Ten years later in another Time article, this time noting the publication of his book, The Good Times, R.Z.Sheppard wrote of him: 
 

“For satire, parody, and burlesque on short notice, he has few equals.  He has had what many journalists would consider a dream career, and nobody tells him what to do.  Or so it would appear.”
 

On the publication of another Baker book Jacques Barzun wrote,
 

“One of his great merits is that he breaks with the excessively verbal tradition of American humor and deals with things.”
 

And David Halberstam wrote of Baker in 1997, in Vanity Fair,
 

“  He is simply the most talented New York Times journalist of one and quite possibly two generations, and his column in the Times has been a National treasure.”
 

What lead to this extraordinary writing career ?
 

Sui generis he was. There isn’t another American writer who could perform such stunning and daring acrobatic feats with words.

Articles written about Perelman in life, like the obituaries printed last week, often contained an acrobatic simile because there was no better way to describe what the humorist did so superbly.

“For more than 50 years,” wrote Robert Taylor in the Boston Globe obituary, “Perelman hurtled through the air without a net, executing dazzling triple and quadruple somersaults and landing on his feet effortlessly as he reached the swinging platform at the end of a sentence.”

Ten years earlier, in the New York Times Magazine, William Zinsser made the point that “Life today has become so outlandish that it outstrips the writer’s comic imagination…Against such odds the miracle is that Perelman keeps going out on the wire.”

Zinsser – a friend of Perelman’s and author of that sui generis gag – wrote that his admiration of the great humorist was based on his courage: “No other kind of writer risks his neck so visibly or so often on the high wire of public approval. It is the thinnest wire in all literature, and the writer lives with the certain knowledge that he will frequently fall off.”

It was with Bill Zinsser that I first med Sid Perelman. The encounter was in a Manhattan Chinese restaurant. The food was good and the conversation both comic and competitive.

We had all traveled a great deal, but neither Zinsser nor I could hold our own against Perelman’s travelmanship. The three of us might have been to Bangkok, for example, but only Sid would know about the opium-addled and alcoholic Scotsman who ran a bakery specializing in scones (I asked whether he ever sold cold scones sober) and haggis. Or perhaps an obscure bookshop in Rangoon that specialized in 13th century religious erotica.

Years later, at another dinner in London, I asked Perelman whether he had ever heard from a famous woman editor who had been ridiculed and rapiered by him in a piece called “The Hand That Cradles the Rock.”

He chuckled. The editor had, like Perelman himself, moved to London. A notorious party-giver and namedropper, she must have been torn between Perelman as the cause of her punctured pride and Perelman as a social prize.

The latter won out, so she sent him a party invitation that began, “Dear S.J.” – something Sid was never called by those who knew him well. After he had told the end of the story, I wondered: Was he correct in assuming that it was funnier to sign his note of regret “S.J.” as he did, than to hoist her by her gaffe by signing “Sid?” Later I decided he was right. She would eventually find out and wince.

“Generally speaking,” Perelman told Zinsser in that magazine interview, “I don’t believe in kindly humor…One doesn’t consciously start out to be a social satirist. You find something absurd enough to make you want to push a couple of anti-personnel bombs under it.”

Perelman was a tough specimen, who; if he had been told that a heart of gold beat beneath his flinty exterior, would have demanded a transplant – if only to avoid aiding and abetting a cliché.

He appraised mankind’s activities with the cool eye of a jeweler at work. What he saw was a world filled with poltroons, boobs, brigands, blackguards, gold diggers, social climbers, fanatics, and fakes.

(He found them all in Hollywood, which he learned to loathe. Writing about the movie “Sweethearts,” starring Jeanette MacDonald and Nelson Eddy, to which he had contributed some dialogue, Perelman said, “My name never made the crawl on ‘Sweethearts,’ for which I still beam eternal gratitude. The two stars were not called ‘The Iron Butterfly’ and ‘The Singing Capon’ inadvisedly; their archness made toes curl all over the world.”)

Sentiment made him nervous. One couldn’t picture him decorating a tree on Christmas Eve. He was no Scrooge, but he was certainly no Santa.

It was possible to imagine him wassailing, though – in part because of the drinking ceremony’s association with England, which he loved, and in part because it was a neat word, which he loved even more.

THE AMERICAN PEOPLE WILL DISCOVER WHERE CONGRESSMEN COME FROM.
The late Margaret Mead, anthropologist, wrote about a Pacific isle where natives had not made the connection between sexual intercourse and the birth of babies.  Nine months is a long time and it simply hadn’t occurred to the islanders that the two events were linked.

In the same way, Americans still have not, as they emerge from the 1970’s, made the connection between their own political apathy and ignorance on one hand and, on the other, a Congress crowded with felons, loonies, jingoists, buffoons, demagogues, fanatics, and scoundrels.

Call me a giddy optimist, but I predict that in the 1980’s Americans will find out that they themselves are the ones who elect the Congress (for which only 15 percent of the voters have any use, according to polls); that congressmen are not brought by storks or chosen by court astrologers or left by the tooth fairy, but are conceived in polling booths all over the nation.

THE REST OF THE WORLD – AND THE SOUTH KOREANS THEMSELVES – WILL DISCOVER WHAT HAS BEEN GOING ON IN SEOUL. 
The South Korean capital has been the scene of a murky tragio-comic opera – the cast and plot of which cannot be sorted out by reporter or computer.  It will not all come clear in the 1980’s, but at least some sense will emerge.

JEANE DIXON, THE SEERESS-ASTROLOGER-CRYSTAL BALL READER, WILL BE RIGHT ABOUT ANOTHER LONG-SHOT PREDICTION, BUT THE PUBLIC WILL DISCOVER THAT 3,749 OTHER FORECASTS WERE ALL WET.  AND THEY WILL IGNORE HER.
Impossible, you say?  The public has always been gullible?  Well, just wait and see.  But I will admit that this is my long-shot prediction for the decade.

IRANIANS WILL DISCOVER THAT EVERY EMBASSY IN  TEHERAN, AND, INDEED, EVERY EMBASSY IN THE WORLD, SENDS SECRET INFORMATION BACK TO ITS PARENT COUNTRY, AND EMPLOYS SPIES.
If the people holding hostages in the American Embassy are really university students, they must have cut class when the history of diplomacy was taught.  Had they gone to school they would have learned that all embassies perform several functions:  giving parties, encouraging business deals, issuing visas, providing information, and obtaining information.  And of all these functions, the last is the most important.  When the Iranians discover the truth about embassies, they will, of course, apologize and lower the price of oil.

PARENTS WILL DISCOVER THAT ADOLESCENTS HAVE ALWAYS BEEN, AND WILL ALWAYS BE, SLOPPY.  AND THEY WILL RELAX.
This prediction will be greeted with understandable skepticism by youth, but I see signs of

One of the funniest sights I have seen in recent weeks was Bob Yoakum shaking his left index finger under Art Buchwald’s right jowl.

Here were two of the nation’s finest humorists looking for all the world as serious as Sadat and Begin trying to resolve the problems of the West Bank Palestinians.

The scene took place at the First Amendment Fair (shade of Thomas Jefferson, please note) held at Washington, D.C.’s old Pension Building, the site, someone insisted, of Lincoln’s inaugural ball. The fair’s proceeds are to go to a fund established by The Reporter’s Committee to aid those members of the press, who, in the performance of their duties, run afoul of judges who believe it is better to put newspaper people in jail than to permit them to protect news sources. I hope that Thomas Jefferson’s spirit, wherever it may be hovering, appreciated both the need for supporting The First Amendment as well as the fun we had doing it. But, back to the finger-pointing.

The occasion, I was told later by Yoakum, had to do with Buchwald’s recommending Yoakum to New York Times humorist Russell Baker for membership in an obscure humorist organization, the total complement of which would not fill a booth in the crowded night spot where another of this nation’s humorist, Mark Russell, does his thing.

All of which is a long way around the barn to make the point that there just aren’t many funny people in print these days. Well, that is not the right way to say that, of course. There are legions of funny people in print, and it is almost impossible to read straight news stories about them without breaking up — or down, as the case may be.

What is rare is the writer who sees humor where others see little and who is able to conjure the words to express it. It is the most serious of business which is why you rarely see guys who write the stuff smiling.

Writing humor is hard work because its purpose is to attract, amuse, instruct, titillate, inform, chastise, caress, deflate, satirize and to illuminate the subject matter with a special kind of light. No wonder humorists growl at their dogs, children and spouses, in that order.

As a matter of historical note, Buchwald and Yoakum worked together in Paris when both were striplings. When they split, Buchwald took the humor route, and Yoakum decided to go straight. He returned to humor writing a half dozen or so years ago.

Those who read the columns in this newspaper recognize style differences. Art Buchwald’s material usually follows a predictable format. He seizes upon an event of the day, interpolates it into a faintly camouflaged setting and then proceeds to destroy whatever it is that presents itself as an absurdity.

There are probably 999,999 writers out there who know they can do the kind of thing Art Buchwald does. The problem is that the words just do not seem to come out of their typewriters in the right order.

As for Bob Yoakum, his stuff seems even easier. There is no set format. It is an inductive kind of humor, a gentler stroke. There is more subtlety. But a scalpel can cut as deeply as an ax, and the result can be as deadly. There just isn’t so much blood lying about after the coup de grace.

Erma Bombeck, whose material we also use, has an angular style which sends us scurrying up the backstairs one minute, around three turns in the hallway in a rush to find the bathroom, only to find that we’ve been fooled into a broom closet in the basement. She is a gag writer, without peer, the standup comic of writing humorists, who deals with every day frustrations as devastatingly as Mark Russell does the world of politics.

Russell Baker, of The New York Times, casts his fictionalized public events in the same direction as Buchwald, although with a literary flair more reflective of the old New Yorker Magazine, back in the days of Thurber, White, et al. He is Sunday’s bright relief from the deadly fare of The Times, and I look forward to his view from that exalted perch.

Mark Russell has to be seen, in person, to be fully savored. When he is off and flying, which is likely to happen without warning during a regular routine, he is this nation’s finest political satirist. But he is fundamentally, a verbal man, one whose genius is ignited by an appreciative audience in a relatively small room. It is one thing for Russell to write a line and quite another to deliver it in person. Those who read him with appreciation should take the trouble to look him up when in Washington.

Buchwald, Yoakum, Baker, Russell, Bombeck — add a half dozen or so more and you have the nation’s humor cadre. They are a precious few to be stroked, coaxed and applauded as our only real hope for sanity in a zany world.

(Bill Plante is executive editor of Essex County Newspapers.)

Lakeville, Conn. — Of the four topical humorists whose columns run regularly in newspapers across the United States — Russell Baker, Art Buchwald, Art Hoppe and Robert Yoakum — only one lives in the sticks and syndicates himself.

That’s Bob Yoakum, whose twice-weekly column, titled “Another Look,” appears in The Berkshire Eagle, The Sunday Times (London), Katherimini (Athens), Daily Yomiuri (Tokyo) and 76 other periodicals including the Boston Globe and the Alabama Journal (Montgomery).

Yoakum lives outside the Northwestern Connecticut village of Lakeville in a house commanding a view of Lake Wonoscopomuc (more pronounceably known as “Lakeville Lake”). He works a mile down Reservoir Road in a converted residence equipped with one youthful assistant, one old copying machine, two electric typewriters, 58 filing drawers and uncountable stacks of newspapers and magazines.

The arrangement is nearly ideal for a writer-entrepreneur who likes country living. Though the closest city, Hartford, is 50 miles away, Yoakum Features has mastered the mechanics of sending out 600 words of timely copy twice a week to its 80 client newspapers. Neither the writing of the column nor its distribution seems to demand large-city surroundings.

That another journalist could do the same thing at this time is doubtful, though. Would-be self-syndicators who ask Yoakum’s guidance are sympathetically touted off the idea.
Work with an established syndicate, he recommends. For starters, he points to the annual syndicate directory put out by Editor & Publisher. But don’t try to found your own syndicating business, as he did nine years ago. Today the cost and the hassle are out of hand.

Yoakum blames United Press International, mostly, for the mounting difficulties of mini-syndicates. Despite blather about free enterprise, he says, UPI imposes rules and transmission requirements that virtually bar fledgling syndicates from the newspapers UPI serves.

Today UPI tells small operations like Yoakum Features that its newspapers will not accept material that is not already on computer. But the multi-thousand-dollar cost of installing his own electronic system gives Yoakum pause. For an infant business, the outlay could be mortal.

Probably, syndicating will be easier in the future, Yoakum speculates, as computer services spread their lines throughout the country. Within five years it may be a simple matter to transmit directly to client newspapers, perhaps with the network being developed by Bell Telephone.

Meanwhile, getting out the column represents a semiweekly challenge. Without Bonnie Hunter, his bright, no-nonsense assistant — and vice president, managing editor, controller, promotion director, production manager and office foreperson — Yoakum says the job would be hopeless.

It is one of Vice President Hunter’s duties to type Yoakum’s 600 words in the three different scannable type fonts owned by most of the nation’s newspapers using scanners in the printing process. The job is exacting because the three modes call for different spacing, different margins and different quotation marks. Each typing correction must be precisely placed. A flyspeck or a line askew will inspire the machine at the newspaper end to reject the copy.

Managing Editor Hunter feeds the three typed versions into an IBM copier which makes enough copies for the 80 customers. Copies are mailed from the Lakeville Post Office five days in advance of their scheduled publication date. Fifteen go to the Editors Press Service in New York for transmission overseas.

There are occasional glitches. Yoakum, an admitted procrastinator, sometimes finishes his column so close to deadline that Production Manager Hunter completes the typing, copying, stuffing of envelopes and mailing with only minutes to spare. Once or twice insufficient postage has been applied (and unsung allies in the post office made it right). The power supply has been cut by storms, immobilizing the electric typewriters and copier.

But Yoakum Features meets its deadlines. And 59-year-old Bob Yoakum remains fit and productive. Staying well enough to write is important, Yoakum confides, because he has no backup columns for use in case of flu, writer’s block or other catastrophe. If such a crises should occur, some timeless old columns would be posted into the breach.

Why Yoakum does not squirrel away half a dozen columns for emergency use, as he collects everything else in print that crosses his desk, is partly explainable by his need to be in step with the week’s news, partly explainable by simple procrastination. Yoakum’s Law, enshrined in Paul Dickson’s anthology, “The Official Explanations,” goes, “Don’t put off until tomorrow what you can get done some time next week.”

Certainly he does not ache for column ideas. His writing desk and its add-ons form a bullpen surmounted by newspapers soaring to dizzying heights. Each paper is there to be clipped for information that may find its way into his work. A five-foot row of manila folders, nearly buried by other reading matter, contains starting ideas for columns. Across the 20-foot room, six four-door filing cabinets bulge with indexed and cross-indexed clippings.

While many clips are filed by topic in the usual way, others are grouped below titles devised by Yoakum and reflecting his special slant. Some are amusing as they stand, such as the compilation of scoundrels and monsters who have scored successes in life: “How _____s Rise to the Top.”

Along with the humorous are the “not-so-humorous,” as perhaps befits the thinking of the son of a Congregationalist minister who was “always teetering on the edge of agnosticism.”

Under the rubric, “God’s role,” is the account of a pious New York spinster who attended mass every day of her life but was crushed to death when her tenement roof collapsed. In the same file is the story of a planeload of Mecca-bound pilgrims, all killed when their jetliner crashed.

“Here were good people who followed all the rules and regulations and got wiped out,” Yoakum muses, folder in hand. “What sort of a Deity is this? Once you start noticing this stuff, you see a frightening pattern.”

In the same dark vein is Yoakum’s “Suicide” file, a thick wad of clippings attesting to man’s propensity for acting against his best interests.

“Most people and institutions are doing just opposite to what they should be doing,” Yoakum says with a gesture toward the file. “That isn’t theory. It’s all documented, right there.”

Then there is the “L-R, R-L” collection of clips demonstrating likenesses between leftwing and rightwing political groups that claim to be poles apart. As example, Yoakum points to the tendency of left and right extremists to exterminate those who disagree with them.

Plainly, material of this somber hue does not go straight into Yoakum’s humor column. He finds uses for it, though. He contributes to the Nieman Reports and the Columbia Journalism Review. Two recent articles explored obscenity and the First Amendment. An extended essay reviewed “The House of the Prophet,” the Louis Auchincloss novel based on the life of columnist Walter Lippmann.

In collaboration with a longtime friend, William H. Attwood, former editor-in-chief of all Cowles Publications and foreign editor of Look, Yoakum is putting together a book that will contain a lot of his columns plus treatises on subjects that either cannot be handled in 600 words or would make newspaper editors “uneasy.”

Some of his biweekly pieces come close to inducing that effect. Yoakum writes on both sex and religion, subjects generally skirted by topical-humor columnists. Their fear, of course, is that these matters will excite strong, serious feelings in newspaper readers, and then where will be the chuckle?

More often than not, Yoakum’s column evokes a chuckle despite the ingrained hazard of the topic. Racism treatment of the poor, handgun control, the idiocies of extremism, the “loonies” of electronic religion — all these Yoakum themes are heavy, but their treatment is light.

Far from maintaining that sensitive subjects should not be handled with humor, Yoakum believes they often are handled best with humor. He visualizes many of his readers as armored in convictions fashioned and forged to repel direct assault. But good satire can slip inside the helmet and “explode” in the reader’s mind.

The American master of satirical humor, in Yoakum’s canon, was Mark Twain. “We need him more than anyone today. All of us together don’t add up to that talent.” Yoakum cites Twain’s satanic “Letters From the Earth” as a little-celebrated masterpiece. He gives away paperback copies to help spread the word.

Other funny writers whose work Yoakum admires are the late S. J. Perleman, James Thurber, Robert Benchley, Wolcott Gibbs — for that matter, a whole stable of erstwhile New Yorker writers.

Sometimes when you’re writing topical humor, Yoakum says, penetration into the reader’s mind takes place but then there’s no explosion. It is the function of the column’s last section, often the closing paragraph, to supply the detonation while summing up what has gone before. To the degree that the ending achieves this double aim, the column effects new angles of vision in its readers.

Because the closer is critical, Yoakum can take two or three hours to come up with one that seems apt. He shows it to Managing Editor Hunter who — usually busy on another task — may simply shake her head. Yoakum tries another version. If Hunter shakes her head, he tries again. And again. And again, until they agree it is right.

Yoakum has abiding faith in his assistant’s editorial judgement. “Bonnie and Alice are my editors and proofreaders,” he says. “This is not like a newspaper, with copy editors. There has to be someone between the writer and cold print.”

If endings are the most “agonizing” part of column writing, leads come a close second. The trouble, Yoakum says, is that you need to lay out your facts while making it clear they are not to be treated all that solemnly.

As everyone knows who has tried his hand at satire, the ever-present danger is that you will be taken seriously.

“I can write that a UFO landed in my back yard filled with little green men speaking Chinese, and someone is sure to challenge me on the facts,” Yoakum observes. “This is something you have to keep in mind while you’re writing the column.”

One kind of signal he gives the reader is the ludicrous Dickensian name identifying a column character: Boothby Frimble, Congressman Treacle, Prudence Vipps, Prof. Upgraph. Yoakum inserts one of these tipoffs into an early paragraph as often as he can.

Another trick Yoakum has borrowed from Perelman: a short, authentic news item set at the head of the essay and furnishing the springboard for the writer’s subsequent flips. Yoakum is fond of the device and wonders why his friend and former International Herald Tribune co-columnist, Art Buchwald, does not use it too. Buchwald, he claims, sometimes wastes half a column just establishing the facts.
Yoakum takes between one and four hours to write his column, an amount of time he considers “appallingly small.” In addition, he spends at least an equal length of time, up to twice as much, in research. At absolute maximum, then, his twice-weekly stint takes 24 hours, which hardly adds up to a full work week.

But Yoakum says he puts in 60 hours, occasionally laboring into the night. “A lot of that is wasting time,” he explains. “Otherwise, I couldn’t do it.”

Yoakum pays scant attention to promoting his own syndicate, a duty he cordially despises. A business letter placed on his desk quickly becomes hidden by papers and magazines stacked higher by the day. The letter goes unanswered until one of the unstable piles falls over and brings it to light. Depending on the height of the stack, Yoakum’s answer may go out weeks, months — even years— behind time.

Aside from the discomfort of promoting his own works, Yoakum’s chief complaint is absolutism, the moralistic, black-is-black and white-is-white mindset that he holds responsible for much of the world’s grief. He deeply admires the tentative humanistic outlook outlined by novelist E. M. Forster in “Two Cheers for Democracy.” He is proud to be founder and first president of the Anti-Absolutist League — “We’re against absolutists though not, of course, absolutely” — even though it is making slight headway. “I’m sorry to report there are more absolutists every day.”

Even in non-global terms, Yoakum’s world seems no more firmly balanced than one of the newspaper stacks on his desk. His client papers are crying for computerized copy. Soon he may be obliged to make the big, costly switch over to video data transmission.

Even more upsetting, the irreplaceable Bonnie Hunter was married recently and is spending fewer hours on the job. That adds to Yoakum’s load. He is not sure how he will manage.
But he still gets candid, helpful advice from wife Alice, a partner in the Lakeville law firm of Reid & Reige, and 17-year-old son Robert, a sophomore at Cambridge School in Weston, Mass. Two daughters, Elizabeth, 24, living in New York, and Ellen, 22, a senior at MacAlester College, St. Paul, Minn., are only phone calls away.

For refreshment of spirit there remains the lovely Litchfield countryside out the windows of both his house and his office building — placid, green now and undefiled. For amusement, piling up in stacks in front of this droll moralist with the perceptive eye, there is always and endlessly the day’s news.

Chapter One: Yes, It Is a Real Disease

The miserable have no other medicine, but only hope. — William Shakespeare, Measure for Measure

The word nightwalkers describes people (like me) who are forced to endure profoundly disagreeable creepy-crawly symptoms in their legs that can be relieved only by movement or medication. Walking is the method most commonly used, and since the restless limbs suffer more at night, the severely afflicted may have to walk all night long. Hence nightwalkers.

The severity of symptoms ranges from mild (uncomfortable and intermittent), to moderate, to severe (distressing and daily). Those with the severe form — who have the agony of serious sleep deprivation as well as the discomfort of RLS — have in some cases been driven to suicide.

My RLS eventually became severe: sleep was impossible until daybreak. I spent many dark hours walking. I can testify from experience that the name restless legs syndrome, though sounding trivial, does accurately describe the nature of the affliction. Legs, and sometimes arms, demand to be moved.

People with RLS have employed many words in their attempts to relay their unusual discomfort: “prickly,” “jittery,” “pulling,” “an electrical feeling,” “pressure building up,” “fidgety,” “like thousands of ants crawling inside,” “heebie-jeebies,” “a deep ache in the bones,” “as though a very large spring was coiled inside my legs,” “like a cramp that does not fully develop.” The character Kramer on the TV sitcom Seinfeld said his girlfriend had “jimmy legs,” which is probably another way of describing RLS. A psychiatrist with RLS described the sensation as “ineffable,” adding, “It’s like an itch that you can’t scratch,” which gives added force to the aphorism that “the severity of an itch is inversely proportional to the ability to reach it.”

Since RLS is treatable, though not yet curable, the only way for Kramer’s girlfriend to obtain relief is through medication or movement. If she is like most RLS sufferers, her symptoms fluctuate, and she seeks comfort by walking, stretching, rocking, or riding an exercise bicycle.

Early Writing about RLS

Restless legs syndrome has been around for a long time. An early account of RLS appears in the essay “Of Experience” by French author Michel de Montaigne (1533-92):

That preacher is very much my friend who can oblige my attention a whole sermon through; in places of ceremony, where everyone’s countenance is so starched, where I have seen the ladies keep even their eyes so fixed, I could never order it so, that some part or other of me did not lash out; so that though I was seated, I was never settled. As the philosopher Chrysippus’ maid said of her master, that he was only drunk in his legs, for it was his custom to be always kicking them about in what place soever he sat; and she said it, when the wine having made all his companions drunk, he found no alteration in himself at all; it may have been said of me from my infancy that I had either folly or quicksilver in my feet, so much stirring and unsettledness there is in them, wherever they are placed.

A British physician, Sir Thomas Willis, was the first medical observer to describe what appears to have been both RLS and PLM:

Wherefore to some, when being a-Bed they betake themselves to sleep, presently in the Arms and Legs, Leapings and Contractions of the Tendons, and so great a Restlessness and Tossings of other Members ensue, that the diseased are no more able to sleep, than if they were in a Place of the greatest Torture.

This account was published in The London Practice of Physick in 1683. Note that Willis includes arms in his description. For most people, it’s legs that cause discomfort, but scientists prefer the word limb because arms can also be involved. An unfortunate small minority of victims suffer from full-body akathisia, which is “a condition of motor restlessness in which there is a feeling of muscular quivering, an urge to move about constantly, and an inability to sit still.”

The groundbreaking RLS medical study was done by Karl A. Ekbom, a Swedish neurologist, in 1945. In a systematic and comprehensive report, he defined the clinical features of the syndrome, including familial component, epidemiology, and therapy. After his pioneering research, the disease became known in some circles as Ekbom’s syndrome. While in some countries, such as England, the name is still used, it was the brilliant doctor himself who coined “restless legs syndrome,” and that name stuck.

In the nearly three hundred years between the Willis observation and the clinical studies by Ekbom and others, those who wrote about RLS tended to identify it as a “hysterical” condition. Until well into the twentieth century, RLS was labeled anxietas tibiarum, or anxious legs. Only more recently have neurologists begun to realize that we are dealing with a disease of the central nervous system, not a neurosis.

What Causes RLS?

Research into the causes of RLS is ongoing but so far has not pinpointed the mechanism underlying the disease. In other words, RLS has no identifiable origin, as, for example, influenza does. It may be that RLS is a final common pathway for multiple causes and mechanisms. Or it may be that victims have an underlying vulnerability that develops in the presence of one or more precipitating factors.

The word cause is used here in a loose fashion to mean something that appears to cause or trigger the disagreeable symptoms of RLS.

In nearly half of all cases, RLS is familial, but it may be idiopathic (cause unknown) or related to another condition.

Primary RLS

Primary RLS very often includes a positive family history. Between one-third and one-half of RLS cases are transmitted in a pattern consistent with autosomal dominant traits. (Human traits, including an individual’s eye color, hair color, or expression of certain diseases, result from the interaction of one gene inherited from the father and one gene from the mother. In autosomal dominant disorders, the presence of a single copy of a mutated gene may result in the disease. In other words, the mutated gene may dominate or “override” the instructions of the normal gene on the other chromosome, potentially leading to disease expression. Individuals with an autosomal dominant disease trait have a 50 percent risk of transmitting the mutated gene to their children.) There is also some evidence of a recessive inheritance, meaning that RLS cases can be transmitted by the less dominant, or recessive, gene. Primary RLS can also reflect a dopaminergic deficiency, which may result from a malfunction in the brain stem.

Secondary RLS

Features of secondary RLS are referred to as risk factors for RLS or as comorbid — coexisting disease states or disorders that occur in conjunction with RLS. Examples include periodic limb movements (PLM), end-stage renal disease (ESRD), early-onset Parkinson’s disease, venous insufficiency, diabetes, peripheral neuropathy, rheumatoid arthritis, fibromyalgia, lumbar radiculopathy, third-trimester pregnancy, iron-deficiency anemia, uremia, and attention-deficit/hyperactivity disorder (ADHD). There have been some reports of RLS symptoms resulting from deficiencies of vitamin B12, folate, and magnesium.

RLS can be induced by certain drugs, including all drugs that block the dopamine receptor — including neuroleptics, many antiemetic or antinausea drugs, and metoclopramide (Reglan) — as well as tricyclic antidepressants, selective serotonin reuptake inhibitors, and lithium. Alcohol and caffeine use can also trigger restless legs syndrome.

Another trigger appears to be physical trauma. No formal research supports this conclusion, but anecdotal evidence is strong. For example, my own experience, and that of many other people with RLS, leads me to believe that the disease occasionally follows or is at least exacerbated by operations, accidents, or other sorts of insults to the body and brain. In my case it was a radical prostatectomy. Others have reported that RLS was brought on or worsened by an accident.

So should I blame the onset of my RLS on the trauma of the operation itself? Or should I blame the use of Elavil afterward, since nearly all antidepressants are contraindicated for RLS victims? Or was it the accumulation of metabolites in the legs from venous congestion — a possible trigger of RLS, according to Ekbom? (I was hurled back into bed and given a blood thinner on what was to have been the day of my discharge. Dangerous blood clots were discovered in the deep vein of my right leg.) The RLS might have been worsened by the trauma of the operation or by the damaged veins, iron deficiency from blood loss, or either all, or none, of the above.

Other triggers guilty of worsening preexisting mild RLS include arthritis of the lumbar region, and spinal surgery. The most common link, according to Dr. Mark Buchfuhrer, of the former Gallatin Medical Clinic in Downey, California, “seems to be with lumbar laminectomy surgery (possibly due to the fact that this is one of the most common back surgeries), but even cervical (neck) surgery seems to be a not uncommon trigger of this type of RLS.”

“The differential diagnosis of RLS is usually uncomplicated,” Dr. John Winkelman, medical director of the Sleep Health Center at Brigham and Women’s Hospital in Boston and former member of the RLS Foundation Medical Advisory Board, wrote in a November 1999 article in Nephrology News & Issues magazine:

Some forms of peripheral neuropathy are the most difficult disorders to distinguish from RLS, and in fact the two not infrequently coexist. Painful neuropathy is often a “burning” superficial dysesthesia which is usually unaffected by movement, whereas RLS is more often a “crampy” deep-seated feeling which is relieved by movement. Both can worsen in the evening and night.

Patients with both disorders can be taught to distinguish the two types of discomfort, which can be helpful to the treating physician. Other disorders in the differential include pruritus (which can produce abnormal sensations with restlessness and sleep loss), anxiety, and akathisia (inner restlessness caused by dopaminergic blockers or antagonists).

In his search for the cause of his RLS, Leonard J. Uttal, of Blacksburg, Virginia, believes that he “hit the jackpot.”

After trying to get other doctors interested in my RLS, I sought a neurologist with geriatric and psychiatric qualifications on the combined advice from the RLS Foundation and AARP. This gentleman of a doctor spent three hours with me, performed neurological tests, and furnished me with reprints from the literature. He is most conversant with peripheral neuropathy, of which I have a “moderately severe” case and which often is associated with RLS symptoms. Also, together we dug out injuries to my legs I suffered over fifty years ago as a possible cause. Also, since I had heart bypass surgery a year and a half ago, an interrupted blood supply can be a cause, as can some medications. He plans to evaluate everything to try to pinpoint why I have RLS and work from there on. He plans to work with my internist who controls my medications to try to get me off as many as possible. For the first time I feel I am on track, in no small measure due to the RLS Foundation and AARP.

A Soldier’s Tale

I was an infantry platoon commander in the Marine Corps. I was twenty-three years old, a lieutenant. Often my platoon would come back from patrols exhausted. We hadn’t slept for days. The others would fall asleep on the ground, but I’d be there wiggling around with my restless legs forcing me to stay awake. Sometimes I could doze for maybe half an hour. I never got real sleep. I remember ambush situations where we had to lie there and not move. My life, and the lives of the guys with me, depended on it. My legs desperately needed to move but even the slightest motion could betray our position. It was torture.

This Vietnam veteran, Barry Kowalski, had symptoms of RLS as a child, but they were mild and intermittent. Restless legs syndrome typically worsens with age, and this was certainly the case for this soldier. By the time he was in his early twenties, the RLS was appearing almost nightly and he was forced to seek medical help.

Kowalski turned to several doctors, none of whom were very familiar — if at all — with this disease. Together they experimented with various medications, some of which provided temporary relief. Eventually he would develop a tolerance to the medication and need to take an increased dosage.

Unfortunately, Kowalski’s difficulty in finding effective treatment was typical, since at this time very few doctors had even heard of RLS. Indeed, twenty years passed before Kowalski learned that his problem was compounded by PLM, a related disease that causes legs to twitch or jerk about every thirty seconds or so.

Lieutenant Kowalski later became lawyer Kowalski and gained national attention as a prosecutor on the Rodney King case, working for the Civil Rights Division of the Justice Department. In the spring of 1992, after the Los Angeles riots, he went to L.A. to prepare the federal trial.

When I went out to Los Angeles, I knew that my disease had a name, but I hadn’t found a drug that helped much. I never got enough sleep. I was in agony from being so tired. Because of RLS, I usually wouldn’t get to sleep until three in the morning. And I had to get up at six because of the heavy workload. That went on for months. Then came the trial and another two months of stultifying fatigue. Those were tense times, and I was totally exhausted when the trial was over. It was a year of hell. When I gave the closing argument in the case, I remember thinking very vividly that I had had only four hours of sleep in the past two days.

In a recent interview, more than ten years after the Rodney King trial, Kowalski said that the intervening years had been bad, not only because of RLS and PLM but because he was still “badly hooked on Klonopin.” He stayed on a low dose of the drug because “if I cut it out altogether, I got powerful withdrawal symptoms.”

As of this writing, Barry Kowalski takes a potion prescribed by a psychiatric pharmacologist who is learning about RLS. “Now I sleep well, but only after a struggle to get to sleep.” Although not cured, he is much better off than he was. As word spreads about RLS, and as treatments continue to improve, it is unlikely that future victims will spend so many difficult years struggling for relief from this trivial-sounding yet serious disease.

How Common Is It?

How many people have RLS? Medically, RLS is considered a “common” disorder, as well as an epidemic, since it affects 7 to 15 percent of the northern European and U.S. population. Obtaining precise figures is difficult for a variety of reasons, particularly because a lack of research funds makes undertaking a large epidemiologic study impossible. Suffice to say, though, at least 12 million and up to 40 million Americans suffer from RLS — numbers that are far higher than those for widely known diseases such as diabetes and Parkinson’s.

Periodic limb movements (PLM) often coexists with RLS but is a separate affliction that involves leg twitches or jerks that occur about every twenty to forty seconds. PLM is used to describe periodic movement of the limbs while awake or sleeping, and usually in conjunction with RLS. This is not to be confused with PLMS, which is repeated stereotypic movements of the limbs (usually the legs) that occur during sleep. Both are independent of PLMD, or periodic limb movement disorder. The diagnosis of PLMD is made by polysomnography with electromyographic (EMG) recordings from the tibialis anterior muscles. The severity of PLMD is determined by the periodic limb movement index (PLMI), which equals the number of periodic limb movements per hour of sleep. Mild PLMD is defined as 5-25 periodic limb movements per hour of sleep; moderate as 25-50 periodic limb movements per hour of sleep; and severe as more than 50 periodic limb movements per hour of sleep or greater than 25 periodic limb movements associated with arousals per hour of sleep.

The limb movements of PLM are easily measured with monitors; RLS, however, cannot be confirmed by laboratory tests, thus adding to the difficulty of establishing a precise prevalence rate. While RLS keeps people from sleeping at all, PLM keeps people from having sound sleep. According to Dr. Daniel Picchietti, medical director of the Carle Clinic in Urbana, Illinois, “It’s a double whammy. RLS affects the quantity of sleep while PLM affects the quality of sleep.”

Earlier prevalence studies suffered not only from inadequate funding but also from their dependence on patients’ subjective answers to questions. Further, the studies often used minimum frequency criteria, which failed to include many mild, intermittent sufferers.

Here is what we know about the numbers when we extrapolate from available statistics: In the United States and Canada (and probably elsewhere, judging from studies in Italy, Germany, and the United Kingdom), at least 3 percent of adults are fatigued daily by RLS and PLM and face each night with fear and despair. They must walk into the night, perhaps until daybreak, to rid themselves of intolerable sensations.

Stanford University researchers led by Dr. William C. Dement, former chair of the National Committee on Sleep Disorders and President of the American Sleep Disorders Association, and Dr. Clete Kushida, chair of the Standards of Practice Committee, American Academy of Sleep Medicine, were startled to see the results of a 1997-98 study they conducted in Moscow, Idaho. It showed that 29.3 percent of the population has symptoms similar to RLS. Intrigued, researchers launched a new study where the RLS prevalence was reported at a more reasonable 15.3 percent.

The National Sleep Foundation conducted a poll in 2005. It found that 25 percent of adults experienced “unpleasant feelings in their legs (such as creepy-crawly or tingling sensations) a few nights a month or more, 15 percent a few nights a week or more,” and 8 percent reported these symptoms every night or almost every night. Half of those who described symptoms said they couldn’t get a good night’s sleep. Nearly 25 percent of respondents over the age of sixty-five reported having symptoms of RLS. A mere 3 percent of those with symptoms said their doctor had told them they had RLS.

The previous NSF polls in 1999, 2000, 2001, 2002, and 2003 had reported almost identical findings, with 57 percent of respondents saying that symptoms kept them from sleeping; only 2 percent were told by a physician that they had RLS.

Restless legs syndrome can seriously disturb daily activities. This fact, and the profound underdiagnosis rate, have recently been confirmed by the largest multinational study to date. The REST (RLS, Epidemiology, Symptoms and Treatment) Study in Primary Care showed that more than half of RLS sufferers (estimated to be one in thirty of all patients seen by the primary care doctors) reported a lack of energy, disturbance of daily activities, difficulty sitting or relaxing, and a tendency to feel depressed or down. One-third of the sufferers said RLS symptoms had a high negative impact on their quality of life, while two-thirds said they had some negative impact.

Many beleaguered nightwalkers, compelled to move, are deprived of sleep every night. Absent proper medical care, the severely afflicted are discouraged and always fatigued. They are also lonely. Yet, in the care of an informed doctor, nearly all would experience some relief. This was the case for a retired aircraft machinist who had struggled with RLS — although he didn’t know it as that — for more than twenty years.

“I’m at the edge of a cliff,” he told Dr. Philip Becker, president of Sleep Medicine Associates of Texas, “and I’m ready to go over.” Sometimes he walked twenty hours a day. Because of worsening RLS, he was able to sleep only three or four hours at daybreak. His suffering was greatly increased because of two heart bypass operations and three joint replacements. He was also taking medications for diabetes and high blood pressure. Other ailments included sleep apnea and mild peripheral neuropathy that caused numbness in his feet. Hoping to alleviate the machinist’s severe depression, a family doctor had given him an antidepressant, but as is so often the case with these drugs, it made his RLS worse.

Dr. Becker was able to turn this patient’s life around. After a year’s treatment, the man was on a new drug, off the antidepressant, and sleeping six or seven hours a night. Dr. Becker may well have saved his desperate patient’s life.

As yet Dr. Becker’s expertise is not shared by all physicians, but awareness of restless legs syndrome is growing. With progress being made in education and research, many more nightwalkers can now hope to find understanding and, at last, relief.

Copyright © 2006 by Robert H. Yoakum