Part 27 (1/2)
Wigand also proposes, in cases of this desperate nature, to use effusion with ice-cold water to the abdomen and lower extremities, and by this powerful species of counter-irritation, produce a temporary calm for a few minutes--a measure we should fear of as doubtful a character as bleeding.
_Connexion of precipitate labour with mania._ Lastly, we may observe, that the subject of precipitate labour involves a medico-legal question of great importance and interest, which has as yet excited little or no notice in this country, viz. as regards acts of child-murder after labours of this character. The state of mental excitement and frenzy into which a patient is brought, by a labour of such violence and suffering, in many cases falls little short of actual mania. We now and then meet with instances, where, for the first half hour or so after a severe and rapid labour, the patient takes a most insurmountable antipathy to her child, and expresses herself towards it in so unnatural a manner, as to contrast strangely with the tender and affectionate feelings which she had a short time previously expressed for it. Cases have occurred where the patient has been without a.s.sistance, during labour, and where, in a state of temporary madness from mental excitement and pain at the moment of the child's birth, she has committed an act of violence upon it, which has proved fatal; a circ.u.mstance, which, from obvious reasons, would be more liable to occur with single than with married women. These cases have been very carefully investigated in Germany of late, and in many of them the patient has been, we think, very properly acquitted, on the grounds of temporary insanity, having herself voluntarily confessed the act with the deepest remorse, at the same time declaring her utter incapacity to account for the wild and savage fury which seized her at the moment of delivery.
CHAPTER X.
PROLAPSUS OF THE UMBILICAL CORD.
_Diagnosis.--Causes.--Treatment.--Reposition of the cord._
Although by no means a common occurrence, it every now and then happens that a portion of the umbilical cord falls down between the presenting part of the child and the mother's pelvis either just before or during labour; so that, as the child advances through the pa.s.sages, its life is placed in imminent danger from the pressure to which the cord is exposed, obstructing the circulation in it.
There is probably no disappointment, which the accoucheur has to meet with more annoying than a case of this kind; every thing has seemed to promise a favourable labour; the presentation is natural, the pains are regular, the os uteri is dilating readily, the mother, and, as far as we can ascertain, her child, are in perfect health, and yet because a minute loop of the cord has fallen down by the side of its head, the labour, unless interfered with by art, will almost necessarily prove fatal to it.
_Diagnosis._ If the membranes be not yet ruptured, we shall probably be able to feel a small projecting ma.s.s like a finger, close to the presenting part, and possessing a distinct pulsation, which, from not being synchronous with the mother's pulse, instantly declares its real nature. When the membranes give way, more of the cord comes within reach, and probably forms a large coil, which pa.s.ses through the os uteri into the v.a.g.i.n.a, or even appears at the os externum.
_Causes._ The earliest writer that we know of who has given a detailed account of cord presention was Mauriceau; few, even in hospital practice, and certainly none in private practice, have exceeded him in the number of cases described, and very few have surpa.s.sed him in the success of his treatment. He mentions chiefly three conditions as being liable to produce prolapsus of the cord, viz. a large quant.i.ty of liquor amnii, an unusually long cord, and malposition of the child: later authors have enumerated several other causes, many of which are imaginary; of these, by far the most correct list has been given by Boer, of Vienna, who has justly ridiculed the theoretical views which were maintained by his cotemporaries.
”If there be a large quant.i.ty of liquor amnii present, and especially, as is not unfrequently the case, the child is at the same time under the usual size; if the head be not firmly pressed against the brim, and does not enter it sufficiently, or when the child's position is faulty, especially if, at the same time, the cord is unusually long; if, under such circ.u.mstances, a large bag of membranes has formed, and the brim of the pelvis itself is very s.p.a.cious; if perchance, the rupture of the membranes takes place at a moment when the patient is moving briskly on in some unfavourable posture, the cord will be very liable to prolapse.
Nevertheless, cases are occasionally seen which arise without these predisposing circ.u.mstances.” (Boer, _von Geburten unter welchen die Nabelschnur vorfallt_.)
The uterus is the chief means by which the cord is prevented from falling down between the presenting part of the child and the pa.s.sages, from the closeness with which its inferior portion encircles it: without this, from the erect posture of the human female, there would be a liability to prolapsus of the arm or cord in every labour.
”The contraction of the uterus, which comes on with the rupture of the membranes, and sometimes, where they protrude very much, even before, is of great importance. This contraction takes place in the inferior segment of the uterus; it surrounds the head, and when fully developed extends over the whole head of the child. Thus, for instance, if we attempt to operate at an early stage, it feels more like a hard ring round the head, of about a finger's breadth, and it may be felt to extend itself higher up, in proportion as the stimulus of the hand excites the activity of the uterus.” (Michaelis, _Neue Zeiteschrift fur Geburtskunde_, band iii. heft.
1.)
Hence, therefore, whatever prevents the uterus from contracting with its inferior segment upon the presenting part of the child, deprives the cord of its natural support, and, therefore, renders it liable to prolapse.
Many of the causes enumerated by Boer act in this way; thus, where the uterus is distended by an unusual acc.u.mulation of liquor amnii; where the contractions at the beginning of labour have been exceedingly irregular; where the arm, or shoulder, or feet present; or where a large bladder of membranes is formed, the lower part of the uterus will either not contract at all upon the head, or so imperfectly as to endanger the descent of the cord.
Malposition of the child has been mentioned by many authors as a cause of prolapsus of the cord, and in some cases it may possibly act thus from the inferior segment of the uterus being unable to surround sufficiently close so irregular a ma.s.s as the shoulder. In the majority of cases, however, the coincidence of these two circ.u.mstances depends upon their being produced by the same causes; thus an unusually large quant.i.ty of liquor amnii, or irregular contractions of the uterus, will just as much dispose to the one as the other.
The form or size of the pelvis can have, we think, but little effect upon the cord, so long as the uterine action is of the right character and the child alive. Most authors enumerate a large pelvis or small foetal head as a cause, why should we not, therefore, have prolapsus of the cord in every case of precipitate labour which arises from such circ.u.mstances? Nor are we at all disposed to consider deformed pelvis as capable of producing it, so long as the uterus is not immoderately distended and acting naturally: we do not deny that the cord is occasionally found prolapsed in cases of dystocia pelvica, but this is chiefly where the child has died from the severity of the labour, and where the flaccid pulseless cord has gradually slipped down during the intervals of the pains.
So long as the uterus exerts but a moderate degree of pressure round the head, it is impossible for the cord of a living child to descend, particularly as, according to Dr. Michaelis, the circular contraction of the portio v.a.g.i.n.alis commences from below upwards, and would rather push back the cord if a portion of it had descended during the moments of uterine relaxation. The pulsating turgor of the cord when the child is alive will also a.s.sist much in preventing its descent, even where the uterus does not surround the presenting part so closely as usual.
The unusual length of the cord is also a very doubtful cause of its prolapsus, and will evidently, in great measure, depend upon the causes we have already alluded to.
We may also allude to another cause of prolapsus of the cord, which, although noticed nearly a century ago by Levret, and also by two or three authors after him, had nearly fallen into oblivion until lately, when it excited the attention of Professor Naegele, junior. Levret, from the result of numerous observations on the insertion of the cord into the placenta, was led to suppose that the lower the situation of the placenta in the uterus, the lower also was the insertion of the cord into the placenta, so that if the edge of the placenta touched upon the os uteri, the cord was usually inserted into that part of its edge which corresponded with the os uteri.
Although it is certain that the situation of the placenta close to the os uteri, is by no means necessarily attended by insertion of the cord into its edge, and, therefore, by prolapsus of it when the membranes give way, inasmuch, as under such circ.u.mstances we ought to have every case of partial placenta praevia accompanied with the cord presenting: still, however, there is no doubt that cases of the above-mentioned complication do every now and then occur, and must necessarily incur no inconsiderable danger of prolapsus.
”There is no doubt that the situation of the placenta in the vicinity of the os uteri, may be looked upon as one of the predisposing causes of the cord presenting during labour; an accident which is the more to be feared, the nearer the cord is inserted into the inferior edge of the placenta. If its edge extends quite down to the os uteri, and the cord is inserted into it, or the umbilical vessels divide, as in the cases we have described, at some little distance from it, viz. in the membranes, the cord will present as a necessary result, and prolapse as soon as the membranes give way.”
(_Die Geburtshulfliche Auscultation_, von Dr. H. F. Naegele, p. 114.) The two cases referred to by Professor Naegele, jun., of prolapsus of the cord from this cause, occurred so near after each other, as to render the circ.u.mstance the more remarkable. The fact was noticed by Giffard as early as in 1728, in a case of flooding from partial placenta praevia; but he does not appear then to have drawn any inferences from the position of the placenta, which he did not consider was attached, but was ”in part, if not wholly, separated from the uterus.”[137]
Prolapsus of the cord is fortunately not a circ.u.mstance of frequent occurrence. Dr. Churchill, of Dublin, in a valuable paper, (_Edin. Med.
and Surg. Journal_, Oct., 1838,) has collected the results of no less than 90,983 deliveries, amongst which the cord presented in 322 cases, being in the proportion of one in 282-1/4.[138] That prolapsus of the cord occurs most frequently in foot presentations, as supposed by Professor Naegele, senior, is disproved by the results of Mauriceau's large experience, as well as of many others since; thus, out of 33 cases which occurred in labour at the full term, (or nearly so,) 17 presented with the head, 1 with the face, 1 with the feet, 9 with the hand or arm, 3 with the hand or foot, 1 with the hand and breech, and 1 with the hand and head. In the 16,652 births which have been recorded by Dr. Collins, at the Dublin Lying-in Hospital, the cord prolapsed in 97 instances. ”_Twelve_ of the 97 occurred in twin cases, and in seven of the 12 it was the cord of the second child. _Nine_ occurred where the feet presented, (not including two met with in twin children,) which was in the proportion of _one_ in every _fourteen_ of such presentations. _Two_ only where the breech presented, which was in the proportion of _one_ in every 121 of such presentations: this approaches nearly the proportional average in all deliveries, which is _one_ in 171-1/2. _Four_ occurred where the shoulder or arm presented: this is in the proportion of _one_ in _nine_ of such presentations.
_Seven_ occurred where the hand came down with the head. _Seven_ of the children were born _putrid_; _three_ of the 97 were premature, viz. _two_ at the seventh and _one_ at the eighth month.” (Collins's _Practical Treatise on Midwifery_, p. 346.) We may, therefore, conclude with safety, that presentations of the head are by far the most common.