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Book Review   |    
A Cursing Brain? The Histories of Tourette Syndrome
Sheldon Benjamin, M.D.
Psychiatric Services 2000; doi: 10.1176/appi.ps.51.11.1455
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by Howard I. Kushner; Cambridge, Massachusetts, Harvard University Press, 1999, 303 pages, $29.95 hardcover, $16.95 softcover

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Lying at the crossroads of motion and emotion, Gilles de la Tourette's syndrome has much to teach us about both neurology and psychiatry. When the pathophysiology of this syndrome is finally elucidated, neuropsychiatry will have made a great leap forward. In reviewing the history of the understanding of Tourette's syndrome, Howard Kushner teaches us not only about the syndrome itself but about the history of psychiatric and neurologic thought. And he does so while demonstrating a thorough and meticulous approach to the study of medical history in a well-written and carefully footnoted monograph.

Kushner demonstrates how physicians have been blinded by popular beliefs that prevented rational consideration of the evidence that lay before them. The widely held opinion that tics were hereditary or degenerative delayed the discovery of the association between chorea and rheumatic fever, for instance. Even though physicians in the 1890s were developing an awareness of this association, it was forgotten because of what Kushner calls "historical amnesia" until 1956, when the association of Sydenham's chorea with group A strep infection was established.

The author shows how errors in medical history reporting have compounded the problem. Georges Gilles de la Tourette himself obfuscated the truth when he reported that the famous Marquise de Dampierre had been Charcot's patient and was seen repeatedly by him. Kushner tracked down Charcot's actual words from 1887, which indicated that he knew of the Marquise's malady but had not actually seen her himself. The author poignantly makes the case that physicians to this day commonly refer to cases reported by others in the literature without bothering to ascertain the available facts themselves, thus becoming unwitting accomplices in the propagation of medical fictions.

Kushner covers the psychoanalytic influence on thinking about Tourette's syndrome in detail. In their 1902 monograph, Les Tics et Leur Traitement, Meige and Feindel claimed that Tourette's syndrome was caused by regression to infantile behavior.

Ferenczi reinterpreted Meige and Fendel's "Case of O," concluding that tics were "stereotyped equivalents of Onanism" resulting from repressed masturbatory desires. Ferenczi saw catatonia as the opposite end of the spectrum of narcissistic repressed childhood sexuality, and he interpreted postinfectious tics, well known in his day, as an unconscious defense against the infection's stimulation of the affected body area. Kushner's criticism of the psychoanalysts of Ferenczi's day is that they would frame their diagnosis and treatment of actual patients on an emblematic patient whose diagnosis was based on textual interpretation rather than on clinical interaction.

Kushner demonstrates that the conflict about whether this fascinating disorder is primarily neurological or psychiatric continues to the present. French psychoanalysts reject the view championed by American researchers that Tourette's is a neurological syndrome, and even American researchers differ about whether obsessive-compulsive symptoms should be seen as part of the core syndrome.

Howard Kushner is a superb medical historian who has carefully documented and expertly presented a coherent history of Gilles de la Tourette's syndrome. A Cursing Brain? makes excellent reading for anyone interested in the history of neuropsychiatric thought. Both patients and clinicians will find it solid and enjoyable.

Dr. Benjamin is associate professor of psychiatry and neurology at the University of Massachusetts Medical School in Worcester.

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