The man who mistook his wife for a hat (18 page)

   How much is cryptamnesia-confabulation, how much frontal-lobe indifference-equalisation, how much some strange schizophrenic disintegration and shattering-flattening?

   Of all forms of 'schizophrenia' the 'silly-happy', the so-called 'hebephrenic', most resembles the organic amnestic and frontal lobe syndromes. They are the most malignant, and the least imaginable-and no one returns from such states to tell us what they were like.

   In all these states-'funny' and often ingenious as they appear- the world is taken apart, undermined, reduced to anarchy and chaos. There ceases to be any 'centre' to the mind, though its formal intellectual powers may be perfectly preserved. The end point of such states is an unfathomable 'silliness', an abyss of superficiality, in which all is ungrounded and afloat and comes apart. Luria once spoke of the mind as reduced, in such states, to 'mere Brownian movement'. I share the sort of horror he clearly felt about them (though this incites, rather than impedes, their

   accurate description). They make me think, first, of Borges' 'Funes', and his remark, 'My memory, Sir, is like a garbage-heap', and finally, of the
Dunciad,
the vision of a world reduced to Pure Silliness-Silliness as being the End of the World:

   Thy hand, great Anarch, lets the curtain fall; And Universal Darkness buries All.

   
14

   
The Possessed

   In Witty Ticcy Ray (Chapter Ten), I described a relatively mild form of Tourette's syndrome, but hinted that there were severer forms 'of quite terrible grotesqueness and violence'. I suggested that some people could accommodate Tourette's within a commodious personality, while others 'might indeed be "possessed", and scarcely able to achieve real identity amid the tremendous pressure and chaos of Tourettic impulses'.

   Tourette himself, and many of the older clinicians, used to recognise a malignant form of Tourette's, which might disintegrate the personality, and lead to a bizarre, phantasmagoric, pantomimic and often impersonatory form of 'psychosis' or frenzy. This form of Tourette's-'super-Tourette's'-is quite rare, perhaps fifty times rarer than ordinary Tourette's syndrome, and it may be qualitatively different, as well as far more intense than any of the ordinary forms of the disorder. This 'Tourette psychosis', this singular identity-frenzy, is quite different from ordinary psychosis, because of its underlying, and unique, physiology and phenomenology. None the less, it has affinities, on the one hand, to the frenzied motor psychoses sometimes induced by L-Dopa and, on the other, to the confabulatory frenzies of Korsakov's psychosis (see above, Chapter Twelve). And like these it can almost overwhelm the person.

   The day after I saw Ray, my first Touretter, my eyes and mind opened, as I mentioned earlier, when, in the streets of New York, I saw no less than three Touretters-all as characteristic as Ray, though more florid. It was a day of visions for the neurological eye. In swift vignettes I witnessed what it might mean to have

   Tourette's syndrome of ultimate severity, not only tics and convulsions of movement, but tics and convulsions of perception, imagination, the passions-of the entire personality.

   Ray himself had shown what might happen in the street. But it is not enough to be told. You must see for yourself. And a doctor's clinic or ward is not always the best place for observing disease-at least, not for observing a disorder which, if organic in origin, is expressed in impulse, imitation, impersonation, reaction, interaction, raised to an extreme and almost incredible degree. The clinic, the laboratory, the ward are all designed to restrain and focus behaviour, if not indeed to exclude it altogether. They are for a systematic and scientific neurology, reduced to fixed tests and tasks, not for an open, naturalistic neurology. For this one must see the patient unselfconscious, unobserved, in the real world, wholly given over to the spur and play of every impulse, and one must oneself, the observer, be unobserved. What could be better, for this purpose, than a street in New York-an anonymous public street in a vast city-where the subject of extravagant, impulsive disorders can enjoy and exhibit to the full the monstrous liberty, or slavery, of their condition.

   'Street-neurology', indeed, has respectable antecedents. James Parkinson, as inveterate a walker of the streets of London as Charles Dickens was to be, forty years later, delineated the disease that bears his name, not in his office, but in the teeming streets of London. Parkinsonism, indeed, cannot be fully seen, comprehended, in the clinic; it requires an open, complexly interactional space for the full revelation of its peculiar character (beautifully shown in Jonathan Miller's film
Ivan).
Parkinsonism
has
to be seen, to be fully comprehended, in the world, and if this is true of Parkinsonism, how much truer must it be of Tourette's. Indeed an extraordinary description from within of an imitative and antic
ticqueur
in the streets of Paris is given in 'Les confidences d'un ticqueur' which prefaces Meige and Feindel's great book
Tics
(1901), and a vignette of a manneristic
ticqueur,
also in the streets of Paris, is provided by the poet Rilke in
The Notebook of Malte Laurids Brigge.
Thus it was not just seeing Ray in my office but what I

   saw the next day that was such a revelation to me. And one scene, in particular, was so singular that it remains in my memory today as vivid as it was the day I saw it.

   My eye was caught by a grey-haired woman in her sixties, who was apparently the centre of a most amazing disturbance, though what was happening, what was so disturbing, was not at first clear to me. Was she having a fit? What on earth was convulsing her- and, by a sort of sympathy or contagion, also convulsing everyone whom she gnashingly, ticcily passed?

   As I drew closer I saw what was happening.
She was imitating the passers-by
-if 'imitation' is not too pallid, too passive, a word. Should we say, rather, that she was caricaturing everyone she passed? Within a second, a split-second, she 'had' them all.

   I have seen countless mimes and mimics, clowns and antics, but nothing touched the horrible wonder I now beheld: this virtually instantaneous, automatic and convulsive mirroring of every face and figure. But it was not just an imitation, extraordinary as this would have been in itself. The woman not only took on, and took in, the features of countless people, she took them
off.
Every mirroring was also a parody, a mocking, an exaggeration of salient gestures and expressions, but an exaggeration in itself no less convulsive than intentional-a consequence of the violent acceleration and distortion of all her motions. Thus a slow smile, monstrously accelerated, would become a violent, milliseconds-long grimace; an ample gesture, accelerated, would become a farcical convulsive movement.

   In the course of a short city-block this frantic old woman frenetically caricatured the features of forty or fifty passers-by, in a quick-fire sequence of kaleidoscopic imitations, each lasting a second or two, sometimes less, and the whole dizzying sequence scarcely more than two minutes.

   And there were ludicrous imitations of the second and third order; for the people in the street, startled, outraged, bewildered by her imitations, took on these expressions in reaction to her; and those expressions, in turn, were re-reflected, re-directed, re-distorted, by the Touretter, causing a still greater degree of outrage and shock. This grotesque, involuntary resonance, or mutuality, by which
everyone
was drawn into an absurdly amplifying inter-

   action, was the source of the disturbance I had seen from a distance. This woman who, becoming everybody, lost her own self, became nobody. This woman with a thousand faces, masks,
per-sonae
-how must it be for
her
in this whirlwind of identities? The answer came soon-and not a second too late; for the build-up of pressures, both hers and others', was fast approaching the point of explosion. Suddenly, desperately, the old woman turned aside, into an alley-way which led off the main street. And there, with all the appearances of a woman violently sick, she expelled, tremendously accelerated and abbreviated, all the gestures, the postures, the expressions, the demeanours, the entire behavioural repertoires, of the past forty or fifty people she had passed. She delivered one vast, pantomimic egurgitation, in which the engorged identities of the last fifty people who had possessed her were spewed out. And if the taking-in had lasted two minutes, the throwing-out was a single exhalation-fifty people in ten seconds, a fifth of a second or less for the time-foreshortened repertoire of each person.

   I was later to spend hundreds of hours, talking to, observing, taping, learning from, Tourette patients. Yet nothing, I think, taught me as much, as swiftly, as penetratingly, as overwhelmingly as that phantasmagoric two minutes in a New York street.

   It came to me in this moment that such 'super-Touretters' must be placed, by an organic quirk, through no fault of their own, in a most extraordinary, indeed unique, existential position, which has some analogies to that of raging 'super-Korsakov's', but, of course, has a quite different genesis-and aim. Both can be driven to incoherence, to identity-delirium. The Korsakovian, perhaps mercifully, never knows it, but the Touretter perceives his plight with excruciating, and perhaps finally ironic, acuity, though he may be unable, or unwilling, to do much about it.

   For where the Korsakovian is driven by amnesia, absence, the Touretter is driven by extravagant impulse-impulse of which he is both the creator and the victim, impulse he may repudiate, but cannot disown. Thus he is impelled, as the Korsakovian is not, into an ambiguous relation with his disorder: vanquishing it, being vanquished by it, playing with it-there is every variety of conflict and collusion.

   Lacking the normal, protective barriers of inhibition, the normal, organically determined boundaries of self, the Touretter's ego is subject to a lifelong bombardment. He is beguiled, assailed, by impulses from within and without, impulses which are organic and convulsive, but also personal (or rather pseudo-personal) and seductive. How will, how
can,
the ego stand this bombardment? Will identity survive? Can it
develop,
in face of such a shattering, such pressures-or will it be overwhelmed, to produce a Tour-ettized soul' (in the poignant words of a patient I was later to see)? There is a physiological, an existential, almost a theological pressure upon the soul of the Touretter-whether it can be held whole and sovereign, or whether it will be taken over, possessed and dispossessed, by every immediacy and impulse.

   Hume, as we have noted, wrote:

   I venture to affirm . . . that [we] are nothing but a bundle or collection of different sensations, succeeding one another with inconceivable rapidity, and in a perpetual flux and movement.

   Thus, for Hume, personal identity is a fiction-we do not exist, we are but a consecution of sensations, or perceptions.

   This is clearly not the case with a normal human being, because he
owns
his own perceptions. They are not a mere flux, but
his
own, united by an abiding individuality or self. But what Hume describes may be precisely the case for a being as unstable as a super-Touretter, whose life is, to some extent, a consecution of random or convulsive perceptions and motions, a phantasmagoric fluttering with no centre or sense. To this extent he
is
a 'Humean' rather than a human being. This is the philosophical, almost theological, fate which lies in wait, if the ratio of impulse to self is too overwhelming. It has affinities to a 'Freudian' fate, which is also to be overwhelmed by impulse- but the Freudian fate has sense (albeit tragic), whereas a 'Humean' fate is meaningless and absurd.

   The super-Touretter, then, is compelled to fight, as no one else is, simply to survive-to become an individual, and survive as one, in face of constant impulse. He may be faced, from earliest

   childhood, with extraordinary barriers to individuation, to becoming a real person. The miracle is that, in most cases, he succeeds- for the powers of survival, of the will to survive, and to survive as a unique inalienable individual, are, absolutely, the strongest in our being: stronger than any impulses, stronger than disease. Health, health militant, is usually the victor.

   
PART THREE

   
TRANSPORTS

   
Introduction

   While we have criticised the concept of function, even attempting a rather radical redefinition, we have adhered to it nevertheless, drawing in the broadest terms contrasts based on 'deficit' or 'excess'. But it is clear that wholly other terms also have to be used. As soon as we attend to phenomena as such, to the actual quality of experience or thought or action, we have to use terms more reminiscent of a poem or painting. How, say, is a dream intelligible in terms of function?

   We have always two universes of discourse-call them 'physical' and 'phenomenal', or what you will-one dealing with questions of quantitative and formal structure, the other with those qualities that constitute a 'world'. All of us have our own, distinctive mental worlds, our own inner journeyings and landscapes, and these, for most of us, require no clear neurological 'correlate'. We can usually tell a man's story, relate passages and scenes from his life, without bringing in any physiological or neurological considerations: such considerations would seem, at the least, supererogatory, if not frankly absurd or insulting. For we consider ourselves, and rightly, 'free'-at least, determined by the most complex human and ethical considerations, rather than by the vicissitudes of our neural functions or nervous systems. Usually, but not always: for sometimes a man's life may be cut across, transformed, by an organic disorder; and if so his story does require a physiological or neurological correlate. This, of course, is so with all the patients here described.