Famous people with Tourette's syndrome: Dr. Samuel Johnson (yes) & Wolfgang Amadeus Mozart (may be): Victims of Tourette's syndrome?

Tourette's syndrome is a clinical condition characterized by multiple motor tics and vocal tics which occurs in the age range 5-25 years and the intensity of the symptoms changes with time. It is felt that at least two remarkable personalities namely, Dr. Samuel Johnson from England, a man of letters and the compiler of the first ever English dictionary, and Wolfgang Amadeus Mozart from Austria, one of the greatest musical genius of all time, possibly suffered from this condition. Tourette's syndrome is often described as the classical borderzone between neurology and psychiatry and every neurologist wonders at the curious and fascinating clinical features of this condition. It seems that at least two remarkable personalities, Dr. Samuel Johnson, a man of letters and the first person to compile an English dictionary, and Wolfgang Amadeus Mozart, arguably the most creative musical composer of all time, were possibly afflicted with this condition.

Dr. Samuel Johnson (1709-1784)

A devout Anglican, a loyal Royalist and a confirmed Tory, Samuel Johnson is often referred to as ‘arguably the most distinguished man of letters in English history’. He came from a humble background, distinguished himself in studies and attended Pembroke College, Oxford, supported by a munificent grant from a well-wisher. However, he had to discontinue soon since the fund ran dry and therefore had to move to London where he started writing for ‘The Gentleman's magazine’. Everything gainsaid, the particular reason for which Samuel Johnson is immortalized is for compiling ‘A Dictionary of English Language’, which was published in 1755 and it is often referred to as ‘one of the greatest single achievements of scholarship’. He befriended some of the most virile minds in London of that time, like Edmond Burke, the parliamentarian, Edward Gibbon, the historian, Oliver Goldsmith, the litterateur, Adam Smith, the economist, Joshua Reynolds, the painter, David Garrick, the actor and importantly, James Boswell, the lawyer, who wrote a masterly biography on him entitled ‘Life of Samuel Johnson’. As a mark of respect to this eminent Englishman in the 18th century, he was buried in Westminster Abbey.

His Illness

Georges Albert Édouard Brutus Gilles de la Tourette, a French neurologist and one of the blue-eyed pupils of Jean Martin Charcot from Salpêtrière, Paris, was born in 1857 and died in 1904, presumably from general paralysis of the insane. Obviously, the impression that Johnson suffered from the disease that bears Tourette's name must be a posthumous one since Tourette appeared much later. Johnson's friends noted that he had constant and uncontrollable tics and gesticulations and additionally, he used to vocalize grunting, groaning and whistling sounds which startled them. He had compulsive habits like, touching each and every lamp post in London while walking and in case he overlooked one, he used to stop all conversations with his fellow-travellers and rush back in order to feel it, as if to get rid of some kind of inner urge. He also seemed to measure his footsteps while leaving the room. All these features almost compellingly suggest that he was a victim of Tourette syndrome.[1] Fanny Burney, a contemporary diarist who saw him from close quarters, described him in the following way.

‘His mouth is almost constantly opening and shutting as if he were chewing. He has a strange method of frequently twirling his fingers and twisting his hands. His body is in continual agitation seesawing up and down; his feet are never a moment quiet; and in short, his whole person is in continuous motion.’[2]

And furthermore, Frances Reynolds, the sister of Sir Joshua Reynolds, wrote, that the gesticulations were so curious that “men, women, and children gathered around him, laughing”.[3]

James Boswell wrote,

“From Mr. Garrick's account he did not appear to have been profoundly reverenced by his pupils. His oddities of manner and uncouth gesticulations could not but be the subject of merriment to them… while talking or musing as he sat in his chair, he commonly held his head to one side towards the right shoulder, and shook it in a tremulous manner, moving his body backwards and forwards, and rubbing his left knee in the same direction, with the palm of his hand.”[4]

Johnson was almost always observed as muttering to himself or indulging in meaningless vocalizations like, moaning, grunting or even barking. Hector, his childhood friend recalled that while in a gathering, Johnson was more prone to talking to himself than to his companions.[4] Boswell wrote,

“… he made various sounds with his mouth, sometimes as if ruminating, or what is called chewing the cud, sometimes giving a half whistle, sometimes making his tongue play backwards, from the roof of his mouth, as if clucking like a hen, sometimes protruding it against his upper gums in front… he used to blow out his breath like a whale.”[4]

Frances Reynolds wrote about his compulsive behavior.

“…Sometimes he would make the back part of his heels to touch, sometimes the extremities of his toes, as if endeavouring to form a triangle, or some geometrical figure, and as for his gestures with his hands, they are equally as strange… stretching out his arm with a full cup of tea in his hand, in every direction, often to the great annoyance of the person who sat next to him, indeed to the imminent danger of their cloathes… When he wanted to stretch his legs in front of him, as if endeavouring to smooth the carpet, or rather perhaps to rumple it, and every now and then collecting all his force, apparently to effect a concussion on the floor.”[5]

Boswell further observed,

“… his anxious care to get out or in at a door or passage, by a certain number of steps from a certain point, or at least so that either right or left foot,… should constantly make the first actual movement when he came close to the door or passage.”[4]

Johnson was prone to echolalia though coprolalia was not reported. As a matter of fact, he hated profanities and obscenities. However, some believe that he was a coprolaliac as well and his illustrious friends did not mention it for the fear that this might have had tarnished his awesome reputation as a scholar and an intellect.[6] At the same time, it should be borne in mind that coprolalia, coprographia and copropraxia do not constitute the core features of the diagnostic criteria of Tourette's syndrome and they are observed only in about a quarter of cases. However, when they are present in the presence of multifocal motor tics, vocal tics, changing intensity of symptoms with time in an appropriate age, the diagnosis seems unassailable. His appetite was ravenous and his ill-mannered eating habits were accompanied by gustatory sweating. He also showed features of limited self-mutilation, like hitting his fist or legs and cutting his nails deeply which often bled.[1]

William Hogarth, the painter, endorsed Johnson's curious movements. Samuel Richardson, a contemporary literary figure, wrote.

“A person standing at a window in the room, shaking his head, and rolling himself about in a strange ridiculous manner… I have so true a veneration for him, that the very sight of him inspires me with delight and reverence, notwithstanding the cruel infirmities to which he is subject; for he has almost perpetual convulsive movements, either of his hands, lips, feet or knees, and sometimes of all together.”[6]

There are however, views to the contrary. Johnson was born of an extremely difficult labor and plunged into phases of melancholy since his early youth. He was a chronic insomniac, suffered from loneliness and had morbid fear of imminent death. His vision was poor and he was partially deaf.[6] When he was 25 years of age, he felt that he was destined to turn mad some day and in utter desperation, wrote a letter to Samuel Swynfen, a physician and reportedly, his godfather, indicating his morbid thoughts. Swynfen attested his concerns which made Johnson even more preoccupied with his mental state.[7] James Clifford refers to his prayers that he was obsessed with the idea of committed sins, sexual guilt, strong sexual desires which he had expressed to Mrs. Desmoulins and others and possibly, masturbation.[6] Lord Russell Brain of Eynsham and the celebrated neurologist described him as ‘the Great Convulsionary’ and felt that since Johnson could control his odd mannerisms when absolutely essential, suggested a psychological etiology.[8] Thomas Tyers wrote in an article entitled, A Biographical Sketch of Samuel Johnson,

“He was to the last a convulsionary… His gestures, which were to a degree St. Vitus’ dance, in the street attracted the notice of many, stare of the vulgar, but the compassion of the better sort.”[9]

Samuel Johnson died of the complications of cerebrovascular accident in 1784 and with that ended all his tics, antics, obsessions and compulsions.

Mozart has been universally reckoned as one of the most creative musicians of all time, if not the greatest of all of them. Ludwig van Beethoven, possibly the most well known western composer was deeply influenced by his music and Pyotr Ilyich Tchaikovsky, the phenomenal Russian composer wrote an orchestral suite in the name ‘Mozartiana’ as a tribute to his genius. Joseph Hayden, his illustrious senior contemporary, close friend, and teacher wrote that posterity will not see such a genius. He was born in Salzburg, Austria and appointed by Prince-Archbishop Hieronymus Colloredo, as a court musician there at the age of 17. Later, he had a couple of disagreements with him, moved to Vienna and remained there for the rest of his life. In his short life he composed more than 600 works his life was full of miseries and abject penury never left him. In the latter part of his life he was forced to borrow money and was afflicted with depression with the resultant decline in his musical output. He died in 1791 though the precise reason of his death is not fully known and acute rheumatic fever, streptococcal infection, trichinosis, mercury poisoning and influenza have all been advanced as the probable causes. He was given a modest burial in a common grave and thus ended the tragic life of an irrefutably gifted musical genius.

Wolfgang Amadeus Mozart (1756-1791)

Tourette Syndrome

In the first place, Mozart's use of spoken and written words merit some examination. Those were sometimes vulgar and reeked of a scatological content. Though Fog et al.,[10] Davies[11] and Keynes[12] were among the initial investigators to study Mozart's cyclothymic disorder and Fog et al., presented their paper in the World Congress of Psychiatry in Vienna in 1985, it was Benjamin Simkin, an endocrinologist, pianist, musicologist and historian, who carefully studied 371 letters written by Mozart and found evidence of scatology in 39 of them.[13] In nine letters written to his cousin, Mozart uninhibitedly referred to defaecation and anal issues which clearly suggested coprographia. He even titled one of his canons ’. my ….’[14] Interestingly, Mozart scatological intensity varied from time to time, being most pronounced in 1770, 1781 and 1788, corresponding with periods of intense emotional stress and instability[13] and incidentally, one of the diagnostic criteria for Tourette's syndrome is change in intensity with time. However, Joseph Lange, an actor and Mozart's brother-in-law thought otherwise; he felt that Mozart's frivolous and puerile behavior was the manifestation of his creative intensity. He further wrote that these bizarre actions were seen only when he was deeply concentrating and composing. Otherwise, he behaved like a dignified young man though “occasionally made jests of a nature which one did not expect of him… and these sudden outbursts of vulgar platitudes…giving himself pleasure by seeming of making fun of himself”.[15] Some also feel that the scatological features exhibited by him may simply represent a ‘style of speech and silliness that was the acceptable behavior in the population of the South German middle class…’.[1617] Some again feel that Mozart acquired this curious and distasteful habit from his mother who had a tendency towards scatological writing as some her letters to her husband bear out.[11] His sister, Nannerl too, showed florid signs of obscenity as can be garnered from one of her letters to her mother and brother regarding her pet dog, ‘All the same she is quite well, eats, drinks, sleeps, ….s and p….’.[14] Simkin wrote that his mother, sister and father showed 2.5%, 6.7% and 0.3% scatological usage in their correspondences respectively, compared to 10.5% scatological evidence present in Mozart's letters, the most frequent being buttocks and defecation, s…, a… hole, f…, p…, etc.[13] Once in a letter to his cousin Maria Anna Thekla Mozart wrote, “I need to f… already 20 years out of the same h… and is not yet panned out”. Some of his other correspondences to his parents and sister are so full of obscene and vulgar profanities that one feels comfortable in taking leave from expounding on this inexplicably crude, gross and perverse nature in his character. Ashoori and Jankovic in their classic paper entitled ‘Mozart's movements and behavior: a case of Tourette's syndrome?, wrote, ‘Whether such linguistic features suggest coprographia and support the diagnosis of TS or are indicative of excessive humor, arrogant behavior of a savant or impulsive outbursts of stressful life remain controversial’.[18] Furthermore, if one accepts the view that he suffered from rheumatic fever, some of his involuntary movements can also be attributed to Sydenham's chorea or St. Vitus’ dance, a known complication of that disease. This condition is also associated with variable degrees of behavioral problems and other psychiatric co-morbidities.[1920] Incidentally, Sydenham described the condition in 1686 and this is the first variety of movement disorder described in the Western world.[21]

Mozart was known for facial grimaces, repetitive hand and feet movements and moaning and all such antics are generally considered by medical historians as manifestations of his motor and vocal tics.[1822] One description of his physique and behavior reads, “He was thin and pale; and although the actual shape of his face was extraordinary, his expression was memorable in nothing save in its extreme variability. His features would alter from one instant to another, yet never revealing anything save the pleasure or the distress that he happened to feel in that immediate instant. He had one tic or idiosyncrasy which, as a general rule, is a symptom of stupidity: his body was perpetually in motion; he would play incessantly with his hands, or tap restlessly on the floor with his feet.”[13] He also used to jump around incessantly and pace the stairs of a building up and down often unnecessarily and such hyperactive behavior was seen while he was composing,. and during such activities he often used to walk, ride a bicycle or play billiards.[23] Edridge et al., wrote, “At table he would often twist up a corner of a napkin and rub his upper lip with it, without appearing to know what he was doing, and he often made extraordinary grimaces with his mouth.... Also, his hands and feet were always in motion, he was always playing with something, e.g. his hat, pockets, watch-fob, tables, chairs, as if they were a clavier”,[24] while Mozart's sister in law, Frau Hofer, described the ‘restless movements of his hands and the movement of his lips’ at the opera.[13]

Others are on record to have noticed his swinging moods. Once while he was improvising on one of his compositions, “… he suddenly became tired of it, jumped up, and in the mad mood which so often came over him, he began to leap over tables and chairs, miaow like a cat and turn somersaults like an unruly boy”.[16] He was mostly unaware of the social consequences of his inappropriate behaviour and often landed in troublesome situations.[25] Controlling his sudden impulses and restraining from immediately acting on it were alien to him and his sister once wrote, “This same being who, considered as an artist, had reached the highest stage of development even from his very earliest years, remained to the end of his life completely childish in every other aspect of existence. Never, until he died, did he learn to exercise the most elementary forms of self-control.”[26] Such features of attention deficit hyperactivity disorder in him have been addressed by other researchers as well.[1114] He had difficulty in focusing and sustaining his concentration and Karl Ditters von Dittersdorf, an eminent violinist and composer, wrote“ ‘He leaves his hearer out of breath, for hardly has he grasped on beautiful thought than another of greater fascination dispels the first, and this goes on throughout, so that in the end it is impossible to retain any one of these beautiful melodies”.[22] In the famous movie ‘Amadeus’ based on Mozart's life and works, Emperor Joseph II, commented, “…too beautiful for our ears, and far too many notes, my dear Mozart” and many historians feel that it referred to Mozart's frequent and excessive reversals and repetition of rhythm.[27] Davis felt that he suffered from bouts of manic-depressive psychosis. He refers to a classical example of perseveration, and scatological babble of Mozart,

“Muck! Muck! Ah, muck! Sweet Word! Muck! Chuck! That too is fine! Muck, chuck! Muck!... O charmante! Muck, ….! That's what I like! Muck, chuck and …. Chuck, muck and …. Muck.”.[28]

Finally, other funny and gibberish utterances of Mozart include works like, Hinkity Honky, Punkititi, Schlaba Pumfa, Royka-Pumpa, Natschibinitschibi, Sagadarata, Schlamanuzkey, Runzi-funzi, Ramlois- Schurimiri, Gaulimauli, Blatterrizi, Signora Diniminimi His letters to his wife in 1789 and 1791 are replete with prattles like, Schluck and Druck, Spitzegnos, Schlumba and Saperlotte, Stachelschwein, “nu, nu, nu, nu,” Stanzi-marini, Plumpa-Strumpi, LacciBacci, and Snai.’.[13]

That Mozart exhibited traits of obsessive-compulsive disorder can easily be recognized from his compulsive acts and obsessive thought problems. He suffered from the unfounded fear of his wife leaving the house and was obsessively fussy about his wife's manner of hygiene. He once said, “I entreat you to take bath only every other day, and only for an hour. But if you want me to feel quite easy on my mind, do not take them at all, until I am with you again.”[15] He also hd the compulsive habit of touching others and Johannes Hummel described Mozart's actions during his son's piano audition, ‘Mozart nudged me gently with his arm a few times. suddenly put his hand on my knee, pressed it gently.... He then put his hand on the boy's head, took him by the hand, and put him on his lap petting him continually.’[13]

In spite of the fact that Benjamin Simkin's work on Mozart's scatology remains a classic, LR Karhausen feels that Simkin's claims were based on false evidence. He argues that Mozart's involuntary movements and vulgarities were not involuntary but intentional in order to arouse humour and laughter amongst the nearby people.[29] Stafford wrote, ‘his eccentricity “may have a basis in fact, but fact that has been selected, heightened and coloured by its emphasis and selectivity it runs the risk of exaggeration.”[30] Finally, he commented’ ‘Tourette's disorder is the latest Mozart's myth. It sounds like a disparagement disguised as a diagnosis.’[29]

Assessing the idiosyncratic motor, obsessive and compulsive behavior of Dr. Samuel Johnson and Wolfgang Amadeus Mozart, it is somewhat tempting to assume that Johnson was truly a victim of Tourette's syndrome while Mozart's illness should be studied in the broader perspective. Johnson's trade-mark vocal and motor tics and obsessive-compulsive thoughts and actions leave little room for uncertainty that such a posthumous diagnosis can safely be arrived at. Mozart, on the contrary, displayed many features which might hint at a more pronounced psychiatric ailment. Many authorities believe that Mozart's rapid change of behavior from profundity to perversity and his anomalous behavior might have been exaggerated in many accounts and they were merely a personality trait of an eccentric genius rather than a organic disease.[173132] Others advocate that outstandingly creative individuals, deeply engrossed with their work and immersed in the world of creation are often oblivious of their immediate surroundings and such socially deplorable mannerisms and gesticulations may simply be one way of getting rid of the mental tension that grips them.[33] It is often felt that Mozart's perky, curious and inappropriate behavior and foible is the manifestation of an inner conflict between his providentially bestowed talent and the social milieu of his time where he was exposed to.[18] Karl Holz, a violinist, described Mozart as “Outside of his genius as a musical artist, Mozart was a nullity” and Wolfgang Hildesheimer, a contemporary historian commented that “… was as great a stranger to the world of reason as the sphere of human relations. He was guided solely by the aim of the moment” and such comments might also explain to some extent, his questionable prurience, escapades, dalliances and bohemianism.[1333] Others again feel that the oddities and quirksin his nature, like amusing acts and attention towards garish apparel, particularly the red and other bright colors, only represent a kind of mutinous insubordination against the nobility in order to overcome some of his shortcomings like, short height, strange shape of the head and a face riddled with ugly pock marks, large nose and deformed left ear.[12] Again, some historians have noted features suggestive of Asperger's syndrome in Mozart's behavior like, repetitive body movements, motor or vocal tics and preoccupation with objects.[1528] However, such people often have auditory and attention impairment and Mozart's extraordinary aural sensitivity to musical notes seems to annul such hypothesis. In the final analysis, Ashoori and Jankovic argue cogently and sensibly that Mozart's irrefutable and incontrovertible musical genius was not only nature's gift but it also owed its genesis to some distinctive neurological and cognitive dysfunctions. Every subject afflicted with Tourette's syndrome is not so gifted otherwise.[18]