Warning: Non-commercial Purposes only. Copyright 1992, Dr. Oliver Sacks - The New Yorker Magazine; all rights reserved.
|Famed medical writer Oliver Sacks, M.D. has a long-standing interest in people with Tourette Syndrome. His latest work, The Anthropologist from Mars, features a chapter on a Canadian surgeon and amateur pilot with TS.|
Tourette syndrome is seen in every race, every culture, every
stratum of society; it can be recognized at a glance once one is
attuned to it; and cases of barking and twitching, of grimacing, of
strange gesturing, of involuntary cursing and blaspheming were
recorded by Aretaeus of Cappadocia almost two thousand years ago.
Yet it was not clinically delineated until 1885, when Georges
Gilles de la Tourette, a young French neurologist--a pupil of
Charcot's, and a friend of Freud's -- put together these historical
accounts with observations of some of his own patients. The
syndrome as he described it was characterized, above all, by
convulsive tics, by involuntary mimicry or repetition of others'
words or actions (echolalia and echopraxia), and by the
involuntary or compulsive utterances of curses and obscenities
(coprolalia). Some individuals (despite their affliction) showed an
odd insouciance or nonchalance; some a tendency to make strange,
often witty, occasionally dreamlike associations; some extreme
impulsiveness and provocativeness, a constant testing of physical
and social boundaries; some a constant, restless reacting to the
environment, a lunging at and sniffing of everything, or a sudden
flinging of objects; and yet others an extreme stereotypy and
obsessiveness--no two patients were ever quite the same.
Any disease introduces a doubleness into life--an "it," with its own needs, demands, limitations. With Tourette's, the "it" takes the form of explicit compulsion, of a multitude of explicit compulsions: one is driven to do this, to do that, against one's will. Tourette's may seize control at any time. Being "taken over" or "possessed" can be more than a figure of speech for someone with severe Tourette's, and no doubt in the Middle Ages Tourette's was sometimes seen as "possession." (Tourette himself was fascinated by the phenomenon of "possession," and wrote a play about the epidemic of demonic possession in medieval Loudun.)
But the relation of disease and self, "it" and "I," can be particularly complex in Tourette's, especially if it has been present from early childhood, growing up with the self, intertwining itself in every possible way. The Tourette's and the self shape themselves each to the other, come more and more to complement each other, until finally, like a long-married couple, they become a single, compound being. This relation is often destructive, but it can also be constructive, can add speed and spontaneity, and a capacity for unusual and sometimes startling performance. For all its intrusiveness, Tourette's may be used creatively, too.
Yet in the years after its first delineation, Tourette's tended to be seen not as an organic but as a "moral" disease--an expression of mischievousness or weakness of the will, to be treated by rectifying the will. From the nineteen-twenties to the nineteen-sixties, it tended to be seen as a psychiatric disease, to be treated by psychoanalysis or psychotherapy; but this, on the whole, proved ineffective, too. Then, with the demonstration, in the early sixties, that the drug haloperidol could dramatically suppress its symptoms, Tourette's was regarded--in a sudden reversal--as a chemical disease, the result of an imbalance of a neurotransmitter, dopamine, in the brain. But all these views are partial, and reductive, and fail to do justice to the full complexity of Tourette's, which may be almost as complex as human nature itself. Neither a biological nor a psychological nor a moral-social viewpoint is adequate; we must see Tourette's simultaneously from all three perspectives--as a biopsychosocial disorder. And one that is far from uncommon: it affects perhaps one person in a thousand.
Many professions, one would think, would be closed to someone with elaborate tics and compulsions, but this does not seem to be the case. 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, disk jockeys, construction 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.
I first met Dr. Carl Bennett, as I will call him, at a scientific conference on Tourette's in Boston last year. His appearance was unexceptionable--he was fiftyish, of middle size, with a brownish beard and mustache containing a hint of gray, and was dress 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 a town that I will call 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 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 chthonic forces, of immense geological vistas. Such keen, fierce attention to every detail, such constant looking below the surface, such examination and analysis, is 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 of 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.)
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 tic-like, 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 teen-age 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 pock-marked, 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.
"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."
Another expression of his 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."
Bennett sometimes calls Tourette's "a disease of disinhibition." He says there are thoughts, not unusual in themselves, which anyone might have in passing but which 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 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 gambolling 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 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 grace. 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.
Anatomy came "naturally" to him, he said, but he found medical school extremely difficult, not merely because of his tics and touchings, which became more elaborate with the years, but because of strange difficulties and obsessions which obstructed the act of reading. "I'd have to read each line many times," he said. "I'd have to line up each paragraph to get all four corners symmetrically in my visual field." Besides this lining up of each paragraph, and sometimes of each line, he was beset by the need to "balance" syllables and words, by the need to "symmetrize" the punctuation in his mind, by the need to check the frequency of a given letter, and by the need to repeat words or phrases or lines to himself. All this made it impossible to read easily and fluently. Those problems are still with him, and make it difficult for him to skim quickly, to get the gist, or to enjoy fine writing or narrative or poetry. But they did force him to read painstakingly, and to learn his medical texts very nearly by heart.
When he got out of medical school, he indulged his interest in faraway places, particularly the North: he worked as a general practitioner in the Northwest Territories and the Yukon, and worked on icebreakers circling the Arctic. He had a gift for intimacy, and grew close to the Eskimos he worked with; and he became something of an expert in polar medicine. And when he married, in 1968--he was twenty-eight--he went with his bride around the world, and gratified a boyhood wish to climb Kilimanjaro.
For the past seventeen years, he has practiced in small, isolated communities in western Canada--first, for twelve years, as a general practitioner in a small city. Then, five years ago, when the need to have mountains, wild country, and lakes on his doorstep grew stronger, he moved to Branford. ("And here I will stay. I never want to leave it.") Branford, he told me, has the right "feel." The people are warm but not chummy; they keep a certain distance. There is a natural wellbredness and civility. The schools are of high quality, there is a community college, there are theatres, and bookstores--Helen runs one of them--but there is also a strong feeling for the outdoors, for the wilds. There is much hunting and fishing, but Bennett prefers backpacking and climbing and cross-country skiing.
When Bennett first came to Branford, he was regarded, he thought, with a certain suspicion. "A surgeon who twitches! Who needs him? What next?" There were no patients at first, and he did not know if he could make it there, but gradually he won the town's affection and respect. His practice began to expand, and his colleagues, who had at first been startled and incredulous, soon came to trust and accept him, too, and to bring him fully into the medical community. "But enough said," he concluded as we returned to the house. It was almost dark now, and the lights of Branford were twinkling." Come to the hospital tomorrow--we have a conference at seven-thirty. Then I'll do outpatients, and rounds on my patients. And Friday I operate--you can scrub with me."
I slept soundly in the Bennetts' basement room that night, but in the morning I woke early, roused by a strange whirring noise in the room next to mine--the playroom. The playroom door had translucent glass panels. As I peered through them, still half-asleep, I saw what appeared to be a locomotive in motion--a large, whirring wheel going round and round and giving off puffs of smoke and occasional hoots. Bewildered, I opened the door and peeked in. Bennett, stripped to the waist, was pedalling furiously on an exercise bike while calmly smoking a large pipe. A pathology book was open before him--turned, I observed, to the chapter on neurofibromatosis. This is how he invariably begins each morning--a half hour on his bike, puffing his favorite pipe, with a pathology or surgery book open to the day's work before him. The pipe, the rhythmic exercise calm him. There are no tics, no compulsions--at most, a little hooting. (He seems to imagine at such times that he is a prairie train.) He can read without his usual obsessions and distractions.
But as soon as the rhythmic cycling stopped, a flurry of tics and compulsions took over; he kept digging at his belly, which was trim, and muttering, "Fat, fat, fat...fat, fat, fat...fat, fat, fat," and then, puzzlingly, "Fat and a quarter tit." (Sometimes the "tit" was left out.)
"What does it mean?" I asked.
"I have no idea. Nor do I know where `Hideous' comes from--it suddenly appeared one day two years ago. It'll disappear one day, and there will be another word instead. When I'm tired, it turns into `Gideous.' One cannot always find sense in these words; often it is just the sound that attracts me. Any odd sound, any odd name, may start repeating itself, get me going. I get hung up with a word for two or three months. Then, one morning, it's gone, and there's another one in its place." Knowing his appetite for strange words and sounds, Bennett's sons are constantly on the lookout for "odd" names--names that sound odd to an English-speaking ear, many of them foreign. They scan the papers and their books for such words, they listen to the radio and TV, and when they find a "juicy" name they add it to a list they keep. Bennett says of this list, "It's about the most valuable thing in the house." He calls its words "candy for the mind."
This list was started six years ago, after the name Oginga Odinga, with its alliterations, got Bennett going--and now it contains over two hundred names. Of these, twenty-two are "current" at the present time--apt to be regurgitated at any moment, and chewed over, repeated, and savored internally. Of the twenty-two, the name of Slavek J. Hurka--an industrial-relations professor at the University of Saskatchewan, where Helen studied--goes the furthest back; it started to echolale itself in 1974, and has been doing so, without significant breaks, for the last seventeen years. Most words last only a few months. Some of the names (Boris Blank, Floyd Flake, Morris Gook, Lubor J. Zink) have a short, percussive quality. Others (Yelberton A. Tittle, Babaloo Mandel) are marked by euphonious polysyllabic alliterations. It is only the sound of the words, their "melody," as Bennett says, which implants them in his mind; their origins and meanings and associations are irrelevant.
"It is similar with the number compulsions," he said. "Now I have to do everything by threes or fives, but until a few months ago it was fours and sevens. Then one morning I woke up--four and seven had gone, but three and five had appeared instead. It's as if one circuit were turned on upstairs, and another turned off. It doesn't seem to have anything to do with me."
At seven-twenty-five, we drove into town. It took barely five minutes to get to the hospital, but our arrival there was more complicated than usual, because Bennett had unwittingly become notorious. He had been interviewed by a magazine a few weeks earlier, and the article had just come out. Everyone was smiling, and ribbing him about it. A little embarrassed, but also enjoying it, Bennett took the joking in good part. ("I'll never live it down--I'll be a marked man now.") In the doctors' common room, Bennett was clearly very much at ease with his colleagues, and they with him. One sign of this ease, paradoxically, was that he felt free to Tourette with them--to touch or tap them gently with his fingertips, or, on two occasions when he was sharing a sofa, to suddenly twist on his side and tap his colleague's shoulder with his toes--a practice I had observed in other Touretters. Bennett is somewhat cautious with his Tourettisms on first acquaintance, and conceals or downplays them until he gets to know people. When he first started working at the hospital, he told me, he would skip in the corridors only after checking to be sure that no one was looking; now when he skips or hops no one gives it a second glance.
The conversations in the common room were like those in any hospital--doctors talking among themselves about unusual cases. Bennett himself, lying half-curled on the floor, kicking and thrusting one foot in the air, described an unusual case of neurofibromatosis--a young man whom he had recently operated on. His colleagues listened attentively. The abnormality of the behavior and the complete normality of the discourse formed an extraordinary contrast. There was something bizarre about the whole scene; but it was evidently so common as to be unremarkable, and no longer attracted the slightest notice. But an outsider seeing it would have been stunned.
After coffee and muffins, we repaired to the surgical-outpatients department, where half a dozen patients awaited Bennett. The first was a trail guide from Banff, very Western in plaid shirt, tight jeans, and cowboy hat. His horse had fallen and rolled on top of him, and he had developed an immense pseudocyst of the pancreas. Bennett spoke with the man--who said the swelling was diminishing--and gently, smoothly palpated the fluctuant mass in his abdomen. He checked the sonograms with the radiologist--they confirmed the cyst's recession--and then came back and reassured the patient. "It's going down by itself. It's shrinking nicely--you won't be needing surgery after all. You can get back to riding. I'll see you in a month." And the trail guide, delighted, walked off with a jaunty step. Later, I had a word with the radiologist. "Bennett's not only a whiz at diagnosis," he said. "He's the most compassionate surgeon I know."
The next patient was a heavy woman with a melanoma on her buttock which needed to be excised at some depth. Bennett scrubbed up, donned sterile gloves. Something about the sterile field, the prohibition, seemed to stir his Tourette's; he made sudden darting motions, or incipient motions, of his sterile, gloved right hand toward the ungloved, unwashed, "dirty" part of his left arm. The patient eyed this without expression. What did she think, I wondered, of this odd darting motion, and the sudden convulsive shakings he had also made with his hand? She could not have been entirely surprised, for her G.P. must have prepared her to some extent, must have said, "You need a small operation. I recommend Dr. Bennett--he's a wonderful surgeon. I have to tell you that he sometimes makes strange movements and sounds--he has a thing called Tourette's syndrome--but don't worry, it doesn't matter. It never affects his surgery."
Now, the preliminaries over, Bennett got down to the serious work, swabbing the buttock with an iodine antiseptic and then injecting local anesthetic, with an absolutely steady hand. But as soon as the rhythm of action was broken for a moment--he needed more local, and the nurse held out the vial for him to refill his syringe--there was once again the darting and near-touching. The nurse did not bat an eyelid; she had seen it before, and knew he wouldn't contaminate his gloves. Now, with a firm hand, Bennett made an oval incision an inch to either side of the melanoma, and in forty seconds he had removed it, along with a Brazil-nut-shaped wodge of fat and skin. "It's out!" he said. Then, very rapidly, with great dexterity, he sewed the margins of the wound together, putting five neat knots on each nylon stitch. The patient, twisting her head, watched him as he sewed, and joshed him: "Do you do all the sewing at home?"
He laughed. "Yes. All except the socks. But no one darns socks these days."
She looked again. "You're making quite a quilt."
The whole operation completed in less than three minutes, Bennett cried, "Done! Here's what we took." He held the lump of flesh before her.
"Ugh!" she exclaimed, with a shudder. "Don't show me. But thanks anyway."
All this looked highly professional from beginning to end, and, apart from the dartings and near-touchings, non-Tourettic. But I couldn't decide about Bennett's showing the excised lump to the patient. ("Here!") One may show a gallstone to a patient, but does one show a bleeding, mis-shapen piece of fat and flesh? Clearly, she didn't want to see it, but Bennett wanted to show it, and I wondered if this urge was part of his Tourettic scrupulosity and exactitude, his need to have everything looked at and understood. I had the same thought later in the morning, when he was seeing an old lady in whose bile duct he had inserted a T-tube. He went to great lengths to draw the tube, to explain all the anatomy, and the old lady said, "I don't want to know it. Just do it!"
Was this Bennett the Touretter being obsessive or Professor Bennett the lecturer on anatomy? (He gives weekly anatomy lectures in Calgary.) Was it simply an expression of his meticulousness and concern? An imagining, perhaps, that all patients shared his curiosity and love of detail? Some patients doubtless did, but obviously not these.
So it went on through a lengthy outpatient list. Bennett is evidently a very popular surgeon, and he saw or operated on each patient swiftly and dexterously, with an absolute and single-minded concentration, so that when they saw him they knew they had his whole attention. They forgot that they had waited, or that there were others still waiting, and felt that for him they were the only people in the world.
Very pleasant, very real, the surgeon's life, I kept thinking- -direct, friendly relationships, especially clear with outpatients like this. An immediacy of relation, of work, of results, of gratification--much greater than with a physician, especially a neurologist (like me). I thought of my mother, how much she enjoyed the surgeon's life and how I always loved sitting in at her surgical-outpatient rounds. I could not become a surgeon myself, because of an incorrigible clumsiness, but even as a child I had loved the surgeon's life and watching surgeons at work. This love, this pleasure, half-forgotten, came back to me with great force as I observed Bennett with his patients; made me want to be more than a spectator; made me want to do something, to hold a retractor, to join in somehow in the surgery.
Bennett's last patient was a young mechanic with extensive neurofibromatosis, a bizarre and sometimes cancerous disease that can produce huge brownish swellings and protruding sheets of skin, disfiguring the whole body. This young man had had a huge apron of tissue hanging down from his chest, so large that he could lift it up and cover his head, and so heavy that it bowed him forward with its weight. Bennett had removed this a couple of weeks earlier--a massive procedure--with great expertise, and was now examining another huge apron descending from the shoulders, and great flaps of brownish flesh in the groins and armpits. I was relieved that he did not tic "Hideous!" as he removed the stitches from the surgery, for I feared the impact of such a word being uttered aloud, even if it was nothing but a long-standing verbal tic. But, mercifully, there was no "Hideous," there were no verbal tics at all, until Bennett was examining the dorsal skin flap, and let fly a brief "Hid--," the end of the word omitted by a tactful apocope. This, I learned later, was not a conscious suppression--Bennett had no memory of the tic--and yet it seemed to me there must have been, if not a conscious, then a subconscious solicitude and tact at work. "Fine young man," Bennett said, as we went outside. "Not self-conscious. Nice personality, outgoing. Most people with this would lock themselves in a closet." I could not help feeling that his words could also be applied to himself. There are many people with Tourette's who become agonized and self-conscious, withdraw from the world, and lock themselves in a closet. Not so Bennett: he had struggled against this; he had come through and braved life, braved people, braved the most improbable of professions. All his patients, I think, perceived this, and it was one of the reasons they trusted him so.
The man with the skin flap was the last of the outpatients, but for Bennett, immensely busy, there was only a brief break before an equally long afternoon with his inpatients on the ward. I excused myself from this to take an afternoon off and walk around the town. I wandered through Branford with the oddest sense of deja vu and jamais vu mixed; I kept feeling that I had seen the town before, but then again that it was new to me. And then, suddenly, I had it--yes, I had seen it, I had been here before, for a night in August, 1960, when it had a population of only a few thousand and consisted of little more than a few dusty streets, motels, bars--a crossroads, little more than a truck stop in the long trek across the West. Now its population was twenty thousand, Main Street a gleaming boulevard filled with shops and cars; there was a town hall, a police station, a regional hospital, several schools--it was this which surrounded me, the overwhelming present, yet through it I saw the dusty crossroads and the bars, the Branford of thirty years before, still strangely vivid, because never updated, in my mind.
Friday is operating day for Bennett, and he was scheduled to do a mastectomy. I was eager to join him, to see him in action. Outpatients are one thing--one can always concentrate for a few minutes--but how would he conduct himself in a lengthy and difficult procedure demanding intense, unremitting concentration, not for seconds or minutes but for hours?
Bennett preparing for the operating room was a startling sight. "You should scrub next to him," his young assistant said. "It's quite an experience." It was indeed, for what I saw in the outpatient clinic was magnified here: constant sudden dartings and reachings with the hands, almost but never quite touching his unscrubbed, unsterile shoulder, his assistant, the mirror; sudden lungings, and touchings of his colleagues with his feet; and a barrage of vocalizations--"Hooty-hooo! Hooty-hooo!"--suggestive of a huge owl.
The scrubbing over, Bennett and his assistant were gloved and gowned, and they moved to the patient, already anesthetized, on the table. They looked briefly at a mammogram on the X-ray box. Then Bennett took the knife, made a bold, clear incision--there was no hint of any ticcing or distraction--and moved straightaway into the rhythm of the operation. Twenty minutes passed, fifty, seventy, a hundred. The operation was often complex--vessels to be tied, nerves to be found--but the action was confident, smooth, moving forward at its own pace, with never the slightest hint of Tourette's. Finally, after two and a half hours of the most complex, taxing surgery, Bennett closed up, thanked everybody, yawned, and stretched. Here, then, was an entire operation without a trace of Tourette's. Not because it had been suppressed, or held in--there was never any sign of control or constraint--but because, simply, there was never any impulse to tic. "Most of the time when I'm operating, it never even crosses my mind that I have Tourette's," Bennett says. His whole identity at such times is that of a surgeon at work, and his entire psychic and neural organization becomes aligned with this, becomes active, focussed, at ease, un-Tourettic. It is only if the operation is broken for a few minutes--to review a special X-ray taken during the surgery, for example--that Bennett, waiting, unoccupied, remembers that he is Tourettic, and in that instant he becomes so. As soon as the flow of the operation resumes, the Tourette's the Tourettic identity, vanishes once again. Bennett's assistants, though they have known him and worked with him for years, are still astounded whenever they see this. "It's like a miracle," one of them says. "The way the Tourette's disappears." And Bennett himself is astonished, too, and quizzes me, as he peels off his gloves, on the neurophysiology of it all.
Things were not always so easy, Bennett told me later. Occasionally, if he was bombarded by outside demands during surgery--"You have three patients waiting in the E.R.," "Mrs. X wants to know if she can come in on the tenth," "Your wife wants you to pick up three bags of dog food"--these pressures, these distractions, would break his concentration, break the smooth and rhythmic flow. A couple of years ago, he made it a rule that he must never be disturbed while operating, and must be allowed to concentrate totally on the surgery, and the O.R. has been tic-free ever since.
Friday afternoon is open. Bennett often likes to go for long hikes on Fridays, or cycle rides, or drives, with a sense of the trail, the open road, before him. There is a favorite ranch he loves to go to, with a beautiful lake and an airstrip, accessible only via a rugged dirt road. It is a wonderfully situated ranch, a narrow fertile strip perfectly placed between the lake and mountains, and we walked for miles, talking of this and that, with Bennett botanizing or geologizing as we went. Then briefly, we went to the lake, where I took a swim; when I came out of the water I found that Bennett, rather suddenly, had curled up for a nap. He looked peaceful, tension-free, as he slept; and the suddenness and depth of his sleep made me wonder how much difficulty he encountered in the daytime, how much he concealed beneath his genial surface--how much, inwardly, he had to control and deal with.
Later, as we continued our ramble about the ranch, he remarked that I had seen only some of the outward expressions of his Tourette's, and these, bizarre as they occasionally seemed, were by no means the worst problems it caused him. The real problems, the inner problems, were panic and rage--feelings so violent that they threatened to overwhelm him, and so sudden that he had virtually no warning of their onset. He had only to get a parking ticket or see a police car, sometimes, for scenarios of violence to flash through his mind: mad chases, shoot-outs, flaming destructions, hideous mutilation and death--scenarios that would become immensely elaborated in seconds, and rush through his mind with manic-Tourettic speed. One part of him, uninvolved, could watch these scenes with detachment, but another part of him was taken over, and felt impelled to action. He could prevent himself from giving way to outbursts in public, but the strain of controlling himself was severe and exhausting. At home, in private, he could let himself go--not at others but at inanimate objects around him. There was the wall I had seen, which he had often struck in his rage, and the refrigerator, at which he had flung virtually everything in the kitchen. In his office, he had kicked a hole in the wall, and had had to put a plant in front to cover it; and in his study at home the cedar walls were covered with knife marks. "It's not gentle," he said to me. "You can see it as whimsical, funny--be tempted to romanticize it--but Tourette's comes from deep down in the nervous system and the unconscious. It taps into the oldest, strongest feelings we have. Tourette's is like an epilepsy in the subcortex; when it takes over, there's just a thin line of control, a thin line of cortex, between you and it, between you and that raging storm, the blind force of the subcortex. One can see the charming things, the funny things, the creative side of Tourette's, but there's also that dark side. You have to fight it all your life."
Driving back from the ranch was a stimulating, at time terrifying, experience. Now that Bennett was getting to know me, he felt at liberty to let himself and his Tourette's go. The steering wheel was abandoned for seconds at a time--or so it seemed to me, in my alarm--while he tapped on the windshield (to a litany of "Hooty-hoo!" and "Hi, there!" and "Hideous!"), rearranged his glasses, "centered" them in a hundred different ways, and, with bent forefingers, continually smoothed and evened his mustache while gazing in the rearview mirror rather than at the road. His need to center the steering wheel in relation to his knees also grew almost frenetic at this time: he had constantly to "balance" it, to jerk it to and fro, causing the car to zigzag erratically down the road. "Don't worry," he said when he saw my anxiety. "I know this road. I could see from way back that nothing was coming. I've never had an accident driving."
The impulse to look, and to be looked at, is very striking with Bennett, and, indeed, as soon as we got back to the house he seized Mark and planted himself in front of him, smoothing his mustache furiously and saying, "Look at me! Look at me!" Mark, arrested, stayed where he was, but his eyes wandered to and fro. Now Bennett seized Mark's head, held it rigidly toward him, hissing, "Look, look at me!" and Mark became totally still, transfixed, as if hypnotized.
I found this scene disquieting. Other scenes with the family I had found rather moving: Bennett dabbing at Helen's hair, symmetrically, with outstretched fingers, going "whoo, whoo" softly. She was placid, accepting; it was a touching scene, both tender and absurd. "I love him as he is," Helen said. "I wouldn't want him any other way." Bennett feels the same way: "Funny disease--I don't think of it as a disease but as just me. I say the word `disease,' but it doesn't seem to be the appropriate word."
Though Bennett is quite prepared, even eager, to think of Tourette's in neurochemical or neurophysiological terms--he thinks in terms of chemical abnormalities, of "circuits turning on and off," and of "primitive, normally inhibited behaviors being released"--he also feels it as something that has come to be part of himself. For this reason (among others), he has found that he cannot tolerate haloperidol and similar drugs--they reduce his Tourette's, assuredly, but they reduce him as well, so that he no longer feels fully himself. "The side effects of haloperidol were dreadful," he said. "I was intensely restless, I couldn't stand still my body twisted, I shuffled like a Parkinsonian. It was a huge relief to get off it. On the other hand, Prozac has been a godsend for the obsessions, the rages, though it doesn't touch the tics." Prozac has indeed been a godsend for many Touretters, though some have found it to have no effect, and a few have had paradoxical effects--an intensification of their agitations, obsessions, and rages.
Though Bennett has had tics since the age of seven or so, he did not identify what he had as Tourette's syndrome until he was thirty-seven. "When we were first married, he just called it a `nervous habit,'" Helen told me. "We used to joke about it. I'd say, `I'll quit smoking, and you quit twitching.' We thought of it as something he could quit if he wanted. You'd ask him, `Why do you do it?' He'd say, `I don't know why.' He didn't seem to be self-conscious about it. Then, in 1977, when Mark was a baby, Carl heard this program, `Quirks and Quarks,' on the radio. He got all excited and hollered, `Helen, come listen! This guy's talking about what I do!' He was excited to hear that other people had it. And it was a relief to me, because I had always sensed that there was something wrong. It was good to put a label on it. He never made a thing of it, he wouldn't raise the subject, but, once we knew, we'd tell people if they asked. It's only in the last few years that he's met other people with it, or gone to meetings of the Tourette Syndrome Association." (Tourette's syndrome, until very recently, was remarkably underdiagnosed and unknown, even to the medical profession, and most people diagnosed themselves, or were diagnosed by friends and family, after seeing or reading something about it in the media. Indeed, I know of another doctor, a surgeon in Louisiana, who was diagnosed by one of his own patients who had seen a Touretter on "Donahue." Much of this media emphasis has been due to the efforts of the T.S.A., which had only thirty members in the early seventies but now has more than twenty thousand.)
Saturday morning, and I have to return to New York. "I'll fly you to Calgary if the weather's fine," Bennett said suddenly last night. "Ever flown with a Touretter before?"
I had canoed with one, I said, and driven across country with another, but flying with one . . .
"You'll enjoy it," Bennett said. "It'll be a novel experience. I am the world's only flying Touretter-surgeon."
When I awake, at dawn, I perceive with mixed feelings, that the weather, though very cold, is perfect. We drive to the little airport in Branford, a veering, twitching journey that makes me nervous about the flight. "It's much easier in the air, where there's no road to keep to, and you don't have to keep your hands on the controls all the time," Bennett says. At the airport, he parks, opens a hangar, and proudly points out his airplane--a tiny red-and-white single-engine Cessna Cardinal. He pulls it out onto the tarmac and then checks it, rechecks it, and re-rechecks it before warming up the engine. It is near-freezing on the airfield, and a north wind is blowing. I watch all the checks and rechecks with impatience but also with a sense of reassurance. If his Tourette's makes him check everything three or five times, so much the safer. I had a similar feeling of reassurance about his surgery--that his Tourette's, if anything, made him more meticulous, more exact, without in the least damping down his intuitiveness, his freedom.
His checking done, Bennett leaps like a trapeze artist into the plane, revs the engine while I climb in, and takes off. As we climb, the sun is rising over the Rockies to the east, and floods the little cabin with a pale, golden light. We head toward nine-thousand-foot crests, and Bennett tics, flutters, reaches, taps, touches his glasses, his mustache, the top of the cockpit. Minor tics, Little League, I think, but what if he has big tics? What if he wants to twirl the plane in midair, to hop and skip with it, to do somersaults, to loop the loop? What if he has an impulse to leap out and touch the propeller? Touretters tend to be fascinated by spinning objects; I have a vision of him lunging forward, half out the window, compulsively lunging at the propeller before us. But his tics and compulsions remain very minor, and when he takes his hands off the controls the plane continues quietly. Mercifully, there is no road to keep to. If we rise or fall or veer fifty feet, what does it matter? We have the whole sky to play with.
And Bennett, though superbly skilled, a natural aviator, is like a child at play. Part of Tourette's, at least, is no more than this--the release of a playful impulse normally inhibited or lost in the rest of us. The freedom, the spaciousness obviously delight Bennett; he has a carefree, boyish look I rarely saw on the ground. Now, rising, we fly over the first peaks, the advance guard of the Rockies; yellowing larches stream beneath us. We clear the slopes by a thousand feet or more. I wonder whether Bennett, if he were by himself, might want to clear the peaks by ten feet, by inches-- Touretters are sometimes addicted to close shaves. At ten thousand feet, we move in a corridor between peaks, mountains shining in the morning sun to our left, mountains silhouetted against it to our right. At eleven thousand feet, we can see the whole width of the Rockies--they are only fifty-five miles across here--and the vast golden Alberta prairie starting to the east. Every so often, Bennett's right hand flutters in front of me, or his hand taps lightly on the windshield. "Sedimentary rocks, look!" He gestures through the window. "Lifted up from the sea bottom at seventy to eighty degrees." He gazes at the steeply sloping rocks as at a friend; he is intensely at home with these mountains, this land. Snow lies on the sunless slopes of the mountains, none yet on their sunlit faces; and over to the northwest, toward Banff, we can see glaciers on the mountains. Bennett shifts, and shifts, and shifts again, trying to get his knees exactly symmetrical beneath the controls of the plane.
In Alberta now--we have been flying for forty minutes--the Highwood River winds beneath us. Flying due north, we start a gentle descent toward Calgary, the last, declining slopes of the Rockies all shimmering with aspen. Now, lower, to vast fields of wheat and alfalfa--farms, ranches, fertile prairie--but still, everywhere, stands of golden aspen. Beyond the checkerboard of fields, the towers of Calgary rise abruptly from the flat plain.
Suddenly, the radio crackles alive--a giant Russian air transport is coming in; the main runway, closed for maintenance, must quickly be opened up. And another massive plane, from the Zambian Air Force. The world's planes come to Calgary for special work and maintenance; its facilities, Bennett tells me, are some of the best in North America. In the middle of this important flurry, Bennett radios in our position and statistics (fifteen-foot-long Cardinal, with a Touretter and his neurologist), and is immediately answered, as fully and helpfully as if he were a 747. All planes, all pilots are equal in this world. And it is a world apart, with a freemasonry of its own, its own language, codes, myths, and manners. Bennett, clearly, is part of this world, and is recognized by the traffic controller and greeted cheerfully as he taxis in.
He leaps out with a startling, tic-like suddenness and celerity--I follow at a slower, "normal" pace--and starts talking with two giant young men on the tarmac, Kevin and Chuck, brothers, both fourth-generation pilots in the Rockies. They know him well. "He's just one of us," Chuck says to me. "A regular guy. Tourette's--what the hell? He's a good human being. A damn good pilot, too."
Bennett yarns with his fellow-pilots, and files his flight plan for the return trip to Branford. He has to return straightaway; he is due to speak at eleven to a group of nurses, and his subject, for once, is not surgery but Tourette's. His little plane is refuelled, and readied for the return flight. We hug, and say goodbye, and as I head for my flight to New York I turn to watch him go. Bennett walks to his plane, taxis onto the main runway, and takes off, fast, with a tail wind following. I watch him for a while, and then he is gone.