BRITISH MEDICAL JOURNAL
27 OCTOBER 1973
on its care of a child with a hopeless prognosis as on its suc-
cess with the survivors.
The feasibility and desirability of treatment of a grossly
handicapped infant, especially in the neonatal period, is one of
the most difficult decisions in paediatrics. Many factors are
involved and the varying attitudes of individual surgeons and
physicians and the pressures from parents accentuate the diffi-
culties. For centuries the mainstream of medical opinion has
abhorred the extremes and has trod the middle path. This
was expressed in classical form by the nineteenth century
English poet Arthur Clough (1819-61):
Thou shalt not kill; but need'st not strive
Officiously to keep alive.
This attitude has been re-enforced by a letter written by
Cardinal Jean Villot (1970), Vatican Secretary of State, to the
Federationof Catholic Medical Associations.
After stressing the sacred character of life that forbids a doc-
tor to kill and that imposes on him the duty to use all the
resources of his profession to fight against death, the Cardinal
writes: "But for all that, a medical man does not have to
There will always be differences of opinion between in-
dividual physicians and surgeons whether in a particular child
active treatment is justified or not, but we believe that com-
plete rejection and complete acceptance for treatment in spina
bifida are both untenable-the former denies active treatment
where the prognosis and the results of treatment are good
and gives the survivors less than an optimum future; the latter
all the techniques of survival offered by a constantly
keeps alive grossly handicapped children. Reasonably reliable
objective criteria are now available for selection for treatment
-their application has a marked effect on the quality of
We wish to record our thanks to the following members of the
spina bifida team who have worked with us in the clinic since 1961;
Mr. R. S. Hooper, neurosurgeon, and his staff; Mr. P. F. Williams
and Mr. M. B. Menelaus, orthomeedic surgeons; Dr. E. Wann,
psychiatrist; Miss Ruth Magnus, assistant urologist; and a num-
ber of medical social workers, appliance sisters, and paramedical
staff. All have contributed in various ways and have given freely
of their knowledge and experience. The teachers in the preschool
centres and snecial schools for the physically handicapped and,
not least, the parents of the children have also provided essential
information. To all we are greatly indebted.
Hagburg, B., and Siorgen, I. (1966). American3Journal of Diseases ofChildren,
Hide, D. W., Williams, H. P., and Ellis, H. L. (1972). Developmental
Medicine and Child Neurology, 14, 304.
Ingram, T. T. S., and Naughton, J. A. (1962). Developmental Medicine and
Child Neurology, 4, 287.
Laurence, K. M., and Coates, S. (1962). Archives of Disease in Childhood,
Lorber, J. (1971). Developmental Medicine and Child Neurology, 13, 279.
Lorber, J. (1972). Archives of Disease in Childhood, 47, 854.
Matson, D. D. (1969). Neurosurgery of Infancy and Childhood, 2nd edn.,
p. 36. Springfield, Ill., Thomas.
Sharrard, W. J. W., Zachary, R. B., Lorber, J., and Bruce, A. M. (1963).
Archives of Disease in Childhood, 38, 18.
Smith, E. D. (1965). Spina Bifida and the Total Care of Spinal Myelo-
meningocele, p. 75. Springfield, Ill., Thomas.
Smith, E. D. (1972). Journal of Pediatric Surgery, 7, 1.
Villot, Cardinal Jean (1970). L'Ossevatore Romano, Oct. 12-13.
Predictive Factors in Open Myelomeningocele with Special
Reference to Sensory Level
GILLIAN HUNT, WALPOLE LEWIN,JOHN GLEAVE, DOUGLAS GAIRDNER
British Medical Journal, 1973, 4, 197-201
A total of 113 cases of open myelomeningocele operated
on shortly after birth were followed up and the 80 sur-
vivors (71%) were assessed one and a quarter to seven
and a half years later. Their disability was classified in
terms of mobility, intelligence, continence, and major
assessment of overall disability. The overall disability
of the survivors was minimal in 6%, moderate in 40%,
severe in 39%, and very severe in 15%.
A number of clinical features present at birth were
analysed for their predictive value. Of these the sensory
level, which frequently differed from both external and
radiological levels of the lesion, correlated with the
outcome in terms of mobility, intelligence, continence,
major complications, and overall disability; and also
with deaths caused by renal failure.
Addenbrooke's Hospital, Cambridge CB2 2QQ
GILLIAN HUNT, M.B., D.C.H., Research Assistant
WALPOLE LEWIN, M.S., F.R.C.S., Neurological Surgeon
JOHN GLEAVE, F.R.C.S., Neurological Surgeon
DOUGLAS GAIRDNER, D.M., F.R.C.P., Paediatrician
A policy ofconfining operation to those patients with a
reasonable chance of achieving Independence would
involve selecting for treatment a minority of all infants
born with open myelomeningocele.
In the past few years there has been a change in the climate of
opinion, away from routine operative treatment in all cases of
myelomeningocele (Lorber 1971, 1972). At the same time it has
been confirmed that the most severe cases, if not operated on,
rarely survive for long-some 90% dying before the end of the
first year (Hide et al., 1972; Smith and Smith, 1973; Stark and
Drummond, 1973). A policy of selection of cases for operation,
therefore, seems to be indicated and attention needs to be
directed towards criteria by which cases likely to benefit by
surgery-in the sense of achieving a reasonable degree of
independence-can be more accurately identified at the time
of birth or soon after.
In this paper some predictive factors are examined. The
social consequences of this condition will be discussed in a
Subjects and Methods
This survey covers 113 consecutive cases of open myelomenin-