A Leg to Stand On

by Oliver Sacks, M. D.

  The real Reality was not such a moment, not touched in the least by ambiguity or illusion. I had, indeed, just emerged from the mist, and was walking round a boulder as big as a house, the path curving round it so that I could not see ahead, and it was this inability to see ahead which permitted the Meeting. I practically trod on what lay before me—an enormous animal sitting in the path, and indeed totally occupying the path, whose presence had been hidden by the rounded bulk of the rock. It had a huge horned head, a stupendous white body and an enormous mild milk-white face. It sat unmoved by my appearance, exceedingly calm, except that it turned its vast white face up towards me. And in that moment, in my terror, it changed, before my eyes, becoming transformed from magnificent to utterly monstrous. The huge white face seemed to swell and swell, and the great bulbous eyes became radiant with malignance. The face grew huger and huger all the time, until I thought it would blot out the universe. The bull became hideous—hideous beyond belief, hideous in strength, malevolence and cunning. It seemed now to be stamped with the infernal in every feature. It became, first a monster, and now the Devil.

  I retained my composure, or a semblance of composure, for a minute, in which, perfectly “naturally,” as if turning about at the end of a stroll, I swung in mid-stride through 180 degrees, and deftly, daintily, began my descent. But then my nerve suddenly broke, dread overwhelmed me, and I ran for dear life—ran madly, blindly, down the steep, muddy, slippery path, lost here and there in patches of mist. Blind, mad panic!—there is nothing worse in the world—nothing worse, and nothing more dangerous. I cannot say exactly what happened. In my plunging flight down the treacherous path I must have mis-stepped—stepped on to a loose rock, or into mid-air. It is as if there is a moment missing from my memory—there is “before” and “after,” but no “in-between.” One moment I was running like a madman, conscious of heavy panting and heavy thudding footsteps, unsure whether they came from the bull or from me, and the next I was lying at the bottom of a short sharp cliff of rock, with my left leg twisted grotesquely beneath me, and in my knee such a pain as I had never, ever known. To be full of strength and vigor one moment and virtually helpless the next, in the pink and pride of health one moment and a cripple the next, with all one’s powers and faculties one moment and without them the next—such a change, such suddenness, is difficult to comprehend, and the mind casts about for explanations.

  My first thought was that there had been an accident, and that someone I knew had been seriously injured. Later, it dawned on me that the someone was myself; but with this came the feeling that it was not really serious. To show that it was not serious, I got to my feet, or rather I tried to, but I collapsed in the process, because the left leg was totally limp and flail, and gave way beneath me like a piece of spaghetti. It could not support any weight at all, but just buckled beneath me, buckled backwards at the knee, making me yell with pain. But it was much less the pain that so horribly frightened me than the flimsy, toneless giving-way of the knee and my absolute impotence to prevent or control it—and the apparent paralysis of the leg. And then, the horror, so overwhelming for a moment, disappeared in face of a “professional attitude.”

  “OK, Doctor,” I said to myself, “would you kindly examine the leg?”

  Very professionally, and impersonally, and not at all tenderly, as if I were a surgeon examining “a case,” I took the leg and examined it—feeling it, moving it this way and that. I murmured my findings aloud as I did so, as if for a class of students:

  “No movement at the knee, gentlemen, no movement at the hip….You will observe that the entire quadriceps has been torn from the patella. But though it has torn loose, it has not retracted—it is wholly toneless, which might suggest nerve injury as well. The patella has lost its major attachment, and can be flipped around—so!—like a ball-bearing. It is readily dislocated—there is nothing to hold it. As for the knee itself”—and here I illustrated each point as I made it—“we find abnormal motility, a quite pathological range of motion. It can be flexed without any resistance at all”—here I manually flexed the heel to the buttock—“and can also be hyperextended, with no apparent dislocation”—both movements, which I illustrated, caused me to scream. “Yes, gentlemen,” I concluded, summarizing my findings, “a fascinating case! A complete rupture of the quadriceps tendon. Muscle paralyzed and atonic—probably nerve-injury. Unstable knee-joint—seems to dislocate backwards. Probably ripped out the cruciate ligaments. Can’t really tell about bone injury—but there could easily be one or more fractures. Considerable swelling, probably tissue and joint fluid, but tearing of blood vessels can’t be excluded.”

  I turned with a pleased smile to my invisible audience, as if awaiting a round of applause. And then, suddenly, the “professional” attitude and persona broke down, and I realized that this “fascinating case” was me—me myself, fearfully disabled, and quite likely to die. The leg was utterly useless—far more so than if it had been broken. I was entirely alone, near the top of a mountain, in a desolate and sparsely populated part of the world. My whereabouts were known to nobody. This frightened me more than anything else. I could die where I lay, and nobody would know it.

  * * *

  —

  Never had I felt so alone, so lost, so forlorn, so utterly beyond the pale of help. It hadn’t occurred to me till then how terrifyingly and seriously alone I was. I had not felt “alone” when I was romping up the mountain (I never do when I am enjoying myself). I had not felt alone when I was examining my injury (I saw now what a comfort the imagined “class” was). But now, all of a sudden, the fearful sense of my aloneness rushed in upon me. I remembered that someone had told me, a few days before, of “a fool of an Englishman” who had climbed this very mountain, alone, two years before, and had been found a week later dead from exposure, having broken both his legs. It was at an altitude, and latitude, where the temperature sinks well below freezing at night, even in August. I had to be found by nightfall or I would never survive. I had to get lower, if I possibly could, because then at least there was a chance of my being seen. I even entertained hopes, now I came to consider things, that I might be able to descend the entire mountain, with a bum leg, by myself; and it was not till much later that I realized how this, above all, was a comforting delusion. Yet, if I pulled myself together, did what I could, there was a sporting chance that I would make it yet.

  I suddenly found myself very calm and composed. First of all, I had to address myself to the leg. I had discovered that while any movement at the knee was agonizing, and indeed, literally, physiologically, shocking, I was fairly comfortable when the leg lay flat and supported on the ground. But having no bone or “inner structure” to hold it, it had no protection against helpless passive movements at the knee, as might be caused by any unevenness in the ground. So, clearly, it needed an outer structure, or splint.

  And here one of my idiosyncrasies came to my aid. Habit, more than anything else, made me carry an umbrella under all conditions, and it seemed natural enough, or purely automatic, that when I went for a walk in bad weather (even up a mountain over a mile high), I should take my stout and trusty umbrella with me. Besides, it had been useful as a walking stick on the way up. And now it found its finest moment—in splinting my leg—and without such a splint I could scarcely have moved. I snapped off the handle and tore my anorak in two. The length of the umbrella was just right—the heavy shaft almost matched the length of my leg—and I lashed it in place with strong strips of anorak, sufficiently firmly to prevent a helpless flailing of the knee, but not so tightly as to impede circulation. By now about twenty minutes had elapsed since my injury, or possibly less. Could all this have occurred in so short a time? I looked at my watch to see if it had stopped, but the second hand was going round with perfect regularity. Its time, abstract, impersonal, chronological, had no relation to my time—my time which consisted solely of personal moments, life-moments, crucial moments.
As I looked at the dial, I matched, in imagination, the movement of the hands, going steadily round and round—the relentless regularity of the sun in the heavens—with my own uncertain descent of the mountain. I could not think of hurrying—that would exhaust me. I could not think of dawdling—that would be worse. I had to find the right pace, and steadily keep it up.

  I found myself now gratefully taking note of my assets and resources, where before I could only take note of the injury. Mercifully, then, I had not torn an artery, or major vessel, internally, for there was only a little swelling round the knee and no real coolness or discoloration of the leg. The quadriceps was apparently paralyzed, it was true—but I made no further neurological examination. I had not fractured my spine or my skull in my fall. I had three good limbs, and the energy and strength to put up a good fight. And, by God, I would! This would be the fight of my life—the fight of one’s life which is the fight for life.

  I could not hurry—I could only hope. But my hopes would be extinguished if I were not found by nightfall. Again I looked at my watch, as I was to do many anxious times again in the hours that followed. At these latitudes it would be a rather lengthy evening and dusk, starting around 6 and gradually getting darker and cooler. By 7:30 it would be quite cool, and difficult to see. I had to be found by about 8, at the latest. By 8:30 it would be pitch-black—impossible to see and impossible to proceed. And though by strenuous exercise I might, just conceivably, last through the night, the chances were distinctly, indeed heavily, against it. I thought, for a moment, of Tolstoy’s “Master and Man”—but there were not two of us to keep each other warm. If only I had had a companion with me! The thought suddenly came to me once again, in the words from the Bible not read since childhood, and not consciously recollected, or brought to mind, at all: “Two are better than one…for if they fall, the one will lift up his fellow; but woe to him that is alone when he falleth, for he hath not another to help him up.” And, following immediately upon this, came a sudden memory, eidetically clear, of a small animal I had seen in the road, with a broken back, hoisting its paralyzed hindlegs along. Now I felt exactly like that creature. The sense of my humanity as something apart, something above animality and mortality—this too disappeared at that moment, and again the words of Ecclesiastes came to my mind: “For that which befalleth the sons of men befalleth beasts; as the one dieth, so dieth the other…so that a man hath no pre-eminence above a beast.”

  While splinting my leg, and keeping myself busy, I had again “forgotten” that death lay in wait. Now, once again, it took the Preacher to remind me. “But,” I cried inside myself, “the instinct of life is strong within me. I want to live—and, with luck, I may still do so. I don’t think it is yet my time to die.” Again the Preacher answered, neutral, non-committal: “To everything there is a season, and a time to every purpose under the heaven. A time to be born, and a time to die; a time…” This strange, profound emotionless clarity, neither cold, nor warm, neither severe nor indulgent, but utterly, beautifully, terribly truthful, I had encountered in others, especially in patients, who were facing death and did not conceal the truth from themselves; I had marvelled, though in a way uncomprehendingly, at the simple ending of Tolstoy’s “Hadji Murad”—how, when Hadji has been fatally shot, “images without feelings” stream through his mind; but now, for the first time, I encountered this—in myself.

  These images, and words, and passionless feelings did not, as they say, go through my head “in a flash.” They took their time—several minutes at least—the time they would have taken in reality, not in a dream; they were meditations, which did not hurry at all—but neither did they distract me in the least from my tasks. Nobody looking on (so to speak) would have seen me “musing,” would have seen any pause. On the contrary, they would have been impressed by my brisk and workmanlike appearance and behavior, by the quick and efficient way in which I splinted my leg, made a brief check of everything, and set off downhill.

  And so I proceeded, using a mode of travel I had never used before—roughly speaking, gluteal and tripedal. That is to say, I slid down on my backside, heaving or rowing myself with my arms and using my good leg for steering and, when needed, for braking, with the splinted, flail leg hanging nervelessly before me. I did not have to think out this unusual, unprecedented, and—one might think—unnatural way of moving. I did it without thinking, and very soon got accustomed to it. And anyone seeing me rowing swiftly and powerfully down the slopes would have said, “Ah, he’s an old hand at it. It’s second nature to him.”

  So the legless don’t need to be taught to use crutches: it comes “unthinkingly” and “naturally,” as if the person had been practicing it, in secret, all his life. The organism, the nervous system, has an immense repertoire of “trick movements” and “back-ups” of every kind—completely automatic strategies, which are held “in reserve.” We would have no idea of the resources which exist in potentia, if we did not see them called forth as needed.

  So it happened with me. It was a reasonably efficient mode of progress, as long as the path descended continually, and evenly, and not too steeply. If it was not even, the left leg would tend to catch on irregularities of all sorts—it seemed curiously inept at avoiding these—and I cursed it out several times for being “stupid” or “senseless.” I found, indeed, that whenever the terrain became difficult, I had to keep an eye on this not only powerless but stupid leg. Most frightening of all were those sections of the path which were too slippery or too steep, because it was difficult not to slide down almost uncontrollably, ending with a lurch or a crash which agonizingly buckled the knee and exposed the limitations of my improvised splint.

  It occurred to me at one point, after a particularly sickening crash, to cry for help, and I did so, lustily, with huge yells, which seemed to echo and resound from one peak to another. The sudden sound in the silence startled and scared me; and then I had a sudden fear that it might startle the bull, which I had completely forgotten. I had a frightened vision of the animal, now furiously re-aroused, charging down the path to toss me or crush me. Trembling with terror, and with immense effort and pain, I managed to heave myself off the path until I was hidden behind a boulder. Here I remained for about ten minutes, until the continuing silence reassured me and I was able to crawl out and continue my descent. I could not decide whether it had been foolish and provocative to yell, or whether my folly lay rather in fearing to yell. I decided, in any event, not to yell again; and whenever the impulse seized me I held my tongue, remembering that I was still in the bull’s domain, where perhaps he maintained a sharp-eared dominion; and I would further say to myself, for good measure, “Why shout? Save your breath. You’re the only human being in hundreds of square miles.” And so I descended in absolute silence, not even daring to whistle aloud for everywhere now I felt the bull listening. I even tried to mute the sound of my breathing. And so the hours passed, silently, slithering….

  At about 1:30—I had been travelling two hours—I came again to the swollen stream with stepping-stones that I had hesitated to cross even when climbing up, with both legs. Clearly, I could not “row” myself through this. I had therefore to turn over and “walk” on rigidly outstretched arms—and even so my head was only just out of the water. The water was fast-flowing, turbulent and glacially cold, and my left leg, dropping downwards, unsupported, out of control, was violently jarred by stones on the bottom, and sometimes blown like a flag sideways at a right-angle to my trunk. My hip seemed almost as loose as my knee, but it caused me no pain—unlike my knee which, excruciatingly, was buckled and dislocated as I crossed the stream. Several times I felt my consciousness ebbing and feared I would faint and drown in the stream; and I ordered myself to hold on, with strong language and threats.

  “Hold on, you fool! Hold on for dear life! I’ll kill you if you let go—and don’t you forget it!”

  I half collapsed when finally I made the other side, shudde
ring with cold, and pain and shock. I felt exhausted, prostrated, at the end of my strength, and I lay stunned, motionless, for a couple of minutes. Then, somehow my exhaustion became a sort of tiredness, an extraordinarily comfortable, delicious languor.

  “How nice it is here,” I thought to myself. “Why not a little rest—a nap maybe?”