the early manifestations diplegia in ·

THE EARLY MANIFESTATIONS AND COURSE OFDIPLEGIA IN CHILDHOOD

BY

T. T. S. INGRAMFrom the Department of Child Life and Health, Univerity of Edinburgh

(REcEnvED FOR PUBLICATION OCTOBER 21, 1954)

During a recent survey of children suffering fromcerebral palsy in Edinburgh it was found thatdiplegia was relatively infrequently diagnosed beforethe age of 2 years. The average delay between thedoctor seeing the child for the first time, on accountof manifestations of diplegia, and the diagnosisbeing reached was over one year. The classicalpicture of diplegia presented in the textbooks is ofa child affected by rigidity, spasticity and contracturesof the limbs, and only when these features werepresent was the diagnosis made in the majority ofpatients. Yet the symptoms and signs of theearlier stages of diplegia are typical and shouldenable the diagnosis to be made in most patientslong before contractures have occurred. In thepresent paper the early manifestations and courseof diplegia will be discussed.The terminology and classification used during

the survey has been described in an earlier article(Ingram, 1955). The term diplegia is used todescribe a condition of more or less symmetricalparesis of cerebral origin, more severe in the lowerlimbs than in the upper and dating from birth orshortly after. Mental deficiency, epilepsy andstrabismus are frequently associated findings.Patients suffering from diplegia associated withcerebellar ataxia are not considered in this article.

The Case MaterialThe findings described in the present article are

those of 79 patients with diplegia who were ascer-tained during a survey of children suffering fromcerebral palsy in Edinburgh during 1953. Theyvaried in age from a few weeks to 15 years andincluded 49 males and 30 females, figures which givea similar sex distribution to that found by Asherand Schonell (1950). The cases were ascertainedfrom a very large number of sources and theincidence found was 0 75 cases of diplegia per 1,000of the population under the age of 15 years. Thisfigure is somewhat higher than similar incidence

figures obtained by other regional surveys. Itseems probable that the patients may be regardedas being representative of children suffering fromdiplegia in the community.The diplegia was thought to be of congenital

origin in all but one of the 79 patients, and the firstmanifestations had been noted in 64 by parents orguardians before the children were 18 months old.Fifty-eight of these patients were taken to theirdoctors before this age, yet the diagnosis wasreached in only 18 by the age of 18 months and in45 by the age of 2 years. In 14 patients the diagnosiswas reached only when the child was over 4 yearsold (Table 1).

TABLE IAGES AT TIME OF FIRST SIGN OF ABNORMALITY, THECORRECT DIAGNOSIS, FIRST VISIT TO DOCTIOR ANDFIRST CLINIC REFERRAL IN 79 PATIENTS WITH DIPLEGIA

FirstAbnormality First First Correa

Age Noted by Visit to Clinic DiagnosisParents Doctor Referral

Under 6 months 31 23 8 3Over 6 months,

under I year . . 23 10 12 1Over I year, under

18 months 10 25 12 14Over 18 months,under 2 years 11 12 12 27

Over 2 years,under 4 vears 2 7 26 19

Over 4 years 0.0 0 8 14Unknown 2 2 1 1

Totals 79 79 79 79

The Stages of DilegiaThe majority of patients with diplegia do not

show the classical picture of muscular rigidity orspasticity until some time after birth. In fact, afterthe immediate effects of marked prematurity or birthtrauma have worn off the babies are frequentlyregarded as being normal. even when carefullyfollowed up by infant clinics. That there should bea delay, sometimes of months, in the appearane ofdramatic symptoms and signs has led some authors

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to state that diplegia is frequently a condition ofpost-natal aetiology.

Unfortunately few of the classical authors studiedthe early stages of diplegia closely, though a fewshowed some interest in its early manifestations(Little, 1862; Parrot, 1873; Lovett, 1888; Osler, 1889).More recently, however, increasing attention has beenfocused on the nature and significance of posturalreflexes which are transiently present in normalinfants but which tend to persist, sometimes foryears, in children suffering from diplegia. It hasbeen increasingly realized that the neurologicalfindings, and especially the postural reflexes, changeas the patient grows older and as his nervous systemmatures (Bobath and Bobath, 1950).The change from the infant of a few weeks old

who shows little demonstrable abnormality onneurological examination to the child 2 or 3 yearsold with flexion contractures of all four limbs is agradual one. But the sequence of changes thatoccurs in the neurological findings marking thechild's progress to this crippled state is remarkablyconstant. For the purposes of description threestages may be recognized in the gradual develop-ment of this final picture of spasticity with con-tracture of the limbs: the hypotonic stage, thedystonic stage and a third stage in which rigidityand spasticity are present together in varyingdegree.

The Hypotonic Stage. In the first few weeksafter birth the majority of children with diplegiashow little obvious abnormality related to theneurological disorder. From the mothers orguardians of the 79 patients in the present series,however, a history was obtained in 31 which sug-gested that the infants were hypotonic in the firstweeks after delivery. 'His head flopped all overthe place.' 'He felt like a half-filled pillow forweeks and weeks', were typical comments. At thesame time a high proportion of patients were noted toshow a marked poverty of movement. The child

would retain any position in which he was laid downfor many hours. 'He was so still, you wouldn't thinkhe had breathed all night,' said one mother.

Five diplegic patients have been examined in thestage of hypotonia; one of these is included in theseries and four are excluded, because they livedoutside Edinburgh or were born after the surveywas completed. Poverty of movement was observed,especially in the trunk and proximal parts of thelimbs. Apart from small-range, feeble finger move-ments, the patients were very still. On passivemovements of the limbs and when the children wereheld in the arms generalized muscular hypotoniawas evident. In all five children the Moro responsesand grasp reflexes were more clearly defined andeasily elicited than in normal children. The tonicneck reflexes were not exaggerated, and appearedto be less marked than normal in two of the patients.The duration of the stage of hypotonia is veryvariable and patients were encountered in this stagewhose ages varied from 6 weeks to 15 months. In28 of the 31 patients in whom a history of a hypo-tonic stage was elicited it lasted between six weeksand six months.

The Dystonic Stage. At about the time thediplegic child first attempts to hold up the head achange occurs in this picture of little apparentabnormality. The mother finds that when shechanges the child's position abruptly, especiallywhen dressing or washing him, he suddenly becomesstiff in her arms. The neck and back are extended.The upper limbs are adducted and internally rotatedat the shoulder, extended at the elbows, pronatedat the forearms and semiflexed at the wrist andfingers. The lower limbs are extended, adductedand somewhat internally rotated at the hips,extended at the knees, plantar flexed at the anklesand flexed at the toes (Fig. 1). This position,essentially one of opisthotonos, is achieved by asudden dystonic movement of the trunk and neckassociated with extensor movements of the limbs.

FiG. 1.-The position assumed during dystonic attacks by a severely affected dipkegic child aged 15 months.

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The position is maintained for only a few seconds,during which time the tone of the muscles is verygreatly increased and the whole child is rigid.Sometimes there appears to be a slight impairmentof consciousness during the attacks but it is neverlost. Initially the attacks occur only once or twicea day, but over the course of one or two weeks theirfrequency increases. They become more easilyproduced and may occur as often as 20 or 30 timesa day, greatly distressing the child. Frequentlydystonic attacks are diagnosed as being epileptiformbut they respond to none of the commonly usedanticonvulsive drugs.On examination at the height of the dystonic

stage, it is usually found that the child is beginningto hold up the head, but is still unable to hold itsteadily. He makes little attempt to reach forobjects and poverty of voluntary movement is stillevident. The tone of the limbs remains hypotonicat rest. The grasp reflexes are brisk. With carenot to extend the head suddenly the Moro responsesmay be demonstrated in most of the patients. Whenthe child is held vertically there is rigid increase oftone in the limbs. This is more marked in thelower than in the upper limbs. The lower limbsshow a position of extension at the knees and plantarflexion at the anldes. The hips are adducted,slightly internally rotated and may show a positionof full extension or of a few degrees of flexion. Thelegs may scissor. When the child's head is brisklyextended, or he is suddenly rotated into the hori-zontal position from the vertical, supported by ahand in the small of the back, there is a suddengross increase of tone in the trunk and limbs,associated with a quick, writhing, dystonic move-ment of the trunk. The limbs extend and a positionof opisthotonos is assumed for a few seconds. Thisposition corresponds exactly with that described bythe mothers as resulting from changes in theposition of the child when she handles him.

After a variable period the dystonic attacksbecome less easily produced and less frequent. Inthe majority of patients the generalized dystonicattacks are present for between two and six months,but in others the period may exceed one year. Asthe attacks begin to be less frequent the mothernotices for the first time that the limbs are constantlyrigid. This is first evident in the thigh or calfmuscles and she may find that she has to use forceto separate the thighs when placing the napkin, oreven pass it between them on the end of a pencil.When she washes the lower limbs they feel stiff andunyielding. In the course of a few weeks the rigiditybecomes increasingly evident and spreads to involvethe upper limbs in triplegic and tetraplegic cases.

On examination during the period when dystonicattacks are waning a constant muscular rigidity isfound, which is more severe in the lower limbs thanin the upper. In the majority of patients suddenextension of the head still gives rise to a typicaldystonic attack. In a few patients, however, it isnecessary to extend the head and put pressure onthe soles of the feet before dystonia is produced.When the child is made to exert himself, or isdistressed, the affected limbs tend to assume extensorpositions even if true dystonic movements of thetrunk have ceased to occur.During the survey six patients were classified as

being in the dystonic stage of diplegia. Anotherseven with dystonia have been seen who are notincluded in the survey. In all, the essentiallyopisthotonic position described above could beproduced by suddenly extending the head andputting pressure on the soles of the feet. Of the79 children with diplegia in the survey, 39 hadevidence of having had dystonic attacks, either inthe history or on examination. It was noted thata history of dystonia was found much less frequentlyin older children than in younger and it is probablethat if mothers' memories had been longer a greaternumber of patients who had had dystonic attackswould have been ascertained.

The Phase of Rigidty. The third stage of diplegiais conveniently divided into two phases for thepurposes of description, first the phase of rigidityand secondly the phase of spasticity.As has been described, the phase of rigidity

emerges gradually from the stage of dystonia andfor a period, as rigidity increases in extent andseverity, dystonic attacks persist. Somewhat arbi-trarily the phase of rigidity may be said to begin,for purposes of classification, when generalizeddystonic attacks involving the neck, trunk andlimbs cease to occur as a result of changes in thechild's position. This is usually about the time heattempts to sit with support with the knees flexedand is beginning to use the upper limbs in order toreach for objects. The parents notice that theattempts to grasp are clumsy and that the childappears to hold toys at arm's length with theaffected upper limbs extended. In the majority ofthe patients in the series generalized dystonicattacks ceased between the ages of 5 and 12 months.On examination children with predominant

rigidity show clumsiness of voluntary movements.Manipulations with the hands are immature in type,all the fingers being used together as a unit opposedto the palms. The limbs tend to be held in positionsof mild extension at rest, but this tendency is greatly

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increased by exertion, the performance of voluntarymovements, extension of the head or pressure onthe soles of the feet, especially when the child is helderect. When an affected upper limb is movedvoluntarily it tends to adduct at the shoulder,extend at the elbow, pronate at the forearm andflex at the wrist and fingers. This is the reasonfor the impression that the child is holding objects

2. ,

I--'.~~~~~~~~~-

FiGs. 2a and 2b.-Tetraplegic children, aged 4 and 6 years respectively,showing the extended positions assumed by the limbs in the phase

of rigidity.

at arm's length. If the contralateral limb is alsoinvolved it too will show a tendency to attain asimilar position to the operating limb and the lowerlimbs also extend. Thus associated movements ofextension are present in all the other limbs when oneis used and in all the limbs involved when the childexerts himself by straining or attempting to changehis position. These associated movements aresimilar to those observed in the limbs during theearlier dystonic attacks. In the latter, however,the neck and trunk also took part and the involun-tary movement was more rapid, more extensive andmore powerful. In the stage of rigidity theinvoluntary postural activity appears to become

more inhibited. Nevertheless it is found that themanoeuvres which were most potent in causingdystonic attacks at the earlier stage are also thosewhich produce associated movements of limbextension most readily. When the child is held inthe vertical position great rigidity of the lower limbsis evident and they are held scissored and eitherextended at the hips or in a few degrees of flexion.The knees are extended, the feet plantar flexed.The rigid increase of tone in the upper limbs is lessaccentuated and their positions may not be markedlyconstrained. If the feet are placed on the floor,however, or pressure is applied to the soles of thefeet, the involved upper limbs immediately assumea position similar to that found during the earlierdystonic attacks.

Involuntarily the child tends to hold the headwell forward with the neck flexed. The maintenanceof this position minimizes the danger of sudden headextension occurring, with its consequent reflexextension of the limbs and disturbance of posture(Fig. 2). Walking tends to be impossible for a longtime, because this involves pressure on the soles ofthe feet and whenever a step is taken some extensionof the neck is almost inevitable. As a result there isinvoluntary extension of the lower limbs and some-times the back, which makes the child lose hisbalance and is the origin of the extensor thrust,noted by physiotherapists, which may last even intothe phase of predominant spasticity. The childrenusually learn to sit without support with the kneesflexed, though not with them extended during thephase of rigidity. Any excessive exertion, however,is liable to result in extension of the lower limbs sothat if the child is on a chair he is dragged forwardsby pressure of the back of the thighs on the chairedge and pulled to the horizontal position.

During the predominantly rigid phase of diplegiathe tendon jerks are usually sluggish and difficult toelicit. The Hoffmann responses are not obtained,and the true Babinski response is hardly ever found.The tonic neck reflexes are positive, but extensionof the limbs is much more readily produced thanflexion. The grasp reflexes are usually present.The Moro response may be sluggishly present in afew patients but it is never brisk and in the majorityit disappears completely during the stage ofrigidity.

The Spastic Phase. This phase is apparent onlyafter rigidity of the muscles has been present forsome weeks or months. In some spasticity appearsonly after the child has shown predominant rigidityfor many years. Its onset is insidious and is usuallyapparent about the time the child is beginning to

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use the thumb and fingers a little and has learnt tosit without support with the knees flexed. Usuallyattempts to pull himself into the erect position followshortly after this time.The first evidence that spasticity has made its

appearance is commonly a change in the nature ofthe associated movements of the limbs which resultsfrom voluntary activity or exertion. Over a periodof a few weeks the parents notice that instead ofbeing straight the upper limbs tend to be flexed andthat all movements are less clumsy and jerky, thoughLhey may be slower than before. A grandmothernoted, 'His arms used to look as if they'd been puton the wrong way round but then they became allbent up'. The same tendency to flexor positionsrather than extensor positions becomes apparent inthe lower limbs as in the upper. Unless the child isencouraged in all activities at the stage of earlyspasticity, especially standing and walking withsupport, flexion contractures rendering movementimpossible can ensue in a few weeks. One nurse inan institution for the mentally defective sunimarizedthe position when talking of a bedridden tetraplegicpatient, 'First he was too daft to move and now hecan't'.On examination the findings in patients showing

spastic increase of tone in the limbs depend verymuch on the relative severity of rigidity and super-imposed spasticity in the individual patient. Inpatients who remain rigid, associated movementswill remain extensor in type, and in patients whoshow early spasticity flexor associated movementsmake an early appearance. In the majority ofdiplegic patients, however, there is a transitionalperiod during which spasticity is increasing in thelimbs and the associated movements are neithertypically extensor nor typically flexor.By the time spasticity is well marked in the limbs,

not only are the associated movemfents pre-dominantly flexor but there is also a tendency forthe child to hold the limbs in flexed positions at rest.These positions become exaggerated when the childexerts himself. Thus when he walks or attemptsto walk there is flexion of the fingers, wrist andelbows, adduction of the thumbs, pronation of theforearms, and adduction and internal rotation ofthe shoulders in the affected upper limbs. Anincrease of flexion at the hips and knees, adductionof the thighs and plantar flexion also become evident.The typical walking position of the tetraplegic childresults. The legs are scissored, the knees are semi-flexed and the heels are not placed to the ground.The child appears to be leaning forwards with theupper limbs flexed across the chest (Fig. 3). Whena spastic upper limb is used for grasping athetosis

is sometimes evident in the fingers and wrist, thoughthis is not usually marked. Both in the operatingand contralateral upper limb the flexor associatedmovements tend to be most marked at the distaljoints in contrast to the extensor associated move-ments of the rigid phase, which are most marked inthe proximal parts of the limbs.The tonic neck reflex is very marked in the

3. 33FIGs. 3a and 3b.-Tetraplegic children, aged 10 and 15 years respec-tiv.ely, showing the flexor associated movements and contractures of

the limbs in the phase of predominant spasticity.

majority of patients in the spastic phase and bothflexor and extensor positions of the upper limbs arereadily demonstrable in triplegic and tetraplegiccases. The Moro response is absent and the graspreflex present only occasionally. The tone of thelimbs, and especially of the lower limbs, is a mixtureof rigidity and spasticity, which gives rise to a verytypical feel when they are moved passively. Stretchresponses may be demonstrated in the muscles ofthe affected limbs, first and most easily in theadductors of the thighs and in the calf muscles. Thetendon jerks are exaggerated, always to a greaterextent in the lower limbs than the upper, and ankleand patellar clonus is frequent. The Hoffmannresponses are frequently positive. The plantarresponses are extensor bilaterally.Once spasticity is evident, contractures in flexion

are very liable to occur in the affected limbs (Fig. 3).Contractures give rise to an increase of rigidity

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which is accentuated as the limbs are moved pas-sively from the flexed to the extended position, whilethe earlier rigidity of the limbs tended to be constantthroughout the range of passive movement. Thecontracture is most likely to be severe in the lowerlimbs in diplegic patients, and it results, when severe,in a great diminution of the stretch reflexes and thetendon jerks. In those all too numerous patientsin whom repeated tendon lengthenings, muscletransplants and joint fixations have been performed,the true neurological findings may be further con-cealed.

The Relationship of the Stages of Diplegia to EachOther

The importance of recognizing that the findingsin diplegia change in a regular manner as thecondition develops is that this leads not only toearlier diagnosis, but also to better understandingof some of the variations which are encountered inthe final clinical picture. The stages of diplegiamark definite milestones in the development of thechild's motor control. Thus a child who showsdystonic attacks at the age of 4 years and is, there-fore, in the stage of dystonia, must be regarded asshowing a very immature motor control. On theother hand, a child in the phase of spasticity haspassed through all the stages of diplegia and hisneuromuscular mechanisms may be regarded asbeing more mature, though still disordered. Unlessseverely affected by contracture, he will be capableof much more in the way of controlled voluntarvmovement of the limbs than any patient in the stageof dystonia.The findings in the different limbs of patients with

diplegia are not always those of the same stage.Thus it is quite common, even in children aged 10or 12, to find that one limb is predominantly rigidwhile the other limbs are predominantly spastic.The child who holds one arm behind his back in theextended position in order to limit the range of itsinvoluntary postural movements while walking andholds the other like a hemiplegic arm across hischest is not uncommon. Almost invariably thespastic limb is the more useful, unless contractureis severe.

It must be stressed that the stages of diplegia aredetermined by the relative maturity of the child'snervous system much more than by age. Thus onechild was seen at the stage of hypotonia at the ageof 2 years and one showed spastic diplegia at theage of 10 months. Nevertheless it is of some valueto indicate the ages at which the majority of patientsshow the different stages. Of the 79 children in thepresent series, a history suggestive of hypotonia

was elicited in 31. In 20 of these this stage lastedless than six months, and in 11 less than four monthsfrom the time of birth. The dystonic stage wasnoted in 39 patients. In 29 of these, it was evidentbefore the age of 6 months and in eight between theages of 6 months and 1 year. Only two patientsgave a history which suggested that the dystoniahad begun over the age of 1 year. The duration ofthe dystonic stage was unknown in four patientswho were still showing dystonic attacks when thesurvey closed. In the remaining 35 patients it lastedless than six months in 19 patients and between sixmonths and one year in 11. In five patients theduration of the stage of dystonia was over one year.The age at which rigidity was first evident variedfrom 10 weeks to three years. In about half ofthe 72 rigid or spastic patients in the survey, nohistory of a previous dystonic stage was elicited,though that is not to say that it had not beenpresent.As has been noted, a few patients showed per-

sistent rigidity throughout their lives withoutspasticity being superimposed upon this stage. Asmall number of patients appeared to developspasticity at a relatively early age without a historyof either previous dystonia or rigidity. The majorityof patients, however, showed the sequence ofstages-hypotonic, dystonic, rigid and spastic-which hasbeen described. It was, therefore, much more usualto encounter cases showing mixed rigid and spasticincrease of tone in the limbs than cases showingonly rigidity or spasticity.The age at which spasticity was first evident w;

even more variable than the age at which dystoniaor rigidity first appeared. It was unusual to findspasticity before the age of 8 months, and in themajority of patients it made its first appearancebetween the ages of 10 and 18 months. On theother hand, the speed with which contracture couldcripple the child with spastic diplegia was remark-able. One child was unable to extend either elbowbeyond the right angle or pronate either forearm bythe age of 18 months, though spasticity had madeits appearance only at the age of 11 months so faras could be ascertained from the history.

The Course of Diplegia Related to the Extent andSeverity of the Paresis

The severity of diplegia in any case may beassessed roughly by considering the stage of thecondition reached at a given age and the extent ofthe limb involvement. As might be expected, thestages of diplegia are most manifest in patients withsevere tetraplegic involvement; they are much lessclearly defined in patients in whom the upper limbs

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are spared. In particular it is unusual to obtain ahistory of severe generalized dystonic attacks inparaplegic patients. It seems probable that this isdue to the fact that they are much slighter and theduration of the dystonic stage is shorter than inpatients with triplegic or tetraplegic involvement.In two paraplegic patients, not included in thesurvey, dystonic attacks were easily elicited bysudden head extension and pressure on the soles ofthe feet though in neither was a history obtainedwhich suggested that the children had shown adystonic stage. In one case dystonia could beproduced for only three weeks and in the otherfor only five. Clearly with slight attacks occurringfor such a short period retrospective history takingmust frequently fail.

In the present series of 79 patients with diplegia,there was evidence of a dystonic stage either in thehistory or on physical examination in 19 of the 27patients with tetraplegia, in 15 of the 23 patientswith triplegia and of the 29 patients with paraplegia.At the time of the survey one patient was in thestage of hypotonia, six in the stage of dystonia and72 were in the stage of rigidity or spasticity. Sincethe majority of the patients were seen on a numberof occasions it was possible to observe the progressionof some from stage to stage.

The Early Manffestations of DiplegiaIn Table 2 are indicated the commonest initial

TABLE 2NATURE OF FIRST NEUROLOGICAL MANIFESTATIONSRESULTING IN MEDICAL HELP IN 79 CHILDREN WITH

DIPLEGIA

Nature of the Manifestation No. ofPatients

Late milestones or suspected mental defect 20Poverty of movement or suspected paralysis ..9Dystonic attacks or intermittent rigidity of the limbs 10Persistent rigidity of the limbs 14Epilepsy .. . 14Suspected blindness 5Behaviour abnormality I

Other abnormalities 3Unknown 2

Total .79

manifestations of diplegia noted by the parents in79 patients in the present series. It is apparent thatin most cases these should have resulted in a fullneurological examination of the patient. If thepatient had been fully examined neurologically and

the effects of sudden extension of the head beeninvestigated with the child in the erect and supinepositions, the diagnosis of diplegia would have beenmade more frequently at an early age. If diplegiacould be diagnosed earlier, before the stage ofrigidity or spasticity, the danger of permanentdisablement being caused by contractures would belessened.

SummaryDuring a recent survey of children suffering from

cerebral palsy it was found that the average delayin a diagnosis of diplegia being made following thefirst visit to a doctor was over one year. This delayappeared to be due to ignorance of the earlymanifestations to be expected in diplegia befere thelate stage of rigidity or spasticity with contractures.The early manifestations of diplegia are described

as they were encountered during the survey. It issuggested that the majority of patients pass througha stage during which they show hypotonia and astage during which they show sudden generalizeddystonic attacks on changes of position beforerigidity or spasticity is evident. The stage ofdystonia seems to be of shorter duration and thedystonic attacks less marked in patients with para-plegic involvement than in those with triplegia ortetraplegia. It is suggested that the diagnosis wouldbe reached earlier in patients with diplegia if aneurological examination, including attempts toproduce dystonia, was made in every suspected case.

I am grateful to the many physicians and surgeons inEdinburgh who allowed me ready access to theirpatients and case notes. I must thank the staff of theScottish Council for the Welfare of Spastics for theirinterest and encouragement, especially Dr. Charles Balf,Dr. James Naughton and Miss E. I. Thompson. I amindebted to Mr. Clifford Shepley, artist to the Universityof Edinburgh, for his most artistic illustrations drawnfrom many photographs. Miss E. Cruickshank gavemuch secretarial assistance.The survey would never have been made without the

stimulation and guidance of Professor R. W. B. Ellis.I am most grateful to him, also, for his help in thepreparation of this paper.

REMUENE

Asher, P. and Schonell, F. E. (1950). Archives of Disease in Child-hood, 2.5, 360.

Bobath, K. and Bobath, B. (1950). Brit. J. phys. Med., 13, 121.Ingram, T. T. S. (1955). Archives of Disease in Childhood, 30, 85.Little, W. J. (1862). Trans. obstet. Soc. Lond., 3, 293.Lovett, R. W. (1888). Boston med. Surg. J., 118, 641.Osler, W. (1889). The Cerebral Palsies of Children. London.Parrot, J. (1873). Arch. Physiol. norm. path., 5, 59.

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