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Cerebral palsies: epidemiology and causal pathways. Stanley F, Blair E, Alberman E. (Pp 251, hardback; £37.50) Cambridge: Cambridge University Press, 2000. ISBN 1 898 68320 4
Descartes, the father of modern philosophy, in his pivotal workDiscourse on method, published in 1637, set himself the task of doubting everything. From that starting point, he then tried to find a solid base of certainty. Over the years, epidemiologists have attempted to follow the Cartesian approach, not least those epidemiologists who are interested in that heterogeneous group of conditions called the “cerebral palsies”. To doubt everything requires imagination and courage, a setting aside of traditional wisdom; to establish certainties requires scientific rigour, clear thinking and sheer hard work.
For years, the conventional wisdom has been that most children with cerebral palsy have suffered brain damage at birth, which has led to a movement disorder of varying severity with or without additional intellectual and sensory deficit. This view has been challenged from time to time, but in the last 15 years, the dissenting voices have been loud and persistent. There is now a wide acceptance that not more than 10% of cerebral palsy in term babies is due to adverse intrapartum events. This recognition has opened the way to thinking about the alternative and infinitely more complex pathways that lead to this clinical entity. The problem now is to define these, to unravel the sequences of events, their temporal order, their interdependence, and their relative importance.
The authors of Cerebral palsies: epidemiology and causal pathways have taken up this challenge. In a systematic, lucid, way, they give the current data on cerebral palsy frequency, the current thinking on risk factors, and present for us a series of hypothetical causal pathways, most of which have an appealing biological plausibility. The authors are to be congratulated for their imagination and clear thinking. It is an elegantly written book, a landmark in the ongoing saga of the epidemiology of the cerebral palsies. In turn, they have thrown down a challenge for us—to test these possible pathways using sound methodological approaches, some of which, I suspect, have yet to be developed. The research agenda in this field appears to have been set for a number of years to come.
But perhaps the most exciting prospect is that this painstaking epidemiological work will be much enhanced by the advances in two rapidly developing fields. First, neuroimaging techniques now provide a powerful tool for assessing the timing and the structural and metabolic changes in brain injury. Secondly, there is an increased understanding of the complex biochemical changes that make up the maternal, fetal, and neonatal response to infection or hypoxia, and the genetic factors which modify this response. This opens up exciting new preventive and treatment possibilities. The next edition of this book will almost certainly need to draw on a wide multidisciplinary expertise in order to encompass these major advances in our understanding of the pathophysiology of the cerebral palsies.