As someone who teaches the history of psychiatry
to psychiatric residents, I have long hoped to find a single textbook to
spare me the chore of putting together a syllabus each year. Given the
the tremendous explosion in historical studies of psychaiatry over the
last thirty years, however, it has seemed unlikely that anyone would be
able to produce a comprehensive and accessible history to replace Zilboorg’s
History of Medical Psychology. It was, as a result, with skepticism as
well as hope that I turned to Michael Stone’s Healing the Mind .
The book is well designed and will be useful to some psychiatrists.
It contains many short sketches of great and not so great contributors
to the field. These are clearly written and the name of each individual
is printed in a wide margin alongside the sketch. If you are
curious about Friedrich Scheidemantel, Henrik Sjöbring or Sacha Nacht,
you will find them along, of course, with Freud and Pinel. One of the nicest
features of this book is that it has numerous small pictures
of the people mentioned in the text as well as classic pictures of patients.
Psychiatrists lecturing on their research will find this book
useful in providing material about early workers in their field as
well as material for entertaining slides.
Unfortunately it will not be very useful in
teaching history to young psychiatrists. While the subtitle of the book
“A History of Psychiatry from Antiquity to the Present” leads one to expect
a broad survey, more than half of its 435 pages are devoted to the period
after nineteen-sixty. As a result the first half of the book is quite sketchy
while the second half reads like a series of literature reviews.
More serious, however, is the fact that Stone seems unaware that there
there has been and continues to be a lively debate about how to interpret
psychiatry’s history. While the book has a thirty-two page bibliography,
works by Michel Foucault, Roy Porter, Jan Goldstein, Elaine Showalter
and John Burnham are not included. This is not to suggest that this book
does not rely on secondary sources. Indeed there are so many refernces
to Zilboorg, Alexander and Selesnick and Hunter and Macalpine that these
are referred to simply as “Z.,” “A.&S.” and “H.& M.”
There is constant tension in teaching history
to young psychiatrists between their desire to translate everything
historical into familiar terms and the importance of showing
them that studying history can help them acheive a critical distance from
which to reflect on their work. In this regard Stone’s book clearly leans
toward showing how the remote or strange can be understood in terms of
the familiar. Expressions such as “ an example of self-mutilation still
viewed as demonic possession,” or “this view comes closer to our modern
conceptions,” jump out irritatingly from too many pages.
Because psychiatry has, as Michel Foucault
once said, a “low epistemological profile,” it has provided a particularly
good opportunity for historians to demonstrate how social, economic and
political forces influence theories and practice. Stone is
not interested in this angle of vision. His book does not shed much light
on the growth of psychiatric institutions or their place in society.
This is a book about psychiatrists and their ideas. Unfortunately it is
not a very searching or critical one. His discussion of DSM III, for example,
gives the reader no idea of the controversies that surrounded this fundamental
change in psychiatric thinking about diagnosis.
Psychiatrist will be able to use this book as a reference in
certain limited circmstances, but they won’t learn much about the
scholarship that has made the history of psychiatry such a rich field of
study.
SCIENCE Volume 286, Number 5437 Issue of 1 Oct 1999, pp. 56 - 5781999 by The American Association for the Advancement of Science.
NEUROSCIENCE:What Makes One Tic?
A review by Julio Licinio*
A Cursing Brain? The Histories of Tourette Syndrome. Howard I. Kushner. Harvard University Press, Cambridge, MA, 1999. 319 pp. $29.95. ISBN 0-674-18022-4.
The universe is not an idea of mine.
It is my idea of the universe that is an idea of mine.
The night does not fall through my eyes.
It is my idea of the night that falls through my eyes.
Besides my thinking and there being any thoughts
The night falls concretely
And the shining of the stars exists as if it has weight.
F. Pessoa, 10-1-1917 (1)
Part of what makes us human is our persistent need to understand
things. To this end, we develop hypotheses, attribute causes, and classify
events into various categories. As time passes, our knowledge develops
and our belief systems evolve, changing the hypotheses we entertain, the
causes we accept, and the classification systems we use. In A Cursing Brain?
Howard I. Kushner describes the evolution of our understanding of Tourette's
syndrome. He demonstrates that despite repeated changes in the description,
diagnosis, and treatment of the syndrome over the 175 years since it was
first described, throughout this period patients who exhibit the syndrome's
classical symptoms--ticcing (making involuntary motor movements), grunting,
and cursing--have existed.
Kushner, a professor of the history of medicine at San Diego
State University, focuses on an important, but not very common, disease.
His descriptions bring to life clinical presentations that most of us do
not see on a day-to-day basis. He develops his book along two parallel
tracks: A Cursing Brain? is both a detailed clinical description of Tourette's
and a narrative of 19th- and 20th-century ideas about the syndrome. The
radical shifts in the views of this condition in the last two centuries
highlight the making of medical knowledge and humble us enough to question
the validity of our current beliefs.
The syndrome itself consists of a remarkable constellation of physical
and behavioral symptoms. It may develop in childhood, adolescence, or adulthood.
Individuals can exhibit tics, blinking, barks, grunts, yelps, sexual gestures
or displays, imitation of others' behaviors, and vocalizations that range
from quiet muttering to loud cursing. Not all individuals exhibit all of
these symptoms. The severity of Tourette's can vary considerably among
patients and over the course of time for individuals. The syndrome was
formerly considered rare, but diagnoses have been increasing rapidly; it
is now thought to affect 2.9 to 5.3 people per 10,000 in North America.
The clinical picture is fascinating but puzzling. Equally remarkable
are the changing medical views of the syndrome, the author's focus through
most of the book. "The history of Gilles de la Tourette syndrome," Kushner
writes, "is both a history of medicine and a history of the production
and (re)interpretation of case histories." He exhaustively documents the
variety of hypotheses and theories that have been offered since Jean Itard's
1825 description of the tics and cursing that afflicted the Marquise de
Dampierre. In 1885, the neurologist George Gilles de la Tourette selected
this case as the first example of the illness that was soon renamed in
his honor. He and his mentor, Jean-Martin Charcot, insisted that the disease
was progressive and believed they had identified a hereditary degenerative
cause.
Psychoanalytic views of Tourette's syndrome, introduced in the
1920s and 1930s, interpreted the tics as stereotyped equivalents of masturbation
(Sandor Ferenczi), enabled by repressed childhood sexual conflict (Curt
Boenheim), and "an attempt to express a sexual wish or idea" (Oliver English
and Gerald Pearson). In the 1940s, Margaret Mahler attributed the symptoms
to infantilization, parental overindulgence, and overprotection, as well
as eroticized verbalizations and "subterranean penis envy." Serge Lebovici,
who emerged as the leading French child psychoanalyst during the 1950s
and 1960s, was certain that neurotic mothers were the vehicle of transmission
of ticcing behaviors to their children. Other psychoanalytic formulations
are in direct conflict with one another: some, for example, explain the
symptoms as due to excessive masturbation while others blame the suppression
of masturbation.
Alternative theoretical interpretations of Tourette's syndrome
include a post-infectious event that was treated with removal of infected
sinuses (Laurence Selling in the 1920s) and a structural defect that was
treated by lobotomy (James Watts in the 1950s). Sedatives, stimulants,
and carbon dioxide inhalations have all been tried for therapy. In many
cases, psychotropic drugs can ameliorate the symptoms of Tourette's, but
these drugs can have severe side effects that some patients find worse
than their original condition. The normal waxing and waning course of the
syndrome confounds any type of follow-up study.
Over the past two decades, the Tourette Syndrome Association
has effectively promoted the clinical awareness of the condition and research
into its causes. Kushner describes the creation and evolution of this patient-support
group and the important roles Drs. Arthur and Elaine Shapiro played in
its efforts. Particularly interesting sections of the book depict the different
trajectories followed by the clinical and theoretical constructs of Tourette's
in the United States and France. While organic explanations triumphed in
North America, the psychoanalytic frame for the syndrome remained resilient
in France.
One of the book's shortcomings is the absence of consideration of the
syndrome's history prior to its recognition in the 19th century. But the
major weakness of the book is that Kushner systematically cites and highlights
infectious events in the case histories he discusses even though he notes
that "researchers should remain skeptical about new claims and interventions,
even when they appear to work." These events may lead the reader to hypothesize
that the syndrome is a post-infectious (that is, possibly inflammatory
or immune) disorder. The author fails to mention that although the incidence
of post-infectious syndromes, such as Sydenham's chorea, has decreased
in the last decades due to better treatment of infections, the incidence
of Tourette's appears to be increasing. The human need to explain things
is evident in Kushner's own narrative. The sad truth, however, is that
all psychiatric disorders are still of unknown cause.
Of the five major pathological mechanisms of disease--neoplasia,
infection, inflammation, degeneration, and ischemia--inflammation is the
most compatible with the chronic waxing and waning course of disorders
such as Tourette's. But inflammatory theories for psychiatric disorders
are not new. The only Nobel Prize ever awarded to a psychiatrist was granted
in 1927 to Julius Wagner-Jauregg for his work on the beneficial effects
on psychiatric symptoms of the body's response to infection, work which
led to the amelioration of the neurosyphilis symptoms after malaria inoculation.
More recently, the cloning of cytokines (the body's inflammatory mediators)
and their receptors has led to an enormous growth of research on their
possible relevance to neurological and psychiatric disorders. Current research
has shown that cytokines and their receptors are expressed in the brain
and exert their potent central effects through redundant but discrete pathways
and mechanisms. Moreover, the central and peripheral cytokine compartments
are integrated but differentially regulated. The pathways and mechanisms
underlying the effects of inflammatory mediators on brain function can
be activated in the context of stress, inflammation, ischemia, neurodegeneration,
infection, and autoimmunity. Although considerable progress has been made
in basic brain-immune research, it is not yet possible to conclude that
inflammatory mediators cause Tourette's syndrome--or any psychiatric disorder.
I highly recommend A Cursing Brain? as a brilliant and readable
narrative of how, over time, we change our minds when faced with a puzzling
and hard-to-treat constellation of socially maladaptive physical, behavioral,
and psychological symptoms. Despite the subtle but distinct bias towards
currently fashionable theories whose history is not fully provided, Kushner
presents superb and meticulously documented descriptions of Tourette's
and of our understanding of the syndrome. Also emerging from Kushner's
laborious endeavor is that we sometimes violate the Hippocratic oath (to
"first do no harm") because of our persistent efforts to deny our ignorance;
we attribute cause in the absence of a sophisticated understanding of how
a multitude of biological, social, and cultural signals are processed and
integrated to generate adaptive or maladaptive responses. This book might
have suitably been subtitled "Pride and Prejudice in the Absence of Knowledge."
Only the passage of time will reveal the distance between our current ideas
of causation and the concrete reality of symptoms that exist as if they
have weight.
Reference
. F. Pessoa, Seleção Poética (José
Aguilar Editôra, Rio de Janeiro, 1971), p. 178.
The author is in the Department of Psychiatry, School of Medicine, University
of California, Los Angeles, CA 90095-1761, USA. E-mail: licinio@ucla.edu
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