LONDON LANCET;

A JOURNAL OF

BRITISH AND
AND FOREIGN

MEDICAL, SURGICAL, AND CHEMICAL SCIENCE,

CRITICISM, LITERATURE, AND NEWS.

HALF-YEARLY VOLUMES.

VOLUME I.-1857.

EDITED BY

THOMAS WAKLEY, SURGEON, J. HENRY BENNET, M.D.,
AND T. WAKLEY, JR., M.R.C.S.E.

New York:

1857.

THE LANCET.

Journal of Medical, Surgical, and Chemical Science and Practice, Criticism,

MR. WAKLEY, M.P., EDITOR.

Literature and News.

J. HENRY BENNET, M.D., J. WAKLEY, JR., SUB-EDITORS.

VOL. I.

IN TWO VOLUMES ANNUALLY.
NEW YORK, JANUARY, 1857.

A Course of Lectures

ON THE

THEORY AND PRACTICE

OF

No. 1.

large quantity of liquor amnii, and its sudden evacuation, or a pelvis above the average size, may cause prolapsus of the cord. It happens in twin cases, particularly in the delivery of the second child. The position of the placenta is also influential as a cause of funis presentations. The cord is prone to descend when the placenta is partially attached to the os uteri, or when the PHYSICIAN-ACCOUCHEUR TO ST. MARY'S HOSPITAL, AND LEC-placenta is fixed to the lateral walls of the TURER ON MIDWIFERY AND THE DISEASES OF WOMEN IN placenta instead of to the fundus, or when the

OBSTETRICS.

Br W. TYLER SMITH, M.D.,

ST. MARY'S HOSPITAL MEDICAL SCHOOL.

LECTURE XXX.

FUNIS PRESENTATIONS.

placenta being seated near the fundus, the cord is inserted into the edge instead of the centre of its diameter. Mr. Roberton, of Manchester, points out that, in cases of contraction of the brim of the pelvis, where, on the rupture of the membranes, GENTLEMEN, The Funis may present alone at the head does not descend upon the os uteri, but the beginning of labour, or it may descend with remains suspended at the brim, the funis is very the head, arm, nates, and any other presentation apt to float down with the liquor amnii and pass of the fœtus. Its positive frequency is greatest in through the os. An interesting series of cases head cases, but relatively it is more frequent in has been reported by Mr. Roberton, which fully arm and shoulder presentations than in other bears out this view. When the head of the fœtus varieties. This serious complication may occur remains above the os uteri, the relations of the at any time during labour. It may happen be-os to the presentation very much resemble those fore the evacuation of the liquor amnii, when the head or presenting part is passing the os uteri, or when it is emerging from the perinæum.

which obtain in shoulder or nates cases.

There is a want of that apposition between the os uteri and the presenting part which prevents prolapsus of the cord in perfectly natural cases.

The Causes of funis presentations are various. In arm cases, where the body of the child li As regards the Frequency of this complication, transversely, the anatomical position of the umb Dr. Fleetwood Churchill has collected 128,224 licus and the funis favours the descent of the cord, cases of all presentations, which yielded 579 funis and this descent is still further promoted by the cases, or about 1 in 2214. As regards the fact, that in shoulder cases the circular os uteri mother, labour is not in the least degree rendered does not at all points closely embrace the present- more unfavourable than usual, but the mortality ing part, on account of its irregularities. In its to the foetus is very great. Considerably more contractions, the uterus cannot sweep equably than 1 in 2 of the children die in cases where the over the shoulder as it does in cranial presenta- cord presents. In arm presentations the mortality tions during the pains, so as to carry up the funis is rather more than 1 in 2. It will be rememwhen there is any tendency to prolapse. Presen-bered that in breech cases the mortality was 1 in tations of the feet and breech, or of the hands and 34, and in footling cases, 1 in 22. In turning, the feet, are frequently complicated with the funis, foetal mortality is rather more than 1 in 3. Thus and from the same causes. In the case of head the presentation of the funis is more dangerous to presentations, length of the cord, small size of the the child than any other variety of labour. head, the descent of the hand with the head, a 1-VOL. I.

The symptoms of funis presentations are suffi

FIG. 125.

ruptured uterus, a coil of the small intestine may pass through the laceration, and present in the os uteri or the passage. This has in rare instances been mistaken for the cord of a dead child, and pulled down or even cut off by ignorant or incautious persons. A case of this kind occurred in London, and another in Ireland, incredible as it may appear, within the last ten or twelve years. In cases of this kind happening to a midwife, in which a medical man might be called after the rupture of the uterus and prolapse of the intestine, some little caution would be necessary to avoid mischief. An inexperienced accoucheur might pull at the supposed cord, and do the gravest injury, particularly if the previous history of the case had been kept from him.

Of course, the cause of the Mortality in funis cases is the pressure exerted upon the cord, between the presenting parts of the child and the hard and soft parts of the mother. The child dies of asphyxia, the fatal circulation being in severe cases entirely cut off from the respiratory functions of the placenta. We may compare the child under the circumstances of funis presentation, to cases of turning, to cases in which the placenta is separated, or the contractions of the uterus are so intense and continuous as to prevent the circulation of the blood in the maternal side of the placenta. The comparison between the presentation of the funis, and the descent of the nates or feet foremost, is very obvious. Wherever the order of labour is such that the funis, or any portion of it, precedes the descent of the more bulky portions of the foetus, the case is essentially one of funis presentation. Thus, in footling, breech, and turning cases, as soon as the umbilicus engages in the pelvis, pressure is exerted on the cord, and the cases are identical with funis presentation. The mortality depends on the length of time to which the funis is subject to pressure, and the degree of the pressure during the exit of the foetus. Thus it is greatest in funis cases proper, in which the cord comes before or with the presenting part, and is thus subjected to pressure during the whole of labour. Next to this, footciently well marked to make their diagnosis easy. ling cases are the most fatal to the child, as here Sometimes a loop of cord, several inches in length, the pressure on the cord commences as the umhangs from the vagina. It may be pulsating, or bilicus descends through the soft parts, and these it may be cold and flaccid. But in one case the have been but little distended by the descent of umbilical pulse, and in the other the twistede feet and breech in succession. In breech arrangement of the cord, or an ocular inspection cases, the mortality is less than in footling cases, will remove all doubt. In cases where the cord because the soft parts have been distended by the comes down with the advancing part of the child, passage of the nates with the feet doubled up or presents with it at the os uteri, the only part towards the abdomen. In cases of the descent of the full-grown foetus which can be mistaken for of the cord with the head, in cranial or face preit is the closed hand or the toes. The knuckles sentations, the pressure exerted on the cord is when only part of the hand is felt, or the row of greater than under any other circumstances, but toes, may feel somewhat like the end of a loop of it is of short duration, since as soon as air can cord. But the presence or absence of pulsation, reach the mouth of the foetus, pressure on the cord and the examination of a few inches of the cord, becomes of little consequence. No comparison or enough of the extremities to reach the wrist or can be made between the mortality in cases of the ankle, will make the matter clear. There is turning and funis presentations, because the great one complication of labour which it is necessary mortality to the foetus in turning depends on other to mention, in which a mistake respecting the cord causes as well as upon the pressure upon the cord. may lead to the most serious results. In cases of Certain circumstances besides the presentation