A Leg to Stand On

by Oliver Sacks, M. D.

  After forty minutes, then, which left both Miss Preston and me exhausted and frustrated, we desisted, and let the quad be. It was a relief to both of us when she went over the other muscles in the leg, having me move my foot and toes, and other movements at the hip—abduction, adduction, extension, etc. All of these worked spontaneously, instantly, and perfectly, in contradistinction to the quadriceps, which worked not at all.

  * * *

  —

  The session with Miss Preston left me pensive, and grim. The strangeness of the whole thing, and the foreboding I felt—which I had managed to “forget” the previous day, though it returned in my dreams—now hit me with full force, and could no longer be denied. The word “lazy,” which she had used, struck me as silly—a sort of catchword with no content, no clear meaning at all. There was something amiss, something deeply the matter, something with no precedent in my entire experience. The muscle was paralyzed—why call it “lazy”? The muscle was toneless—as if the flow of impulses in and out, such as normally and automatically maintain muscle tone, had been completely suspended. The neural traffic had stopped, so to speak, and the streets of the city were deserted and silent. Life—neural life—was suspended for the moment, if “suspended” was not itself too optimistic a word.

  Normally the muscles relax during sleep, especially deep sleep, and the neural traffic lessens, but never comes to a halt. The muscles keep going night and day, with a vital pulsation and circulation of minute impulses, which can be awakened, at any moment, into full activity. Even in coma the muscles retain some activity. They are still ticking over at a very low rate. The muscles, like the heart, never stop during life. But my quadriceps had stopped, so far as I could judge. It was utterly toneless and paralyzed. It was as if dead, and not just asleep; and, being dead, it could not be awakened—it would have to be—what word could I use?—quickened—to restore it to life. Awake and asleep: the quick and the dead.

  It was the deadness of the muscle which so unnerved me. And deadness was something absolute, unlike tiredness or sickness. This was what I had felt, and suppressed, the previous evening: the sense, the foreboding, that the muscle was dead. It was, above all, its silence which conveyed this impression—a silence utter and absolute, the silence of death. When I called to the muscle, there was no answer. My call was not heard, the muscle was deaf. But was this all? Would this suffice to give me the impression of “silence”? When one calls, one hears oneself calling—even if the call is not heeded, or falls on deaf ears. Perhaps—and this thought made me shudder, seeming to move me into another realm altogether, a realm of infinitely more serious, even uncanny, possibilities—this “silence” I spoke of, this sense of nothing happening, did this not mean that in fact I had not called (or that if I had called, I could not hear myself calling)? The thought, or something like it—premonitory and precursory—had been in the back of my mind, surely, in my session with Miss Preston. This bizarre business of “trying,” which was not truly trying, this business of “willing,” which was not truly willing, this business of “thinking,” which was not truly thinking, this business of “recalling,” which was not truly recalling…

  What was happening with me? I couldn’t try, I couldn’t will, I couldn’t think, I couldn’t recall. I couldn’t think or recall how to make certain movements, and my efforts to do so were delusory, derisory, because I had lost the power to call to a part of myself, the power to call on a part of myself. It seemed to me now, as I mused, more and more darkly, by myself, that the whole business was much deeper, much stranger, than I could have conceived. I felt abysses opening beneath me.

  That the muscle was paralyzed, that the muscle was “deaf,” that its vital impulsional pulsing flow, its “heart,” had stopped—that it was, in a single word, “dead”—all of these things, disquieting in themselves, paled into insignificance compared with what was coming most appallingly into view to me now. For all these things, horrid as they might be, were entirely local and peripheral phenomena, and as such not affecting my essential being—me—any more than the loss of some leaves, or a branch, affect the deep life, the sap-flow, the roots, of a tree. But what was now becoming frightfully, even luridly, clear was that whatever had happened was not just local, peripheral, superficial—the terrible silence, the forgetting, the inability to call or recall—this was radical, central, fundamental. What seemed, at first, to be no more than a local, peripheral breakage and breakdown now showed itself in a different, and quite terrible, light—as a breakdown of memory, of thinking, of will—not just a lesion in my muscle, but a lesion in me. The image of myself as a living ship—the stout timbers, the good sailors, the directing captain, myself—which had come so vividly to my mind in the morning, now re-presented itself in the lineaments of horror. It was not just that some of the stout timbers were rotten and infirm, and that the good sailors were deaf, disobedient or missing, but that I, the captain, was no longer captain. I, the captain, was apparently brain-damaged—suffering from severe defects, devastations, of memory and thought. I fell very suddenly, and mercifully, into an almost swoon-like sleep.

  My sleep, though profound, was suddenly, rudely and bewilderingly broken by the little Javanese nurse, normally so sedate, who burst into my room and shook me awake. She had glanced through the transparent door-panel, before bringing me lunch, and what she saw had made her drop the tray and burst through the door.

  “Dr. Sacks, Dr. Sacks,” she cried, shrill with alarm. “Just look where your leg is—you’ll have the whole thing on the floor!”

  “Nonsense!” I said lazily. I was still half-asleep. “My leg is right here, in front of me, right where it should be.”

  “It isn’t!” she said. “It’s half off the bed. You must have moved in your sleep. Just look where you are!”

  “Come on!” I said, smiling, not bothering to look. “A joke is a joke.”

  “Dr. Sacks, I am not joking! Please raise yourself, and look down and see.”

  Thinking she was still having me on—hospital wards are notorious for their practical jokes—I levered myself up. I had been flat on my back. I looked—and looked harder. The leg was not there! Incredibly, impossibly, the leg was not there!

  Where was it? I spotted the cylinder of chalk way off to my left, sticking out at a funny angle to my trunk and indeed, as Nurse said, more than half off the bed. I must have kicked it here with my good leg, without knowing, while asleep. I had a sudden sense of utter confusion. I had felt the leg in front of me—or, at least, I had assumed it to be there (it had been there before, and I had received no information to the contrary)—but now I could see it wasn’t there at all but had got shifted and rotated through almost ninety degrees. I had a sudden sense of mismatch, of profound incongruity—between what I imagined I felt and what I actually saw, between what I had thought and what I now found. I felt, for a dizzying, vertiginous moment, that I had been profoundly deceived, illuded, by my senses: an illusion—such an illusion—as I had never before known.

  “Nurse,” I said, and I found my voice trembling, “would you be so kind as to move the leg back? It’s not too easy for me to shift it, lying flat like this.”

  “Of course, Dr. Sacks—and high time too! It’s almost over the edge—and you did nothing but talk.”

  I waited for her to move it, but to my surprise she did nothing. Instead she bent over the bed, straightened up and started for the door.

  “Nurse Sulu!” I yelled—and it was her turn to be startled. “What’s going on? I’m still waiting, please, for you to move my leg back!”

  She turned round, her almond eyes wide with amazement.

  “Now you’re joking, Dr. Sacks! I did move your leg back.”

  For once, I was completely lost for words, and grabbing the monkey-bar I hauled myself into a sitting position. Indeed she wasn’t joking—she had moved the leg back! She had moved it back, but I hadn’t felt her do it. W
hat the hell was going on?

  “Nurse Sulu,” I said, very sober and subdued, “I’m sorry I got excited. May I ask you a favor? Would you be kind enough, now I’m sitting up and can see, to take the cast by the ankle, and move it around—just move it, if you please, any way you want.”

  I watched her carefully, and narrowly, as she did so—lifting it up, lowering it, moving it to either side. I could see all these movements, but I couldn’t feel them at all. I watched her intently as she took the leg and moved it—a little up, a little down, a little to either side.

  “And now some really big movements, please, Nurse Sulu.”

  Gallantly—because it was heavy, dead-weight, and unwieldy, and floppy—she lifted it right up, in flexion, to a right angle, and then way out to the side, at a right angle again. I could see all the movements, but I couldn’t feel them at all.

  “Just one final short test, Nurse Sulu, if you don’t mind.” My voice (I observed, as from a distance) had assumed a quiet, matter-of-fact, “scientific” tone, concealing the abominable fear, the opening abyss, that I felt.

  I closed my eyes, and asked her to move the leg once again—first small movements and, if I said nothing, huge movements, as before. Well, we would see! If you move a man’s arm while he’s looking, he might find it difficult to pick out the feel from the sight. They are so naturally associated that one is not used to distinguishing one from the other. But, if you ask him to close his eyes, he has no difficulty judging the tiniest passive movements—a fraction of a millimeter’s excursion, with a finger, for example. And indeed it is this “muscle sense,” as it was once called, before Sherrington investigated it and renamed it “proprioception”—it is this sense dependent on impulses from muscles, joints and tendons, usually overlooked because normally unconscious, it is this vital “sixth sense” by which the body knows itself, judges with perfect, automatic, instantaneous precision the position and motion of all its movable parts, their relation to one another, their alignment in space. There used to be another old word, still often used—kinesthesia, or the sense of movement—but “proprioception,” less euphonious, seems an altogether better word, because it implies a sense of what is “proper”—that by which the body knows itself, and has itself as “property.” One may be said to “own” or “possess” one’s body—at least its limbs and movable parts—by virtue of a constant flow of incoming information, arising ceaselessly, throughout life, from the muscles, joints and tendons. One has oneself, one is oneself, because the body knows itself, confirms itself, at all times, by this sixth sense. I wondered how much the absurd dualism of philosophy since Descartes might have been avoided by a proper understanding of proprioception. Perhaps indeed such an insight was hovering in the great mind of Leibniz, when he spoke of “minute perceptions” intermediating between body and soul, although…

  “Dr. Sacks!” Nurse Sulu’s voice broke in, sharp with impatience. “I thought you’d fallen asleep or something. My poor arms are aching, and you haven’t made a sound. I’ve had a proper work-out with this great heavy cast of yours. I’ve moved it every way as far as it will go. Now don’t tell me you didn’t feel that!”

  “Nurse Sulu,” I said solemnly, “I felt nothing at all. In fact, I was still waiting for you to begin!”

  Nurse Sulu shook her head, having helped me nobly, and took leave, shaking her head in bewilderment and incomprehension. “He seemed so nice, so normal, so sane, this morning,” I imagined her thinking, behind her smooth Javanese brow, “and now he’s acting weird!” She would have been far more disturbed had she seen my actions through the glass-panelled door; and still more disturbed had she had any conception of what I was thinking, experiencing, feeling. “Weird” she would have found much too feeble a word. Indeed she would have found no word in her language, my language, any language, to convey the inconceivable character of what I was experiencing.

  * * *

  —

  As soon as she had taken her leave—I indicated that I had lost my appetite for lunch—I turned at once to my leg, with a keen, startled and almost fierce attention. And in that instant, I no longer knew it. In that instant, that very first encounter, I knew not my leg. It was utterly strange, not-mine, unfamiliar. I gazed upon it with absolute non-recognition. I have had—we all have had—sudden odd moments of non-recognition, jamais vu; they are uncanny while they last, but they pass very soon, and we are back in the known and familiar world. But this did not pass—it grew deeper and deeper—and stronger, and stranger.

  The more I gazed at that cylinder of chalk, the more alien and incomprehensible it appeared to me. I could no longer feel it as mine, as part of me. It seemed to bear no relation whatever to me. It was absolutely not-me—and yet, impossibly, it was attached to me—and even more impossibly, continuous with me.

  It must be the cast, I said to myself. A great object like that—it would throw anyone off; although it was odd that only now should it disturb me so much. After all, I had been put in a cast at Odda on Saturday. Why should I now, the following Thursday, find it so strange—a ludicrous object with no relation to me. This wasn’t how I had regarded it when it was put on at Odda—I had the clearest memory of finding it not only a protection and comfort, but somehow friendly and hospitable and warm, a nice cozy home which would lodge my poor leg till it was better. Now it didn’t look friendly, or hospitable, or warm at all. Nor could I conceive how it had ever done so at any time in the past. On the other hand, it didn’t seem nasty, or unfriendly, or hostile—it didn’t seem anything: it had no qualities at all.

  In particular, it no longer seemed a “home.” I couldn’t conceive it housing anything, let alone part of me. I had the feeling that it was either totally solid, or empty—but, in either case, that it contained nothing at all. I looked at the rim of toneless flesh above the cast, and then thrust a hand down inside. There was so much room, indeed, that I could put both hands in. The experience was inconceivably shocking and uncanny. The day before, when I had put my hand down and palpated the quadriceps, I had found it horrible—limp and pulpy, like a sort of soft, inanimate jelly or cheese. But the horror was nothing to what I felt now. The day before, touching it, I had at least touched something—unexpected, unnatural, unlifelike, perhaps—but nevertheless something; whereas today, impossibly, I touched nothing at all. The flesh beneath my fingers no longer seemed like flesh. It no longer seemed like material or matter. It no longer resembled anything. The more I gazed at it, and handled it, the less it was there, the more it became Nothing—and Nowhere. Unalive, unreal, it was no part of me—no part of my body, or anything else. It didn’t “go” anywhere. It had no place in the world.

  That which is not Body is no part of the Universe…and since the Universe is all, that which is not Body is Nothing—and No Where.

  —THOMAS HOBBES

  I had lost something—that was clear. I seemed to have lost my leg—which was absurd, for there it was, inside the cast, safe and sound—a “fact.” How could there be any doubt in the matter? And yet there was. On this very matter of having or possessing a leg, I was profoundly doubtful, fundamentally unsure.

  When I closed my eyes, as a start, I had no feeling whatever of where the leg lay—no feeling that it was “here,” as opposed to “there,” no feeling that it was anywhere—no feeling at all. And what can be felt, what can be posited, about something that is not there? It seemed, indeed, as if it was this profound disturbance of proprioception, which had only been discovered and revealed by a fluke, though then investigated carefully by Nurse Sulu and myself—it seemed as if this, in particular, was somehow the last straw. Serious problems and questions had already arisen, relating especially to the injured and operated muscle: its great atrophy, its atonia, its apparent paralysis. And questions of a higher sort, just before I fell asleep—the apparent breakdown in know-how and idea, so that I could no longer think or recall how to make muscular movements involving t
he muscle. There was already something odd going on at this point. But a total, absolute, existential breakdown immediately followed, and seemed precipitated by, the discovery of the breakdown of sensation and feeling, for it was then, and only then, that the leg suddenly assumed an eerie character—or, more precisely, if less evocatively, lost all its character—and became a foreign, inconceivable thing, which I looked at, and touched, without any sense whatever of recognition or relation. It was only then that I gazed at it, and felt, I don’t know you, you’re not part of me, and, further, I don’t know this “thing,” it’s not part of anything. I had lost my leg. Again and again I came back to these five words: words which expressed a central truth for me, however preposterous they might sound to anyone else. In some sense, then, I had lost my leg. It had vanished; it had gone; it had been cut off at the top. I was now an amputee. And yet not an ordinary amputee. For the leg, objectively, externally, was still there; it had disappeared subjectively, internally. I was therefore, so to speak, an “internal” amputee. Neurologically, neuropsychologically, this was the salient fact. I had lost the inner image, or representation, of the leg. There was a disturbance, an obliteration, of its representation in the brain—of this part of the “body-image,” as neurologists say. Part of the “inner photograph” of me was missing. I could also use some of the terms of ego-psychology, which had a more-than-coincidental correspondence to those of neurology. I could say that I had lost the leg as an “internal object,” as a symbolic and affective “imago.” It seemed, indeed, that I needed both sets of terms, for the inner loss involved was both “photographic” and “existential.” Thus, on the one hand, there was a severe perceptual deficit, so that I had lost all feeling of the leg. On the other, there was a “sympathetic” deficit, so that I had lost much of my feeling for the leg. Both were implied in the terms I used—the sense of my personal, living, beloved reality having been replaced by a lifeless, inorganic, alien dissolution of reality.