A Leg to Stand On

by Oliver Sacks, M. D.

  I consoled myself, after a fashion, by saying, “This is not me—not the real me—but my sickness which is speaking. A well-documented phenomenon—the hateful spite of the sick.”

  And I added, “You may feel it, but be sure you don’t show it.”

  Greatly shaken, appalled, I tottered back to my seat. The day was still sunny, but morally overcast.

  I had a similar experience the very next day, when as I wandered in the grounds I came across rabbits in a hutch. Again I was surprised by a spasm of hate: “How dare they frolic, when I am disabled?” And, again, by a beautiful cat, whom I hated precisely for her beauty and grace.

  I was appalled by these reactions, this venomous, bilious turning-away from life, these sudden floodings of bile after the exalted, lyrical sentiments I professed. But they were instructive, and it was important to face them; important, too, to confess them, for the understanding of others. And here my fellow-patients were marvelous, for when I did confess, shamefaced and stuttering, they said, “Don’t worry, we went through it ourselves. We all go through it—it’ll go away soon.”

  I hoped they were right. I could not be sure. All I could be certain of was my hate at the time. I smiled, kindly, at the aged and infirm; indeed I could tolerate nobody else. My heart went out to the ailing and suffering, but shut itself with a snap at the spectacle of health.

  But on Monday, when I started on the physiotherapy program, and the therapist was affirmative and profoundly encouraging, giving me the feeling that I might hope for a virtually complete recovery, I discovered that the hateful feeling was gone. I stroked the cat, I fed the rabbits, and I spent an hour watching the young footballers with pleasure. Here, then, was a radical turning to life.

  I find it difficult to write of all this, even years later. It is easy to recollect the good things of life, the times when one’s heart rejoices and expands, when everything is enfolded in kindness and love; it is easy to recollect the fineness of life—how noble one was, how generous one felt, what courage one showed in the face of adversity. It is harder to recollect how hateful one has been.

  I lied when I said, “It’s not me, not the real me. It’s the sickness that’s speaking.” For sickness has no voice, and it was me, a nasty me. How can I claim that my goodness, my lofty feelings, constitute the “real me,” and that my rancor and malice are just “sickness” and not me?

  We can readily see in others what we do not care, or dare, to see in ourselves. The patients I work with are chronically ill. They have, they know they have, little or no hope of recovery. Some of them show a transcendent humor and gallantry, an unspoilt love and affirmation of life. But others are bitter, virulent, envenomed—great haters, great spiters, murderous, demonic. It is not the sickness but the person that shows here, his collapse or corruption with the cruelties of life. If we have youth, beauty, blessed gifts, strength, if we find fame, fortune, favor, fulfillment, it is easy to be nice, to turn a warm heart to the world. But let us be disfavored, disfigured, incapacitated, injured; let us fall from health and strength, from fortune and favor; let us find ourselves ill, miserable and without clear hope of recovery—then our mettle, our moral character, will be tried to the limit.

  I was tried myself, but only a little, and even so showed an ugly reaction. It soon went away. I did not have to live with a permanent disability—with a sense of permanent disability and misfortune. There was another patient at my table—a young painter who had just come back from open-heart surgery, after years of increasing cardiac disability. He was physically distressed for much of the time, and he looked haggard and aged and had a mean skunk-like look. He was at pains to suppress his feelings of rancor, which added to his miseries, and of which he felt ashamed; but they showed, in his eyes, even when he bit his tongue to keep silent. And my feelings to him, not too amiable, must have shown too, because one day he burst out, “It’s OK for you. You’re getting better. You’ll soon be well. You’ll be able to do whatever you want. But what do your doctor’s eyes tell you of me? I’ve got a bum heart, rotten vessels, the bypass isn’t working. Sure, I’ll go out, but I’ll be back again. I’ve been here five times. They know me by now. People don’t like to look in my face. They see the death-sentence, and that I’m taking it badly. They see my blue lips, and my meanness as well—as you see it, and then pretend you’ve seen nothing. Not nice, not a pretty sight, not dignified, not fine. But tell me what the hell I do about it, friend?”

  Like college, the Convalescent Home had structure and freedom—both, perhaps, in an unusual degree. There were set meal times, and set tables in the refectory for patients, set times for physiotherapy, and other activities, set times for medical visits and, at first, set limits for all other visits. Going out was not permitted to begin with, and when it was it was limited. Permission had to be given, with return by the curfew. And yet, in contrast to these almost monastic restrictions, there was the timelessness, the freedom, the idealism, of a monastery. A single thought or feeling held us together, the long pilgrimage which would finally return us to health and home, a thought at once devotional and practical. This was the unity and center of our lives—and perhaps it was not so far from the thought of a monastery—or, in its best sense, of a university also. We had known sickness as one knows error or evil, and now sought for health, the restored balance of being, as one seeks for goodness or truth.

  The daily curriculum, the set limits, were important. Without them we might have drifted into structurelessness and chaos, misjudged our capacities and either lain about, regressively and passively, or pushed ourselves far beyond our capacities. None of us yet had the resilience of health. We were still brittle, precarious; and we needed structure and care. We could not yet physically enjoy the freedom of health, its unthinking carelessness, exuberance and abundance. Thus our daily activities, our lives, had to be measured—and only gradually allowed to approach the normal.

  I was constantly escaping and overdoing things myself. I would go for a vast walk in the grounds, lured by the spacious lawns which led downwards, and the great sense of ease in these springy descents—only to find at the bottom, where the brook ran, that I was profoundly exhausted; and as I painfully made my way back I would find strength and tone in the left leg wilt away, and then, for my pains, a massive effusion in the knee which might lay me up, bedridden, for twenty-four hours. There was this sense of deceptive ease—but also of immense effort and difficulty in quite simple matters. It was not easy to get into or out of bed, or to maneuver into position for toilets and chairs. Constantly the crutches had to be at hand, and the yard-long caliper to grasp things at a distance. I found it hard to put on my left sock in the morning. I had to use a peculiar device, which had to be cast, snagged and then drawn on to the foot—like an exercise in fly-fishing.

  We had come for convalescence. We had to get better. But getting better is not an automatic and simple process, though getting sick, sickening, may occur by itself. It is significant perhaps that we do not have the corresponding word or concept, “healthening.” Instead we have “healing,” which means “making whole,” which implies, not a process, but an act—many acts.

  There is, of course, an automatic recovery—in regard to tissues, for example. This, indeed, was the only meaning of recovery, so far as the surgeon was concerned. Tissues had been severed, tissues had been joined; his job was done, for tissue-healing is automatic. Strictly speaking, qua surgeon, qua “carpenter,” he was right, though there was a sort of grudging prescription for “physiotherapy, post operative,” as if this was something purely medical or mechanical.

  There was, and is, a mechanical aspect to this. Muscles must be exercised, or they lose strength and tone. Exercise is necessary, and beneficial, for the muscles—necessary, and yet not enough. For standing, walking, let alone more complex motor skills and activities, are not just a matter of muscles (even if, as in my own case, the prime injury be muscular). Rehabil
itation involves action, acts. Rehabilitation must be centered on the character of acts—and how to call them forth, when they have come apart, disintegrated, been lost—or forgotten. Without this I would, indeed, have remained bedridden—precisely as Hippocrates says.

  But I could not do this by will power, or on my own steam, alone. The initiation, the impulse, had to come from without. I had to do it, give birth to the new act, but others were needed to deliver me, and say, “Do it!” They were the permitters, the prescribers, the midwives of the act—and, of course, its supporters and encouragers. And this was not just neurosis or passivity. Every patient, no matter how strong-minded or strong-willed, encounters precisely the same difficulty in taking his first step, in doing (or re-doing) anything anew. He cannot conceive it—“the imagination is subdued”—and others, understanding, must tip him into action. They (inter)mediate, so to speak, between passivity and action.

  This was the supreme act, the high point, of recovery. But it was not the end, only the beginning. And if I had to spend another six weeks thereafter, it was because other acts were needed, of a similar kind, because the restoration of higher function is not smooth and automatic. Rehabilitation, in this way, is recapitulation, second childhood; for, like childhood, it involves decisive acts of learning, sudden ascents from one level to the next, each level inconceivable to the level below. Physiology, or at least the physiology of higher functions, is dependent upon, embedded in, experiences and acts, and unless experiences and acts are made possible—the essential role of the therapist or teacher—the nervous system, the organization, will neither mature nor heal.

  Thus, in the Convalescent Home, though I grew daily stronger, and could do the same things with ever-greater power and ease, I could not do anything different, or new. This always required the intervention of another. This was shown, very strikingly, when the time came for me to “graduate”—to one crutch, and then, later, to a cane.

  There was a particularly fine and understanding young surgeon, Mr. Amundsen, who who visited the Convalescent Home three times a week, a man who understood, and with whom communication was possible. I once asked him about this (I could ask him such a question, where I could ask nothing, or almost nothing, of my surgeon in the hospital).

  “It’s simple,” he replied. “Maybe you guessed the answer. I’ve been through this myself. I had a broken leg….I know what it’s like.”

  So, when Mr. Amundsen said that the time had come to graduate, and give up one crutch, he spoke with authority—the only real authority, that of experience and understanding. I believed him. I had faith in him. But what he suggested was—impossible.

  “It’s impossible,” I stammered. “I can’t imagine it.”

  “You don’t have to ‘imagine’ it, only to do it.”

  Nerving myself up, quivering with tension, I tried—and immediately tripped and fell flat on my face. I tried again—and fell flat again.

  “Don’t worry,” he said. “It’ll just come—you’ll see.”

  (It “came” later that day—but it came in a dream.)

  It was at this time that I received a phone call from a friend. There was to be an anniversary service in Westminster Abbey for W. H. Auden—could I come? I loved and revered Auden, I wanted to come. More, I felt a duty to pay my last respects. I was painfully conflicted, but the terror won out:

  “I’m terribly sorry,” I said. “Of course I would come if it were physically possible. But at this stage, I’m afraid, its completely unthinkable. I so wish I could come, but it’s not to be thought of.” Yes, these were the words, the very words, I used.

  The next morning the physiotherapist looked in to see me—she had seen the proofs on my table of an article I had written on Auden—and remarked, “They said it was a deeply moving ceremony in the Abbey. You tell me all about it—of course you were there.”

  I was thunderstruck. My mental world seemed to shake. “But,” I stammered, “I couldn’t go.”

  “Why not?” she demanded.

  “I was asked to, I wanted to, but it was unthinkable, not to be thought of.”

  “Unthinkable!” she exploded. “Not to be thought of? Of course, you could have gone. You should have gone. What the hell stopped you? Why shouldn’t you go out?”

  My God, she was right! Who stopped me, what stopped me? What nonsense I had uttered about “not to be thought of.” The moment she spoke and said “Why not?” a great barrier disappeared—though I had not thought of it as a barrier, just “not to be thought of.” Was I “prohibited”—or was “the imagination subdued”?

  Whatever it was, I was liberated by her words, and said, “Godammit, I am going out right now!”

  “Good,” she replied. “And high time, too.”

  Swiftly, unthinkingly, I strode out of the gate and up the hill to Highgate. Wonderful! Ecstasy! My first walk outside the grounds of Caenwood. Until this walk, this moment, going outside had been unthinkable—I had felt an inmate and an invalid, and couldn’t imagine it otherwise. I had been completely unable to take this crucial step. Stepping outside into the wide world needed her “Why not?”

  I found a little teashop, at the top of Highgate Hill, and boldly, unhesitatingly, went in for tea.

  “You made it,” said the waitress. “You finally made it here.”

  “Do you know me?” I asked, amazed.

  “I don’t know you personally,” she said. “I know how it is. You folks sit in the Convalescent Home till you’re ready to explode—and, all of a sudden, you do explode, and the explosion takes you up the steep hill to Highgate, and right to this teashop, for your first meal outside!”

  “Yes,” I said, “you’re right on all counts.”

  And then I ordered myself, not just a pot of tea, but a veritable feast to celebrate my release.

  “They all do that!” the waitress declared.

  “They all,” “You all.” What did I care? Indeed it pleased me that I had acted, evidently, as many others before me. It made me feel less apart, less alienated, or “unique”: it placed me in the common rut, among others, a part of the world.

  I ordered almost everything on the menu—from anchovy toast to rum-balls and meringues—and everything was marvelous. Not only marvelous, but holy—I felt the meal as a sacrament, my first communion with the world. I had been starved of the world, now, for more than six weeks. I was hungry for the world, and I felt it as a feast. With every sacred mouthful—and I ate slowly, though hugely, with thanksgiving and reverence—I felt I was partaking of that holy feast, the world. The substance, the sensuousness, was spiritual as well. The food and drink were blessed—a sacramental feast.

  From this moment there was no stopping me. I went out constantly, I fell in love with the world, I chartered taxis as extravagantly as a potentate visiting from another land. And, in a sense, this is what I felt like—a man, a king, long exiled, returning, accorded a wonderful, royal welcome by the world he was returning to. I wanted to hug familiar dear buildings; I wanted to hug chance strangers in the street—to hug them, devour them, like my first meal in the teashop—for they too were part of the wonderful feast. I must have smiled and laughed a great deal, or otherwise exuded happiness and love, because I received a great deal in return. I felt this especially in the pubs around Hampstead—wonderful, jolly, crowded pubs, with gardens and awnings bright in the warm sun, and people the most genial and congenial in the world. My crutches (for I needed both, to get in and out of taxis), my cast, served as a passport of universal validity. I was welcomed, I was made much of, wherever I went. And I loved it, I who had been so withdrawn and so shy. I found myself singing, playing darts, telling bawdy stories, laughing.

  Everywhere, and in myself, I discovered a Rabelaisian gusto—a coarse, but festive, and perfectly chaste gusto. But also, and equally, I sought for the byways of life, quiet glades, moonlit walks, for meditation. I wan
ted to give thanks, in every mode—in energy, in quietude; in company, alone; with friends, with strangers; in action, in thought. The joy of this time was extraordinarily intense—but it seemed to me a healthy joy, without mania or sickness. I felt that this was how one should find the world—how the world really was, if one were not jaded or tarnished. I felt the gaiety and innocence of the newborn.

  And if this was “the truth,” or how things should be, how could one find the world dull? I wondered if what one normally calls “normal” was itself a sort of dullness, a deadening of sense and spirit, if not, indeed, a very closure of their doors. For myself, now, liberated, released, emergent from the dark night and abyss, there was an intoxication of light and love and health.

  I felt that a profound crisis had occurred in my life, and that from now on I would be profoundly and permanently transformed. I would take less for granted—indeed nothing for granted. I would see life, all being, as the most precious of gifts, infinitely vulnerable and precarious, to be infinitely prized and cherished.

  * * *

  —

  On Monday, October the 7th—six weeks after my operation—I was taken back to the hospital, to be checked and uncasted—uncasted for good, if all was well. I had no fear, I knew all was well—and I wanted to see my once-cursed surgeon and his team in an amicable light.

  Happily this occurred, and presented no problem. Mr. Swan found himself faced with a beaming grateful patient, who showed nothing but affability and regrets for past ire. He could not but respond in kind to all this, though his response had a quality of shyness and reserve. He smiled, but not widely; he shook my hand, but not warmly; he was cordial, but not amiable. I marveled that I could have endowed him with such hatefulness before—for he wasn’t really hateable, any more than he was lovable: just a decent, quiet man, professional and reserved; technically admirable, I had never doubted this at any time, but uncomfortable with the realities of powerful emotions, and incapable of meeting emotional demands—at least, demands as extreme as I had made, in my anguish. Now my anguish was over and my apprehensions were stilled, now I was better, I made no demands—and this pleased him greatly, and allowed a faint smile. As he changed for me, doubtless I changed for him. I imagined him chatting with the “team” later: “Not a bad chap, that Sacks—a bit emotional, of course. He was a bit of a nuisance in hospital, mind you—but maybe it was a difficult time for him. Wouldn’t care to be in that situation myself. But he’s fine now, isn’t he? Leg looks splendid. All’s well that ends well.” And with this he would dismiss me from his mind.