Two years follow up study of sixty-two cases of neonatal cerebral damage are reported. Nineteen of the thirty-six survived cases in series had cerebral palsy. These cases include, seven with hyperbilirubinemia, five with asphyxia, three with intracranial hemorrhage, one with intracranial hemorrhage and asphyxia, one with intracranial hemorrhage with hypoglycemia and one with hypoglycemia and hypocalcemia. The causes of hyper bilirubinemia include ABO incompatibility, administration of Salcylate and idiopathic origin. Kernicterus occurred in cases with bilirubin level over 20mg/d/ in full term infants, whereas 14 mg/dl in premature infants with asphyxia or hypoglycemia. Fifty per cent of anoxic encephalopathies in the neonatal period had cerebral palsy. In group whose convulsive seizure improved within one day, there had no cerebral palsy, whereas in group whose seizure last more than 4 days, all had cerebral palsy. All cases of intracranial hemorrhage and two of the three cases of neonatal hypoglycemia had cerebral palsy. The autopsy findings of one case of cerebral palsy caused by neonatal asphyxia revealed the nerve cell destruction and the gliosis of the basal ganglions but there was no pathological finding in the cerebral cortex.
For the purpose of early diagnosis of cerebral palsy, electroencephalographic examination of 178 newborns and the follow up study of these infants for the period of at least six months or the longest for 4 years and 4 months were performed From the results of these follow up observations we evaluated the significance of EEG of the newborns for detecting brain damage as well as predicting the prognosis. 1) It was found that all the 53 normal EEG group without any pre- or perinatal complication proved to be normally grown-up 2) The group with diffuse brain pathology (cerebral palsy and mental deficiency) all were found to have developed from the abnormal EEG group. In contrast, only 2 cases of epilepsy was found in the normal EEG group with pre- or perinatal complication. 3) As for the neonatal EEG patterns indicative of poor prognosis, the basic pattern showed flat pattern or diffuse slow wave dysrhythmia, and the sleep pattern revealed undifferentiated EEG and no trace alternant pattern. 4) The abnormal trace alternant pattern (i. e. bilateral independent, bilateral asynchronous, and isoelectric interburst) was deeply associated with diffuse brain damage. 5) Focal sharp waves were observed in 12 cases (6. 7 per cent) out of the 178 newborns. Seizure discharge seems to be of no value for evaluating the prognosis of diffuse brain pathology. 6) In our comparative studies on the relationship between mean visual evoked potentials and the prognosis we have been able to demonstrate that the peak latency delayed decidedly in the majority of abnormally grown up. 7) We have emphasized the importance of neonatal EEG findings to be included in the evaluation of at-risk baby in neonatal period.
From the viewpoint of pediatrics I expalain the some problems of cerebral palsy (C. P.), especially etiology, prevention, early diagnosis and early education and treatment of C. P. and emphasize the following 3 points. 1) As the etiology of C. P., I explain the possibility of the participation of the intra-uterine abnor mality or disturbance. Therefore, in consideration of C. P. prevention I think that maternal-child health is more impor tant and if proper maternal-child health is not considerable, it would be not disappearance of C. 2) I report the prognosis of C. P. from the viewpoint of their life and emphasize that tension athetosis is more necessary of pediatric health care etc. 3) I explain the necessary of the education of C. P., the double handicapped and most severly han dicapped children, hereafter, on the education coure of pediatrics.
I stated the medical treatment of cerebral palsy from a view-point of an orthopedic surgeon, and I think I can summarize the points as follows: 1. We should not treat each joint deformation of cerebral palsy separately, but treat as a whole including his process of growing. 2. The rehabilitation should be emphasized in the course of the treatments of cerebral palsy, and orthopedic treatments (including the plaster of Paris bandages, braces and orthopedic surgery opera tions) should be the supplementary means. 3. If we can find cerebral palsy in an early stage and if we can treat him from an early years the treatments can be more and more effective.
256 cerebral palsied adults had been training for medical treatment and social adjustment in Osaka Rehabilitation Center from 1951 to 1970. In retrospective study of 205 subjects suspected accidents of brain damage were distributed as follow: 64 abnormal delivery, 51 asphyxia, 11 abnormal neonatal jaundice and 27 convulsion in infancy and childhood. Only 4 had episodes of convulsion in preschool age. Delayed onset of walking was found in 52 per cent of the subjects. For the purpose of further estimation of ability in adult cerebral palsy, 38 young adults, a group who are in residenced in the center at present, was studied. The result of walking tests for the dis tance of 50 meters and one kilometer showed fairly well the endurance of locomotion under conditions affecting muscle tone and spastic deformities of lower extremities. Hand skill and its related activities, such as postural control at sitting and standing jobs, fine grasp, holding tools, assembly and positioning objects, indicated low score in a series of job sample tests. Communication disorder in adult subjects remained as it was in childhood. The ability for independence of the subjects was investigated by two previous follow-up studies (1965 and 1968). Of 205 subjects between the age of 19 and 48 years old, 43 are working at the sheltered work shop in the center. In 133 follow-up cases of cerebral palsied adults who left the center, 60 per cent were completely independent among this population 50 per cent were in good and open employment, 9 per cent were in self-supporting work and 32 per cent were unemployed. Length of time in job was one to 5 years duration in most of the cases. Only 3 were employed for 10 years or more. Their occupations were varied. The highest distribution of the occupations was factory work and simple lador. Married cerebral palsied were 18 (8%). The subjects who had children were 8. Their 12 children were living and well after normal delivery.
Among autopsy cases diagnosis as cerebral palsy clinically, there were 18 cases of congenital anoma lies, 21 of post-icteric encephalopathy and 20 of sequela of pen-natal brain damages. The former two included cases superimposed with perinatal brain damages. The first series contain various types of anomalaies. Majorities of cases were spastic type and showed agenesis or severe hypoplasia of the pyramidal tract. The 4 cases showd developmental disturbance or early involution of the thymus. 20 cases were defined as sequela of birth injuries according to presence of histories indicating sign of difficulties of delivery. There were four major sites of cerebral lesions as follows., 1. Cerebral cortex (2cases). 2. Subcortical structure including basal ganglia and thalamus (14cases). 3. Extensive cereb ral involvement (4cases). Clinically 18 cases were spastic, one athetosis and one hypotonic. The pyra midal tracts were either degenerated or poorly developed except for a case of status marmoratus in the putamen. Characteristic feature of all 21 cases of post-icteric encephalopathy was a set of lesion in the sub thalamic nucleus and globus pallidus. Changes of the other site showing yellow discolouration in acute stages of the Kernicterus were inconstant and may be obscure unless Holzer stain was employed. In general the pyramidal tracts were hypoplastic. This was especially true in cases of premature birth or low birth weight child and with history of birth injury. 13 cases of post-natal brain damage were examined pathologically. Some showed sequelae of en cephalitis and meningitis. Majorities, however, showed lesions of circulatory base probably related to convulsion. 3 cases of cerebral hemiatrophy were included.
Recently there are several reports about the psychological appraisal of the cerebral palsied children, especially their intellectual aspects. These reports have chiefly concerned about the assessment and the construction of intelligence. In this report I studied about the construction of intelligence in cerebral palsied children and con cluded as follow: 1) The pure factor of the intelligence, i. e., not the acquired, is mostly non-detective compared with the acquired factors. 2) The application of IQ to evaluate the intelligency in the cerebral palsied children is not justified, because there are several differences about the intelligent factors between the cerebral palsied and normal child, though the developmental aspects in the construction of intelligence are nearly the same. 3) The routine test batteries of IQ may not be used for the estimation of intellectual potenciality in the cerebral palsied.
Paralysis of cranial nerves reveal not only difficulty in speech and articulation, but numbness of taste, lose of appetite, difficulty in swallowing, digestive disturbance and therefore have an effect on nutrition of patient. Paralytic condition of nine of cranial nerves were examined. They were oculo motor, trochlear, abducens, trigeminal, facial, glossopharyngeal, vagus, accessory and hypoglossal nerves. The subjects are 77 children with cerebral palsy (spastic type 41, athetotic type 34, ataxic type 2). Ataxic type was excluded because it had few cases. Comparing spastic type with athetotic type, dysfunction of oculomotor, trochlear and abducens was 68. 3% in spastic type and 70.6% in athetotic type, in which a distinct difference was not seen. About the facial nerve, disorder was foundin almost all the cases in both types, 85.4% in spastic type and 100% in athetotic type. Clear differ ences between spastic and athetotic type were seen about trigeminal (14.6%, 50.0%), vagus (14.6%, 64.7%), hypoglossal (41.5%, 91.1%) and accessory nerve (46.3%, 79.3%). Relation between diffi culty in speech and disease type was also examined. That is, its degree was classified into 4 steps as severe, moderate, slight and non disorder. The result was that only 4 cases (9.8%) in spastic type showed speech dysfunction in daily life (it belongs to severe and moderate group), but athetotic type showed much higher percentage 30 cases (88.2%), and speech dysfunction was mainly due to facial and hypoglossal paralysis.
The Metropolitan Jonan Branch Hospital and Day Center for Handicapped was started in 1969. The aim of this center is the habilitation of handicapped children for the preschool-aged. Now there are 9 day centers, 4 crippled children's hospitals and 4 institutes for severely handicapped in Tokyo. In the last one year, 120 handicapped children visited the Jonan Day Center and only 20 of them have attended the day nursery every day. This was relatively small numbers of visitors than the expected, and its reason seemed to be depend on the following three factors, the first was inconvenience of transportation, the second was too short time for training and nursing in a day, and the third was too close standing of the same kind centers. The cerebral palsied (CP) group occupied 53.3%, and the non-CP group occupied 46.7%. In CP group, 51.6% were spastic paraplegic and 32.8% were athetotic tetraplegic. Most of the handicapped children were dependent in ADL, and severely handicapped children were 21.9% in CP group and 41.0% in non-CP group. Associated handicaps in these children were high percentages of visual disturbances in CP group (64.3%) and dental disorders in both groups (26.8-37.5%). EEG showed abnormalities of basic activities in 51.7-62.5% of the children. Minor anomalies were more frequently observed in non-CP group, especially in the group of prenatal and unknown cause, than in CP group.