A Leg to Stand On

by Oliver Sacks, M. D.

  What could cause such a profound, such a calamitous, change, such a total breakdown of feeling-of and feeling-for, such a total breakdown of neural image—and imago?

  * * *

  —

  A long-forgotten memory came to me dating from the time when I was a student or “clerk” on the neurology wards. One of the nurses called me in considerable perplexity, and gave me this singular story on the phone: that they had a new patient—a young man—just admitted that morning. He had seemed very nice, very “normal,” all day—indeed, until a few minutes before, when he awoke from a snooze. He then seemed excited and strange—“not himself” in the least. He had somehow contrived to fall out of bed, and was now sitting on the floor, “carrying on” and vociferating, and refusing to go back to bed. Could I come, please, and sort out what was happening?

  When I arrived I found the patient lying on the floor by his bed and staring at one leg. His expression contained anger, alarm, bewilderment and amusement—bewilderment most of all, with a hint of consternation. I asked him if he would go back to bed, or if he needed help, but he seemed upset by these suggestions and shook his head. I squatted down beside him, and took the history on the floor. He had come in, that morning, for some tests, he said. He had no complaints, but the neurologists, feeling that he had a “lazy” left leg—that was the very word they had used—thought he should come in. He had felt fine all day, and fallen asleep towards evening. When he woke up he felt fine too, until he moved in the bed. Then he found, as he put it, “someone’s leg” in the bed—a severed human leg, a horrible thing! He was stunned, at first, with amazement and disgust—he had never experienced, never imagined, such an incredible thing. He felt the leg gingerly. It seemed perfectly formed, but “peculiar” and cold. At this point he had a brainwave. He now “realized” what had happened: it was all a joke! A rather monstrous and improper, but a very original, joke! It was New Year’s Eve, and everyone was celebrating. Half the staff were drunk; quips and crackers were flying; a carnival scene. Obviously one of the nurses with a macabre sense of humor had stolen into the Dissecting Room and nabbed a leg, and then slipped it under his bedclothes as a joke while he was still fast asleep. He was much relieved at the explanation; but feeling that a joke was a joke, and that this one was a bit much, he threw the damn thing out of the bed. But—and at this point his conversational manner deserted him, and he suddenly trembled and became ashen-pale—when he threw it out of bed, he somehow came after it—and now it was attached to him.*2

  “Look at it!” he cried, with revulsion on his face. “Have you ever seen such a creepy, horrible thing? I thought a cadaver was just dead. But this is uncanny! And somehow—it’s ghastly—it seems stuck to me!” He seized it with both hands, with extraordinary violence, and tried to tear it off his body, and failing, punched it in an access of rage.

  “Easy!” I said. “Be calm! Take it easy! I wouldn’t punch that leg like that.”

  “And why not?” he asked, irritably, belligerently.

  “Because it’s your leg,” I answered. “Don’t you know your own leg?”

  He gazed at me with a look compounded of stupefaction, incredulity, terror and amusement, not unmixed with a jocular sort of suspicion. “Ah, Doc!” he said. “You’re fooling me! You’re in cahoots with that nurse—you shouldn’t kid patients like this!”

  “I’m not kidding,” I said. “That’s your own leg.”

  He saw from my face that I was perfectly serious—and a look of utter terror came over him. “You say it’s my leg, Doc? Wouldn’t you say that a man should know his own leg?”

  “Absolutely,” I answered. “He should know his own leg. I can’t imagine him not knowing his own leg. Maybe you’re the one who’s been kidding all along?”

  “I swear to God, cross my heart, I haven’t….A man should know his own body, what’s his and what’s not—but this leg, this thing”—another shudder of distaste—“doesn’t feel right, doesn’t feel real—and it doesn’t look part of me.”

  “What does it look like?” I asked in bewilderment, being, by this time, as bewildered as he was.

  “What does it look like?” He repeated my words slowly. “I’ll tell you what it looks like. It looks like nothing on earth. How can a thing like that belong to me? I don’t know where a thing like that belongs….” His voice tailed off. He looked terrified and shocked.

  “Listen,” I said. “I don’t think you’re well. Please allow us to return you to bed. But I want to ask you one final question. If this—this thing—is not your left leg” (he had called it a “counterfeit” at one point in our talk, and expressed his amazement that someone had gone to such lengths to “manufacture” a “facsimile”) “then where is your own left leg?”

  Once more he became pale—so pale that I thought he was going to faint. “I don’t know,” he said. “I have no idea. It’s disappeared. It’s gone. It’s nowhere to be found….”

  I was deeply perturbed by the entire business—so deeply, indeed, I now reflected, that I had forgotten it for more than fifteen years, and although I called myself a neurologist I had totally forgotten him, thrust him out of my consciousness, until—until I found myself, apparently, in his position, experiencing (I could scarcely doubt it) what he had experienced, and, like him, scared and confounded to the roots of my being. It was clear that in some sense my symptoms were identical with this young man’s—that they all went together to constitute an identical “syndrome.”

  * * *

  —

  Such a syndrome was first described in the nineteenth century by Gabriel Anton and is often referred to as “Anton’s Syndrome,” though he only picked out a few of its features. More had been delineated by the great French neurologist Joseph Babinski, who had coined the term “anosognosia” for the singular unawareness that characterized such patients. Babinski had given memorable descriptions of the bizarre, almost comic, presentation in some cases: patients in whom the first sign of a stroke was an inability to recognize one side of their body—and the feeling that it was someone else’s, or a “model,” or a joke, so that they might turn to someone sitting next to them on a train, saying of their own hand, “Pardon me, Monsieur, you have your hand on my knee!” or, to a nurse clearing away the breakfast, “Oh, and that arm there—take it away with the tray!” And I thought of singular examples I had encountered myself: for instance, the patient at Mount Carmel who “discovered” his long-lost brother in his bed. “He’s still attached to me!” he said indignantly. “The cheek of it! Here’s his arm!” holding up, with his right hand, his own left arm. Babinski pointed out further that many such patients had been regarded as mad. Indeed they had a special category of madness tailor-made for them—somatophrenia phantastica, in Kraepelin’s terminology. But this “madness” was extraordinarily specific and constant in its features, and not only occurred, often suddenly, in well-balanced people, who had shown no hints of any madness before, but was specifically associated with lesions of the brain—in particular of the posterior portions of the right hemisphere, which controlled the general awareness, or gnosis, of the left side of the body. Otto Pötzl of Vienna had enriched these descriptions and had perhaps discussed their nature with Freud, comparing and contrasting them with somatic delusions. For Freud, who had been a neurologist, and a great one, in his youth (indeed he had coined the word agnosia in 1891) and who retained his neurological interests to the end, these delineations of Pötzl’s syndrome (optic-kinesthetic allesthesia) would have been of quite extraordinary interest, as also to his daughter Anna, already eminent for her early studies in ego-psychology. What would have fascinated the Freuds, father and daughter, was that here was a specific pathophysiological syndrome, associated with damage in the posterior right hemisphere, which could produce specific and singular changes in body-identity—so that a patient might find a limb unfamiliar, or be unable to ascribe or relate it to himself, and (by
way of rationalization and defense) might attribute it, if only temporarily, to someone else. There were also, Pötzl brought out, peculiar and specific changes in affect—as indeed was apparent in the preposterous (and often comic) aspect of the histories—when patients might nonchalantly wave a limb away, asking the nurse to be so kind as to remove it with the breakfast. Such patients, who showed perfectly normal reactions and affects in all other ways, might show an extraordinary indifference to the affected limbs. This, as Babinski noted, was one of the reasons why many of them had been diagnosed as having hysteria, schizophrenia or some other “dissociative” disorder. There was, indeed, a most striking “dissociation”—not only neurally, but emotionally and existentially too. This, however, was due not to repression of a concept and affect, but to a consequence of neural disconnection.

  Very early in life, at Charcot’s suggestion, Freud wrote a classic paper on the distinction of organic and hysterical paralyses, and he would have been deeply intrigued to find, towards the end of his life—Pötzl’s syndrome was described in 1937—that some features which could easily have been taken as “hysterical”—the characteristic dissociation and bland or joking indifference—were, in those instances, entirely organic. More precisely, he would have been intrigued to find how a person and his ego-structure—which defined the boundaries of what was “me” and “not-me”—responded when faced with a massive body-agnosia. Had not Freud, himself rooted in physiology and biology, always said “The Ego is first and foremost a body Ego”?

  * * *

  —

  Well, what now? Did I have Pötzl’s syndrome? My case certainly looked indistinguishable from it! I could have been used as a classroom demonstration of this rare and singular “neuro-existential” pathology—and, for a moment, I imagined myself, Professor Dr. Anton-Babinski-Pötzl-Sacks, demonstrating a fascinating case of this syndrome—on myself! Then, as on the mountain, I suddenly realized that this fascinating case was myself—not just a case for Dr. Anton-Babinski-Pötzl-Sacks to demonstrate and write up, but a very frightened patient, with a leg not only injured and operated upon but doubly disabled, indeed rendered useless, because it was no longer a part of my inner image of myself—having been erased from my body-image, and also my ego, by some pathology of the most serious and inexplicable kind.

  With my poor patient, whom I had seen on that memorable New Year’s Eve, emergency neurosurgery had disclosed a large vascular tumor overlying the right parietal lobe of the brain. It had actually started to bleed while he slept, so that by the time he awoke the leg area—that part of the brain in which the position and presence of the leg are represented—had been virtually obliterated. As a result it was impossible for him to feel his leg normally—to feel it as present or part of himself, so that when he did discover it, it seemed to be a strange object introduced into his bed—“someone else’s leg,” “a corpse’s leg,” and, finally, a sort of uncanny, immaterial “counterfeit” leg.

  What, then, of myself? It was clear that I too had Pötzl’s syndrome, with extinction of the left leg—and that I too, like my patient, must have some massive pathology in the right parietal lobe. “Physiology, anatomy, etiology” we are taught, and my mind, smooth and skilled, ran swiftly on these tracks. The physiology was that of right-hemisphere dysfunction; the anatomy, in correspondence, was a large “lesion” in this area. And the etiology, the cause, what was it? I could not doubt it for a moment: I had thrown an embolus, or dropped my blood-pressure, under anesthesia, and sustained in consequence a cerebral infarction, a massive stroke in my posterior right-hemisphere. “Anesthetic complication,” they would write in the notes….

  To think it had come to this—that I had escaped, through a miracle, death or disastrous disability on the mountain, that I had been brought, with infinite trouble, to one of the best orthopedic units in the world, only to succumb to a post-operative stroke! I visualized, in a single sweeping panorama, replete with the most minute and mortifying details, the wretched half-life which lay ahead of me with so massive a stroke—confined to a wheelchair, humiliatingly dependent, and with a leg at once so useless and alien, so amputated internally, that it would be best and simplest to amputate it externally as well, which would at least relieve me of having to drag around a totally useless, functionless and indeed defunct limb. It ought to be removed as one would remove a mortified leg, because it was, in effect, mortified: it was neurally, functionally and existentially dead.

  I lay engrossed in this vision, for an unconscionable time, in a sort of icy, fatalistic despair; groaning, meditating suicide and twiddling my toes. My toes! I had forgotten—my toes were all right! There they were, pink and lively, twiddling away, as if twiddling in mirth at my absurd train of thought. Grim and gloomy hypochondriac though I might have been, I was not ignorant of elementary neuro-anatomy. A stroke massive enough to have knocked out the rest of the leg would certainly have knocked out the foot as well. As soon as this occurred to me, I burst into a hearty roar of laughter. My brain was all right—I hadn’t had a stroke. I didn’t know what I did have, but I didn’t have a stroke.

  I rang the bell and Nurse Sulu reappeared, concern writ large on her young placid face.

  “What is it, Dr. Sacks? Are you all right?”

  “Fine,” I said. “Splendid. Never better! I find I have regained my appetite again. Do you think it would be possible to get me a sandwich or something?”

  “My gracious goodness!” she said. “How you do change! When I left you looked terrible—pale, shivering, a dreadful look on your face. And now you seem fine! As you did back at breakfast.”

  “Well, I’ve been thinking a bit. I let myself get upset….If a sandwich is difficult, just a cup of tea and a biscuit.”

  “But, Dr. Sacks, you can have your whole lunch. They’re still serving it, you know.”

  “They are? How long is it since you were testing the leg out with me?”

  She glanced at her watch. “Not ten minutes,” she said. “Does it seem longer?”

  Not ten minutes! I could hardly believe my ears. In that ten minutes, it seemed to me, I had been through a lifetime’s experience. I had voyaged round a whole universe of thought. I had travelled so far—and they were still serving lunch!

  Nurse Sulu brought me in a tray. I found myself quite ravenously hungry, which seemed very natural, after my physical and metaphysical exertions of the morning—hungry, and sensuous, craving the good things of the world.

  My mind regurgitated, while eating, the words of the young man with the brain tumor who had “lost” his left leg. Fortunately for him, the tumor was benign, and prompt surgical intervention restored complete cerebral function. I went to visit him, when he was convalescing, several weeks later, to see how he was doing, and whether he had any memories, or feelings, about his New Year’s Eve.

  The experience, he told me, was the most uncanny and frightening in his life, and he wouldn’t have believed it possible unless he had experienced it. He said—he repeated the word—it was “potty,” it made no sense. One of his major fears was that he had gone completely mad. This was aggravated by his attempts to speak to the staff, who kept telling him it was “nothing” and not to be “silly.” He was very glad, very grateful, that I at least had listened—because even though I was a student, and “didn’t know anything,” I had tried to understand. He said he was glad, in a way, when the neurosurgeons (whom I had called in) assured him that it was real, and not in his mind—even though he was very scared to think that he had a brain tumor needing surgery. But even though the mechanism of the extinction was explained, along with the probability that his leg would “come back” when the pressure was removed, he found he couldn’t believe it. It wasn’t, he tried to explain, like an ordinary loss—when you misplace something somewhere. What was so awful about this sort of loss was that the leg hadn’t been misplaced, but had in fact lost its place. And since there was no longer any
place it could come back to, he just didn’t see how his leg could come back. This being so, nothing anyone said could really reassure him, and when they said his leg would come back, he just nodded and smiled.

  Yes, this was my position—my position exactly. The leg had vanished, taking its “place” with it. Thus there seemed no possibility of recovering it—and this irrespective of the pathology involved. Could memory help, where looking forward could not? No! The leg had vanished, taking its “past” away with it! I could no longer remember having a leg. I could no longer remember how I had ever walked and climbed. I felt inconceivably cut off from the person who had walked and run, and climbed just five days before. There was only a formal continuity between us. There was a gap—an absolute gap—between then and now; and in that gap, into the void, the former “I” had vanished—the “I” who could thoughtlessly stand, run and walk, who was totally and thoughtlessly sure of his body, who couldn’t conceive how doubts about it could possibly arise. Into that gap, that void, outside space and time, the reality and possibilities of the leg had passed, and disappeared. I had often thought the phrase “vanished into the blue” at once absurd, yet mysteriously significant. As if to rebuke my unbelief, my own leg had vanished “into the blue”; and, like the young patient with the bleeding brain tumor, I couldn’t imagine it returning in any “normal” or physical way, because it had vanished from space and time—vanished taking its space-and-time with it. If it went into the gap, the void, the “blue,” it would have to come out of the gap, the void, the “blue”: the eerie, stunning mystery of its going could only be matched by an equal mystery of coming or becoming. It had passed out of existence (whatever one meant by “existence”); and, by the same token, it would somehow have to come back into existence. My mind was dizzied with these thoughts of dissolution and re-creation. The waters became deeper and deeper all the time; I dared not think too much, in case they closed over me.