BOOK REVIEWS 325
abound : subgenual portions of the gyms
cin-guli (p. 21) , location of trigeminal motor
nu-cleus (p.
123)
, choroid plexus not recognizablein the drawing so labeled (p. 125), division of
the basis peduncle (p. 131
)
, inconsistentloca-tion of the trigeminal mesennucleus both
within and without the griseum centrale
mes-encephali (p. 130-131), diencephalon (pp.
138, 140) , lack of correspondence of horizontal
and coronal levels (pp. 160-163), blood sup-ply of brain (p. 166), sternocleidomastoid
in-nervation (p. 236) , and emergence of roots of
IX, X and XI dorsal to the supraolivary sulcus
(p. 283) . Typographical errors include afferent
for efferent (p. 188) and direction of arrow-heads for the tnigeminal sensory nuclei (p. 251).
At least two major conceptual limitations
have been inherited as part of the tradition of
neurology-namely, the concept of
representa-tion of function within the cortex (allowing one to parcel up the cortex into “functional”
regions) and the preparation of “wiring”
dia-grams based only upon subhuman
expenimen-tal material or upon speculation.
In summary, I would agree with the author that this is not a formal manual. While some of the drawings are good as didactic aids, it
re-mains up to the teacher choosing to use this
at-las to ferret out those accurate neuroanatomi-cally and suitable to his tutees.
FLOYD H. GILLES, M.D. Boston, Massachusetts
MINIMAL BRAIN DYSFUNCTION IN CHILDREN,
by Paul H. Wender, M.D. New York:
Wiley-Interscience, A Division of John
Wiley & Sons, Inc., 1971,
242
pp., $10.50.Every medical student, physician, and
scien-tist should read the story of the Emperor’s new
clothes and identify with the child who, unim-pressed by the weight of authoritative opinion, cried “But the Emperor has no clothes.” Leon
Eisenberg is a children’s psychiatrist whom I
respect enormously. But although I am glad to have read this book, I can’t accept his
unquali-fled recommendation of it.
Not all the blame lies with the author, for
the publisher’s assessors have not done their
job. They haven’t adequately advised the
au-thor about the organization of his material or
about his way of writing.
In English, dyspraxia (p. 18) is not
synony-mous with impaired coordination, though it is
one cause of it.
On p. 143 what does the word “push” mean in “a lack of push could be due to either exces-sive “drive” or insufficient “control”?
Does the footnote on p. 138 mean what it
says: “See Z’s
(
1968) report on the favorableconsequences of the absolutely predictable use
of an isolation room in controlling a very active child.”
The 12-line paragraph in the middle of
p. 137 could, it seems to me, be paraphrased to
“since much of learning depends on reward
and punishment, if there is diminished ability
to feel pleasure and pain, decreased ability to
learn is likely to accompany this.”
Lacking studies of sleep in minimal brain
dysfunction (MBD) children, the author, on p.
140, uses studies of sleep in enuretics by the
process of assuming that many of (them) are
presumably MBD children.
Publishers were created not only to make
money but to help authors to be accurate,
clean, and readable so that readers may
assimi-late the ideas and enjoy doing so. However,
reaching p. 193, I found the author refers to his book as “this essay,” a very disarming remark. While I don’t think it is a major clinical contri-bution or a comprehensive review, it is, as an essay, lively and vigorous, albeit a dangerous
one in its enthusiastic recommendation of
am-phetamine.
The sufferings of families with a child who
has brief attention span, high activity achieving no goals, disinhibited, labile and often
explo-sive behavior, who is impervious to reward and
punishment and must be watched
continu-ously, are often borne with astounding-even saintly-patience. The golden years in which he might be learning are passing, irretrievably. Are physicians thinking enough, trying enough,
and mobilizing all resources to help the
chil-dren and their families?
At this stage the child-like mind is heard say-ing “But if the behavior and learning
difficul-ties are so great, the brain dysfunction is NOT minimal.”
A word on nomenclature: If we listen to this
voice and abandon the word minimal, we are
left with “Brain Dysfunction” and as we tell that there is unusual brain function because the
behavior is unusual, we arrive at saying that
what this essay is about is the behavioral
326 BOOK REVIEWS
call it the “hyperactivity-etc.” syndrome, but the better solution may, as it often is in clinical problems as yet not fully explained, be the use
of an eponym “the Strauss-Lehtimen
syn-drome.” The Oxford Study Group of 1962, Bax
and MacKeith 1963, wanted to kill the idea
that there is any good evidence that all these children have had anatomical damage to brain tissue; to fill the gap left by abolition of the
phrase “brain damage” it put forward
“cere-bral dysfunction.” But, mea culpa, we let the erroneous adjective minimal slip through.
The ground is now clear for an approach
which considers the abnormal symptoms and
attempts to identify any underlying disorders and then the cause.
If we want to help the child, we need to look at all of him. This which I think of as the
“Clem-ents” approach to MBD, means assessing the
dysfunction in each area, motor, visual,
audi-tory, language, learning, concentration and
drive, emotional and social and then planning
ways of helping in each area. As Paul H. Wen-den, author of this book, observes, treating a
“hyperactivity-etc.” child’s clumsiness may help him a great deal in other dimensions of functioning.
Wender is anxious that “MBD” shall be
more widely diagnosed so that the benefits of treatment by amphetamine or methylphenidate
(Ritalin) shall not be withheld from any
chil-dren who would benefit from it. He adds that
some children with hypoactivity benefit from
amphetamine. This is a reasonable reminder but he makes the conclusion that they too have
“MBD.” The logic seems to me faulty.
Fur-thermore, if he is widening the syndrome to in-elude not only a group of symptoms, but also a positive response to amphetamine, he might look again at the data he reports showing that 30 to 75% of his MBD children do not respond positively.
The review of prevalence refers to three
studies. One is Prechtl and Stemmer ( 1962) in
which 20% of school children had choreiform
movements and of these children 90% had
reading difficulties. There is no reference to other authors, e.g., Peter Wolff who had
con-firmed the prevalence of choreiform
move-ments but found no close relationship to
learn-ing difficulties.
In the Isle of Wight Survey (Rutter, Graham and Yule, 1970) nine cases of hyperkinetic
syndrome were recorded among 2,326 children. (One in the general school population of 2,189
children, one among 63 children with
uncom-plicated epilepsy, three among 36 children with evidence of brain lesions above the brain stem, and five in 38 children excluded from schooL
)
In this series there is a clear associa-tion between (what Rutter, Graham, and Yule called) the hyperkinetic syndrome and abnor-mal neurological signs.It is therefore surprising that Wender says of
his MBD children that “the prevalence of hard
(
neurological) signs is approximately normal.” Of course, it is possible that from his categoryof MBD children, Wender excludes all
“hyper-active-etc.” children who have good overt
hard signs, e.g., of a hemiplegia, because they have major brain dysfunction. This would be a disadvantage because, as far as I know, having a hemiplegia does not prevent a “hyperactive -etc.” child from responding positively to am-phetamine.
Dr. Wender’s review of the evidence of the effects of amphetamine is not adequate in view of the fact that he so enthusiastically recom-mends its use for his MBD children. Pages 88 to 94 review the subject in the light of only
three papers, published in 1937, 1950, and
1967; then follows a mention but no abstract
or discussion of seven other references. There
is no word of discussion of the idea that from the point of view of the community the
dan-gens of widespread use of amphetamine
out-weigh its benefits; that it could be restricted to a very limited number of disorders such as
nar-colepsy. (The doctors of Ipswich and other
towns in England have agreed not to prescribe
it; in these towns there is none to be stolen
from the pharmacist’s shops and warehouses. This idea has the support of the British Medical Association.
)
If amphetamine was no longer available, the “hyperactive-etc.” children who appear to need stimulants could have meth-ylphenidate, at least until that too becomes a widely used drug of addiction.Having been perfectly horrid about Dr.
Wender’s clinical and therapeutic ideas, I must briefly state mine so that he (and perhaps Leon Eisenberg) can shoot me down.
There are children with the clinical picture of high-activity, short span of attention, lack of inhibition, and imperviousness to reward and
BOOK
REVIEWS
327common, but the fully developed syndrome is
rare (0.5% of school children).
The “high activity-etc.” picture occurs in
varying degrees, in
(
1) Two-year-old childrenin whom it is normal, (2) Some highly
intelli-gent children with great exploratory drive, (3)
Some anxious children, (4) Children with
fre-quent subclinical seizures, and (5) What I
rather feebly call “true hyperkinetic syndrome” of which a third or half have evidence of motor
or learning handicap.
The major part of their care is listening and
explaining. Sedatives like Phenobarbitone will
make children of groups 1, 2, and 5 worse and
often those of group 3, but may be useful in
group 4. Methylphenidate deserves a trial for
children of group 5.
When the underlying cause is not very clear,
trials may be made of drugs like chlorproma-zine and haloperidol, of anti-epilepsy drugs, and of methyiphenidate.
I enjoyed reading the review of Etiology in Chapter Two. I am glad to have Dr. Wender’s idea of decreased experience of both pleasure
and pain in MBD syndrome, and to read his
tentatively suggested hypothesis of a defect in
monoamine metabolism.
RONALD C. MACKEITH, D.M., F.R.C.P. London, England
PEDIATRIC CONFERENCES WITH Snrc
GELLIS, Tape
#
1, Audio Cassette Tape( C-60, 2 track
)
, issued 6 times per year,directed by Sydney Gellis, M.D.
Phila-delphia: W. B. Saunders Company, 1971,
$47.50.
(
Sold by subscription only.) This is the first review in our Book Reviewssection of a standard C-60, 2 track 1-hour tape
cassette. This cassette, containing six pediatric conferences, directed by Sydney Gellis, the first of a bimonthly series, emanates from one of the
most respected publishers of medical books in
the United States.
Many of our readers, including myself, will
wonder if Dr. Gellis’ prescience long ago
con-vinced him that Marshall McLuhan is really
proclaiming the death of print as a medium of
instruction. Is Dr. Gellis trying to tell us that Gutenberg’s linear line of movable type on a two dimensional sheet of paper is now anachronistic because of the speeds of electronic
communica-tion? And, is he inferring that purely visual
means of acquiring knowledge may just be too
slow to be effective? I do not think so nor do I believe Dr. Gellis does.
Many of our readers are probably unaware of
the brilliant, analytic studies of Walter Ong, S.J. dealing with the writings of Peter Ramus, the
sixteenth-century French philosopher and
edu-eaton. Father Ong in his book Ramus, Method
and Decay of Dialogue (Harvard University Press, 1958) nicely points out the difference
be-tween the Hebrew and Greek ideas of knowing. The Greeks thought of knowing (and learning)
more by analogy with seeing; whereas the
He-brews thought of knowing more as if it were
hearing. We typically think like the Greeks.
The Greek word idea has the same root as
video in Latin, meaning 1 see. We say “I see”
to mean “we understand.” Ideas are spoken of as images and viewpoints.
Dr. Geffis, I believe, is quite aware of Father Ong’s thesis, namely, that in contrast to the
Greeks, the ancient Hebrews associated
know-ing or learning with hearing. Thus the
He-brews were event-minded and so were tuned
in on sound because sound is the only sensory
field that always indicates something is going
on.
By this diversion, I hope I have further
em-phasized my belief that Dr. Gellis hopes to
re-store the ear (rather than the eye) , at least in
part, as the primary sensory organ of
trans-mitting knowledge. He can accomplish this
superbly because, as most of us know, he
handles the spoken word deftly, always with
the right amount of jocosity, and with occasional mordancy if speakers become to pompous.
Six discussions are included in this cassette;
each speaker is given about 10 minutes to
pre-sent his talk and then Dr. Gellis asks each of the speakers a number of excellent-and often witty-questions to clarify ambiguities or
omis-sions in the discussions.
The topics discussed are: (a) A delightful
introduction of how and why this series was
conceived, (b) Red cell enzymes by Dr. Frank Oski, (c) Early discharge from hospital of low birth weight infants by Dr. Robert Berg, (d)
Early feeding of the newborn by Dr. Gellis,
(e) The problems of iron-fortified formulas by Dr. Frank Oski, and (f) Intensive transfusion therapy by Dr. Thomas Necheles.
