ANNOTATIONS

hare-lip ( 1 lateral cleft palate) and of midline cleft palate; the total incidence is about 3 per thousand births, compared with under 2 pcr thousand in England.

Recently IVY* has published figures for the incidence of clefts of the lip and palate in Pennsylvania for the year starting January 1961. when information on both malforninlions and the child’s colour began to be recorded on the birth certificate. Tlic incidences itre totals, as the a u t h o r does not d i Ire ren t ia t e t hc genetical I y d is t i nc t ma I for n i a t ion of m id I i nc cleft palate without a cleft of the lip. In over 26,000 ‘non-white’ births, only 6 cxilmplcs of ‘cleft lip-cleft palate’ malformations were recorded--that is, I in 4.000. 1 ti contrast. thc incidence in ‘white’ births was I in 750. It is clcur that if the recording of malformations is accurate the ratio of the incidence of these two malformations i n American Negroes. American and European whites and Japanese is approxiinately 1.5%.

To distinguish between genetic and environmental causes of thcse racial differences (both genetic and environmental factors play a part i n the causation of clefts of the lip and palate) it is valuable to have incidence figures for different races in different environments. A migration will change at least part of the environment, but if it is non-selcctive it will have little effect on gene frequencies for several generations. A table in Ivy‘s paper giving the incidence of other malformations shows that the very high incidence of polydactyly and the low incidence of spina bifida cystica, typical of Negroes in Africa, is also prcscnt in his non-white group. His figures for clefts of the lip and palate in whites are similar to those for west Europeans. It would be useful to know whether the low incidence hc has I’ound in non-whites is also found in native west-Africans. I t would also be useful to have informa- tion from America on whether the high incidence of clefts of tlie lip and palatc i n Japan is also found in Japanese who have been in the United States for two or three generations.

*Ivy, R. H. (1962) ‘The influence of race on the incidence of certain congenital anomalie,, notably clcrl CtDRIC CAllTEK

lip-cleft palate. Plus/. reconsrr. Surg., 30, 58 1-585.

MEDICAL TREATMENT FOR SQUINT? IF the search for a medical treatment of strabismus is successful a grcat advance will havu been made and many unfortunate children will be spared what is now almost tlie most frequent operation performed in childhood.

The experiences of DR. MARY FLETCHER,* of Houston, Texas, with chlordiazepoxide (‘Librium’) are therefore stimulating because they show that squints can be modified by a d y g which acts on the central nervous system. She has donc a double-blind study of thc effects of this drug on strabismus in 51 children, aged from 10 mqnths to I I years. Two groups, A and B, were given chlordiazepoxide and a placebo alternately for four weeks each, A starting with the drug and B with the placebo. Ophthalmological and orthoptic examinations were made before treatment and every week during the eight weeks of the trial. Eighteen patients, all with the esotropia or esophoria-tropia type of strabismus, showed improvement in prism and cover and gains in fusional amplitude. Patients with other kinds of strabismus did not respond. A high proportion of the children developed side-effects, such as temper tantrums, irritability or drowsiness, on 2 mg./kg. and some still had mild side-effects when the dosage was reduced, but only 6 children had to be taken off the drug because of side-effects. The author had the impression that they were not influencing the strabismus by the tranquillizing or sedative action of the drug.

The unpredictable effect of chlordiazepoxide on squints, one case even becoming worse

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while on treatment, its liability to produce tiresome side-effects, and the relapses which occurred when the drug was withdrawn are severe limitations on its usefulness. Indeed, the improvements recorded would nearly all be more justly called modifications, because there is no indication in this experiment that consistent progress towards a cure is being made in most cases, and, while it is certainly true that a wider range of fusion and a lessening of the deviation is a beneficial difference, such changes do not raise great hopes of ultimate cure. The author herself expresses disappointment that the drug fails to pro- duce a ‘predictable, measurable and all-or-none response’.

She quotes one remarkable case where paresis of both superior recti and both superior obliques disappeared while on treatment only to reappear on its cessation. This is a most uncommon type of squint, and in this particular case the mode of action of the drug is even more obscure than usual.

We still understand too little of the fundamental mechanisms involved in the early stages of concomitant strabismus in children or of why it so often deteriorates later into an irreversible state; so we can do no more than make guesses at what will eventually prevent squints or cure them by rational therapy not involving surgery. Dr. FLETCHER’S conclusion that the use of this and other drugs in the treatment of children with strabismus should be explored is undoubtedly valid and her preliminary report should encourage further efforts along these lines. PETER GARDINER

REFERENCES *Fletcher, M. C. (1961) ‘Chlordiazepoxide (“Librium”) in the treatment of strabismus; a preliminary

report.’J. Amer. med. Worn. Ass., 16, 37-44.

RESIDENTIAL TREATMENT THE publication of the papers from the International Study Group at Oxford last September on the ‘Indications for Residential Treatment in the Early Years’, shows that we are now thinking of cerebral palsied children as having feelings as well as lesions. (Three appear in this number, while papers by Ellis, Kershaw and Michell were published in February).

All six papers emphasise that these children need both family life and early treatment, and discuss obstacles in the way of providing them together. The difficulties inherent in distance from treatment centres, in tensions within the family or in the strain on parents and other children, are sympathetically explored. Milani-Comparetti helps us to further clarification by asserting firmly that when the choice makes non-residential treatment impossible, ‘these cases cannot be counted as “indications” for residential treatment’. The continuing admission that residential treatment in the early years is always second best is of primary importance, however inevitable it seems in particular cases. It underlines the need for vigilance in planning, whether for an individual child or for the development of services in general. Probably many of us know at least one family which i s both able and willing to move nearer to a treatment centre if the child’s dual needs are fairly and squarely discussed. Unfortunately, we cannot always rule out a bias towards residential care in some of us who are professionally concerned, either because, as in England, residential education is highly respectable, or because the parents are not the best co-operators. Acceptance that separation, whatever its benefits, is a bad substitute for family life plus treatment should make us look diligently at every means for avoiding it, as is clearly done in Newcastle. Is the home which, in Kershaw’s words, is ‘actively harmful to the child’ really beyond

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