A Leg to Stand On

by Oliver Sacks, M. D.

  As if to dissipate this metaphysical fog, there suddenly appeared, in my mind’s eye, the robust and rumbustious figure of Dr. Johnson. My unconscious had summoned him to wake me from a Berkeleyan nightmare. I saw him with extraordinary clarity—and immediately loved him, and his strong common sense. When asked his opinion of “the Berkeleyan doctrine”—the supposed unreality of material objects—his reply had been to aim a mighty kick at a stone, saying “Bah! Thus I refute it!” I had always regarded this answer as quite perfect—theoretically, practically, dramatically, comically: it was the obvious, the only thing to do—but it required Johnsonian genius to do it. For the answer to such questions is given by acts.

  I had a vivid mental picture of Johnson kicking the stone—so vivid, so droll, I kept laughing to myself. But how could I apply Johnson’s “test” to myself? I longed to aim a mighty kick at a stone, and in so doing show the actuality of the kicking leg and the stone. But how could I kick with my unimaginable, “immaterial” leg? I could not make any contact with the stone. Thus the Johnsonian test would backfire on me, and its failure, or untryability, would serve only to confirm the unreality of the leg, and sink it further into a Berkeleyan circle. The image of my stout and doughty champion faded. Even good Sam Johnson, if caught in my position, would be unable to refute it.

  Johnson’s place, in my proscenium, was now taken by Wittgenstein—I fancied that the two men, seemingly so different, might get on rather well (I continually invent imaginary meetings and dialogues). I heard, in Wittgenstein’s voice, the opening words of his last work, On Certainty: “If you can say, Here is one leg, we’ll grant you all the rest….The question is, whether it can make sense to doubt it.” (And only later did I realize that my memory, or imagination, had interposed “leg” for “hand.”) “Certainty,” for Wittgenstein, was grounded in the certainty of the body. But the certainty of the body was grounded in action. The answer to Wittgenstein’s question as to whether one can be sure of one’s hand was to raise it, or sock someone in the face—as Samuel Johnson’s answer was to kick the stone.

  Johnson and Wittgenstein were in perfect agreement: one existed, and could show it, because one acted—because one could lift, or kick, a stone. I suddenly thought: a man with a phantom—a phantom leg—could not kick a stone.

  I became all of a sudden desolate and deserted, and felt—for the first time, perhaps, since I had entered the hospital—the essential aloneness of the patient, a sort of solitude which I hadn’t felt on the mountain. Desperately now, I wanted communication, and reassurance, like the young patient who had brought out, though with difficulty and embarrassment, the sort of thing which had happened to him. I myself needed to communicate above all to my physician and surgeon: I needed to tell him what had happened to me, so that he could say, “Yes, of course, I understand.”

  * * *

  —

  I fell asleep and was woken by the arrival of my very favorite aunt, my Auntie Len. I had half hoped she might come, but doubted if she would, because it was her birthday. Undaunted, at eighty-two, after a breakfast and a lunch with friends—and more, she said, would be coming for dinner—she had crossed London to have her birthday tea with me, since I could not, as I usually did, go to have it with her. Suddenly remembering, at breakfast time, that it was her birthday, I had prevailed upon Nurse Sulu, when she brought me breakfast, to procure a birthday book for her, selecting, after some hesitation, Cordial Relations: The Maiden Aunt in Fact and Fiction. I gave this to her somewhat fearfully, saying I hadn’t read it, and maybe it was awful (though it was said to be excellent), and maybe she didn’t like the category of “maiden aunt.”

  “But I love it!” she exclaimed, taking the book. “I love being a maiden aunt. I wouldn’t be anything else. Especially a maiden aunt with eighty-seven nephews and nieces, two-hundred-and-thirty grand-nephews and -nieces, and all the children I have taught—my children—for sixty years! So long as the book doesn’t portray us as barren or lonely!”

  “If it does,” I said, “I’ll send it back to the author!”

  She rummaged in her bag and brought out a parcel. “And I’ve got a birthday book for you. You were away on your birthday, up in the Arctic. I know you love Conrad. Have you read this?”

  I unwrapped the parcel and found The Rover. “No, I haven’t,” I said, “but I like the title.”

  “Yes,” she said. “It suits you. You’ve always been a rover. There are rovers, and there are settlers, but you’re definitely a rover. You seem to have one strange adventure after another. I wonder if you will ever find your destination.”

  Over a lovely and tranquil tea—my good aunt had somehow persuaded the usually forbidding Sister to provide cress sandwiches and a huge pot of tea—under the affectionate and truthful gaze of my aunt, I related some of my discoveries that day.

  She listened intently, not saying a word. “Dearest Bol,” she said, when I drew my tale to a close, “you’ve been in some very deep waters, but these are the deepest.” A shadow seemed to pass over her face. “Very deep waters,” she murmured, half to herself. “Very deep and strange and dark. I wonder…” But I never learned what it was she wondered at the moment, because she emerged from her abstraction, broke off, looked straight at me, and said: “I can’t begin to understand, but I am sure that it can be understood, and that after roving to-and-fro you will reach an understanding. You’re going to have to be very clear and strong and bold. You’re also going to have to bow your head, and be humble, and acknowledge that there are many things which pass the understanding. You mustn’t be arrogant—and you mustn’t be abject. And you mustn’t expect too much from the surgeon. I’m sure he’s a good man, and a first-rate surgeon, but this goes far beyond the province of surgery. You mustn’t get angry if he doesn’t understand completely. You mustn’t expect the impossible of him. You must expect, and respect, limits. He’ll have all sorts of limits—we all do. Professional limits, mental limits and emotional limits, most especially…” She stopped, arrested by some recollection or reflection. “Surgeons are in a peculiar position,” she said, at last. “They face special conflicts. Your mother—” She hesitated, scanning my face. “Your mother was a dedicated surgeon, and a very gentle sensitive soul, and it was sometimes difficult for her to reconcile her human feelings with her surgery. Her patients were very dear to her, but as a surgeon she had to see them as anatomical and surgical problems. Sometimes, when she was younger, she seemed almost ruthless, but this was because her feelings were intense: she would have been overwhelmed by them, if she hadn’t maintained a rigorous distance. It was only later that she achieved a balance—that essential balance of the technical and the personal.

  “Be gentle, Bol!” she admonished me. “Don’t react to Mr. Swan. Don’t call him ‘the Surgeon.’ It doesn’t sound human! Remember he’s human—as human as you are. All too human, probably, and even shyer than you are. All the trouble starts when people forget they’re human.”

  Good, wise, simple words. If only I had heeded them! If only I had had that rare mildness and magnanimity which characterized my good aunt, that inner serenity and security which allowed her to face everything with a sweet and even humor, and never to exaggerate, distort or dismiss.

  Over a second pot of tea—my aunt drank as much tea as Dr. Johnson—the conversation became looser, slighter, easier, and the somber shadows, the terrible seriousness, which I had felt earlier, unable to withstand the playful atmosphere, seemed to dissolve and depart in the gay air.

  As she gathered herself to leave, very suddenly, and in rapid succession, my aunt told me three jokes, of an astounding obscenity but delivered with a demure precision and propriety of utterance.

  I burst out laughing with such violence, that I feared I would burst the stitches, and while I was laughing my aunt rose and left.

  Yes, yes! Everything would be understood, set to rights, taken care of. All was well, and
all would be well. There had been a minor complication, attributable to surgery, trauma, or both. The nature of this was a little hazy to me, but all would be made clear by Swan in the morning. He was a good man, I understood; he had had years of orthopedic experience; he must have seen this sort of thing hundreds of times before; I could count on a simple, reassuring diagnosis and prognosis. He would say—well, I didn’t quite know what he would say, but he would say the right thing, and all would be well. Yes! I could confidently put myself in his hands—I should have thought of this before, instead of consuming myself in intense, solitary effort and thought. Thinking to help myself, I had quite needlessly over-alarmed myself.

  What sort of a man would Swan be? I knew he was a good surgeon, but it was not the surgeon but the person I would stand in relation to, or, rather, the man in whom, I hoped, the surgeon and the person would be wholly fused. My encounter with the young surgeon in Odda had been perfect in its way. He was perfect for then, for that moment; but now my situation was more complex and obscure, and a heavier burden would rest on Mr. Swan. He could not flit in, dance, smile, and be gone; he had a heavy responsibility, the weight of caring for me for perhaps weeks or months. I ought not to demand too much of him, or over-burden him with the intensity of my distress. If he was a sensitive man he would be instantly aware of the distress and dispel it, with the quiet voice of authority. What I could not do for myself in a hundred years, precisely because I was entangled in my own patienthood and could not stand outside it, what seemed to me insuperably difficult, he could cut across at a single stroke, with the scalpel of detachment, insight and authority. He did not have to explain; he had only to act. I did not require an actuarial statement, such as “We see this syndrome in 60 per cent of all cases. It has been variously attributed to x, y, and z. The recovery rate is variously estimated as such-and-such, depending on this-and-that, and other imponderables.” I required only the voice, the simplicity, the conviction, of authority: “Yes, I understand. It happens. Don’t fret. Do this! Believe me! You will soon be well.” Or words to that effect—words utterly direct and transparent, words without a hint of prevarication or indirection.

  If he could not, in truth, reassure me with such words, I would want an honest acknowledgement of the fact. I would equally respect his integrity and authority if he said: “Sacks, it’s the damndest thing—I don’t know what you’ve got. But we’ll do our best to find out.” If he showed fear—frank fear—I should respect that too. I should respect whatever he said so long as it was frank and showed respect for me, for my dignity as a man. If he was frank and direct, I could take almost anything.

  In the thought of Swan’s visit, his understanding, his reassurance, I was permitted, at last, a profound repose. I had had the most bizarre and alarming day of my life—more bizarre and alarming, in its way, than my day on the mountain. For there my fears, though ultimate, were natural and real—I could and I did confront the thought of death. But what now confronted me was un-natural and un-real. There was perplexity here of a terrible kind. But Swan would understand this, he would have encountered it before; I could depend on him to say the right thing. How often had I myself, as a physician, mysteriously stilled the apprehensions of my patients—not through knowledge, or skill, or expertise, but simply by listening. I could not give myself repose, I could not be physician to myself; but another could. Swan would, tomorrow….

  Thus the day ended in a profound trusting sleep, a deep and dreamless sleep—at least for half the night. But then I fell into a succession of dreams, dreams of a most grotesque and uncanny sort, dreams of a kind I had never had before, neither in anxiety, in fever, in delirium, ever. For hours, increasingly, I was the victim of these dreams. I would wake from them briefly, in startled horror, only to re-enter them the moment I slept again. In a sense they were scarcely like dreams at all—they had a monotony, a fixity, which was thoroughly undreamlike—more like the repetition of some changeless physiological reality. For all I dreamed of was the leg—the non-leg. I repeatedly dreamed that the cast was solid, that I had a leg of chalk or plaster or marble, inorganic. I would be sitting in a chair, at dinner perhaps, or sitting on a park bench, enjoying the sun—these parts of the dream were simple and prosaic; but whatever I was doing—it was never standing or walking—there was that white stony cylinder in place of my leg, as fixed and motionless as that of a statue. Sometimes it was not plaster or marble, but something friable and incoherent, like sand or cement—and these dreams contained an additional fear: that there was nothing to hold the gritty mass together, no inner structure or cohesion, but a mere outer surface, visuality without substance. Frequently I dreamed that the cast-leg was perfectly hollow—though this is not quite an adequate word: not so much hollow as absolutely empty, a chalky envelope, a mere shell, about nothingness, a void. Sometimes it was a leg made out of mist, which retained, nevertheless, its motionless fixed shape; and sometimes—this was the worst—a leg made of darkness or shadow, or a leg impossibly made of nothing whatever. There was no change whatever in the dreams of that night. Or, rather, there were changes which were merely peripheral and incidental, in minor matters of setting and scene. At the center of each was this immovable, immaterial, blank somewhat. None of the dreams seemed to tell any “story.” They were fixed and static, like tableaux or dioramas, solely designed, as it were, to exhibit their appalling-boring centerpiece, this nothingness, this phantom, of which nothing could be said.

  I would wake from them briefly—I must have had dozens that night—take a sip of water, turn on the light, and there, facing me, unchanged by waking, lay the chalky-blank reality, or unreality, of my dreams. It was in one of these wakings—the gritty intimations of dawn now showing through the window—that I suddenly realized that these were neurological dreams, not devoid of obsessive Freudian determinants, but centered on an unchanging organic determinant. And now I suddenly realized that, although I had never had such dreams myself before, I had sometimes heard of precisely such from my patients: patients with strokes, with paraplegias, with severe neuropathies—phantoms of amputees; patients with various pathologies and injuries, but all having in common severe disorders of body-image. What such patients would dream of, night after night—as indeed I was to do—was based precisely on their disorders of body-image, and the pseudo-images, the phantoms, which these engendered. My own dreams, it now seemed to me, confirmed precisely this—that part of my body-image, body-ego, had died a frigid death. Great alarm, and great relief, attended this conclusion, and forthwith I fell asleep again—into a deep and dreamless sleep, which gave way, towards morning, to a most singular nightmare, although it appeared, at first, to be no more than a “conventional” nightmare. We were at war—with whom, and why, was never too clear. What was clear, or on everyone’s lips, was the fear that the enemy had an ultimate weapon, a so-called derealization bomb. It could, so it was whispered, blow a hole in reality. Ordinary weapons only destroyed matter extended through a certain space: this destroyed thought, and thought-space, itself. None of us knew what to think or expect, since, we had been told, the effect was unthinkable.

  Like many people in my dream, I felt a need to be out in the open, and was standing with my family in our garden at home. The sun was shining, all seemed normal—except for the uncanny stillness about us. Suddenly I had a sense that something had happened, that something was beginning to happen, though what it was, I had no idea. I became aware that our pear tree was missing. It was slightly to the left of where I was looking—and now, suddenly, there was no pear tree, the pear tree wasn’t there.

  I did not turn my head to investigate this further. For sorry reason, indeed, it did not occur to me to shift my gaze. The pear tree was gone, but so was the place where the pear tree stood. There was no sense of a place vacated; it was simply that the place was no longer there. No longer? Could I be sure that it had been there? Perhaps there was nothing missing. Perhaps there had never been a pear tree there. P
erhaps my memory or imagination was playing me a trick. I asked my mother, but she was as confounded as I was, and in just the same way: she too could no longer see the tree, but also doubted whether it had ever been there. Was this the derealization bomb at work, or were our apprehensions begetting ludicrous fancies?

  And now part of the garden wall was missing—including the gate which led on to Exeter Road. Or was it missing? Perhaps there had never been any garden wall. Perhaps there had never been a gate which faced on to Exeter Road, and no Exeter Road. Perhaps there had never been anything whatever to the left. My mother herself, who had moved so that she now stood straight ahead of me, seemed bisected in an extraordinary way. She stopped in the middle—she had no left half. But…but…could I be sure that she had a left half? Was not the very phrase “a left half” somehow meaningless? An extreme dread and nausea suddenly gripped me. I felt I would vomit….