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during delivery; for Naegele and M. P. Dubois have seen it appear after easy deliveries, during which the head of the fœtus had not experienced any remarkable pressure. Michaelis and Palletta considered s. that cephalaæmatoma was the result of a disease of the bone previous to birth, because a bony circle often existed at the base of the tumour, which was looked upon as of old formation. But the bony circle does not always exist, and there is no appreciable altera-istade tion of the bone. Naegele supposes a rupture of the vessels of the bone containing blood which forms a small effusion, increased at birth by the establishment of the respiration, and the immense activity given to the circulation. M. P. Dubois attributes the development of cephalæmatoma to a simple separation of the pericranium, occasioned u by some violence, a separation which, by leaving pervious the numerous orifices of the vessels of the bone, allows the blood to accumulate

Jubeis beneath the pericranium, forming a collection of blood of greater or Simple

less size. M. P. Dubois reasonably brings forward to the support

of this ingenious explanation, the results of experiments which consist

in elevating a portion of the pericranium, and in injecting a liquid an into the middle meningial artery, which is observed to appear, and

to escape by the porosities and openings of the external table of the bone.

ANATOMICAL LESIONS.

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After having incised the scalp and the subjacent aponeurosis, which presents nothing particular, we arrive at the pericranium raised by the hæmorrhage. Ecchymoses exist on the surface and in the cellular tissue situated above it. The pericranium remains transparent, and is simply thickened; its internal surface is shining like a serous membrane, and is, in fact, lined by an exceedingly delicate membrane, discovered by M. Valleix, and in which numerous fibro-plastic elements are found. The surface of the bone is also shining, and covered by a similar membrane to the preceding one, having the same structure and being continuous with it, so that there is in the interior of the cephalæmatoma, according to M. Valleix, an adventitious membrane enveloping the clot of blood on all sides. I thought I had observed the same disposition in a cephalæmatoma presented by M. Morel pinal to the Society of Biology; but an examination made in the interim by M. Ch. Robin, demonstrated to me that if there had been a false membrane adherent to the pericranium, and a precisely similar one adherent to the bone, these two membranes did not become continuous with each other at the circumference of the tumour, as had been stated. M. Robin added, that around the tumour there was only amorphous fibrine, and no fibro-plastic tissue, announcing the existence of a false membrane.

The bone on which the effusion of blood is observed, sometimes

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[Part III. wing presents more or less apparent asperities, but no caries or necrosis; it is often shining and polished like ivory. Caries and necrosis are the only met with when the disease is of long standing, and when suppura

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tion has existed some time.

Lastly, around the effusion at the base of the tumour, a circular elevation often exists, appreciable during life, formed by an osteophyte, that is to say, a bony production of new formation.

This bony ring, circle, or elevation, its designation is of little importance, is never more than one line in thickness and two or three

Regele z in breadth. It surrounds the cephalaematoma in its entire circumference
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beneath the pericranium, and according to M. Valleix, it would be separated from the clot by the thin and delicate membrane which envelops it. It adheres rather strongly to the bone, from which it may be separated. It is hard to cut, and presents all the appearances of a recent osseous production. It scarcely exists around commencing Fatdet af cephalematoma, it is very evident at the end of several days when fident

the disease is well characterized.

Sun Once, in a case, different from the one just alluded to, M. Morel

exhibited to the Society of Biology the bony swelling of a cephalama

toma existing only at one side of the tumour and not on the opposite side.

G&G The effused blood varies in weight from seven drachms to eight ounces, it is sometimes black and liquid, sometimes black and coagulated, already presenting a commencement of decolouration; it is sometimes mixed with a small quantity of pus.

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SYMPTOMS.

Cephalæmatoma is formed in preference on the parietal bones, more frequently on the right side than the left, sometimes on both sides; it has been observed on the occipital, temporal, and frontal bones; but these instances are more rare. The blood generally remains collected on one bone and does not extend to the neighbouring one. The effusion appears to be limited by the sutures, however it may overstep these and extend from one bone to another. M. Ducrest has observed, a still more curious circumstance, this effusion situated on the parietal bone extend to the bi-parietal suture, pass through it, then beneath the opposite parietal bone, between this bone and the dura mater.

The cephalæmatoma appears in the shape of an indolent wellcircumscribed, soft, fluctuating tumour, without any change in the colour of the skin. It often commences before parturition, for it may already exist at the time even when the child is about to be born; but in other cases it is only observed from the first to the fourth day after the birth. It becomes raised, progressively enlarges, and becomes fuller without extending much beyond the size of a nut or

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Book II, Chap. IV.]

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At the commencement it is sometimes the seat of

evident pulsations which soon disappear. Its size gradually diminishes appears and finally disappears, without leaving any traces of its existence.

The epicranial cephalæmatoma often presents an osseous circle atent the base which separates it from the adjoining parts. The presence ang of this circle has been the subject of some contradictions. Although.

its existence is not constant, it is not on that account the less real,' and it is in my opinion connected with the age of the cephalæmatoma. This circle is scarcely apparent at the commencement of the disease, but it becomes more so at the end of some days. Thus M. Fortin

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found on the left parietal bone of a child, even before the delivery ung as

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was terminated, a cephalæmatoma of the size of a pigeon's egg. re Immediately after the birth he ascertained that there was no bony swelling, and two days afterwards he discovered a very evident one. 92ons [Dr. Weber (Beitrage zur Pathologischen Anatomie der Neugebornen) appears to participate in the views of Valleix, who considers that "the ecchymosis' is due to circular pressure, which can only be exerted by the neck of the uterus; M. Valleix admitting, however, the exceptional cases, in which the intervention of the osseous walls of the pelvis may act in producing the tumour. That the latter must be very rarely the case, this writer considering, is proved by the fact of cephalæmatoma almost always being observed after easy labours only. On the other hand, from this very circumstance, M. Pauli has sought to establish the influence of the bone of the pelvis, since the tumour only then occurs from the head of the infant being exposed to shocks and brusque pressure in rapid labours (Vide Fabre, Maladies des Enfants, t. ii, p. 220.) Again, in reference to the opinion of Valleix, it has been asked-How is it, the cause being constant and inevitable, that cephalæmatoma are not more frequently met with? The answer is, that the cases which are most favourable for their production are those in which a very large extent of the parietal surface of the head presents at the neck of the uterus, to the exclusion of other portions of the cranium; and such cases are sufficiently rare. Out of seventy-four examples, Bednàr (Die Krankheiten der Neugebornen, &c., p. 175) found the tumour forty times over the right, twenty-two over the left parietal bone, and six over each; four times over the occipital, once both over both parietals and the occipital, and once over the frontal bone. The tumour reached its largest circumference over the parietal, and its smallest over the frontal bone. It was the opinion of many of the older writers that cephalæmatoma was always connected with primitive disease of the cranial bones. Such opinion had its origin in the following facts: On examining the tumour during life, soon after it appears, a hard and apparently bony ridge is felt running round and limiting its base, and on post mortem inspection the surface of the bone beneath it is found in many cases to present appearances very different from usual or healthy structure. This ridge was assumed by many (Michaelis, Paletta, Dzondi, &c.) to be the limit or edge of the external table of the bone deficient from vice of conformation, or destroyed by caries. Naegele, in 1819, was the first to dispute the necessary connection of the tumour with lesion of the bone, having seen cases "in which the bones were quite sound and smooth." In later times different views have been held upon the matter. The existence of the ridge, in most cases, if not in all, an unusual condition of the upper surface of the bone in some, and a healthy state of it in other instances, are now generally admitted to occur. But what is the nature of this ridge, and what are

the relations of cause and effect between the appearance of the surface of the bone and the sanguinnolent or other extravasation or tumour? Opposing themselves to the views of the earlier observers before alluded to (Michaelis, &c.), Zeller and Pignè regard the ridge as resulting from the pressure of the effused liquid on the bone within its circle; Dubois considers it formed by indurated or diseased periosteum; Carus as the reflected edge of the latter; Krause believes it to be a true osseous ring; Valleix an osseous pad or cushion (bourrelet); whilst Busch, Wokurka, and Bartsch, refer it to "une pure hallucination de toucher!"- Fabre, Op. Cit. Finally, M. Doepp (Annales de la Chirurg. Franc. et Etrang. t. x, 1844), from observations made on two hundred and fifty-five children, asserts that in the vast majority of cases the ridge in question has its origin in coagulation of the blood, precisely at that spot where the periosteum, elevated by the effusion, begins to separate itself from the cranial bone. M. Dopp, however, admits that in certain and rare cases, when the tumour has remained in existence a long time, the superior table of the skull disappears from absorption, or is destroyed by caries, and that in such instances the ridge may indicate the limits between the locality of the deficient bone and that which remains in sound condition. A modification of M. Doepp's views is now received by many pathologists as the true explanation of the matter. It is admitted that the blood in the tumour quickly coagulates and that the edge of the coagulum imparts to the touch the sensation of a peripheral ring; but that the firm and hard ring, felt as the tumour gets older, is the result of a reparative process, in the course of which a fibrinous exudation is poured out, and heaped up in great abundance at the place before indicated; in some cases also, bony matter is deposited in this fibrinous ridge, so as really to cause it to be an osseous circle. (Vide Lectures on tate Diseases of Infancy and Childhood, by Dr. West, edit. 2nd, p. 39. Also, Medico Chirurgical Transactions, vol. xxviii.) Admitting that there are cases in which an original abnormal condition of the bone exists, predisposing to the formation of a sanguinnolent tumour, yet it appears to be the fact, that in a very great majority the appearances of osseous disease are truly the effect of the extravasation and not its cause; an effect seen in the destruction of the surface of the bone by pressure in one set of cases, and in another evinced by an attempt at separation being made, "bony plates" being formed at the spot where extravasation existed, causing the surface of the bone to appear as if roughened by ulcerations or caries. Ibid. British and Foreign Medico Chirurgical Review, vol. x, p. 9.—P.H.B.]

PROGRESS-TERMINATION.

If the blood contained in a cephalæmatoma is not let out by an operation, it may be absorbed and the tumour disappears. When this termination does not take place, an inflammatory process is established, in consequence of which pus becomes formed, which escapes externally, and the child may then recover. But sometimes, as Hore, Naegele, and Kopp have observed, the bone which supports the tumour becomes diseased, is attacked with necrosis and is perforated. Once, Hære remarked this perforation of the bone occasioned cerebral hernia.

PROGNOSIS.

Cephalæmatoma is a serious lesion, being very often fatal, but which loses much of its importance if treated in a proper manner, and if as Naegele and Hore point out, the sac is opened early so as

to evacuate the blood contained therein and to favour the contraction of its walls.

TREATMENT.

No one has pointed out the therapeutic indications of epicranial cephalæmatoma more precisely than M. P. Dubois. A portion of the following is borrowed from him.

Three methods of treatment are recommended; some would bring on resolution, others suppuration, and, lastly, others the immediate evacuation of the tumour by an incision.

Resolution

The resolution of cephalæmatoma is sometimes the result of the Aberinte natural law taken advantage of by the efforts of the organism. It may be assisted by aromatic applications, wine, brandy, either pure or camphorated, sal ammoniac, acetate of lead, &c. If it takes place too slowly, and if, at the end of ten or twelve days, the tumour has not appreciably diminished, we should no longer delay, and the practitioner should have recourse to the operation.

Suppuration effected in the tumour is the method of treatment proposed by P. Moscati, adopted by Goelis and Palletta. The latter obtained this result by means of the seton. The base of the cephal

aematoma was pierced with a special needle, furnished with a narrow strip of linen. Blood, serosity, and lastly, pus escaped from the tumour; the suppuration was increased by an epispastic ointment, and at the end of fifteen days the cure was complete. This method is simple, and has no other inconvenience than that of sometimes occasioning a very considerable febrile attack.

Goelis employed caustic potash in order to act superficially on the skin, and to bring about the suppuration of the subjacent parts. It is a difficult remedy to manage in this way, it would, perhaps, be ' better to have recourse to a limited application of the actual cautery.

The evacuation of the cephalæmatoma by incision should only be employed when a tumour of large extent has scarcely diminished in size during the first ten or twelve days of the disease. Some make a puncture with a lancet, press out the blood from the tumour, and cover it with resolvent applications. Others, amongst whom may be ranked Michaelis, Naegele, and P. Dubois, practise a simple incision extending the whole length and depth of the cephalæmatoma down to the bone, remove the blood, draw the edges of the wound together by means of sticking plaster, and slightly compress the head with a moderately tight bandage, or simply with a linen cap, properly applied and fixed by a large bandage round the chin.

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