Layton, E. N.

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HEMATOMA OF THE NEW BORN.THERESA BANNAN, M.D.SYRACUSE, N. Y.Case 1.\p=m-\T. P. was born Aug. 20, 1893, at Hospital of theGood Shepherd; weight 4% lbs. The mother was a primi-para, labor was uneventful.History\p=m-\Onthe second day jaundice occurred. On the sameday a swelling appeared over the right parietal bone, followedsoon by a similar tumor over the left parietal. Both increasedin size and were limited and separated by the parietal sutureuntil the fifth day.Dr. John Van Duyn photographed the child and aspiratedthe tumors, finding blood. The jaundice deepened, the stoolbecame green, child grew weaker, and died on the ninth day.Autopsy.\p=m-\Postmortemby Dr. Van Duyn showed infant verythin and yellow; the internal organs were normal. The tumorswere beneath the pericranium and contained about six ouncesof fluid clotted blood (Fig. 1).Case 2.\p=m-\T.K. was born March 17, 1906; weight 9 lbs.History.\p=m-\Thelabor, in a primipara, was characterized byshort pains, some delay at the inferior strait, and scantyamniotic fluid. The pelvis was large and roomy, the soft partsdistensible. The cord was around the neck and there was someasphyxia neonatorum. The child's body was long and thin, andthe head of the average size. On the second day a swelling ap-peared over the right parietal bone, and on the third day asimilar swelling occurred over the occipital. Both increased insize and were separated from each other by a narrow strip atthe suture, until the fifth day. The parietal tumor, which wasthe larger, covered the greater part of the parietal bone androse 1% inches or more above the surrounding level. It wasovoid, limited in the median line by the suture. The occipitaltumor was circular and it seemed as if the two must coalesce.The baby was slightly yellow for two or three days, but seemedotherwise perfectly well and nursed and cried with vigor. Theoccipital swelling receded rapidly, the parietal more slowly.Fig. 1.—Infant In Case 1, 5 days' old.When the child was one month old the tumors were as theyappear in Figure 2; one was nearly gone, the other was muchreduced in size.It was assumed that these tumors contained blood be-cause of their characteristic appearance. They weresmooth, tense, fluctuating, sharply outlined, limited byRead before the Syracuse Academy of Medicine, April 17, 1900.the sutures, unaffected by change of position and withthe base as extensive as the greatest circumference, ap-parently painless, and occurring after birth. They arefree from the scalp which they lift almost at right anglesto the skull. The circumference of the base of thesetumors feels like an edge of bone marking an opening inthe skull beneath the tumor mass. At birth, however, ifthe child's head had been examined and found normalthe evidence is contradictory. So, too, when the tumorgradually increasing in size changes its circumferenceFig. 2.—Infant in Case 2, aged 1 month.there is a sensation of an opening in the skull, where »few hours before was palpable bone.The cause of these tumors might be interesting ifknown. Theoretically, pressure during labor or by theforceps might be the cause. In practice, however, severelabors and instrumental deliveries are not as a rulefollowed by hematomata. No treatment except hygienicseems indicated.503 Warren Street.A CASE OF ISOLATED PALSY OF THEEIGHT EXTERNAL RECTUS.E. N. LAYTON, A.M., M.D.Instructor in Clinical Neurology in Northwestern UniversityMedical School.CHICAGO.Patient.\p=m-\Mrs. J. R., a house-wife, aged 25.Family History.\p=m-\Her father died at about fifty years ofage of some acute illness; her mother is living and well, andis about 56 years old; two brothers and one sister are livingand well. There is no hereditary taint.Previous History.\p=m-\Thepatient had cervical adenitis when achild, the glands broke down and opened spontaneously, andhealed with considerable scarring, but quite promptly. Shehas had what she describes as "sick headaches" all her life.The pain is of sudden onset, is neuralgic in character, locatedover the left temple, left side of forehead and extendingthrough the left eye and ear; the teeth and face are not in-volved. The attacks come on irregularly every two or threeweeks and last from one to three days. During one of theseseizures the patient is completely prostrated, is weak, dizzyand unable to hold up her head. Nausea always accompaniesDownloaded From: http://jama.jamanetwork.com/ by a Simon Fraser University User  on 06/09/2015an attack and vomiting frequently occurs. For two or threedays after such an attack she is weak, tired and drowsy,from this time until the onset of another "spell" she is entire-ly free from pain and enjoys the best of health. These attacksare, of course, typical of migraine, although there is none tohe found in any other of her family or relatives.Recently she had an attack of grip, from which she believesshe has recovered, although she feels a good deal "rundown."Her menstrual history is negative; the periods began atfourteen years, are of the twenty-eight-day type, moderate inamount and never very painful. She has one child ninemonths old, born spontaneously at term and at present quitehearty and well. There have been no abortions or prematurelabors. No venereal infection is acknowledged. Her bowelswere always regular until her pregnancy, but have been slight-ly constipated since.Present Illness.—The onset occurred while she was still feel-ing very poorly after the rather severe attack of influenzafrom which she was just recovering, and while suffering fromone of her periodic headaches. The patient was walking alongthe street when she became aware that her vision was notso acute as usual ; then she began to have difficulty in pass-ing the people whom she met and several times collided withthem and with lamp-posts and buildings. She then noticedthat she was "seeing double," and came to my office greatlyagitated, believing she was about to become blind. There wasno other subjective complaint, except a dull frontal headache,which she believed to be of the type ordinarily troubling her ;she did not associate this pain with the eye trouble.Examination.—This showed a robust, well-nourished youngwoman ; the skin was cool and moist ; pulse, 90, soft, full andtegular; temperature 98.6°, respiration, 22; she appeared tobe much wrought up mentally. Speech was normal, but showedevident excitement and concern.Subjective Symptoms: There was dull pain over both eyes,being a little worse on the .eft side, as is usual in her migrati-ons attacks. Vision was not acute, and she found that shecould see very much better with the left eye alone than withthe right alone, or with both eyes; also that with both eyesopen, she could see much better by turning the head far tothe right.Objective Sensation: This was undisturbed (tactile, pain,temperature, stereognosis, muscle-sense.)Gait: The gait was a little uncertain with both eyes open,and she said that she was afraid all the time of bumpingagainst something. There was no staggering, no rigidity,spasticity or ataxia.Reflexes : The reflexes were all normal and equal : therewas no Babinski or Gordon reflex and no ankle-clonus.Tremor: A tremor of the protruded fingers was apparent,rapid and coarse in character. (This was never present insubsequent examinations and was due to her excitement ). Thetongue, lips and eyelids were negative as to tremor.Coordination: Coordination (as in touching tip of nosewith extended index finger; approximating tips of fingers,etc.) was normal. She was unable to execute any very finemovements, such as threading a needle, cutting accuratelywith the shears, etc. The sphincters were not disturbed.Special senses: The hearing was normally acute; taste andsmell were unaffected.Eyes: The left eye was normal in vision, field and move-ments. There was no ptosis and both lids followed their globesfreely and normally.The right eye showed a convergent squint entirely inde-pendent of the left eye. She could turn the right eye normallyto the nasal side and w-as then able to abduct it through onlyabout 30° ; movements up and down were free and normal inextent. Vision was 20/60 and very easily fatigued.The two pupils were of equal size and reacted normally tolight and accommodation. There was no nystagmus; bothfundí were normal. The distribution* of the fifth nerve wasi,ot involved, there was no facial asymmetry.Mentality.- The mental state was normal; memory, con-sciousness and sleep were natural and undisturbed; there wereno hallucinations or delusions.Diagnosis.—The clinical diagnosis is, therefore, an isolatedparalysis, or strictly, a paresis, of the right sixth cranialnerve, the abducens, there being no involvement of either thethird or fourth nerves.The findings already detailed will serve to locate the causa-tive lesion. To sum up, there was a paralysis of the rightexternal rectus muscle alone; no involvement of the otherrecti, Ihe superior oblique or of the palpebral muscles, thusruling out a lesion encroaching on the third or fourth nerve.The fundi and discs of both eyes were negative. If it werea central (cerebral) lesion, the distribution in the muscles andsensory terminals would be much more extensive. It was notlocated in the nucleus of the nerve affected, for in such a easethe movement of the other eye to the nasal side is impaired.It was not located at the most common site of such lesions.namely at the sphenoida] fissure, for if that were the case, itwould almost certainly have involved the inferior and pos-sibly the superior division of the third, or even the fourthand the frontal and nasal branches of the fifth, all of whichare in such intimate relation in this narrow passage. Thelesion was, then, distal to the sphenoidal fissure and involvedthe sixth nerve alone—an isolated peripheral neuritis.The pathologic process was probably a simple neuritis andperi-neuritis of rheumatic or influenzal origin, following theattack of general systemic influenza from which the patientsuffered two weeks before the onset of the present trouble.Hemorrhage at this point is extremely rare, would have beenmuch more gradual in its manifestation and, in all prob-ability, would have involved the other related structures; thereis no history of trauma and no history or evidence of arterialdisease. A neoplasm would have caused very gradually in-creasing symptoms, among which pain would have been pre-eminent; the onset would have extended over months or years.and ultimately the related structures would have become in-volved. There is no evidence of present or past syphilitic in-fection; she is a total abstainer from alcoholics and temper-ate in all her habits.Course of Illness.—The illness extended over nine weeks,from the onset until the recovery of normal visual and motorpower in the affected eye. The improvement was steady andthe recovery complete and there has been no hint of recur-rence after eleven months. The general health of the patientis excellent, with the exception of an occasional paroxysm ofthe old pain in the head.Treatment.—Fifteen-grain doses of potassium iodid everysix hours for four days had no appreciable effect. To thiswas then added one-thirtieth grain of strychnia four timess day, and after ten days, when the condition was undoubtedlyno longer progressive, a five to eight milliampere galvanic cur-rent was applied over the temporal and ocular regions. Thiswas used on alternate days for fifteen minutes at a timethroughout the remainder of the course of the disease. Thepatient experienced almost immediate benefit from this cur-rent and after the third application there was an appreciableincrease in the power of abduction in the affected eye. Dur-ing this same period, the fluid extract of cannabis indica wasgiven in capsule, beginning with three minims and graduallyincreasing the dosage up to ten minims three times a day, forthe migraine. The headaches were much improved and at theend of the treatment of the ocular palsy, the patient had beenfree from these prostrating attacks for six weeks. They havesince recurred, in less degree, but are always promptly re-lieved by the cannabis indica. The patient was under mycare for nine weeks, at the end of which time all movementsof both eyes were normal and vision perfect, there being nopain or diplopia.Remarks.—From a careful study of this case as here pre-sented, I believe the diagnosis of paresis of the right externalrectus oculi due to an isolated influenzal neuritis of the rightabducens, peripheral to the sphenoidal fissure, is clearly justi-fied, and is so infrequent in clinical experience and the litera-ture as to merit such extended notice.1125 West 51st Street.Downloaded From: http://jama.jamanetwork.com/ by a Simon Fraser University User  on 06/09/2015

A Case of Isolated Palsy of the Eight External Rectus.

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A Case of Isolated Palsy of the Eight External Rectus.

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