June 2024

The 19th volume we’ve read in the increasingly poorly named Essay Project, this being (another) book that does not contain essays. But we’ve become fascinated by O.S. from reading his two autobiographies and the edited collection of his letters, and just can’t stop.

Contents

About the Book

This is the third book that Sacks published (1984), following Migraine and Awakenings. To me this is the book where he found his narrative voice, or at least the voice that has proved so engaging to non-medical readers. It is a breakthrough in his writing style. And it is a gripping narrative, with lucid and beautiful writing. Gone are the clinical passages and case histories that were interspersed throughout his first two books. It will be interesting to see if his subsequent ‘neurographies’ continue in this more narrative and engaging voice.

This book begins with an accident in 1974 in which O.S. nearly died, severely injured his leg and, during his recovery, experienced very odd neurological ‘side effects.’ The book discusses both the neurological issues, but also leads him to reflect on the state of institutional medical care, and — from his new vantage point as a patient — the relationship between physician and patient.

Chapter by Chapter

C1: The Mountain

Sacks hikes up a mountain in a remote area of Norway; he believes he is the only person within 10 miles. Part way up he encounters a gated fence and a sign that says “Beware of the Bull.” He ignores it and proceeds.

A couple miles farther up the mountain he rounds a rock and encounters the bull:

It had a huge horned head, a stupendous white body and an enormous mild milk-white face. It sat unmoved by my appearance, exceedingly calm, except that it turned its vast white face up towards me. And in that moment, in my terror, it changed, before my eyes, becoming transformed from magnificent to utterly monstrous. The huge white face seemed to swell and swell, and the great bulbous eyes became radiant with malignance. The face grew huger and huger all the time, until I thought it would blot out the universe. The bull became hideous-hideous beyond belief, hideous in strength, malevolence and cunning. It seemed now to be stamped with the infernal in every feature. It became, first a monster, and now the Devil.

Oliver Sacks, A Leg to Stand On, p. 5-6

He panics “and runs heedlessly down the mountain “and I ran for dear life-ran madly, blindly, down the steep, muddy, slippery path, lost here and there in patches of mist. Blind, mad panic! —there is nothing worse in the world-nothing worse, and nothing more dangerous.” He has no memory of the accident, but regains consciousness at the bottom of a cliff. His left leg is badly injured. He assesses the situation and realizes that if he is not able to get back down the mountain he will die of exposure when night comes.

He manages to splinter his leg with an umbrella and begins to drag himself down the mountain. He tries to call for help, but falls into a panic again, believing he may have attracted the bull and hides. Nothing happens. He recovers and continues making his way down. Evening comes, and he can see the villiage he left from far below, and realizes he will not make it. Then, ten minutes before total darkness arrives, he hears a yodel and is rescued by a shepherd and his son. They care for him, summon help from the village, and he is rescued.

ADD NOTE ON HIS PAYCHOLOGACAL STATE DURING THUS TIME.

C2: Becoming a Patient

Sacks is taken to a very small hospital. It is decided that he should return to London for surgery on his leg. But while he is in the small hospital he has an amazing experience.

I immediately fell asleep again, and slept soundly and well until a most amazing apparition entered the room, so that I rubbed my eyes thinking I was still dreaming. A young man-dressed, preposterously, in a white coat, for some reason came in dancing, very lightly and nimbly, and then pranced round the room and stopped before me, flexing and extending each leg to its maximum like a ballet dancer. Suddenly, startlingly, he leapt on top of my bedside table, and gave me a teasing elfin smile. Then he jumped down again, took my hands and wordlessly pressed them against the front of his thighs. There, on either side, I felt a neat scar.

“Feel, yes?” he asked. “Me too. Both sides. Skiing … See!” And he made another Nijinski-like leap.

Of all the doctors I had ever seen, or was later to see, the image of this young Norwegian surgeon remains most vividly and affectionately in my mind, because in his own person he stood for health, valor, humor-and a most wonderful, active empathy for patients. He didn’t talk like a textbook. He scarcely talked at all he acted. He leapt and danced and showed me his wounds, showing me at the same time his perfect recovery. His visit made me feel immeasurably better.

–ibid., 27

Sacks is transported to London and has a disillusioning experience with the dehumanizing bureaucracy if the hospital. Before and after the surgery he has a disappointing experience with the surgeon, though the nurse is kind. He discovers that his injured leg is unnaturally flaccid and that he can neither move nor feel it. The PT person is horrified, as is he, but the surgeon ignores his concerns. As time progresses he loses the sense that the leg even belongs to him; he cannot imagine it or imagine how to tense its muscles or otherwise control it. He finds this experience bizarre and terrifying. Thus ends chapter 2.

… reading break …

Limbo

The previous chapter ends with his surgeon denying any interest in Sacks’ experience with the ‘absence’ of feeling in and of his leg. He doesn’t acknowledge it, and tells Sacks that other patients do not experience, that Sacks is ‘unique.’ This adds to Sacks’ distress:

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.

But, instead, he did the reverse. By saying nothing, saying “Nothing,” he took away a foothold, the human foothold, I so desperately needed. Now, doubly, I had no leg to stand on; unsupported, doubly, I entered nothingness and limbo.

—ibid., 85

The rest of this brief chapter is a lyrical meditation on being lost, hopeless, abandoned, in limbo. He draws comfort, or at least finds a degree of resonance, in the mystics – from Donne John, to T. S. Eliot, to the Psalms. He also recalls, early on, what a surgical resident (not his own) had said to him: “Take it easy! The whole thing, going through it, is really a pilgrimage.”

This period of limbo lasts 12 days:

Throughout these twelve endless yet empty days the leg itself had not changed a jot; it remained entirely motionless, toneless, senseless, beneath its white sepulchre of chalk. Its absolute fixity and unchangeability, its replacement, so to speak, by an inorganic white cylinder, its lifeless, petrified and calcarious quality, were re-presented to me every night, countless times a night.

— ibid., p. 93

The period is exacerbated by him being in an effectively windowless room, so interior that his radio can not pick up music.

Quickening

After his twelve days in limbo, he begins to get feeling in his leg. At first it is a few flashes of prickly pain, and some involuntary twitches. He characterizes this as feeling like an electrical storm, an “electrical muttering and crackling in the nerve-muscle.“

Sacks had requested that his friend, Jonathan Miller, bring a tape recorder so that he could hear music. Miller did so, but had only one cassette, Mendlessohn’s Violin Concerto. Sacks, for whom this had not been a favorite, found it transporting, giving him hope of healing, and lifting his mood.

The next day — the fourteenth since his surgery – Sacks went in to have the cast removed, and sounds like he had a somewhat hallucinatory experience while that was happening, with Mr. Enoch, the person removing the cast, seeming at turns taciturn and threatening, and then quiet and competent. He sees his leg and touches it, but it has no feeling. The nurse who removes the stitches warns him that he might feel discomfort, but he feels nothing. In fact, he can’t tell she is doing anything — he sees her as just fiddling around — until, suddenly, she has finished and the stitches are out. Now Mr. Enoch lifts the leg and Sacks can see that the knee cap now locks in place, and that it is, mechanically, at least, working properly. He feels hope and although the leg still seems a stranger to him, he sees it as a fetus, and the new cast that is being applied as a chrysallis.

Returning to his room from the casting room, he is wheeled past open windows, and they pause: he sees the sky, and feels the sun and wind on his flesh, and is transported. On returning to the room he finds a new radio that works, and can hear more music. He feels hope and falls into the first deep, dreamless sleep since his accident. When he awakes he can flex his leg. This doesn’t last, but returns sporadically, in flashes, though the day. It is both the power of moving the leg, and the idea of moving it, that are appearing and vanishing… it seems clear that there is a connection between the function of the nerves in his leg, and his proprioceptive mental model in his mind — Sacks uses the term “ideomotor.” Sacks comments that the feeling — “half jerk, half act” — comes on him unaware; he cannot will it.

The chapter ends with the approach of the 18th day since his accident, the appointed day for him to stand and walk. Sacks finds difficulty even imagining that he can do this.

Solvitur Ambulando

This chapter begins with Sacks being stood up by two physical therapists, with two crutches to support himself. He cannot feel his leg, or locate it; even looking at it he has difficulty recognizing it as his leg. His therapists both urge him to put weight on it. He tries, but finds himself overcome with a sort of sensory vertigo – the same things seem close one second, and impossibly far away the next; the leg — the casted cylinder – seemed a thousand feet long one second, and a couple millimeters the next. He was ‘infinitely unsteady.’

I was present, it is true, but only as an observer— a mere spectator at a primordial event, or “Big Bang,” which was the start of inner space, the microcosm, in me. […] A true miracle was being enacted before me, within me. Out of nothingness, out of chaos, measure was being made. The jumping fluttering metrics were converging towards some average a proto-scale. I felt terror, but also awe and exhilaration of spirit. Within me there seemed to be the working of a cosmic mathematics, the establishment of an impersonal microcosmic order.

—ibid., p.115

After this, he can’t think how to take a step, but the nurse moves his leg, and now he finds he is able to do so, but only with full conscious attention to each movement and its distance and direction. He is dismayed by this and wonders if he will ever get back the feel of walking. Then, suddenly, he hears the Mendhelssohn concerto in his mind, and is able to walk with the music. In that moment, the leg comes back, and feels like his, and he is able to walk with it. He walks for a few minutes, and then ‘forgets’ again (and the music stops); he rests, and then it comes back, with the music again, and he is able to walk back to his room just a few steps away.

Everything was transformed, absolutely, in that moment, in that leap from a cold fluttering and flashing to the warm stream of music, the stream of action, the stream of life. The delirium, the pandemonium, the kaleidoscope, the cinema — this was essentially inanimate, discontinuous; whereas the stream of music, of action, of life, was essentially, and entirely, and indivisibly, a stream, an organic whole, without any separations or seams, but articulate, articulated, articulate with life. An entirely new principle came into effect-what Leibniz called a “new active principle of unity”—a unity only present in, and given by, action.

—ibid., p. 122-123

… reading break …

C6: Convalescence

[…]

Now I realized that such regression was universal. It would occur with any immobilization, illness, or confinement. It was an unavoidable, natural shrinking-down of existence, made both bearable and untreatable because not realizable— not directly realizable. How could one know that one had shrunk, if one’s frame of reference had iself shrunk? One had to be reminded of the great world one had “forgotten” —and then, only then, could one expand and be cured.

— ibid., p. 131-132

We speak, glibly, of “institutionalization,” without the smallest personal sense of what is involved — how insidious, and universal, is the contraction in all realms (not least the moral realm), and how swiftly it can happen to anyone, to oneself.

Sacks writes of the transformation that being able to use his leg brought about, how it enabled himself to think of himself as an agent that could move about and act upon a world, an attitude that “incredibly, ominously, I had half forgotten about.
He notes that his recovery proceeded unevenly, that he would sometimes fall back into the delirium which (in my view) coincided with the dissolution of the proprioceptive model of his leg.
Later he is moved to a new and larger room, and discovers that his stereo vision is confined the volume of his former room, and that it recovers in fits and starts, expanding to fit the increasingly voluminous scopes as he experiences them.
Sacks speaks of two miseries that attended his affliction. One was the physical or existential one; but more pernicious was what he called a moral affliction. That had to do with the loss of control — the confinement or restriction of what he was able and allowed to do; he also describes finding himself “not just contracted, but contorted as well into roles and postures of abjection.” P 152.
He also remarks that it was often himself that was the author of his constricted view of his life and agency, or if not himself, the part of him that had internalized the institution. But now that he was beginning to encounter other patients, he could see the limitations they imposed on themselves, though he could not recognize this in himself.
He tells a great story about when he is finally shamed into leaving the grounds of the convalescent house, he ends up at a tea house, and the waitress recognizes that he has finally gotten himself to leave (to explode out of the house as she puts it) — as many patients do this — and that now he is ready for his first meal ‘outside.’
Upon his leaving the grounds of the home, he is overcome with joy, almost in a manic state: “I fell in love with the world; I chartered taxies as extravagantly as a potentiate visiting from another land.” (p -157)
Sacks goes to see a senior neurologist who observes that he is not using his knee. This neurologist understands what Sacks has been through, and suggests that he has ‘forgotten’ his knee. He asks Sacks his favorite physical activity, and on hearing Sack’s reply “Swimming!” calls a taxi and sends Sacks off to a swimming pool. There he hesitantly approaches the pool, and to his surprise the lifeguard takes his cane and pushes him in, challenging him to a race. Sacks is surprised and furious, and sets out to ‘show the fellow.’ After the race, Sacks finds that he is now using his knee normally. The next day it becomes clear the the neurologist had set all this up, because in cases like this one must be “tricked into action.” He added, “It’s the same with a dog.”

C7: Understanding

This experience has changed Sacks’ life, and after he returns to practice he pays close attention to this type of neurological injury, particularly those triggered by peripheral disorders.
Subsequently he finds other case studies that describe similar disturbances of the body-image due to peripheral disorders. .

Every such patient, it became increasingly clear, goes through a profound ontological experience, with dissolutions or annihilations of being, in the affected parts, associated with an elemental derealization and alienation, and an equally elemental anxiety and horror. This is followed, if they are fortunate enough to recover, by an equally elemental sense of “re-realization” and joy.

–ibid. p 174

Afterword (1992)

Sacks tells the story of how, just after the publication of the first edition of Leg, he fell and injured his right quadriceps. This time he was able to have the surgery under a spinal anesthesia, so he could watch it; afterwards he experiences no loss of body-image.
He also notes that by 1984, neurologists had come to recognize that time was of the essence in getting patients who have experienced deinnervation (or amputation) to re-experience the presence of a limb (or prosthesis). This minimizes disruption of the body-image.
Sack returns to his experience, and the general phenomenon, and makes further tries at analyzing and understanding it that view embodiment as fundamental to ego and consciousness. This is interesting material, but I will not summarize it here.

# # #