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Intracranial Thrombophlebitis
174 resistance can be induced fairly readily in the testtube and there are reports from this7 and other countries of resistant strains in clinical practice. THOMSON 7A. and his colleagues in Australia have found an increasing incidence of resistant coliform organisms as well as of staphylococci in hospital, where cross-
that in the
great majority of patients with otitic hydrocephalus the ventricles are of normal size, the hydrocephalus- being a communicating one with an equal rise of cerebrospinal-fluid pressure inside and outside the brain. The prognosis in these cases is almost uniformly good ; the papilloedema and raised infection undoubtedly plays a part. Cross-resistance intracranial pressure gradually subside, owing to between aureomycin and terramycin, which are recanalisation of the thrombus. Occasionally, howclosely related, is common ; but resistance between ever, optic atrophy with failure of vision takes place these two substances and chloramphenicol is more before the natural recession of the papilloedema. to The usual treatment is repeated lumbar puncture to resistance increased irregular. - Strangely enough, this group of drugs may be accompanied- by enhanced reduce the intracranial pressure; commonly the sensitivity to streptomycin or penicillin. pressure falls after two or three punctures, but in The latest observations on the synergistic and some cases puncture may have to be repeated for antagonistic activities of drugs and the development several weeks. In general this treatment is safe, but of resistance8 and cross-resistance should stimulate SYMONDS 13 - has recently described a patient with further study of their mode of action on bacteria, about otitic hydrocephalus who died shortly after lumbar which we still know remarkably little. Meanwhile, puncture. Probably this was a result of cerebral what has already been learnt should serve as a oedema with tentorial herniation due to withdrawal deterrent to the indiscriminate use of these drugs ; of cerebrospinal fluid ; and he advises that the fluid for they are not only very expensive but have a should be withdrawn slowly and the pressure not be selective action against infections, most of which allowed to fall below 150 mm. water. terminated satisfactorily in the pre-antibiotic era. Another complication of otitis media, which may arise in association with otitic hydrocephalus or apart Intracranial Thrombophlebitis from it, is Gradenigo’s syndrome, in which a sixthIN the past twenty years thrombosis of cerebral nerve palsy develops on the side of the infected ear. veins and of the dural sinuses, particularly the This condition is probably also due to thrombosis of a superior longitudinal sinus, has been increasingly sinus-the inferior petrosal sinus. 13 This sinus and the recognised as a cause of sudden episodes of focal neuro- sixth nerve pass from the posterior to the middle fossa raised intracranial pressure. logical disturbance and through a tightly fitting dural sheath-Dorello’s In 1912 PASSOT9 described a syndrome which canal-and the palsy results from compression of the occasionally followed otitis media and was charac- nerve by the thrombosed sinus, the nerve recovering terised by headache, drowsiness, and papilloedema its function as the sinus becomes recanalised. without pyrexia or signs of meningeal irritation ; Thrombophlebitis of superficial cerebral veins may the pressure of the cerebrospinal fluid was raised but occur in association with infection in the ear or nasal its constituents were normal. The condition was not, sinuses or with localised or generalised infections elsehowever, generally recognised until 1931 when where in the body’41-5; and here the usual clinical SYMONDS10 described again the clinical features, picture is of focal epileptic attacks followed by loss of emphasised that the prognosis was good, and named function of the parts of the body involved in the the disorder otitic hydrocephalus. A few years later attack. More rarely hemiplegia or aphasia may he suggested 11 that the cause of the raised intracranial develop suddenly without preceding- epilepsy. Often pressure was thrombosis of the superior longitudinal there are general symptoms of infection, and the sinus, basing this view on the presence of thrombosis cerebrospinal fluid may show a cellular reaction, unlike of the lateral sinus on the side of the affected ear in a the state with sinus thrombosis where the fluid is high proportion of the cases in which the mastoid was usually normal. The diagnosis from a cerebral abscess explored, and on the necropsy findings in a case may be difficult, and indeed an abscess may occasiondescribed by BAILEY and HASS 12 in which thrombosis ally follow cerebral thrombophlebitis. With the of the lateral sinus had spread to the superior longiadministration of antibiotics, however, the majority tudinal sinus with resulting papilloedema and raised of patients make a good recovery, though there may intracranial pressure. This view of the pathology of be residual hemiparesis or hemianopia, depending on otitic hydrocephalus is now generally accepted. The the part of the brain involved and the extent of brain raised intracranial pressure with thrombosis of damage. the superior longitudinal sinus may be due to Intracranial thrombophlebitis also occasionally either of two mechanisms. The clot may spread comes on during the puerperium 16; and possibly the from one lateral sinus to the torcula and in this way sudden cerebral vascularcatastrophes after childbirth shut off the opposite lateral sinus and obstruct the described by MÉNIÈRE17 in 1828 were of this nature. main venous return from the cranial cavity. with MARTIN 18 has suggested that in these cases subsequent cedema of the brain ; or, alternatively, the starting-point may be thrombosis inpuerperal a pelvic vein, clot in the superior longitudinal sinus may block the and that a detached fragment of clot may pass as an arachnoid villi and in this way impede the absorption embolus up the extrathecal vertebral plexus of veins, of cerebrospinal fluid. Ventriculography has shown which is largely without valves and communicates with 7. Clarke, S. K. R., P. .
Dalgleish,
G., Gillespie, W.A., Lancet, 1952,
i. 1132. 7A.
8. 9. 10. 11. 12.
Thomson, E. F. 1952, i, 870.
J. clin.
Path. 1952, 5, 169 ;
the intracranial
venous
sinuses.
KENDALL,15
on
Med. J. Aust.
Eagle, H., Fleischmann, R., Levy, M., J. Bact. 1952, 63, 623. Passot, R. These de Paris, 1912. Symonds, C. P. Brain, 1931. 54, 55. Symonds, C. P. Ibid, 1937, 60, 531. Bailey, O. T., Hass, G. M. Ibid, p. 293.
13. 14. 15. 16. 17.
Symonds, C. P. Ann. R. Coll. Surg. 1952, 10, 347. Symonds, C. P. Brit. med. J. 1940, ii, 348. Kendall, D. Brain, 1948, 71, 386. Martin, J. P., Sheehan, H. L. Brit. med. J. 1941, i, 349. Ménière, P. Arch. gén. Méd. 1828, 16, 489. 18. Martin, J. P. Proc. R. Soc. Med. 1944, 37, 383.
the
175
other hand, has pointed out that in the puerperium There some factors favour " primary " thrombosis. is an increase of blood-platelets,19 especially if there has been severe postpartum haemorrhage ; the plasmafibrinogen is raised20;and there is increased " stickiof the circulating blood,21 possibly owing to an ness increased number of newly formed cells. These factors would all enhance the tendency to thrombosis. n the presence of damage to the endothelium of intracranial veins or sinuses, which might occur during labour. In this connection it is interesting that thrombosis of intracranial venous sinuses has been reported following combined insulin-induced hypoglycaemia and electric convulsive therapy 22 in the The suggestion was treatment of schizophrenia. that the endothelium was damaged during the fits, and thrombosis was precipitated by the dehydration from sweating and salivation during hypoglycsemia. "
Stillbirth and Social Conditions PROGRESS, like growth, is a thing of fits and startsand stops ; and no better illustration of this can be found than the behaviour of the stillbirth-rate in recent years. Whereas during the nine years 1931-39 the rate scarcely declined, falling from 41 to 38 (7%), in the next nine years 1939-47 it fell from 38 to 24 (37%). This change was all the more remarkable because it took place mainly during the years of war and because it has not continued during the years of relative peace ; in the last four years, 1948-51, the stillbirth-rate has remained constant at 23. There are two ways of looking at these changes. On the one hand it may be said that what has happened is no more than was to be expected. The improvement in the technical quality of the maternity service consequent on the better control of sepsis, the use of antibiotics, and the improved facilities for blood-transfusion was bound to reduce the number of stillbirths just as it lowered maternal mortality 23 ; and delay of a few years between cause and full effect need not surprise us. Though the beneficial effect of the antibiotics, &c., were soon apparent, obstetricians had to tread warily when it came to testing the many other new measures that were the logical outcome of these changes. For example, the expectant treatment of some cases of antepartum haemorrhage, and the extended use of cæsarean section to include cases
actually infected, were to practice ; but during the
become part of obstetric years under review these methods were still on trial, and no material decline in the number of stillbirths could have been expected until they were firmly established. Such might be some of the arguments supporting a close relation between the quality of obstetric practice and the stillbirth-rate. On the other hand, it may be argued that this is only half the picture. The stillbirthrate of late years has failed to keep pace in its decline with the maternal-mortality rate, and there are other findings which together suggest that social conditions and change are also important and that the influence of environment on the stillbirth-rate should be examined in some detail.
potentially
or
19. Dowburn, R. Y., Earlham, F., Evans, W. H.
J. Path. Bact.
1928, 31, 833.
20. Gilligan, D. R., Ernstein, A. C. 552.
Amer. J. med. Sci. 1934, 187,
21. Wright, H. P. J. Path. Bact. 1942, 54, 461. 22. Donnelly, J., Radley-Smith, E. J. Lancet, 1950, ii, 904. 23. See Lancet, 1952, i, 85.
reasonable to suppose that those enjoying standard of living will show a better reprohigh ductive performance than those with a low standard of living. If this is so, may it not be that most of the decline in the number of stillbirths during the war and immediate post-war years should be ascribed to the social changes in the years in question ? This period saw the virtual elimination of unemployment, with an increase in the amount of money spent on food, which, together with food rationing and the system of priorities, ensured for the expectant mother her fair and proper share. Such a hypothesis could explain the abrupt check in 1948 to the rapid decline in the stillbirth-rate. The previous year, 1947, it will be remembered, was a disastrous year of prolonged winter, severe flooding, and drought, in which dairy produce, meat, eggs and egg products, and oils and fats were all scarce.24 The main question to be answered in regard to stillbirths may well be not so much whether social conditions are important as whether they are more or less important than those matters of a more technical or strictly obstetrical nature ; and there is perhaps some urgency in seeking an answer, because the stillbirth-rate is no longer declining, and because further striking improvements in the technical quality of the obstetric service are improbable-at least such as those we have witnessed in the last fifteen years. Stillbirths have been registered in England and Wales since the Births and Deaths Registration Act, 1926, which came into force in 1927, and in Scotland since 1939, and many trends in the national figures have been detected. For example, it is known that the stillbirth-rate is adversely affected by low social class and, broadly speaking, by advancing age after 25, by primiparity, and by’ increasing multiparity after the second child; it is also known 25 that the stillbirth-rate is similarly affected by decreasing height (or more particularly leg length) of the mothera physical characteristic which in its turn is closely related to expenditure on food. Illegitimacy increases the likelihood of stillbirth, especially if the mother is under the age of 30, as also do unemployment and poorly paid work, though not overcrowding 2s ; and there are striking geographical differences in the stillbirth-rate. 27 A poor environment and consequent lack of proper food and amenities can only be harmful to reproductive function, and may well be more harmful than factors more strictly obstetrical. It is not yet clear, however, at what age the woman is most vulnerable. Is it when she is a growing girl this be the case we have to look back many years (if for the explanation of recent trends), or is the environmental effect more harmful when acting during pregnancy ? Whatever the answer, it is clearly important that a constant watch be kept on the diet of growing girls and adult women. As the first report of the Expert Committee on Maternity Care28 says, " where food is in short supply the expectant and nursing mother and the child are the first groups in the community to suffer." It
seems
a
H.M. Stationery 24. The Urban Working-class Household Diet. Office, 1951 ; p. 56. 25. Baird, D. New Engl. J. Med. 1952, 246, 561 ; see also Lancet, 1947, ii, 531 ; 1949, i, 1079. 26. Sutherland, I. Stillbirths. London, 1949 ; see also Lancet, 1946, ii, 953. 27. Munro Kerr, J. M., Moir, J. C. Operative Obstetrics. London, 1949 ; p. 927. 28. World Health Organisation. Geneva, 1952.
that in the
great majority of patients with otitic hydrocephalus the ventricles are of normal size, the hydrocephalus- being a communicating one with an equal rise of cerebrospinal-fluid pressure inside and outside the brain. The prognosis in these cases is almost uniformly good ; the papilloedema and raised infection undoubtedly plays a part. Cross-resistance intracranial pressure gradually subside, owing to between aureomycin and terramycin, which are recanalisation of the thrombus. Occasionally, howclosely related, is common ; but resistance between ever, optic atrophy with failure of vision takes place these two substances and chloramphenicol is more before the natural recession of the papilloedema. to The usual treatment is repeated lumbar puncture to resistance increased irregular. - Strangely enough, this group of drugs may be accompanied- by enhanced reduce the intracranial pressure; commonly the sensitivity to streptomycin or penicillin. pressure falls after two or three punctures, but in The latest observations on the synergistic and some cases puncture may have to be repeated for antagonistic activities of drugs and the development several weeks. In general this treatment is safe, but of resistance8 and cross-resistance should stimulate SYMONDS 13 - has recently described a patient with further study of their mode of action on bacteria, about otitic hydrocephalus who died shortly after lumbar which we still know remarkably little. Meanwhile, puncture. Probably this was a result of cerebral what has already been learnt should serve as a oedema with tentorial herniation due to withdrawal deterrent to the indiscriminate use of these drugs ; of cerebrospinal fluid ; and he advises that the fluid for they are not only very expensive but have a should be withdrawn slowly and the pressure not be selective action against infections, most of which allowed to fall below 150 mm. water. terminated satisfactorily in the pre-antibiotic era. Another complication of otitis media, which may arise in association with otitic hydrocephalus or apart Intracranial Thrombophlebitis from it, is Gradenigo’s syndrome, in which a sixthIN the past twenty years thrombosis of cerebral nerve palsy develops on the side of the infected ear. veins and of the dural sinuses, particularly the This condition is probably also due to thrombosis of a superior longitudinal sinus, has been increasingly sinus-the inferior petrosal sinus. 13 This sinus and the recognised as a cause of sudden episodes of focal neuro- sixth nerve pass from the posterior to the middle fossa raised intracranial pressure. logical disturbance and through a tightly fitting dural sheath-Dorello’s In 1912 PASSOT9 described a syndrome which canal-and the palsy results from compression of the occasionally followed otitis media and was charac- nerve by the thrombosed sinus, the nerve recovering terised by headache, drowsiness, and papilloedema its function as the sinus becomes recanalised. without pyrexia or signs of meningeal irritation ; Thrombophlebitis of superficial cerebral veins may the pressure of the cerebrospinal fluid was raised but occur in association with infection in the ear or nasal its constituents were normal. The condition was not, sinuses or with localised or generalised infections elsehowever, generally recognised until 1931 when where in the body’41-5; and here the usual clinical SYMONDS10 described again the clinical features, picture is of focal epileptic attacks followed by loss of emphasised that the prognosis was good, and named function of the parts of the body involved in the the disorder otitic hydrocephalus. A few years later attack. More rarely hemiplegia or aphasia may he suggested 11 that the cause of the raised intracranial develop suddenly without preceding- epilepsy. Often pressure was thrombosis of the superior longitudinal there are general symptoms of infection, and the sinus, basing this view on the presence of thrombosis cerebrospinal fluid may show a cellular reaction, unlike of the lateral sinus on the side of the affected ear in a the state with sinus thrombosis where the fluid is high proportion of the cases in which the mastoid was usually normal. The diagnosis from a cerebral abscess explored, and on the necropsy findings in a case may be difficult, and indeed an abscess may occasiondescribed by BAILEY and HASS 12 in which thrombosis ally follow cerebral thrombophlebitis. With the of the lateral sinus had spread to the superior longiadministration of antibiotics, however, the majority tudinal sinus with resulting papilloedema and raised of patients make a good recovery, though there may intracranial pressure. This view of the pathology of be residual hemiparesis or hemianopia, depending on otitic hydrocephalus is now generally accepted. The the part of the brain involved and the extent of brain raised intracranial pressure with thrombosis of damage. the superior longitudinal sinus may be due to Intracranial thrombophlebitis also occasionally either of two mechanisms. The clot may spread comes on during the puerperium 16; and possibly the from one lateral sinus to the torcula and in this way sudden cerebral vascularcatastrophes after childbirth shut off the opposite lateral sinus and obstruct the described by MÉNIÈRE17 in 1828 were of this nature. main venous return from the cranial cavity. with MARTIN 18 has suggested that in these cases subsequent cedema of the brain ; or, alternatively, the starting-point may be thrombosis inpuerperal a pelvic vein, clot in the superior longitudinal sinus may block the and that a detached fragment of clot may pass as an arachnoid villi and in this way impede the absorption embolus up the extrathecal vertebral plexus of veins, of cerebrospinal fluid. Ventriculography has shown which is largely without valves and communicates with 7. Clarke, S. K. R., P. .
Dalgleish,
G., Gillespie, W.A., Lancet, 1952,
i. 1132. 7A.
8. 9. 10. 11. 12.
Thomson, E. F. 1952, i, 870.
J. clin.
Path. 1952, 5, 169 ;
the intracranial
venous
sinuses.
KENDALL,15
on
Med. J. Aust.
Eagle, H., Fleischmann, R., Levy, M., J. Bact. 1952, 63, 623. Passot, R. These de Paris, 1912. Symonds, C. P. Brain, 1931. 54, 55. Symonds, C. P. Ibid, 1937, 60, 531. Bailey, O. T., Hass, G. M. Ibid, p. 293.
13. 14. 15. 16. 17.
Symonds, C. P. Ann. R. Coll. Surg. 1952, 10, 347. Symonds, C. P. Brit. med. J. 1940, ii, 348. Kendall, D. Brain, 1948, 71, 386. Martin, J. P., Sheehan, H. L. Brit. med. J. 1941, i, 349. Ménière, P. Arch. gén. Méd. 1828, 16, 489. 18. Martin, J. P. Proc. R. Soc. Med. 1944, 37, 383.
the
175
other hand, has pointed out that in the puerperium There some factors favour " primary " thrombosis. is an increase of blood-platelets,19 especially if there has been severe postpartum haemorrhage ; the plasmafibrinogen is raised20;and there is increased " stickiof the circulating blood,21 possibly owing to an ness increased number of newly formed cells. These factors would all enhance the tendency to thrombosis. n the presence of damage to the endothelium of intracranial veins or sinuses, which might occur during labour. In this connection it is interesting that thrombosis of intracranial venous sinuses has been reported following combined insulin-induced hypoglycaemia and electric convulsive therapy 22 in the The suggestion was treatment of schizophrenia. that the endothelium was damaged during the fits, and thrombosis was precipitated by the dehydration from sweating and salivation during hypoglycsemia. "
Stillbirth and Social Conditions PROGRESS, like growth, is a thing of fits and startsand stops ; and no better illustration of this can be found than the behaviour of the stillbirth-rate in recent years. Whereas during the nine years 1931-39 the rate scarcely declined, falling from 41 to 38 (7%), in the next nine years 1939-47 it fell from 38 to 24 (37%). This change was all the more remarkable because it took place mainly during the years of war and because it has not continued during the years of relative peace ; in the last four years, 1948-51, the stillbirth-rate has remained constant at 23. There are two ways of looking at these changes. On the one hand it may be said that what has happened is no more than was to be expected. The improvement in the technical quality of the maternity service consequent on the better control of sepsis, the use of antibiotics, and the improved facilities for blood-transfusion was bound to reduce the number of stillbirths just as it lowered maternal mortality 23 ; and delay of a few years between cause and full effect need not surprise us. Though the beneficial effect of the antibiotics, &c., were soon apparent, obstetricians had to tread warily when it came to testing the many other new measures that were the logical outcome of these changes. For example, the expectant treatment of some cases of antepartum haemorrhage, and the extended use of cæsarean section to include cases
actually infected, were to practice ; but during the
become part of obstetric years under review these methods were still on trial, and no material decline in the number of stillbirths could have been expected until they were firmly established. Such might be some of the arguments supporting a close relation between the quality of obstetric practice and the stillbirth-rate. On the other hand, it may be argued that this is only half the picture. The stillbirthrate of late years has failed to keep pace in its decline with the maternal-mortality rate, and there are other findings which together suggest that social conditions and change are also important and that the influence of environment on the stillbirth-rate should be examined in some detail.
potentially
or
19. Dowburn, R. Y., Earlham, F., Evans, W. H.
J. Path. Bact.
1928, 31, 833.
20. Gilligan, D. R., Ernstein, A. C. 552.
Amer. J. med. Sci. 1934, 187,
21. Wright, H. P. J. Path. Bact. 1942, 54, 461. 22. Donnelly, J., Radley-Smith, E. J. Lancet, 1950, ii, 904. 23. See Lancet, 1952, i, 85.
reasonable to suppose that those enjoying standard of living will show a better reprohigh ductive performance than those with a low standard of living. If this is so, may it not be that most of the decline in the number of stillbirths during the war and immediate post-war years should be ascribed to the social changes in the years in question ? This period saw the virtual elimination of unemployment, with an increase in the amount of money spent on food, which, together with food rationing and the system of priorities, ensured for the expectant mother her fair and proper share. Such a hypothesis could explain the abrupt check in 1948 to the rapid decline in the stillbirth-rate. The previous year, 1947, it will be remembered, was a disastrous year of prolonged winter, severe flooding, and drought, in which dairy produce, meat, eggs and egg products, and oils and fats were all scarce.24 The main question to be answered in regard to stillbirths may well be not so much whether social conditions are important as whether they are more or less important than those matters of a more technical or strictly obstetrical nature ; and there is perhaps some urgency in seeking an answer, because the stillbirth-rate is no longer declining, and because further striking improvements in the technical quality of the obstetric service are improbable-at least such as those we have witnessed in the last fifteen years. Stillbirths have been registered in England and Wales since the Births and Deaths Registration Act, 1926, which came into force in 1927, and in Scotland since 1939, and many trends in the national figures have been detected. For example, it is known that the stillbirth-rate is adversely affected by low social class and, broadly speaking, by advancing age after 25, by primiparity, and by’ increasing multiparity after the second child; it is also known 25 that the stillbirth-rate is similarly affected by decreasing height (or more particularly leg length) of the mothera physical characteristic which in its turn is closely related to expenditure on food. Illegitimacy increases the likelihood of stillbirth, especially if the mother is under the age of 30, as also do unemployment and poorly paid work, though not overcrowding 2s ; and there are striking geographical differences in the stillbirth-rate. 27 A poor environment and consequent lack of proper food and amenities can only be harmful to reproductive function, and may well be more harmful than factors more strictly obstetrical. It is not yet clear, however, at what age the woman is most vulnerable. Is it when she is a growing girl this be the case we have to look back many years (if for the explanation of recent trends), or is the environmental effect more harmful when acting during pregnancy ? Whatever the answer, it is clearly important that a constant watch be kept on the diet of growing girls and adult women. As the first report of the Expert Committee on Maternity Care28 says, " where food is in short supply the expectant and nursing mother and the child are the first groups in the community to suffer." It
seems
a
H.M. Stationery 24. The Urban Working-class Household Diet. Office, 1951 ; p. 56. 25. Baird, D. New Engl. J. Med. 1952, 246, 561 ; see also Lancet, 1947, ii, 531 ; 1949, i, 1079. 26. Sutherland, I. Stillbirths. London, 1949 ; see also Lancet, 1946, ii, 953. 27. Munro Kerr, J. M., Moir, J. C. Operative Obstetrics. London, 1949 ; p. 927. 28. World Health Organisation. Geneva, 1952.