A Leg to Stand On

by Oliver Sacks, M. D.

  After my temperature had been taken, I was carted off to have the leg X-rayed.

  All went smoothly until the technician, unthinkingly, lifted up the leg by the ankle. The knee buckled backwards and instantly dislocated, and I am afraid I let out an involuntary howl. Seeing what had happened, she immediately put a hand under the knee to support it, and very gently, tenderly, lowered it to the table.

  “I am so sorry,” she said. “I didn’t realize at all.”

  “That’s fine,” I said. “No harm has been done. It was a complete accident. With Nurse Solveig it’s deliberate.”

  I waited on the stretcher while the doctor was checking my X-rays. She was a local G.P., a nice motherly woman, who was covering the hospital that night for emergency call. No fractures of the long bones, she said—one couldn’t really examine or X-ray the knee. She’d never seen such an injury before, but thought it was probably no more than a torn quad, though this could only be determined at surgery. It was quite a big operation, she said—“but straightforward,” she added at once, with a smile, seeing my obvious fear. I might be laid up as much as three months. “Probably less, but you should be prepared.” I would be wisest to get it done in London, she said. The Red Cross would arrange transport to Bergen—a pretty road if one was in the mood—and there were lots of planes from Bergen to London….

  I phoned my brother, a doctor in London. He sounded concerned, but I quickly reassured him. He told me he would arrange everything, and not to worry.

  But worry one does, and as I lay there in my hospital bed at Odda—I had been returned to bed after seeing the doctor—with the breathless, coughing young man to one side and a poor old fellow, a moribundus, with an IV, on the other, I felt miserably anxious. I tried to sleep—they had given me a sedative—but it was difficult to get my mind off the leg, especially since the least movement of the knee caused sudden intense pain. I had to hold myself almost motionless, which did not conduce to sleep.

  As soon as I began to drop off and, relaxing, moved involuntarily, I would be jerked awake by sudden violent pain in my knee. The good doctor was consulted, and she advised that a temporary cast be put on, to immobilize the knee.

  Back in bed, with my new cast, I fell instantly asleep, with my glasses on my face—for they were still there when I was woken at six from a dream that the entire leg was being squeezed in a vise. I woke to find that the leg was indeed being squeezed, though not by a vise. It had swollen up enormously—what I could see of it put me in mind of a vegetable marrow—and was obviously being constricted by the cast. The foot was very swollen, and cool from edema.

  They incised the cast along its entire length on one side, and with the relief of pressure and pain I immediately fell asleep again, and slept soundly and well until a most amazing apparition entered the room, so that I rubbed my eyes thinking I was still dreaming. A young man—dressed, preposterously, in a white coat, for some reason—came in dancing, very lightly and nimbly, and then pranced round the room and stopped before me, flexing and extending each leg to its maximum like a ballet dancer. Suddenly, startlingly, he leapt on top of my bedside table, and gave me a teasing elfin smile. Then he jumped down again, took my hands and wordlessly pressed them against the front of his thighs. There, on either side, I felt a neat scar.

  “Feel, yes?” he asked. “Me too. Both sides. Skiing…See!” And he made another Nijinski-like leap.

  Of all the doctors I had ever seen, or was later to see, the image of this young Norwegian surgeon remains most vividly and affectionately in my mind, because in his own person he stood for health, valor, humor—and a most wonderful, active empathy for patients. He didn’t talk like a textbook. He scarcely talked at all—he acted. He leapt and danced and showed me his wounds, showing me at the same time his perfect recovery. His visit made me feel immeasurably better.

  The ride to Bergen—six hours in the ambulance over mountain roads—was more than pretty. It was like a resurrection. Perched high on my stretcher, at the back of the ambulance, I feasted my eyes on the world I had so nearly lost. Never had it seemed so lovely, or so new.

  Getting into the plane at Bergen was a nerve-racking experience. They weren’t equipped to take a stretcher, so I had to be hoisted up the gangway and deposited obliquely across two first-class seats. I felt, for the first time, somehow peevish and fretful, with a sort of irritable-anxious restlessness which I was hard put to control.

  The captain, a big burly man, like an old buccaneer, was sensible and kind.

  “No use fretting, son,” he said, putting a huge hand on my shoulder. “First thing about being a patient—you have to learn patience!”

  * * *

  —

  As I was taken in the ambulance from London airport, to the great hospital where I was to be operated on the next day, my good humor and sanity began to leave me, and in their place came a most terrible dread. I cannot call it the dread of death, though doubtless that was contained in it. It was rather a dread of something dark and nameless and secret—a nightmarish feeling, uncanny and ominous, such as I had not experienced on the mountain at all. Then, on the whole, I had faced what reality had in store, but now I felt distortion rising, taking over. I saw it, I felt it, and I felt powerless to combat it. It would not go away, and the most I could do was to sit tight and hold fast, murmuring a litany of reassurance and commonsense to myself. That journey in the ambulance was a bad trip, in all ways—and behind the dread (which I could not vanquish as its creator), I felt delirium rocking my mind—such a delirium as I used to know, all too well, as a child, whenever I was feverish or had one of my migraines. My brother, who was riding with me, observed some of this, and said:

  “Easy now, Ollie, it won’t be so bad. But you do look dead white, and clammy and ill. I think you’ve a fever, and you look toxic and shocked. Try and rest. Keep calm. Nothing terrible will happen.”

  Yes, indeed I had a fever. I felt myself burning and freezing. Obsessive fears gnawed at my mind. My perceptions were unstable. Things seemed to change—to lose their reality and become, in Rilke’s phrase, “things made of fear.” The hospital, a prosaic Victorian building, looked for a moment like the Tower of London. The wheeled stretcher I was placed on made me think of a tumbril, and the tiny room I was given, with its window blocked out (it had been improvised at the last minute, all the wards and side-wards being taken), put me in mind of the notorious torture chamber, “Little Ease,” in the Tower. Later, I was to become very fond of my tiny womb-like room, and because it was windowless, I christened it “The Monad.” But on that ghastly, ominous evening of the 25th, seized by fever and fantastical neurosis, shaking with secret dread, I perceived everything amiss and could do nothing about it.

  “Execution tomorrow,” said the clerk in Admissions.

  I knew it must have been “Operation tomorrow,” but the feeling of execution overwhelmed what he said. And if my room was “Little Ease,” it was also the Condemned Cell. I could see in my mind, with hallucinatory vividness, the famous engraving of Fagin in his cell. My gallows-humor consoled me and undid me and got me through the other grotesqueries of admission. (It was only up on the ward that humanity broke in.) And to these grotesque fantasies were added the realities of admission, the systematic depersonalization which goes with becoming-a-patient. One’s own clothes are replaced by an anonymous white nightgown, one’s wrist is clasped by an identification bracelet with a number. One becomes subject to institutional rules and regulations. One is no longer a free agent; one no longer has rights; one is no longer in the world at large. It is strictly analogous to becoming a prisoner, and humiliatingly reminiscent of one’s first day at school. One is no longer a person—one is now an inmate. One understands that this is protective, but it is quite dreadful too. And I was seized, overwhelmed, by this dread, this elemental sense and dread of degradation, throughout the dragged-out formalities of admission, until—suddenly, wond
erfully—humanity broke in, in the first lovely moment I was addressed as myself, and not merely as an “admission” or thing.

  Suddenly into my condemned cell a nice jolly staff nurse, with a Lancashire accent, burst in, a person, a woman, sympathetic—and comic. She was “tickled pink,” as she put it, when she unpacked my rucksack and found fifty books and a virtual absence of clothes.

  “Oh, Dr. Sacks, you’re potty!” she said, and burst into jolly laughter.

  And then I laughed too. And in that healthy laughter the tension broke and the devils disappeared.

  As soon as I was settled in, I was visited by the Surgical Houseman and Registrar.*1 There were some difficulties about “the history,” because they wanted to know the “salient facts,” and I wanted to tell them everything—the entire story. Besides, I wasn’t quite certain what might or might not be “salient” in the circumstances.

  They examined me as best they could with a cast. It seemed to be no more than an avulsed quadriceps tendon, they said, but complete examination would only be possible under general anesthesia.

  “Why general?” I asked. “Couldn’t it be done under spinal?”

  For then I could see what was happening. They said, no, general anesthesia was the rule in such cases, and besides (they smiled) the surgeons wouldn’t want me talking or asking questions all through the operation!

  I wanted to pursue the point, but there was something in their tone and manner that made me desist. I felt curiously helpless, as with Nurse Solveig in Odda, and I thought: “Is this what being a patient means? Well, I have been a doctor for fifteen years. Now I will see what it means to be a patient.”

  I was exaggeratedly upset. As soon as I thought about it, I recognized it readily. They hadn’t meant to sound inflexible or peremptory. They seemed pleasant enough, in an impersonal way: doubtless they lacked authority in the matter; I would do best to ask my surgeon in the morning. They had said that my operation was scheduled for 9:30, and that the surgeon—a Mr. Swan—would look in to see me first for a chat.

  I thought, “Damn it, I hate the idea of being put under, and relinquishing consciousness and control.” Besides, more important, my entire life had been directed towards awareness and observation—was I to be denied the opportunity of observation now?

  I phoned up my family and friends, to let them know what had happened, and was happening, and to say that if I should, by malchance, die on the table, I wished and willed them to make suitable extracts from my notebooks and other unpublished writings, and publish these as they thought fit.

  After phoning them, I felt I should make it more formal, and so I wrote everything out in legal-sounding language, dated it, and asked two nurses to witness my signature. Feeling that I had “taken care” of everything—or everything it was in my power to take care of—I had no difficulty falling asleep; and I slept well and deeply until a little after five, when I woke with a foul dry mouth, feeling a bit feverish, and with a throbbing in my knee. I asked for some water, but was told “NPO”—nothing by mouth the day of operation.

  I waited eagerly for Swan to come. Six o’clock, seven o’clock, eight o’clock…Wasn’t he coming, I asked Sister, a formidable-looking woman in severe dark blue (the jolly staff nurse of the night before had been in a striped uniform).

  “Mr. Swan will come when he pleases,” she said tartly.

  At 8:30 a nurse came in to give me my premeds. I said I needed to speak to the surgeon about spinals. No problem, she said: one got the same premeds for a general and a spinal.

  I wanted to say that I might be muzzy from the premeds and unable to think clearly when Mr. Swan came. She said not to worry, he’d be here any moment, before the premeds had time to act. I let the matter rest—I took it.

  Very soon I had a dry mouth, and phosphenes—spots and flashes in front of the eyes—and something of a dreamy-silly feeling. I rang for the staff nurse. It was 8:45—I hadn’t taken my eyes off the watch since the injection—and I asked what I had been given. The usual, she said—phenergan and hyoscine, such as they use for “twilight sleep.” I groaned inwardly—I would be unmanned, softened up by medication.

  Mr. Swan made his appearance at 8:53 and found me gazing at my watch. I had a momentary impression of a very shy man, but this was instantly effaced by his brisk, hearty voice.

  “Well,” he said loudly. “How are we doing today?”

  “Bearing up,” I replied, and my voice sounded muzzy.

  “Nothing to worry about,” he continued briskly. “You’ve torn a tendon. We reconnect it. Restore continuity. That’s all there is to it…nothing at all!”

  “But…” I said slowly—but he had already gone from the room.

  With a great effort, because I felt dragged down and somehow lazy from the premeds, I rang the bell and asked for Sister.

  “What is it?” she said. “Why have you called me?”

  “Mr. Swan,” I said enunciating my words carefully. “He didn’t stay very long. He was just in and out. He seemed to be in an awful hurry.”

  “Well, I never,” Sister huffed. “He’s a very busy man. You’re lucky he looked in at all.”

  A last memory—before going under…The anesthetist had asked me to count aloud, while he injected Pentothal intravenously. I watched, curiously emotionless, as he entered the vein, drew up some blood to make sure and slowly injected. I noticed nothing—no reaction whatever. When I got to nine, some impulse made me glance at the clock. I wanted to catch my last moment of consciousness and, perhaps, by concentrating, hold on to it. As soon as I looked, I saw something was amiss.

  “The second hand,” I said, drunkenly clearly. “Has it actually stopped, or is it an illusion?”

  The anesthetist glanced up, and said, “Yes, it’s stopped. Must be stuck.”

  And with this I lost consciousness, for I remember no more.

  * * *

  —

  My next memory, or first memory on coming round, does not quite deserve the word “next.” I was lying in bed and had the impression that someone was shaking me or calling my name. I opened my eyes and found the Houseman leaning over me.

  “How do you feel?” he said.

  “How do I feel?” I replied, in a voice so coarse and violent I scarcely recognized it as my own. “I’ll tell you how I feel! I feel fucking awful! What the hell’s going on? A few minutes ago my knee felt fine, and now it feels like hell—fucking hell!”

  “That wasn’t a few minutes ago, Dr. Sacks,” he replied. “That was seven hours ago. You’ve had an operation, you know.”

  “Good God!” I said, stunned. It hadn’t occurred to me that I had had, or might have had, an operation. There was no sense whatever of any “nextness” or “in-between”—that time had passed, or that anything had “happened.”

  “Well, well,” I said, sobered. “How did it go?”

  “Fine,” he said blandly. “No problems at all.”

  “And the knee,” I went on. “Was that thoroughly explored?”

  He hesitated, or seemed to hesitate, a bit. “Don’t worry,” he said, finally. “The knee should be fine. We didn’t go into it. We felt it was OK.”

  I wasn’t entirely reassured by what he said, or by his tone when saying it, and my last thought, before sinking into the depths again, was that they might have overlooked some quite crucial injury to the knee, and that maybe I wasn’t in quite trustworthy hands.

  Apart from the conversation with the Houseman, which I remembered precisely, and have recorded practically verbatim, I have almost no coherent memories of the 48 hours following the operation. I was quite feverish, shocked, and toxic, and there was intense pain in my knee. I was given doses of morphine every three hours. I had periods of delirium, of which I remember nothing. I felt horribly sick and intensely thirsty, but was only allowed rare sips of water. I couldn’t pass my urine
, and had to have a catheter inserted.

  I didn’t really come to, then, till the Wednesday evening, two days after the operation—two days which were pretty much lost, at least so far as any coherent and consecutive consciousness was concerned. I revived rather suddenly, with the fever and delirium gone, and the pain so much better that the injections could be stopped, and the catheter—yes, the catheter, that abomination—was taken out, and I could enjoy the pleasure of pissing freely. I felt wonderfully refreshed in mind and body, which may sound strange for someone who had had quite a major operation, was shocked from tissue destruction, and feverish and delirious into the bargain, but this is the way. One bounces back, as they say, re-invigorated, regenerated. One is almost a new man.

  A sharp sweet breeze was blowing through the window—a sweet evening breeze, carrying with it the sounds of birds at evensong in the quadrangle outside. I took a deep breath with delight, and murmured a prayer of thanksgiving at this speedy—and, yes, luscious—recovery. Ninety-six hours ago, I reflected, I had been groping in the dusk on a chill mountain in Norway, in a land of darkness, and the shadow of death. Now I was back in the land of the living!

  I stretched luxuriously—and this action, as I pulled on the plaster, suddenly reminded me that I had a cast—and, yes, indeed, a leg in the cast! Well, there it was—a little bit of it anyhow, a rim of thigh at the top, and my foot, pink and lively, if rather swollen, at the bottom. It was splendid to think that continuity was restored, the tendon reconnected, and everything in good order. All was well, and all would be well. It would take time, no doubt. I had to anticipate a month or so in hospital, and then a couple of months’ convalescence. There would be some wasting of muscle under the cast—I had often seen how quickly the quadriceps wasted with bedrest and disuse—and I could not expect an instant return of full strength and use to the leg….All this I understood, and accepted—accepted gladly. It was a small price to pay for my delivery from death or devastating, permanent disability. The vital point, surely, was this: that I had, as by a miracle, survived my accident, that my injury had been repaired by an excellent surgeon, that a careful search at operation had found nothing damaged other than the tendon, that recovery should be straightforward, and that no “complications” of any sort had been encountered, or were to be expected.