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Brain damage in the newborn and its neurologic sequels. Towbin A. [Pp 764, hardback $302]. PRM Publishing Ltd, 1998. ISBN 0-9660551-0-1 .
Clinicians working with children with cerebral palsy see the end result of damage which occurred many years before. To understand the causes and timing of this damage, you need to look at its origins in the fetal and newborn periods, because it is now abundantly clear that most cerebral palsy arises in prenatal life; in only a small proportion of children is there evidence of injury at birth.
The causes are by no means understood. Hypoxia and ischaemia have long been regarded as the most important, but pathological and epidemiological studies show that very similar forms of damage also result from maternal and placental infections, possibly mediated by cytokines crossing the placenta into the fetal brain, by metabolic disease, iodine deficiency, etc.
The contribution of very early intrauterine damage to birth asphyxia was first noted by Sigmund Freud over 100 years ago; not all birth asphyxia is what it seems. Many of these infants were set up months beforehand for a difficult birth.
Dr Abraham Towbin recognised the value of studying the fetal and neonatal brain. He worked with the most eminent of neuropathologists, Paul Yakovlev, and from him learned the method of celloidin embedding. Using this technique, these tiny, fragile, and precious specimens can be embedded whole in plastic and entire brain sections cut and examined under the microscope, with unparalleled preservation of the pathologic anatomy. You won’t persuade a technician to undertake this technique today; it is far too costly, both in time and resources for modern laboratories.
This book represents a celebration of Dr Towbin’s 40 plus years in paediatric neuropathology. It is a meticulously documented collection of over 200 case studies accompanied by detailed obstetric and clinical histories. It is beautifully produced and the illustrations are superb. They include gross and microscopic pathology of the brain, placenta, and body organs as well as many radiographs. Most are full colour, every one is clean and crisply focused, and the legends are economical.
The weakest part of the book is Dr Towbin’s interpretation of the pathogenesis of developmental brain damage. It is idiosyncratic and he paints with a very broad brush. The clinical chapters are scarcely more informative.
But the real value of this book is that it allows us to share in a rare wealth of carefully archived material; an invaluable resource for pathologists, obstetricians, neonatologists, neurologists and developmental psychiatrists.
This book has a timely message in an age of ever-increasing litigation. Only a small proportion of developmental brain damage occurs at birth; in over 80% we still have to seek causes and establish prevention in the prenatal period.