Читать книгу The Surgery of the Skull and Brain - Louis Bathe Rawling - Страница 70

Attention was first drawn to the question of intracranial birth-hæmorrhages by Little, who showed that a history of difficult labour could be obtained in a large percentage of cases in which children in after-life suffered from uni- or bilateral spastic paraplegia; hence the name, ‘Little’s disease’ or birth palsy. Further information was supplied by Sarah MacNutt, and the whole question was fully investigated by Harvey Cushing.

In all cases a history of difficult and protracted labour can be obtained, with considerable post-partum respiratory difficulties, the child being described as ‘blue in the face’ for some hours after birth.

The stress and strain which the advancing head undergoes, and the consequent moulding and overlapping of the various segments of the skull, exposes the brain to great alterations of pressure, and throws considerable tension on the intracranial veins. It is, in fact, rather surprising that birth-hæmorrhages are not more common.

The hæmorrhages may be wholly within the meshes of the pia-arachnoid system, but, in the great majority of cases, the lesion is more serious, and the extravasation comes to lie within the subdural space.

Occasionally the bleeding takes place beneath the tentorium cerebelli, the blood-clot lying in relation to the pons and medulla. Such hæmorrhages are said to be observed only in vertex presentations. The more common supratentorial hæmorrhages—usually resulting from difficult breech presentations—either remain more or less localized to a certain region of the cortex, or become widely diffused over the surface and base of the brain.

It is probable that Cushing is correct in his observations with respect to the source of these supratentorial hæmorrhages. He states that the blood is derived from one or more radicles of the superior longitudinal sinus, especially from those veins which, in their upward passage in the sulci of the brain, leave their cerebral beds for a short and comparatively unprotected course, immediately previous to their entry into the lacunæ laterales of the superior longitudinal sinus.

In addition, he points to the very important fact that the localized hæmorrhages are commonly situated in relation to the mid-cerebral cortex, close to the sinus, and on one or both sides of the falx cerebri. In addition, therefore, to the symptoms of general cerebral compression, certain definite localizing symptoms are to be observed, these being in direct proportion to the size of the clot.

In an analysis of 74 autopsies on infants still-born or dying within the first few days, Archibald[11] found ‘intrameningeal’ hæmorrhage in 32, in 19 of which it was of considerable extent: and in 5 others there was extra-dural hæmorrhage. In only two or three was effused blood found within the cerebral cortex. The importance of these facts from a surgical point of view cannot be over-estimated.

Fig. 25. Diagram to illustrate the Effects and Position of a Birth-hæmorrhage. sc., Scalp; b., Bone; d.m., Dura mater; br., Brain; s.l.s., Superior longitudinal sinus; c.v.¹, The protected part of a superficial cerebral vein; c.v.², The unprotected part of a superficial cerebral vein; c., The subdural clot, exercising pressure on (1) the cortical leg arm, (2) the arm area, and (3) the face area.