- Email: [email protected]
INTRACRANIAL INJURY DURING BIRTH.
1302
ANNOTATIONS shock is absent, the rise of intracranial pressure should be combated by repeated lumbar puncture, THE first meeting of the members of the Commission unless there is evidence of haemorrhagic disease, in was held on Monday last in the Office of THE LANCET, which case the bleeding and clotting times should when Lord Crawford presided over a full attendance. first be brought to normal. The terms of reference were explained and the first Dr. Randolph Byers recognises two types of nervous directions of the work, as defined by those terms, were lesions in infants: (1) due to strain on supporting settled. The favourable reception of the inquiry structures with of the vessels which they rupture by the general and medical press was reported, and contain, as described by Eardley Holland; and the attention of the meeting was drawn to certain (2) small intracerebral haemorrhages as described by of the many communications which had been received. P. Schwartz. Both types are common. His series It was announced that the inquiry would be pursued of 12 cases the variety of situations of illustrating in all representative centres, and it is hoped to secure birth trauma deserves detailed study. Some of them cooperation and to collect information on the various lend confirmation to the work of Crothers and Putnam problems involved. on spinal trauma in breech deliveries ; in one case he Any organisation or individual wishing to provide is able to demonstrate the morbid anatomy of this evidence for the Commission to consider, or to make condition in a child which died of intercurrent disease proposals relating to the improvement of conditions in the fourth month. In most of his cases of intraof service of the nursing profession, is asked to com- cranial haemorrhage the bleeding was considered to municate with the hon. secretary at THE LANCET be intracerebral, especial attention being paid mainly Offices, 7, Adam-street, Adelphi, London, W.C. to cases of this kind in which hyperkinesis subsequently developed, and in which it is suggested that the lesions involved the basal ganglia. Dr. Byers is INTRACRANIAL INJURY DURING BIRTH. in general inclined to attribute the pathogenesis of A RECENT meeting of the Massachusetts Medical cerebral lesions met with in childhood to natal rather vociety’- was devoted to the effect on the nervous than prenatal causes. A paper by Dr. G. B. Fleming and Dr. Ellen system of injury during birth. As an obstetrician Dr. F. C. Irving frankly resented the common assump- Morton,2of the Royal Maternity Hospital, Glasgow, tion that intracranial hsemorrhage is due to bad can usefully be compared with those read at the obstetrics. The cardinal sign of intracranial heamor- Massachusetts Medical Society. They take the view rhage, he says, is disturbance of respiration, the later that the clinical signs of cranial haemorrhage are signs being apathy, refusal to suck, pallor, and a unconvincing, and that the most reliable evidence tense fontanelle. At the Boston Lying-in Hospital during life is obtained from the presence of a xanthoof 182 autopsies from all causes, 73 (40 per cent.) chromatic spinal fluid. They think, however, that revealed intracranial haemorrhage as the cause of intracerebral haemorrhage’ is rare, and they infer from ,death. In 23 of these cases labour had been normal; the presence of xanthochromatic fluid that the 23 were delivered by the breech, 21 with forceps, haemorrhage is meningeal-an assumption hardly .and 3 by Caesarean section. These figures suggest supported by sufficient evidence. An account is that no particular obstetric procedure is especially given of 103 infants suffering from intracranial responsible. Dr. Irving maintains that asphyxia is haemorrhage, of whom 50 died before discharge and a true cause of haemorrhage, even in the absence of 7 subsequently. The duration of labour showed no and infants showing signs of intra-uterine significant relation to the mortality, but labour was trauma, asphyxia can sometimes be saved, he believes, by abnormal in 50 per cent. of the cases, as against 27 Caesarean section. per cent. of all women delivered in the hospital. Dr. Donald Munro gave further details of his In the fatal cases tentorial tears were the commonest series of 117 cases of cranial and intracranial injuries lesions, being found in 16 out of 39 autopsies. Of (THE LANCET, 1929, i., 31). In no less than 54 of the non-fatal cases 33 were examined after they had these the infants were first-born. Cerebral cedema passed the first year, and only 5 of these were suffering without macroscopic haemorrhage was a Tom any defect. and significant finding, and microscopic examination usually showed some associated intracortical haemorINTESTINAL FLORA. rhage. On further analysis of his series Dr. Munro finds that the most frequent symptoms were hyperTHE bacteriology of the more accessible parts of tonicity, abnormal or poor cry, cyanosis, and failure the alimentary canal has long been studied and recently to nurse ; tense fontanelle was slightly less common. intubation has made it possible to take cultures the gastric and duodenal fasting contents. Hypertonicity was relatively frequent in the which survived, and cyanosis in those which apart from operation and autopsy, the nature Less common symptoms, which were associated with the flora lower down has only been deduced from high mortality, were flaccidity and pallor, often with examination of the faeces, and in clinical work this apathy and failure to suck; in these cases the many fallacies. Certain bacteria, such as those pressure of the cerebro-spinal fluid was below normal.of the typhoid group, are known to cause disease; These symptoms are indicative of surgical shock, but of the hosts of other inhabitants of the intestinal and occur typically with gross meningeal damage. Itract it is hard to say which are real parasites and In the absence of surgical shock all cases with cerebral which are of no pathogenic significance. Moreover, œdema or haemorrhage showed increased owing to drying in the colon many bacteria are cranial pressure. Dr. Munro recommends no active dead before the faeces are voided. The Einhorn treatment during the stage of surgical shock, method of intubation which was introduced for possibly rectal magnesium sulphate. When surgical therapeutic purposes offers new means of taking THE COMMISSION ON NURSING.
common
____
casesfrom
died.But, I of
has
i
intra-
except I
1 New Eng. Jour.
Med., Sept. 11th, p. 499.
2
Arch. Dis. in Childhood, October, 1930, p. 361.
ANNOTATIONS shock is absent, the rise of intracranial pressure should be combated by repeated lumbar puncture, THE first meeting of the members of the Commission unless there is evidence of haemorrhagic disease, in was held on Monday last in the Office of THE LANCET, which case the bleeding and clotting times should when Lord Crawford presided over a full attendance. first be brought to normal. The terms of reference were explained and the first Dr. Randolph Byers recognises two types of nervous directions of the work, as defined by those terms, were lesions in infants: (1) due to strain on supporting settled. The favourable reception of the inquiry structures with of the vessels which they rupture by the general and medical press was reported, and contain, as described by Eardley Holland; and the attention of the meeting was drawn to certain (2) small intracerebral haemorrhages as described by of the many communications which had been received. P. Schwartz. Both types are common. His series It was announced that the inquiry would be pursued of 12 cases the variety of situations of illustrating in all representative centres, and it is hoped to secure birth trauma deserves detailed study. Some of them cooperation and to collect information on the various lend confirmation to the work of Crothers and Putnam problems involved. on spinal trauma in breech deliveries ; in one case he Any organisation or individual wishing to provide is able to demonstrate the morbid anatomy of this evidence for the Commission to consider, or to make condition in a child which died of intercurrent disease proposals relating to the improvement of conditions in the fourth month. In most of his cases of intraof service of the nursing profession, is asked to com- cranial haemorrhage the bleeding was considered to municate with the hon. secretary at THE LANCET be intracerebral, especial attention being paid mainly Offices, 7, Adam-street, Adelphi, London, W.C. to cases of this kind in which hyperkinesis subsequently developed, and in which it is suggested that the lesions involved the basal ganglia. Dr. Byers is INTRACRANIAL INJURY DURING BIRTH. in general inclined to attribute the pathogenesis of A RECENT meeting of the Massachusetts Medical cerebral lesions met with in childhood to natal rather vociety’- was devoted to the effect on the nervous than prenatal causes. A paper by Dr. G. B. Fleming and Dr. Ellen system of injury during birth. As an obstetrician Dr. F. C. Irving frankly resented the common assump- Morton,2of the Royal Maternity Hospital, Glasgow, tion that intracranial hsemorrhage is due to bad can usefully be compared with those read at the obstetrics. The cardinal sign of intracranial heamor- Massachusetts Medical Society. They take the view rhage, he says, is disturbance of respiration, the later that the clinical signs of cranial haemorrhage are signs being apathy, refusal to suck, pallor, and a unconvincing, and that the most reliable evidence tense fontanelle. At the Boston Lying-in Hospital during life is obtained from the presence of a xanthoof 182 autopsies from all causes, 73 (40 per cent.) chromatic spinal fluid. They think, however, that revealed intracranial haemorrhage as the cause of intracerebral haemorrhage’ is rare, and they infer from ,death. In 23 of these cases labour had been normal; the presence of xanthochromatic fluid that the 23 were delivered by the breech, 21 with forceps, haemorrhage is meningeal-an assumption hardly .and 3 by Caesarean section. These figures suggest supported by sufficient evidence. An account is that no particular obstetric procedure is especially given of 103 infants suffering from intracranial responsible. Dr. Irving maintains that asphyxia is haemorrhage, of whom 50 died before discharge and a true cause of haemorrhage, even in the absence of 7 subsequently. The duration of labour showed no and infants showing signs of intra-uterine significant relation to the mortality, but labour was trauma, asphyxia can sometimes be saved, he believes, by abnormal in 50 per cent. of the cases, as against 27 Caesarean section. per cent. of all women delivered in the hospital. Dr. Donald Munro gave further details of his In the fatal cases tentorial tears were the commonest series of 117 cases of cranial and intracranial injuries lesions, being found in 16 out of 39 autopsies. Of (THE LANCET, 1929, i., 31). In no less than 54 of the non-fatal cases 33 were examined after they had these the infants were first-born. Cerebral cedema passed the first year, and only 5 of these were suffering without macroscopic haemorrhage was a Tom any defect. and significant finding, and microscopic examination usually showed some associated intracortical haemorINTESTINAL FLORA. rhage. On further analysis of his series Dr. Munro finds that the most frequent symptoms were hyperTHE bacteriology of the more accessible parts of tonicity, abnormal or poor cry, cyanosis, and failure the alimentary canal has long been studied and recently to nurse ; tense fontanelle was slightly less common. intubation has made it possible to take cultures the gastric and duodenal fasting contents. Hypertonicity was relatively frequent in the which survived, and cyanosis in those which apart from operation and autopsy, the nature Less common symptoms, which were associated with the flora lower down has only been deduced from high mortality, were flaccidity and pallor, often with examination of the faeces, and in clinical work this apathy and failure to suck; in these cases the many fallacies. Certain bacteria, such as those pressure of the cerebro-spinal fluid was below normal.of the typhoid group, are known to cause disease; These symptoms are indicative of surgical shock, but of the hosts of other inhabitants of the intestinal and occur typically with gross meningeal damage. Itract it is hard to say which are real parasites and In the absence of surgical shock all cases with cerebral which are of no pathogenic significance. Moreover, œdema or haemorrhage showed increased owing to drying in the colon many bacteria are cranial pressure. Dr. Munro recommends no active dead before the faeces are voided. The Einhorn treatment during the stage of surgical shock, method of intubation which was introduced for possibly rectal magnesium sulphate. When surgical therapeutic purposes offers new means of taking THE COMMISSION ON NURSING.
common
____
casesfrom
died.But, I of
has
i
intra-
except I
1 New Eng. Jour.
Med., Sept. 11th, p. 499.
2
Arch. Dis. in Childhood, October, 1930, p. 361.