Epileptic convulsions are seen chiefly in cerebral hemiplegia, in bilat eral hemiplegia, and in microcephalic rigidity. They are less common in universal rigidity, and still more rare in bilateral chorea and athetosis. In paraplegic rigidity and in choreic paralysis they are practically never seen.
The same thing is true of dementia and idiocy. In this respect also the cases exhibit every grade, from conditions in which the para lytic symptoms predominate, with a mild degree of feeble-mindedness, to those in which the loss of intelligence is very great, while the so matic phenomena are practically absent. In the same way there are all grades of disturbances of the intelligence from feeble-mindedness to absolute idiocy. In most cases the child is merely silly; the more active forms of feeble-mindcdness with imperative movements and tic like habits are rare in cerebral infantile palsy. On the other hand, dis turbances of speech and complete inability- to speak, as well as mastur bation, are quite common in children suffering from cerebral infantile palsy. Defective intelligence occurs chiefly in cases of microcephaly, unilateral and bilateral hemiplegia, and posthemiplegic chorea and athetosis. It is less pronounced in general rigidity and still less in para lytic rigidity. It must not be forgotten that these children, even when the intelligence is not greatly impaired, are in many ways, owing to the znotor disturbances Frain which they suffer, deprived of normal stimuli and of intercourse with other children, and for this reason alone give the impression of being more or less feeble-minded.
Epilepsy and dementia are very frequently present in the same indi vidual, and the same inequality in the intensity of the two phenomena is observed as in the case of palsies. In cases with severe epilepsy a marked degree of idiocy almost always makes its appearance sooner or later.
Finally it should be mentioned that diseases of the eye ground may run their course in a similar manner and that atrophy of the optic nerve may remain as the only symptom of an acute cerebral process —another instance of Freud's "cerebral palsy without paralysis.'' which was referred to in the beginning of the chapter.
It would be a great advance in the diagnosis of cerebral infantile palsy if it were possible to discover some definite connection between the various clinical pictures of cerebral infantile palsy just described— some of which are very distinetive—and certain anatomical diseases of etiologic conditions. For the present is is impossible, as has alreaciy
been stated. The following table, in which we have attempted to set forth those relations between the clinical symptoms and anatomical findings which, in the present state of our knowledge, appear to be approximately correct, must not be regarded as more than tentative: The course and the prognosis of cerebral infantile palsy are such as we should expect from the nature of the disease. Since we are deal ing with a reparative process, we do not expect additional focal symp toms to develop but rather look for the further improvement of the palsy. This is what occurs in the great majority of cases and, as a mat ter of fact, children suffering from severe unilateral or bilateral paralysis are seen to recover. But the improvement is limited; in palsies of the hand particularly recovery is very incomplete. The spasms and the posthemiplegic disturbances exhibit even less tendency to improve ment. Although occasionally the rigidity subsides and the muscular tension diminishes, we also see eases in which the contractures go on inereasing, and the usefulness of the extremities is severely and perma nently impaired. The same is true of choreic and athetoid movements which show no tendency whatever to subside. The arms and hands suffer most in this permanent posthemiplegic condition, as all the finer movements which are necessary for any kind of work appear to be interfered with. On the other hand, children usually learn to walk, though it may be with great difficulty and not without resorting to many artificial aids.
It follows therefore that, in addition to the mild cases in which a relative improvement occurs and the child is ultimately able to work, a large number of individuals with cerebral infantile palsy, partieularly with cerebral iliplegia, are rendered permanently unable to earn their living. They are often found in hospitals for incurable diseases, in in stitutions for the feeble-minded and not infrequently in the streets, where their bizarre contortions and strange attitudes excite the pity of the passers-by.