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A STUDY OF CEREBRAL PALSY IN THE CIHLDHOODPOPULATION OF
EDINBURGH
BY
T. T. S. INGRAMFrom the Departmnt of Child Life and Health,
University of Edinburgh
(REasCEDv FOR PUBLICATnON AUGUST 30, 1954)
There is increasing interest in the needs of childrensuffering
from cerebral palsy for special educationand medical treatment and
for measures to rendermore of them employable. Many schemes
toprovide facilities for education and employment arebeing planned,
but there are only a few scatteredsystematic surveys of the
incidence of cerebral palsyin childhood, and so the size of the
problem islargely unknown. This article presents the resultsof a
recent investigation which was designed toassess the incidence of
cerebral palsy in childrenresident in Edinburgh.
The Plan of the SwveyThe survey was confined to children born in
the
years 1938 to 1952 inclusive who lived within theboundaries of
the City of Edinburgh. Since thepopulation of this age group in the
city was morethan 100,000 it was clearly impossible to examineevery
child individually. On the other hand, themedical services of the
city work in close liaison andthe school medical and public health
authorities arehighly developed. Due largely to the propagandaof
the Scottish Council for the Care of Spastics thereis a great
awareness of, and interest in, the problemsof the child with
cerebral palsy among doctors,teachers and medical auxiliaries.
Therefore childrenin whom cerebral palsy was suspected tended to
beover-examined rather than neglcted. Thus inmany ways Edinburgh
was an ideal city in which toobtain information about children with
cerebralpalsy and make a survey of its incidence.
The Metds of the SwveyDetails of the children who might be
suffering
from cerebral palsy were obtained in three ways inthe first part
of the survey. First, large numbers ofcase notes and reports from
clinicians were examin-ed, and all cases in which cerebral palsy
was sus-pected were noted. Secondly, all patients whoserecords
showed that they suffered from conditions
known to be associated commonly with cerebralpalsy were listed.
These included children withmental defect with clumsiness,
epilepsy, hydro-cephalus, talipes equinovarus and arthrogryposis.At
the same time all patients who gave histories ofhaving suffered
from conditions likely to lead tocerebral palsy were noted. These
included patientswith apparent birth injury, rhesus
incompatibility,meningtis, encephalitis, cerebral
thrombophlebitisand head injury. Thirdly, inspections and
briefexaminations were made of groups of children inwhom a high
incidence of cerebral palsy might beexpected. Thus large numbers
were examined inschools for the physically and mentally
handicapped,in clinics for the premature infant and in
institutionsfor the mentally defective.
Sores of AsetimetThe sources of information about possible
and
probable cases of cerebral palsy were very numerousand
overlapped considerably. The more importantsources of information
will be mentioned. Accesswas given to the case notes of the
officers of theSchool Medical Service, who were uniformly
mosthelpful in providing information and facilities forthe
examination of their patients. In all, over 6,000case notes were
examined in various schools and over400 patients seen in schools by
arrangement withschool nmdical officers. Information about
educa-tional difficulties and progress was obtained in asmany cases
as possible from teachers.
Fifty-five private schools were contacted andinformation sought
about any children with dis-abilities suggestive of cerebal palsy.
Replies werereceived from 53 of the private schools.The officers of
the Maternity and Child Welfare
Service were most helpful in giving informationabout children
they felt might be suffering fromcerebral palsy, and access was
given to case notes andpatients in their clinics. The results of
the routinehealth visiting of the department were also
madeavailable to the investigation. The PubLic Health
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ARCHIVES OF DISEASE IN CHILDHOOD
Department physicians and surgeons providedinformation about
patients with cerebral palsyvisiting their clinics.
All hospitals in Edinburgh concered with thediagnosis and
treatment of children's diseases, ofwhatever type, and maternity
hospitals in the citywere contacted and in each instance ready
access tocase notes and patients was granted. Medical,nursing and
auxiliary staff were questioned aboutpossible cases and
approximately 2,500 case notesdating back to 1940 were examined.
Out-patientstaffs and case notes were consulted as well as
in-patient notes and staffs. Many consultants, phy-sicians and
surgeons gave access to their privatepatients and went to
considerable trouble to arrangefor the investigator to examine
these children.The Scottish Council for the Care of Spastics
gave
free acces to their patients and records and muchvaluable
information was obtained from the highlytrained members of their
staff.The response of general practitioners to the
request for information about their patients wasdisappointing.
It was intended to contact allgeneral practitioners in Edinburgh by
letter request-ing details of children who, they thought, mightbe
suffering from cerebral palsy. As a first step, 25practitioners
were circularized and asked for infor-mation. They were known at
that stage of theinvestigation to have at least 28 patients with
cere-bral palsy in their practices, but only two nameswere obtained
and only one of these was unknownto the survey. General
practitioners were not here-after contacted specifically to obtain
informationabout the numbers of patients with cerebral palsy
intheir practices, but whenever permission was soughtto examine
known cases doctors were always askedfor details of any other cases
known to them.
Other research projects amongst children inEdinburgh provided a
number of cases of cerebralpalsy. These included investigations of
childrenwith mental defect, of children who had sufferedfrom
meningitis, of infants with retrolental fibro-plaia, the
prematurely born and children who hadsuffered cerebral birth
injury.A few additional cases were reported by district
nurses, infant clinics, speech therapists, childguidance clinics
and teachers.
DIrct Ascertaimnt of Cases ofCereb{ Palsy
Direct ascertainment of children with cerebralpalsy was carried
out in groups of children in whoma high incidence of cerebral palsy
was to be expected.The usual procedure was to watch the children
atplay for as long as possible and then when they
attempted to sit still. Those in whom cerebralpalsy was
suspected on the basis of these inspectionswere examined. After a
few months, during whichexperience was gained, it was found that
quite asmany cases of cerebral palsy were noted using thismethod as
were discovered by detaied examinationof all the children in a
group.Approximately 4,000 children were inspected in
ordinary schools, special schools, nurseries, insti-tutions for
the mentally defective and infant clinics.
Resul of Plfnwry AswdmnAs a result of the first part of the
investigation
484 children were classified as possible cases ofcerebral palsy
and 165 as probable cases. Probablecases were those children who
had been diagnosedas suffering from cerebral palsy by other
observersor were felt to suffer from the condition as a resultof
the inspections of the investigator. Possible caseswere those
children in whom a diagnosis of cerebralpalsy could not be excluded
on the basis of informa-tion provided in case notes which had been
inspected,or who had suffered from some condition known tolead to,
or be associated with, cerebral palsy in aproportion of patients.
It was felt to be desirable toexamine and obtain some details of
the history of thedevelopment and course of the condition in all
thechildren in both the possible and probable categories.
Probable and Possie Cases. All the 165 childrenwho were
considered to be probable cases of cerebralpalsy were examined with
the exception of two forwhom permission for exammiation was
refused. Infour cases a detailed history could not be obtained.Of
the 484 possible cases of cerebral palsy all but
85 were examined. Of the latter it was possible toobtain
reliable information of recent medicalexaminations in 52 so that
the presence of cerebralpalsy could be excluded. In the remaining
33patients it was impossible to obtain such informationand it was
not found possible to examine them.The 399 patients who were
examined were usuallyseen briefly at the time of the routine school
medicalexamination for the first time and then examined inmore
detail later if the presence of cerebral palsywas confirmed.The
history was obtained from the mother when-
ever possible and was suplemented by details ofhospital
admissions and clinic visits, maternityhospital and infant clinic
notes and the recollectionsof other relatives.
In practically all the patients in the sers physicaexaminations
were performed on more than oneoccasion, preferably in different
surroundings andpreferably at intervals of a few months. Full
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CEREBRAL PALSY IN EDINBURGHclinical examinations were
supplemented by specialexaminations, blood investigations,
radiographs,intelligence tests and electroencephalograms in
rela-tively few cases, but frequently these were availableas a
result of previous hospital admissions or schooltesting.
palsy are found together in categories of 'rigidity'and
'spasticity'. To eliminate such confusions it isdesirable to resort
to the earlier, well tried types ofclassification by neurological
syndromes.The present classification is based on that sug-
gested by Freud (1893, 1897). shown in Table 2, with
Classfition of Types of Cerebrl PalsyThe classification by
neurological syndromes
which was used during the survey is shown inTable 1. It will be
observed that it is not based on
TABLE ICLASSIFICATION OF CEREBRAL PALSY IN CHILDHOOD
NeurologicalDiagnosis
Hetmiplegia
Extent
I RightILeft
Double hemiplegia
DiplegiaHypotonicDystonicRigid or spastic J
Ataxic diplegiaHypotonicSpastic
AtaxiaCerebellarVestibular
DyskinesiaDystonicChoreoidAthetoidTensionTremor
I ParaplegicTriplegic
l Tetraplegic
( ParaplegicTriplegicTetraplegic
Severity
MildModerately severeSevere
( idModerately severel Severe
MildModerately severe
l Severe
I MildModerately severeSevere
IPredominantly (MildUnilateral Moderately severe(Bilateral
Severe
MonoplegicI HemiplegicITripkegicI Tetraplegic
MildModerately severe
l Severe
single clinical features, such as alteration of muscletone, as
have many recent classifications (Phelps,1940; Hellebrandt,
1950-51). By laying stress onsingle clinical features of cerebral
palsy greatconfusion has been caused. Too close adherence torigid
classification on this basis has led to verbalabsurdities like
categories of 'aspastic spastics' andnosological confusions like
'cerebellar releaseathetosis'. Cases of hemiplegia may be found
underheadings of 'rigidity' and 'spasticity', though theonly
difference in clinical features is that contractureis more marked
in the former group. It is note-worthy that, when authors using
some of thesecomplex modern classifications wish to compareseries
of patients suffering from different forms ofpalsy, they
immediately resort to grouping para-plegic, triplegic and
tetraplegic cases together anddistinguish them from the hemiplegic
forms. Yetin their classifications all these types of cerebral
TABLE 2CEREBRAL PALSY IN CHILDHOOD AS
CLASSIFIED BY FREUD (1897)
Unilateral disorders Hemiplegiarightleft
Bilateral disorders DiplegiaParaplegic ngidityGeneralized
rigidityBilateral hemiplegiaChoreoathetosis
Possibly other groups
some modifications rendered necessary by thewidened scope of the
term 'cerebral palsy' since histime, and by advances made in the
knowledge ofthe nature of some forms of the condition.
Freudincluded cases showing involuntary movements asthe predominant
clinical findings in the categoryof diplegia, though with some
misgivings. In thepresent classification cases showing
involuntarymovements as the presenting symptom have beengrouped
under the heading of dyskinesia, and classi-fied as suggested by
Perlstein (1952). Largely toachieve some uniformity with
contemporary Ameri-can classification Freud included cases of
bilateralhemiplegia under the heading of 'diplegia' (Lovett,1888;
Osler, 1889). In the present classificationthese cases have been
placed in a separate category.In accordance with modern practice
the categoryof ataxia has been added.By 'diplegia' is understood a
condition of more or
less symmetrical paresis of cerebral origin moresevere in the
lower limbs than the upper and datingfrom birth or shortly
afterwards. It will be observedthat separate categories have been
made for patientsshowing diplegia without ataxia and those
showingdiplegia associated with cerebellar ataxia. Theaetiologies
of these disorders differ, and the courseand findings on
examination are dissimilar.A high proportion of patients suffering
from
diplegia without ataxia are born prematurely (400%in the present
series). Many show associatedmental defect, epilepsy and
strabismus. There is aconstant pattern of development of the
paresis,inadequately described in modern textbooks, inwhich only
the final stage of diplegia, characterizedby spasticity and
contractures, is mentioned. In atleast half the patients suffering
from diplegia without
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ARCHIVES OF DISEASE IN CHILDHOOD
ataxia three stages may be distinguished in thedevelopment of
the final clinical picture.For a period after birth the child may
be thought
to be normal, but in a proportion of patients theparents note
that the baby is floppy and flaccid onhandling and shows a relative
poverty of movementwhen compared with others of the same age.
Onexamination at this stage these patients show general-ized
hypotonia without any other apparent neuro-logical abnormality in
most cases. The stage ofhypotonia persists for between six weeks
and fivemonths in the majority of those showing it and issucceeded
by the stage of dystonia.The stage of dystonia is first manifested
by sudden
generalized dystonic movements involving the trunkand limbs and
precipitated by changes in the positionof the child, especially
extension of the head relativeto the trunk. The involuntary
movement consistsof a sudden extension of the head and
trunk,extension of the hips and knees, and plantar flexionof the
feet. The upper limbs are adducted andsomewhat internally rotated
at the shoulders andextended at the elbows. The wrists and fingers
aresemiflexed and the forearms are pronated. Onexamination when in
this position marked rigidityis found in all the muscles of the
trunk and limbs.The child maintains the position of extension of
thetrunk and limbs for a few seconds during which timeconsciousness
may seem slightly impaired, thoughit is never lost, and then the
muscles again relax.Initially the sudden dystonic attacks occur
relativelyinfrequently and only when the child's position
issuddenly or grossly altered, but over a period of twoor three
weeks the attacks become more frequent andmore readily
precipitated. The generalized attacksseldom persist for less than
three weeks or for longerthan six months. Towards the end of the
dystonicstage they become less frequent and more difficultto
produce. At about the time the child is able tohold the head up
steadily the generalized dystonicattacks cease in most patients and
simultaneouslyrigidity of the limbs first becomes apparent,
markingthe end of the dystonic and the beginning of the rigidor
spastic stage of diplegia. With the cessation ofthe generalized
attacks the child tends to show anincrease in the range and control
of voluntarymovements and begins to reach for objects. It
isobserved at this stage that though voluntary move-ments or
changes in position no longer result ininvoluntary extension of the
trunk, the limbs con-tinue to assume positions similar to those
notedduring the earlier dystonic attacks. Rigidity isusually first
evident in the thighs. It increases ina matter of a few weeks and
at the same timespreads to involve the distal parts of the lower
limbs
and, in all but paraplegic patients, the upper limbs.The
rigidity tends to result in the limbs being heldin positions of
predominant extension as in theearlier dystonic attacks, and these
positions areaccentuated by voluntary movements or passivechanges
in position. The phase of rigidity withpredominantly extensor
associated movementsusually persists until the patient is able to
sit withoutsupport with the knees flexed and handle
objects.Commonly this is shortly before the age of I year
inpatients who are not mentally defective. The phaseof rigidity
merges imperceptibly into the phase ofspasticity at about this
stage of the child's develop-ment. The tendon jerks become
increased insteadof being difficult to elicit and stretch
responsesappear in the muscles. The Babinski responsesbecome
positive. Instead of extensor associatedmovements predominantly
flexor associated move-ments accompany voluntary movements of
thelimbs. When spasticity is present, contracture ofthe limbs in
flexion almost invariably follows unlessthe child is treated, and
the final stage of diplegia isreached.The stages which are apparent
in the development
of diplegic paresis appear to be of more significancethan mere
indications of the diagnosis. In severecases the stage of rigidity
or spasticity may never bereached and dystonic attacks may persist
throughoutlife whenever the child attempts voluntary
movementinvolving changes in posture. The child's neuro-muscular
development may be regarded as havingbeen arrested at the
relatively primitive stage ofdystonia. On the other hand, the
infant in whomspasticity with flexor associated movements
isevident, shows neuromuscular development whichmay be regarded as
being more mature. The childwill be able to achieve more adequate
motor controlthan will the child with persistent dystonia
providedcontracture is prevented. One remnant of thegeneralized
dystonic attack persists quite commonlyin patients showing
predominant rigidity in themuscles and they may be regarded as
being in anearly phase of the rigid or spastic stage of diplegia.It
is found that when these children attempt to walka sudden extension
of the neck, trunk and lowerlimbs ensues, a phenomenon known to
physio-therapists as extensor thrust. By classifying thepatient
with diplegia according to the stage of thedevelopment of his
condition, a clear indicationis given of the maturity of his
neuromuscular control.
Patients with diplegia associated with cerebellarataxia show
only two of the stages found in casesof diplegia without ataxia.
Initially most of thechildren are hypotonic, but the majority
showincreasing spasticity of the limbs, more marked in
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CEREBRAL PALSY IN EDINBURGH
the legs than the arms from the age of 9 or 10 months.Attacks of
dystonia are never found and the pre-dominant associated movements
are flexor notextensor. The increase of tone is never rigid, butis
spastic and the tendon jerks are invariably muchincreased. The
Babinski responses are alwaysbilaterally positive. A high
proportion of thesepatients and their relatives are mentally
defective,and in three females of the 13 patients with diplegiaand
cerebellar ataxia in the present series, there wasa similar
condition in the mother or in femalesiblings. On examination, in
addition to the find-ings of paresis of the limbs, with a spastic
increase oftone, there is cerebellar ataxia, which may be
pre-dominantly unilateral or bilateral.
Cases which could not be conveniently classifiedin any of the
foregoing categories were placed in thecategory of 'other'. They
included only two patientsin the present series, one with
arthrogryposis andcerebral palsy confined to the cranial nerves and
onewith post-encephalitic Parkinsonism.
Tbe Extent and Severity of the PalsyThe number of limbs so
severely involved neuro-
logically that their full normal functions were im-paired is
stated for each category of cerebral palsy.Limbs involved
neurologically but not affectedseverely enough to limit their
functions were classi-fied as nc-mal limbs. Thus the extent of the
palsywhich is stated is the extent of functional impair-ment and
not of neurological involvement. It wasrare, for example, to find
paraplegic patients whodid not show some evidence of slight
affection of theupper limbs. The side affected by hemiplegia
wasstated in every case.
The severity of the palsy was somewhat arbi-trarily decided on
the basis of different criteria foreach form of cerebral palsy.
Thus mild cases ofhemiplegia were those in which the affected arm
wascapable of being used, if somewhat clumsily.Moderately severe
cases were those in which thearm was useful only as an assistant to
the unaffectedarm, and severe cases were those in which there
wasvery little if any functional use in the affected upperlimb.
Mild cases of diplegia and diplegia withataxia were those in which
the gait was clumsy butnot grossly impaired. Moderately severe
cases werethose in which walking without support was possiblebut
the gait was abnormal and activities were limitedbecause of this.
Severe cases were those in whichwalking without support was
impossible or possiblefor only very limited distances. Mild cases
ofataxia and dyskinesia were those in which thechild's activities
were not limited, moderately severecases were those in which some
ordinary activities,such as dressing and feeding, were possible
onlywith difficulty. Severe cases were those in which allnormal
activities were severely handicapped. Bi-lateral hemiplegia was
always a relatively severecondition. Moderately severe cases were
thosewhich could stand or walk without support. Severecases were
those in which walking was impossible,and, since the upper limbs
were more handicappedthan the lower limbs, the former were
generallyalmost functionless.
Inidene of Cerebal Palsy by Year of BirthIn Table 3 is shown the
incidence of cerebral palsy
in Edinburgh children born between 1938 and 1952as ascertaied
during the survey. It will be seen
TABLE 3INCIDENCE OF CEREBRAL PALSY BY YEAR OF BIRTH IN
EDINBURGH*
Number of Patients Incidence per 1,000 in 3-year PeriodsYear
ofBirth Population Hesniplegia Diplegia All Types Hemiplegia
Diplegia All Types
1938 6,7491939 6,5741940 6,209
194119421943
6,0996,3886,538
1944 6,5331945 5,9931946 7,902
194719481949
8,9007,7007,500
1950 7,2001951 7,1001952 6,900
1938-52 104,285 75 79 208 0-719
Based on figures obtained from the Education Authority and
estimates of the Registrar-General.
89
1033
444
748
867
5
380
24S
1137
7413
363
171382
10I13124
249
19)i211424)1185 i
0-819
0-631
0-930
0-871
0-330
0-563
0-578
1-028
0-996
0- 66
1-945
1 -839
2-546
2-448
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ARCHIVES OF DISEASE IN CHILDHOOD
that for the two three-year periods from 1944 to1949 the
incidence of cerebral palsy is approximately2-5 cases per 1,000 of
the population. For theperiods before 1944 and after 1949 the
figures forincidence are lower.The apparently lower incidence of
cerebral palsy
in children bom between 1950 and 1952 is partlydue to there
being a smaller proportion of acquiredcases of cerebral palsy than
in those born between1943 and 1949. Though the majority of cases
ofacquired cerebral palsy occur before the age of3, a few occur
after this age, and clearly a numberof children in the group born
between 1950 and 1952have yet to develop the condition. The
importantcause, however, of the smaller number of patientsfound
among children born in this period comparedto those born in earlier
years is defective ascertain-ment. This is true for all the
categories of thecondition and for congenital as well as for
acquiredcases.The reasons for defective ascertainment of
patients
in the younger age group are of some importance.In a large
proportion of patients the early mani-festations of the disorder
had been misinterpretedor ignored by the doctor to whom the mother
tookthe child. Thus in the 79 cases of diplegia in theseries, 64
had symptoms before the age of 18 months.In 58 cases the symptoms
resulted in the child beingtaken to the doctor before this age. Yet
the diag-nosis of some form of cerebral palsy was made inonly 18
cases and the majority of patients had towait for between 18 months
and two years beforediagnosis and treatment were undertaken. A
delayof this duration resulting in children appearing fortreatment
only at the age of 3 years or more meansthat many have reached the
stage of contracturebefore anything is done to limit the effects of
thecondition. Because the diagnosis of many patientswith cerebral
palsy born between 1950 and 1952 wasunknown to doctors and the
patients had notreached clinics or treatment centres, they were
notascerained during the survey.The apparently lower incidence of
cerebral palsy
in children born between 1938 and 1943 than inthose born between
1944 and 1949 appears to be dueto a number of factors. It was
difficult to discoverwhy ascertainment should have been more
defectivefor this age period than for those born in the
laterperiod. The same sources of information wereavailable and the
numbers of routine medical exami-nations in schools and clinics was
greater in theolder groups than in the younger. It might havebeen
expected that ascertainment would be more,not less, effective in
the older children. It seemedlikely that the apparently lower
incidence of cerebral
palsy in those born between 1938 and 1943 com-pared with that of
those born between 1944 and 1949was either a true reflexion of a
difference in thenumbers of patients developing the condition or
ofthe proportion of patients surviving in spite of it.The death
rate in children suffering from cerebral
palsy is unknown, though various estimates based onunpublished
or inadequate evidence have been made.It seems probable, however,
that the commonestcause of death among children suffering from
cere-bral palsy is infection, especially of the reiratorytract in
those with bulbar involvement complicatingsevere bilateral
affection of the limbs. Since theadvent of antibiotics these
infections can morefrequently be controlled and a higher proportion
ofseverely affected children with cerebral palsy may beexpected to
survive. In the present series there is,in fact, a higher
proportion of severe forms of thecondition, especially diplegia of
tetraplegic dis-tribution and bilateral hemiplegia, among
childrenborn between 1944 and 1949 than in those bornbetween 1938
and 1943.
In addition to the increase in the number ofpatients with
cerebral palsy born in 1944-49 com-pared with those born in 1938-43
due to the lowerdeath rate in the later period, there is an
increase inthe numbers suffering from the condition as a resultof
certain aetiological factors. The increase ismost marked in cases
of acquired ataxia and hemi-plegia. The numbers suffering from the
latter whowere born in the periods 1938-43 and 1944.52 areshown in
Table 4. It will be observed that there is
TABLE 4RELATIVE NUMBERS OF CASES OF ACQUIREDHEMIPLEGIA IN
1938-43 AND 1944-52 COMPARED
No. of Cases ofNo. of Cases of No. of Cases of Acquired
Period Hemiplegia Acquired HemiplegiaHeniplegia Treated with
1938-43 28 8 2*1944-52 47 25 171938-52 75 33 19
* Both developed infections which were treated with penicilli
after1943.
a significantly higher proportion of patients in thesecond group
who suffered from acquired hemi-plegia, the result of the cerebral
complications ofacute infections. It seems probable that the effect
ofantibiotic therapy has been to lower the mortalityfrom these
acute infections and that a higher propor-tion of patients
suffering from them are surviving toshow the effects of cerebral
damage. Similarly,there appears to be an increase in the numbers
of
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CEREBRAL PALSY IN EDINBURGH
patients born in the period 1944-49 compared withthose born in
1938-43 who show ataxia as a resultof tuberculous and septic
meningitis.
It is more difficult to assess the effects on theincidence of
cerebral palsy of the improvements inobstetric and infant care
which have taken placesince 1938. Between 1938 and 1952 the
infantmortality in Edinburgh was halved. Much of thisimprovement
was due to a reduction in the numberof infants dying from
infections, but the mortalityfrom other conditions was also
reduced. Unfor-tunately the extent of the reductions in the
deathrate during the past 15 years is unknown for patientswith
cerebral birth injury, rhesus incompatibility,and other disorders
likely to result in cerebral palsy.Nor can the relative importance
of these disordersin the aetiology of various forms of cerebral
palsybe established in many instances. There does seemto have been
an increase in the proportion of pre-maturely born infants
surviving in the past 15 years,indicated in one Edinburgh hospital
by a 39%reduction in the neonatal mortality in infants withbirth
weights between 3 and 51 lb. It has beenestimated that the
incidence of diplegia in pre-maturely born children who survive is
approxi-mately 1 %, and a large proportion of these patientsgive a
history of neonatal asphyxia, pulmonaryatelectasis and respiratory
infections (Ingram andKerr, 1954). Clearly, if an increasing number
ofpremature infants survive, especially of those suffer-ing from
these complications, an increase in theincidence of diplegia must
be expected. When thenumbers of patients with diplegia born in the
periods1938-43 and 1944-49 are compared, it is found thatthe
incidence of diplegia is increased in those deliver-ed in the later
period and that a higher proportionwere premature than in the
earlier (Table 5).
TA.BIE 5NOS. OF DIPLEGIC PATIENTS AND OF PREMATURELY
BORN DIPLEGIC PATIENTS ASCERTAINED INEDINBURGH BORN IN THE
YEARS
1938-43 AND 1944-49
No. of DiplegicPeriod of Birth No. of Diplegic Patients Born
Patients Prematurely
1938-43 22 51944-49 45 19
It seems probable that there has been someincrease in the
numbers of infants surviving theeffects of rhesus incompatibility
and cerebral birthinjury in the past 15 years, but the extent of
thedecrease in mortality and its effects on the incidence
of cerebral palsy, and particularly of congenitalhemiplegia and
dyskinesia, cannot be estimated.
If the incidence of prematurely born diplegicpatients, the
incidence of acquired hemiplegia andthe incidence of severe
bilateral forms of cerebralpalsy had been as high in children born
between 1938and 1943 as it was between 1944 and 1949 the figuresfor
the total incidence of cerebral palsy in theseperiods would have
been very similar. It seemsprobable, therefore, that the apparent
increase in theincidence of cerebral palsy since the period 1938
to1943 is due largely to the widespread use of anti-biotics and to
improved obstetric and infant care.
Comparison of Incidence of Cerebral Palsyin Present Svvey and
with Other Surveys
An attempt has been made to compare the inci-dence of cerebral
palsy found during the presentsurvey with the figures obtained
during other specialinvestigations. Some comparable figures are
shownin Table 6. It will be seen that estimates of the
TABLE 6INCIDENCE OF CEREBRAL PALSY IN CHILDREN OF
SCHOOL AGE IN VARIOUS URBAN AREAS OFGREAT BRITAIN
Incidence ofAuthority Town 'Cerebral Palsy
per 1,000
Selected rban areasBritish Council for the Welfare (Wallasey
2-4
of Spastics (1948) . orwich 2-0Salford 2-0(oldam 1-9
Cohen (1954) .. Sheffield 1-9Smallwood (1953) .. .. .. Bristol
2-0This survey (1954) . . Edinburgh 2-3
incidence of the condition in children of school agevary between
I 9 and 2 4 cases per 1,000 of thepopulation. A figure of between 2
and 2 5 casesper 1,000 of the school population is probably a
fairestimate of the incidence of significant handicaps asa result
of cerebral palsy in urban areas.
During the survey records were kept in every caseof the
authorities who were aware of the existence ofeach patient with
cerebral palsy (Table 7). It washoped to compare roughly the
incidence figures ofother authors whose sources of ascertainment
weremore limited than in the present survey. It will beobserved
that if only the school medical service, thepublic health
authorities and general practitionershad been contacted, the
incidence of cerebral palsywould have been approximately 1 per
1,000 of thepopulation under the age of 15 years. With casesknown
to hospitals added the incidence becomes
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ARCHIVES OF DISEASE IN CHILDHOODTABLE 7
SOURCES OF ASCERTAINMENT IN 208 PATIENTS WITHCEREBRAL PALSY IN
EDINBURGH
Nos. of Cumulative IncidenceAuthority Patients Totals per
1,000
School medical service andschool for spastics -. 97
Public Health Department.. 16General practitioners .. 1
Total known to authonitesbefore present survey . . 114 1-094
Hospitals .. .. .. 52 156 159Institutions for the mentally
defective .. .. .. 8Personal cases 34
Grand total .. .. .. .. .. 208 1991
1 - 59. These figures may be compared with thefigures of a
number of recent surveys shown inTable 8. On the basis of these
figures it seemsunlikely that the incidence of cerebral palsy
variesgreatly in different large towns though, necessarily,this
conclusion must be regarded as somewhattentative.
Comparison of Prootonal Distrion ofForms of Cerebal Palsy in
Different SwveysIt is rather difficult to compare the incidence
of
the different forms of cerebral palsy in differentsurveys owing
to the wide variations in terminologyused and to the different
types of classificationswhich are found. In Table 9 an attempt has
beenmade to compare some of the larger recent series ofcases with
those found during the present survey.Owing to the inadequate data
available the reclassi-fication of cases in other surveys is
somewhatspeculative.
TABLE 8INCIDENCE OF CEREBRAL PALSY IN SCHOOL CHILDRENASCERTAINED
AS A RESULT OF LOCAL AUTHORITY
RETURNS AND RECENT SURVEYS
IncidenceAuthor Source of Data Plac per 1,000
British Council forthe Welare ofSpastics (1948) .. Local
authorities England 1-0
Asher and Schonell School Medical(1950) .. .. and Public
Health Author-itiesandgeneralprattioners Birmingham I-O
Dunsdon (1952) .. Local authorities Various 1-3
Holoran (1952) .. School Medicaland PublicHealth Author-ities,
somehospitals Leeds 1-6
There is a considerable difference in the propor-tion of
patients suffering from the various forms ofcerebral palsy in the
surveys. In general, the seriesbased on the examination of
candidates for specialschools for children with a physical handicap
orcerebral palsy show a higher proportion of patientswith
dyskinesia and a lower proportion of those withhemiplegia. The
latter can more frequently managein normal schools, whereas the
former, though themajority of them are relatively intelligent,
requirespecial educational provision. Thus Evans's (1948)and
Dunsdon's special school candidates show asmaller number with
hemiplegia than are found insuch surveys as Dunsdon's regional
survey, thesurvey of Asher and Schonell (1950), or the
presentseries. The lower figure obtained for the incidenceof
dyskinesia in the present series is also partly dueto the fact that
patients showing the dystonic stage
BIF 9
PROPORTIONAL DISTRIBUTION OF VARIOUS TYPES OF CEREBRAL PALSY IN
RECENT SURVEYS
This Asher andSurvey Schonell Evans Hellebrandt Dunsdon
Year .1953 1950 1948 1950 1952
No. of patients .208 349 112 531 780
Special SelectedSchools Areas
Hemiplegia .. 36-05% 29' . 9// 24'. 13% 35-3%Diplegia .( ..-..).
(37 95%)Typenotstated - 0- 6. 2'. 7. - -Paraplegia .13-93% 26% 10/.
26% 25-5%Triplegia .11-06% 5'% 4'%Tetraplegia .. 12 96, J
42Bilateral hemipgia .3-86, 222'. ,19% 137% 19-6%Diplegia and
ataxia .5-78. . . - - -Ataxia .7-23-i 1 ' 3'. 8'. - -Dyskinesia
.8-18x. 10', 40' 27'. 13% 7-8%Other. 0-95% 0-3% - %Mixedforms .-
6-0', 4-0% - 11% 11-8%
100% 99-9% 100% 100% 100% 100%
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CEREBRAL PALSY IN EDINBURGH
of diplegia or rigidity with some dystonic mani-festations have
been classified as diplegia and not ascases of dyskinesia.
It will be noted that the figures quoted for theincidence of
ataxia in the present series and in thatof Hellebrandt (1950)
derived from a specializedcerebral palsy clinic are higher than
those of theother series. This is probably due to the fact
thatchildren with quite severe cerebellar or vestibulardeficit may
compensate to a remarkable extent byusing the eyes. In many of
these patients theRomberg test is negative and very careful
examina-tion is necessary to demonstrate even moderatelysevere
ataxia.
It is interesting that the proportional distributionof patients
in the other categories of cerebral palsyin this series and in the
regional surveys of Asherand Schonell and Dunsdon are broadly
comparable.
Sex Distnbuto of Cases of Cerebrl PalsyIn this series, 60 5% of
the patients were males
and 39 5% females. This distribution is similar tothat reported
in a number of other recent regionalsurveys (Asher and Schonell,
1950; British Councilfor the Welfare of Spastics, 1948). In other
surveysa more equal distribution is reported (Cohen, 1954).
In the present series females outnumber males intwo forms of
cerebral palsy only, bilateral hemi-plegia and dyskinesia. The
higher proportion ofmales in the groups of hemiplegic patients
wasespecially marked.
The Severity of the PalsyIn Tables 10 and 11 is shown the
distribution of
cases by their severity and the numbers of limbsinvolved. By
'normally useful upper limb' isimplied a limb which can be used for
normalactivities, such as dressing and feeding withoutgross
clumsiness being evident, whether neuro-logical involvement is
present or not.
It will be seen that 52 of the 208 patients (25 %)
TABLE 10SEVERITY OF CEREBRAL PALSY IN 208 PATIENTS
No. of Moder-Type of Palsy Mild ately Severe Totals
Cases Severe
Hemiplegia 27 26 22 75Diplegia 13 35 31 79Diplegia and ataxia 4
4 4 12Ata .. 4 8 3 15Dyskinesia.. .. 4 6 7 17Bilateral hemiplegia 0
0 8 8Other .. .. 0 0 1 2
Totals.. .. 52 80 76 208(25'.) (38%) (37%) (100,)
were classified as slightly handicapped by cerebralpalsy, 80
children (approximately 38 ) as moder-ately severely handicapped
and 37% as severelyhandicapped. Apart from those suffering
fromhemiplegia severely handicapped patients usuallyneeded
assistance in looking after themselves andwere unsuitable for
employment in present con-ditions. In patients classified as being
moderatelyseverely affected, the possession of one
functionallynormal upper limb was of crucial importance indeciding
if a child required special help in lookingafter himself or
not.
TABLE 11EXTENT OF CEREBRAL PALSY IN 208 PATIENTS
Two One NoUseful Useful Useful
Type of Palsy Upper Upper Upper TotalsLimbs Limb Limb
Hemiplegia 27 48 0 75Diplegia 33 19 27 79Diplegia with ataxia 4
6 2 12Ataxia 15 0 0 15Dyskinesia 3 3 11 17Bilateral hemiplegia 0 0
8 8Other I.. .. 1 1 2
Totals 83 76 49 208(40%) (37%) (23 (100.)
Associated Manifesations of Cerebal PalsyIf paresis of the limbs
was the only maRifestation
of cerebral palsy the vast majority of patients wouldbe
educable. It is because of the associated effectsof the condition,
in particular, intellectual impair-ment, epilepsy, speech defects,
visual abnormalityand specific learning difficulties, that the
majority ofpatients need special educational help. In Table 14some
of the more important handicaps found in theseries of208 patients
with cerebral palsy are recorded.
Inteectual Impaiment in Patientswith Cerebral Palsy
Routine intelligence tests were not performed onall the patients
examined during the survey, butintelligence quotients were obtained
for most ofthose of school age from schools, hospitals and
child-guidance departments (Table 12). Since the esti-mates were
obtained as a result of different tests,in the hands of different
testers in differing circum-stances, too much reliance cannot be
placed on theresults quoted. However, they are comparable tothe
more accurate and better controlled resultsobtained by other
surveys (Table 13).The majority of the children with cerebral
palsy
in the present series were of subnormal
intelligence.Approximately 44% of the tested patients had
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ARCHIVES OF DISEASE IN CHILDHOODTABLE 12
INTELLIGENCE QUOTIENTS OF 208 PATIENTS WITH CEREBRAL PALSY
I g Quoient Over 115 100-114 85-99 70-4 55-69 Under 55 Untested
Totals
HemiplegiaMild. 1 2 4 4 8 5 3Moderately severe .2 4 2 4 7 4
3Severe 0 4 4 9 2 2 1
Total hemipegia .3 10 10 17 17 11 7 75
DilegiaParaplegic. 1 5 4 6 7 1 5Triplegic .2 2 0 5 3 3
8Tetrapegi.c 0 0 2 4 3 11 7
Total diplegia .3 7 6 15 13 15 20 79
Diplegiawih ataxia .0 2 3 1 1 2 3 12Ataxia .0 . 1 3 6 3 0 2
15Dyskinesia .1 2 2 4 2 1 5 17Bilateral p0 0 0 0 0 8 0 8Oter .1 0 0
0 1 0 0 2
Total. . . 8 22 24 43 37 37 37 | 208
Percentagedistnrbutn 3 -8 10-6 11-5 20-7 17-8 17-8 17-8 100
Peracagedistnbution .. 49 12-8 14-3 24-2 21 9 21-9 - 100
TABLE 13PERCENTAGE DISTRIBUTION OF INTELLIGENCE QUOTIENTS IN
THIS SURVEY COMPARED WITH
OTHER RECENT INVESTIGATIONS AND A GROUP OF UNAFFECTED SCOTrISH
ClJILDREN
IntelligenceQuotients 130orMore 115 to 129 100 to 114 85 to 99
70 to 84 55 to 69 Under55
Dunsdon (1952) 0-5 2 6-2 155 17 2 23-6 35
This survey .. 4-9 12-8 14-3 24-2 21 9 21-9
130orMore 110 to 129 90 to 109 70 to 89 50 to 69 25 to 49
Under25 Untestable
AsherandSchonell(1950) 0-6 3 -4 20-1 26-8 22-9 10-7 11-6
3-9Holoran(1952) .. - 2-8 22-0 36-2 21-3 8-5 3-5 5-7
Unaffected children(Macmeeken, 1939) 4-7 21-2 48-6 24-3 1-3
intelligence quotients of 69 or less. They were,therefore, in
need of special educational provisionwhatever the severity of their
palsy. Fifty-four ofthe patients, or 32% of those tested, had
intelligencequotients of 85 or more and may, charitably, in
somecases, be regarded as of normal intelligence.
I 1denc of EpilepsyIn Table 15 are shown the numbers of
patients
who suffered from epileptic attacks of various types.Sixteen
patients suffered from petit mal or similarattacks involving brief
impairment of consciousness.Some of these patients also suffered
from grand mal.Petit mal occurred more frequently in those
withsevere or extensive cerebral palsy than in those witha mild
disability. It was, therefore, a nuisance tothe already severely
handicapped children ratherthan a cause, in itself, of serious
limitation ofactivities. Grand mal and attacks of Jacksonian
type with more prolonged severe impairment or lossof
consciousness were present in 53 patients orapproximately 25% of
those suffering from cerebralpalsy. In the majority attacks
occurred betweenonce a month and once a year, in spite of
anti-epileptic drugs. The proportion of children suffer-ing from
severe cerebral palsy who showed epilepsywas not much higher than
the proportion of mildlyaffected patients. The attacks were,
therefore, animportant cause of limitation of activities in
somepatients.
Inience of Speech DefectsThe crude criterion used during the
present survey
to determine if a child suffered from significantspeech defect
or not was whether comprehensionof what he said was rendered
difficult. Minorspeech defects which were not sufficiently severe
toimpair comprehension of what was said were
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CEREBRAL PALSY IN EDINBURGHTABLE 14
NO. OF PATIENTS WITH CEREBRAL PALSY BETWEENAGES OF 6 AND 11
FOUND REVERSING LETTERS WHENREADING OR WRITING IN A SMALL EDINBURGH
SURVEY
No. of, BothType of Patients Reading Writing! ReadingPalsy Ques-
Only Only and Totals
tioed Writing
Right hmipea.. 12 1 4 3 8Lefthem ia .. 13 0 1 1 2Diplegia .. 24
0 3 2 5Ataxia and diplegia
with ataxia .. 5 0 2 0 2Dyskinesia.. 3 0 0 0 0
Totals 57 I 10 6 17
ignored. Generous allowance was made for retard-ation of speech
in children with mental defect.One hundred and two of the patients
(approxi-
mately 49%) were considered to suffer from signi-ficant speech
defects. This may be compared to thefigure obtained in one recent
series where, in all,79% of the palsied children of school age were
foundto suffer from speech defects, including minor defectsand
probably some patients with aphasia (Dunsdon,1952). Of the patients
in the present series, 10 5%had no more than one or two words of
speech andare included in a total of 24-5% who had speech
defects of such severity that they could not expresstheir ideas
adequately in speech.
of Visuma Defects
Visual defects due to other causes than refractiveerrors were
found in 35 patients (Table 15). Theincidence of partial blindness
was much higher inpatients with severe cerebral palsy and
mentaldefect than in those who were mildly affected. Alleight of
the patients with bilateral hemiplegia, forexample, had only
partial vision. In seven patientswho were considered to be educable
the visualdefects were thought to be sufliciently severe
tonecessitate education by non-visual means, now orin the future.
Four of these patients were sufferingfrom retrolental fibroplasia,
which was found in sixpatients in the series in association with
diplegia.It was interesting to note the very good compensa-tion
achieved by some patients who suffered fromsevere field
defects.
of Behaviour Disorder
The majority of the children with cerebral palsyin the present
series, especially those with acquiredcerebral palsy, showed
functional behaviour dis-
TABIE 15ASSOCIATED DISABILITIES AND SCHOOLING IN 208 PATIENTS
SUFFERING FROM CEREBRAL PALSY
Epilepsy SchoolingVisual Speech Over-
assifiation No. of Grand Petit Aphasia Defect Defect acivityof
Palsy Cases Mal Maland Normal P.H. M.H. Inedu- Not yet
Jack- Other School School School cable atsonian School
HemiplegiaMild .... 27 6 0 2 1 11 3 9 2 8 4 4Moderately severe
26 10 4 6 4 8 4 6 4 5 1 10Severe .. 22 8 0 4 6 2 2 8 5 2 4 3
Total .. .. 75 22 4 12 11 21 9 23 11 15 9 17
DiplegiaParaplgia .. .. 29 6 1 0 2 7 0 7 9 5 0 8Triplegia .. ..
23 9 3 3 3 14 0 3 3 5 4 8Tetraplegia .. .. 27 7 5 1 8 14 0 1 0 6 9
11
Total .. .. 79 22 9 4 13 35 0 11 12 16 13 27
Dipkgia with ataxiaTriplegia .. .. 9 1 2 0 0 8 1 2 3 1 2
1Tetraplegia .. .. 3 0 2 0 1 2 0 0 1 1 0 1
Total 12 1 4 0 1 10 1 2 4 2 2 2
Ataxia .. 5 3 1 0 2 I 1 4 2 7 3 0 3
Dyskinesia 17 0 4 0 0 15 1 2 7 2 1 5
Bilateral bemiplegia 8 5 0 0 8 8 1 0 0 0 8 0
Other forms of cerebralpalsy .2 0 0 0 0 2 0 0 2 0 0 0
Grand total .. 208 53 22 16 35 102 16 40 43 38 33 54
Pecentage .. 28-4 10-5 7-7 16-8 48-8 7-7 19-3 20 7 18-2 15-9
25-9
Percentage ofschool age 26-0 27-9 24-7 21-4
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ARCHIVES OF DISEASE IN CHILDHOOD
order at some time or another, the result of difficultyin
adapting to their disability. In addition, anumber of children
showed a rather typical form ofover-ctivity which was characterized
by an intensepreoccupation with the immediate surroundings,gross
impairment of concentration and attention-span, and complete lack
of common sense or insight.These patients were never still. All
objects in theroom, furniture and people attracted great
superficialmomentary interest. Objects were handled andfrequently
put to the mouth, chewed and then dis-carded. The over-activity
appeared to be mostsevere up the age of 8 or 10 and then gradually
todecrease. This form of behaviour disturbance wasfound in 16
patients and was most frequent in thosewith hemiplegia, especially
when it affected the rightside, and was associated with epilepsy
(Table 15).Until the over-activity lessened most children
suffer-ing from it were ineducable.
Incdec iof Aphasia and DyspasiaAphasia or dysphasia was evident
in 16 patients
(approximately 8%) with cerebral palsy. Twelveof the patients
suffered from hemiplegia, only one ofthem on the left. All but two
of the 16 aphasic ordysphasic patients suffered from moderately
severeor severe cerebral palsy, and a mild or moderatedegree of
mental defect was present in nine. In all,however, the degree of
verbal difficulty was out ofall proportion to the severity of the
mental impair-ment. Cases of severe mental defect in which
thereseemed to be some specific difficulty in comprehen-sion were
classified as mental defective but not alsoas aphasic.The most
important effects of aphasic and dys-
phasic disorders were seen in the first years at schoolwhere a
number of the patients were considered to bedefective until careful
intelligence testing wasperformed.
Specific Lrning Difficulties in Childrenwih Cer Palsy
In addition to the handicaps imposed on thechild's ability to
learn by motor impairment, visualdefects, aphasia and speech
defects a number ofpatients showed specific educational
difficulties.Some appeared to have great difficulty in
recognizingand forming letters, numbers and shapes of smallwords,
and learning to read and write was thereforemuch retarded. Mild
manifestations usually lastonly a few months and take the form of
reversals ofletters and small words in writing, and, less
com-monly, in reading. In its more severe forms, how-ever, the
laning disability deserves the name of true
word-blindness. Ataxic patients appeared to showparticular
difficulty in writing letters, and letterreversals and word
inversions were especially fre-quent and severe.
It was impossible to obtain details of the earlyeducational
progress of all the children in the survey,but in 57 patients,
whose intelligence quotients variedfrom 60 to 125, details were
obtained and the resultsare shown in Table 14. It will be seen that
a rela-tively high proportion of patients, especialy thosewith
right hemiplegia, showed directional con-fusions in writing.A high
proportion of patients with cerebral palsy
showed rather poor powers of concentration and avery limited
attention span, even when intellectualimpairment was relatively
slight. Very skilteaching is necessary.
The EdMcin of Children wi Cerebral PasyIn Table 15 are shown the
numbers of children of
school age in the series who attended various typesof school or
were classified as ineducable. Thefigures obtained during this
survey were comparedwith those of other similar surveys. The
proportionsof children in different schools vary in
differentsurveys. This is probably a reflexion on theselective
nature of some series and of the differencesin the types of schools
available in different districtsrather than a measure of
differences in the types ofhandicap suffered by children in
different areas.Nevertheless, the surveys show that not more
thanone quarter of the children who suffer from cerebralpalsy are
capable of benefiting from normal educa-tional methods. Only three
patients in the presentseries were thought to be capable of taking
theirhigher leaving certificates. Over half the patientsin normal
schools suffered from hemniplegia and,therefore, had at least one
functionally normalupper limb. In contrast, only 11 patients
withdiplegia were in normal schools and there wastetraplegic
paresis in only one of these. In general,types of cerebral palsy
which tended to involve alllimbs resulted in a smaller proportion
of children innormal schools. Thus, in spite of the relatively
lesssevere mental impairment than in other forms ofcerebral palsy,
only two patients with dyskinesiawere in normal schools. Of the 12
patients ofschool age who showed ataxia, there were onlytwo in
normal schools.
Thirty-three of the patients of school age (approxi-mately 21-5
%) were classified as ineducable. Inpractice this category was
found to consist almostentirely of severely mentally defective
children.Thirteen of the patients classified as ineducable werein
institutions for the mentally defective. The
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CEREBRAL PALSY IN EDINBURGHremainder were in occupation centres
or at home.Twenty-one were bedridden and in need of constantcare
and attention. Eighty-one of the patients ofschool age (52 6
attended special schools for thementally or physically handicapped.
The decisionas to which type of school was best for the childwas
decided on the basis of the relative severity ofthe palsy and of
the intellectual impairment. Thoughthere was some overlapping of
the types of casefound in these schools; in general, those
withintelligence quotients of under 70 were found inschools for the
mentally handicapped and thosewith intelligence quotients of over
70 were in schoolsfor the physically handicapped. Forty-three
chil-dren, approximately 28% of those of school age,were in schools
for the physically handicapped, ofwhom six were in residential
schools.
Prospects of Regular Employment forChldre with Ceal Palsy
During the survey some experience was gained ofthe employment
difficulties encountered by a numberof patients between the ages of
16 and 18 whosuffered from cerebral palsy. On the basis of
thisexperience an attempt was made to assess theprospects of
regular employment and the need forcare of the cases of school age
ascertained duringthe survey. Patients were placed in three
categories,probably employable, possibly employable, orunemployable
(Table 16).
TIhe majority of patients who attended normalschools were
considered to be probably employable
with the exceptions of two relatively severely affectedpatients
with diplegia, who were placed in the'possibly employable' group.
Three patients withhemiplegia and two with diplegia in schools for
thephysically handicapped were felt to be probablyemployable. In
all 43 patients, or 28% of those ofschool age, were considered to
be probably em-ployable.
Patients with intelligence quotients of less than 70were
automatically classified as unemployable.Because of intellectual
impainment they were onlyfitted for unskilled manual work, which
they wereunable to do on account of their physical
handicaps.Patients with intelligence quotients of between 70and 85
might be expected to be suitable for unskilledwork, but the
majority would only be capable ofthis if the palsy was of a
relatively slight degree.Therefore those who were moderately
severely orseverely affected were classified as unemployable,and
patients with mild cerebral palsy were classified,somewhat
optimistically, as being possibly employ-able. In all 86 patients,
approximately 56% ofthose of school age, were classified as
unemployable.
Twenty-five patients were classified as possiblyemployable, 16%
of those of school age. Two casesin this category came from normal
schools, 20 fromschools for the physically handicapped,
includingfive patients with ataxia and six with dyskinesia.Three
patients came from schools for the mentallyhandicapped. They had
intelligence quotients ofbetween 70 and 85 and relatively mild
cerebralpalsy.
TABLE 16ASSESSMENT OF PROSPECTS OF EMPLOYMENT IN PRESENT
CIRCUMSTANCES OF
154 CHILDREN OF SCHOOL AGE WITH CEREBRAL PALSY
Unemployable Nos. of Possibly Employable Nos. of Probably
Employable Nos. ofCriteria Patients Criteria Patients Critena
Patients
Inteligence quotient below 70Hemiplegia with epilepsy
Hemiplegia
Hemiplegia.. 22 P.H. schools .. . 5 Normal schools .. .. 23Mild
hemiplegia Hemiplegia
Diplegia .25 M.H. schools .. .. 2 P.H. schools. . . 3Paraplegia
Paraplegia
Other 15 P.H. schools .. . I Normal schools .. .. 7
Total I.Q. under 70 . .. 62
InteUigence quotient betwen 70 and85, but severely affected
Hemiplegia..Triplegia
3 Normal schoolsP.H.M.H. ,,
P.H. schools ..
2
Tetraplegia TriplegiaDiplegia .10 Normal schools .. .. 1 Normal
schools .. . 2
P.H. ,, .IOthers Others
r Other . 11 P.H. schools .12 Normal schools .. . 6
Total I.Q. between 70 and 85 .. 24
Total unemployable .. .. 86 Total possibly employable . 25 Total
probably employable 43
Percentage .56 Percentage possibly Percentage probablyemployable
.. 16 employable .. 28
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98 ARCHIVES OF DISEASE IN CHILDHOODIt seems clear from this
somewhat speculative
assessment of the chances of regular employmentfor children with
cerebral palsy that not more thanone-third are likely to be self
supporting in presentconditions. A number of the patients who
doobtain regular work will obtain only jobs in whichprospects are
poor. In present labour conditionsrelatively few of the 16% of
children in the 'possiblyemployable' group are likely to obtain
regularemployment, though in favourable conditions andunder some
form of supervision many might makea contribution to their own
maintenance.The 560% of patients in the unemployable group
are unlikely to be able to make any contribution totheir own
maintenance. The majority will be inneed of constant care for many
years. Twenty-oneof the patients in this group are bedridden
andprobably all will eventually be in need of constantnursing
attention in institutions.
Summary and ConcluiosA description has been given of a recent
survey
in Edinburgh designed to ascertain the incidence ofcerebral
palsy in children born between 1938 and1952. Evidence is presented
which suggests thatthe incidence is between 2 and 2 5 cases per
1,000children, and this estinate is compared with theincidence of
the condition found in other surveys.The number of children
suffering from cerebral
palsy born between 1950 and 1952 who were ascer-tained was
small. It is shown that this is largelydue to the present great
delay in the diagnosis ofchildren with early symptoms of cerebral
palsy.A smaller incidence of cerebral palsy was found
in the six-year period 1938 to 1943 than in theperiod 1944 to
1949. It is suggested that thedifference in incidence is partly due
to more patientswith cerebral palsy born in the later period
survivingbecause complicating infections could be controlledby
antibiotics. A more important cause of thegreater incidence amongst
children born between1944 and 1949 is the fact that the survival
rate forthose suffering from conditions likely to lead tocerebral
palsy was increased in this period byimprovements in infant care
and the widespread useof antibiotics.The severity of the handicaps
imposed on the child
because of cerebral palsy and associated physical andmental
abnormalities are described. The relatively
low proportion of patients capable of benefitingfrom normal
educational methods, and the highproportion who are likely to be a
burden to thecommunity throughout life is stressed. An assess-ment
is presented of the numbers of patients likelyto obtain regular
employment eventually and thenumbers who will require care and
attendance.
It is pointed out that earlier diagnosis and treat-ment of
children with cerebral palsy might lead toa reduction of the
physical handicap resulting fromcontractures of the limbs. Though
not likely to befinancially rewarding, it is apparent as a result
ofthe survey that much more attention must be paid toobtaining
training and employment, if necessaryunder supervision, for
patients with cerebral palsy.
This survey could not have been made without thecooperation of
so many physicians and surgeons inEdinburgh that it is impossible
to mention them indivi-dually. I am especially grateful to Dr. W.
N. BoogWatson, of the School Medical Service, and Dr. H. P.Tait, of
the Maternity and Child Welfare Service, fortheir unfailing help,
and to the paediatricians of theRoyal Hospital for Sick Children
and Western GeneralHospital, Edinburgh. I owe thanks to the records
officersof these and other hospitals and institutions, and to
MissE. Cruickshank for much secretarial assistance.
I am deeply indebted to Professor R. W. B. Ellis forhis guidance
and encouragement during the survey andfor his help during the
preparation of this paper.
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