[Reprinted from The Medical News, August 6, 1892.] 
4 LABOR COMPLICATED BY CONGENITAL 
HYDROCEPHALUS. 
By OLIVER HOPKINSON, Jr., M.D., 
VISITING PHYSICIAN TO THE LYING-IN CHARITY AND NURSE SCHOOL 
OF PHILADELPHIA. 
By permission of Dr. Thomas Hunter, in consultation 
with whom I saw the patient, I report the history of a 
labor complicated by intra-uterine hydrocephalus. The 
case is especially interesting on account of the rarity of 
the complication (occurring, according to the statistics 
of Madame La Chapelle, fifteen times in forty-three 
thousand five hundred and forty-five deliveries), of the 
dangers to both mother and child always involved in 
these cases, and of the peculiar manner of the delivery 
of the head. I wish to add here that it was not until 
after the expulsion of the head that a true diagnosis was 
made. 
We supposed from the large size and perfect form of 
the child's body that the difficulty was due to a corre- 
spondingly large head, with excessive ossification, in- 
creased by its position (the occiput was in the left iliac 
fossa; the chin dipped in the pelvis, with the face in 
relation with the right sacro-iliac synchondrosis). 
There was nothing unusual discovered by palpation 
except the large size of the head. Both Dr. Hunter and 
myself can testify to the truth of the following statement 
of Playfair : " The diagnosis of intra-uterine hydroceph- 
alus is by no means so easy as the description in obstetric 
works would lead us to believe." 2 
Mrs. X., thirty years old, a quartipara, had a good 
family history. Her first husband, by whom she had 
three healthy children, died five years ago of pulmonary 
tuberculosis. Two years later, she married her second 
husband, the father of the child under consideration. 
Her previous confinements had been easy and natural, 
except the first, which was instrumental; all were vertex 
presentations. 
Mrs. X. enjoyed good health until the beginning of 
this pregnancy, when she began to lose flesh and 
strength, with almost constant cough, nausea, and vom- 
iting, and in the latter part with dyspnea that caused 
much distress-symptoms with which she had not been 
troubled in former pregnancies. She stated that the 
nausea, vomiting, and dyspnea were due to the position 
of the head, which she could feel " below the right 
breast-bone," and which "sunk in and out'' whenever 
she coughed. About five months ago, Dr. Hunter, being 
consulted, detected evidences of slight trouble at the 
apex of the right lung. 
The first sign of approaching labor was the rupture of 
the membranes at io p.m. The woman felt no pains 
until three hours afterward, when she had two or three 
rather severe ones, by which the breech was expelled. 
Then the pains left her. Dr. Hunter arrived at 2.30 
a.m., one hour and a half after the expulsion of the 
breech, and found the fetus dead, the body born to the 
umbilicus, the back anteriorly, the head and arms in 
the cavity of the uterus, with the shoulders in close 
proximity to the vulva. With great difficulty he suc- 
ceeded in bringing down both arms. After making 
several unsuccessful attempts to deliver by the usual 
methods he advised a consultation. The application of 
forceps was impossible from the position of the shoul- 
ders. I saw the patient at 5 a.m. Repeated attempts to 
move the head having failed, we decided to detruncate 
and apply the forceps before resorting to craniotomy. 3 
The neck was severed with a scalpel, and pieces of bone 
removed as far toward the base of the brain as possible, 
in order that the soft parts of the mother should not be 
injured. 
The severing of the neck was followed by an escape 
of fluid (several ounces or more), which we mistook for 
the liquor amnii-an excusable error, as we did not see 
from where the water came, the neck being drawn up 
in the vagina by the great tension. I then tried to apply 
Tarnier's axis-traction forceps in order to rotate the head 
to a transverse position - it being still oblique - but 
failed. 
Whilst the craniotomy instruments were being pro- 
cured the patient had about an hour's rest, with good 
effect; for during that time there were several good 
pains-the first since the birth of the breech-which 
caused a favorable change in the uterus. Preparations 
were now completed for craniotomy. Dr. R. O. Kevin 
administered the ether. I found the uterus smaller and 
harder, the chin and mouth lower in the pelvis, but the 
occiput was still resting upon the ilium, with the neck 
high up behind the symphysis, the suboccipito-frontal 
diameter in correspondence with the right oblique pelvis. 
This change induced us to make one further effort with 
the forceps, which was easily adjusted to the sides of the 
head, and, by traction combined with compression (such 
a degree of force and compression being used as were 
considered justifiable and safe), the head was brought 
down, till the chin (still posterior) touched the pelvic 
floor. 
Meeting with resistance, the instruments were removed, 
it being decided to leave the termination of the case to 
Nature, or, if that failed, to resort to craniotomy, which 
would now be comparatively a safer and easier opera- 
tion, for both the pelvis and vagina were capacious. 
Happily, the pains increased in force and frequency, 
and with constant supra-pubic pressure the chin began 4 
to rotate anteriorly, sweep over the perineum, and glide 
under the symphysis-the mouth and nose at the vulva. 
There being now a delay, notwithstanding several 
good pains, grasping the chin with the placenta forceps, 
I made traction directly upward during the following 
pain, when the forehead, occiput, and neck were born 
successively. The neck underwent a complete revolu- 
tion. Probably ten minutes elapsed between the removal 
of the forceps and the birth of the head, which occurred 
at 7.30 A.M., six and a half hours after the birth of the 
breech. 
The cause of the engagement of the face seems to be 
that, after the severing of the neck and the escape of 
serum, which the pains, with supra-pubic pressure, has- 
tened, the suboccipito-frontal, biparietal, and bitemporal 
diameters, the ones chiefly concerned, were lessened by 
the collapse of both parietal bones. 
Dr. Hunter informs me that the convalescence was 
unattended by any abnormal pelvic symptoms, but that 
the pulmonary complication has rapidly and decidedly 
advanced. 
The etiology of intra-uterine hydrocephalus is obscure. 
I can find no cause in this case, unless it be the tuber- 
culous condition of the mother.