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A Survey of 400 Cases Ofcerebral Palsy In Arch Dis Child: first published as 10.1136/adc.25.124.360 on 1 December 1950. Downloaded from A SURVEY OF 400 CASES OF CEREBRAL PALSY IN CHILDHOOD BY PATRIA ASHER and F. ELEANOR SCHONELL From the Department of Paediatrics and Child Health, University of Birmingham, and the Birmingham Institute of Child Health (REEV FOR PUBuJCATO MARCH 31, 1950) In recent years cerebral palsy, a previously to assess the physical and mental handicap suffered neglected subject, has attracted much attention, at by these children. Finally, our results enable us to first in the U.S.A. and, more recently, in this make certain observations on the aetiology of country. In many districts plans are being made for cerebral palsy. the treatment and education of affected children. Before such plans can be effective we need to know how many children with cerebral palsy are to be ORGANIZATION OF THE SURVEY expected in any community, and what will be the In the sunmmer of 1947 Professor Smellie wrote to Protected by copyright. nature of their physical and mental handicap. all the doctors in Warwickshire, Staffordshire, Hitherto information of this nature has been scanty, Worcestershire, Shropshire, and Herefordshire, and estimates of the incidence of cerebral palsy asking them to report any cases of cerebral palsy have been based on the numbers found in institu- known to them. About 70% of these doctors tions, those presenting for treatment at special replied, and a register was compiled of the cases they centres, or cases detected during routine school reported. Later, many more names were sent in, medical inspections. usually by medical officers of health and school In making this survey of cerebral palsy among medical officers. The great majority of the children children in Birmingham and the neighbouring we saw came from the three first named counties; counties (Warwickshire, Staffordshire, and Worces- a few came from outside the Midlands. tershire) our aim was to locate and examine every At,the time of writing there are 587 cases on the case in the area. We did not achieve this aim for, register, of whom we have seen 466. Sixty-six of at the time of writing (October, 1949) there are 131 those examined proved to be suffering from some cases awaiting examination, and doubtless there are condition other than cerebral palsy-usually uncom- http://adc.bmj.com/ many others as yet unknown to us, especially among plicated mental deficiency. The remaining 400 form very young children. Still, we believe that we are the basis of this communication. now in a position to make a rough estimate of the incidence of cerebral palsy, at least in certain towns covered by our survey. Moreover, our sample, THE INCIDENCE OF CEREBRAL PAISY though not yet complete, we believe to be repre- In four cities-Birmingham Coventry, Stoke-on- sentative. We made every effort to see every case Trent, and Walsal-we saw enough cases to make on September 27, 2021 by guest. reported by general practitioners, specialists, school an estimate of the incidence of cerebral palsy among medical officers, welfare officers, school teachers and school-age children in these cities of some value. by the parents themselves; we searched mental We did not see enough under-fives to make such an defective institutions, special schools, and hospitals estimate for the younger children. for cases we might otherwise have missed. We have The low incidence for Stoke-on-Trent shown in seen every type of case, from the hopeless quadri- Table 1 is due to the fact that we saw no low grade plegic ament, bedridden in an institution, to the defectives there, where nearly all our cases were mildest hemiplegic or paraplegic attending a normal referred by the school medical officer. school. The physical and mental examination of We can make a better estimate of the incidence these children has enabled us to estimate the relative by including 85% of the cases referred but not yet incidence of the different types ofcerebral palsy, and seen, as we found that just over 85% of the cases we 360 Arch Dis Child: first published as 10.1136/adc.25.124.360 on 1 December 1950. Downloaded from SURVEY OF CEREBRAL PALSY 361 TABLE I not attend for interview. The history of the child's INCIDENCE OF CEREBRAL PALSY IN THE SCHOOL-AGE birth was not checked by reference to hospital or PoPuLATioN oF FouR CrrIEs other records; Evans (1948) foumd that such records usually confirmed the mother's story. In cases of No. of Cases acquired cerebral palsy records of the child's stay in Population of C.P. Incidence hospital, if any, at the time of the original illness, City (5-15 years) (5-15 years) per 1,000 were obtained wherever possible. Brmingham .. 144,000 110 0-76 Every child was examined clinically by one of us Coventry .. 32,836 31 0-94 (PA.) and, of those over 3 years old, all but two Stoke-on-Trent 39,583 23 0-58 Walsall .. 13 0-77 were seen by the psychologist for an assessment of 17,330 intelligence (carried out by F.E.S. in all but ten cases). Blood for Rh and Wassermann tests was did see-400 out of 466-proved to be cases of taken in some instances. cerebral palsy. As the additional numbers are small Our 400 cases fall into the following groups: the figures for the smaller towns have been combined. A. Congenital cerebral palsy 349 cases (1) Spastic paralysis 290 cases (83%) TABLE 2 Symmetical quadri- plegia 77 (22%) ESMATmD INc1wc oF CEREBRAL PALSY Asymmetrical quadri- plegia and triplegia 18 ( 5%) Paraplegia 90 (26%) Hemiplegia (60 right, 42 left) 102 (29%) Cityt :, u" 8& J Others 3 ( 1O/) .a 8 (2) Athetosis 36 (bo) i~ ~ Protected by copyright. (3) Mixed spastic and athetoid 17 (15%) (4) Ataxia 3 ( 1%) Birmingham 144,000 110 26 132.1 0 9 (5) Flaccid cerebral palsy 2 ( 06°o) CoventryA (6) Tremor and rigidity .. 1 ( 0-3%) StOke-on- Trent 89,749 67 14 85-5 0-88 B. Acquired cerebral palsy (including WalSall kerniterus) 51 cases (1) Kemicterus 19 ,, (2) Post meningitic 11 (3) Other infections 2 In view of the admirable cooperation of general (4) Acute infantile hemiplegia 14 practitioners, specialists, and public health officers (5) Progressive tive spastic in these areas we think it unlikely that any great ()racysiskull 4,, number of cases of school age escaped us. Probably (6) Fractured skull . I1 , the incidence of cerebral palsy among these children is in the region of 1 per 1,000. This is very much A. CONGENITAL CEREBRAL PAISY http://adc.bmj.com/ less than Phelps's (1941a) estimate of six children with cerebral palsy per 100,000 total population per History and Clnical F year; this would mean 600 cases aged 5-15 years in Hstory. In a large number of these cases there Birmingham (population one million) where we was a history of difficult birth, and the neonatal estimate that about 150 school-age children are period had been stormy. (Ths facts will be affected. Phelps, however, does not give the data discussed in detail later.) The neonatal period once on which his figures are based. Our results are the child seemed to develop until the over, normally on September 27, 2021 by guest. similar to those of Professor Mackintosh who, in age of 6 to 9 months, when he was noticed to be an address to the British Council for the Welfare of backward in sitting up. Backwardness in passing Spastics (1946), estimated that there were 1-2 cases the usual milestones was the first sign of the trouble of cerebral palsy per 1,000 children of school age in the vast majority of cases. In a few cases in Scotland. abnormalities of tone or posture were noticed from the earliest stages. The difference between the two hands makes for the earlier diagnosis of hemiplegia METHODS OF EXAMINATION AND RESULTS than of other types of cerebral palsy; thus in 34% A careful history was taken from the mother of hemiplegics some abnormality was noted before whenever possible; a questionnaire was sent to the the age of 6 months, and in only 11 % of paraplegics; mothers of children seen in institutions if they could for athetoids and quadriplegics the figures are 20% 26 Arch Dis Child: first published as 10.1136/adc.25.124.360 on 1 December 1950. Downloaded from 362 ARCHIVES OF DISEASE IN CHILDHOOD and 300% respectively. The diagnosis of cerebral Deafness. Deafness was noted by the mother in palsy was usually made during the second year of 10 out of 55 athetoids (including cases of kernicterus) life, and subsequent development depended upon and in only three of all the other cases. Audiometry, the nature of the child's affliction. however, shows that there is often some hearing loss Among the children whom we examined we found even in those who do not seem deaf to their the following symptoms. associates. Difficulty in Walking. This was the commonest General Condition Although the great majority symptom in most groups. Thus, of 320 cases over of these children were well looked after by devoted the age of 3 years 102 (32%) could not walk and 42 parents, nearly all of them were undersized and (13 %) could only just walk. The proportion was underweight. naturally highest among the quadriplegic spastics Head Chrumference. The head was commonly and athetoids. on the small side. The more severe the other signs Difficulty in Using the Hands. This was very of brain damage the smaller, on the average, was noticeable among the athetoids, even the milder the head.
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