A Leg to Stand On

by Oliver Sacks, M. D.

  Yes, indeed, with the cast off, my leg did look splendid—it had fleshed out handsomely, though it was still thinner (and somewhat cooler) than the other one, and the surgical scar was neat and trim—and handsome, too, in its way, especially if I thought of it as a battle scar, heroic. There was none of the alienation which had so shocked me four weeks before. The leg was clearly alive, clearly real, clearly flesh, clearly mine, with only a slight vagueness or oddness about the knee. I was somewhat surprised, therefore, to find the skin numb—absolutely numb, anaesthetic, throughout the whole area where the cast had been. It wasn’t a deep numbness—proprioception seemed normal (which went with the normal, unalienated feel of the limb)—but a dense, superficial one.

  As I returned to Caenwood in the ambulance I rubbed and kneaded the leg in my hands; and as I did so, as I stimulated the skin and its sensors, sensation came back, minute by minute, and had almost completely returned in the hour of the trip. Whether it was the deprivation of ordinary sensations inside the cast, or the pressure of the plaster, I wasn’t sure. I found that other patients had found similar numbness—superficial, transient, and seemingly not of much account. The loss of deep sensation, of proprioception, was quite different, and deadly.

  I say “almost,” because one area, on the outside of my thigh and knee, didn’t yield to my ministrations and remained totally without any sensation whatever. This was where the skin branches of the femoral nerve had been cut in the operation.

  Now the cast was off, a final problem remained—getting some movement at the knee, which seemed immovably rigid, transfixed in extension by a huge mass of scar tissue. I had to spend half an hour each day forcefully, forcibly, making the knee bend, trying to loosen up and break down the hard fibrous scar.

  On Friday, since all was going well, I was permitted to spend a night at home. The whole family gathered to welcome me—it was Sabbath Eve. The next morning, I went to the synagogue with my father and brothers, and we were all called up together for the reading of the law. And this, to my surprise, was an inexpressible joy; for behind my family I felt embraced by a community and, behind this, by the beauty of old traditions, and, behind this, by the ultimate, eternal joy of the law. The portion was from Genesis, near the beginning, most appropriate to a man who felt reborn; for shortly before, on Simchat Torah—The Rejoicing of the Law—the year-long reading of the law had come to its end, and restarted, and the shofar had been blown, followed by a great cry: “Now the world is new created.”

  The service, the ceremonies, the Bible stories, now made sense in a way which they had never fully or truly done before. A pantheistic feeling had infused the past month, the feeling that the world was God’s gift, to be thanked back to God. Now, within the religious ceremonies and stories, I found a true parable of my own experience and condition—the experience of affliction and redemption, darkness and light, death and rebirth—the pilgrimage which fortune, or my injury, had forced upon me. Now, as never before, I found relevance in the scriptural symbols and stories. I felt that my own story had the shape of such a universal existential experience, the journey of a soul into the underworld and back, a spiritual drama—on a neurological basis.

  In a sense my experience had been a religious one—I had certainly thought of the leg as exiled, God-forsaken, when it was “lost” and, when it was restored, restored in a transcendental way. It had, equally, been a riveting scientific and cognitive experience—but it had transcended the limits of science and cognition. I felt it likely that this would effect a permanent change, and dispose me sympathetically to philosophy and religion, without abating a jot my scientific passion and rigor. I saw, I foresaw, how they would come together in me.

  Another twelve days and I was discharged from Caenwood, an exemplary convalescent judged fit for the world. I had loved it there and formed real bonds with others, and saying farewell was a poignant experience, which resounded with its original and proper meaning. We had journeyed together, for a brief but profound portion of life; we had shared our feelings with a rare intimacy and candor; and now we were parting and going our ways, wishing each other to fare well on the journey of life.

  * * *

  —

  I had known great happiness and great peace at Caenwood, but it was an interlude in life, and so had to have its end. I was still not wholly functional, and I felt I wanted another opinion—from some experienced orthopedist who would look at me with fresh eyes and give me advice for the future.

  I phoned Mr. W.R. of Harley Street, who said he would see me the next day.

  I presented myself hopefully, but with no particular expectations. He was a ruddy, genial man, who immediately put me at my ease, and listened with attention, occasionally asking a penetrating question. He gave me the sense that he was interested in me—me as a person, no less than as a problem; and he seemed to have all the time in the world, though I knew he was one of the most sought-after men in England. He listened, with perfect concentration and courtesy, and then he examined me, swiftly, but authoritatively, in detail.

  This is a master, I said to myself: I will listen to him as he has listened to me.

  “Quite an experience, Dr. Sacks,” he concluded. “Ever consider making it into a book?”

  I was flustered, and flattered, and said that I had.

  “The alienation,” he continued, “—it’s a common phenomenon. I often see it in my patients, and I warn them beforehand.”

  Here was a master indeed, I thought. Would things have been different if he had been my surgeon?

  “In your case, of course, the alienation was worse, because of the profound proprioceptive deficit. I can still demonstrate this, at the knee, though it is no longer symptomatic. But you may get symptoms if you push the leg too hard. You will have to exercise judgment for a year, at the least.

  “Now, as regards your walking, and as regards your knee, you walk as if you still had the cast. You hold the leg stiffly, as if you had no knee. Yet you have 15 degrees of flexion already—not much, but enough. Enough to walk normally if only you used it.”

  I nodded assent.

  “Why do you walk as if there were no knee? It is partly habit—this is how you walked with the cast—partly, I think, because you have ‘forgotten’ your knee, and can’t imagine what using it is like.”

  “I know,” I said. “I feel that myself. But I can’t seem to use it in a deliberate way. Whenever I try, it feels awkward. I stumble.”

  He thought for a moment. “What do you like doing?” he continued. “What comes to you naturally? What is your favorite physical activity?”

  “Swimming,” I answered, with no hesitation.

  “Good,” he said. “I have an idea.” There was a half-smile, somewhat impish, on his face. “I think your best plan is to go for a swim. Will you excuse me for a minute? I have a phone call to make.”

  He came back in a minute, the smile more pronounced.

  “A taxi will be here in five minutes,” he said. “It will take you to a pool. I’ll see you at the same time tomorrow.”

  The taxi arrived, and took me to the Seymour Hall Baths. I rented a towel and trunks, and advanced tremblingly to the side. There was a young lifeguard there, lounging by the diving board, who looked at me quizzically and said, “Why, what’s the matter?”

  “I’ve been told I ought to take a swim,” I said. “The doctor told me, but I’m disabled. I’ve had surgery, I’m sort of scared.”

  The lifeguard unwound himself, slowly, languidly, leaned towards me, looked mischievous and suddenly said, “Race you!”, at the same time taking my stick with his right hand and pushing me in with his left.

  I was in the water, outraged, before I knew what had happened—and then the impertinence, the provocation, had their effect. I am a good swimmer—a “natural”—and have been since childhood—from infancy, indeed, for my father, a swimming-champ, had th
rown us in at six months, when swimming is instinctual and doesn’t have to be learned. I felt challenged by the lifeguard. By God, I’d show him! Provocatively he stayed just a little in front of me, but I kept up a fast crawl for four Olympic lengths, and only stopped then because he yelled, “Enough!”

  I got out of the pool—and found I walked normally. The knee was now working, it had “come back” completely.

  When I saw Mr. W.R. the next day, he gave a big laugh and said, “Splendid!”

  He asked me the details, I told him and he laughed even more.

  “Good lad!” he said. “He does it just the right way.”

  I realized then that the whole scene, the scenario, was his doing, his suggestion—that he had told the lifeguard precisely what to do. I burst out laughing too.

  “Damnedest thing,” he said. “It always seems to work. What one needs is spontaneity, to be tricked into action. And you know,” he leaned forward, “it’s the same with a dog!”

  “A dog?” I repeated, stupidly blinking.

  “Yes, a dog,” he replied. “It happened with mine—Yorkshire terrier, sweet bitch, broke her silly leg. I set it, it healed perfectly, but she’d only walk on three legs—kept sparing the broken one, had forgotten how to use it. It went on for two months. She wouldn’t walk properly. So I took her down to Bognor, and waded out to sea, carrying this stupid sweet animal with me. I took her out as far as I could, and then dumped her in and let her swim back. She swam back with a strong symmetrical paddle, and then scampered off along the beach on all four legs. Same therapy in both cases—unexpectedness, spontaneity, somehow evoking a natural action.”

  I was delighted with this story, and with Mr. W.R. generally. I was rather pleased to be compared with a dog—I much preferred it to being called “unique.” And it brought home something about the elemental nature of the animal soul and animal motion, and about spontaneity, musicality, animation.

  Spontaneity! That was it! But how could one plan spontaneity? It was almost a contradiction in terms. Spontaneity, playfulness, it was comically clear, lay at the heart of W.R.’s theory and practice of therapy—the finding of some activity which was natural and meaningful, an expression of a will that found delight in itself—“condelectari sibi” in Duns Scotus’ words. “What do you enjoy?” he had said. “What gives you delight?” W.R.’s therapy was essentially “Scotian”—and he had arrived, intuitively, at the point of view that all function is embedded in action, and that acting, therefore, is the key to all therapy—be it playful, earnest, impulsive, spontaneous, musical, theatrical, so long as it is action.

  The next day I went to our local pool in Kilburn—the pool my father had thrown me into, forty years before—and had a delectable Scotian swim, so full of delight that I could have gone on forever—for in activity which is joyful, as opposed to activity that is labor, there is no drive, no exhaustion, only delight and repose. Leaving the pool at last, not exhausted but refreshed, I saw the bus I wanted rounding a corner. Without thinking, just responding, I ran after it, caught it, jumped onto it and ran up the stairs. And there were another two victories for Scotus—I had not known I could run or jump, and had I tried, deliberately, I would have come to grief. Indeed that very morning I said mournfully to myself, “You can walk, my boy, but you’ll never run or jump.”

  On Friday evening I took myself off, profanely, to the Cricklewood dance hall. I watched with delight the dancers dancing—contrasting this with my sourness five weeks before, when I had turned away in hate from the young footballers at Highgate. I felt the itch, the impulse, to dance myself, but I would not have dared to do so—me, a middle-aged man, just out of a cast—if a bunch of dancers hadn’t grabbed my arm and gaily forced me to join their rhythm. I didn’t have to think. I had no decision to make, I was caught up in joyful motion, natural will—ut natura—before I realized what was happening.

  * * *

  —

  I slept late the next morning, and didn’t wake up till my brother came in, saying, “Here’s a letter from your pal Professor Luria in Moscow.”

  I took the letter from him, trembling with excitement. It had been several weeks since I had written to Luria, feeling that he, and he only, would understand what I wrote. I had been fearful when weeks passed without a reply, for he had always responded promptly when I had written to him before (but the delay was benign, he had been in his summer dacha). What would he say? He would certainly say what he felt. He was incapable of dissimulation, as he was incapable of grossness. Would he say, delicately, that I had been hysterical, mad? I tore open the letter, afraid of my own thoughts.

  Yes, yes, he believed me! He believed what I was saying—and found it “most important.” He found my observations surprising, yet ultimately coherent—with the unity one would expect, given the functional unity of the organism. He felt I was really “discovering a new field” and that it was vital that I tell my story.

  Ah, what a letter! The most beautiful, understanding, generous letter in the world! A letter of salutation—and profound affirmation. Drunk with happiness, I found myself walking to the Heath. In childhood, Hampstead Heath had been my playground and dreamscape—the favored place of all my childhood fantasies and games. As an adolescent and a young man, I had fallen in love with it again. Here, more sedately, I would walk and talk with my friends, timelessly, all day. More important perhaps, Hampstead Heath was later the scene of long meditative rambles, when the childish fancies became the scientific dreams and theories of the young man.

  I walked to Parliament Hill, one of the highest points, commanding fine vistas in every direction. I thought of all that had passed in the previous nine weeks—the immense adventure, now drawing to its close. I had seen depths and heights not commonly seen. I had dwelt in them, explored them, the far limits of experience. Now, in a sense, I would come down to earth, would be leading a more normal and ordinary life, without the wild extremities and epiphanies of the past weeks. I felt this as a loss. My adventure was ending. But I knew that something momentous had happened, which would leave its mark, and alter me, decisively, from now on. A whole life, a whole universe, had been compressed into these weeks: a density of experience neither given to, nor desired by, most men; but one which, having happened, would refashion and direct me.

  “I am sorry it happened to you,” wrote Luria, “but if such a thing happens it can only be understood, and used. Perhaps it was your destiny to have the experience; certainly it is your duty now to understand and explore…Really you are opening and discovering a new field.”

  * Similar phenomena, I had heard, occurred with pygmies living in rainforest so dense that their far-point was no more than six or seven feet away. If taken out of the forest, they would be totally bewildered, have no perception of space or distance beyond a few feet, might try to touch distant mountaintops with their outstretched arms. If they remained out of the rainforest, perceptual adaptation rapidly occurred, so that within a few days there was “normal” perception of space and distance.

  CHAPTER SEVEN

  Understanding

  The truth of things is after all their living fulness, and some day, from a more commanding point of view than was possible to any one in [a previous] generation, our descendants, enriched with the spoils of all our analytic investigations, will get round to that higher and simpler way of looking at nature.

  —WILLIAM JAMES

  Thought ceased and the investigator rested during the happy weeks of convalescence. I was recovering daily. I was active. I was rejoicing in the world—in a situation no longer problematical.

  But the sense of the problematic—the problem, the many problems, which faced me—was merely deferred, and was precisely focussed for me when I received Luria’s letter. Where the surgeon had said to me, “Sacks, you’re unique: I’ve never heard anything like this from a patient before,” Luria wrote: “Your letter brings to
gether into a unity what I have heard of in fragments for the past fifty years….” Why were such experiences so rarely presented, he wondered, and what might be the basis for such an experience? “The body is a unity of actions, and if a part of the body is split off from action, it becomes ‘alien’ and not felt as part of the body.” This was well described, he said, with cerebral lesions, especially when they affected the right hemisphere of the brain, in the sensory (or parietal) lobe. He instanced Pötzl’s syndrome, in which, as a result of a stroke or a tumor, the left half of the body, or part of it, was ignored, or felt as alien and unreal. This, indeed, had been my own first thought—that I must have suffered a stroke during the course of anesthesia. But such syndromes had hardly ever been described as a consequence of a peripheral disorder or lesion.