Discussion. Dr. J. A. Larrabee: The case is not only interesting, but also somewhat unique as far as I am aware. We are all familiar with the double wrapped cord, but in this case the acrobatic movements of the child must have been considerable, in utero, to have produced the condition described by Dr. Anderson; the child had evidently been engaged in jumping the rope for some time. When the cord is wrapped around the neck of the child as described, I think the best plan is to expedite delivery. Of course in the primipara we must not be in too great a hurry, we must utilize melting or crowning pressure to prevent injury, but the management of these cases I think is entirely that of dystocia, and powerful external pressure upon the fundus of the uterus, bringing it down as low as possible, is the proper plan of expedition. In the case reported, however, no amount of external pressure would have accomplished any thing; fortunately the snapping of the cord enabled the doctor to deliver and resuscitate the child, which is about the only thing that could have been done. In this case it would have been almost impossible to have divided the cord. Aside from the anomaly of the case, which is worthy of especial mention, I do not know of any proceeding which would have been equal to that which was followed. It is a little strange that the placental attachment did not give way; if this had been true, if there had been a separation of the uterine attachment of the placenta, then we would have expected the placenta to have been expelled with the child instead of a rupture of the umbilical cord.
Dr. J. L. Howard: I would like to ask Dr. Anderson if usually, when the cord is wrapped around the neck of the child, the cord is not an abnormally long one? I have had this accident happen twice in my experience, but no trouble resulted because of the abnormal length of the cord in each instance.
Dr. J. G. Cecil: This is an accident which as we know happens frequently, as well as many other anomalous things in connection with the umbilical cord. I would have been disposed, if the labor had been delayed in this case, that is, the final delivery of the child, more than four or five minutes, to have severed the cord, fearing that it might have had something to do with the delay. If there was no pulsation in the cord, there would have been little risk in cutting and not tying it; then there would have been no further delay to the delivery; there would have been no danger from hemorrhage, from premature separation of the placenta, or danger from inversion of the uterus. However, as the case turned out so well under the management that was adopted, it does not become us to criticise that management, because the successful issue proves the wisdom of the plan followed.
I have once or twice encountered some delay in expulsion of the child by reason of a short cord wound around the neck. I have never seen one so displayed around the shoulder as in the case reported by Dr. Anderson. I remember to have seen one case, however, in which there was a knot tied in the cord, and tied so tightly that it shut off the circulation and resulted in death of the child, and also complete atrophy of the cord between the knot and the navel end. This was a very interesting case, and was reported to the Louisville Clinical Society three or four years ago by Dr. Peter Guntermann; it was one of the most interesting cases of accidents to the cord that I have ever seen. How the knot was tied so tightly in the cord can not well be explained; knots in the umbilical cord are not very unusual, but it is unusual to see one tied so tightly that the circulation is shut off thereby. It was thought, I believe, by the reporter on that occasion that the accident was due to a fall which the mother sustained just before the delivery, which was premature.
Dr. Wm. Bailey: Nothing in the management of the case reported by Dr. Anderson can be criticised by me. I am inclined to think that under no circumstances was pressure made on the cord sufficient to interrupt the circulation until after the head of the child was delivered. Then it became a question as to the proper management. I believe it would have been better to have cut the cord, as it might have lessened the difficulty of delivery, and that there would have been no harm done to the child in this case, because there was no pulsation in the cord. The doctor had all the time for this delivery that would have been allowed him if he had a breech presentation with the head making pressure upon the cord, and ordinarily he would deliver such a case in from five to seven minutes, and that would give a chance for resuscitation of the child just as in the case of drowning. The child can be deprived of circulation through the cord, in an accident like this, as long a time as a person can be submitted to water, or drowned, and be resuscitated. I have seen but one case in which there was a rupture of the cord during delivery. I saw one exceedingly short cord, in which delivery of the child ruptured the cord; it was not around the neck, it was simply too short for the child to be delivered without detaching the placenta; just as the child was delivered the cord was spontaneously severed at the umbilicus, simply allowing me a sufficient amount to be caught with the fingers and held until a ligature could be applied. I do not remember the exact length of the cord, but it was so short that it was not possible to deliver the child without either breaking the cord or detaching the placenta. The cord ruptured spontaneously, and there was no further accident or trouble.
I believe if Dr. Anderson had to attend another case under exactly the same circumstances he would prefer to cut the cord rather than to break it off at the placental attachment. Inasmuch as he did not cut the cord and the child was successfully delivered, and also as there was no trouble in delivering the placenta, of course it makes no difference; but I always like to have the cord attached to the placenta so that if it becomes necessary to go after the placenta, in case of retention for instance, I can have the cord as a guide. In Dr. Anderson’s case there was no possible advantage in having the cord intact; as it was pulseless, no injury could have been done the child by cutting the cord before completing the delivery, and by cutting the cord as soon as it was found that it encircled the neck, all possible difficulties as far as the cord preventing delivery was concerned would have been removed.
Dr. T. S. Bullock: I am very much interested in this case; I have never seen one exactly like it. The greatest danger in this particular instance was that alluded to by Dr. Cecil, viz., producing inversion of the uterus. I think Dr. Anderson managed the case in the proper manner, and by his method of expression the only possible danger was inversion of the uterus.
I have only seen one instance of dystocia from short cord; that was a case in which the cord was the shortest I ever saw, and was wrapped around the neck, where it was necessary in order to deliver the child to cut the cord after tying it and then employ instruments, the cord being so short that with each uterine action you could feel the cupping of the uterus from tension on the cord.
I think there would be less danger from premature separation of the placenta than from inversion of the uterus. In the case Dr. Anderson has reported the danger to the child from compression of the cord was obviated by prompt delivery.
Dr. J. A. Larrabee: Will not Dr. Bullock tell us whether the case he refers to, where he could feel a descending or cupping of the uterus by the expulsive efforts, was a primipara?