Panic in Level 4

by Richard Preston

  He went to high school, attending special ed classes, but as a teenager he became harder for his parents to manage. They eventually made him a ward of the state of California and had him put in a rest home for elderly people, hoping that he would receive good care there. The staff of the nursing home began giving him medication. He was a young man, full of energy, who ended up on sedatives in a room with Alzheimer’s patients. “There was only one other young person in the rest home besides me, and she was a sixteen-year-old girl,” Elrod said. “The worst part of it was they wouldn’t let me do any gardening.” This seemed to disturb the demon, and one day he threw himself through a glass window, cutting himself badly. His parents had him transferred to a nursing home in Sacramento. There he was allowed to have a garden, and he gave the products of his garden to the residents of the home—they got vegetables to eat and flowers to brighten their rooms. “The garden had really good soil,” he said. “I planted all kinds of bulbs there. I had tomatoes, cucumbers, squash, and beans growing in it, and good, big pumpkins. It had these really big sunflowers growing in a row.”

  His sister, Marjorie, visited him there and discovered that the staff was giving him heavy doses of drugs—overmedicating him, in her view. “I raised Cain every time I went to see him there,” Marjorie said to me. “The staff said they were just doing what they had to do. They told me that I needed to have an appointment before I could see him. I told them I was going to come see my brother whenever I wanted. That was when James starting smashing his face on the table.” The nursing home couldn’t handle him.

  At twenty-one, Elrod ended up at the Agnews Developmental Center in San Jose. Gardening was out of the question at the state institution. Elrod ended up being paired with a roommate who was profoundly retarded and couldn’t speak, though he made continual noise. “My roommate was a screamer, twenty-four/seven,” he said.

  “It was just horrible for him,” Marjorie said.

  In the state institution, his hands began to go out of control. They began attacking his face. He bit his hands in order to protect his face from attacks by them—he needed to hurt his hands in order to scare them away. He began to realize that his hands would stop at nothing if they got a chance. It was in the state institution one day when his left hand hacked off his nose with a fork. The Lesch-Nyhan demon came brilliantly awake, and turned its gaze on Elrod with murderous intent.

  THERE HAVE BEEN about twenty autopsies of Lesch-Nyhan patients over the years. Their brains appeared to be perfectly normal. “It’s a problem in the connections, in the way the brain functions,” H. A. Jinnah, the Johns Hopkins neurologist, said. He had gotten interested in Lesch-Nyhan as a scientific enigma, but he quickly found that families all over the United States were sending Lesch-Nyhan patients to him, hoping for help. He couldn’t turn them away, and he had ended up looking after a large number of boys and young men with Lesch-Nyhan who were his patients. “It’s an orphan disease,” he explained. “Almost nobody studies it.”

  During some of the autopsies, doctors had tested samples of brain tissue to see if they contained a normal balance of neurotransmitters—chemicals that are used for signaling between nerve cells. In the Lesch-Nyhan brains, a lemon-sized area containing structures called the basal ganglia, near the center of the brain, had 80 percent less dopamine—an important neurotransmitter—than a normal brain. The basal ganglia are wired into circuits that run all over the brain; they affect a wide range of behaviors: motor control, higher-level thinking, and eye movement, as well as impulse control and enthusiasm.

  “People with Lesch-Nyhan have an excess number of involuntary movements,” Jinnah said. “It’s as if they are stepping on the gas too hard when they try to do something. If you ask them to look at a red ball, for instance, their eyes go to everything except the red ball, and they can’t explain why. Then, if you introduce a yellow ball into their field of view but you don’t say anything about it, they watch the yellow ball.” The moment you draw their attention to it, however, they look away. Most Lesch-Nyhan people can’t read, and even watching television may be difficult or impossible for them—their eyes refuse to follow the action on the television screen.

  “Lesch-Nyhan is at the far end of a spectrum of self-injurious behavior,” Jinnah went on. “You and I and everyone who is human, we all do things that are bad for us. We’ll sit down in front of the television and eat a quart of ice cream. We all have self-injurious impulses, too. Driving a car, we can have a strange impulse to drive it the wrong way and smash it into something.” People who are afraid of heights can experience the sensation that they may throw themselves from a high place, driven by some impulse they can’t control. Edgar Allan Poe called such promptings “the imp of the perverse.” The imp may be signals coming out of the basal ganglia of the brain. “Many people bite their fingernails,” Jinnah said. “They’ll tell you it’s gross and that they don’t want to do it—‘Sometimes I get nervous and start biting my fingernails,’ they’ll say. There are people who chew their lips nervously. Now let’s turn up the volume a little: some people bite their cuticles. Turn up the volume a little more: some people bite their cuticles until they bleed. Now let’s turn the volume way up. Now you have someone biting off tissue and bone in his fingers, biting off the whole finger, and chewing his lips off. Where, in this spectrum of behavior, is free will?”

  We can all think of things we’ve done to ourselves that make us cringe. It’s the inexplicable choice that brings about the very thing we feared the most. A shadow of self-sabotage seems to move behind the scenes on the stage of history. Napoleon’s invasion of Russia comes to mind. The mass behavior of much of the German population before and during the Second World War has a Lesch-Nyhanish quality. Israelis and Palestinians fight, neither side seeming able to compromise sufficiently to truly benefit their self-interest; Palestinian factions fight one another, like the hand attacking the face. Wars are about power, control of resources, and unrighted wrongs, to be sure, but they also seem to reveal a glimpse of self-mutilation in the human species. Perhaps there is a little bit of Lesch-Nyhan in each of us.

  In a medical sense, Lesch-Nyhan looks like Parkinson’s disease reversed. People with Parkinson’s have trouble starting physical actions. Lesch-Nyhan people start actions too easily and can’t stop an action once it starts. Because Parkinson’s is also associated with a deficiency in the dopamine of the basal ganglia, scientists have looked to each disease for clues to the other.

  In 1973, a researcher named George Breese, at the University of North Carolina School of Medicine, was working with rats that modeled Parkinson’s disease. He was treating newborn rats with compounds that changed the dopamine levels in their brains when, to his surprise, the rats started chewing off their paws. He had inadvertently created a Lesch-Nyhan rat. He was absolutely horrified, yet felt he might be tantalizingly close to a cure for Lesch-Nyhan. “I’ll not go further into the details of what the rats were doing. They weren’t biting their mouth tissues the way human patients do,” Breese told me. If he gave the self-injuring rats another compound, they stopped biting their paws—that is, he found a way to reverse the symptoms. “We treated the rat the moment we saw the animal make the first pinprick injury to its paws,” he said. The compound, however, has never been approved for use on humans.

  * * *

  IN APRIL 2000, Takaomi Taira, a neurosurgeon at the Tokyo Women’s Medical University, performed brain surgery on a nineteen-year-old man with Lesch-Nyhan. The young man was living with his parents in a district north of Tokyo. In addition to exhibiting self-injurious behavior, he had the spastic, stiff, thrashing movements of dystonia. “These dystonic movements were getting more severe almost by the day, and his parents were getting desperate,” Taira said to me recently. He decided to perform a procedure called deep-brain stimulation to try to calm down these movements.

  Deep-brain stimulation was developed by doctors more than twenty years ago for treating people with Parkinson’s disease. One or more thin
wires are carefully navigated through the brain until they stop in a part of the basal ganglia called the globus pallidus (the “pale globe”). The wires are connected to a battery pack, which is implanted under the skin of the patient’s chest, and a faint, pulsed current of electricity runs through them into the globus pallidus, numbing a spot the size of a pea. The patient feels nothing. The procedure often helps calm the tremors in Parkinson’s patients’ hands and limbs, and helps them walk more easily.

  “After the surgery, the boy’s dystonic movement completely disappeared,” Taira said. He sent him home with the deep-brain stimulator, feeling that the operation had helped. Several months later, the young man’s parents told Taira that he had stopped biting himself. He was still in a wheelchair, and his uric-acid levels remained high, but he was reading comic books and watching television, and seemed to be enjoying life as never before. “It was completely unexpected, remarkable, almost unbelievable,” Taira said. A few years later, the young man suddenly began biting his hands again, and the parents brought him back. “I checked the device and found that the battery was flat. I replaced the battery, and his symptoms were controlled again,” Taira said.

  A group at the Research Group on Movement Disorders in Montpellier, France, led by a neurosurgeon, Philippe Coubes, has given deep-brain-stimulation implants to five Lesch-Nyhan patients. His method involves the insertion of four wires into the brain. “So far, we have three patients who are doing very well and two who are having an intermediate response—the response of one of those is not poor but is not as good as the others,” Coubes said. “I’m not sure we will be able to control all their behaviors over the long term, but we are in the process of getting a better understanding of deep-brain stimulation for these patients.” The imp of the perverse could be put to sleep, but nobody knew how to make it go away.

  Scientists aren’t sure why deep-brain stimulation seems to work in some patients. Indeed, the results are a reminder of how obscure the workings of the brain still are. William Nyhan was cautious about the procedure’s potential. “I see these kids as fragile, and they don’t respond very well to surgical invasions,” he said.

  At Johns Hopkins, though, Jinnah was anxious to begin a study on a group of Lesch-Nyhan patients using deep-brain stimulation. He still needed to get funding and to receive approval from the federal government. (The procedure has not been specifically approved for Lesch-Nyhan patients.)

  Jinnah has never had an easy time getting funding and attention for Lesch-Nyhan research. “People ask me, ‘Why not study more common diseases?’ My answer is that if we neurologists did that we’d all be studying Alzheimer’s disease, Parkinson’s disease, and strokes. There are thousands of other brain diseases out there, and they’re all orphans. But these rare diseases may teach us something new about the brain, something relevant to the common brain diseases that affect so many people.”

  * * *

  I WENT BACK several times to visit James Elrod and Jim Murphy and began helping their staff with daily tasks. Elrod spat in my face a few times, and gave me a left jab to the jaw that made me see stars, for which he apologized afterward. Once, his Kevlar-covered fingers closed on my skin like pliers; he apologized while we both worked to get them loose. Murphy, at his thirty-first birthday party, planted his face in his birthday cake, then punched me in the groin so hard that I collapsed to the floor. Nevertheless, I came to like them a lot.

  Murphy had a record of making trouble in shopping malls. Malls put him in a bad mood, especially around Christmastime. “Too many people around. They make me nervous,” he explained to me.

  One time, his assistants took him to a mall to do some Christmas shopping. A man dressed as Santa Claus was sitting in a snow scene that day, with children lining up to meet him. Murphy told his assistants that he would like to have his picture taken with Santa (one of them had a camera). They didn’t see how they could refuse the client’s request. They parked Murphy’s wheelchair in the line of children, and Murphy cautioned the children to watch out for his arms and legs. (Neither Murphy nor Elrod had been known to lash out at a child.)

  Murphy got to the head of the line. The Santa asked Murphy if he’d like to sit on his lap.

  Murphy said yes. The assistants placed him on the Santa’s lap. The assistant with the camera, a young man named Dan Densley, got ready to take a picture.

  “Ho, ho, ho! What do you want for Christmas?” Santa asked.

  “A woman,” Murphy answered, and delivered a punch to Santa’s jaw. Santa’s beard seemed to explode, and his eyeglasses went flying. The assistants grabbed Murphy and rolled him out of the mall at a dead run.

  * * *

  JIM MURPHY had a passion for off-road driving, which he was not usually able to indulge. One day, I showed up in Santa Cruz in a rented Ford Expedition with four-wheel drive. A woman named Tracye Overby came along as Murphy’s assistant, while another assistant, Christopher Reeves, accompanied Elrod. Into the back of the vehicle we put a cooler holding a roast chicken and beer, and I drove the group to a dried-out lake bed near Watsonville called College Lake, which we’d heard was a good place for four-wheeling. On the way, I stopped to get directions from a California state trooper. “I would not advise going there with disabled people,” he said.

  College Lake turned out to be a mile-wide expanse of clay covered with sand. The lake bed had a dark, wet-looking center and was surrounded by thickets of willows. I edged the Expedition out onto the sand, while Murphy and Elrod began to egg me on from the backseat. “Go faster,” Murphy said. “You’re driving like an old lady.” I gunned the engine, the Expedition leaped forward, and we raced across the sand. When I turned sharply, the men shouted with delight. I started cutting cookies and performed a figure eight, then aimed the vehicle toward the center of the lake and floored the accelerator. With the engine roaring, we passed the sunken carcass of a truck, buried up to its roof in clay. The Expedition began slowing down, even though the engine was running at full power. Then the vehicle began tipping over—which was when I realized that we were driving across quicksand. If we stopped, we would go down. I floored it again and turned back for the shore, but it was too late. We slowed to a halt with the engine making an extreme wailing sound and the wheels spinning. The Expedition settled down until its axles were buried; then the engine suddenly died. There was a moment of complete silence. Then the men erupted with profanities. “Jackass!” Elrod yelled.

  The two helpers seemed unperturbed. “This is just the nature of our work,” Chris Reeves said. “Everything that you plan never goes as you planned it.”

  I opened the door and tested my weight on the sand. At least the Expedition seemed to be floating on it. I got out my cell phone and started calling local towing services.

  Elrod leaned over me. “Tell them you’ve got two Lesch-Nyhan guys in the car, and we’re going to cut your head off.”

  After a number of calls, it became clear that the local towing companies wouldn’t touch College Lake. “I’ll just have to get somebody to tow me out,” one man said.

  “We could call my lawyer,” Elrod suggested.

  “Forget it!” Jim Murphy said. “Your lawyer won’t do us any good. Call the fire department. Help! Fire! Fire!”

  I tried an outfit called Speed of Light Towing. A young guy answered the phone and said he couldn’t do it.

  I told him it was a desperate situation. “I’ve got two disabled guys with me. They’re in wheelchairs and can’t walk. We’re in the middle of the lake,” I said.

  “What?” he said. He needed to hear that again. “All right. I’ll try,” he finally said. I would have to pay him when he arrived, no results guaranteed.

  “I’m nervous,” Murphy said. Blood dribbled out of his mouth—he was biting himself. Tracye Overby lifted him out of the car, carried him across the sand to the shade of some willows, and sat down, holding him in her lap. She wiped the blood from his mouth with a napkin, cradled his head in her arms, and began singing a song to
him:

  Oh Mama, oh Papa, I’m feeling so down,

  I can’t believe there’s no milk in this town…

  I’ll do anything for a glass of white milk.

  I live in a town, a town without milk.

  “I’m sorry, Tracye,” Murphy said.

  “What are you apologizing for?” She patted his stomach.

  Murphy looked at me. “It’s your fault, Richard. No more off-roading with you.” He began to laugh.

  “What’s so funny?” Overby said to him.

  “I’ve had enough, Tracye. I’m leaving. I’m getting out of here right now. Good-bye.” He thrashed around on his back, kicking and laughing. He couldn’t even sit up.

  Elrod, sitting in the front seat of the Expedition, began laughing, too. Their laughter drifted through the silence of College Lake. The men were connoisseurs of what I had done: I had ignored the advice of a police officer and driven two disabled men at high speed into the mud. They saw something familiar in my behavior.

  Stranded in College Lake.

  Tracye Overby (left) and Christopher Reeves (right) with Jim Murphy lying between them. He seems quite entertained. (Note his sock-wrapped hand resting on Reeves’s left arm.)

  Richard Preston

  I popped a beer and handed it to Elrod. “Are you okay?”

  “Just fine.”

  I opened a beer for myself. “There’s chicken in the cooler. Do you want some?”

  He ate pieces of chicken with his gloves on, and asked me not to hand him any pieces that had sharp bones.

  It was a cloudless day in spring, without a breath of wind. The Santa Cruz Mountains stretched into the distance, blanketed with many colors of green. Canyons wandered down through the mountains, jammed with the dark spires of redwoods. A flock of coots burst from the willows and flew straight across the lake bed, heading west toward the sea. Overhead, violet-green swallows dodged and looped. The birds were behavioral phenotypes, their movements controlled by their genes. A streak of dust appeared in the east, at the edge of the lake, and extended toward us: something moving fast. Speed of Light Towing was coming for us. A battered pickup truck with fat tires stopped a good distance away. A young man got out. He walked over to us, dragging a chain and stomping his feet on the sand as he went along, testing the sand. His name, it turned out, was Robert, and he was the same person I’d spoken with. He glanced at the Lesch-Nyhan men. “Hey, how are you?” he said in friendly way.