immediately went on to write “The Bull on the Mountain” (as the first chapter of this book, when published separately, was called). From here I went on to complete the book. If a bull was the occasion of my accident, the entire experience—a sow was thus the occasion of its recollection, this book.
In this edition I have revised the text slightly, making some additions to it, adding a few footnotes. The largest change has been restoring the original (U.K.) version of the last chapter (“Understanding”) in place of the version in previous American editions, “The Long Road.” The most substantial addition is a new afterword, in which I attempt to comprehend the entire experience in terms of some new and exciting concepts of brain and mind. I have, finally, added a short annotated bibliography, which includes a bibliographic history of this book.
O.W.S.
Acknowledgements
I am profoundly grateful to the physicians, physiotherapists, nurses and others who did so much to care for me when I was an “impossible” patient. I am also grateful to Dr. Henry Fleck, who later performed electrical studies on my own damaged leg. I further want to thank a series of editors—Mary-Kay Wilmers, Robert Silvers, Ileene Smith, Kate Edgar, Jim Silberman and, above all, Colin Haycraft—for their assistance in the making of this book (a particularly difficult editorial task, because the original manuscript was 300,000 words long). It has been a special pleasure being able, almost twenty years later, to return to some of the puzzles raised by the original experience in 1974, with a sense that they could now be “solved.” I owe a great debt to Israel Rosenfield for his stimulating discussion of issues raised in my 1993 afterword, and for freely sharing his ideas with me. And a unique debt to Jonathan Miller, for suggesting the title A Leg to Stand On.
Medicine always claims that experience is the test of its operations. Plato therefore was right in saying that to become a true doctor, a man must have experienced all the illnesses he hopes to cure and all the accidents and circumstances he is to diagnose….Such a man I would trust. For the rest guide us like the person who paints seas, rocks and harbors while sitting at his table and sails his model of a ship in perfect safety. Throw him into the real thing, and he does not know where to begin.
—MICHEL DE MONTAIGNE, Essays 3.13
CHAPTER ONE
The Mountain
This world of limitless silences had nothing hospitable; it received the visitor at his own risk, or rather it scarcely even received him, it tolerated his penetration into its fastnesses in a manner that boded no good: it made him aware of the menace of the elemental, a menace not even hostile, but impersonally deadly.
—THOMAS MANN, The Magic Mountain
Saturday the 24th started overcast and sullen, but there was promise of fine weather later in the day. I could start my climb early, through the low-lying orchards and woods, and
by noon, I reckoned, reach the top of the mountain. By then, perhaps, the weather would have cleared, and there would be a magnificent view from the summit—the lower mountains all around me, sweeping down into Hardanger fjørd, and the great fjørd itself visible in its entirety. “Climb” suggests scaling rocks, and ropes. But it was not that sort of climb, simply a steep mountain path. I foresaw no particular problems or difficulties. I looked forward to the walk with assurance and pleasure.
I soon got into my stride—a supple swinging stride, which covers ground fast. I had started before dawn, and by half past seven had ascended, perhaps, to 2,000 feet. Already the early mists were beginning to clear. Now came a dark and piney wood, where the going was slower, partly because of knotted roots in the path and partly because I was enchanted by the world of tiny vegetation which sheltered in the wood, and was always stopping to examine a new fern, a moss, a lichen. Even so, I was through the woods by a little after nine, and had come to the great cone which formed the mountain proper and towered above the fjørd to 6,000 feet. To my surprise there was a fence and a gate at this point, and the gate bore a still more surprising notice:
BEWARE OF THE BULL!
in Norwegian, and for those who might not be able to read the words, a rather droll picture of a man being tossed.
I stopped, and scrutinized the picture and scratched my head. A bull? Up here? What would a bull be doing up here? I had not even seen sheep in the pastures and farms down below. Perhaps it was some sort of joke, tacked there by the villagers, or by some previous hiker with an odd sense of humor. Or perhaps there was a bull, summering amid a vast mountain pasture, subsisting on the spare grass and scrubby vegetation. Well, enough of speculation. Onwards to the top. The terrain had changed again. It was now very stoney, with enormous boulders here and there; but there was also a light topsoil, muddy in places because it had rained in the night, but with plenty of grass and a few scanty shrubs—fodder enough for an animal which had the whole mountain to graze. The path was much steeper and pretty well marked though, I felt, not much used. It was not exactly a populous part of the world. I had seen no visitors apart from myself, and the villagers, I imagined, were too busy with farming and fishing, and other activities, to go jaunting up the local mountains. All the better. I had the mountain to myself! Onwards, upwards—though I could not see the top, but I had already ascended, I judged, 3,000 feet, and if the path ahead was simply steep, but not tricky, I could make the top by noon, as I had planned. And so I forged ahead, keeping up a brisk pace despite the gradient, blessing my energy and stamina, and especially my strong legs, trained by years of hard exercise and hard lifting in the gym. Around eleven o’clock, when the shifting mists allowed, I had my first glimpses of the mountain top—not so far above me—I would make it by noon. There was still a light mist clinging here and there, sometimes shrouding the boulders so that they were difficult to make out. Occasionally a boulder, half seen through the mist, looked almost like a vast crouching animal, and would only reveal its true nature when I came closer. There were ambiguous moments when I would stop in uncertainty, while I descried the shrouded shapes before me….But when it happened, it was not at all ambiguous!