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European Journal of Neurology 2005, 12: 582587

REVIEW ARTICLE

A historical perspective on cerebral palsy as a concept and a diagnosis


A. Kavcic and D. B. Vodusek
Division of Neurology, University Medical Centre, Ljubljana, Slovenia

Keywords:

cerebral palsy, Littles


disease, Sigmund Freud
Received 16 July 2004
Accepted 4 August 2004

Sigmund Freud was the rst to write about cerebral palsy as a nosographic category,
uniting various infantile motor decits of brain origin. He did not ascribe more than a
temporary value to the term (infantile) cerebral palsy, but it has become and still is
an indispensable part of the nosographic system. Nevertheless, it is still easier to
explain what cerebral palsy is not than to dene it precisely.

Introduction
If a historical study of cerebral palsy (CP) is undertaken, it soon becomes apparent that not only are there
several denitions, but also a variety of interpretations.
The fact that CP has been known as a clinical entity for
over a hundred years (Freud, 1968), and is still to some
extent loosely dened (Badawi et al., 1998; Bax, 2001),
is surprising and, we think, worth considering.

Freuds analysis
In clinical practice, the term CP was often used interchangeably with the eponym Littles disease [after the
British orthopaedic surgeon who described spastic
diplegia, which he considered to be due to birth complications (Little, 1862)] for many years (Freud, 1968;
Russell and Kennedy, 1937; Fanconi and Wallgren,
1950). It was, however, Sigmund Freud [a promising
neuropathologist from Vienna who became a prominent psychiatrist (Ferris, 1998)] who rst wrote about
(infantile) CP1 as a nosographic category, uniting various infantile motor decits of brain origin (Freud,
1968).
In all previous publications on motor decit of children, the term CP, if it had already been used, had been
written either only in a plural form (Osler, 1987; Sachs
and Peterson, 1890) or, if in the singular, only in specic
combination with other words as a synonym for a
particular motor decit (i.e. infantile meningeal haemorrhage cerebral birth palsy, infantile hemiplegia
acute cerebral infantile palsy) (Gowers, 1888). Nevertheless, in the routine clinical practice of the second half
of the 19th century, (apparently) static motor decits of

Correspondence: Professor David B. Vodus ek, Division of Neurology,


University Medical Centre, SI-1525 Ljubljana, Slovenia (tel.:
+386 1 5221501; fax: +386 1 5222293; e-mail: david.vodusek@kclj.si).
1

The German term die infantile Cerebrallahmung used in the original


publication by Freud was translated into English as infantile cerebral
paralysis, although cerebral palsy was preferred at that time
(Bartram, 1964; Bobath, 1969).

582

children had to be labelled generally in the sense of a


medical diagnosis, for Freud in his monograph on
infantile CP wrote that the term infantile CP characterized what already has been applied over a long
period of time to pathological condition in which
paralysis is overshadowed or replaced by muscular
rigidity or spontaneous muscular twitching. (Freud,
1968).
Freuds concept of infantile CP was broader than
that formulated some decades later by other authors.
He actually suggested that this term should be applied
even to neurological cases in which paralysis was
completely absent, as, for example, in children with
mental retardation, or where disorders did not manifest
themselves permanently, such as epilepsy (Freud, 1968)
[what is very close to the concept of (early) brain
damage formulated much later (Amiel-Tison et al.,
1994)].
Freud probably decided to unite the various motor
decits of children in one nosographic category because
he did not nd any other alternative to bring more
order to the eld. This hypothesis is supported by the
fact that he had begun studying motor decits of children separately. First he researched cerebral hemiplegia
in co-operation with Oskar Rie (Freud and Rie, 1891).
Then, he considered the remaining motor decits of
children. He unied them into one clinical group,
termed cerebral diplegias, dened as those manifesting
a physical handicap of the whole body (i.e. both sides of
the body). Among these, he dierentiated four main
types: (1) general cerebral stiness, (2) paraplegic stiness, (3) bilateral hemiplegia, and (4) general chorea
and bilateral athetosis (Freud, 1893). Finally, he covered all these various motor decits by one nosological
entity, i.e. infantile CP (Freud, 1968).

Littles view
In the mid-19th century William John Little earned the
reputation of substantiating the causal relationship
between birth complications and disorders of mental
and physical development after birth (Little, 1843). His

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A historical perspective on cerebral palsy

views on this topic were summarized in the article


entitled On the inuence of abnormal parturition, difcult labours, premature birth, and asphyxia neonatorum,
on the mental and physical condition of the child, especially in relation to deformities, probably the most
commonly cited article on CP, which he addressed to
the Obstetric Society. From the three responses published at the end of the article, it is clear that Little
logically drew attention to the, at that time, unknown
eld of injuries to which the nervous system was liable
during, and immediately after, birth (Little, 1862). In
connection with birth complications, he actually described one clinical picture of non-progressive motor
decit of brain origin, namely spastic rigidity, which, at
the end of the 19th century, constituted one of four
main clinical forms of such motor decits in children
(Freud, 1968). All the same, no other name has become,
and remains, so closely associated with CP than his.

Little versus Freud


Given that Little discussed one clinical form of motor
decits of children, which he never termed CP, nor
linked it with other motor decits of brain origin, his
comparatively great inuence on the common understanding of CP seems at rst sight unwarranted. Littles
clear and objective reply to the immediate response of
his contemporaries showed that he did not claim a
pioneering position in discovering neurological sequelae
of abnormal and premature parturition. When he found
no reference to this theme in the works of English
medical writers, he referred to Shakespeare, who, universal as he was, did not disappoint him. In the physical
character of Richard III2, he in fact recognized a kind
of deformity which, in his opinion, originated at birth
(Little, 1862).
Freud, however, combined all infantile motor decits
of brain origin except rapidly progressive into one
nosological entity (Freud, 1968). Certainly, it can be
said that Freuds decision to introduce the unifying
concept was prudent, with the concept surviving for
over a century. All the same, Freud, who supposed that
motor decits of children would eventually be dened
more precisely (preferably aetiologically) by new insights into the human nervous system, did not ascribe
more than a temporary value to the entity he introduced (Freud, 1968).
2

I that am curtailed of this fair proportion,


Cheated of feature by dissembling Nature,
Deformd, unnishd, sent before my time
Into this breathing world, scarce half made up,
And that so lamely and unfashionable
That dogs bark at me as I halt by them. (Shakespeare, 1985; Little,
1862)

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583

From a distance of more than a hundred years, it is


obvious that both Little and Freud contributed signicantly to the understanding of the natural history of
CP. Because Freud studied motor decits of children
approximately 34 decades later than Little, the question of priority is not contested. Undoubtedly, Littles
aetiological approach represents one of the great milestones of studying motor decits of children. This was
recognized immediately. By contrast, the value of
Freuds conceptual approach had been growing almost
imperceptibly until decades later it was realized that his
concept of CP was a great milestone as well.

Attempts to solve the terminological


confusion
In the 20th century it became gradually evident that CP
was a useful nosographic category, although its terminology was rather confused (Bax, 1964). In the mid20th century, as at the end of the 19th century, CP
represented a clinical entity for some, while for others it
was just a general denotation for similar clinical entities
(Phelps, 1947; Perlstein, 1952). This lack of consensus
became less and less tolerable, for it made scientic
study dicult.
The American Academy for Cerebral Palsy (later the
American Academy for Cerebral Palsy and Developmental Medicine) coped with this problem in 1953 by
inquiring extensively of its members about the nomenclature and classication of CP (Minear, 1956).
Another initiative for re-thinking the terminology of
CP in the mid-20th century was taken by two Englishmen, Ronald MacKeith and Paul Polani. Adherents
soon began to gather around them, and in 1957 they
formed the Little Club (Bax, 1964).

Great contribution but little contemporary


influence
The terminological confusion that continued to aict
the eld of CP for the rst half of the 20th century
shows that, with his concept of infantile CP, Freud did
not signicantly inuence his contemporaries. From the
viewpoint of the current understanding of CP, which is
basically the same as Freuds, this is surprising.
If the publications on infantile motor decits of brain
origin of the 19th century are read comparatively (Little, 1862; Vogel, 1870; Bastian, 1875; Gowers, 1888;
Osler, 1987; Sachs and Peterson, 1890), it seems that
Freuds work on this topic (Freud and Rie, 1891;
Freud, 1893; Freud, 1968), being both analytic and
descriptive, was too theoretical for his time. He based
his work much more on literature review than on his
own clinical experiences. If there had not been the

584

A. Kavcic and D. B. Vodus ek

precise descriptions of infantile motor decits of Jacques Mathieu Delpech, William John Little, William
Osler, William Richard Gowers and many others,
Freud would not be able to develop his insightful
concept of CP. He nished his extensive work in this
eld with his monograph on infantile CP (Freud, 1968),
and then became renowned for psychoanalysis. It
overshadowed practically all his other works (Ferris,
1998), perhaps contributing to the lack of inuence of
his excellent work on CP. In retrospect, this contributed
to the persistence of terminological confusion.

Causal relationship between birth asphyxia


and cerebral palsy
In over 20 years of orthopaedic practice, Little came to
the conclusion that the proportion of entire recoveries
from the eects of asphyxia neonatorum is smaller than
has hitherto been supposed. He based his opinion on
approximately 200 well-documented personal cases of
spasticity with birth complications in their history
(Little, 1862). Because he did not use any statistical
methods, but only a descriptive comparison with the
general opinion of that time, we cannot know how
frequent such motor decit of children were in the
mid-19th century.
Freud considered the relationship between birth
asphyxia and infantile motor decit of brain origin
critically because of the fact that the development of
children with birth asphyxia could be completely normal (Freud, 1893). Little, who was an orthopaedic
physician, did not see such cases in his practice, or at
least not frequently. But Freud with his analytical approach could not fail to notice these cases. He allowed
the possibility that spasticity could be a result solely of
intrauterine factors or combined with birth complications (Freud, 1968).
Freuds analysis of birth asphyxia as a cause of CP
elicited no lively discussion among his contemporaries,
although it was noticeably dierent to Littles views. As
the usage of the term CP gradually increased, Littles
conclusion on the causal relationship between asphyxia
(and other complications) during birth and spasticity
was even generalized to all clinical types of CP (Scott,
1976).
Since the mid-20th century, when CP has also been
studied epidemiologically, it has been shown again and
again that relatively few cases can be explained on the
basis of birth asphyxia (Scott, 1976; Paneth, 1986;
Nelson and Leviton, 1991), although besides spastic
diplegia, as spastic rigidity was termed at that time, CP
also comprised other forms of non-progressive brain
motor decits (i.e. other spastic, ataxic and dyskinetic
disorders) (Hagberg et al., 1975; Mutch et al., 1992).

The question, as to whether CP is, to a large extent, the


result of birth complications, seemed thus practically
solved. Then, studies appeared that demonstrated that
birth asphyxia could not be regarded as a rare cause of
CP among term infants (Hagberg et al., 2001; Moster
et al., 2001), leading to the renaissance of a hypothesis
thought obsolete.

Cerebral palsy in the 21st century


The eorts of the American Academy for Cerebral
Palsy and the Little Club notwithstanding, the discussion on terminology and classication of CP continued
(Bax, 1964; Mutch et al., 1992). In epidemiological
studies, the Swedish classication of CP (Hagberg,
1989) became by far the commonest classication used.
This has not changed yet, although recently the usage of
the European classication has been slowly increasing
(Surveillance of Cerebral Palsy in Europe, 2000). This
happened without there being evidence that the Swedish
classication is the most appropriate, and without any
particular eorts to establish a consensus. In dening
CP, pragmatism has not yet prevailed. Several dierent
denitions are still used, although the compatibility of
epidemiological studies is strongly dependent on the
uniformity of the methodology used.
If several denitions of CP are read one after another, signicant dierences between them are perhaps not noticed (Table 1). If a study of CP is
planned, however, the denition (no matter which has
been chosen) has to be dened precisely, if a study is
to be rmly based. It is not possible to avoid the
ambivalence of the issue of brain maturation (at what
age the brain ceases to be immature). In the denitions of CP, formulations such as: in the period of
early brain growth or in the early stages of its (i.e.
brain) development can still be found. It is also not
possible to avoid the question as to whether aetiologically and/or pathologically well-determined motor
decit beginning early in life although not being
hereditary, as for instance kernicterus because of Rh
incompatibility, or schizencephaly, are justiably
termed CP.
The upper age limit of the onset of motor decit
being recognized as CP is (exactly) dened in only a few
denitions of CP (Wilson, 1916; Vining et al., 1976).
None of these has been used widely, although chronological specication of the early stages of development
(the immature brain) would make the denition of CP
clearer. It does not seem a logical decision, but per se it
was wise, for, instead of dening an authoritative
agreement on what exactly CP is, it enabled the gradual
evolution of the concept, which more easily lent itself
to the inclusion of new discoveries about the human

 2005 EFNS European Journal of Neurology 12, 582587

A historical perspective on cerebral palsy

585

Table 1 Some characteristic/frequently used denitions of CP


Infantile cerebral palsy would thus be dened as the general concept of all cerebral diseases in infancy caused by a direct effect of accidental
etiology, occurring either in the fetal period or after birth, and affecting one or more neuron systems. (Freud, 1968)
Infantile cerebral palsy is a paralysis of cerebral origin occurring in the rst six years of life. It is always a hemiplegia, and the cases which affect
both sides of the body will be found to be no exception to this rule, but are simultaneous lesions upon the hemispheres. (Wilson, 1916)
Cerebral palsy may be dened as a condition characterized by paralysis, paresis, incoordination, dyskinesia, or any aberration of motor function
that is due to involvement of the motor control centres of the brain. (Perlstein, 1952)
Cerebral palsy is a descriptive term applied to a group of motor disorders of young children, in whom full function of one or more limbs is
prevented by paresis, involuntary movement, or incoordination. (Balf and Ingram, 1955)
Cerebral palsy is a persistent but not unchanging disorder of movement and posture, appearing in the early years of life and due to a nonprogressive disorder of the brain, the result of interference during its development. (The Little Club, 1958 (Bax, 1964))
The term cerebral palsy does not designate a disease in any usual medical sense. It is, however, a useful administrative term which covers
individuals who are handicapped by motor disorders which are due to nonprogressive abnormalities of the brain. (Crothers and Paine, 1988)
The term cerebral palsy may be dened as one component of a group of childhood neurologic disorders which reect cerebral dysfunction rather
than damage per se and which may result from cerebral maldevelopment, infection, injury, or anoxia before or during birth or in the early years of
life. (Denhoff and Robinault, 1960)
Cerebral palsy is a disorder of movement and posture due to a defect or lesion of the immature brain. (Bax, 1964)
Cerebral palsy is a group of disorders characterised by reduced ability to make voluntary use of the muscles, caused by a non-progressive and nonhereditary brain disorder arising before or at delivery or during the rst years of life. (Christensen and Melchior, 1967)
Cerebral palsy is the result of a lesion or maldevelopment of the brain, non-progressive in character and existing from earliest childhood. The
motor decit nds expression in abnormal patterns of posture and movement, in association with an abnormal postural tone. (Bobath, 1969)
Cerebral palsy is dened as a nonprogressive disorder of motion and posture due to brain insult or injury occurring in the period of early brain
growth (generally under 3 years of age). (The Kennedy Institute (Vining et al., 1976))
Cerebral palsy is a descriptive term for a collection of nonprogressive neuromotor disorders of central origin that become manifest early in life and
are not the result of a recognized cerebral malformation. (Paneth, 1986)
Cerebral palsy is an umbrella term covering a group of non-progressive, but often changing, motor impairment syndromes secondary to lesions or
anomalies of the brain arising in the early stages of its development. (Mutch et al., 1992)

nervous system function than a rigid denition without


a rm biological base could. Because of complex and
dynamic processes, taking place simultaneously and
successively, depending on heredity and environment,
the ontogenetic development of the human brain can be
chronologically divided in several dierent ways, each
defendable (Connolly and Forssberg, 1997; Kandel
et al., 2000).
Knowledge of the human nervous system is continuously growing; therefore it would be unlikely to
expect that the concept of CP will not continue to
evolve.
Nadia Badawi et al. from Australia suggested that
the concept of CP as a separate entity was becoming
outdated because of the better understanding of the
pathology underlying infantile motor impairment syndromes. But on the other hand they stated that the term
CP was well recognized and still useful for service
provision and management and hence it should not be
abandoned. To improve interobserver agreement about
the application of the term CP in epidemiological
studies, they provided an extensive list of various
developmental syndromes or infantile diseases with
motor impairment and put forward which of these

 2005 EFNS European Journal of Neurology 12, 582587

syndromes (diseases) to cover by the term CP and


which not (Badawi et al., 1998). They took traditional
use into account and so they in fact widened the CP
category into other nosographic spectra for several
cases had been included in CP registers only because
knowledge had been insucient to recognize them as
separate entities.
The foregoing proposal of Australian experts published in 1998 has not elicited an intensive debate yet.
Given that it did not bring into question the concept of
CP but its internal structure, it seems that CP will remain a part of our nosographic system, at least in the
near future.

How to redefine cerebral palsy?


To delineate CP rmly and clearly, a consensus is required. The history of the term CP (certainly not short)
shows that there has not been a complete or long-lasting consensus about details of CP as yet. We believe
that it will always be dicult to achieve, for
(unchangeable) biological dimensions of CP are less
signicant than (changeable) nosographic, therapeutic
or social ditto.

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A. Kavcic and D. B. Vodus ek

Table 2 An example of the diagnostic criteria for cerebral palsy (CP)


Possible CP
Mandatory inclusion criteria: disorder of movement and posture manifesting as spastic diplegia, spastic hemiplegia, spastic tetraplegia, ataxia,
dystonia, choreo-athetosis - alone or in any combination; onset early in life; no evidence of progression.
Mandatory exclusion criteria: active disease that could explain the foregoing features; chromosomal disorders.
Supportive features: other signs of brain dysfunction that could be caused by the same pathological process as the foregoing disorders of movement
and posture (epilepsy, learning disorders, disorders of speech, vision or hearing); born after multiple pregnancy; vanishing twin syndrome;
intrauterine growth retardation; major antenatal placental abruption; preterm birth; acute intrapartum hypoxia; reduced fetal heart rate variability
from the onset of labour; extensive chorioamnionitis; congenital coagulation disorders; autoimmune disease of the mother; no child with the same/
similar clinical picture in a family.
Probable CP
Mandatory inclusion criteria: disorder of movement and posture as in possible CP; onset early in life; no evidence of progression or other disease
that could explain the foregoing features at school age.
Denite CP
Mandatory inclusion criteria: disorder of movement and posture as in probable CP, plus still no evidence of progression unrelated to aging or other
disease that could explain the foregoing features at age 18 or older.

In neurology, there has been a tendency in the last


decades to delineate ambiguously dened disorders by
diagnostic criteria. Such an approach works well in
both clinical practice and scientic studies. We propose
that agreement about the diagnostic criteria for CP (an
example of them incomplete as is incomplete our
knowledge of CP is presented in Table 2) would prove
fruitful.

Conclusion
The concept of CP arose as a temporary solution in an
era, which is separated from the present by amazing
progress in neural science. CP has, nevertheless, become
an indispensable part of the nosographic system. Perhaps the umbrella term CP has continued to be used in
spite of new discoveries of the human nervous system
function because, as it is not rmly dened, it did not
obstruct scientic progress; at the same time, however,
it can ll the appointed nosographic emptiness. Whatever the explanation of this phenomenon might be, CP
remains a handy term for scientic description and
medical diagnosis, although it is still easier to explain
what CP is not than to dene it precisely.

Acknowledgements
AK was supported by the Ministry of Education,
Science and Sport, grant no 98-35 0106.

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