by Oliver Sacks
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 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 would not 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, misshapen 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 compulsive 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 the surgery somehow.
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. 60
60. This was the condition, grotesquely severe, that afflicted the famous Elephant Man, John Merrick.
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, perceive this, and it is one of the reasons they trust 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 déjà 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, had stopped here for a night in August 1960, when I was hitchhiking through the Rockies, to the West. It had a population then 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 that 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, focused, 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 said. “The way the Tourette’s disappears.” And Bennett himself was astonished, too, and quizzed me, as he peeled 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.
Bennett’s operating brings up all the conundrums of Tourette’s, along with deep issues such as the nature of rhythm, melody, and “flow”, and the nature of acting, role, personation, and identity. A transition from uncoordinated, jerky ticciness to smoothly orchestrated, coherent movement can occur instantly in Touretters when they are exposed to, called into, rhythmic music or action. I saw this with the man I described in “Witty Ticcy Ray”, who could swim the length of a pool without tics, with even, rhythmic strokes—but in the instant of turning, when the rhythm, the kinetic melody, was broken, would have a sudden flurry of tics. Many Touretters are also drawn to athletics, partly (one suspects) because of their extraordinary speed and accuracy 61 and partly because of their bursting, inordinate motor impulse and energy, which thrust toward some motor release—but a release that, happily, instead of being explosive, can be coordinated into the flow, the rhythm, of a performance or a game.
61. What most of us call a startling or “abnormal” speed of movement appears perfectly normal to Touretters when they show it. This was very clear in a recent experiment of target pointing with Shane F., an artist with Tourette’s. Shane showed markedly reduced reaction times, and reaching rates of almost six times normal, combined with great smoothness and accuracy of movement and aim. Such speeds were achieved quite effortlessly and naturally; normal subjects, by contrast, could achieve them, if at all, only by violent effort and with obvious compromise of accuracy and control.
On the other hand, when Shane was asked to stick to (our) normal speeds, his movements became constrained, awkward, inaccurate, and tic filled. It was clear that his normal and our normal were very different, that the Tourettic nervous system, in this sense, is more highly tuned (though, by the same token, given to precipitancy and reaction).
A similar speed and precipitancy were to be seen in many postencephalitic patients, especially when they were activated by L-DOPA. Thus, as I remarked of Hester Y., in Awakenings, “If Mrs. Y., before L-DOPA, was the most impeded person I have ever seen, she became, on L-DOPA, the most accelerated person I have ever seen. I have known a number of Olympic athletes, but Mrs. Y. could have beaten them all in terms of reaction time; under other circumstances she could have been the fastest gun in the West.”
One sees very similar situations with playing or responding to music. The convulsive or broken motor or speech patterns that may occur in Tourette’s can be instantly normalized with incanting or singing (this has also long been known to occur with stutterers). It is similar with the jerky, broken movements of parkinsonism (sometimes called kinetic stutter); these too can be replaced, with music or action, by a rhythmic, melodic flow.
Such responses seem to involve chiefly the motor patterns of the individual, rather than the persona, the identity, in any higher form. Some of the transformation while Bennett was operating, I felt, was occurring at this elementary, “musical” level. At this level, Bennett’s operating had become automatic; there were, at every moment, a dozen things to attend to, but these were integrated, orchestrated, into a single seamless stream—and one that, like his driving, had become partly automated with time, so that he could chat with the nurses, make jokes, banter, think, while his hands and eyes and brain performed their skilled tasks faultlessly, almost unconsciously.
But above this level, coexisting with it, was a higher, personal one, which has to do with the identity, the role, of a surgeon. Anatomy (and then surgery) have been Bennett’s constant loves, lying at the center of his being, and he is most himself, most deeply himself, when he is immersed in his work. His whole personality and demeanor—sometimes nervous and diffident—change when he puts on his surgical mantle, takes on the quiet assurance, the identity, of one who is a master at his work. It seems part of this overall change that the Tourette’s vanishes, too. I have seen exactly this in Tourettic actors as well; I know one man, a character actor, who is violently Touretty offstage, but totally free from Tourettisms, totally in role, when he is acting.
Here one is seeing something at a much higher level than the merely rhythmic, quasi-automatic resonance of the motor patterns; one is seeing (however it is to be defined in psychic or neural terms) a fundamental act of incarnation or personation, whereby the skills, the feelings, the entire neural engrams of another self, are taking over in the brain, redefining the person, his whole nervous system, as long as the performance lasts. 62
62. The matter is especially complex, for some Touretters are given to mimicry, imitation, and impersonation of a more convulsive kind. (I describe an example of this in “The Possessed.”) This sort of imitation has no transformative effect; on the contrary, it thrusts the person deeper into Tourette’s. The Tourettic character actor was very given to convulsive impersonations and other Tourettisms offstage, but these were quite different from the deep and healing role-playing that he was able to do onstage. The superficially imitative or impersonative impulse comes from, and stimulates, a superficial part of the person (and his neural organization)—it is only a deep, total identification, as with Bennett, that can work the transformation.
Such identity transformations, reorganizations, occur in us all as we move, in the course of a day, from one role, one persona, to another—the parental to the professional, to the political, to the erotic, or whatever. But they are especially dramatic in those who move in and out of neurological or psychiatric syndromes, and in professional performers and actors.
These transformations, the switches between very complex neural engrams, are typically experienced in terms of “remembering” and “forgetting”—thus Bennett forgets that he is Tourettic while operating (“it never even crosses my mind”), but remembers it as soon as there is an interruption
. And in the moment of remembering, he becomes so, for at this level, there is no distinction between the memory, the knowledge, the impulse, and the act—all come or go together, as one. (It is similar with other conditions: I once saw a parkinsonian man I know take a shot of apomorphine to help his rigidity and “freezing”—he suddenly unfroze a couple of minutes later, smiled, and said, “I have forgotten how to be parkinsonian.”)
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, whether he might not sometimes be stressed to the limit. I wondered how much he concealed beneath his genial surface—how much, inwardly, he had to control and deal with.
