A Leg to Stand On

by Oliver Sacks, M. D.

  The door suddenly opened, and Nurse Sulu entered looking very concerned.

  “I’m sorry for bursting in like this,” she said, “but I peeped through the panel, and you looked terribly white, as though you were in shock. And your chest was heaving. I thought you were about to vomit. Do you feel all right?”

  I nodded numbly, staring at her. “Why are you staring at me like that?” she asked.

  “Oh…ummm…it’s nothing,” I said. “I just had a bad dream.” I didn’t care to tell Nurse Sulu, who had had enough shocks already, that she was bisected, and half of her was missing. And for those first waking seconds—or was I still half-asleep?—I had the strange feeling that, perhaps, she was complete as she was. I had remembered her saying, yesterday, that she was “only half-qualified,” and for a moment I connected this with her appearance. And then, suddenly, with a most enormous and wonderful relief, I realized: I was having one of my migraines. I had completely lost my visual field to the left, and with this, as would sometimes happen, the sense that there was (or had been, or could be) any world on the left. My migraine scotoma had come on during sleep, and formed the physiological reality of the “derealization bomb” and the strange disappearance of the pear tree, the garden wall and the left half of my mother. And waking I had found this dream a reality, or rather what was real in the dream, and not merely staging, setting, symbolic, was equally real now that I was awake.

  “But you do look very pale and sick,” Nurse Sulu persisted, speaking quite normally despite having only half a face.

  “Well, yes. I woke up with a migraine—one of my auras.” I giggled. The half-vision, the hemianopia, seemed rather funny now I knew what it was, and that it would go away soon. “But I’ll be all right soon. Maybe a nice cup of tea, and some toast, in a few minutes, when my stomach and my eyesight”—I giggled again—“has settled.”

  Reassured, Nurse Sulu turned to the door, regaining as she did so her unbisected form.

  Yet knowing that I was hemianopic, with a super-added hemi-inattention for the affected side—knowing this, intellectually, did nothing to alter the hiatus in perception, or, rather, the hiatus in sense, the feeling that there was nothing other than what I saw, and that it was therefore senseless to look at, or look for, the “left” half of the room, so-called. With a violent effort of will, like a man forcing himself to move, inch by inch, in a nightmare, I turned my head towards the left. And there, thank God, there came into view the remainder of my bed, the half-covered window, the dim lithograph (showing Lord Lister, apparently, strangling a patient), the left wall of the room and—ah! nice to know I still had it—my left arm outflung on the pillow. Absurdly relieved at finding everything in its place, I turned my head slowly back to the straight forward position, amused at the gradual disappearance, once again, of the left half of my visual field, the left half of the room, the left half of the world, the idea of “leftness.”

  Yes, I could find it amusing, and instructive, now—now that I knew what was going on, and that it was transient—but I had found it absolutely terrifying in my dream, and in the first moments of waking, before I realized what had happened. And as a child, I recollected, when I used to get such attacks I found them inconceivably frightening. In those vulnerable years I became acutely sensitive to two things: first, the least change or disorder in my perceptions, and second, the dangers of admitting any such change to the wrong people, in case they were regarded as made-up or crazy.

  These thoughts passed swiftly through my mind, while I was still hemianopic, followed by a sudden piercing sense of analogy and insight: “Why, this is what’s going on with the leg! How could I be such a fool? I have a scotoma for the leg! What I am experiencing with half my visual field is essentially similar to what I am experiencing with my leg. I have lost the ‘field’ for my leg precisely as I have lost part of my visual field.”

  I felt an immense sense of relief as the thought became clear in my mind. It left all other sorts of questions and uncertainties unresolved—including the rather crucial question whether it would ever get better—but it gave me a central support and insight to hold on to.

  And now—yes—something was happening in the blind half of my visual field. A most delicate filigree pattern had appeared while I mused, more delicate and transparent than the finest spider web, and with a sort of faint, quivering, trembling, boiling motion. It became clearer, brighter, a lattice of exquisite geometric beauty, composed, I could now see, entirely of hexagons, and covering the whole half-field like gossamer lacework. The missing half of the room now grew visible, but remained entirely contained within the lacework, so that it appeared itself latticed in structure—a mosaic of hexagonal pieces, perfectly dovetailed and juxtaposed with each other. There was no sense of space, of solidity or extension, no sense of objects except as facets geometrically apposed, no sense of space and no sense of motion or time.

  At this point, when I was relishing with a sort of detached, impersonal, mathematical interest this spaceless, motionless mosaic vision (which I had experienced, occasionally, before), Nurse Sulu entered with a cup of tea and toast. “You’re looking much better,” she said. “You look half-dead one minute and bright-eyed the next. I have never had such a changeable patient.”

  I thanked her for the tea, which she put on my bedside table to the right, and then, impulsively, I asked if she had a minute.

  “What now?” she smiled, thinking of my bizarre experiments the day before.

  “Nothing much,” I replied. “I won’t ask you to do anything. But, if you would, could you go over to the other side of the room, by the window maybe, or by that sinister picture of Lord Lister?”

  She crossed the room, suddenly being transformed as she did so, into a mosaic herself: there was an astounding moment, precisely in the middle, when one half of her was mosaic, and the other half real. She stood motionless by the window, backlit by the morning light which filtered through—and, in that moment, half-silhouetted, half-illuminated, her geometrized form in the embrasure of the window made me think of a madonna set in a medieval stained-glass window. Suddenly I felt frightened. She had become inorganic, part of the mosaic! How would I perceive movement, life, in this crystalline world?

  I asked her to look at the picture, talk, gesture, make faces, anything, so long as she moved. And now, to my mixed delight and disquiet, I realized that time was fractured, no less than space, for I did not see her movements as continuous, but, instead, as a succession of “stills,” a succession of different configurations and positions, but without any movement in-between, like the flickering of a film run too slow. She seemed to be transfixed in this odd mosaic-cinematic state, which was essentially shattered, incoherent, atomized. And I couldn’t imagine how this broken mosaic world could ever become one of continuity and coherence. I couldn’t imagine—but, all of a sudden, it did! The mosaic, the flickering, were gone in an instant—and there was Nurse Sulu, no longer decomposed in space and time, but real and solid, warm and alive, quick, beautiful, once more in the stream of action and life. There had been beauty, mathematical beauty, in the crystalline world, but no beauty of action, no beauty of grace.

  “That’s it,” I said with delight. “I think you helped to chase the aura away! And the nausea’s all gone. Now—yes, now—I would like those kippers I smelled earlier.”

  I ate an enormous, a most sumptuous breakfast, much to the surprise of Nurse Sulu, who had seen me ashen-pale and retching less than an hour before. But after such attacks the patient “awakes a different being” (as the great Dr. Edward Liveing wrote), and I indeed felt a different being, resurrected, reborn after my night of horrors and migraine. But what made this rebirth even more joyous was the feeling that I had achieved by analogy some understanding of my leg. This understanding had no effect on the physiological reality, but it took it out of the realms of the incomprehensible, the unmentionable—I could discuss it with Sw
an. He, I felt sure, would be deeply fascinated—and in turn could reassure me on the two points which now mattered: what had caused my scotoma and how long would it last? There were other questions I would like to put to him, if time permitted: how often did he see such scotomata in his practice, and were they well described in the medical literature? Yes, not only would I be given the reassurance I so badly needed, but I would have the chance of a fascinating exchange with my colleague, which would make clearer for us both this fascinating field on the borders of orthopedics and neurology.

  I was so excited by the prospect, that I ate my huge breakfast in a state of abstraction, only subliminally appreciating the lovely crisp kippers.

  * * *

  —

  In due course Sister came in.

  “Look what a mess you are in, Dr. Sacks!” she said, in good-humored reproof. “You have books and letters and pieces of paper all round you—and, I do believe, you have spilt ink on the sheets!”

  “It’s my fountain pen,” I apologized. “Sometimes it leaks.”

  “Well, we must get everything cleared up and shipshape after breakfast. It’s Grand Rounds today” (Sister’s voice somehow seemed to capitalize the words) “and Mr. Swan will be here promptly at nine!”

  With a smile, and a headshake, she bounced out.

  “She’s a good sort,” I thought, in my kipperish euphoria. “A bit stern, a bit of a martinet, but a Sister must be that. She’s a good-hearted old thing, under that rough voice, that awful exterior.”

  My teapot was whisked away before my third cup, and Nurse Sulu brought me a basin, and whispered, “Quick! Shave!”

  I removed the untidy growth of six days—was it just six days since I set out on the mountain?—and trimmed my beard. I cleaned my teeth and gargled.

  Nurse Sulu helped me into the chair, put clean sheets on the bed and tidied the room. Then she helped me back into bed, saying: “Sister likes the patients propped up, right in the middle. Try and stay in the center. Don’t lean to one side!”

  I agreed to follow her instructions and asked her to leave the door open, because I had caught the sounds of the whole ward being cleared up and made shipshape—sounds so extraordinary that I wanted to hear them more clearly. Sister was barking, but good-humoredly, like a sergeant-major. The nurses and aides were running to and fro, all untidiness and litter were being softly abolished. There was the half-serious, half-comic sense of a military inspection—boots shined, puttees blancoed, chests out, stomachs in, everything ready and perfect.

  The bustle, shouting and laughter was terrific. I was sorry I could only hear it, not see it. In the vast din everything was becoming orderly under the power of Sister’s voice and eye. Now I saw us less as a parade ground, more as a great ship being readied and made shipshape for something.

  Suddenly the bustle and clatter seemed to cease, and was replaced by an extraordinary stillness. I heard a whispering, a murmuring, of which I could distinguish nothing.

  And now Swan entered, accompanied by Sister bearing his surgical and ceremonial tools on a tray, followed by the Senior Registrar and his Juniors in long white coats. Finally came the Students, in short coats, looking unusually subdued. Formally and somberly as a religious procession, the chief and his retinue entered my room.

  Swan neither looked at me nor greeted me, but took the chart which hung at the foot of my bed and looked at it closely.

  “Well, Sister,” he said, “and how is the patient now?”

  “No fever, now, Sir,” she answered. “We took the catheter out on Wednesday. He is taking food by mouth. There is no swelling of the foot.”

  “Sounds fine,” said Mr. Swan, and then turned to me, or, rather, to the cast before me. He rapped it sharply with his knuckles.

  “Well, Sacks,” he said. “How does the leg seem today?”

  “It seems fine, Sir,” I replied, “surgically speaking.”

  “What do you mean—‘surgically speaking’?” he said.

  “Well, umm—” I looked at Sister, but her face was stony. “There’s not much pain, and—er—there’s no swelling of the foot.”

  “Splendid,” he said, obviously relieved. “No problems then, I take it?”

  “Well, just one.” Swan looked severe, and I started to stammer. “It’s…it’s…I don’t seem to be able to contract the quadriceps…and, er…the muscle doesn’t seem to have any tone. And…and…I have difficulty locating the position of the leg.”

  I had a feeling that Swan looked frightened for a moment, but it was so momentary, so fugitive, that I could not be sure.

  “Nonsense, Sacks,” he said sharply and decisively. “There’s nothing the matter. Nothing at all. Nothing to be worried about. Nothing at all!”

  “But…”

  He held up his hand, like a policeman halting traffic. “You’re completely mistaken,” he said with finality. “There’s nothing wrong with the leg. You understand that, don’t you?”

  With a brusque and, it seemed to me, irritable movement, he made for the door, his Juniors parting deferentially before him.

  I tried to catch the expression of the team as they turned, but their faces were closed and told me nothing. Swiftly the procession wheeled from the room.

  I was stunned. All the agonized, agonizing uncertainties and fears, all the torment I had suffered since I discovered my condition, all the hopes and expectations I had pinned on this meeting—and now this! I thought: what sort of doctor, what sort of person, is this? He didn’t even listen to me. He showed no concern. He doesn’t listen to his patients—he doesn’t give a damn. Such a man never listens to, never learns from, his patients. He dismisses them, he despises them, he regards them as nothing. And then I thought—I am being terribly unfair. I was provocative, unwittingly, when I said “surgically speaking.” Further, we were both on the spot, because of the formality, the officialdom, of Grand Rounds. Both of us, in a sense, were forced to play roles—he the role of the All-knowing Specialist, I the role of the Know-nothing Patient. And this was sharpened and made worse by my being, and being seen as, and partly acting as, his peer, so that neither of us really quite knew where we stood. And again; I could be certain that he was not really unfeeling—I had seen feeling, strong feeling, which he had to suppress, precisely as Miss Preston did when she saw the denervation. How different it might have been if we had met as individuals—but this was impossible in the grim context of Grand Rounds. Perhaps all would be different if I could have a quiet word with his Registrar—a cozy man-to-man chat after Grand Rounds.

  The staff nurse said “Yes,” she would ask him to drop by. But the Registrar, alas, was exasperated and exasperating, obviously annoyed that I had asked for this special extra meeting.

  “Well, Sacks,” he snorted. “What’s the matter now? Haven’t you been told there is nothing the matter? Are you critical of the surgery or post-operative care?”

  “Not at all,” I replied. “Both seem exemplary.”

  “What is the matter then?”

  “The leg doesn’t feel right.”

  “This is very vague and subjective. Not the sort of thing we can be concerned with. We orthopods are really carpenters, in a way. We are called in to do a job. We do it. And that’s that.”

  “Since you speak of carpentry,” I replied, “that’s just what it feels like. Carpentry would suffice if it were a wooden leg. And this is exactly how the leg feels—wooden, not like flesh, not alive, not mine.”

  “Sacks, you’re unique,” the Registrar said. “I’ve never heard anything like this from a patient before.”

  “I can’t be unique,” I said, with anger, and rising panic. “I must be constituted the same way as everyone else! Perhaps (my anger was getting the better of me now), perhaps you don’t listen to what patients say, perhaps you’re not interested in the experiences they have.”

 
“No, indeed, I can’t waste time with ‘experiences’ like this. I’m a practical man, I have work to do.”

  “Experience aside then, the leg doesn’t work.”

  “That’s not my business.”

  “Then whose business is it? Specifically, there is something physiologically the matter. What about a neurological opinion, nerve-conduction tests, EMGs, etc.?”

  He turned away and gave me no answer.*3

  *1 English and American parlance is still widely separate in these hospital terms. A houseman would be called an intern in the United States, and a registrar a resident. Surgeons are called “Mr.” in England, rather than “Dr.,” and the chief nurse on a ward is called the Sister.

  *2 This story is included as a chapter in The Man Who Mistook His Wife for a Hat, along with a similar story from a colleague.

  *3 It was only four years later that I was put through nerve-conduction tests, electromyograms, and so forth. These showed that there was still quite severe denervation of the quadriceps, and marked impairment of conduction in the femoral nerve which supplies it. At the time of my alienation, my scotoma, these impairments must have been profound—or absolute.

  CHAPTER THREE

  Limbo

  A land of darkness, as darkness itself—and of the shadow of death, without any order; and where the light is as darkness.

  —JOB 10:22

  The scotoma, and its resonances, I had already experienced—frightful, empty images of nothingness, which surged, and overwhelmed me, especially at night. As a bulwark against this—I had hoped, and supposed—would come the genial understanding and support of my doctor. He would reassure me, help, give me a foothold in the darkness.