New long-stay patients in a hospital for mental handicap

Better Services for the Mentally Handicapped (1971) forecasts a diminution in the number of beds in hospitals for mental handicap. It can be achieved only by the admission of fewer new long-stay patients. This paper considers 50 new long-stay cases admitted to a hospital for mentally handicapped in the five years 1970 to 1974. Of these admissions 42% were children, and of all the admissions 54% had Wechsler intelligence quotients under 25. Further, 62% of the admissions were for behaviour problems and 38% were for physical infirmity and helplessness. It is concluded that there are some mentally handicapped people who have problems with which only a hospital can cope. The high nursing dependency and the profound mental retardation of a majority of the new long-stay patients present a formidable challenge.

Lissencephaly

The first reported case of lissencephaly resulting from a consanguinous union strengthens the supposition that in some cases, it is transmitted as an autosomal recessive trait. Comparison of this case with a sporadically occurring case of lissencephaly, with different cortical morphology, suggests that lissencephaly may be an example of either varying gene expressivity or genetic heterogeneity. Lissencephaly and pachygyria may eventually be shown to be due to different causes, some inherited, some acquired. The classical examples of lissencephaly are different morphologically from a case in which antenatal cytomegalovirus infection had produced a small smooth brain. This suggests that antenatal viral infections are destructive rather than teratogenic.

Antenatal infection: adequate protection against hyaline membrane disease?

It has been argued that fetal and placental infections decrease the incidence of hyaline membrane disease (HMD). However, others contend that this is not so. We performed a rigidly controlled clinicopathologic investigation of one group of infants with evidence of severe antenatal infection compared with another group free of infection. This study shows that placental infection correlated positively with neonatal sepsis and that in this series of patients neither infection nor prolonged rupture of membranes is associated with a decrease of HMD. Our data do not support the proposal that antenatal infections protect the neonate against later development of HMD.

Pre-, peri- and postnatal prevention of major neuropediatric handicaps

Actual preventive aspects on major neuropediatric handicaps -- particularly cerebral palsy and severe mental retardation -- are surveyed. Based on Swedish epidemiologic studies on the changing pattern through 1954--70 it has been possible to conclude that postnatal preventive measures are largely completed, and that perinatal brain damage syndromes have significantly decreased, while prenatal mechanisms now dominate and still constitute mainly unsolved problems. The study has convincingly revealed that modern neonatal intensive care does pay and has given favorable gains not only in surviving but in undamaged babies.

[Results of a follow up study of small for date babies. II. Mental development (author's transl)]

The second part of the follow-up investigation of 74 small for date babies presents the results of neurological investigation and psychological testing. A correlation was found between the period of the intrauterine noxa and the results. A third of the children in group I (where the intrauterine influences were more severe and more prolonged) had an IQ below average. Minor cerebral damage, poor school performance and mental disturbance were significantly more common than in group II. The EEG-investigation did not contribute additional information. In both groups social factors had an important influence.

[Results of a follow up study of small for date babies. I. Physical development (author's transl)]

74 small for date babies were investigated at the age of 10 years. The first part of the paper deals with the children's physical development and state of health. An attempt to correlate the degree of intrauterine malnutrition and postnatal development was made taking into account possible etiological factors, genetic, pre- and postnatal influences. Four children who had been exposed to several harmful intrauterine factors showed general developmental retardation. All the other childrens demonstrated normal physical development including the group who had shown signs of prolonged intrauterine malnutrition.

Spontaneous uterine rupture in cattle; a review of 26 cases

The clinical features of uterine rupture in 26 cows are reviewed. In 12 animals, the foetus was still mainly or entirely within the uterus but in the remaining 14 it was displaced into the peritoneal cavity. Apparent predisposing causes suggest that the condition is usually secondary to some other form of dystocia.

[Functional organization of the sleep state in infants under normal conditions and in brain damage]

Polygraphic study of day sleep was carried out in 30 nurslings with consideration to the EEG, oculogram, muscle tone indices, variations in skin resistance, respiration, ECG, rheoencephalogram and rheogram of the calf. Nurslings with cerebral affections of perinatal genesis were examined by the same method. It was possible to distinguish the main stages of slow sleep and stages of rapid sleep in young nurslings, although the electroencephalographic expression of the stages in children had its specific features. Age dynamics of the polygraphic picture of sleep showed electroencephalographic, vegetative and motor components of sleep to distinctly coordinate by stages and, at the same time, to possess marked autonomicity; this was also confirmed by analysis of cerebral pathology.

Multiple cystic and focal encephalomalacia in infancy and childhood with brain stem damage

Two cases are described in which damage to the brain stem was associated with extensive necrosis of the cerebral hemisphere. In the first case--a monochorionic twin--there was clear evidence that injury of an ischaemic or hypoxic type had occurred during fetal life and some evidence that an inadequate share of the placental circulation was an important aetiological factor. In the second case death occurred 4 yr after an asphyxial episode at birth. The lesions in the hemispheres and brain stem were extensive, although less than in the first example. The lesions are discussed in the context of our knowledge of the anatomy and physiology of the developing nervous system. Although they cannot as yet be fitted into the concepts of "critical periods" and "vulnerable periods" of development, this is perhaps because observations on human cases are scanty in comparison with the extensive animal studies which have been reported. The lesions are contrasted and compared with those seen in animals.

Significance of meconium during labor

Continuous fetal heart rate (FHR) monitoring and routine fetal scalp blood sampling was utilized in the evaluations of 366 fetuses during labor. One hundred and six patients had meconium in the amniotic fluid at some time during labor. A total of 26,110 uterine contractions were monitored during these 366 labors. The incidence of FHR patterns as a percentage of uterine contractions was calculated for the meconium and nonmeconium groups. Although there was a 3 1/2-fold increase in the incidence of low five-minute Apgar scores (less than 7) in the meconium group, signs of fetal distress were, with rare esception, not significantly different from those in the nonmeconium group. The presence of meconium in the amniotic fluid without signs of fetal asphyxia (late decelerations and acidosis) is not a sign of fetal distress and need not be an indication for active intervention. The combination of fetal asphyxia and meconium staining of the amniotic fluid, however, does enhance the potential for meconium aspiration and a poor neonatal outcome. Universal fetal heart rate monitoring and appropriate fetal acid-base evaluation is recommended for following patients with meconium in the amniotic fluid during labor.

[Triploidy as a cause of midtrimester gestosis(author's transl)]

The authors report a case of triploidy in a prematurely born child. The pregnancy was complicated by severe toxemia beginning during the second trimester and terminating in preeclampsia leading to cesarian section in the 33th week of gestation. The externally female child was underweight, hypotonic and asphyctic and died shortly after birth. She exhibited a complex brain malformation including excessive hydrocephaly, cebocephaly and aplasia of the piturary gland, and multiple dysmorphic signs. Autopsy revealed hypoplasia and dysplasia of the adrenal glands; no uterus, tubes and ovaries were present, but no testes were found. The placenta showed localized hydatidiform degeneration and was relatively large. The karyotype was 69,XXY, and with the aid of fluorescence markers, paternal origin of the additional haploid chromosome set was demonstrated. Typical findings in pregnancies with fetal triploidy are discussed and the possibility of prenatal diagnosis of triploidy by chromosome analysis in cultivated amniotic fluid cells is pointed out.

The effect of intrauterine hypoxia on the child surviving to 4 years

Intrauterine hypoxia/asphyxia is an unchallenged cause of perinatal death, but whether sublethal degrees of hypoxia result frequently in brain damage in surviving infants is less certain. To test this hypothesis, obstetric patients with abruptio placentae, placenta previa, and prolapse of the umbilical cord were computer matched on several factors with normal control patients to determine the degree of risk of lower 4 year Stanford-Binet I. Q. scores or abnormalities on the 4 year fine motor and gross motor testings. The mean I. Q. score of babies born of mothers with one of these complications was no different from that of the normal controls. Similarly negative results were recorded on the 4 year fine motor and gross motor testings. Children of low birth weight in either group experienced lower I. Q. scores and higher risk of abnormal findings on the motor tests at 4 years than the babies of mature birth weight. Intrauterine hypoxia/asphyxia apparently is not a major cause of neurologic dysfunction in the surviving child.

[The valence of genetics and exogenous factors in epilepsies of childhood (author's transl)]

Exogenous and genetic factors must be taken into consideration in the etiology of epilepsy. Exogenous lesions may arise pre-, peri- or postnatally. The effect of genetics on the etiology has previously been suggested by a markedly increased familial occurrence of epileptic patients with seizures, investigations of twins and the occurrence of attacks in demyelinating diseases and congenital metabolic disorders. A modern method of examination in epileptic patients is the electroencephalographic family investigation. The results obtained in examinations by this method are described.

Clinical characteristics of pregnancies complicated by intrapartum fetal asphyxia

The clinical characteristics of 124 pregnancies complicated by intrapartum fetal asphyxia have been reviewed. The evidence of fetal asphyxia tends to appear earlier in patients with maternal medical and obstetric complications than in those with labor complications. Evidence of clinical fetal distress was present in 36 per cent and was not related to the severity of the asphyxia. Low Apgar scores occurred in 40 per cent of infants with moderate asphyxia and in 80 per cent of infants with severe asphyxia at delivery. In the newborn infants, clinical evidence of cerebral abnormality was observed in 3 per cent, and evidence of the respiratory distress syndrome was seen in 3 per cent of the study group.

Possible role of the fetal adrenal glands in the etiology of postmaturity

Plasma cortisol levels were studied in the cord blood and neonatal blood of the following vaginally delivered groups: (A) postmature; (B) postterm (but not postmature); and (C) term neonates. Significantly lower levels of 8 A.M. neonatal plama cortisol were found in postmature neonates when compared with term neonates (P LESS THAN 0.02) or merely postterm neonates (P LESS THAN 0.02). No difference was found in the cord blood cortisol levels in all three groups. Contrary to the traditional belief that postmaturity results from placental aging, our findings appear to indicate that postmaturity represents a specific fetal disorder. Fetal adrenal insufficiency may be a characteristic of this disorder. Prolonged pregnancy in these cases may be reflected inability of the affected fetus to initiate labor.

Brain hypoxia, minimal brain dysfunction, and schizophrenia

The author hypothesizes that individuals who suffer brain hypoxia prenatally, perinatally, or immediately postnatally constitute a population at risk for minimal brain dysfunction and for schizophrenia in adulthood. This hypothesis has implications for early intervention with children who have MBD and their families and for multidisciplinary management of these cases throughout childhood.