When the cord presents at the vulva, it may appear normal, but often it is greenish, reddish, soft, as if withered. Pulsations may be present, or be lacking. From the absence, however, we cannot positively conclude that the infant is dead. In a case where the pulsations had ceased ten minutes before our arrival, as attested by the attending physician, imme diate version delivered an infant apparently dead, but which was resusci tated by insufflation and survived.
Prognosis.—If prolapse of the cord is of no moment as regards the mother, it is an accident which seriously compromises the life of the child. Thus: There are a number of circumstances which influence the prognosis. According to certain writers, thick cords run less risk than thin. This is illusory, but it is different with the variety of prolapse, the position of the fcetus, the part of the pelvis at which the prolapse occurs, the amount of the cord which is provident. Presentations of the head and breech are the most dangerous attendants on the prolapse, and when the prociden tia occurs at the sides of the pelvis, it is less exposed to compression than at the anterior or posterior portion. Finally, the conformation of the pelvis, the duration of labor, the degree of the contractions, have an in• fluence. Every cause which retards labor, of course influences the prog nosis for the child. Further, the nature of the interference modifies the prognosis.
Results of the Prolapse.—Prolapse of the cord does not, of course, in fluence in the least the progress of labor, except in those very exceptional cases where the loop surrounds the head or the breech of the foetus, and opposes the descent of the presenting part. The consequence of prolapse is death of the infant. What is the cause of its death ? Smellie, Osiander, Schweighanser, Joerg, Hebenstreit, and others, laid stress on cooling of the cord, prolapsed outside of the vulva, and consecu tive coagulation of the blood in the umbilical vessels; others, Mauricesn, Roederer, Baudelocque, Siebold, Carus, Meissner, admit refrigeration as an adjuvant cause, but insist, in particular, on compression of these TES sels. All modern authors admit only compression as the cause of the in fant's death. Kohlschuetter has proved that the theory of refrigeration was based on nothing at all positive, and that in the vagina the cord does not cool, and yet the infant dies if the cord be compressed. Difference of opinion only exists in regard to what vessels are compressed. Some say the vein, others the arteries, others both vein and arteries. Mittel hanger, May, Wigand, Deneux, Bartscher, Baudelocque, who contend for compression of the umbilical vein alone, attribute the death of the foetus to hemorrhage, anemia, syncope. The foetal blood is carried to it
by the arteries, but cannot return through the compressed vein.. There results diminution in the amount of blood, and Imemia of the foetus. Schurt remarks, with justice, that the spiral arrangement of the vessels in the cord, will not permit of compression of the vein alone, and further that we ought to find the placenta gorged with blood, which is not the case.
Ruhland, Adolph, Faust, Gelder, contend for compression of the arteries only, and that there results congestion in the foetal viscera, and the infant dies of apoplexy.
Finally, others contend for compression of all the vessels, and Heben streit attributes death to the accumulation of blood in the heart, Adolph in the lungs; Waldkirsch believes in cerebral apoplexy, either primitive or secondary. Now in cases of foetuses dead from compression of the cord, - we find neither anemia, nor hypertemia, nor apoplexy, and therefore Schnri. and all accoucheurs are in accord in the belief that the fetus dies from asphyxia. Even as the adult has need of oxygen in order to live, so too the foetus. But whilst man gains his oxygen from the ex ternal air, and his food from the intestine, the foetus acquires its oxygen from the maternal blood, through the placenta and the cord. The pro ducts of retrograde metamorphosis return to the maternal blood from the foetal. If this interchange between the mother and the foetus is inter rupted, the foetus asphyxiates and dies. In the normal state the foetus is in a condition of apnea, that is to say it does not need to respire, since it acquires otherwise a sufficiency of oxygen. Under normal conditions this state is only modified after the birth of the infant, and the infant only makes its first respiratory movement at birth. But if the cord is com pressed, and if, in consequence, the regular supply of oxygen is suppressed, the infant ceases to be apneic, it makes an inspiratory movement, and the consequences of this first act are: 1. Suppression of the placental circulation, or at least notable diminution, lowering of the blood pressure in the right ventricle under the influence of the enormous sudden dilata tion of the pulmonary arteries; 2. Suction into the respiratory passages of liquor amnii. The oxydation of the foetal blood does not occur, and the inspiratory acts recurring and drawing more and more into the thorax the blood from the right heart, and carbonic acid accumulating more and more in the blood, and the excitation of the medulla diminishing, paraly sis of the heart ensues, and the infant dies.