The man who mistook his wife for a hat (15 page)

   Under an ebullient, eruptive, clownish surface, he was a deeply serious man-and a man in despair. He had never heard of the TSA (which, indeed, scarcely existed at the time), nor had he heard of Haldol. He had diagnosed himself as having Tourette's after reading the article on 'Tics' in the
Washington Post.
When

   I confirmed the diagnosis, and spoke of using Haldol, he was excited but cautious. I made a test of Haldol by injection, and he proved extraordinarily sensitive to it, becoming virtually tic-free for a period of two hours after I had administered no more than one-eighth of a milligram. After this auspicious trial, I started him on Haldol, prescribing a dose of a quarter of a milligram three times a day.

   He came back, the following week, with a black eye and a broken nose and said: 'So much for your fucking Haldol.' Even this minute dose, he said, had thrown him off balance, interfered with his speed, his timing, his preternaturally quick reflexes. Like many Touretters, he was attracted to spinning things, and to revolving doors in particular, which he would dodge in and out of like lightning: he had lost this knack on the Haldol, had mistimed his movements, and had been bashed on the nose. Further, many of his tics, far from disappearing, had simply become slow, and enormously extended: he might get 'transfixed in mid-tic', as he put it, and find himself in almost catatonic postures (Ferenczi once called catatonia the opposite of tics-and suggested these be called 'cataclonia'). He presented a picture, even on this minute dose, of marked Parkinsonism, dystonia, catatonia and psychomotor 'block': in reaction which seemed inauspicious in the extreme, suggesting, not insensitivity, but such over-sensitivity, such pathological sensitivity, that perhaps he could only be thrown from one extreme to another-from acceleration and Tourettism to catatonia and Parkinsonism, with no possibility of any happy medium.

   He was understandably discouraged by this experience-and this thought-and also by another thought which he now expressed. 'Suppose you
could
take away the tics,' he said. 'What would be left? I consist of tics-there is nothing else.' He seemed, at least jokingly, to have little sense of his identity except as a ticqueur: he called himself 'the ticcer of President's Broadway', and spoke of himself, in the third person, as 'witty ticcy Ray', adding that he was so prone to 'ticcy witticisms and witty ticcicisms' that he scarcely knew whether it was a gift or a curse. He said he could not imagine life without Tourette's, nor was he sure he would care for it.

   I was strongly reminded, at this point, of what I had encountered in some of my post-encephalitic patients, who were inordinately sensitive to L-Dopa. I had nevertheless observed in their case that such extreme physiological sensitivities and instabilities might be transcended if it were possible for the patient to lead a rich and full life: that the 'existential' balance, or poise, of such a life might overcome a severe physiological imbalance. Feeling that Ray also had such possibilities in him, that, despite his own words, he was not incorrigibly centred on his own disease, in an exhibi-tionistic or narcissistic way, I suggested that we meet weekly for a period of three months. During this time we would try to imagine life without Tourette's; we would explore (if only in thought and feeling) how much life could offer, could offer
him,
without the perverse attractions and attentions of Tourette's; we would examine the role and economic importance of Tourette's to him, and how he might get on without these. We would explore all this for three months-and then make another trial of Haldol.

   There followed three months of deep and patient exploration, in which (often against much resistance and spite and lack of faith in self and life) all sorts of healthy and human potentials came to light: potentials which had somehow survived twenty years of severe Tourette's and 'Touretty' life, hidden in the deepest and strongest core of the personality. This deep exploration was exciting and encouraging in itself and gave us, at least, a limited hope. What in fact happened exceeded all our expectations and showed itself to be no mere flash in the pan, but an enduring and permanent transformation of reactivity. For when I again tried Ray on Haldol, in the same minute dose as before, he now found himself tic-free, but without significant ill-effects-and he has remained this way for the past nine years.

   The effects of Haldol, here, were 'miraculous'-but only became so when a miracle was allowed. Its initial effects were close to catastrophic: partly, no doubt, on a physiological basis; but also because any 'cure', or relinquishing of Tourette's, at this time would have been premature and economically impossible. Having had Tourette's since the age of four, Ray had no experience of any normal life: he was heavily dependent on his exotic disease

   and, not unnaturally, employed and exploited it in various ways. He had not been ready to give up his Tourette's and (I cannot help thinking) might never have been ready without those three months of intense preparation, of tremendously hard and concentrated deep analysis and thought.

   The past nine years, on the whole, have been happy ones for Ray-a liberation beyond any possible expectation. After twenty years of being confined by Tourette's, and compelled to this and that by its crude physiology, he enjoys a spaciousness and freedom he would never have thought possible (or, at most, during our analysis, only theoretically possible). His marriage is tender and stable-and he is now a father as well; he has many good friends, who love and value him as a person-and not simply as an accomplished Tourettic clown; he plays an important part in his local community; and he holds a responsible position at work. Yet problems remain: problems perhaps inseparable from having Tourette's-and Haldol.

   During his working hours, and working week, Ray remains 'sober, solid, square' on Haldol-this is how he describes his 'Haldol self. He is slow and deliberate in his movements and judgments, with none of the impatience, the impetuosity, he showed before Haldol, but equally, none of the wild improvisations and inspirations. Even his dreams are different in quality: 'straight wish-fulfilment,' he says, 'with none of the elaborations, the extravaganzas, of Tourette's'. He is less sharp, less quick in repartee, no longer bubbling with witty tics or ticcy wit. He no longer enjoys or excels at ping-pong or other games; he no longer feels 'that urgent killer instinct, the instinct to win, to beat the other man'; he is less competitive, then, and also less playful; and he has lost the impulse, or the knack, of sudden 'frivolous' moves which take everyone by surprise. He has lost his obscenities, his coarse chutzpah, his spunk. He has come to feel, increasingly, that something is missing.

   Most important, and disabling, because this was vital for him- as a means of both support and self-expression-he found that on Haldol he was musically 'dull', average, competent, but lacking energy, enthusiasm, extravagance and joy. He no longer had tics

   or compulsive hitting of the drums-but he no longer had wild and creative surges.

   As this pattern became clear to him, and after discussing it with me, Ray made a momentous decision: he would take Haldol 'dutifully' throughout the working week, but would take himself off it, and 'let fly', at weekends. This he has done for the past three years. So now there are two Rays-on and off Haldol. There is the sober citizen, the calm deliberator, from Monday to Friday; and there is 'witty ticcy Ray', frivolous, frenetic, inspired, at weekends. It is a strange situation, as Ray is the first to admit:

   Having Tourette's is wild, like being drunk all the while. Being on Haldol is dull, makes one square and sober, and neither state is really free . . . You 'normals', who have the right transmitters in the right places at the right times in your brains, have all feelings, all styles, available all the time-gravity, levity, whatever is appropriate. We Touretters don't: we are forced into levity by our Tourette's and forced into gravity when we take Haldol.
You
are free, you have a natural balance: we must make the best of an artificial balance.

   Ray does make the best of it, and has a full life, despite Tourette's, despite Haldol, despite the 'unfreedom' and the 'artifice', despite being deprived of that birthright of natural freedom which most of us enjoy. But he has been taught by his sickness and, in a way, he has transcended it. He would say, with Nietzsche: 'I have traversed many kinds of health, and keep traversing them . . . And as for sickness: are we not almost tempted to ask whether we could get along without it? Only great pain is the ultimate liberator of the spirit.' Paradoxically, Ray-deprived of natural, animal physiological health-has found a new health, a new freedom, through the vicissitudes he is subject to. He has achieved what Nietzsche liked to call 'The Great Health'-rare humour, valour, and resilience of spirit: despite being, or because he is, afflicted with Tourette's.

   
11

   
Cupid's Disease

   A bright woman of ninety, Natasha K., recently came to our clinic. Soon after her eighty-eighth birthday, she said, she noticed 'a change'. What sort of change? we queried.

   'Delightful!' she exclaimed. 'I thoroughly enjoyed it. I felt more energetic, more alive-I felt young once again. I took an interest in the young men. I started to feel, you might say, "frisky"-yes, frisky.'

   'This was a problem?'

   'No, not at first. I felt well,
extremely
well-why should I think anything was the matter?'

   'And then?'

   'My friends started to worry. First they said, "You look radiant- a new lease on life!", but then they started to think it was not quite-appropriate. "You were always so shy," they said, "and now you're a flirt. You giggle, you tell jokes-at your age, is that right?" '

   'And how did
you
feel?'

   'I was taken aback. I'd been carried along, and it didn't occur to me to question what was happening. But then I did. I said to myself, "You're 89, Natasha, this has been going on for a year. You were always so temperate in feeling-and now this extravagance! You are an old woman, nearing the end. What could justify such a sudden euphoria?" And as soon as I thought of euphoria, things took on a new complexion . . . "You're sick, my dear," I said to myself. "You're feeling
too
well, you have to be ill!" '

   'Ill? Emotionally? Mentally ill?'

   'No, not emotionally-physically ill. It was something in my

   body, my brain, that was making me high. And then I thought- goddam it, it's Cupid's Disease!'

   'Cupid's Disease?' I echoed, blankly. I had never heard of the term before.

   'Yes, Cupid's Disease-syphilis, you know. I was in a brothel in Salonika, nearly seventy years ago. I caught syphilis-lots of the girls had it-we called it Cupid's Disease. My husband saved me, took me out, had it treated. That was years before penicillin, of course. Could it have caught up with me after all these years?'

   There may be an immense latent period between the primary infection and the advent of neurosyphilis, especially if the primary infection has been suppressed, not eradicated. I had one patient, treated with Salvarsan by Ehrlich himself, who developed
tabes dorsalis
-one form of neurosyphilis-more than fifty years later.

   But I had never heard of an interval of
seventy
years-nor of a self-diagnosis of cerebral syphilis mooted so calmly and clearly.

   'That's an amazing suggestion,' I replied after some thought. 'It would never have occurred to me-but perhaps you are right.'

   She was right; the spinal fluid was positive, she did have neurosyphilis, it
was
indeed the spirochetes stimulating her ancient cerebral cortex. Now the question of treatment arose. But here another dilemma presented itself, propounded, with typical acuity, by Mrs K. herself. 'I don't know that I
want
it treated,' she said. 'I know it's an illness, but it's made me feel
well.
I've enjoyed it, I still enjoy it, I won't deny it. It's made me feel livelier, friskier, than I have in twenty years. It's been fun. But I know when a good thing goes too far, and stops being good. I've had thoughts, I've had impulses, I won't tell you, which are-well, embarrassing and silly. It was like being a little tiddly, a little tipsy, at first, but if it goes any further . . .' She mimed a drooling, spastic dement. 'I guessed I had Cupid's, that's why I came to you. I don't want it to get worse, that would be awful; but I don't want it cured-that would be just as bad. I wasn't fully alive until the wrigglies got me.
Do you think you could keep it just as it is?'

   We thought for a while, and our course, mercifully, was clear. We have given her penicillin, which has killed the spirochetes,

   but can do nothing to reverse the cerebral changes, the disinhi-bitions, they have caused.

   And now Mrs K. has it both ways, enjoying a mild disinhibi-tion, a release of thought and impulse, without any threat to her self-control or of further damage to her cortex. She hopes to live, thus reanimated, rejuvenated, to a hundred. 'Funny thing,' she says. 'You've got to give it to Cupid.'

   
Postscript

   Very recently (January 1985) I have seen some of these same dilemmas and ironies in relation to another patient (Miguel O.), admitted to the state hospital with a diagnosis of 'mania', but soon realised to be suffering from the excited stage of neurosyphilis. A simple man, he had been a farmhand in Puerto Rico, and with some speech and hearing impediment, he could not express himself too well in words, but expressed himself, exhibited his situation, simply and clearly, in drawings.

   The first time I saw him he was quite excited, and when I asked him to copy a simple figure (Figure A) he produced, with great brio, a three-dimensional elaboration (Figure B)-or so I took it to be, until he explained that it was 'an open carton', and then tried to draw some fruit in it. Impulsively inspired by his excited imagination, he had ignored the circle and cross, but retained, and made concrete, the idea of 'enclosure'. An open carton, a carton full of oranges-was that not more exciting, more alive, more real, than my dull figure?