LETTER XXIX.. Management of the Child.

MANAGEMENT OF THE CHILD.

Of Separating the Umbilical Cord—Practices of different Nations—Of Still-Birth, and Resuscitation of the Child—Washing and Dressing it.

It was necessary, in describing the three stages of labor, to pass over for the time an important matter, namely, that which relates to our attention to the umbilical cord. In treating of this subject, it will be necessary for me to repeat some things which I have said in another volume, a “Treatise on the Management and Diseases of Children.”

Soon after the birth of the child, separating the umbilical cord requires our attention. How shall this be done? Shall we use a sharp or a dull instrument in making the division? Shall we apply a ligature? where, and in what manner to the cord?

It is reported of the aborigines of Brazil, that they merely bite or chew off the cord, as many of the animal tribes are found to do. This is imitating nature closely enough, certainly, and more so, perhaps, than the usages of civilized society would warrant us in doing at the present day.

Dr. William Hunter, in 1752, remarked in his manuscript lectures concerning the method which the instinct of animals leads them to adopt, as follows:

“I will give you an idea of their method of procedure, by describing what I saw in a little she dog of Mr. Douglass’. The pains came on, the membranes were protruded; in a pain or two more they burst, and the puppy followed. You cannot imagine with what eagerness the mother lapped up the waters, and then taking hold of the membranes with her teeth, drew out the secundines; these she devoured also, licking the little puppy as dry as she could. As soon as she had done, I took it up, and saw the navel-string much bruised and lacerated. However, a second labor coming on, I watched more narrowly, and as soon as the little creature was come into the world, I cut the navel-string, and the arteries immediately spouted out profusely. Fearing the poor thing would die, I held the cord to its mother, who, drawing it several times through her mouth, bruised and lacerated it, after which it bled no more.”

This chewing, bruising, or tearing a part in which blood-vessels exist, causes them to contract in such a way as to prevent the occurrence of hemorrhage. This fact we see exemplified in cases where an arm or other limb is torn off with machinery, in which it is found that no bleeding of consequence takes place. But if a limb is severed with a sharp-cutting instrument, the arteries must be secured.

The New Zealanders, I am informed by a medical friend who spent some time among that people, cut, or rather tear off the umbilical cord with the edge of a shell, something like that of the clam or oyster of our own country.

It matters little, however, what instrument or material is used to effect the object in question. The cord being immediately after birth a dead substance, possessing no sensibility whatever, we may bite it off, or we may use a shell, a sharp knife, or a pair of good scissors or shears, whichever method we choose, remembering always that it is of little consequence how we do it, and that it is as natural, precisely, for a man to exercise his ingenuity in making and using a convenient instrument as it is for a brute to use his teeth.

In the time of Hippocrates, it was not customary to divide the umbilical cord previously to the expulsion of the placenta. If this was slow in coming away, the child was placed upon a pile of wool, or on a leather bottle with a small hole in it, so that by the gradual subsidence of the skin or pile of wool, the weight of the child might draw almost by insensible degrees upon the placenta. In this way it was extracted without violence.

In modern times, it has been almost universally the custom to separate the child very soon after delivery, and before the after-birth has come away. “As soon as the child cries lustily, proceed at once to separate the cord,” is the common doctrine among medical practitioners. But it is better, evidently, to wait, before this is done, until all pulsation has ceased in the cord. If we take the cord between the thumb and finger, we readily ascertain when its pulsation has ceased. It has a large vein in it for the transmission of blood from the mother to the child, and two small arteries, which return the impure or worn-out blood after it has gone the rounds of the fetal circulation. Blood is the only nourishment the child has while it is in the mother’s womb. Hence it would be manifestly improper to rob the child of any portion of the fluid coming from the mother to it.

The ancients not only waited for the expulsion of the after-birth before tying the cord, but if the child was at all feeble or dead at birth, the placenta, when expelled, was laid upon its belly as a comforting and restoring application. This practice, singular as it may appear to us in modern times, is not altogether without its philosophy; the mild, genial warmth of the after-birth was supposed to act favorably on the feeble powers of life, if such existed, or if it was dead, it was supposed the infant might thus be recovered.

Speaking of later methods, Dr. Denman observes: “It has been the practice to divide the funis (cord) immediately after the birth of the child; and the weaker this was, the more expedition it was thought necessary to use; for the child being supposed to be in a state similar to that of an apoplectic patient, a certain portion of blood might, by this means, be discharged from the divided funis, and the imminent danger instantly removed. There is another method which I have seen practiced, the very reverse of the preceding; for in this the loss of any quantity of blood being considered as injurious, the navel-string was not divided, but the blood contained in its vessels was repeatedly stroked from the placenta toward the body of the child. In all these different methods, and many others founded on caprice, or on directly contrary principles, children have been treated in different times and countries, and yet they have generally done well; the operations of nature being very stubborn, and, happily, admitting of considerable deviation and interruption, without the prevention of her ends.”

“There is yet, in all things,” continues this author, “a perfectly right as well as a wrong method; and, though the advantage or disadvantage of either may be overlooked, the propriety and advantage of the right method must be evidently proved by individual cases, and of course by the general result of practice. In this, as well as in many other points, we have been too fond of interfering with art, and have consigned too little to nature, as if the human race had been destined to wretchedness and disaster, from the moment of birth, beyond the allotment of other creatures.”

It is the testimony of this author, however, that some children, after they had began to breathe, had respiration checked, and died after the cord was divided in consequence, this having been done too soon. Beyond a doubt, many children have been destroyed in this way, and in this, as in many other things in the healing art, medical men have been too much in the habit of interfering with nature, and thwarting her in her operations.

It is the order of nature, and moreover a truly wonderful phenomenon, that in proportion as respiration becomes established in the new-born child, the pulsation in the umbilical cord begins to cease, first at the placenta, and so gradually onward to the child; physiologists are puzzled to explain the circumstance, but the fact is plain.

Hence it follows, that if the cord were left to itself, without any ligature, it would not expose the child to hemorrhage, or other accidents, even though it should be cut clean, and not contused or torn; some little blood might flow from the cut end, but every thing being left to nature, this could amount to but little, and such as would do no harm. But for the sake of cleanliness, it is proper that a ligature should be applied.

But it will be objected, that in some cases—though very rare—children have been known to bleed to death at the umbilicus. This has, indeed, happened in some few cases, in spite of ligatures, and every thing else in the way of styptics that could be applied. But these extreme cases are not to serve as guides in forming rules of practice. Nature has exceptions to all her rules. Besides, we may account for many of these occurrences, by the fact that the natural operations are often perverted by improper treatment. Thus, if children are swathed tightly, as has been too often the case in civilized society, compressing the chest and the abdomen, and causing them to cry from distress, the embarrassed state of the viscera suffices to disorder the general circulation, and enable the blood again to pass out of the navel.

Hence, as a matter of practical safety, although it is not necessary, as a rule, to apply a ligature to the umbilical cord, even when we cut it very near the abdomen of the child, we had better do it, as no harm can come from the procedure; it is possible for it to do good, even to save the life of the child; properly applied, it is not possible for it to do harm.

As to the point at which we divide the cord—whether at a half an inch or an inch and a half from the abdomen—every one must be his own judge. It is an old woman’s notion, both in this country and in the old, which was derived from the physiology of the ancients, and which requires that the cord should be cut very near the umbilicus if the child was a girl, and very far from it if it is a boy; such a mode of cutting being supposed to exert a great influence upon the development of the generative organs.

Notwithstanding the objections of some of the old women, I have separated the cord very near—say within half an inch of the abdomen. This is a much neater and more cleanly mode than it is to leave two or three inches of a dead substance to putrefy upon the child; besides, the more cleanly the part is kept, the more quick does the healing process take place.

“As to the ligature itself,” says Velpeau, “De la Motte advises us to apply it at the distance of one inch, Deventer, Levret, and the moderns, at the distance of two fingers’ breadths, others at three, four, five, six, and even twelve inches from the abdomen. Some persons have recommended the application of two, and in such a way that the one nearest the abdomen should not be so tight as the other. Sometimes it has been recommended to draw it very tightly, at others very loosely. One person is content with a single turn, and a single knot; and another thinks there should be two turns, and a double knot; a third, like Planck and M. Desormeaux, makes first one turn and one knot, and then bends the cord into a noose to tie another knot upon it.”

“A majority of the Philadelphia accoucheurs,” says Professor Meigs, of that city, “in tying the navel-cord, pass two strong ligatures each twice around it, securing them with two knots; the one an inch and a half, and the other two inches and a half from the abdomen, and divide it between the two with a pair of sharp scissors. This is a cleanly practice in all cases, and prudent, if not essential, in twins;” cleanly, that is, because, as the professor means the second ligature—that is, the one that is nearest the mother—prevents the blood coming from the placenta, and soiling the bed; the same principle I usually adopt, only the first ligature is placed half an inch, instead of an inch and a half from the abdomen. Sometimes, however, as in the night, it is perhaps better to leave the cord an inch or two long, and the next day tie it nearer the body. The ligature, since we use it at all, should be drawn very tightly; the cord being a dead animal substance after birth, very soon shrinks; hence if the ligature is not very tightly drawn, it may slip off in a day or two. In tying the ligature, we should be careful not to pull at the child, for in so doing we might cause a rupture, or a tendency to such an occurrence.

In making the division—which is usually done with a pair of good shears or scissors—we must be careful to avoid cutting off a finger, toe, or the private member. The infant, in its struggles, is very apt to get some of these parts in the way just as one is making the cut.

As to the kind of ligature: some think they must always have a narrow tape; and hence we often find, in attending a case, that the mother has already prepared herself with this material. But a common round thread is to be preferred; we can draw this more tightly than we can a flat ligature. A strong linen thread, doubled and twisted if we think it necessary, I consider the best. “Some would not dare to use any thing except tape,” says Velpeau; “whereas wiser persons make use of whatever they can find at hand.”

One circumstance should be particularly noticed in regard to tying the cord. It is said that it is possible for umbilical hernia to take place before the child’s birth. In such case a portion of its intestine must have protruded into cord. Hence, in such case, if we were to tie a ligature about the cord near the body, and where the intestine is—a fact that we can know by the cord being bulged out, or enlarged at the part—and should cut it off so as to sever the intestine, we should inevitably kill the child. Few practitioners have ever seen such a case; but inasmuch as it is said that such hernia may possibly exist, we should always watch for it. It would be easy to detect, but if one should have any doubt as to whether there is hernia or not, he may apply the ligature an inch or two from the child’s body, and thus make sure of doing no harm.

It is important to remember, that at the time of, and before making the separation, the child should be so placed as to allow the most free respiration; it has just begun to breathe for the first time in life; it is just as important that it has good air as it is for any of us. Many a tender infant has been injured at the very beginning by being smothered among the bed-clothes as soon as born. People everywhere, think it will take cold as soon as it is exposed to the air; but think, you who understand the anatomy and physiology of the human system, how exceedingly delicate the fine internal net-work of its little lungs is! And think you that the external skin is less able to bear the new impression of the atmosphere than the lungs are?

As to difficulties at the child’s navel, I have never had them. It is certainly a very simple thing to leave it altogether to itself, with the exception, the second day and onward, of laying upon it a soft, clean, wet compress, of four or five thicknesses, so that it remains constantly moist. This water-dressing, often renewed, and kept thoroughly clean, heals the navel more quickly than can be done in any other known way.

From what I have been able to learn, I infer that with water-dressing this healing is effected from one fourth to one third less time than by the usual methods.

The period of the natural separation of the cord varies considerably in different cases. According to M. Gardien, it usually falls off on the fourth or fifth day. M. Orfila says the fourth, fifth, or sixth day. M. Dennis the fifth, sixth, seventh, or eighth day. M. Billard remarks, that the desiccation is complete toward the third day, and it is on the fourth or fifth day that the cord is separated from the abdomen.

Dr. Churchill, of Dublin, kept an account of the period of its decadence in 200 cases, and it occurred as follows:

In 1 case it fell on the 2d day. „ 4 cases „ 3d „ „ 20 „ „ 4th „ „ 52 „ „ 5th „ „ 81 „ „ 6th „ „ 24 „ „ 7th „ „ 10 „ „ 8th „ „ 7 „ „ 9th „ „ 1 case „ 10th „

According to Dr. Churchill, then, it would appear, that the fifth and sixth days are the ordinary periods of the detachment. The cord has been known to remain undetached as long as fifteen days; but such cases must be very rare.

Complete cicatrization is commonly effected by the end of the second week. The healing powers vary somewhat in different cases. In one case, where both the father and the mother were of scrofulous tendency, it was a number of weeks before the healing process was fully completed. The child, however, in the end did well.

OF STILL-BIRTH.

The child may be born still, from its not having passed to its full period, or from various causes it may not have vital stamina enough to enable it to live. In some cases the child is born without any manifestations of life whatever appearing. The face is swollen and livid, the body flaccid, and the navel-string does not pulsate.

In such cases we should not at once wholly despair of life, although there is not usually much to hope for; yet, inasmuch as cases of this kind are now and then recovered, they ought not to be immediately abandoned without making suitable efforts for the resuscitation of the vital powers.

A frequent cause of the absence of respiration in the new-born infant is, separating the umbilical cord too soon after birth. Such is the opinion of Denman, Burns, Baudeloque, Dewees, Elberle, etc., etc., and there can be no doubt that many a child has been destroyed by this inconsiderate practice. By all well-qualified and skillful practitioners it is laid down as a rule, “that the cord is not to be tied until the pulsations in its arteries have ceased;” and this any person of ordinary understanding, and without medical knowledge, can easily ascertain, by simply taking the cord between the thumb and forefinger.

In consequence of the neglect of this rule, Doctor Dewees tells us that he had reason to believe he had seen several instances of death, and this of a painful and protracted kind. “And that this is probably one of the causes of the many deaths, in the hands of ignorant midwives and practitioners,” this author observes, “we have too much reason to suppose.” The practice with many is, to apply a ligature to the cord the instant the child is born, without any regard whatever to its pulsation, or the state of the child’s respiration.

Treatment.—In the cases of asphyxia, to which I have referred, various methods of treatment have been adopted, some of which are, no doubt, valuable, while others are meddlesome, and worse than useless.

If the child is livid and dark-colored, it has been recommended to abstract blood. This is best done at the umbilical cord; that is, by separating it. If the blood will not flow, it is recommended to strip some blood from it. It is, however, admitted that, in general, very little, if any, can be obtained in this way.

It has also been recommended to apply a cupping-glass to the umbilicus, so that by exhausting the air from the part the blood may be brought into motion, and thus made to flow, and this even after the heart has ceased to act. I know of no author, however, who has succeeded in this method.

The object of abstracting blood in any of these various ways is to set the vital fluid in motion, and to relieve the congested parts. But it appears to me that there is a far better method than this, and that is simply by friction with the wet hand. The child has in no case too much blood; it is only in the wrong place. The wet hand does not at all injure the skin; the cold water—for cold only should be used here—acts as a stimulus to the vital power, and the motion of the hand and the pressure will set a hundred-fold more blood in circulation than the mere separating of the umbilical cord could do. Hence it is that I would depend much upon friction, and very little, if any, upon the abstraction of blood. This latter practice is destined to become as obsolete in time, as that of bleeding in a severe injury or shock of the system—a method which has deservedly gone out of date among all scientific practitioners of the medical art.

In conjunction with the measure which I have just recommended, there is another of importance, which should be faithfully made; and that is, an effort to excite the respiratory function by artificial inflation of the lungs, and compression of the chest with the hands, so as to imitate in a measure the natural acts of inspiration and expiration. In doing this the operator must apply his mouth to that of the infant—the latter having been first freed of the mucus that attaches to it—at the same time closing its nostrils, and endeavor by a moderate but uniform force of expelling the air from the mouth, to fill the lungs of the child. As the air is thrown into the lungs, the chest of the child must be allowed to expand as much as it will; and then, as this act is discontinued, the chest should be compressed a little, carefully, so as to imitate the natural motion of these parts.

Authors disagree as to the amount of force allowable in forcing air into the lungs of a new-born child. Some have recommended a “forcible insufflation,” while others contend that such a practice is fraught with danger to the child. It appears from a series of experiments that have been made in France on animals, and from observations relative to the human subject, that no very great force of insufflation is necessary to rupture the delicate air-cells, and cause a fatal emphysema of the pulmonary structure. In sheep, and in the dead human subject, the air-cells were ruptured by a force of insufflation not greater than that which may be made by a person of ordinary respiratory vigor, without any very violent effort.

To obviate the unfortunate accident of rupturing the air-cells of the lungs, the air should be thrown into the respiratory passage through a silk handkerchief folded double, or a fine napkin laid over the mouth of the infant.

In all cases of retarded, impeded, or suspended respiration immediately after birth, care should be promptly paid to the removal of the viscid mucus, which is usually to be found lodged in the mouth and throat of new-born infants. In some instances the quantity of mucus is so great, and its quality so tough, that it is believed the child could not possibly breathe if the obstruction was not removed from the parts. In all cases, therefore, if there appears to be any difficulty whatever in regard to respiration, it is best to remove this mucus by means of the finger, surrounded by a handkerchief or piece of soft linen. If there is reason to believe that the mucus is also lodged in the throat and beyond the reach of the finger, it has been recommended that the child should be turned with its face downward, and the body raised higher than the head. In this position, the child’s back, between the shoulders, is to be patted with the hand, and its body gently shaken, so as to disengage any matters that may be lodged in the trachea, and permitting it to flow out of the mouth by making this the depending part. At the same time, if the back is rubbed with the hand wet in cold water, the stimulating effect will aid in the expulsion of the offending cause from the throat.

Infants are sometimes born in a state of asphyxia, when, instead of lividity and swelling of the countenance, there is the opposite extreme, the face and surface of the body, generally, being pale, exhibiting a want of vitality. In such cases, it is of the utmost importance that the cord be not divided too hastily; on no account, indeed, should this be done until the pulsation has ceased. The viscid mucus should at once be removed from the mouth and fauces by the methods before mentioned; and it has been recommended to apply brandy, spirits of camphor, hartshorn, etc., to the mouth and nostrils, with the view of exciting the respiratory function. It is doubtful, however, if such articles do any permanent good whatever, and they are certainly liable to harm. At any rate, it is better, I am confident, to sprinkle cold water upon the surface, and to make friction with the cold wet hand. This will set the blood in motion, and aid the vital powers incomparably more than the stimulants mentioned.

It is also advisable in these cases, if respiration is particularly tardy, to inflate the lungs carefully, according to the method before recommended. But the applying hot brandy, flannels wrung out of hot spirits, etc., which have often been used on such occasions, are worse than useless, and ought never to be resorted to.

Infants, in this condition, should not be given up too hastily. Numbers of cases have happened in which a half hour or more has elapsed before respiration has been established. Even a much longer period than thirty minutes has transpired in some cases before the breathing has been established.

The time will come, probably, when electricity will become so well understood as to enable us to make it a valuable agent in cases of still-birth and suspended animation. In the present state of knowledge, however, it is better, I think, to depend on the stimulus of cold water, frictions, and the other means to which I have already referred. But great care is necessary in the management of all such cases; and I have no doubt that many more infants have been killed by too meddlesome and injudicious management, than have been saved by the use of artificial means. The tendency in cases of this kind always has been to do too much. It is one of the greatest acquirements in art to learn when not to do.

WASHING AND DRESSING THE CHILD.

I have a few words to say here on these topics; but I must refer you to my Treatise on Children for a much more full and explicit explanation of them than the limits of this work would admit of. You can all of you who have need obtain that work, I trust; and surely, after you have borne a child, you will feel the greatest interest in learning all that it is possible for you to know respecting the best modes of rearing it.

In general terms, then, I remark, that a child should, soon after its birth, be carefully cleansed by means of pure water and the addition of a little mild soap. The water should not be either too warm or too cold; a moderate temperature, as from 70° to 80° Fah., will be found best. The child should be carefully washed, I said; and in all that is done in handling it, you should remember that it is a frail, delicate thing. Nor need I hint to a mother that inasmuch as some one had to perform all of these small yet multiform offices for us, so should we be willing to perform them for others.

The dress should be loose, and merely sufficient for the purposes of warmth. The child should not be in any way bound with its clothing; nor should a binder or bandage be used.