Mrs. L. sent for me at midnight, April 11–12, for her fourth confinement. The previous labours had been normal. Labour had begun at 6 p.m. I found the breech presenting in the dorso-anterior position. As the os was fully dilated I ruptured the membranes, when a very considerable quantity of amniotic fluid escaped. The birth of the body soon followed, and with a little manipulation the arms came down. But the head remained at the brim of the pelvis. The cord pulsated for some time, and, the pulsations becoming feebler and feebler, I made traction on the body for a good half-hour, but without further effect than damage to the child. Examining the maternal abdomen I found the uterus as large as at the seventh month of pregnancy, the upper part soft and the lower hard, the latter giving a crackling sensation. Per vaginam the finger could be passed freely as far as the eyes, also up to the occipital region. With one hand on the hard tumour of the uterus and the finger of the other hand on the occipital region, fluctuation between them was found.

The case therefore was apparently one of hydrocephalus; and my colleague, Dr. Claridge, whom I now ca1led in, and for whose kind assistance I am greatly indebted, confirmed these observations and this diagnosis.

The received method of treatment is to use the perforator against which, however, many objections may be urged. It is a clumsy instrument to use on an after-coming head, so I put it aside.

I then, recollecting Dr. Ballantyne’s paper in the British Medical Journal of the 10th December last, attempted to pass a catheter up the spinal canal. But in making the preliminary incision I had the misfortune to turn the edge of my knife; so this method had to be abandoned.

I then passed a large ascites trochar and cannula to the occipital bone, plunged it forwards towards the centre of the head, and was at once rewarded by a copious flow of fluid. When it ceased, gentle traction brought away the child. It was now 2 a.m.

The head presented a peculiar appearance, due to the overlapping of the parietal bones by the frontal bone, carrying the scalp with it. The wound in the occipital was, of course, small, and presented none of the sharp edges that would have been produced by the perforator.

Recovery was uneventful.