An Anthropologist on Mars (1995) (14 page)

Many professions, one would think, would be closed to someone with elaborate tics and compulsions or strange, antic behaviors, but this does not seem to be the case. Tourette’s affects perhaps one person in a thousand, and we find people with Tourette’s—sometimes the most severe Tourette’s—in virtually every walk of life. There are Tourettic writers, mathematicians, musicians, actors, disc jockeys, construction workers, social workers, mechanics, athletes. Some things, one might think, would be completely out of the question—above all, perhaps, the intricate, precise, and steady work of a surgeon. This would have been my own belief not so long ago. But now, improbably, I know five surgeons with Tourette’s.
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53. A further four surfaced (one an ophthalmic surgeon) following the original publication of this piece. In addition to these Tourettic surgeons, I now know of three Tourettic internists, two Tourettic neurologists, but only one Tourettic psychiatrist.

I first met Dr. Carl Bennett at a scientific conference on Tourette’s in Boston. His appearance was unexceptionable—he was fiftyish, of middle size, with a brownish beard and mustache containing a hint of gray, and was dressed soberly in a dark suit—until he suddenly lunged or reached for the ground or jumped or jerked. I was struck both by his bizarre tics and by his dignity and calm. When I expressed incredulity about his choice of profession, he invited me to visit and stay with him, where he lived and practiced, in the town of Branford, in British Columbia—to do rounds at the hospital with him, to scrub with him, to see him in action. Now, four months later, in early October, I found myself in a small plane approaching Branford, full of curiosity and mixed expectations. Dr. Bennett met me at the airport, greeted me—a strange greeting, half lunge, half tic, a gesture of welcome idiosyncratically Tourettized—grabbed my case, and led the way to his car in an odd, rapid skipping walk, with a skip each fifth step and sudden reachings to the ground as if to pick something up.

The situation of Branford is almost idyllic, nestled as it is in the shadow of the Rockies, in southeast British Columbia, with Banff and its mountains to the north, and Montana and Idaho to the south; it lies in a region of great gentleness and fertility but is ringed with mountains, glaciers, lakes. Bennett himself has a passion for geography and geology; a few years ago he took a year off from his surgical practice to study both at the University of Victoria. As he drove, he pointed out moraines, stratifications, and other formations, so that what had at first seemed to my eyes a mere pastoral landscape became charged with a sense of history and cathonic forces, of immense geological vistas. Such keen, fierce attention to every detail, such constant looking below the surface, such examination and analysis, are characteristic of the restless, questioning Tourettic mind. It is, so to speak, the other side of its obsessive and perseverative tendencies, its disposition to reiterate, to touch again and again.

And, indeed, whenever the stream of attention and interest was interrupted, Bennett’s tics and iterations immediately reasserted themselves—in particular, obsessive touchings of his mustache and glasses. His mustache had constantly to be smoothed and checked for symmetry, his glasses had to be “balanced”—up and down, side to side, diagonally, in and out—with sudden, ticcy touchings of the fingers, until these, too, were exactly “centered.” There were also occasional reachings and lungings with his right arm; sudden, compulsive touchings of the windshield with both forefingers (“The touching has to be symmetrical”, he commented); sudden repositionings of his knees, or the steering wheel (“I have to have the knees symmetrical in relation to the steering wheel. They have to be exactly centered”); and sudden, high-pitched vocalizations, in a voice completely unlike his own, that sounded like “Hi, Patty”, “Hi, there”, and, on a couple of occasions, “Hideous!” (Patty, I learned later, was a former girlfriend, her name now enshrined in a tic.)
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54. Tics can have an ambiguous status, partway between meaningless jerks or noises and meaningful acts. Though the tendency to tic is innate in Tourette’s, the particular form of tics often has a personal or historical origin. Thus a name, a sound, a visual image, a gesture, perhaps seen years before and forgotten, may first be unconsciously echoed or imitated and then preserved in the stereotypic form of a tic. Such tics are like hieroglyphic, petrified residues of the past and may indeed, with the passage of time, become so hieroglyphic, so abbreviated, as to become unintelligible (as “God be with you” was condensed, collapsed, after centuries, to the phonetically similar but meaningless “goodbye”). One such patient, whom I saw long ago, kept making an explosive, guttural, trisyllabic noise, which revealed itself, on analysis, as a very accelerated, crushed rendering of “Verboten!” in a convulsive parody of his father’s constantly forbidding German voice.

A recent correspondent, a woman with Tourette’s, after reading an earlier version of this piece, wrote that “ ‘enshrinement’—is the perfect word to describe the interplay between life and tics—the process by which the former gets incorporated into the latter—It is almost as if the Tourettic body becomes an expressive archive—albeit jumbled—of one’s life experience.”

There was little hint of this repertoire until we reached town and got obstructed by traffic lights. The lights did not annoy Bennett—we were in no hurry—but they did break up the driving, the kinetic melody, the swift, smooth stream of action, with its power to integrate mind and brain. The transition was very sudden: one minute, all was smoothness and action; the next, all was broken-upness, pandemonium, riot. When Bennett was driving smoothly, one had the feeling not that the Tourette’s was in any way being suppressed but that the brain and the mind were in a quite different mode of action.

Another few minutes, and we had arrived at his house, a charming, idiosyncratic house with a wild garden, perched on a hill overlooking the town. Bennett’s dogs, rather wolflike, with strange, pale eyes, barked, wagged their tails, bounded up to us as we drove in. As we got out of the car, he said “Hi, puppies!” in the same quick, odd, high, crushed voice he had earlier used for “Hi, Patty!” He patted their heads, a ticlike, convulsive patting, a quick-fire volley of five pats to each, delivered with a meticulous symmetry and synchrony. “They’re grand dogs, half-Eskimo, half-malamute”, he said. “I felt I should get two of them, so they could companion each other. They play together, sleep together, hunt together—everything.” And, I thought, are patted together: Did he get two dogs partly because of his own symmetrical, symmetrizing compulsions? Now, hearing the dogs bark, his sons ran out—two handsome teenage kids. I had a sudden feeling that Bennett might cry “Hi, kiddies!” in his Touretty voice and pat their heads, too, in synchrony, symmetrically. But he introduced them, Mark and David, individually to me. And then, as we entered the house, he introduced me to his wife, Helen, who was preparing a late-afternoon tea for all of us.

As we sat at the table, Bennett was repeatedly distracted by tics—a compulsive touching of the glass lampshade above his head. He had to tap the glass gently with the nails of both forefingers, to produce a sharp, half-musical click or, on occasion, a short salvo of clicks. A third of his time was taken up with this ticcing and clicking, which he seemed unable to stop. Did he have to do it? Did he have to sit there?

“If it were out of reach, would you still have to click it?” I asked.

“No”, he said. “It depends entirely on how I’m situated. It’s all a question of space. Where I am now, for example, I have no impulse to reach over to that brick wall, but if I were in range I’d have to touch it perhaps a hundred times.” I followed his glance to the wall and saw that it was pockmarked, like the moon, from his touchings and jabbings; and, beyond it, the refrigerator door, dented and battered, as if from the impact of meteorites or projectiles. “Yeah”, Bennett said, now following my glance. “I fling things—the iron, the rolling pin, the saucepan, whatever—I fling things at it if I suddenly get enraged.” I digested this information in silence. It added a new dimension—a disquieting, violent one—to the picture I was building and seemed completely at odds with the genial, tranquil man before me.
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55. Some people with Tourette’s have flinging tics—sudden, seemingly motiveless urges or compulsions to throw objects—quite different from Bennett’s flinging in rage. There may be a very brief premonition—enough, in one case, to yell a warning “Duck!”—before a dinner plate, a bottle of wine, or whatever is flung convulsively across the room. Identical throwing tics occurred in some of my postencephalitic patients when they were overstimulated by L-DOPA. (I see somewhat similar flinging behaviors—though not tics—in my two-year-old godson, now in a stage of primal antinomianism and anarchy.)

“If the light so disturbs you, why do you sit near it?” I asked.

“Sure, it’s ‘disturbance,’ ” Bennett answered. “But it’s also stimulation. I like the feel and the sound of the click. But, yeah, it can be a great distraction. I can’t study here, in the dining room—I have to go to my study, out of reach of the lamp.”

The sense of personal space, of the self in relation to other objects and other people, tends to be markedly altered in Tourette’s syndrome. I know many people with Tourette’s who cannot tolerate sitting in a restaurant within touching distance of other people and may feel compelled, if they cannot avoid this, to reach out or lunge convulsively toward them. This intolerance may be especially great if the “provoking” person is behind the Touretter. Many people with Tourette’s, therefore, prefer corners, where they are at a “safe” distance from others, and there is nobody behind them.
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56. This was comically shown on one occasion when I went to a restaurant for dinner with three Tourettic friends in Los Angeles. All three of them at once rushed for the corner seat—not, I think, in any competitive spirit, but because each saw it as an existential-neural necessity. The lucky one was able to sit calmly in his place, while the other two were constantly lunging at other diners behind them.

Analogous problems may arise, on occasion, when driving; there may be a sense that other vehicles are “too close” or “looming”, even that they are suddenly “zooming”, when they are (a non-Tourettic person would judge) at a normal distance. There may also be, paradoxically, a tendency to be “attracted” to other vehicles, to drift or veer toward them—though the consciousness of this, and a greater speed of reaction, usually serves to avert any mishaps. (Similar illusions and urges, stemming from abnormalities in the neural basis of personal space, may occasionally be seen in parkinsonism, too.)

Another expression of Bennett’s Tourette’s—very different from the sudden impulsive or compulsive touching—is a slow, almost sensuous pressing of the foot to mark out a circle in the ground all around him. “It seems to me almost instinctual”, he said when I asked him about it. “Like a dog marking its territory. I feel it in my bones. I think it is something primal, prehuman—maybe something that all of us, without knowing it, have in us. But Tourette’s ‘releases’ these primitive behaviors.”
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57. Tourette’s should not be regarded as a psychiatric disorder, but as a neurobiological disorder of a hyperphysiological sort, in which there may occur subcortical excitation and spontaneous stimulation of many phylogenetically primitive centers in the brain. A similar stimulation or release of “primitive” behaviors may be seen with the excitatory lesions of encephalitis lethargica, such as I describe in Awakenings (pp. 55-6). These were often apparent in the early days of the illness and became prominent again with the stimulation of L-DOPA.

Bennett sometimes calls Tourette’s “a disease of disinhibition.” He says there are thoughts, not unusual in themselves, that anyone might have in passing but that are normally inhibited. With him, such thoughts perseverate in the back of the mind, obsessively, and burst out suddenly, without his consent or intention. Thus, he says, when the weather is nice he may want to be out in the sun getting a tan. This thought will be in the back of his mind while he is seeing his patients in the hospital and will emerge in sudden, involuntary utterances. “The nurse may say, ‘Mr. Jones has abdominal pain,’ and I’m looking out of the window saying, ‘Tanning rays, tanning rays.’ It might come out five hundred times in a morning. People in the ward must hear it—they can’t not hear it—but I guess they ignore it or feel that it doesn’t matter.”

Sometimes the Tourette’s manifests itself in obsessive thoughts and anxieties. “If I’m worried about something”, Bennett told me as we sat around the table, “say, I hear a story about a kid being hurt, I have to go up and tap the wall and say, ‘I hope it won’t happen to mine.’ ” I witnessed this for myself a couple of days later. There was a news report on TV about a lost child, which distressed and agitated him. He instantly began touching his glasses (top, bottom, left, right, top, bottom, left, right), centering and recentering them in a fury. He made “whoo, whoo” noises, like an owl, and muttered sotto voce, “David, David—is he all right?” Then he dashed from the room to make sure. There was an intense anxiety and overconcern; an immediate alarm at the mention of any lost or hurt child; an immediate identification with himself, with his own children; an immediate, superstitious need to check up.

After tea, Bennett and I went out for a walk, past a little orchard heavy with apples and on up the hill overlooking the town, the friendly malamutes gamboling around us. As we walked, he told me something of his life. He did not know whether anyone in his family had Tourette’s—he was an adopted child. His own Tourette’s had started when he was about seven. “As a kid, growing up in Toronto, I wore glasses, I had bands on my teeth, and I twitched”, he said. “That was the coup de grâce. I kept my distance. I was a loner; I’d go for long hikes by myself. I never had friends phoning all the time, like Mark—the contrast is very great.” But being a loner and taking long hikes by himself toughened him as well, made him resourceful, gave him a sense of independence and self-sufficiency. He was always good with his hands and loved the structure of natural things—the way rocks formed, the way plants grew, the way animals moved, the way muscles balanced and pulled against each other, the way the body was put together. He decided very early that he wanted to be a surgeon.