A Leg to Stand On

by Oliver Sacks, M. D.

  It would be good to tense the quadriceps again, to feel again my power and control, which had been so disquietingly lost when the tendon was ruptured. Now it was united again, I would get the muscle going again, and build it up as fast as I could. I knew well how to build up muscle and strength, being an old hand at this from my weight-lifting days. I would amaze everybody, and show what I could do!

  Smiling with anticipation, I tensed the quad—and, inexplicably, nothing happened, nothing at all. At any rate I didn’t feel anything—but I hadn’t been looking. Perhaps there had only been a small contraction. I tried again—a strong pull this time—watching the quadriceps closely at the top of the cast. Again nothing—no visible motion whatever, not the least trace of any contraction. The muscle lay motionless and inert, unmoved by my will. Tremblingly I put down my hand to feel it. It was tremendously wasted, for the cast (which had presumably been snug after surgery) now allowed me to put my entire fist underneath it.

  Some atrophy, at least, was only to be expected, on the basis of disuse. What I did not expect, and what struck me as exceedingly strange and disquieting, was to find the muscle completely limp—most horribly and unnaturally limp—in a way one would never find with disuse alone. Indeed, it scarcely felt like muscle at all—more like some soft inanimate jelly or cheese. It had none of the springiness, the tone, of normal muscle; and it wasn’t just “flabby”—it was completely atonic.

  I had a qualm of absolute horror, and shuddered; and then the emotion was immediately repressed or suppressed. I hurriedly shifted my attention to pleasanter things. This was very easy to do. Doubtless I’d find that I’d been making some absurd mistake—like putting the key upside-down in the lock—and discover that everything was working OK in the morning.

  My father, and old friends, would be dropping in soon—I had asked the staff to spread the word that I was conscious, and “receiving.” And as for that nonsense with the leg—well, it was just that, nonsense. The physiotherapist would be coming in the morning, and we’d put the damn thing through its paces.

  I had a splendid evening—a celebration really. It was lovely to have my old friends about me, my friends whom I had “dreamt” about when, as I thought, I was dying on the mountain. (I told them the story, but I didn’t tell them that.) It was a lovely, happy, convivial evening in which, to the Night Supervisor’s amusement and outrage, we split a magnum of champagne between us. It was deeply reassuring to my friends as well, for I had declined to see them on Sunday evening, but had phoned them up, frighteningly, asking that they be my executors, if something “happened.” Well, nothing had happened—and I was exuberantly alive. I was alive, and they were alive. We were all alive, and contemporaries, and living together, travelling companions on the journey of life. That evening, the 28th, amid my friends’ smiles and laughter (and sometimes tears), I felt, as never before, what conviviality meant—not just being alive, but sharing life, being alive together. I had felt my aloneness on the mountain as being, in a sense, almost sadder than death.

  It was such a good evening, so festive, that we were reluctant to break up.

  “How long do you think you’re going to be in this joint?”

  “Not a minute longer than necessary—just as soon as I can walk out of it. I should be running around in a couple of weeks.”

  I lay in a glow of good feeling and good fellowship when they left, and then, in a few minutes, drifted off to sleep.

  But all was not well, down in the depths. I had, indeed, had a momentary qualm about my leg, but I had managed—I thought successfully—to dismiss this as something “silly,” some kind of “mistake,” and it certainly cast no shadow on my spirits in our convivial evening. I had indeed “forgotten” it, forgotten all about it; but down in the depths it had not been forgotten.

  And in the night, when I descended to the depths (or the depths erupted and surfaced in me), I had a dream of peculiar horror, which was the more horrific as it seemed so literal and undream-like. I was on the mountain again, impotently struggling to move my leg and stand up. But—and this, at least, was a dream-like conflation—there was a peculiar confusion of past and present. I had just had my fall, and yet the leg was sewn up—I could see the row of tiny neat stitches. “Splendid!” I thought. “Continuity is restored. They came along with a helicopter and sewed me up on the spot! I’m all re-connected, I’m ready to go!” But the leg, for some reason, didn’t budge in the least, even though it was so neatly and nicely sewn up. There wasn’t a twitch, not so much as the stirring of a single muscle fiber, when I tried to use the leg and get to my feet. I put my hand down, and felt the muscle—it felt soft and pulpy, without tone or life. “Heavens above!” I said in my dream. “There’s something the matter—quite dreadfully the matter. The muscle’s been denervated, somehow or other. It’s not just the tendon—the nerve-supply’s gone!” I strained and strained, but it was no use at all. The leg lay motionless, and inert, as if dead.

  I woke from this dream, sweating, in terror, actually trying to tense the flaccid muscle (as, perhaps, I had been doing in my dream). But it was useless, it didn’t work—as in the dream. I said to myself: “It’s the champagne. You’re delirious, you’re excited. Or perhaps you’re not awake, but in another dream. Go back to sleep—deep restful sleep—and you’ll find that everything’s OK in the morning.”

  I fell asleep, but entered dreamland once again. I was on a riverbank overgrown with enormous lush trees, whose shadows dappled the slightly rippling water. It was sublimely quiet, almost tangibly quiet, the deep quiet wrapping me round like a mantle. I had my binoculars and camera with me. I was out to sight an extraordinary new fish—a wonderful thing, it was said, though few people had ever seen it. I understood that it was called a “Chimaera.” I waited patiently, by its lair, for a while, and then whistled and clapped, and threw a stone in the water, to see if I could arouse the indolent beast.

  Suddenly, very suddenly, I saw a motion in the water, a stirring which seemed to come from unimaginable depths. The waters appeared to be being sucked in at the middle, leaving a vast space, a vastation, a vast gurgitation. Myth had it that the Chimaera could swallow the whole river at one gulp, and in this moment my wonder changed to terror, because I realized that the myth was literally true. From the vast space of his creation, the Chimaera arose, rose up from the depths in majestic splendor, all milky-white, furrowed, like Moby Dick—except, unbelievable!—he had horns on his head, and the face of a vast browsing animal.

  Now, outraged, he turned his gaze on me—with immense bulbous eyes, like the eyes of a bull, but a bull which could draw a whole river into his mouth, and with a vast scaly tail as big as a cedar.

  As he turned—his vast face towards me, his vast eyes upon me—a wild and terrible panic overcame me, and frantically I tried to leap backwards up towards safety, up the river bank behind me. But I couldn’t spring. The movement came out wrong and instead of throwing me backwards threw me violently forwards, beneath what I now saw were the hooves of the fish….

  The violence of my sudden movement jerked me awake, and I found that I had contracted my hamstrings most violently in my sleep, to the limit. My right heel had actually kicked my buttock, while my left heel was ground into the edge of the cast. It was a bright shining morning. This much I could see, for light could come in, to say nothing of wind, sounds, and scents (it was only vision, pattern, detail, which was blocked by the scaffolding rising outside barely a foot from the window). A bright Thursday morning—and I could hear the tea-trolley in the corridor, and smell buttered toast! I suddenly felt wonderful—this was the very morning of life: I sucked in the good air, and forgot my foul dreams.

  “Tea or coffee, Dr. Sacks?” asked the little Javanese nurse. (I had seen her, and liked her, briefly noticing her on that dread morning of surgery.)

  “Tea,” I replied. “A whole pot of tea! And porridge, and poached eggs, and buttered t
oast with marmalade!”

  She looked at me wide-eyed, almond-eyed, sweet-eyed, amazed. “Well, you are better today!” she said. “You wanted nothing but sips of water the last two days. I’m very glad for you now that you feel good again.”

  Yes, so was I. I felt good and glad, a returning vigor, and a desire for exercise and movement. I had always been active—activity was vital. I loved all motion, the quick motion of the body, and hated the thought of lying idle in bed.

  I spotted a monkey-bar, a sort of trapeze, suspended from the bed. I reached up to it, grabbed tight, and did twenty chin-ups. Lovely movement, lovely muscles—their action gave me joy. I rested, and did another set—thirty this time—and then lay back savoring the good feeling.

  Yes, I was still in good shape—injury, surgery, tissue-damage notwithstanding. That was damn good to do fifty chin-ups, considering I’d been delirious, and in shock, only fifteen hours before. It gave me not only gladness, but confidence as well—confidence in my body, its strength, its resilience, its will to recovery.

  * * *

  —

  After breakfast, I had been told, the physiotherapist would be coming. She was absolutely first-class, everyone said, and we’d start work together—get that leg of mine toned up, ship-shape, and working with the rest. I somehow felt like a ship when I said “ship-shape” to myself, a living ship, a ship of life. I felt my body was the ship in which I travelled through life, all parts of it—strong timbers, alert sailors working harmoniously together, under the direction and co-ordination of the captain, myself.

  A little after nine the physiotherapist came in, a powerful hockeyish woman with a Lancashire accent, accompanied by an assistant or student, a young Korean woman with demure, downcast eyes.

  “Dr. Sacks?” she roared, in a voice as might carry across an entire field.

  “Madam!” I said quietly, inclining my head.

  “Happy to meet you,” she said, somewhat less loudly, giving me her hand.

  “Happy to meet you,” I replied, somewhat less softly, giving her mine.

  “How’s the old leg? How’s it feeling? Probably hurts like Billy-O, what?”

  “No, doesn’t hurt much now—just an occasional flash. But it seems sort of funny—not working right.”

  “Mmm!” she harrumphed, considering for a moment. “Well, let’s have a look, and get down to work.”

  She pulled back the sheet, revealing the leg, and as she did so I saw a sudden startled look on her face. It was instantly replaced by a serious, sober expression of professional concern. She seemed, all of a sudden, less bouncy, more subdued and methodical. Taking out a tape measure, she measured the thigh and then, for comparison, the good side. She seemed disbelieving of the measurements, and repeated them again, throwing a brief glance at the silent Korean.

  “Yes, Dr. Sacks,” she said at last. “You’ve quite a bit of wasting—the quadriceps down seven inches, you know.”

  “That sounds a lot,” I said. “But I suppose it atrophies pretty quickly from disuse.”

  She seemed relieved at the sound of the word “disuse.” “Yes, disuse,” she muttered, less to me than herself. “I’m sure it can all be explained by disuse.”

  She put down her hand again, and palpated the muscle, and again I thought I saw a startled and disturbed look, and even a trace of unguarded disgust, as when one touches something which is unexpectedly soft and squirmy. Seeing this expression—which was, again, effaced in an instant, and replaced by a bland professional look—all my own fears, suppressed, came back redoubled.

  “Well,” she said—and again that over-loud, hockey-field voice. “Well,” she bellowed, “enough of all this—feeling, measuring, talking, and what-not. Let’s do something.”

  “What?” I asked, mildly.

  “Contract the muscle—what do you think? I want you to tense the quad on this side—don’t need to tell you how. Just tense the muscle. Firm it up now—firm it up right under my hand. Come on, you’re not trying. Do it with this one.”

  Instantly and powerfully I tensed the quad on my right. But there was no trace of tensing, no firming up, when I tried on the left. I tried again—and again, and again—without result.

  “I don’t seem to be very good at this,” I said in a small voice.

  “Don’t be discouraged,” she roared. “There’s lots of different ways. A lot of people find tensing—isometric contraction—tricky. One needs to think of a movement, not a muscle. After all, people move, they do things, they don’t tense their muscles. Here’s your patella—right under the cast.” She rapped the cast with her strong fingers and it emitted an odd chalky, inorganic sound. “Well, just pull it towards you. Pull your knee-cap right up—you’ll have no difficulty now the tendon’s been fixed.”

  I pulled. Nothing happened. I pulled again, and again. I pulled till I was grunting and panting with exertion. Nothing happened, nothing whatever, not the least shiver or quiver of movement. The muscle lay motionless as a deflated balloon.

  The physiotherapist was beginning to look flustered and frustrated, and said to me severely, in her games-mistress voice: “You’re not trying, Sacks! You’re not really trying!”

  “I’m sorry,” I said weakly, wiping the sweat off my brow. “It seems to me I was putting in a lot of effort.”

  “Well, yes,” she said, grudgingly. “It looked like hard work—and yet nothing happened! Well, not to worry, we’ve got other ways! Pulling on the patella is still isometric in a way—and it may be more difficult because you can’t see your patella.” She rapped the opaque cast with her knuckles this time, as if knocking for admittance.

  “It would be nice if they made transparent casts,” I suggested.

  She nodded vigorously. “And better still if they didn’t use casts at all. They’re great clumsy objects, and cause all sorts of problems. They’d do much better to immobilize joints with a brace—but you could never tell that to an orthopedist. A fat lot they know about physiotherapy!” She stopped suddenly, embarrassed. “I didn’t mean to say that,” she said, in a voice very far from her games-mistress one. “It just came out! But…” She hesitated, and then, finding understanding and encouragement in my face, went on: “I’m not saying anything against orthopods—they do a wonderful job—but they never seem to think of movement and posture—how you do things once the anatomy’s been put right.”

  I thought of Swan’s lightning visit just before surgery, and of his saying: “We reconnect it. Restore continuity. That’s all there is to it.” I found myself taking to this good physiotherapist.

  “Miss Preston,” I said, glancing at her name-tag (I had only thought of her as “the physiotherapist” up to this point). “I think you are talking very good sense indeed and I wish more doctors thought as you do. Most of them have got their heads in a cast”—and now it was my turn to rap the chalky cylinder for emphasis—“but coming back to me, what shall I try now?”

  “I’m sorry,” she said. “I got carried away….Let’s have another go. It’s all plain sailing once the muscle gets going. One little contraction—that’s all you need—it’s the first little twitch, and then you go from there. I’ll tell you what”—here her voice became sympathetic and friendly—“I was just supposed to do isometrics with you today, but it’s very important you have a success. I know how upsetting it is to keep trying—and fail. It’s very bad to end up with a miserable sense of failure. We’ll try active contraction—and something you can see. They don’t want you lifting your leg, but I’ll take all the weight. I’m going to lift your left leg nice and gently off the bed, and all you do is join in and help me….We have to get you sitting up a bit.” She nodded to the young Korean student, who bolstered up the pillows till I was in a sitting position. “Yes, that should bring in the hip-flexor action nicely. Ready?”

  I nodded, feeling, Yes, this woman understands, she’ll h
elp me get it going if anyone can, and prepared myself for an almighty effort.

  “You don’t have to brace yourself like that,” laughed Miss Preston. “You’re not trying for one of your weight-lifting records. All you do, now, is to lift up with me….Up, up….Do it with me….Just a little bit more….Yes, it’s coming now….”

  But it wasn’t coming. It didn’t come, nothing came at all. And I could see this in Miss Preston’s face, as I saw it with the leg. It was a dead-weight in her hands—without any tone or motion or life of its own—like jelly, or pudding, packed in a cast. I saw my own concern and disappointment writ large, undisguised, on Miss Preston’s face, which had lost its facade of professional indifference, and become alive and open, transparent and truthful.

  “I am sorry,” she said (and I knew she was sorry). “Perhaps you didn’t quite get it that time. Let’s try again.”

  We tried, and tried, and tried, and tried. And with each failure, each defeat, I felt more and more futile, and the chances of success seemed smaller and smaller, and the sense of impotence and futility grew stronger and stronger.

  “I know how much you’re trying,” she said. “And yet, it’s like you’re not trying at all. You put out all this effort—but somehow the effort isn’t managing to do things.”

  This was very much what I felt myself. I felt the effort diffuse uselessly, unfocussed, as it were. I felt that it had no proper point of application or reference. I felt that it wasn’t really “trying,” wasn’t really “willing”—because all “willing” is willing something, and it was precisely that something which was missing. Miss Preston had said, at the start of our session, “Tense the quad. I don’t need to tell you how.” But it was precisely this “how,” the very idea, which was missing. I couldn’t think how to contract the quadriceps any more. I couldn’t “think” how to pull the patella, and I couldn’t “think” how to flex the hip. I had the feeling that something had happened, therefore, to my power of “thinking”—although only with regard to this one single muscle. Feeling that I had forgotten something—something quite obvious, absurdly obvious, only it had somehow slipped my mind. I tried with the right leg. No difficulty at all. Indeed I didn’t have to “try” or “think.” No effort of willing or thinking was needed. The leg did everything naturally and easily. I also tried—it was Miss Preston’s last suggestion—“facilitation” she called it—to raise both legs simultaneously, in the hope that there might be some overflow or transfer from the good side. But, alas, not a trace! No “facilitation” whatever!