BIRTH-HÆMORRHAGES
Extracranial hæmorrhages.
As the result of injury sustained during protracted labour, hæmatomata may develop beneath the aponeurosis of the occipito-frontalis or underneath the pericranium, the latter being the more common situation. The right side of the head is the more frequently involved, and the parietal region is the part usually affected. Occasionally these hæmatomata are bilateral and symmetrical.
The two varieties of cephalhæmatoma—subaponeurotic and subpericranial—possess certain peculiarities that aid materially in their differential diagnosis.
Subaponeurotic hæmatomata.
The blood, though spreading widely throughout the subaponeurotic space, tends to gravitate towards the lower confines of that space, and, from the position assumed by the patient, is most evident in the occipital region. The presence of the blood is evidenced by œdema, doughiness, and ecchymosis.
Subpericranial hæmatomata.
The blood is confined to the region of the particular bone affected, usually the right parietal bone. This is due to the fact that the pericranium blends at the margins of the bone with the tissue intervening between that bone and the neighbouring parts of the skull.
Subpericranial hæmatomata present further peculiarities. The tumour is usually more or less circular in outline, and fluctuates freely. It may arise immediately after the birth of the child, but, more commonly, some two or three days elapse before attention is drawn to its existence. Within a few days clotting occurs at the periphery of the hæmatoma with the formation of a circumferential ridge. The central portion of the clot remains soft but tense, so much so that firm pressure is required before the examining finger is enabled to feel the underlying bone. These cephalhæmatomata are not infrequently mistaken for depressed fractures, but no difficulty should be experienced if the existence of the circumferential ridge be appreciated and if the underlying bone can be felt at the centre of the tumour. In cases of doubt the blood should be drawn off by aspiration and the swelling again examined.
For differential diagnosis, see [p. 57].
Treatment.
The less extensive hæmatomata require no active surgical treatment, the absorption of the clot being aided by protection of the part and by cooling lotions.
Similar expectant treatment is generally advised with regard to the extensive subpericranial hæmatomata, but as infection of the clot may take place, and as its resolution invariably requires a considerable period of time—often many weeks—more active measures can be adopted. The region of the hæmatoma is carefully shaved and cleansed, and, under local anæsthesia, a small incision made through the scalp, the clot squeezed out, and firm pressure applied. Under this form of treatment the patient is well within a few days.
Intracranial birth-hæmorrhages.
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.
Symptoms.
Besides the history of protracted labour and the ‘blue’ asphyxiated appearance of the baby, other evidence is to hand with respect to both general and local increase of brain-pressure.
The general increase is evidenced first and foremost by the bulging and non-pulsatile anterior fontanelle. The fontanelle may be regarded as an index of intracranial pressure. The margins of the fontanelle are outlined with some difficulty, and, owing to the free communication between the intra- and extra-cranial venous systems, the scalp-veins are unduly prominent. The general condition of the child varies according to rise of intracranial pressure. In the more serious cases it may be impossible to arouse the patient: in the slighter hæmorrhages the child may appear but little the worse, with the exception, perhaps, of being rather more irritable than usual.
The effect of the pressure on the medullary centres is shown by respiratory difficulties—irregularities of rhythm, &c.—some retardation in pulse-rate, and increase in blood-pressure. The reflexes are increased and the child is readily thrown into general convulsions.
The effect of the localized pressure on the upper Rolandic centres seldom becomes evident till after the lapse of a few days—and often after a longer period—when muscular weakness, twitchings, rigidity, or paralysis—more especially of the contralateral lower extremity—becomes apparent. The mother often draws attention to the fact that the child does not move one of its legs properly.
When the extravasation is extensive, spreading downwards over other motor areas, the upper extremities and even the face may be involved.
When a small hæmorrhage is present, situated on either side of the falx cerebri, both lower extremities suffer and diplegia results.
In some cases, chemosis of the conjunction, œdema of the lids, and proptosis have been observed. In any case an ophthalmoscopic examination should be carried out. Frequently some fullness of the retinal veins and diminution in the calibre of the arteries supply confirmatory evidence.
In the event of doubt in diagnosis, lumbar puncture should be carried out. It should be noted, however, that although the positive evidence of free blood corpuscles points to subdural hæmorrhage, yet that absence of blood in the fluid withdrawn does not exclude the possibility of a localized and more or less encapsulated hæmorrhage. In the event of failure at recognition of the serious lesion present, disastrous results will ensue—monoplegia, diplegia, hemiplegia, epilepsy, and idiocy.
Treatment.
The age of the patient must not be allowed to weigh in the balance against operative treatment, for, if due precautions be taken, the new-born child stands operation well. Cushing points out that ‘the possibilities of surgical relief are limited to the first week or two after the hæmorrhage has occurred, for old cortical scars can neither be helped by medicine nor by the scalpel’.
The clot can be exposed by craniectomy or by craniotomy. The latter operation results in a more complete exposure, but the shock is undoubtedly more severe. Exposure by craniotomy is advocated by Cushing, and carried out in the following manner: ‘An omega-shaped incision just within the outer margin of the parietal bone is carried down to the bone through the scalp and pericranium, and the latter is scraped away so as to expose the thin serrated edge of the parietal bone. Under this a blunt dissector is passed, so that the edge of the bone is tilted up, and then, with a proper cutting instrument (strong blunt-pointed scissors suffice), the bone is incised in a line conforming with the skin incision 1 centimetre or more within the parietal margin. The parietal bone is then broken across at its base. The dura is opened by a curved incision some distance within the bony margin, and the superficial clot broken away or lifted off in fragments, or irrigated away with a gentle stream of warm saline solution. The dura should be accurately sutured, the bone replaced, and the skin closed with suture.’
He reports on 9 cases so treated, with 4 recoveries, apparently complete and permanent. The fatal cases were all associated with extensive extravasation over the entire hemisphere. In 3 cases bilateral exposure was necessitated.
Taking, however, the question into more general consideration, it would appear that equally satisfactory results can be obtained, with a lesser degree of operative danger, by carrying out craniectomy in the manner described in the treatment of ‘traumatic subdural hæmorrhage’ (see [p. 156]).