Dr. J. A. Ouchterlony: I am reminded, hearing these reports, of some cases of the same kind that occurred in my own practice. I think I have had three cases of intra-uterine hydrocephalus, as far as I can remember. The first was one where it so often happens, owing to mal-distribution of weight of the two extremities of the child, there was also mal-position, and the child had been born all but its head; it was a breech presentation, the cord protruded, and was perfectly cold and pulseless, and the efforts that had been made very persistently to deliver the child's head had proved unavailing. I made an examination and convinced myself that it was a case of hydrocephalus. I introduced Thomas' perforator and emptied the cranial cavity of its contents, and then introduced Churchill's craniotomy forceps, simply twisted the flaccid tissues of the head around it, and delivered very easily.

Another case was one where the head presented, and the quantity of fluid the cranial cavity contained was excessive. The physicians in charge of the case had met with the same difficulty in applying forceps. that those who had charge of Dr. Cecil's case had encountered; and I may say in passing that when the forceps slip off over and over again it is one of the indications of hydrocephalus. In that case I did as in the first; I emptied the cranial cavity by means of Thomas' perforator, introduced Churchill's craniotomy forceps, and had no difficulty in bringing the child into the world. The force that you can apply by means of this instrument is considerable.

The third case I do not recall with sufficient clearness to make even a brief report of it; but these cases are interesting first of all because of their rarity, secondly because of the almost inevitable death of the child prior to delivery, and thirdly because of the ease with which ordinarily delivery can be accomplished when the nature of the case is recognized.

Dr. A. M. Vance: To-day I met a doctor from the country who told me of an obstetrical case which recently occurred in his county. The woman was forty-five years of age, a primipara, who had been in labor some hours without any progress. The physician in attendance applied forceps and made all the traction he could without result; he then called another doctor in consultation, and they both pulled on the forceps together without any effect; they then exerted greater traction, and succeeded in pulling the child's head off. One of the physicians then introduced his hand, and, after considerable manipulation (the child

evidently had been dead for a long time), succeeded in getting his hand into the child's thorax and endeavored to make traction upon the bony parts in this way, but made no progress whatever. In further manipulation he evidently perforated the diaphragm, and a great quantity of fluid was discharged, and finally after working a good while he delivered a fetus which proved to be a monster; it turned out to be a hydrops of the abdominal cavity of enormous proportions; the child had no lower extremities; it was deformed; it had little rudimentary feet, attached to the buttocks.

Dr. L. S. McMurtry: I am reminded of a report that appears in Leishman's Treatise on Obstetrics of a case where two English practitioners in the country applied forceps to deliver the head; after exerting all the traction possible with their combined efforts, they pulled the child's head off, as in the case Dr. Vance has reported; not knowing exactly what to do at this stage, they immediately proceeded to perform a cesarean section, which was followed by death of the mother.

Dr. Turner Anderson: Cases of the kind reported by Dr. Cecil are of great interest. The management of his case, considering the time at which he saw it, was perhaps as satisfactory as was possible under the circumstances. The point referred to by Dr. Gilbert is important. Now if this course had been pursued in Dr. Cecil's case, the woman might have been more promptly delivered. After it was found that the forceps would not hold, it seems to me the logical inference would be that there was something radically wrong, and that the proper procedure would have been to have introduced the hand for the purpose of making a diagnosis. The special point I desire to make in connection with the case is this: If I am called upon in consequence of faulty position or abnormality of fetal development to introduce my hand in order to make a diagnosis, I feel it my duty to effect a podalic version as a rule, believing that when the head is unable to descend under these conditions, that podalic version is a more satisfactory procedure than a high forceps operation. Podalic version under these circumstances is a line of practice I adopted several years ago, and I could report several cases seen in my own practice and in consultation with medical friends where forceps would not hold, the head being arrested at the superior strait from faulty position, where the operation of podalic version was quite easy and safe.

In this special case I think, when the forceps failed to hold, if the hand had been introduced I am quite certain that the hydrocephalic

condition would have been recognized, and the doctor would also have recognized that the child was dead, and craniotomy should have been performed promptly without further effort to deliver by means of forceps. In all the cases of hydrocephalic head I have seen obstructing labor I have not had much difficulty, after opening the head, removing one bone after another by simply introducing two or more fingers, reducing the obstruction, and finally continuing my efforts until I could get a firm hold with my fingers and, pulling down, using the pericranium, which is a very tough, unyielding structure, upon which to make traction; after removing the obstruction by removing the cranial bones, without the use of a blunt hook or any other special instrument, I have succeeded in accomplishing delivery.

The only criticism I care to make in this case is that podalic version should not have been practiced. There was a ruptured perineum, a traumatic hematoma of the labia; both these conditions may have been brought about by efforts at delivery with forceps. If the hand had been introduced in this case and the condition diagnosed, the indications for treatment would have been very plain. I do not advocate turning in cases of enormous hydrocephalic head, because we would encounter difficulties afterward, just as occurred in one of the cases referred to by Dr. Ouchterlony, and it would be necessary to puncture the head even after version after the head had been brought down to the superior strait of the pelvis.

Dr. J. A. Ouchterlony: I would like to ask Dr. Cecil if there was any varicosity of the labia to begin with in relation to the hematoma?

Dr. Wm. Bailey: I would not undertake to criticise a case that was delivered successfully; I think Dr. Cecil is to be commended for what he did. We have a case here which presents unusual difficulties, first the age of the patient, second the condition of the head of the fetus, as was easily recognized, and the failure of forceps to hold. I want to say that I believe podalic version gives us much better control of the delivery than can be done by application of forceps or instruments to such a head as this. I believe that most cases of hydrocephalus are well treated by, might I say, perforation of the cranium and death of the child. At any rate it is a mercy to the child that it is not saved, particularly after the mutilation which is sometimes necessary in effecting delivery, and it occurs to me that if Dr. Cecil at the time he perforated the head had proceeded to delivery by version it would have been an easier task than the plan he followed. I would also spring the question whether, after

the head has been opened, after the bones have been loosened and made jagged in this way, if there is not more danger, in delivering head first, of injuring the soft parts of the mother by the bones protruding from the opening made in the scalp? I think the dangers of laceration of the soft parts would be much less by bringing the feet down first, then such a head would collapse and follow the body more easily. I think it would be much safer to the mother, unless the case were such as referred to by Dr. Vance, where podalic version would be extremely difficult, with a child ordinarily developed aside from the hydrocephalic head, to practice podalic version-I believe this would be the best plan of management. In Dr. Cecil's case, as I understand it, I believe it would have been better after he had opened the head and removed some of the difficulties to have performed version; in this way he could have reached the foot and brought it down into the canal and accomplished the delivery perhaps with less trouble and with more ease than by the plan he followed.

Dr. J. G. Cecil: With reference to the criticism of Dr. Bullock, I did not recognize the hydrocephalic condition at first. Dr. Ed Grant, whom we all recognize as a very skillful physician, told me he had an enormous caput to deal with, which of course was easily recognized. While we could feel immediately within the vulva the vagina largely filled with this caput, which afterward proved to be the hydrocephalic head, still by deep pressure we could feel the bones of the head, and we could also recognize the position of the child, which was still suprapubic, not having entered the superior strait. If I had recognized the condition of hydrocephalus at once, of course my course of procedure would have been what it finally was after the condition was recognized.

The criticisms that have been made are just, and I thank the gentlemen who have spoken therefor, still it is to be said in extenuation that when I applied the forceps the third time (I believe) that I succeeded in lowering the entire body of the fetus, the head entering the canal, then the bag of waters representing the head protruded from the vulva, and then it was that we recognized we had a hydrocephalus to deal with; meantime the head had already entered the superior strait, and, having got that far, I thought we could accomplish delivery promptly, and did so after ten or fifteen minutes' hard work, using the blunt hook and craniotomy forceps, simply grasping the collapsed head and pulling in this way until we could get hold of the shoulders and finally accomplish delivery.

The matter of podalic version in the hands of Dr. Anderson is a beautiful thing; he does it skillfully and more easily than any man I have seen operate; it is not an easy thing though in unskilled hands like mine. I have succeeded in doing podalic version with little difficulty at times, but when the head has already entered into the canal it is not so easy to dislodge it and practice version. I would not think of doing a version in a case of hydrocephalus without perforation, witness the case reported by Dr. Ouchterlony where the body of the child was delivered, leaving the head within the uterus, and the head might easily have been severed from the body by an undue amount of traction, as reported by Dr. Vance, and a serious complication would then have ensued. After perforation and recognizing a hydrocephalic head, I believe version is the better plan of procedure than to try to deliver by blunt hook or forceps, but when one has gotten into a situation of this kind, however, and has a good hold with the craniotomy forceps, then he is disposed of course to go ahead by that method.

The point made by Dr. Bailey is a good one, that where the head is broken up the jagged ends of the bones are of course liable to do injury to the soft parts of the mother unless protected by the scalp. In this case the scalp fully protected all the crushed bones; none of the bones had been removed from the head; a scalpel was simply introduced into the head as it protruded from the vulva, there was a complete collapse of the head, no jagged edges of ends of bone and consequently no danger of wounding the soft parts.

In answer to the question asked by Dr. Ouchterlony, I do not know what the condition of the labia was in the beginning of the case in relation to the hematoma; I take it, however, that it was explained by Dr. Anderson, that it was simply a traumatic hematoma resulting from slipping of the forceps, which accident ruptured the perineum at the same time. Dr. Grant, when I first went into the case, told me that we had a face presentation to deal with; that he had been able to make out the diagnosis early in the case. I must confess that I was unable to make out a face presentation, and do not know whether it was one or not; in fact, I do not know what part of the head was presenting; I take it, however, that the presentation was naturally a brow or vertex. very fond of the operation of version, I believe in it in skilled hands, and the practice of Dr. Anderson is one which is well worthy of commendation by all of us, but it is not easy, and I do not know that I have ever been "hotter" in my life than when trying to do a version, espe