[Reprinted from The Medical News, September 6,1890.]

CEPHALH/EMA TOMA.

A Case of Sub-pericrania! Blood-tumor in the Newborn Child

HOWARD A. KELLY, M.D.,GYNECOLOGIST AND OBSTETRICIAN TO THE JOHNS HOPKINS HOSPITAL,

BALTIMORE.

My desire in reporting a case of this interestingdisease is not so much to place on record anotherexample of a rare affection, but rather to call theattention of the profession to one of the most im-portant, and as yet but rarely recognized diseases ofvery early childhood, as well as to prepare the wayfor a discussion of this subject at the meeting of theAmerican Gynecological Society, to be held onSeptember 16th of this year. Few men outside ofthe ranks of the pure specialists are aware that sucha disease as cephalhsematoma (cephalohsematoma)exists. Cases which occur in the practice of thegeneral practitioner are diagnosed and treated byhim upon “general principles.”

The information which he possesses upon thissubject is fairly comparable to that of a physicianpractising early in the last century.

A well-defined disease appearing soon after birth,running a brief, definite course, tending, as a rule,to resolution, but capable of seriously affecting thehealth, or even of implicating the life of the child,

2 KELLY,

must be a matter of interest to every medical man ;and the interest is heightened by the relative fre-quency of the disease (probably one in 250 obstetriccases), with the certainty that even a moderateobstetrical experience will sometimesurely bring oneor more cases under observation, and demand deci-sion as to their nature and the course to be pursued'

Our curiosity is still further aroused, and ourinterest enhanced, when we learn that we have herealso one of those curious examples of the tendency,felt even in scientific matters, of an important dis-covery to remain fora long time in the almost exclu-sive possession of its original promulgators, while, inthe face of the clearest demonstrations and the mostnumerous writings, surrounding nations long seemto ignore its existence.

Thus the discovery of cephalhaematoma datesfrom the close of the last century, when Dr.Michaelis, of Harburg, wrote in the second volumeof Loder's Journal, “ upon a peculiar kind of bloodtumor,” 1 giving a full, clear account of the affec-tion. This able article provoked within the suc-ceeding thirty years a host of other writings, andabundant records of cases, in various German jour-nals, and since that time cephalhsematoma has beenregularly registered among the more important dis-eases to which the newborn are liable.

In the following brief description of the disease,before illustrating my subject with the report ofa case, I will make free use of the language ofMichaelis.

1 “ Ueber eine eigene art von Blutgeschwiilsten."

CEPHALHEMATOMA.

Cephalhematoma (the name given to the diseaseby Naegele 1) is a circumscribed effusion of bloodbetween the periosteum and one of the flat cranialbones, appearing usually the day after birth, andgradually increasing in size until it forms a tense,prominent, rounded, or ovoid swelling. Its com-monest seat is over one or both parietal bones. Itis always lateral, never crossing a suture. The skinover the tumor remains movable and unaltered inappearance. The tumor is not painful, and doesnot decrease in size upon pressure. After two orthree weeks, as a rule, it gradually disappears byabsorption.

One of the most important diagnostic signs of thedisease is the existence of a bony wall, one or twomillimetres in height, which surrounds the wholeouter circumference of the tumor. This can bedistinctly felt through the skin, and gives at oncethe impression of a depressed fracture.

Injury usually has no apparent connection withthe origin of this tumor, which often appears afternatural, easy, and short labors, and upon a part ofthe head which was not prominent in the birth. In-stead of being absorbed the collection of bloodmay undergo suppuration, perforating the cranialcavity, or rupturing externally.

The earlier observers frequently incised thetumor, cleaned out the blood, and put on a com-press. The best treatment to-day is to wait for twoor three weeks for resolution by absorption, and, if

IV. Zeller: De Cephalhaematomate seu sanguineo craniitumore recensnatorum. Heidelberg, 1822.

4 KELLY,this should not take place, to incise and empty thesac under strict antiseptic precautions, and apply anantiseptic dressing. Whenever signs of suppurationarise the tumor should be freely opened at once,well washed out, and drained.

This, in brief, is the outline of the disease towhich I desire to call attention by this preliminarynote, in advance of a more formal, elaborate articleupon the same subject, prepared for the meetingof the American Gynecological Society. Thefollowing case recently came under my observa-tion :

I was called early one morning last June to attendMrs. A., primipara, forty-one years old. She wasof medium height, had a normal pelvis, and theuterus contained a living child.

She had had pains with great regularity during thepreceding night, with the effect of bringing the headwell into the pelvis, with the occiput to the left andanterior. The watershad already discharged throughthe os, which was dilated to about 2 centimetres.By noon the strong, regular pains had brought thehead to within an inch of the floor of the pelvis—-well flexed, and the flat bones extensively over-lapping. At this point the head became firmlywedged. From 1.38 to 7.25 o’clock in the eveningshe had 106 pains, without bringing the head a halfinch nearer the pelvic floor. The child was in goodcondition, but the mother seemed so exhausted that1 then gave her benumbing doses of chloroform byinhalation, and applied Naegele’s forceps. Byassisting each pain I delivered her after an hour, witha slight tear, entirely within the vagina and in the leftsulcus. The child was a female, weighing about3000 grammes. At the outer angle of its right eye

CEPHALHEMATOMA. 5

was a slight indentation in the skin from the pressureof the forceps, which disappeared in two days.

A large caput succedaneum covered the occipitalregion. No other deformity or evidence of injurywas visible. On the second day I observed a reni-form swelling over the most prominent portion ofthe right parietal bone, 6 cm. in length by 2.5 inbreadth, lying entirely within the border of thebone, which could be felt on all sides around theswelling. The concavity of its circumference lookeddownward toward the right ear, while its convexitywas more or less parallel with the sagittal suture.

Showing the position of the cephalhsematoma. Its relative sizeis greater than natural. The dotted triangles represent the bonyplates which formed in the pericranium as the tumor disappeared.

At first slightly elevated, the tumor distended intwo or three days, until it formed a prominent,rounded, tense sac. Its circumference did not appearto increase. Elasticity and fluctuation were dis-tinct. There was no pulsation.

Pressure was painful only upon being prolongedwhen the child became restless. It did not reducethe size of the tumor. The scalp over the tumorwas movable and unchanged in appearance. Sur-

6 CEPHALHEMATOMA.

rounding the whole margin of the tumor a distinctsharp ridge could be felt, and within this craterousorifice palpation at first conveyed the sensation thatthe bone was wanting. Deeper palpation, however,touched the bony floor, removing the deception.

The tumor thus formed resembled in shape apotato cut in half lengthwise and laid flat on thehead. It thus made a very conspicuous deformity,giving the head an extraordinary lop-sided appear-ance. The treatment was a policy of inactivity.

I did absolutely nothing to the tumor. In aboutten days it began to diminish in size, and in threeweeks and a half it had almost entirely disappeared.At this time there was still a slight elevation, and onpressure the fluid seemed to shoot under a parch-ment-like membrane. The borders felt rough, andfrom the upper margin two triangular plates pro-jected over the denuded bone, apparently lying inthe periosteum. Later no trace of the tumor couldbe detected.

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