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Hole in the World

A Leg to Stand On

by Oliver Sacks
Summit Books, 222 pp., $14.95

Neurologists lead philosophically confounded professional lives—by necessity rather than choice. No other profession is so implacably condemned to dwell in that restless and prismatic space that lies between body and mind. If to the philosopher the mind–body problem is a playground for fancy analytic footwork, for the neurologist, it is a dilemma that compels the same kind of awesome respect that the mariner feels for the sea. For there is a compelling contradiction in any enterprise that, on the one hand, must diagnose highly subjective, introspective states, and, on the other, must locate the “causes” of these states and narratives in the objective world of brain tracts, nuclei, tissue bundles, Brodmann areas, and the rest. When Descartes located the soul in the pineal gland (the only unpaired structure in the brain) and argued that it must be so, because the soul too is unitary, he was only playing a hyperbolic version of the neurologist’s game.

The idea that psychological “dispositions”or “functions” have “seats” in the brain is a very ancient one. Its shrill explicitness in the phrenology of Franz Gall and Johann Spurzheim in the midnineteenth century was by no means its dying cry. It is an appealingly simple idea, localization, and it seemed to explain, in a deceptively superficial way, the findings from brain lesions, from stimulating the exposed brain directly with weak electrical current, and most recently, from the study of “unit receptors” in the cortex that fire, say, only when the eye is stimulated by contours, by lines in horizontal or vertical position, or by similar minutiae of stimulation. In consequence, “bits” of sensation or behavior have got matched up with bits of brain, and maps of the correspondences are drawn and redrawn for the textbooks showing “where” different functions “reside.”

It is a curious logical exercise, such neural cartography, particularly since we have also known for a long time that there are in the mantle of the human cortex alone a staggering 5 X 109 available connections between individual nerve cells, as well as reverbatory or Lorente de No circuits that proliferate connections between larger units than single cells. To say, for example, that stimulating a particular spot along the front of the fissure of Rolando is responsible for the contraction of the index finger is no more or less sensible than to say that the ticket printer in the Conrail ticket office is responsible for the grimy ride from Grand Central to New Haven. No wonder, then, that neurology is a discipline that suffers perennially the ravages of misplaced concreteness. Were it not so, we would never have experienced the ghastly trephinings of sick patients by medieval brain surgeons or, for that matter, the prefrontal lobotomies performed in our own century by their inheritors, one of whom (I hope to the perduring embarrassment of the committee) was awarded the Nobel Prize for Medicine in 1949.

But it is not only the “tissue side” of neurology that has suffered from the passion for topographic localization. The psychological side has suffered also, and perhaps more deeply, from a matching effort to describe finite behaviors that fit finite brain sites. To match “centers” and “seats” in the brain, neurologists have “discovered” (stipulated might be a better word) “functions” that reside (like the soul in the pineal) in this region or in that area. Neurologists will tell you today that speech “resides” in Broca’s area of the brain, or Wernicke’s, in the left temporal lobe of the cortex. Not surprising then that (in spite of what patients try to tell them) neurologists have so little to say about what happens to the will, to the self-image, to spontaneous expressions of zest, or, for that matter, to the ego, superego, and id, when tissue is damaged or destroyed, and why, in the main, the science of neurology has so appallingly little to offer beyond “the course of nature” when it comes to rehabilitating the brain that is injured.

But there has always been a curious counterreaction among neurologists, a tribe that gets its good share of the high flyers in graduating classes at first-class medical schools. Some of them find out soon enough that there is a good deal more to their craft than the classically received doctrine, that what happens to patients, however they may have acquired their lesions, is not simply a matter of a loss of this function or that. Patients’ lives change, their outlook, their worlds, the very narratives they construct to explain themselves. Some of the most literate of the neurologists have given us accounts of these post-traumatic changes that are milestones not only in psychological science, but also in psychological writing. Taken as science, their accounts permit us to go back over what happened and to reconstruct hypotheses about the nature and functioning of the mind and of the kinds of neural processes that are necessary to it. As the work of sensitive writers, they have provided oblique glimpses of broken souls engaged in strange and desperate struggle.

The clinical literature of neurology, in consequence, has its masterpieces of narrative description: Sir Henry Head’s classic accounts of aphasic patients; Kurt Goldstein’s vivid description of, say, “Case Lanuti,” a patient who could only recognize objects by trying to use them in action; or, most masterful of all, A.R.Luria’s brilliant study, The Man with a Shattered World (Basic Books, 1972), of a patient whose progress he followed for two decades after he received a penetrating head wound during the war, a wound that converted organized experience into broken shards. I had the experience of doing rounds with Luria at the Neurological Institute in Moscow. His professional forte was the use of “little tests” to spot disturbances in mental functioning. But his genius was in entering the subjective lives of his patients with an empathy and sensitivity worthy of Henry James, or perhaps William.

Oliver Sacks is a neurologist in this great tradition—indeed, he has dedicated his book to Luria, with whom he corresponded in an almost father–son way during Luria’s last years until he died in 1977. Sacks is the son, moreover, of a father who was Sir Henry Head’s admiring resident at Queen’s Square. He has shown himself to be a brilliant observer of mental states associated with neural trauma. His Awakenings (E.P.Dutton, 1973), on sleeping sickness and Parkinson’s disease, was praised by both Luria and W.H.Auden. His new book is about a horribly injured leg, his own, what he thought and learned while living through the terrors and raptures of recovering its function. But it is also a book about the philosophical dilemma of neurology, about the philosophy of mind, about what it might take to create a “neurology of the soul” while still hanging on to your scientific marbles.

The metaphor around which both Sack’s drama and his reflections revolve is the scotoma, and I had better say a word at once about these holes in experience, these pieces of self that evaporate, that escape the control of intention. For Sacks—for all that he concentrates on his disconnected leg—is writing about experience , self, intention, about their injury and restoration.

The visual scotoma—that is, a gap in the visual field—provides a good model of the metaphor. When a piece of occipital cortex is penetrated and/or invaded by a tumor or a toxic agent, there develops in a corresponding part of the visual field a “hole,” a dead area. Often the patient does not know he has it, complaining instead of “dimness” on that side. It is easy to miss a scotoma, for central processes often complete seen figures parts of which fall in the dead area. Sometimes the part of the world that falls into this hole suffers “neglect” altogether and is ignored completely. Occasionally involvement of the tempero-parietal area of the cortex produces a very strange version of a visual scotoma. The patient reports nothing there and shows the usual hole: if you present an object or picture to the “hole” the patient reports seeing nothing. But now ask him to guess which of several things it might have been. Even if he swears he cannot see anything, he will almost invariably guess correctly. The phenomenon is called “blindsight” and it is now under intense study with the few unfortunate cases who exhibit it.

Current theories hold that this form of awareness, unadorned by consciousness, is mediated by the intact old part of the brain, the optic tectum, that in its evolutionary history aimed the frog’s tongue at the natural fly and the trout’s lunge at a rising nymph. It may, in fact, be the same mechanism that accounts for “subliminal” information that people seem to gain from a very rapidly presented display that they also claim not to be able to see. Scotomata “blind” us, but the better way of saying this is that they cause the world to disappear where they occur: they create an existential, ontological hole rather than a cookie-cutter hole. But that needs modifying too. For there are some lighter scotomata where, if “neglect” (that telltale word of neurologists) is overcome by “hyperattention,” if we try very hard to see, then things come back into view and the hole is filled. Holes in the world, in short, pose very puzzling problems for the neurologist—and for the philosopher. After his injury, and after the surgery had rejoined the quadricep to the femoral nerve in his left leg, Oliver Sacks had a scotoma, a hole in the world for his leg. He could not feel it or move it. What he saw stretched out there below him was alien, “not-him,” nonexistent.

The circumstances of the injury have the quality of a fable, worthy of the kind of analysis developed by the folklore specialist Vladimir Propp. Sacks tells it with consummate skill. A fortyish, robust, and reflective English neurologist on holiday sets off to walk the six-thousand-foot mountain that surmounts the Hardanger fiord. He departs in the misty dawn from the village in whose church he has heard the Mozart Requiem the night before, hoping to reach the top by noon and be back down the steep mountain path before night sets in. Halfway up he reaches a path to the gate of which there is tacked a sign in Norwegian, BEWARE THE BULL! “A bull? Up here?” On he trudges, blessing Nature for strong legs trained by years of pushing himself at sports. Higher now, he threads his way among the great boulders, and as he rounds one, he comes upon the seated 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 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…. It seemed now to be stamped with the infernal in every feature. It became, first a monster, and now the Devil.

The Englishman panics, turns, and plunges headlong back down the treacherous and slippery path, unsure whether the thudding steps he hears are his own or those of the bull pounding after him. Then the slip, and he is at the bottom of a short, sharp cliff, his left leg twisted grotesquely beneath him, his knee in unimaginable pain. It flashes in his doctor-mind that somebody has been seriously injured, and in the next instant he realizes it is himself. The leg is dead, no tone, no motion. He pulls himself together and diagnoses: “Muscle paralyzed and atonic—probably nerve-injury. Unstable knee-joint—seems to dislocate backwards. Probably ripped out the cruciate ligaments.” He is alone in a desolate, unpopulated part of the world, with a totally useless leg, near the top of a mountain at an altitude and latitude where the temperature drops well below freezing at night, even in August. And then begins the fight for life.

He carries a stout umbrella for a walking stick on all his rambles; it is there by his side. He rips his anorak into strips, splints the umbrella to his paralyzed and numb leg, and starts down the long mountain—backward, on all threes, gulping in pain, dragging himself through a glacier-cold swollen stream on whose stepping stones he had fearfully leapt on the way up, feeling his consciousness ebbing from cold and shock. Down, down, until at seven the sun disappears. “I could no longer hear myself…. This must be the beginning of the end.”

Suddenly a shout: a man and a boy with rifles, a reindeer hunter and his son. He is saved, brought down the mountain, put in a local hospital, then flown to London and placed under the care of a noted orthopedic surgeon. Now the physical, spiritual, and philosophical ordeal begins.

The doctor has become a patient; he is operated upon by the brisk surgeon and is assured that the tendons have been reconnected to the quadriceps muscle, that all is well. But the leg is still paralyzed dead and lacking not only in the ordinary sensation but in the deep sense of “proprioception” that makes it possible to know that the leg is even there, let alone knowing where it is. No effort of will can reach it and nothing at all comes through by way of sensation. A scotoma where there was once a leg, an existential nothing.

For days on end he lies in his small room, taunted by nightmares of his lost capacities, failing persistently to reconnect his will to his leg in spite of the games-mistress urgings of his physiotherapist. No way to find the leg in the scotoma, no way of getting hold of it to move it—it is untethered, gone. He becomes convinced that there is “not just a lesion in my muscle, but a lesion in me.” He recalls Wittgenstein’s remark in his last book, On Certainty, to the effect that certainty is grounded in our certainty about our bodies, a certainty that comes from the capacity to act. He falls into a state of desolation. The brisk surgeon, grandly on rounds with his entourage of interns, inspects the casted leg and holds up his hand to interrupt patient Sacks as he recounts his troubles. “There’s nothing the matter…. You’re completely mistaken. There’s nothing wrong with the leg.” And so into limbo with the scotoma. Twelve empty days.

First came stabs of lightning pain, then one morning freshly awakened, there is a flash, an impulse to move the left leg, and with the impulse comes a spasm of movement, “half jerk, half act.” Will had connected again with action, but it was not spontaneous action, rather like “convulsions of will.” What was lacking was the music, the wholeness of an act. “Something spontaneous must happen—or nothing would happen at all.” Cajoled, bullied by the therapists, he takes his first step, dares it, does it—and remembers how to walk. “All of a sudden, I remembered walking’s natural, unconscious rhythm and melody; it came to me, suddenly, like remembering a once familiar but long-forgotten tune…,” like Zazetsky in Luria’s The Man with a Shattered World who makes the sudden discovery one day that writing is not, after all, those lines and letters but requires “giving yourself over” to its natural flow.

The long road to recovery follows, through convalescence, “not to be seen as a smooth slope, but as a series of radical steps, each…the quality of miracle.” With his scotoma, his “frame of reference” had shrunk, the visual depth of things beyond his narrow range squashed flat somehow. It returns, and with each return an insane optimism about what is now possible, leading most often to damaging overexertions. In the process he slowly recovers from the role of the patient, dependent for when to rise and when to walk (as John Donne long ago put it) upon a doctor’s word and will. For recovery also required a moral recovery from the “stationless status” of the helpless patient.

Throughout the book runs the theme of spontaneous “natural” action, of connecting self with natural act through intention. A consultant in Harley Street (seen because Sacks cannot get his uncast knee to act naturally in walking) asks him what sport he likes best. “Swimming.” “Good,” and he phones a swim bath, gets Sacks to go right over, where the tippedoff lifeguard laughingly pushes him into the pool with a “Race you!” Four laps of the Olympic pool; Sacks climbs out and walks naturally for the first time since the injury. He has found the music for his knee (as W.H. Auden tells him later, quoting Novalis: “Every disease is a musical problem, every cure a musical solution”).

Well recovered, years later, Sacks goes back to read the great neurologists, Luria in the meanwhile having urged him to write it down the better to start a new chapter in neurology. In Henry Head’s Studies in Neurology he finds only asides on such matters, Head’s attention being riveted instead on mechanisms and functions. He remembers his father saying that Head, though ordinarily hard-nosed, would be fascinated by such matters. “But it is precisely this ‘fascination’ that is missing from the Studies.” And then, “To be deaf to metaphysical implication is one thing, but to be deaf to anguish is another; and this was my indictment of classical neurology.” For to Sacks metaphysical deafness produces an existential deafness, a functional scotoma in the neurologist not only to the subtle links between mind and brain but to the human condition of the suffering patient.

And that, in essence, is the deep plea of Sack’s book, its philosophical position. As he reads, his heroes desert him, even the beloved and encouraging Luria, who, in the end, he sees as lured to soulless cybernetic models. He heaps angry scorn on two of Luria’s closest colleagues, Leont’ev and Zaporozhets, for their book The Rehabilitation of the Hand, in which “they spoke of patients being ‘blind’ and ‘deaf’ to their own hands. Yet they themselves were blind and deaf to the elemental implications of such ‘blindness’ and deafness.” For they scotomize unwittingly “the center, the living self, of their patients.” Though they observe the power of spontaneity in restoring function, they fail to see it.

That for Sacks—and for the philosophically confounded neurologist and contemporary philosophy as well—is the heart of the matter: how to deal with intention, will, self, spontaneity, where limits are drawn either by a topographic neurology or by a view of human action dominated by cybernetics and the theory of automata. Sacks has no solution to offer, only the kind of attentiveness to experience he demonstrates in his book and the hope that the fearless cultivation of both sides of the chasm in Goethe’s “Gray is all theory; green grows the golden tree of life,” may someday close the gap between the two modes of thought—the selfless, intentionless world of scientific paradigms, and the human domain of living creatures where self is defined by the vicissitudes of intention and the narratives that such struggles create.

This is a moving, at times perhaps over-emotional book, its descriptions sometimes evoking the late Erving Goffman, sometimes even Conrad. It is a masterful instance of what Alexander Luria lovingly and longingly used to refer to as “romantic science.” But for all that, it is also instructive to the philosopher coping with the ontology of intention, with those problems that Elizabeth Anscombe dealt with a quarter-century ago in her classic, Intentions, and that John Searle (among others) deals with today in the battle against an image of man on the model of the brainy automaton whose recursive loops enable “him” readily to reflect on his own action, indeed to reflect on his reflections, and to represent it all in memory store, but never to intend in sensu strictu, never to generate the form of spontaneity whose thwarting throws the machine into a stage of existential anguish. Sacks has written a book about a leg, his leg; but it is a story about the nature of selfhood—a narrative comparable to Conrad’s The Secret Sharer.

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