Antecedents of Infantile Cerebral Palsy

The causes of infantile cerebral palsies, and especially of diplegia, have been much argued. Collier's (1924) able discussion of diplegia shows the incontlusiveness of many of the arguments. Before studying particular features, it seemed reasonable to survey the histories antecedent to the development of palsy obtained in a series of cases. The term ' infantile cerebral palsy ' includes several syndromes, and these different conditions may have different causes. The series has, therefore, been grouped into sets of cases with similar clinical pictures. Only two of these, the spastic and the athetoid, form large enough groups for statistical study, and this paper is concerned mainly with them. Owing to the different methods of classification used by various observers (Evans, 1948) only patients examined personally are included. Furthermore, children whose mothers were not questioned are excluded; fathers rarely have precise knowledge about the birth of their children. Information was also sought by written questionnaire from doctors or midwives in attendance at childbirth, or from hospitals or nursing homes where the patients were bor. Replies were received from 80 per cent. of those questioned. The history was thus usually compiled from two sources. They were rarely contradictory. Where they were, the case was judged on the apparent merits of the two stories. The medical record was often more precise about pregnancy and labour, while the mother was almost always more circumstantial in her account of the condition of the newly born child. About half the patients were seen in hospital and private practice, and the rest at the preliminary examination of children whose admission to a school for children with cerebral palsy was sought. The mothers of fifty children not suffering from disease ofthe central nervous system, seen in hospital and private practice, were questioned similarly. There may have been differences in social class between the children in the ' control group ' and the patients, as no control for the children seen at the school was devised. This should be taken into account in considering such factors as parental age, size of family, and use of obstetric analgesia. The groups were balanced as to age, and all were seen within the same period of about fifteen months. Their ages varied from 1 to 13 years (average 6-4 years, standard deviation 3-1). The total number of patients was 122. In eight the mother was not interviewed, and only the remaining 114 are considered here. Chssification Tbe clinical condition may be classified by reference to the distribution of the palsy and to its functional type. The distribution is expressed in terms of the limbs affected as monoplegia, hemiplegia, paraplegia, triplegia, and tetraplegia. The last term is preferred to ' diplegia ' because this is sometimes unfortunately used in the same sense as ' paraplegia '. On the functional side there have also been ambiguities, but there must be few cases which cannot be described as spastic, athetoid, flaccid, choreic, or ataxic. The terms may be combined, theoretically in any combination, but in practice as spastic or flaccid paraplegia or tetraplegia. Athetosis, chorea and ataxia are usually generalized and only exceptionally need topical qualification. Hemiplegia is almost always spastic. Double hemiplegia may be a useful concept, and indeed two cases classified in this series as 'mixed type, spastic legs and athetoid arms' were probably double hemiplegias. Some of the athetoid patients might also be given the same label. For reasons indicated elsewhere (Evans, 1948) I have not considered extensor plantar responses as a criterion for taking these children out of the athetoid group. It is often difficult to distinguish between paraplegia and mild tetraplegia. I have therefore included paraplegias and tetraplegias in the same group. The classffication of the 114 patients in this series is shown in table 1. Nearly two-fifths were cases of spastic paraor tetraplegia and will be referred to simply as 'spastic'; a similar number of cases of athetoid tetraplegia or double athetosis will be referred to as' athetoid.' Phelps's (1941) generalization that 40 per cent. ofcases are spastic, 40 per cent. athetoid, and 30 per cent. ataxic is borne out only as far as the two major groups are concerned. 213