Ronald Mac Keith

The Little Club

During the past year and a half a number of interested people have rnet at the Little Club to discuss a memorandum on the terminology and classification of “cerebral palsy”. The memorandum in its present state* was put forward for discussion at the Oxford Study Group on Child Neuroloqy and Cerebral Palsy. The participants in the discussions were: Dr. N . S. Alcock, Dr. J . Bates, Dr. E. A. Carmichael, Dr. J . Crosland, Dr. P. R . Evans, Dr. M . C. Joseph, Dr. M . J . McArdle, Dr. A . D. McDonald, Dr. R . C . Mac Keith, Dr. I . C. K . Mackenzie, Prof. A. A. Moncriefl, Dr. P. E. Polani and Sir Charles Symonds. The memorandum gives a definition of “cerebral palsy”, notes the need for definition of clinical ierms and sugqests that at the present time clinical features offer the most useful basis for classification; the clinical features of hypertonus are discussed in detail and then Q clinical approach to diagnosis is put forward. This suggests thar the spastic cases should first be recognised and then, from among the remainin? cases, the dystonic and choreoathetoid cases, leaving a residue which will include mixed cases, ataxic caws and cases o f atonic diplegia.

A Frequent Factor in the Origins of Primary Nocturnal Enuresis: Anxiety in the Third Year of Life

Primary nocturnal enuresis is not always due to the same cause and often several factors contribute. As the child grows older, the factor mainly responsible for his enuresis usually changes. The various current explanations appear to apply only to minority groups. Primary nocturnal enuresis sometimes causes anxiety but it is not evidence of underlying psychological disorder.

Shufflers with Spastic Diplegic Cerebral Palsy: A Confusing Clinical Picture

Many perfectly normal children shuffle rather than crawl before walking, and the clinical features associated with the shuffling trait can mask the signs of spastic diplegic cerebral palsy. An analysis of case records covering a seven year period shows that cerebral palsy was diagnosed significantly earlier in children who crawled than in those who shuffled.

DEVELOPMENT OF PÆDIATRIC NEUROLOGY

Abstract The diagnosis and care of children with acute and chronic neurological disorders is a part of the work of all doctors who care for children. The investigation and treatment of children with rare, complex, or obscure neurological disorders can often only be undertaken in specialised units of paediatric neurology which have access when necessary to the special facilities of large neurological and neurosurgical and other units dealing primarily with adults. The continuing care of children with neurological disorders requires close cooperation between paediatric and community services. Both need to be increased to meet the needs of children. The facilities for undergraduate, vocational, and continuing training in developmental paediatrics urgently need to be increased. Every regional paediatric academic centre should have an academic paediatric neurology unit, providing clinical care, research, and teaching in developmental paediatrics and in the acute and chronic neurological disorders of childhood.

Good nipples promote successful breast feeding

Summary 1. For comfortable and successful breast feeding, easily protractile nipples are essential. 2. All nipples should be subjected to the special test for protractility. 3. Treatment with glass or plastic breast shields, properly carried out, practically guarantees a cure.

BREAST FEED FOR THE FIRST TWO MONTHS

THE wider interests of the modern paediatrician suggest to him that the significance of breast-feeding for optimum development may be a good deal greater than seemed apparent when his interests were limited to ensuring a rapid weight gain. This rapid weight gain must come under review because of animal experiments which showed that the faster the rate of gain in weight in the early weeks the shorter the life span. The shortening of life span was due to a higher incidence of cancer, lung infections and arterial disease in middle age. The bad effect was especially notable on a diet of high protein content (see review by MAC KEITH’~) which leads the doctor to remember that cow’s milk has double the protein content of breast-milk. More on this below. Another oblique reminder that early feeding may be important is that the early basis of communication in the human species appears to be involved with feeding. If we compare the foal’s or lamb’s feeding with that of the human infant, the compulsive fixation of his mother’s face during feeding (GOUCH~) by the latter strongly suggests that the feeding situation may be an interpersonal dialogue with implications for optimum development of communication. What is happening about breast-feeding today? Mothers in most maternity wards today are, it seems, expected to bottle-feed their babies, little effort being made to encourage or to give efficient help to those who are undecided or even to those who want to breast-feed. The interest of the nurses is in the processes of parturition and the paediatrician is preoccupied with the niceties of care of tiny infants. Yet, in a series of 2,847 mothers, SEDGWICK~~ found that 96 per cent were able to breast-feed, and the presence of a ‘lactation nurse’ in the lying-in ward can double the proportion of women successfully breast-feeding their babies for several month^.^ The present position is that mothers do not want to breast-feed and the reason is that it is unfashionable. Why has it become so widely unpopular? Backed by the inexhaustible tin can, bottle-feeding is more often an easier method to get going and the bottle offends modesty less than does a naked breast. Young mothers have not seen breast-feeding and, like primiparous primates giving birth in zoos, they have to be shown how to do it; this piece of behaviour is not handed on in the DNA and, if the art has not been demonstrated in the parentcraft teaching, the mother, feeling ignorant and fearing failure, may opt for the bottle. The arguments for breast-feeding are cumulative rather than emphatic. In epidemic diarrhoea of the newborn, the breast-fed have a low mortality4* 13* l6 and the same is true of diarrhoea in older infants.6 Neonatal tetany occurs only in bottle-fed babies. 2 * Obesity is far less common in breast-fed b a b i e ~ , ~ and obesity in infancy is liable to persist into adult life.’ Jn adults, ulcerative colitis is less common in those who were breast-fed. After six to ten months on cows’ milk there is half as much calcium again in the infant’s body as there is after breast-feeding and twice as much protein.17 This may not be ‘A Good Thing’, to use the terminology of’the history book ‘1066 and All That’, for in rats a high protein diet in the early weeks of life is associated with a higher incidence of cancer, arterial disease and lung infection in middle age. This is a trio which has an unpleasantly familiar

INFANTILE SPASMS AND HYPSARRHYTHMIA OR HYPSARHYTHMIA

FOR the very unusual type of EEG record found in certain cases of infantile spasms it is useful to have a name, and many have used the word ‘hypsarrhythmia’ and restricted its use to the EEG. It has become customary in some circles to speak of infantile spasms with hypsarrhythmia. The origin of this term appears to be as follows. In 1952 Dr. Frederic A. GIBBS~ coined a word ‘hypsarhythmia’ (with one r) for the syndrome of infantile spasms with which a very bizarre EEG is commonly associated. He now explains that he intentionally did not employ the usual usage of a double r because the word had implications extending beyond its Greek roots. In a letter to the Editor of Dorland’s Medical Dictionary in September, 1963 he offered the following definition of it: H YPSARH YTHMIA, an electroencephalographic abnormality of injants characterized by random, high-voltage slow waves and spikes which arise from multiple foci and spread to all cortical areas. This disorder is usually associated with spasms or quivering spells and is commonly followed by mental retardation. A writer may use any existing word in any way, provided he makes clear what he is using it to mean, but he is usually wiser to adopt the currently accepted meaning and use because he will be more easily understood and will not create confusion. Similarly, a word may be coined on original lines, but neologisms are usually more helpful if common usages are followed. It seems rather a pity that when he devised a new word for the syndrome, Dr. GIBBS employed the word hypsarhythmia with one r, because in its pronunciation it is indistinguishable from the potential word hypsarrhythmia. This 2-r version in fact rapidly came into circulation as indicating the type of EEG commonly associated with ‘hypsarhythmia (sic, Gibbs 1952)’. The position is now that there are two words of identical pronunciation in circulation. We suggest that the syndrome be known as ‘salaam spasms’ or ‘infantile spasms’, and the bizarre EEG as ‘hypsarrhythmia’. RONALD MAC KEITH

JOURNAL OF CHILD PSYCHOLOGY AND PSYCHIATRY AND ALLIED DISCIPLINES

central nervous system, and they call this ‘dentochronology’. They also suggest that a study of dental morphology might help in the detection of other developmental abnormalities throughout the body, a subject they name ‘odontoglyphics’. It seems, though, that a great deal of further investigation will be needed to link any particular dental abnormality with a particular systemic condition, and that any association between the frequency of dental defects and level of intelligence is extremely unlikely.

EXCELLENT WORK, BUT UNFAIR TO VISION AND HEARING

7. 8. Locksley, H. B. (1966) ‘Natural history of subarachnoid haemorrhage, intracranial aneurysm and arteriovenous malformations.’ Journal of Neurosurgery, 25, 219. Pakarinen, S. (1967) ‘Incidence, aetiology and prognosis of primary subarachnoid haemorrhage, A study based on 589 cases diagnosed in a defined urban population during a defined period.’ Acta Neurologica Scnndinavica, Suppl. 29. Dodge, H. W. (1956) ‘Cephalic bruits in children.’ Journal qf Neurosurgery, 13, 527. Matson, D. D. (1969) Neurosurgery in Infancy and Childhood. Springfield, Ill.: Charles C Thomas.