‘Yes, Father,’ she said to me on one occasion.
‘Yes, Sister,’ on another.
‘Yes, Doctor,’ on a third.
She seemed to use the terms interchangeably.
‘What am I?’ I asked, stung, after a while.
‘I see your face, your beard,’ she said, ‘I think of an Archimandrite Priest. I see your white uniform—I think of the Sisters. I see your stethoscope—I think of a doctor.’
‘You don’t look at all of me?’
‘No, I don’t look at all of you.’
‘You realise the difference between a father, a sister, a doctor?’
‘I know the difference, but it means nothing to me. Father, sister, doctor—what’s the big deal?’
Thereafter, teasingly, she would say: ‘Yes, father-sister. Yes, sister-doctor’, and other combinations.
Testing left-right discrimination was oddly difficult, because she said left or right indifferently (though there was not, in reaction, any confusion of the two, as when there is a lateralising defect of perception or attention). When I drew her attention to this, she said: ‘Left/right. Right/left. Why the fuss? What’s the difference?’
‘Is there a difference?’ I asked.
‘Of course,’ she said, with a chemist’s precision. ‘You could call them enantiomorphs of each other. But they mean nothing to me. They’re no different for me. Hands . . . Doctors . . . Sisters . . .’ she added, seeing my puzzlement. ‘Don’t you understand? They mean nothing—nothing to me. Nothing means anything ... at least to me.’
‘And . . . this meaning nothing . . .’ I hesitated, afraid to go on. ‘This meaninglessness . . . does this bother you? Does this mean anything to you?’
‘Nothing at all,’ she said promptly, with a bright smile, in the tone of one who makes a joke, wins an argument, wins at poker.
Was this denial? Was this a brave show? Was this the ‘cover’ of some unbearable emotion? Her face bore no deeper expression whatever. Her world had been voided of feeling and meaning. Nothing any longer felt ‘real’ (or ‘unreal’). Everything was now ‘equivalent’ or ‘equal’—the whole world reduced to a facetious insignificance.
I found this somewhat shocking—her friends and family did too—but she herself, though not without insight, was uncaring, indifferent, even with a sort of funny-dreadful nonchalance or levity.
Mrs B., though acute and intelligent, was somehow not present— ‘de-souled’—as a person. I was reminded of William Thompson (and also of Dr P.). This is the effect of the ‘equalisation’ described by Luria which we saw in the preceding chapter and will also see in the next.
The sort of facetious indifference and ‘equalisation’ shown by this patient is not uncommon—German neurologists call it Witzel-sucht (‘joking disease’), and it was recognised as a fundamental form of nervous ‘dissolution’ by Hughlings Jackson a century ago. It is not uncommon, whereas insight is—and the latter, perhaps mercifully, is lost as the ‘dissolution’ progresses. I see many cases a year with similar phenomenology but the most varied etiologies. Occasionally I am not sure, at first, if the patient is just ‘being funny’, clowning around, or schizophrenic. Thus, almost at random, I find the following in my notes on a patient with cerebral multiple sclerosis, whom I saw (but whose case I could not follow up) in 1981:
She speaks very quickly, impulsively, and (it seems) indifferently ... so that the important and the trivial, the true and the false, the serious and the joking, are poured out in a rapid, unselec-tive, half-confabulatory stream . . . She may contradict herself completely within a few seconds . . . will say she loves music, she doesn’t, she has a broken hip, she hasn’t . . .
I concluded my observation on a note of uncertainty:
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.