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Denman, p. 326, notices delay and difficulty, where the head has been expelled and the funis twisted round the neck, and he says, "lest the placenta should be separated, or the body of the child be hindered from advancing till it suffers detriment, or is brought into absolute danger," the cord must be brought over the head. If this cannot be done, slide the funis back over the shoulders; if either of these intentions cannot be accomplished without violence, they must be omitted, nevertheless the child will be usually expelled, if we wait for the return of a few pains, which we may safely do without any other inconvenience than some increased distention of the perineum. Where, however, the child is retarded a long time, the funis may be divided before it is expelled.
Professor Meigs, in his excellent manual, "The Philadelphia Practice of Midwifery," designed principally for students, but containing many choice reflections, gives similar directions as those authors already quoted, in cases where the cord is around the neck of the child-but says, if "the child seems to be detained by the tightness of the cord, as does rarely happen, or in danger from the compression of its jugular veins, the funis may be cut with the scissors and tied after the delivery."
The umbilical cord varies in length; while it is usually found about the length of the foetus, say from eighteen to twenty inches, it has been found as long as eighty-four inches by Desormeaux, and the shortest one known, was only two inches in length. This occurred in the General Lying-in-Hospital in London, where after two or three violent pains, the child was suddenly expelled and the cord was found ruptured two inches from its navel. The other end of the funis was sought for, but could not be found; on removing the placenta from the uterus, it was discovered that the cord had been ruptured at its very insertion. The shortening of the umbilical cord, by being coiled around the neck of the child, is of frequent occurrence, and according to some authors, takes place as often as once in five or six cases. agree in opinion with those writers whom I have quoted, that the cases of difficulty arising from such a shortening are rare. But that they do occur, that they may cause delay, retard delivery, endanger the life of the child, and that the cord may be ruptured before the delivery of the body of the child, I would present the following case in point, from my memorandum of
On the twentieth day of August, 1846, I was sent for about 12, M., to visit Mrs. R. in labour with her fifth child. As her previous accouchement had been remarkably quick, and as I had been informed, so were her former ones, I made all haste and was soon at her bedside, where I found her in strong pains. An
examination per vaginam, led at once to the opinion that I was "just in time" to receive the child, as the head was pressing forcibly during the pain against the perineum. I was, however, doomed to experience disappointment in my sanguine hope of a speedy delivery and a short detention. As the pain subsided, the head receded quite high up, and remained there, until the following pain brought it down once more to the "crowning" point of labour. Again and again, for many successive pains, I was obliged to contend with this alternate advancing and receding of the head, until the clock struck two, and until my patience was wearied, and my patient and her friends wondered at the delay.
Although unable to diagnosticate by the touch without the introduction of the hand, yet I surmised and even communicated my suspicions as to the cause of the impediment, to be, either a natural or artificial shortening of the funis. I was led to this opinion, because there was a normal conformation of the pelvis of the mother and the foetal head of the child, because the soft parts were fully and sufficiently relaxed for every necessary purpose, because the uterine contractions were vigorous and frequent, and because the head was in the first position of Baudelocque, being the most favorable for the termination of labour without the interposition of art, unless there existed some mal-conformation of the body of the foetus, or, as I suspected in the present case, either an artificial or natural shortening of the umbilical cord.
For more than two hours I waited and watched anxiously the result. At length a powerful and continued effort of the womb expelled the head of the child beyond the vulva, but when the uterine action had ceased, the head remained firmly wedged against the os externum.
The appearance of the child at this stage of the birth, indicated immediate strangulation, unless relief could be afforded, as I now discovered by passing my finger around the neck, that it was closely compressed by being encircled with two turns of the cord, which by this arrangement, was artificially shortened. The face was now assuming a very dark purple colour from the accumulation of blood in the return vessels, in consequence of the obstruction of the jugular veins. There was no time to lose. Accordingly, I made an effort to remove the cord by bringing down a loop and passing it over the head, but it was drawn so tight that I found it difficult even to insert my finger beneath it, much less to bring down a portion and slip it over the head or pass it back over the shoulders, as various authors direct.
Thus situated, I was in momentary fear of witnessing those spasmodic jerks, which are so clearly indicative of the death of the fœtus, when another pain returned. At this crisis, I determin
ed to pass my finger beneath that portion of the cord which was coiled around the neck, not only to prevent an increase of pressure on the circulation of the jugular vessels, but to separate the cord and thus relieve the extreme danger, when suddenly the cord gave way, and almost at the same moment of time the child was precipitated into the world and lay at the breech of the mother. The bleeding from the ruptured umbilical extremity of the funis soon relieved the apoplectic symptoms. I put a ligature on the umbilical extremity of the cord, which, singular to relate, was ruptured about two inches from the navel. In a very few minutes the child breathed and cried freely, and I handed to the nurse a fine healthy boy.
The placenta cante away in season, and from that hour the mother and child did well.
There are two points in the above case of "artificially shortened funis with rupture before delivery," which may afford us subjects for practical reflection.
1. Can a shortened funis obstruct delivery?
2. Would it endanger the life of the mother or child?
All authors to whom I have had access, agree that one or more coils of the umbilical cord around the neck of the fœtus is a common occurrence, happening as often as once in every six or seven labours; but that it ever changes a natural into a preternatural labour, they are not so well agreed.
Baudelocque, Dewees, James, Burns and Blundell, do not believe that a short cord ever protracts or retards labour, while on the other hand, Smellie, Rigby, Lee, Moreau, Denman and Meigs are of opinion that it may produce delay, though rarely, and each of them give some directions how to proceed when it does occur. I fully agree in opinion with these last named gentlemen, and although my case was not protracted for several days as was that of Smellie's, still it does not change the principle, nor my opinion, that the case of Mrs. R. was hindered for two hours, and perhaps longer, by an artificially shortened funis.
Would a shortened funis endanger the life of the mother or child?
Here I have not the least hesitation in pronouncing judgment in the affirmative, and am supported in my opinion by Baudelocque, Lee, Moreau and others.
In the expulsion of the foetus, the violence of the dragging pains may tear the placenta from the womb, and expose the mother to a destructive flooding, or produce an inversion of that organ, or the pressure of the cord around the neck of the child may retard the free circulation of the blood in the brain, producing asphyxia, apoplexy and death, or should the cord rupture and assistance not be at hand, the child might perish from
the loss of blood. On this point there can be but little difference of opinion. Almost every author I have consulted, gives short directions for the removal of the cord from the neck of the child, and several of them recommend the cutting of it before the body shall be delivered, in order to protect its life.
Who would be willing to follow the recommendation of Blundell, and believe with him that "a better method" is to leave the cord around the neck until the body of the child is born, rather than remove it or cut it, when it was evident from the livid suffusion of the countenance of the half-born fœtus, that the circulation was impeded and death threatening? It is in such a case that procrastination would be attended with danger. It is here, that a "meddlesome midwifery," to employ in part the language of this fanciful writer, would be proper, rather than trust the case in the hands of that "excellent accoucheur in natural labour— Nature, the mother of us all."
The case I have presented is one of interest, and not only rare in its occurrence, but still more novel in its character; for as far as my researches have extended, I find no such instance on record. Baudelocque believes that it is possible for a cord, if short, to be ruptured before delivery; and Rigby says it has taken place, and he furnishes a reference in the London Med. and Surg. Journ. for May, 1835, p. 426, of a case which happened in the London General Hospital-but it was one of natural shortening of the cord-which was only two inches in length, and was ruptured before the child could be born. La Motte's cases and Burton's cases, as cited by Rigby, were artificial shortenings, but in neither of these did a rupture take place spontaneously before delivery. Burton ruptured both of his, and La Motte, who had three cases, cut one with his scissors, dragged another away with the placenta, and the third was delivered with little else than force.
Retention of Urine, a Sequela of Scarlatina, successfully treated with Strychnia. By GEO. L. Upshur, M. D.
W. H- a delicate child, æt. 7, of a nervous temperament and strumous diathesis, was attacked January 21st with ordinary symptoms of catarrh, accompanied by considerable febrile excitement, though he did not feel sufficiently indisposed to go to bed. On the 22d, he complained a little of sore throat; had not been exposed to scarlatina, but there was a case of well marked rubeola two doors off. Fever continued moderate until the night of the 24th, when it became higher, and the catarrhal symptoms were entirely superseded by the sore throat. I was called to
see him on the morning of the 25th, and found his condition as follows: Face flushed; throat red, swollen, and painful; headache; tongue furred white, with papillæ projecting; constant nausea and vomiting; and over the whole surface of the body there was an eruption partaking of the character of the rash of scarlatina and measles combined, but not sufficiently distinct to render the diagnosis certain; there was no cough or suffusion of the eyes. Prescription.-Warm mustard pediluvium. B. Pulv. Hyd. Chlor. Mit. gr. viii, Pulv. Ipecac. gr. iv, M. Pil. 4.-S., one every two hours. 26th. Rash abundant, and evidently that of scarlatina; fever moderate; thirst; great tenderness of the surface where the eruption is found; bowels were moved during the night; no nausea; thirst less painful. The patient continued in this condition without other treatment than a dose of Ol. Ricini, until the 29th, when the throat being more painful, I prescribed an emetic of Ipecac. and a gargle made of infusion of carrots.
From this time the patient commenced to convalesce, and I should not have bestowed further attention upon the case, but for the illness of another child in the same house. On the 9th of February, he complained to his mother of pain about the neck of the bladder, and inability to urinate. I was requested to see him in the afternoon of the 10th. Found him feverish, the bladder considerably distended, and suffering with headache. Had passed little or no urine since early in the morning. Ordered him to be put in a warm bath, and to take an ounce of caster oil and forty drops of laudanum immediately.
11th. Bladder very much distended; passed a restless night; bowels were moved twice, but no urine came away during the night; this morning there is styllicidium. Introduced the catheter, the operation being somewhat difficult from the smallness of the parts, and the existence of a partial congenital phymosis. There were three spasmodic strictures, situated about half an inch apart, the first one being about an inch from the external orifice of the urethra. By keeping the point of the catheter steadily pressed upon the seats of stricture, in the course of ten minutes they gave way and the instrument entered the bladder. About eight ounces of urine were drawn off; when it ceased to flow, the catheter being clogged with mucous. After trying in vain to clear it with the wire staff, I was obliged to withdraw it, and he refused to permit me to introduce it again. The urine was turbid, and of the odour of asparagus.
12th. Passed no urine during the night, and has slept none; considerable fever and a haggard countenance. Ordered successively, a warm bath; tobacco leaf steeped in alcohol to the perineum; nauseating doses of tartar emetic: and last an opiate
All of these means failing to relieve, resorted again to