- Email: [email protected]
PRETENDING TO BE UNCONSCIOUS
852
adjustment) U.S.S.R. syndrome stress
for " uxorial situational
2801 South
King Drive, Chicago, Illinois 60616, U.S.A.
I
hope
siastic
reaction ".
that English physicians of the pill.
avoid
can
Child Psychiatry Service, State Psychopathic Hospital, 500 Newton Road, Iowa City, Iowa 52242, U.S.A.
EMERY D. ROBERT.
our
overenthu-
use
MARK A. STEWART.
PRETENDING TO BE UNCONSCIOUS
SIR,-Dr Sargant’s letter (Sept. 22, p. 670) regarding the efficacy of fluphenazine in this condition is interesting. If it is true that " hysteria " and " schizophrenia are but two sides of the same coin (the name of the coin being " conditioned inhibition "), then surely it is not surprising that a drug effective in the treatment of " schizophrenia should also work with " hysteria ". "
"
Clare House,
Tiverton,
J. W. MALTBY.
Devon EX16 6NJ.
MINIMAL BRAIN DYSFUNCTION
SIR,-You reviewed this subject very fairly (Sept. 1, 487), but your conclusions may have been too optimistic. First, the apparent difference between the prevalence of hyperactivity in Englandand in the United States2 probably stems from a difference in diagnostic habits. Rutter and his colleagues required extreme overactivity, distractability, short attention span, and impulsiveness ", while investigators in Canada and the United States have diagnosed children with milder problems as hyperactive.3,4 If the idea of minimal brain dysfunction " takes hold in England, the related term hyperactive will probably be
p.
"
"
used more freely. The validity of attributing children’s difficult behaviour to " minimal brain dysfunction " is doubtful,5 and Graham and Rutter 6 pointed out that the range of disturbances seen in children with definite brain damage does not differ from that seen in children without such a history. But beyond these objections, acceptance of the concept has important medical and social implications, the most obvious of which is that the origin of many children’s problems is physiological. It is then a short step to the idea that these children need physical treatment. Physicians find it hard to resist a simple answer to the confusing behaviour and learning problems of children, especially when the immediate results of giving stimulants are impressive. Worried parents and teachers in the United States press for drug treatment and will not be put off by the absence of studies on whether children do better in the long run, and whether there are psychological drawbacks to this approach. I believe that the only way to prevent large numbers of English schoolchildren being put on stimulants is to develop parents’ and teachers’ understanding of difficult children, and their ability to raise and teach them successfully. This is a tall order for a society, requiring education on child management and readily available counselling for parents and teachers, but with the effort of parents’ organisations, such as the Association for Children with Learning Disabilities, and the interest of educators in exceptional children, the United States is moving toward this goal. 1. Rutter, M.,
Tizard, J., Whitmore, K. Education, Health and
Behavior. London, 1970. 2.
3. 4. 5. 6. 7.
Werner, E., Bierman, J. M., French, F. E., Simonian, K., Connor, A., Smith, R. S., Campbell, M. Pediatrics, 1968, 42, 112. Weiss, G., Minde, K., Werry, J. S., Douglas, V., Nemeth, E. Archs gen. Psychiat. 1971, 24, 409. Mendelson, W., Johnson, N., Stewart, M. A. J. nerv. ment. Dis. 1971, 153, 273. Sroufe, L. A., Stewart, M. A. New Engl. J. Med. 1973, 289, 407. Graham, P., Rutter, M. Br. med. J. 1968, iii, 695. Stewart, M. A., Olds, S. Raising a Hyperactive Child. New York, 1973.
SIR,-It seems rather odd that your editorial (Sept. 1, p. 487) should start off by using a definition which includes normal intelligence" as a sine qua non the possession of without going into an argument as to what is normal and "
"
what is not normal intelligence. How else is insult to the brain, whether it be by physical, biochemical, or any other means, likely to show itself except by impairment of its highest and most recently developed functions ? Retrograde amnesia is merely the loss of recently acquired learning and shows without any neurological sequels which are a relatively crude method of detecting cortical disorganisation, The younger the brain the less there is to unlearn, but loss or slowness of memory might inevitably be rated as part of intelligence. Indeed, there are intelligence tests specifically aimed at detecting organic involvement. It can be found in practice that many children of level of intelligence (do you call educationally subnormal these normal " ?) have mothers who give a history of a difficult birth or 9 stormy pregnancy. Fortunately as obstetric services improve the grosser conditions of cerebral dysfunction are becoming seen early and less often. Can it not be accepted that with better treatment the resulting childhood disability will be not only less but later as the higher centres develop and grow in their complexity ?1 Is there any other organ in the body whose non-physical functions are regarded as so little to do with the medical "
profession ? be measured only by psychometry and the proper interpretation of the test results. It may be true that as you say British pxdiatricians and child-psychiatrists are ill-equipped by training and experience to deal with children bearing the label minimal brain dysfunction ". May I suggest that school medical officers with special expertise are so equipped and deserve mention ?
These
can
"
Eden House, Clifton Lawns, Chesham Bois,
Amersham, Bucks.
B. H. BURNE.
TESTICULAR FEMINISATION AND INGUINAL HERNIA
SIR,-German et al.l report a prospective study on the incidence of testicular feminisation in prepubertal girls with inguinal hernias. They found no case of testicular feminisation in 30 girls ascertained over 30 months. We began similar studies in July, 1970. All girls with inguinal hernias have a buccal smear taken at the time of admission for surgery. In the three years July 1, 1970, to June 30, 1973, we have assessed 120 girls, 1 of whom had testicular feminisation. This is approximately the same incidence reported in the four retrospective studies cited by German et al. We agree that nuclear-chromatin screening provides a simple practical method for detecting new cases of testicular feminisation before puberty. St.
Christopher’s Hospital for Children, 2600 North Lawrence Street, Philadelphia, Pennsylvania 19133, U.S.A.
1.
HOPE H. PUNNETT MILDRED L. KISTENMACHER MARIA TORO-SOLA.
German, J., Simpson, J. L., Morillo-Cucci, G., Passarge, E. De Mayo, A. P. Lancet, 1973, i, 891.
adjustment) U.S.S.R. syndrome stress
for " uxorial situational
2801 South
King Drive, Chicago, Illinois 60616, U.S.A.
I
hope
siastic
reaction ".
that English physicians of the pill.
avoid
can
Child Psychiatry Service, State Psychopathic Hospital, 500 Newton Road, Iowa City, Iowa 52242, U.S.A.
EMERY D. ROBERT.
our
overenthu-
use
MARK A. STEWART.
PRETENDING TO BE UNCONSCIOUS
SIR,-Dr Sargant’s letter (Sept. 22, p. 670) regarding the efficacy of fluphenazine in this condition is interesting. If it is true that " hysteria " and " schizophrenia are but two sides of the same coin (the name of the coin being " conditioned inhibition "), then surely it is not surprising that a drug effective in the treatment of " schizophrenia should also work with " hysteria ". "
"
Clare House,
Tiverton,
J. W. MALTBY.
Devon EX16 6NJ.
MINIMAL BRAIN DYSFUNCTION
SIR,-You reviewed this subject very fairly (Sept. 1, 487), but your conclusions may have been too optimistic. First, the apparent difference between the prevalence of hyperactivity in Englandand in the United States2 probably stems from a difference in diagnostic habits. Rutter and his colleagues required extreme overactivity, distractability, short attention span, and impulsiveness ", while investigators in Canada and the United States have diagnosed children with milder problems as hyperactive.3,4 If the idea of minimal brain dysfunction " takes hold in England, the related term hyperactive will probably be
p.
"
"
used more freely. The validity of attributing children’s difficult behaviour to " minimal brain dysfunction " is doubtful,5 and Graham and Rutter 6 pointed out that the range of disturbances seen in children with definite brain damage does not differ from that seen in children without such a history. But beyond these objections, acceptance of the concept has important medical and social implications, the most obvious of which is that the origin of many children’s problems is physiological. It is then a short step to the idea that these children need physical treatment. Physicians find it hard to resist a simple answer to the confusing behaviour and learning problems of children, especially when the immediate results of giving stimulants are impressive. Worried parents and teachers in the United States press for drug treatment and will not be put off by the absence of studies on whether children do better in the long run, and whether there are psychological drawbacks to this approach. I believe that the only way to prevent large numbers of English schoolchildren being put on stimulants is to develop parents’ and teachers’ understanding of difficult children, and their ability to raise and teach them successfully. This is a tall order for a society, requiring education on child management and readily available counselling for parents and teachers, but with the effort of parents’ organisations, such as the Association for Children with Learning Disabilities, and the interest of educators in exceptional children, the United States is moving toward this goal. 1. Rutter, M.,
Tizard, J., Whitmore, K. Education, Health and
Behavior. London, 1970. 2.
3. 4. 5. 6. 7.
Werner, E., Bierman, J. M., French, F. E., Simonian, K., Connor, A., Smith, R. S., Campbell, M. Pediatrics, 1968, 42, 112. Weiss, G., Minde, K., Werry, J. S., Douglas, V., Nemeth, E. Archs gen. Psychiat. 1971, 24, 409. Mendelson, W., Johnson, N., Stewart, M. A. J. nerv. ment. Dis. 1971, 153, 273. Sroufe, L. A., Stewart, M. A. New Engl. J. Med. 1973, 289, 407. Graham, P., Rutter, M. Br. med. J. 1968, iii, 695. Stewart, M. A., Olds, S. Raising a Hyperactive Child. New York, 1973.
SIR,-It seems rather odd that your editorial (Sept. 1, p. 487) should start off by using a definition which includes normal intelligence" as a sine qua non the possession of without going into an argument as to what is normal and "
"
what is not normal intelligence. How else is insult to the brain, whether it be by physical, biochemical, or any other means, likely to show itself except by impairment of its highest and most recently developed functions ? Retrograde amnesia is merely the loss of recently acquired learning and shows without any neurological sequels which are a relatively crude method of detecting cortical disorganisation, The younger the brain the less there is to unlearn, but loss or slowness of memory might inevitably be rated as part of intelligence. Indeed, there are intelligence tests specifically aimed at detecting organic involvement. It can be found in practice that many children of level of intelligence (do you call educationally subnormal these normal " ?) have mothers who give a history of a difficult birth or 9 stormy pregnancy. Fortunately as obstetric services improve the grosser conditions of cerebral dysfunction are becoming seen early and less often. Can it not be accepted that with better treatment the resulting childhood disability will be not only less but later as the higher centres develop and grow in their complexity ?1 Is there any other organ in the body whose non-physical functions are regarded as so little to do with the medical "
profession ? be measured only by psychometry and the proper interpretation of the test results. It may be true that as you say British pxdiatricians and child-psychiatrists are ill-equipped by training and experience to deal with children bearing the label minimal brain dysfunction ". May I suggest that school medical officers with special expertise are so equipped and deserve mention ?
These
can
"
Eden House, Clifton Lawns, Chesham Bois,
Amersham, Bucks.
B. H. BURNE.
TESTICULAR FEMINISATION AND INGUINAL HERNIA
SIR,-German et al.l report a prospective study on the incidence of testicular feminisation in prepubertal girls with inguinal hernias. They found no case of testicular feminisation in 30 girls ascertained over 30 months. We began similar studies in July, 1970. All girls with inguinal hernias have a buccal smear taken at the time of admission for surgery. In the three years July 1, 1970, to June 30, 1973, we have assessed 120 girls, 1 of whom had testicular feminisation. This is approximately the same incidence reported in the four retrospective studies cited by German et al. We agree that nuclear-chromatin screening provides a simple practical method for detecting new cases of testicular feminisation before puberty. St.
Christopher’s Hospital for Children, 2600 North Lawrence Street, Philadelphia, Pennsylvania 19133, U.S.A.
1.
HOPE H. PUNNETT MILDRED L. KISTENMACHER MARIA TORO-SOLA.
German, J., Simpson, J. L., Morillo-Cucci, G., Passarge, E. De Mayo, A. P. Lancet, 1973, i, 891.