CEPHALHEMATOMA OF THE 
NEW-BORN. 
BY 
CHAS. WARRINGTON EARLE, M. Ik£ 
- ® 
cure AGO. 
Read before the Section on Diseases of Children, Cleveland, 
Ohio, 1883. 
Reprinted from the Journal of the American Medical Association. CEPH AL/E M ATOM A OF THE NEW-BORN. 
This is a soft, elastic, fluctuating tumor, generally 
painless, and situated upon one of the cranial bones. 
It takes place, it seems to me, with somewhat greater 
frequency than the literature of the subject would 
lead us to suppose. I have already seen six cases in 
twelve years' practice. 
It is stated by most writers, that in the great ma- 
jority of cases, indeed in almost all, the tumors have 
been upon the right parietal bone, inasmuch as it is 
this bone that is exposed to the pressure of the rigid 
os uteri in the greatest number of deliveries. Con- 
trary to the experience of other observers, five cases 
which I have seen have taken place upon the left 
parietal bone and one on the right. It has, in a 
few cases, been noticed upon both of the parietal 
bones, although this has not occurred in my practice. 
Professor Byford has observed at least one case of 
this kind, and Jacobi and other authorities make 
mention of a double cephalaematomae. 
The tumor has not, in my cases, made its appear- 
ance immediately after birth. From one to four 
days usually elapse before my attention has been 
called to the difficulty. 
When it is first noticed it is usually a soft and 
painless enlargement, but in the course of a few days 
a firm ridge is usually noticed surrounding its base. 
This ridge, which is almost, if not quite, pathogno- 
monic, is produced by the efforts of nature to repair 
the injury. 4 
The seat of the difficulty is between the bone 
proper and the periosteum, and the enlargement is 
caused by the rupture of a blood-vessel in this posi- 
tion. The hard ring which I have mentioned is 
bony material thrown out from the periosteum, and 
does not in every case contract evenly in all directions. 
In one or two cases I have noticed hard projections 
apparently springing toward the summit of the tumor 
with greater rapidity than in other places. 
As this deposit goes on, the tumor loses its soft 
fluctuating feel, and in the course of a few weeks 
nothing can be detected except a slight want of sym- 
metry in the two parietal bones, and even this usually 
disappears in a few months. 
We have been taught that this difficulty is caused 
by pressure upon the cranial surface by a rigid os 
uteri. In all probability the great majority of these 
cases are caused by this pressure, but from the fact 
that cephalaematoma have been observed in breech 
deliveries,1 it must be admitted that the rigid os 
does not, in every case, produce the tumor. 
It is possible, it appears to me, that, in addition to 
the pressure exerted by a rigid os uteri, and from 
injuries received by forceps, that there may exist in 
the blood-vessels a tendency to rupture with ease,- 
an undue thinness of these vessels, which produce 
a liability to haemorrhage. 
The most important question, however, connected 
with this entire subject is its diagnosis, and it appears 
to me that there are four difficulties with which it is 
liable to be confounded : 
1. Caput succedaneum. 
2. Congenital encephalocele or hernia cerebri. 
3. Erectile tumors. 
1 Vogel, p. 57. 5 
4. Craniotabes. 
There appears to be a tendency on the part of 
some writers upon the subject, to confound caput 
succedaneum with cephalsematoma. There is ab- 
solutely no similarity between the two difficulties, 
excepting, perhaps, that they are projections or 
enlargements upon a certain part of the head. 
The caput succedaneum is. an cedematous condition 
of the tissues, a difficulty of the scalp, cellular tissue 
and blood-vessels, etc., etc., which is usually found 
directly upon the presenting part, and may embrace 
one of the sutures. It does not fluctuate, and disap- 
pears rapidly. It is more prominent, more pointed, 
and has altogether a more boggy feel than the 
cephalaematoma. A cephaigematoma is a collec- 
tion of blood between bone and its periosteum. It 
never is in the line, of a suture. It fluctuates, and 
has every appearance of free fluid, surrounded by 
tissues. In the course of a few days, the bony ridge, 
to which I have already alluded, can be made out, 
and our diagnosis is complete. 
1 should remark before leaving this part of my sub- 
ject, that a caput succedaneum may hide a cephal- 
hematoma for three or four days. That is, we may 
have an ordinary cedernatous tumor on the presenting 
part of the head, and under this, and between the 
bone and its covering proper, a ruptured blood- 
vessel and a collection of fluid blood, which makes 
itself known after the oedema subsides. 
Congenital encephalocele never occurs, with pos- 
sibly an exception in necrosis from syphilis, in the 
body of the cranial bones. It always appears in the 
line of some suture. A pulsation is usually felt syn- 
chronous with the heart. Cries and agitation of the 
child cause it to enlarge. 6 
A vascular tumor has somewhat the same boggy 
feel which I have noticed in caput succedaneum. It 
may take place in the same position that we usually 
find a cephalaematoma, but it does not fluctuate. It 
has no bony ridge. It usually does not protrude as 
a cephalaematoma does. 
By craniotabes, is meant the soft places which are 
found upon the cranial bones in rickety children. It 
has appeared to me that a layer of bone in some 
of these children can be so thin, or can be absolutely 
wanting to such an extent that a softness and fluctu- 
ation could almost be made out, thus giving rise to 
the suspicion that a bloody tumor of the scalp existed 
at this point. Such a case as this never occurred in 
my practice, but it always appeared to me possible, 
and, in my teachings I have cautioned my students 
in this respect. 
Treatment.-The treatment of these cases really 
amounts to a judicious letting alone. Nature, in a 
great majority of the cases, cures this difficulty with- 
out any assistance. There is, however, on the part 
of parents and friends, a constant desire to interfere, 
and the physician will be importuned, in season and 
out of season, to poultice and blister and to open, 
and in every possible way interfere with the process 
that nature is following out to perfect a cure. 
Formerly it was regarded as good practice to open 
these tumors, but from the fact that a number of 
them thus opened were followed with long con- 
tinued suppuration and exhaustion, and, in some 
cases, death, it has more recently been regarded the 
best practice to not expose the internal part of the 
tumor to the air by opening them, but to allow nature 
to perfect a cure. Some mild anodyne liniment or 
embrocation may be ordered and the tumor should 7 
be protected from any external violence. Where the 
tension is very great, and the tumor somewhat larger 
than usual, and in cases where the child experiences 
considerable pain, it is probably better to depart 
from the usual methods of treatment, that of letting 
it alone, and with proper antiseptic precautions open 
the tumor, cleanse out the cavity and dress it in such 
a manner as to prevent, as nearly as possible, sup- 
puration. 
A case similar to this has recently been observed 
in the Cook County Hospital of Chicago, where the 
tumor became so painful that the child was kept from 
obtaining its usual rest, and its nutrition became 
very greatly impaired ; until finally an incision was 
made with the precautions which I have stated above 
and the child made an excellent recovery. 
What I desire to call attention to in this brief 
paper is, first, the greater frequency of this difficulty 
than we have hitherto supposed; secondly, the pres- 
ence of the tumor in the right parietal bone in five 
cases of the six I have seen ; third, to the four points 
of differential diagnosis; and, finally, that in a 
few cases, where the pain, swelling and tension be- 
comes very great, it is admissible, indeed, the best 
practice to open these enlargements and treat them 
antiseptically.