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 AN ESSAY 
 
 ON THE 
 
 LIGATION 
 
 AND 
 
 attaptmt of % toWkal (to 
 
 AT 
 
 CHILDBIRTH; 
 
 BY 
 
 A. F. A. KING, M. D., 
 
 MEMBER OF THE CLINICO-PATHOLOGICAL SOCIETY OF D. C. AND OF THE AMERICAN 
 
 MEDICAL ASSOCIATION; SECRETARY OF THE MEDICAL SOCIETY OF D. C; 
 
 LATE LECTURER ON TOXICOLOGY, NATIONAL MEDICAL COLLEGE, 
 
 (MEDICAL DEPARTMENT OF COLUMBIAN COLLEGE,) 
 
 WASHINGTON, D. C. 
 
 ""^™ 
 
 WASHINGTON, D. C. 
 
 PRINTED BY WILLIAM H. MOORE. 
 
 1867. 
 
 V 
 
./era 
 
 Entered according to Act of Congress, in the year 1867, 
 
 By A. F. A. KING, M. D. 
 
 In the Clerk's Office of the Supreme Court of the District of Columbia. 
 
F IR E IF -A. O E . 
 
 To all practicing physicians and accoucheurs, but especially to those who 
 have charge of lying-in hospitals, or who are otherwise particularly inter- 
 ested in Obstetrics, with a view of inducing them to test by clinical experi- 
 ment the truth or falsity of the principles inculcated in the ensuing pages, 
 this essay is, with the greatest respect, addressed. The labor which he thus 
 solicits of others, the author greatly regrets, is not — from lack of opportunity 
 — in his own power to perform. 
 
 Theoretical principles that are at present supported only by a limited ex- 
 perience, it is prudent to anticipate, will, in the future, require some modi- 
 fication. The author, therefore, does not assume but that the theories he 
 advocates and the practice he recommends may each be improved upon, as 
 the truth is more positively revealed, by clinical observations yet to be in- 
 stituted. 
 
 While, however, on some points erroneous ideas may have been enter- 
 tained, or doubtful ones too positively expressed, — while also there may be- 
 long to the style and manner of the work, many imperfections which it has 
 been beyond the author's ability to rectify — for it is almost his first attempt 
 at authorship — notwithstanding these drawbacks, what has been written is 
 submitted, with all confidence, to the members of our profession, trust- 
 ing that they will for themselves, sift truth from error, and with the hope, 
 that although the anticipations of the writer may not be fully realized, yet 
 that what has been done may itself result, or indirectly lead to results, by 
 which the cause of science may be promoted, and new facts developed, the 
 useful application of which, in practice, may contribute towards the general 
 good. 
 
 A, F. A. KING, M. D. 
 422 14th Street West, May, 1867. 
 
:lig.a.tio:n; 
 
 OF THE UMBILICAL CORD. 
 
 There is, perhaps, no manipulation in Obstetrics, no operation in Sur- 
 gery, and no course of treatment in Medicine that has been more univer- 
 sally practised, in all ages and countries, and by all authorities, than liga- 
 tion of the umbilical cord at childbirth; and every one has believed in 
 the propriety, utility, and necessity of the operation. Under such cir- 
 cumstances one cannot but feel timid, if not actually self-accused, in ven- 
 turing to advocate an opposite practice. My only excuse for so doing — I 
 trust an acceptable one — is simply the conviction that the principles I 
 advocate are true, and that if put in practice as hereafter recommended, 
 they would tend to mitigate or prevent disease, and to lessen the mortality 
 of infants — "a consummation devoutly to be wished." * 
 
 The object of the present paper has now been anticipated. Its design 
 is to prove — 
 
 1st. That ligation of the umbilical cord at childbirth is in all, or at 
 least in the very great majority of cases, unnecessary. 
 
 2d. That it is in many cases injurious. And, 
 
 3d. That certainly in some, and probably in not a Jew, it is actually 
 fatal to life. 
 
 In the latter part of the paper are submitted for the consideration of 
 practical obstetricians some general directions for what the author believes 
 to be, as proved by his own practice, the best mode of managing the cord 
 without ligation. 
 
 As to the necessity of the operation, we may remark, first, that ligation 
 of the umbilical cord in the human infant is unnecessary, because it is a 
 proceeding not required at the birth of any other animal. The human 
 species, and our own race in particular, is justly conceded to constitute 
 
 * Since writing the above, I learn (from Beck's Jurisprudence, vol. 1, p. 544, 11th 
 ed.) that the necessity of tyirg the cord was first disputed by J. Fantoni, Professor of 
 Anatomy at Turin, "who suggested that this precaution was useless, and that the 
 neglect of it was unattended with any danger to the life of the child. After his time 
 the same opinion was adopted and defended by Michael Alberti, in 1731, and J. H. 
 Schultius, in 1733, both professors in the University of Halle. In 1751, Kaltsmidt 
 maintained the same doctrine at Jena." — (Beck.) 
 
6 
 
 the highest order of the animal creation. Man has greater powers of 
 endurance, and his system is endowed with a greater facility of adapting 
 itself to new and unnatural conditions, than any other living being on the 
 face of the globe. He can live in all countries and climates at all seasons, 
 can endure the greatest extremes of heat and cold ; is omniverous — capa- 
 ble of assimilating every kind of food, and of laboring in all kinds of oc- 
 cupation ; in one word, our own species is stamped with a superiority 
 that does not belong to any other class of living creatures. While, there- 
 fore, all animals, foreign and domestic, bring forth their young without 
 assistance, is it not, I ask, strangely inconsistent to proclaim — as the prev- 
 alent theory and practice of all medical authorities do proclaim — that the 
 progeny of man — the Caucassian infant — should require the ligation of 
 an artery during the first minute of its extra-uterine life, and before the 
 birth is admitted to be complete ? 
 
 But to this view it may be objected, that if the superiority of the con- 
 stitution of man over other animals, is a reason why ligation of the cord 
 should be omitted, then all other obstetric operations might be dismissed 
 upon the same ground. To this, however, it may be replied, that the 
 causes which often render parturition difficult, do not always influence 
 the child after delivery ; moreover, while it is acknowledged, as statistics 
 prove, that in ninety-six per cent of all cases of labor, the unaided efforts 
 of nature are sufficient to complete delivery, in no single instance is it 
 admitted, that ligation of the cord can be dispensed with, I therefore re- 
 gard it fair to assume that if ligation of the funis is not required in the 
 inferior animals, it surely cannot be necessary in man. 
 
 Prof. C. R. Gilman tells us, that the only argument of any value offered 
 by the writers of the XVIIth century, who maintained that ligation of the 
 cord was unnecessary, " is that from analogy with the lower animals." 
 '* But this analogy (he continues) does not hold ; for, according to Prof. 
 Brendel, (Medicinsejorensis sive legalis,p. 9,) there is in the lower ani- 
 mals a peculiarity of structure tending to interrupt the flow of blood and 
 lessen the chance of hemorrhage." (Beck's Jur., revised by Prof. Gil- 
 man, 11 ed., p. 544, vol. 1.) 
 
 In an old edition, I think the first, of the work already referred to, the 
 author observes as follows : " That there is some difference in the 
 structure of the human cord and that of other animals, is not merely a 
 rational conjecture, but proved by actual observation. Prof. Brendel, in 
 examining pups and heifers, found their umbilical vessels full of rugae 
 or folds throughout the whole of their course, and their size much less 
 also in proportion. In another place the same writer says, that in brutes 
 the vessels of the cord are much smaller than in man, and that when the 
 animal is born, they are in a measure closed by a kind of cellular struc- 
 ture. From this it appears that in brutes there is a peculiar structure of 
 the vessels of the cord, tending to interrupt the flow of blood through 
 them, and favoring their speedy contraction after they have been cut." 
 
 Again, it has been remarked, and with good reason, by Drs. Beck, 
 Wharton, Stille, Hunter and others, as contra to the argument by analogy, 
 that in animals the cord is never cut, as it is in children, but torn asunder, 
 by which the disposition of the vessels to contract, so as to prevent hem- 
 orrhage, is greatly increased. Moreover, it seems to be the general opinion 
 of some medical writers, in high authority, that it is very common, or uni- 
 versally the case, that animals bite the cord in twain with their teeth, or, 
 
when it has accidentally broken, chew the foetal extremity of it, in such a 
 manner as to secure its contraction, conditions which do not often occur 
 in man. Thus Wharton, and Stille, (note to Med. Jur., art. Infanticide,) 
 in referring to the case of a woman who was reported to have followed 
 the animal instinct and divided the cord with her teeth, remark, that 
 " though this is not the practice with all domestic animals, it is so with the 
 dog, cat and pig, who, moreover, devour the afterbirth, but in the horse 
 and ruminating animals, the cord is gently broken by the fall of the 
 young when the mother is in the standing position, or, when delivered in 
 the recumbent position, by getting up," also in a note to Beck's Juris., 
 (11th ed. p. 541, vol. 1) we find reference is made to a case purporting 
 to be from the pen of Dr. Wm. Hunter, and found in a late edition, 1838, 
 of Merriman's synopsis, in which it is said, Dr. Hunter, watched the 
 parturition of a bitch, and thus records the result : 
 
 " The pains coming on, the membranes were protruded ; in a pain or 
 two more, the puppy followed. You can imagine with what eagerness 
 the mother lapped up the water, and then taking hold of the membranes 
 with her teeth, drew out the secundines. These she devoured also, lick- 
 ing 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. How- 
 ever, 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 it to its mother, who, drawing it (the cord) several times 
 through her mouth, bruised and lacerated it, after which it bled no more. 
 This, I make no doubt, is the practice of other animals." 
 
 Thus the objections urged against the argument by analogy with the 
 lower animals, are these : First, It is said that, in the cords of animals 
 there is a peculiarity of structure provided, of such a sort as to inter- 
 rupt the flow of blood, and thus prevent the occurrence of a dangerous or 
 fatal hemorrhage, and which, it is assumed, does not exist in man. This 
 I hold to be manifestly incorrect, for, as I have hereafter shown, the form- 
 ation of the human umbilical cord, and the structure of its vessels, are so 
 admirably and beautifully adapted to provide against the occurrence of a 
 dangerous loss of blood, as to be unsurpassed, as we should apriori sup- 
 pose them to be, by the umbilical structures of any inferior animal. — (See 
 p. 9.) 
 
 It has been objected, secondly, that the size of the umbilical vessels of 
 other animals is in proportion smaller than it is in man. Admitting that 
 this may be true of some animals, I believe it is not the case with all, or 
 if it is, the fact yet remains to be proved; and while it is so, the objec- 
 tion is not conclusive. Every organ in the body is observed to differ, 
 both in size, being sometimes proportionately greater and sometimes less, 
 and in many other particulars, in different animals, the peculiarity of 
 formation being adapted for its particular design. Is it not therefore fair 
 to assume that there may be instances, and perhaps not a few, (for I be- 
 lieve no extended inquiries have been made in this direction,) in which 
 the size of the umbilical vessels is greater in proportion than it is in man. 
 At any rate, until this is disproved, by a sufficiently-extended examina- 
 tion, the objection urged above must necessarily be inconclusive. 
 
 With regard to the third statement, that the cord in man is cut, while 
 
8 
 
 in animals it is torn asunder or bitten, this we admit. The fact, however, 
 proves, not that there is any difference as regards the liability to hemor- 
 rhage in the being, (i. e. between the animal and the human,) but in the 
 circumstance — the manner of separation. A lacerated cord will bleed not, 
 in either man or animal ; a cut one will bleed in both. The analogy is 
 not destroyed. Dr. Hunter's puppy bled so "profusely" when he cut 
 its funis with the scissors that he " feared its death" and held it to the 
 mother that the end of the cord might be lacerated by chewing; and I 
 suppose the same result would have been observed, under similar cir- 
 cumstances, in most other animals. The disposition to hemorrhage does 
 not therefore belong to man more than the rest, and the ligature is alike 
 unnecessary, under like circumstances, in all. 
 
 I trust that the argument, by analogy with the lower animals, in sup- 
 port of the non-necessity of ligation, has now been satisfactorily sustained, 
 notwithstanding the objections urged against it. 
 
 In connection with this part of our own subject, it may be of interest 
 to remark further, that I have myself witnessed repeatedly, and closely 
 watched the process of parturition and delivery in sheep, cows and pigs. 
 In relation to the last I may be allowed to state that the result of my ob- 
 servation, altogether conflicts with the remark by Wharton and Stille, 
 (see ante, page 7), that in the pig the cord is divided with the teeth. 
 In not one instance have I observed this, but the mode of separation has 
 been as follows : The mother (I now refer to the pig only) lies at full 
 length upon her side exactly in the position in which the animal is observed 
 when suckling her young. The latter are born singly, a slight interval, 
 often of some minutes duration, elapsing between each. In the cases 
 witnessed (multiparas) the labors were almost painless, the mother re- 
 maining quiet, and apparently unconcerned, during the whole process. 
 As each youngster came into the world, its first instinct, (pig-like,) was 
 to obtain food. This desire was manifested almost immediately ; say 
 within a minute, and while the cord was yet unbroken. All the efforts 
 of the little one are now employed in attempting to reach the mammae, the 
 obstacles to which, are his weak, but gradually increasing powers of 
 locomotion ; traction of the cord ) and the barrier offered by one (that 
 nearest the ground) of the mother's hind legs, over which the young must 
 climb before the teats can be gained. It is during the repeated, and for 
 sometime fruitless efforts to surmount these difficulties, that the cord is 
 finally torn asunder, the point of separation being an inch or two from 
 the umbilicus. A variable quantity of blood is always lost, and from both 
 free extremities of the ruptured funis. The little one now attaches himself 
 to' a teat, and in a short time more — the craving appetite having been satis- 
 fied — he is fast asleep, soon however to be roused by the discontented squeak 
 of some newly-arrived and hungry brother. So it continues until the ac- 
 couchment is complete, which may occupy the better part of an hour, more 
 or less, the mother meantime remaining on her side as before, and having 
 offered no assistance either in dividing the cord, or by bruising its foetal 
 remnant. It should not be overlooked, however, that the funis may have 
 suffered considerable contusion, previous to rupture, by having been tram- 
 pled between the hard straw and the horny toes of the new visitor. In the 
 cow and sheep, rupture takes place much in the same way, and the cord, in 
 some instances, is in like manner trampled upon. In these, however, it 
 most frequently happens that a forcible separation takes place immediately 
 
9 
 
 after birth, either by the young falling — -the mother being erect when de- 
 livered ; or by her getting up suddenly when delivery has taken place in 
 the recumbent posture. Under such circumstances, hemorrhage from the 
 cord is sometimes quite considerable, but I have never seen or heard of a 
 case, in which it was sufficient to endanger life. 
 
 From what has now been said I think it cannot appear otherwise than just and 
 reasonable, to consider tying the umbilical cord in man unnecessary, because 
 it is so in all other animals. 
 
 But again we may observe that the operation of ligation is superfluous, 
 because the imagined necessity for it, viz : to prevent hemorrhage, does not 
 exist : that no such fear (viz : of hemorrhage) need be apprehended, will 
 distinctly appear from a knowledge of the formation of the cord itself, and 
 of the histological structure of its component vessels. 
 
 On examination it will be first observed, that the cord itself is not straight 
 but wrinkled and tortuous in its course, so that the impetus of the blood 
 circulating through it, is diminished by the current impinging against the 
 tortuosities which naturally obstruct its flow; just as the rapidity of the 
 arterial currents entering the cranium is moderated by the deflection of the 
 internal carotid and vertebral arteries, observed in the course of those ves- 
 sels, immediately before they enter the cranial cavity. 
 
 Upon a more scrupulous examination we further notice that the umbilical 
 arteries from which bleeding is to be feared, (if there was any ground for 
 fear at all,) more than it is from the vein, are two in number, while the 
 vein is but one, hence, as there is supposed to be as much blood going in one 
 direction as the other, the calibre of each artery is but half the diameter of 
 the vein, an arrangement which admirably exhibits the wisdon of nature in 
 providing against an accident, which our practical obstetricians seem to in- 
 sist on believing has not been provided for. 
 
 But the wisdom of nature in so disposing these vessels as to prevent a 
 dangerous hemorrhage, is yet more beautifully apparent in the fact that the 
 tortuousness of the arteries in their course along the cord, exceeds, beyond 
 all comparison, the tortuosity of the vein ; for is it not true, that the two 
 arteries are wrapped in spiral turns round the vein, much in the same man- 
 ner, that we dispose a strip of muslin round a limb, in the ordinary opera- 
 tion of applying a spiral (unreversed) bandage. Yet further, the signifi- 
 cance of the facts at present referred to, almost dwindles into i/2-significance 
 when compared with what we discover upon examination of the minute 
 structure of the coats of the umbilical vessels. On this point I will simply 
 quote verbatim from Virchow's " cellular pathology. " In lecture 5, pp. 
 128, 129, speaking of" the three large trunks,' 7 the vessels of the cord, he 
 says, " these are all of them remarkable for the great thickness of their 
 walls, which, as we have really only known since the investigations of Kol- 
 liker, are enormouslu rich in muscular fibres. In a transverse section of 
 the umbilical cord, it may be observed, that the thick middle coat of the 
 vessels is entirely composed of smoothe muscular fibres, lying in immediate 
 contact, one with the other, and in such abundance as is scarcely to be 
 seen in any completely developed vessel. This peculiarity, (he continues,) 
 explains the extraordinary great contractility of the umbilical vessels, 
 which can be so readily seen in action on a large scale when mechanical 
 stimuli are' applied, when the vessels are divided with scissors or are pinched, 
 or after the employment of electrical stimuli. Sometimes upon the action 
 of external stimuli, they even contract to such a degree that their canal is 
 
10 
 
 entirely closed) and thus after birth, even without the application of a 
 ligature, as when for example the umbilical cord has been torn asunder, the 
 bleeding may stop of itself." 
 
 Such is the unequivocal statement of that most careful observer and world- 
 renowned pathologist, Rudolph Virchow. No one surely will dispute it. 
 
 But still more conclusively to settle this question, as to the fear of hemor- 
 rhage, which is so generally entertained amongst us, I will simply mention 
 what is better than any theoretical speculations, some practical facts bearing 
 on the subject. 
 
 We are all aware that it is by no means an uncommon accident for a child 
 at full term to be suddenly expelled from the uterus while the mother is in 
 the erect position, or while she is seated over the cloaca of a water-closet, 
 the child falling to the ground, and the umbilical cord being ruptured, or 
 torn out at its socket from the abdomen. Under such circumstances, do we 
 have hemorrhage from the cord, to such a considerable extent as to endanger 
 life, or do we not? This question must be answered without hesitation, in 
 the negative. There is no fear of dangerous hemorrhage under such cir- 
 cumstances. 
 
 Witness for example the following array of cases. In Dr. Taylor's work on 
 Medical Jurisprudence, (4th Am. Ed., pp. 381, 372,) we find eight instances 
 mentioned as having occurred in the practice of different authors, in three 
 of which cases the cord was torn out by its root from the abdomen, but the 
 children sustained no injury; in five it was ruptured at a distance varying 
 from two to three inches from the abdomen, and all of these children survived 
 without injury except one, which died six days after birth, its skull having 
 been fractured by falling to the ground at delivery. Further on (p. 384) 
 it is remarked, that " among the cases of sudden delivery reported by Dr. 
 Olshausen, the cord was torn through at three inches from the navel in one, and 
 no bleeding followed. In two the cord was torn at its middle, and at first 
 there was great bleeding. In three it was torn close to the umbilicus, and 
 no bleeding had occurred. In four the cord was torn at five or six inches 
 from the navel, and there was no bleeding. Thus taking all these cases to- 
 gether, we find them eighteen in number, in six of which the cord was torn 
 out of the abdomen, but in no instance was there a fatal or even dangerous 
 hemorrhage. The " great bleeding at first," said to have occurred in 
 one case, gives no definite idea of the amount of hemorrhage. Furthermore, 
 we find (Jurisp., Wharton & Stille,) that in 26 cases given by Dr. Klein, 
 in which the cord was torn off close to the navel, " no hemorrhage occurred." 
 " In eleven cases reported by Elssasser, in which the child had fallen from 
 the mother upon the hard ground or pavement, and the cord was ruptured, 
 no hemorrhage resulted, except in two. In these the life of the child was 
 saved by timely help." " In two cases in which the cord had been cut and 
 no ligature applied to it, no hemorrhage resulted from the omission." 
 
 In the four cases (consecutive ones,) referred to in another part of this 
 paper, in which the cord was cut by myself and the ligature intentionally 
 omitted, there was no hemorrhage of any consequence in three, and in one, 
 none at all. " Casper in his long and ample experience, never met with a 
 single instance of this sort, (referring to fatal hemorrhage from the funis 
 when ligation was omitted,) although not less than four cases came under 
 his observation, in which the cord was divided close to the navel, and as he 
 adds, examples of the cutting or laceration of the cord at various distances 
 from the body, and without death by hemorrhage, are of every day occur- 
 rence." (Juris., Wh. & St., p. 387.) 
 
11 
 
 Notwithstanding the ample evidence thus recorded, (and more of like 
 character might be added,) of how little danger there is, of hemorrhage 
 from the cord when ligation is omitted, it will be found by referring to the 
 authorities on medical jurisprudence, (Beck, Taylor, Wharton & Stille,) 
 that they all agree as to the fact, that a child may die from loss of blood 
 when the cord has not been properly ligated. Moreover, the intentional 
 omission of the ligature may render a person liable to the charge of 
 infanticide. 
 
 It will be noticed, however, that all they affirm, is the possibility of 
 death, — " a child may die," &c. Now, this, I should say, no one would 
 attempt to dispute, for that' it is possible for a child to die by bleeding 
 from an unligated cord, is unquestionable, but upon an impartial investi- 
 gation, it will be found that such cases are among the rarest of the most 
 rare, and, we might venture to believe, never occur where the child and 
 its appendages are in a normal condition, but only in those where there 
 is disease, such as ossification, varicosity, &c, of the umbilical vessels, 
 or some other unknown, and therefore unappreciated, derangement. 
 Prof. Taylor, (Jur., p. 368,) in discussing the question "whether, in the 
 event of the umbilical cord being left untied after cutting or laceration, 
 such a degree of hemorrhage could in any instance occur as would prove 
 fatal to a child," decides in the affirmative, but bases his opinion, upon 
 " an instance reported," one only — and of this, the text does not say by 
 whom, or at what date it was observed. Wharton &, Stille refer, by note, 
 to four or five works and journals, mostly foreign ones and nearly obsolete 
 also, in which they tell us fatal cases have been reported. No particulars, 
 however, are given except in two instances, concerning one of which it 
 is said, the child bled to death seven days after birth; and of the other 
 (by Dolcius, 1845,) it is remarked, " that the fragment of cord remaining 
 on the child was sixteen inches long; that it had been torn, not cut, by 
 the mother, and that the child had breathed." In the former case, — dying 
 seven days after birth, we can hardly attribute death to the neglect of 
 ligation; and in the latter one, it is almost out of the question, to suppose 
 that fatal hemorrhage could have occurred, unless the umbilical vessels 
 had been diseased, probably by ossification. In Beck's Jurisprudence, 
 (v. 1, p, 545,) it is stated by the reviser, Prof. Gilman, that " dangerous 
 hemorrhages from the cord occur under the observation of every one who 
 practices midwifery at all extensively, and fatal cases are unhappily not 
 very rare." Prof. G., however, gives no cases, nor refers to any. In 
 the same work, (pp. 558-9,) Dr. Beck refers to a case of hemorrhage 
 from ossification of the vessels, reported by Mr. Logan (Edin. Med. & 
 Surg. Jour.,) in which the cord gave way several times from pressure of 
 the ligature, and from pulling on it during the expulsion of the placenta. 
 Reference is also had to a case, related by Dr. Devees, in which a danger- 
 ous hemorrhage took place in a child three days old, and which, on ex- 
 amination, was found to be owing to a varicose state of the cord. In 
 neither of these instances, however, is it stated that the bleeding was fatal, 
 but only dangerous. In the same place Dr. Beck refers to a case, by Mr. 
 distance, " in which the child was suddenly expelled on the bed with 
 such violence as to rupture the cord very near the body." " It died in a 
 few hours, although there was no hemorrhage." I have entered some- 
 what at length into these details in order to show how extremely rare fatal 
 cases of hemorrhage from the cord, resulting from omission of the ligature, 
 
12 
 
 really are. In truth, so far as I have been able to extend my researches, 
 I have not yet succeeded in rinding a single instance — a fair one — of 
 which any particulars have been given, and which was known to have 
 died from omission of the ligature. With regard to the cases reported 
 years and years ago, when pathology and the science of pathological 
 anatomy were yet in their infancy, it may justly be questioned, whether 
 there was not, in them, some other cause of death, than that (by hemor- 
 rhage) which seemed to be the apparent one; and especially will this 
 appear probable when we reflect how many causes there are, some of 
 them altogether unappreciated or indeed unrecognizable, which occasion 
 death in the new born infant ; and how easy would it be, (as it most 
 likely has been in the darker ages of the past,) where a considerable 
 hemorrhage has occurred, to attribute death to the bleeding, when it really 
 had been occasioned either entirely by some other cause, or by the con- 
 joint action of it, and the bleeding. In conclusion, it may, however, be 
 remarked that if one single case has been known to occur since the crea- 
 tion of man, that one would be all sufficient to justify the reasonable de- 
 duction of the authorities on medical jurisprudence, "that a child may die 
 from loss of blood when ligation of the cord has been omitted." I may 
 be permitted to repeat, finally, that such instances are evidently among 
 the rarest of the most rare, — probably not one in the million. Therefore 
 it is we adhere to the opinion, that ligation of the cord is unnecessary, 
 because the imagined necessity for it (viz : to prevent hemorrhage) does 
 not exist. 
 
 Ligation not necessary jor cleanliness 1 sake. — It has been considered, 
 I believe pretty generally so, that ligation of the funis is necessary, 
 or at least proper, as a matter of cleanliness. On this point, how- 
 ever, little need be said, for if it is true, as I hope to show hereafter, 
 that the operation is actually injurious, the question of cleanliness 
 must then vanish. Still we may remark that the soiling of clothes 
 consequent upon omission of the ligature, is of little moment when com- 
 pared with that caused by the discharge of blood and liquor amniifrom 
 the uterus, which occurs in most cases of labor. Furthermore, since 
 many of the highest obstetrical authorities now altogether ignore the ap- 
 plication of a second ligature to the placental extremity of the cord, — on 
 the ground that loss of blood from that point facilitates the separation and 
 expulsion of the placenta, and without any regard for cleanliness, — then 
 surely, it would not be just to insist upon the application of the first 
 ligature, on the ground that its omission would be unclean. 
 
 Other considerations which render the assumption, that ligation of 
 the cord is necessary, unreasonable. — It is universally acknowledged 
 that wherever, in a healthy organism, formation is considered with 
 respect to its design, we behold a perfect adaptation of means to ends, 
 — the apparatus being exactly suited to perform its functions without 
 defect, without redundancy. Thus we all admire, — in so far as the 
 human mind in its littleness, has yet been able to comprehend them, — 
 the intricate functions of ovulation, fecundation and conception i and 
 we watch, with increasing wonder, through its succeeding stages, the 
 amazing transformation of a simple cell into a full-developed organ- 
 ism, capable, at the allotted time, of a separate and independent 
 existence. At conception and during the subsequent period of gestation, 
 
13 
 
 the changes that take place in the uterus and its tributary organs, — the 
 new character assumed by the general nutritive functions of the female — 
 the secret formation of chorion, amnion, allantois, umbilical vesicle, pla- 
 centa, &c, within the uterine labyrinth — the curious mechanism of the 
 circulatory and respiratory organs of the fgetus, together with the develop- 
 ment of its osseous and nervous structures — and finally the crowning 
 wonder of parturition and delivery — all these, with a perfection that can- 
 not be surpassed, illustrate, how admirably the constitution of woman 
 and the organs of her generative system, are adapted to perform, without 
 defect, that cardinal function for which they were mutually designed — the 
 reproduction and perpetuation of the species. Under such circumstances, 
 and in the face of so much beauty and harmony of design, is it not, I ask, 
 unreasonable to assume that there should belong to the process of repro- 
 duction, so glaring an imperfection as that the product of conception 
 should be lost, in the " eleventh hour," — at the moment of its final sepa- 
 ration from the mother — because, (as it would seem to be believed by those 
 who advocate the ligature,) nature has committed the egregious mis- 
 take of omitting to make provision for such separation. In other words, 
 the harmony of nature's contrivances is acknowledged, — the reproductive 
 organs are admitted to be wonderfully well adapted to perform their func- 
 tions, — and everything, it is confessed, is admirably suited to accomplish 
 the grand consummation of bringing forth a new being into the world, 
 save only (what it is universally affirmed is wanting before the birth of a 
 single child can be satisfactorily and safely completed) a strand of thread 
 upon the umbilical cord. Is this not, and to say the least of it, unreason- 
 able. 
 
 Furthermore is it to be supposed that the Great Designer of the world 
 and man, who, at the creation commanded woman to "be fruitful and 
 multiply," should have constituted her reproductive system in so imper- 
 fect a manner, as that a single infant could not be safely born, without 
 the interposition of a strand of thread. Strange that an all-wise and all- 
 just Creator should have thought well to mould an organism unfitted of 
 itself to perform, what in the beginning he saw fit to command — and what 
 every other living organism, vegetable as well as animal, on the face of 
 the earth, does perform — the multiplication of its species! Yet nothing 
 short of this is implied by the prevailing opinions of the day. 
 
 This will conclude all that we deem it requisite to say in support of 
 the assertion, that ligation of the cord is unnecessary. 
 
 We come now to consider our second proposition, to wit: that ligation 
 of the umbilical cord at childbirth is in many cases injurious. 
 
 Believing the operation to accomplish no good, it requires but a short 
 step further to admit that it is an evil; for an unquestionable truth it is — 
 the processes of nature in a healthy org inism being perfect — that any at- 
 tempted improvement upon such processes, devised by human invention, 
 when not called for by some untoward accident, must be superfluous; and, 
 generally speaking, what is useless and superfluous is nearly always in- 
 jurious, and had better be omitted. In obstetrics especially, the officious 
 interference with natural processes is imperatively forbidden by that good 
 old maxim — universally admitted — thn "-meddlesome midwifery is bad." 
 
 I now propose, however, to present the evidence from which it may be 
 seen that ligating the cord is positively mischievous and productive of 
 
14 
 
 disease. And here we may remark — strange coincidence though it is, 
 and beautifully illustrating the folly of " meddlesome" interference — 
 
 1st. That the operation produces that very accident, the occurrence ox 
 which it has been erroneously supposed to prevent, viz: umbilical hemor- 
 rhage. In proving this to be a fact, in the manner that we could wish to 
 prove it — by the practice and statistics of the past — one great difficulty 
 meets us. It is, that the application of the ligature — (except only in those 
 comparatively few instances in which the cord had been accidently rup- 
 tured or torn from the abdomen, and in the modicum of cases — before re- 
 ferred to — where ligation had been intentionally omitted by myself,) — I 
 say that, except in these, the application of the ligature has been univer- 
 sally practiced upon all. 
 
 If we could find a given number of cases (and a large number would be 
 required, for one form of umbilical hemorrhage is extremely rare,) in which 
 ligation had been omitted, and consider them in connection with a like num- 
 ber where the ligature had been employed in the usual manner, we might 
 by noting how many times bleeding occurred in each, be enabled to prove 
 beyond question, how far the ligature had been instrumental in producing 
 the accident. Ji priori we should suppose that hemorrhage, subsequent to 
 that, be it little or much, which occurs when the mother and child are sepa- 
 rated, would be extremely rare, or more likely altogether unknown, in that 
 number of cases where ligation was not practiced. At present, however, 
 past records furnish no such cases, hence the difficulty of proving our posi- 
 tion by statistics — a difficulty which it is hoped the observations of the future 
 will at no distant day remove. But there are other sources of proof, though 
 perhaps less conclusive ones within our reach. In considering these, it 
 should be born in mind that most recent authors who have written upon 
 umbilical hemorrhage, group all cases of the disease into two great classes ; 
 one class including those supposed to depend upon constitutional or cachectic 
 disorder, such as the hemorrhagic diathesis, &c, and a second, embracing 
 all other cases, of whatever kind, not included in ihejirst. 
 
 For convenience sake, and for that only, we shall follow this classification, 
 and first consider the class of cases last mentioned — those namely, in which 
 it is allowed no constitutional derangement exists. Among these are in- 
 cluded cases of bleeding at some considerable time subsequent to birth, ac- 
 companied with ulceration and fungoid excresence of the navel, on which 
 they have seemed to depend, and also those cases, called "traumatic" and 
 " accidental,' ' where the cord had been imperfectly tied, where it had been 
 prematurely removed, or in which the ligature had become loose from the 
 shrinking of a cord that was very gelatinous; or in which the blood flowed from 
 the side of the cord in consequence of a rupture or ulceration of one of the 
 varicose dilatations of the umbilical vein; * or finally, in which the umbili- 
 cal vessels having been ' : perfectly secured," " a constant oozing or perco- 
 lation of blood takes place round the root of the cord, at the part where it is im- 
 planted in the walls of the abdomen ; ' (Condie.) 
 
 The modus operandi of ligation in causing these accidental hemorrhages, 
 and the proofs that it does produce them, now claim our attention. 
 
 The ligature, then, produces hemorrhage from the cord or navel, by caus- 
 ing to be retained in the umbilical vessels, and thereby distending them, 
 
 " :f First described by Dewees, and considered by Condie to be a "not uncommon 
 form of umbilical hemorrhage in young infants." 
 
15 , 
 
 the blood that would naturally have escaped at the time when the funis was 
 first divided, if no ligature had been applied. That in many cases a cer- 
 tain amount of hemorrhage is natural when the navel string is first divided, 
 both in man and animals, I think cannot be questioned. The quantity of 
 blood lost, will vary greatly in different individuals, in some being almost 
 nil, while in others, the discharge may be sufficient to merit — what it has 
 sometimes been called, " profuse ; " and the same difference will be observed 
 in animals. A variety of circumstances might be mentioned, and there are 
 no doubt others with which we are not familiar, in explanation of this di- 
 versity, as, for instance, a difference in the time at which the cord is broken 
 after the expulsion of the foetus j the absence or presence, or difference in 
 the strength of the pulsation of the cord at the time of separation ; a ple- 
 thoric or anemic condition of the foetus ; or again, the child may have lost 
 blood, and the umbilical vessels have been depleted before expulsion, in 
 consequence of hemorrhage having taken place from a lacerated placenta — I 
 mean from a laceration of the foetal half of that organ — and so forth. At any 
 rate it concerns us most to know the fact, for fact it is, howsoever to be ex- 
 plained ; that when the cord is separated without ligation, whether in man 
 or animals — hemorrhage varying in quantity, will take place in some, from 
 the extremity of the cord, while in others it will not. And with this fact 
 we meet the objection that might otherwise be justly urged against the doc- 
 trine that ligation causes hemorrhage, viz : that while the ligature is applied 
 in nearly all cases, bleeding occurs only in some. In other words those in- 
 stances where bleeding occurs subsequent to ligation, are the same that 
 would have bled when the cord was divided, if no ligature had been employed. 
 It is easy to see how the rupture or ulceration of a varicosed umbilical 
 vein, or the varicosity itself, or the oozing and percolation of blood from the 
 root of the funis, may all be due to the abnormal distention of the vessels 
 from the accumulation in them of blood that should naturally have been 
 suffered to escape. The ulceration and fungoid excresence of the navel, 
 from which bleeding often occurs, may probably have a similar origin. For 
 myself, I cannot consider it normal that the cord should separate in any 
 instance by ulceration ; or that there should be any appearance of redness, 
 inflammation, or suppuration at or surrounding the umbilicus. I believe the 
 natural process of separation is that by " dessication " or drying, as we al- 
 ways see it, if I mistake not, without exception, in the lower animals. But 
 when the navel string does not dry, there is then no other alternative but that it 
 should be detached by the suppuration and ulceration of its junction with 
 the umbilicus. Now I maintain that there is nothing so well calculated to 
 prevent dessication, and thus cause ulceration and ultimately fungoid granu- 
 lations, as the application of the ligature, for by its employment, not only 
 is there retained in the vessels of the cord a quantity of fluid blood, which 
 might otherwise have drained away, but which now has to disappear by the 
 drying process, and which, by the by, is in part replenished as fast as it 
 disappears, by the exit of new blood from that portion of the umbilical ves- 
 sels within the abdomen, -which last, it may reasonably be supposed are also 
 unusually distended ; not only this, but ligation maintains the cord in a state 
 of undue moisture, and thus retards dessication, by preventing the liquid 
 portion of the gelatinous matter surrounding the blood vessels from draining 
 away at the free extremity of the funis as it naturally should do.* 
 
 * It will be seen hereafter, that I have ventured to dissent from the usual method 
 of dressing the funis, on the ground that it also interferes with the natural process 
 of dessication. 
 
16 
 
 In this manner, therefore, those cases of umbilical hemorrhage which 
 have been said to depend upon the presence of fungoid excresences, may be 
 seen to have had their primary cause in the act of ligation. 
 
 There are other cases of hemorrhage, already referred to, in which it 
 is generally believed, the bleeding occurs on account of the cord shrink- 
 ing and so permitting the ligature to become loose and admit the flow. 
 That some such instances occur is very probable, if however, the blood- 
 vessels had been allowed to empty themselves through the open extremity 
 of the funis when it was first divided, I doubt not the occurrence of such 
 cases would be wanting. Furthermore, besides the ligature becoming 
 slack, there is another consideration not to be overlooked, by which such 
 hemorrhages may be accounted for ; I mean passive relaxation — loss of 
 power — in fact paralysis, of the muscular walls of the umbilical vessels. 
 These muscular fibres maintain themselves in a state of active contraction, 
 not by any motive power conveyed to them by nerves, (for no traces have 
 yet been discovered of nervous tissue in the umbilical cord,) but by vir- 
 tue of their "inherent contractility " — the same power by which other 
 muscular tissues — especially the muscles of the heart in cold-blooded an- 
 imals — are stimulated to contract after being separated from all nervous 
 connection with the body, upon the application of external irritants. It 
 is a lingering vitality in the muscular tissues, which must soon cease alto- 
 gether, and which we might reasonably suppose, would be soonest ex- 
 hausted where the muscles had been called upon to maintain themselves 
 continuously in a state of over-action. The longer, oftener, and more strong- 
 ly that contraction is excited, the sooner will the excitability of the muscle 
 cease, its vital contractility be expended, and relaxation or paralysis nec- 
 essarily follow—and thus do I conceive it is with the distended and over- 
 taxed muscular walls of the funial vessels, when gorged with blood that 
 would have escaped, but for the ligature ; for a time the power of contrac- 
 tion is sufficient in conjunction with the ligature to close the canal and pre- 
 vent hemorrhage, even in spite of the blood pressure from within, but so 
 soon as the muscular fibres lose their power, the walls of the vessel relax, 
 and the accumulated blood, now opposed by no obstacle, flows even more 
 freely than it would have done if it had been suffered to escape when 
 the cord was first separated — the ligature, therefore, instead of diminishing, 
 has increased the liability to hemorrhage. 
 
 When, at the time the cord is first divided, blood is permitted to drain 
 away from its open extremity, so that the vessels are emptied and their walls 
 allowed to come in contact with each other, we have every reason to suppose 
 that the contractile power of the muscular fibres — not being opposed in their 
 contraction from the interior by the resistance of accumulated blood — would 
 be exerted for a longer time than it would under the opposite circumstances, 
 at the same time when finally the power of the muscles was exhausted, the 
 walls of the vessels would remain in contact as they had contracted them- 
 selves, because there would be no blood pressure on the inside to separate 
 them ; moreover, if dessication had not been interrupted, as I have striven 
 to show it may be by the ligature, it is most likely that by the time when 
 the vitality of the coats of the blood vessels had been lost, their relaxation 
 would be effectually prevented by the gelatinous matter upon their exterior 
 becoming stiff and hard, thus giving a support to the sides of the cord, and 
 a seal to its end y firm as a wall of adamant. 
 
 Having now shown in what manner ligation may be a cause of " acciden- 
 
17 
 
 tal" hemorrhage, viz : by its retaining within the umbilical vessels blood 
 that should naturally have been permitted to escape, thereby preventing the 
 normal process of dessication, and invoking the abnormal one of ulceration ; 
 also maintaining patency of the vessels when they should have been closed, 
 in consequence of a premature exhaustion of their vital contractility; — hav- 
 ing done this, I may next briefly consider, apart from theory, what proof 
 there is practically, that ligation causes hemorrhage. The proof is in the 
 simple fact — for I believe, as far as we yet know, it is a fact — that where 
 there has been no ligation there also has there been no hemorrhage, i. e., 
 none after that which normally may take place at or immediately following 
 separation. 
 
 In animals, umbilical hemorrhage is unknown, so is ligation of the cord. 
 In those cases also of ruptured funis in man, where the blood has been per- 
 mitted to flow without interruption, no instance of the occurrence of a sec- 
 ondary hemorrhage, is on record ; at least I have not met with such. If, 
 as is possible, such a case should be found, some unhealthy deviation, or 
 malformation of the organism, would most probably be associated with it — 
 for example, the hemorrhagic diathesis, and malformation of the liver, or 
 its ducts, &c. 
 
 In my own cases, (few though they are,) in which ligation has been in- 
 tentionally omitted and blood suffered to drain away from the cord at birth, 
 ad libitum, there has been no secondary hemorrhage. 
 
 Whether the deductions to be drawn from these few instances, are cor- 
 rect or not, I fearlessly leave to be decided, as it only can be, by the test of 
 future experiment and observation. 
 
 Xext in order comes the consideration of that other class of cases of um- 
 bilical hemorrhage in which it is currently believed the bleeding is depen- 
 dent upon, or associated with, constitutional derangement, either of the 
 parents, or their offspring, or both. This kind of umbilical hemorrhage 
 would be of comparatively little interest practically, on occount of its ex- 
 tremely rare occurrence, were it not for the fact of its great fatality. Dur- 
 ing the two years preceding January, 1853, at the Foundling Hospital in 
 Paris, but one single case occurred, among over 9000 children. In the Dub- 
 lin Lying-in Hospital, no cases are reported during a period of 12 years, 
 though there were 6,654 births. In 2,000 births at the Emigrant's Refuge, 
 Ward's Island, N. Y., two instances of this hemorrhage existed. (See 
 Trans. Am. Med. Ass., vol. 11, note to p. 265.) Among 16,276 children, 
 who came under the observation of Dr. West, not a single case was met 
 with. (Dis. of Infancy and Childhood, 2d ed., p. 417.) 
 
 The fatality of the complaint, according to Dr. Minot, (Am. Jour. Med. 
 Sci., Oct., 1852, p. 320) was 84 per cent, or 39 deaths out of 46 cases. 
 According to Dr. Jenkins, " five-sixths (83.7 per ct.) of those attacked suc- 
 comb to the disease or its sequelae," (149 out of 178 cases.) 
 
 It will be remembered that this form of umbilical hemorrhage is very 
 frequently associated with intense jaundice, clay colored stools, <fcc; and 
 with a purpuric eruption (of extravasated blood) beneath the cuticle, and 
 various parts of the mucus surface ; there is also not unfrequently bleeding 
 from the gums, and hemorrhage from the bowels and stomach. Now, with 
 regard to the cause of this affection, I beg to maintain, that in many, 
 perhaps the majority of cases, though not in all, it is caused by ligating 
 the umbilical cord; or rather I might say, by preventing, with the ligature, 
 that hemorrhage, which it is necessary and natural, in the economy of the 
 new born child, should take place, when the funis is first divided. 
 
18 
 
 That this proposition can be certainly proved, at the present time, is I 
 believe impossible. Positive evidence can only be derived from the ex- 
 periments and observations of the future; we cannot well fall back upon 
 the records of the past, for the reason that those records relate only to 
 but one order of cases, viz: those in which the cord has been lighted, and 
 as these embrace all, there are, of course, none left from which to observe 
 the result of wow-ligation. Moreover, we may remark that even should 
 the ligature be altogether abandoned, it would still require some centuries 
 to decide the point in question, for the reason, as just stated, that the cases 
 we are considering (viz: constitutional umbilical hemorrhage, so-called,) 
 only occur once in several thousand births. The study of this part of 
 our subject is therefore of necessity at this time, unsatisfactory and incon- 
 clusive; and perhaps I ought to be content with having simply suggested 
 the theory of ligation, as above stated. At the same time it may not be 
 inappropriate, with a view of giving, at least, some weight and probability 
 to tne opinion I have chose to entertain — that we consider for a few mo- 
 ments the causes that have been alleged by other authors to produce the 
 form of umbilical hemorrhage now under consideration. In considering 
 these, one thing strikes us which I would not omit to mention. It is, that 
 all writers have acknowledged the great obscurity of the subject. The 
 investigations of one have collided with those of another; theory has 
 conflicted with theory; fact with fact; until the broad highway to truth, 
 in whichever direction it may lie, tins been twisted into a wandering 
 maze where the student of science is lost within the darkness of its laby- 
 rinthine paths. Apparently, therefore, some great fact has been left out, 
 some stumbling block encountered, which clogs the progress of the investi- 
 gation; and here the suggestion occurs to us, that the mistake has been, 
 an indifferent regard to the effects of the disastrous ligature. 
 
 Returning, however, to consider the supposed causes of this form of 
 hemorrhage, we find enumerated among them " any influence which 
 lessens the normal plasticity or coagulability of the blood;" such influ- 
 ences being, as it is alleged — 1st, existing predisposition to hemorrhage; 
 2d, an inherited scrofulous or syphilitic taint; 3d, an excessive use of 
 alkalies by the mother during pregnancy ; 4th, insufficient food, privation, 
 and depression of spirits during pregnancy; 5th, arrest, from whatever 
 cause, of the fetal development of the liver, thus impairing its blood- 
 making qualities; 6th, indulgence in polydipsia, or the excessive drinking 
 of diluent fluids, during pregnancy; 7th, it is universally admitted that an 
 existing predisposition to hemorrhage, from whatever cause, is the more 
 likely to be followed by its occurrence, when the mechanical obstacles 
 which ordinarily impede its progress cease to exist, i. e., when the um- 
 bilical vessels are not naturally obliterated; finally, it is maintained, that a 
 diseased condition of the umbilical vessels, the result of their inflamma- 
 tion, is undoubtedly a cause of hemorrhage from the navel. (See Report 
 by Dr. Jenkins' Trans. Am. Med. Ass., vol. 11, pp. 308-9-10.) It now 
 remains for us to consider how far these causes really do have the effect, 
 in producing hemorrhage, which they have been supposed to have. That 
 the influences referred to, as lessening the normal plasticity of the blood, 
 might have such an effect, when they existed; and that such a diminution 
 of the coagulability of the circulating fluid, would give us a tendency to 
 hemorrhage, I will not dispute. The question is, do these conditions 
 exist? Now, that they do, there is no adequate proof; but that they really 
 
19 
 
 do not would seem to be most probable, from the fact — indisputable, and 
 universally recognized — that the great majority of children in whom this 
 fatal form of hemorrhage has been observed, were, at birth, born of healthy 
 parents, delivered by natural labors, and in themselves were, to all ap- 
 pearances, perfectly healthy. Nay, many of them are described as being 
 "heavy," "hearty," "remarkably symmetrical,'' " apparently strong," 
 and even "particularly plump." Thus, of thirty-two cases collected by 
 Dr. Minot, twenty-six are described as being well at birth and perfectly 
 healthy; and in the reoort of Dr. Jenkins, among eighty cases in which 
 the condition at birth was positively noted, sixty-one were healthy, while 
 only nineteen were feeble or diseased. Is it, therefore, to be supposed, 
 that the abnormal conditions of the blood, before referred to, could have 
 existed with these healthy appearances of the body? We should think 
 not. 
 
 With regard to the hereditary transmission of the hemorrhaa-ic diathesis 
 being a cause of umbilical hemorrhage, this is uncertain; for Dr. Jenkins 
 himself, after striving to prove by some of his cases in which the mothers 
 had been liable to profuse mennorrhagia, and excessive bleeding after 
 labor or injuries, that there existed a hemorrhagic tendency, is forced to 
 acknowledge, that " despite the hereditary bequeathal of the disease, as 
 thus evinced, he had been surprised to notice, that of families known as 
 'bleeders,' where the slightest injuries often induced serious hemorrhage, 
 scarce any record exists of infantile umbilical bleeding;" and Dr. Manley 
 remarks, »* that these cases differ from the ordinary rule in the history of 
 bleeders, for in none of them is the direct transmission of the hemorrhagic 
 constitution clearly proved." 
 
 One fact that has been adduced in support of the theory, that the um- 
 bilical bleeding is dependent on the hemorrhagic diathesis, is the occur- 
 rence of several cases in a family of children from the same parents ; but 
 this again is neutralized by the opposing fact, that other children born of 
 the very same parents, and in whom we should also expect to find the 
 same diathesis — altogether escape the umbilical hemorrhage. Really, 
 therefore, as before stated, there is yet no certainty that our complaint 
 depends upon a constitutional tendency to hemorrhage. (In this con- 
 nection we might suggest the propriety, in any given case, of applying 
 leeches, or making scarification upon the skin of the child, in order to 
 test positively whether it was affected with the hemorrhagic diathesis or 
 not.) 
 
 Respecting the opinion that the hemorrhage often depends upon the non- 
 obliteration of the umbilical vessels, this perhaps all will admit. In Dr. 
 Minot's cases these vessels were- examined eight times. In seven, both ar- 
 teries and vein were pervious; and in the eighth the vein and left artery were 
 almost obliterated, while the right artery was pervious. We have already at- 
 tempted to explain in what manner ligating the cord may induce an abnormal 
 patency of these vessels. Perhaps the principal question remaining to be stud- 
 ied in this connection, is, at what period after birth is it natural and proper 
 that the funial vessels should be obliterated? By reference to the books we 
 find the greatest diversity of opinion on this question; the time of obliteration 
 as given by different authors ranging from five days up to twenty-five. For 
 ourselves we entertain no opinion on the subject, and feel justified in so do- 
 ing, for who can say what is the time at which obliteration should naturally 
 take place, when all the cords thus far observed have been subjected to un- 
 
20 
 
 natural treatment by the unmerciful application of the ligature. It is only 
 from those in whom no ligature has been applied that the natural time of 
 obliteration can be learned ; and this of course can be easily ascertained in 
 future, by the simple omission of the ligature.* 
 
 With regard to inflammation of the umbilical vessels being a cause of hem- 
 orrhage, this is undoubted. In 1853, M. Henri Roger, physician to the 
 Foundling Hospital at Paris, in his memoir read before the Medical Society 
 of the Parisian Hospitals, considered that umbilical arteritis was a frequent 
 cause, and ''that the want of obliteration, of which the hemorrhage is the 
 consequence, is due to this alteration of the artery/' and that " the dilated, 
 friable and ulcerated arterial vessels cannot retract and oppose the outflow 
 of blood from the umbilicus." 
 
 »Prof. Simpson also states in his obstetric works, (Am. Ed. vii, p. 423,) 
 that secondary hemorrhage from the umbilicus is frequently combined locally 
 with deposits and disease in the walls of the umbilical vessels. (See report 
 of Dr. Jenkins, before referred to.) Now, in considering the cause of such 
 vascular " inflammation " and " deposit/' we are forced to adopt the opinion 
 that nothing is more likely to produce them than the impinging of a tight 
 ligature upon the vessels, and the consequent retention within them of ac- 
 cumulated blood, by which also they are distended. 
 
 Finally, with regard to the causes of this so-called "constitutional umbilical 
 hemorrhage," there is certainly one set of cases in which the ligature may 
 be left entirely out of the question ; we refer to those in which there is 
 absence or congenital atresia of the biliary ducts. In these the liver be- 
 coming congested from retention of bile, throws back an excess of blood upon 
 the whole portal circulation, and especially into the umbilical vessels, when 
 bleeding from the navel is a natural consequence. 
 
 Now, to finish up this part of our subject, all that I wish to deduce from 
 the facts thus stated, in support of my opinion that many of these cases of 
 hemorrhage are caused by ligation of the cord, is simply this : it will be seen, 
 that among the alleged causes of the affection, those that are obscure and 
 uncertain in their action, and even uncertain as to their existence, such 
 as blood changes, scrofula, syphilis, the hemorrhagic diathesis, &c, can in 
 no way be referred to the ligature, while those causes, the existence of which 
 has been positively demonstrated, and their modus operandi explained, such 
 as deposits and inflammation, and a want of obliteration of the umbilical ves- 
 sels, can with all reason be referred to the effect of a ligature upon the 
 umbilical cord. 
 
 But the question is still open for discussion j the future alone can decide it. 
 
 Leaving therefore, the subject of umbilical hemorrhage, we now pass on to 
 consider another affection, which we think it can be shown, is in all proba- 
 bility due to ligation of the umbilical cord. This is infantile jaundice. A 
 slight degree of jaundice, such as to impart but a faint tinge of yellow to 
 the skin, is of so frequent occurrence during the first few days of infant 
 life, that some writers have been led to regard it as a physiological pheno- 
 menon, rather than as a pathological one. When however, the affection — 
 
 *For those who have facilities for such experiments (which I unhappily have not) 
 a ligature might be applied at birth to the funis an half the number of a litter of pigs 
 or puppies, while in the other half it might be omitted. The animals being 
 killed and examined at the same time, would test the influence of ligation in retard- 
 ing obliteration, &c, &c. 
 
21 
 
 though still of the same kind, has been greater in degree, so that the yellow 
 cutaneous tinge has become distinctly icteroid ; the stools clay-colored; the 
 urine saffronized; the conjunctiva discolored, and so on • then, the patho- 
 logical character of the appearance is fully recognized. 
 
 Admitting therefore that a decided icteroid color of the skin is abnormal, 
 is it not unfair to assume that the same condition, when less marked, is 
 normal ? Since the affection appears in every shade and degree, who can 
 say at what stage of intensity it is legitimate to affirm, the normal charac- 
 ters are lost, and the abnormal begun? The inference is obvious; any 
 degree of icterus is unhealthy. Indeed, how can it be otherwise? for we 
 may yet further remark, that if a certain degree of jaundice — of yellow- 
 ness of the skin — is strictly a physiological and healthy condition, then 
 we are almost necessarily forced to the position, that the infant in whom 
 there is no such slight degree of jaundice and yellowness of the skin, is 
 fcmhealthy. But this we know is incorrect. 
 
 Dismissing, therefore, the hypothesis that jaundice in moderation is 
 normal, (and if the reader is not willing to agree on this point, there are 
 still enough well marked cases of the disease — for they are of very fre- 
 quent occurrence — to merit his consideration,) let us now enquire: Is the 
 affection really caused by ligation of the cord? and, in what manner does 
 the ligature act to produce it? 
 
 Bedside experiments — ligating the cord in some, and omitting the liga- 
 ture in others, then observing the comparative frequency with which 
 jaundice occurs in each class of cases — can be easily made to answer the 
 first question, and in the best and most positive manner, without argu- 
 ment. I regret exceedingly that necessity — the want of hospital facilities, 
 and a limited practice — compel me to leave to others, who may be better 
 favored in these respects, the privilege of proving by practical demon- 
 stration, what it is only in my power to attempt to prove by theory and 
 argument. I may be permitted to state, however, that in the few instances 
 where I have omitted the ligature there has been no sign of jaundice, al- 
 though in the cases that I had just previously attended, where the ligature 
 was applied, it was the exception not to see some icteroid symptoms follow. 
 I would here again suggest the experiment, already recommended, of tying 
 the cord of a certain number, and omitting to tie in others, of a litter of 
 pigs, pups, or kittens, and notice the condition of the liver, and of the skin, 
 conjunctiva, &c, in each class of cases. An experiment of this sort, per- 
 formed on the different members of the same brood, would be perhaps 
 more conclusive, or at least more readily so, than by operating upon sin- 
 gle individuals, born and conceived, it may be, under very different circum- 
 stances. 
 
 But to continue the argument, we find that jaundice, though occurring 
 so very frequently in new born children who have been subjected to liga- 
 tion, is unknown in the young of other animals where the ligature is not 
 applied. By the by, I have not been able to find any case recorded, 
 among those where the funis was accidentally torn out or ruptured and 
 where there was some hemorrhage at birth, in which jaundice was subse- 
 quently noted. 
 
 Again, we may observe that jaundice occurs in infants who have been 
 born perfectly healthy, strong, or even plethoric, and who have been ex- 
 posed to no unnatural process — to no cause of disease — save only ligation 
 of the cord. True it is, very reliable authorities affirm that the chief 
 
22 
 
 causes of this Icterus Neonatorum, are exposure to cold or bad air, and 
 the ingestion of improper food irritating the stomach or duodenum. But, 
 I ask, do we not see it in our daily practice affecting infants born of 
 mothers living in the highest classes of society, and surrounded by every 
 provision of good, dry air, warmth and suitable food. I can myself testify 
 to having met with it in children where there had certainly been no ex- 
 posure, either to cold or damp, and where, in obedience to my directions, 
 no particle of food, drink, or medicine % had been administered, besides 
 the mother's milk. In such cases — born of healthy parents — born with- 
 out the slightest indication of icterus — and having been subjected to no 
 recognized cause of disease, and being affected with no organic malfor- 
 mation — in such, why happens it that in twenty-four or forty-eight hours 
 after birth, we begin to recognize so frequently the appearance of infantile 
 jaundice. The obscurity of the symptom, or rather of its origin, has 
 been universally acknowledged — an obscurity, I maintain, which can 
 only be banished, by a proper appreciation of the mischievous influence 
 exerted on the infant economy by the accoucheur's funial string. 
 
 We do not, of course, assume to dispute, in opposition to all authorities, 
 that cold, damp, and irritating ingesta may produce jaundice, but what 
 we do venture to affirm is, that these causes would be less effective, or 
 perhaps altogether inoperative, if their influence was unassisted by that 
 of the ligature. 
 
 Next as to the modus operandi of umbilical ligation in producing icterus. 
 If experiments and practice prove that jaundice is caused by the ligature, 
 it is of course a secondary consideration as to how it does so. Still it is 
 never amiss to explain practice by theory when possible. We have been 
 led to regard the matter thus: Ligation, by preventing the flow of blood 
 through the umbilical vein, which should naturally take place when the 
 cord is separated, (and which is doubtless designed by nature, when it 
 occurs, to effect some good office in depleting the hepatic circulation,) in 
 this way maintains the liver in a state of congestion, hyperaema, or san- 
 guineous engorgement, soon, perhaps, to be followed by some degree of 
 subacute inflammation of the parenchyma of the organ. And further, the 
 hepatic congestion, it is fully probable, maybe the first step towards that 
 change in the character of the biliary secretion, by which it is rendered 
 thick, viscid, and finally inspissated, so as to clog up and obstruct the 
 passages of the biliary, hepatic and cystic ducts. Furthermore, conges- 
 tion of the liver and portal circulation necessarily occasions engorgement 
 of the vessels of the stomach, intestines, mesentary and abdominal viscera 
 generally ; and under such circumstances these structures are peculiarily 
 liable, under exciting causes, of taking on inflammation; hence thickening 
 and congestion of the mucus membrane, or submucus tissue of the duo- 
 denum, in the neighborhood of the ductus communis choledochus, may 
 easily arise, especially when irritating food or medicine has been admin- 
 istered, so that the thickened and congested tissues thus encroach upon 
 the oritice of the duct and obstruct it. 
 
 Each of the conditions now mentioned as resulting from umbilical liga- 
 tion, are well known causes of jaundice, and need no further explanation. 
 
 If it should be objected to the views thus expressed, that evidence is 
 wanting to prove that venous bleeding from the end of the cord at birth is 
 natural and necessary; and if it should be further stated, that many infants, 
 when the ligature is omitted, bleed but very little, and some not at all : we 
 
23 
 
 may reply — that as the bleeding from the untied cord differs in quantity, 
 from nothing up to a "profuse hemorrhage," so the jaundice in children 
 who have been ligated, will be absent in some; in others but barely per- 
 ceptible ; and again in others more intense, until it presents itself as an 
 uumistakable and profound icterus. In the delicate state of the general 
 organism that attaches to infancy, and especially remembering, with regard 
 to'the Liver, its " undue size at birth ;" u the important part it has played 
 during foetal life;" its disproportionate activity before, and the change to 
 comparative quiescence after birth, — bearing these facts in mind, it is easy 
 to believe how the retention of even but a small superfluity of blood in the 
 hepatic circulation, might be followed with derangement of both structure 
 and function, such as would be manifested by jaundice. Nay, may we not 
 go further and believe it probable, or at least possible, that the slight de- 
 rangement of the liver and chylo-poietic viscera generally, occasioned by a 
 transient congestion of the portal circulation — the result of ligating the cord 
 — may, occurring as it does in this primal hour of infant life, lie the foun- 
 dation for many of those other "ills," especially of the abdominal organs, 
 to which infant " flesh is heir;" which are particularly mortal during the 
 first and second year; * and for which, be it remembered, calomel, which 
 acts upon the Liver so as to increase its secretion and thereby lessen portal 
 congestion, is, above all other remedies, our " sheet-anchor." It is need- 
 less to recount the diseases of infancy that appear to depend upon, or at 
 least to be associated with, congestion of the Liver and its annexise. Only 
 admitj — and if this point can be proved by experiment, it is all we require, 
 — only admit that the retention and accumulation of an undue amount of 
 blood in the umbilical vessels causes sanguineous engorgement of the liver and 
 portal circulation, and we may then truthfully say of the diseases produced 
 by ligating the cord, " their name is legion." Some authors tell us that a 
 certain amount of hepatic congestion is nearly constant in early infancy, as 
 if they were inclined to regard such a condition as physiological and not at 
 all indicative of disease, except when it was excessive. We are able to 
 meet this remark, however, with the statement, that while the liver conges- 
 tion has been "nearly constant," so also has been, ligation of the cord. 
 Until in the future, livers are observed of children whose cords have not 
 been ligated, it is probable an entire absence of congestion will be rare. 
 Among the alleged causes of infantile jaundice presented in the works of 
 recent authors, there is not much inclination — in fact none — to include liga- 
 tion of the cord. Nevertheless we are not entirely alone in the opinion that 
 ligation may produce it. For example, " Leuret," says Dr. Churchill, 
 " conceives that the blood remaining in the umbilical vein, after it is tied, 
 may become corrupted, and give rise to engorgement of the liver and jaun- 
 dice." And Dr. Condie tells us, (Dis. children, 4th ed., p. 750,) "It has 
 been supposed by Eberle, that this condition, (meaning jaundice,) is most 
 apt to occur in infants who, when born, present a turgid and livid appear- 
 ance of the face and body, and an oppressed state of the brain, and which 
 have not been sufficiently relieved by a flow of blood from the divided ves- 
 sels of the cord." 
 
 * "It has been remarked," says Underwood, "that the first month, and particularly 
 the first day of the birth, is marked by the greatest number of deaths; so that out of 
 2,785 children who have died very youug, 1,292 have expired the first day. 11 
 
 How far the ligature has been instrumental in swe ling this number remains to be 
 seen. 
 
24 
 
 These ideas, however, of the older authors, seem to have been ignored by 
 the moderns — the latter, at the same time, while attributing infantile icterus 
 to some abnormal modification in the capillary circulation of the Liver, ac- 
 knowledge themselves unacquainted with the precise principles of the path- 
 ology of this condition. 
 
 From the accounts I have read of that form of jaundice which attends 
 schlerema, or induration of the cellular tissue, it seems that that also — 
 and possibly even the schlerema itself — may have been caused by liga- 
 ting the cord ; or, perhaps with more propriety we might say, that the 
 schlerema and its accompanying jaundice could both have been prevented, 
 in some instances, by the omission of the -ligature. Witness, for example, 
 the following language of Dr. Billard, in his work on Diseases of Children, 
 (p. 151.) Alluding to schlerema, he says : " What is of more importance 
 to note, is, that all the indurated or oedematous children exhibit a universal 
 sanguineous congestion, that is very remarkable. Venous blood especially 
 predominates in their tissues; the heart is almost always gorged with 
 blood, and the large vessels filled, and when the bodies of those who have 
 died of this disease are examined, it flows from all parts on the incision 
 of the scalpel. This general congestion is more owing to a superabund- 
 ance of blood in the system, to a kind of congenital plethora, rather than 
 to any mechanical obstruction in the blood-vessels." If such is the con- 
 dition that attends schlerema and its accompanying jaundice, who can say 
 how far it could have been obviated, and most likely in the very way 
 which Nature had designed it should be, by suffering the umbilical ves- 
 sels to bleed when they were first divided? On the other hand, if it is 
 proper and natural, as it most likely is, in such cases of "congenital ple- 
 thora," that a certain amount of blood should be lost from the cord at 
 birth, how easy is it to believe that the phenomena of oedema, jaundice, 
 &c, may have been caused, or increased in intensity by applying the lig- 
 ature so as to prevent such natural flow of blood? 
 
 If it could be shown, that in most infants — the subjects of jaundice — 
 plethora was the reigning condition, this would be an additional fact in sup- 
 port of our theory that the disease is caused by umbilical ligation. 
 
 Opposed to this, however, Dr. West informs us that " the children in whom 
 jaundice is most frequent and most intense, are the immature and the feeble ) 
 while in none is it so often met with, or in such an intense degree, as in in- 
 fants affected with induration of the cellular tissue.'' He further states 
 that " the jaundice of young children is not due to any cause primarily 
 seated in the liver, but rather to the defective respiration, and impaired 
 performance of the functions of the skin, of which the hepatic disorder and 
 jaundice are but the effects." 
 
 While, therefore, it must be admitted, that jaundice occurs in infants who 
 are not plethoric, but feeble — and these we should expect to be most suscep- 
 tible to the injurious influence of cold and damp — still there are suffi- 
 cient cases, occurring in our daily practice, and recorded by others, (like 
 those of Schlerema by Billard) as well as those already discussed as being 
 associated with umbilical hemorrhage, in which, so far from there being any 
 condition of " feebleness," there is actually the opposite one of plethora. 
 The children are strong and healthy ; many of them of good weight ; and 
 some '* particularly plump." Really, therefore, there may be two sets of cases. 
 First, the feeble and anemic, in which probably cold and damp are the chief 
 causes; and second, the robust and plethoric, where the icterus is brought 
 
25 
 
 about by ligation. Every one perhaps has seen jaundice, in the adult, 
 caused by the suppression of an habitual flow of blood from ^ hemorrhoidal 
 vein, how much more easy is it to conceive, therefore, that the same condi- 
 tion should be generated in the delicate organism of a new-born infant, by 
 the forcible retention of a natural sanguineous flow, -in a vein, (the umbili- 
 cal) that communicates far more directly with the liver than the vena hem- 
 o rr hoidales. 
 
 Enough, I trust, has now been said on the subject of jaundice to warrant 
 us in assuming it at least probable, that the disease, in many instances, is 
 caused by ligation of the umbilical cord ; and to direct the attention, and 
 enlist the aid, of those who have ample facilities for clinical observation and 
 experiment, who, it is hoped, will be hereby persuaded, to give the question 
 a practical test at the bedside. 
 
 But there are yet other diseases, which in all probability sometimes have 
 their origin in a ligated umbilical cord — one of these is 
 
 Erysipelas. "Infantile Erysipelas," says Tanner, " most frequently oc- 
 curs about the region of the umbilicus ; and may be due to some mismanage- 
 ment of the remains of the funis. 
 
 According to the observations of Meckel and Osiander, it occasionally 
 has its origin in umbilical phlebetis, and Dr. Condie remarks, that accord- 
 ing to his experience a very common form of Erysipelas in infants, is that 
 described by Dr. Friebe, in the journal for the diseases of children, under 
 the name of Omphalitis exsudativa. It commences about the umbilicus, 
 is frequently accompanied with ulceration of the navel, and with deposits 
 of lymph and pus in the partially obliterated umbilical vessels. " It often 
 proves fatal ; often within the course of forty-eight hours, and without 
 having extended more than three fingers breadth around the navel/' Dr. 
 Condie, from whose work on diseases of children (p. 552) these facts are 
 gleaned, further observes, " our observations have convinced us that, in 
 the majority of cases at least, it is dependent upon phlebetis of the umbil- 
 ical veins; the evidences of inflammation of the latter, were unquestionably 
 present in almost every instance in which we have made an examination." 
 " M. Trousseau, remarks that the umbilical vein is often found imflamed and 
 filled with pus, as far as the transverse furrow of the liver ; and has obser- 
 ved that in infants predisposed to erysipelas, the umbilical cicatrix does not 
 form readily, and the ulceration which results is sometimes the occasional 
 — the local cause of the cutaneous disease." A German physician, Dr. 
 Mildner, of Prague, has recorded (Prager Vierteljahrschrift, vol. 2, 1848,) 
 the results of forty-six cases of fatal imflammation of the umbilical vessels 
 in children born in the Lying-in Hospital of that city. Among the symp- 
 toms which attended it, were, congestion of the liver, impairment of its 
 functions and icterus, as well as, in many of the cases, peritonitis, inflamma- 
 tion of the abdominal integuments, purulent infection of the blood, and the 
 formation of abscesses in the joints, which occurred thirty-three times, while 
 in four cases, hemorrhage took place from the umbilcus. (See West on 
 Dis. of children, p. 152, 3d Am. ed.) 
 
 I have only to suggest in this connection, the reasonableness of supposing 
 the inflammation of the umbilical vein, the deposits of lymyh, pus and prob- 
 ably disintegrated blood, within its interior, to be due to the impression 
 made on the vessel by the ligature ; or to the distension of the vessel from 
 accumulated blood that would have escaped if no ligature had been 
 applied. And that this is, in some instances, the true state of the case, 
 
26 
 
 would seem to be corroborated by the correlative fact, that the disease is 
 often associated with jaundice — the two kindred complaints, both resulting 
 from the same parent cause — ligation of the cord. 
 
 We might go on to mention a great number of maladies, some trivial and 
 others serious, which, it seems to us, might with good reason be referred, 
 either directly or indirectly, to placing a ligature on the funis. For ex- 
 ample, intestinal hemorrhage, " which usually occurs during the first twenty- 
 four hours of life ; which in fifty 'per cent oj the cases is jatal ; which 
 has no well known apparent cause, but is " regarded as the salutary crisis of a 
 plethoric condition" and is believed to be due to a sanguineous " injection 
 oj the intestinal tube, 1 ' &c, &c. 
 
 In the same manner we might speak of hemorrhage from the stomach, 
 shortly after birth, and from the vagina and other parts, the etiology of which 
 is manifestly obscure, but regarded by most authors as being explicable on 
 the theory that they are due to that excessive vascularity of the mucus 
 membranes that naturally belongs to infants. 
 
 We will not dwell to weigh the influence of the ligature in laying the 
 foundation of atroply, both general and of the liver, of tabes mesenterica, 
 marasmus, cholera infantum, and even perhaps, (by its effects upon the 
 arterial portion of the umbilical circulation,) of hydrocephalus, cyanosis, 
 &c. &c. 
 
 What effect the retention of an undue quantity of blood within the um- 
 bilical vessels, and consequently within the liver, may exert upon the func- 
 tions of the stomach and adjoining viscera, we are not prepared to say; it 
 may not be out of place, however, to remark, at this point, that in all mam- 
 miferous animals it is impossible for the new-born young to begin the pro- 
 cess of digesting food before the cord has been separated, and this for the 
 simple reason, that the cord unbroken is not oj sufficient length to permit 
 the young animal to reach the mammas. It would seem therefore, as if 
 nature had ordained that this salutary wastegate — the ruptured funis — 
 through which the liver and digestive organs might rid themselves of any 
 contained superfluity of blood — should be first opened before the function of 
 digestion is permitted to begin. And if such is the ordinance of nature, 
 who can tell to what extent we disturb the equilbrium of the digestive func- 
 tions in a new-born child, by ligating the cord, and then placing the infant 
 to the breast, without the natural depletion taking place, which might if 
 necessary, have occured, had no ligature been applied ? May it not be pos- 
 sible that the vomiting, acidity, indigestion, constipation, &c. &c, of young 
 infants, often find their starting point, in a congestion or plethora of the 
 chylopoietic viscera, caused by the prevention of that natural bleeding through 
 the untied cord which was designed by nature to relieve any condition 
 of plethora that might exist ? 
 
 Finally, and to conclude this part of the subject, we therefore feel justi- 
 fied in asserting our second proposition : that " ligation of the umbilical 
 cord is in many cases injurious;" because, as we have endeavored to 
 show, it may with all reason be considered as a cause of secondary um- 
 bilical hemorrhage, or hemorrhage from the stomach, intestines and va- 
 gina; of erysipelas; of jaundice; of schlerema; of indigestion, constipa- 
 tion, and, probably, of that innumerable category of fatal infantile affec- 
 tions which so frequently have their origin in congestion of the portal 
 circulation. We leave this, as we must leave all, to be proved or dis- 
 proved, by the tests of future experience and clinical observation. 
 
27 
 
 We now proceed to consider the remaining proposition: that ll certainly 
 in some, and probably in not a few, the operation of ligating the cord, is 
 actually a direct cause of death." All authors, teachers, and educated 
 practitioners of obstetrics, agree that there are certain cases of children 
 still born — affected with apnoea, apoplectic asphixia, or cyanosis — in 
 which no remedy is to be relied upon for resuscitation except bleeding 
 from the umbilical cord. When everything else has failed, this has 
 afforded prompt relief. 
 
 It follows therefore as a natural consequence, that the instances of 
 children so " still born," which have chanced to fall into the hands of 
 ignorant midwives, or of ignorant, careless, or hasty practitioners of 
 obstetrics, and which have been subjected to ligation almost at the first 
 moment of delivery, (for there are many such.) and have not been suffered 
 to bleed subsequently by loosening the string — in such, when death 
 results, as it often does, I think it is not going too far to say, that they 
 have been literally killed by the operation of ligating the funis. And in 
 this assertion I do not stand alone. ''We are of opinion," says Dewees, 
 " with Mr. White, Dr. Denman, Bandelocque, &c, that tying of the cord 
 prematurely is very often, if not always, injurious to the child." " We 
 have reason to believe we have seen several instances of death, and this 
 of a painful and protracted kind, from the premature application of the 
 ligature," ''And that this is probably one of the causes of the many 
 deaths, in the hands of ignorant widwives and practitioners, we have too 
 much reason to suppose." (Dewees on Child., 5th ed., pp. 275 — 277.) 
 Condie remarks, (p. 283,) " that the premature application of a ligature 
 to the cord has, we believe, in many instances, given rise to asphixia." 
 And that there are cases in which the removal of the ligature is the only 
 means of obviating impending death, ample testimony can be found. 
 Alluding to apoplectic asphixia, Dr. Condie remarks, that " when an infant 
 is born in this condition, no time is to be lost. The umbilical cord should 
 be immediately divided, and more or less blood, according to circum- 
 stances, allowed to flow from it." Walshe, also, (on Dis. of Heart, p. 
 332,) referring to " apoplexia neonatorum," remarks that it "lapses into 
 fatal asphixia, unless treatment, especially bleeding from the umbilical cord, 
 prove successful." Again, Dr. Dewees, in the chapter already quoted, 
 tells us that when the child is still born, with its face livid, black and 
 swollen, " nothing can save it from immediate death, but instantly ab- 
 stracting blood, by cutting the cord." Pie continues, "this practice of 
 bleeding from the funis, in our hands, has always answered a valuable pur- 
 pose, in this congestive state of the brain." " Baudelocque recommends 
 this plan; and we can bear witness, in many cases, to its entire success; 
 for we have repeatedly seen respiration established by this remedy, and 
 by this alone." Dr. Beck, (Med. Jurisp., vol. 1, pp. 559-' 60,) uses the 
 following language: " A child may die from prematurely tying the um- 
 bilical cord. We know that circulation by the cord and respiration are 
 vicarious functions, and if The former be arrested before the latter is in 
 operation, life must cease. It is accordingly laid down as a rule by prac- 
 tical writers, that the cord should never be tied or divided, until respira- 
 tion has been established. 
 
 "That the neglect of this important rule of practice is an occasional 
 cause of death to the new born infant in the hands of ignorant midwives 
 and practitioners, does not admit of doubt. By Dr. Eberle, a case is 
 
28 
 
 recorded, which illustrates the evil effects of premature tying of the cord. 
 The child breathed freely, as soon as it was born. After waiting three or 
 four minutes, until the cord pulsated feebly, it was tied. As soon as the 
 ligature was drawn, the breathing became catching, irregular, and in a 
 few moments almost wholly suspended, and the lips acquired a deep lived 
 hue. The cord was immediately divided below the ligature, but only a 
 few drops of blood could be obtained from it, and it was only with the 
 greatest difficulty that the action of the heart and lungs could be re-estab- 
 lished. Dr. Campbell recorded a similar case in which the application 
 of the ligature was followed by breathlessness and lividity of countenance. 
 The child was relieved by the application of two leeches to the region of 
 the heart." 
 
 It would be a work of supererogation to multiply evidence showing 
 that ligation of the cord, in a certain manner, and under particular circum- 
 stances, is directly fatal to life. 
 
 The fact is unquestionable, and its positive character contrasts in a very 
 marked manner with the supposed fact, at best uncertain — as shown in a 
 former part of this essay — but generally believed, that a child may die 
 from loss of blood when the ligature is omitted. 
 
 If now we examine the action of premature ligation upon the organs of 
 circulation, and the manner in which it produces death, in the cases above 
 referred to, we shall discover still new reasons to admire the wonderful 
 wisdom displayed in the construction of the infant organism, and especi- 
 ally shall we see how beautifully the open vessels of the umbilical cord — 
 when not ligated — -are adapted to preserve the safety of the child, against 
 the exigencies and accidents that may occur, while it is passing through 
 the precarious ordeal of delivery. 
 
 The stillborn child is in a state of apncea — breathlessness, want of res- 
 piration — which, if not relieved, soon ends in fatal asphixia — pulseless- 
 ness, want of circulation. An absent or obstructed respiration, therefore, 
 leads to a fatal suspension of the circulation, and this in both child and 
 adult. The action of the heart, however, continues some time after breath- 
 ing has ceased, and even after both have ceased, there are yet methods by 
 which they can again be restored, if not too long delayed. Still-born in- 
 fants have been re-animated half an hour after birth. 
 
 In the ordinary phenomena of apncea and its consequent asphixia in the 
 adult, we observe as follows : the venous blood sent to the lungs through 
 the pulmonary arteries not-being arterialized. as it ought, stagnates in the 
 lung capillaries, collects in the pulmonary arteries, and distends the right 
 ventricle of the heart. It is this congestion and distension of the right 
 ventricle that causes the action of the heart to cease, and when that action 
 has ceased entirely, (though only for a short time,) it can be renewed by 
 unloading the right ventricle, and this can be accomplished in a variety of 
 ways, as by restoring the action of the lungs, thus permitting the blood 
 collected in the pulmonary arteries to proceed on its course, which is the 
 natural method; or by puncturing the right ventricle or the right auricle, 
 or by opening the jugular vein, &c. Only lessen the distension of the right 
 ventricle, and the action of the heart will be restored. 
 
 Now let us return to the infant : Here we observe exactly the same 
 thing, only modified somewhat by the peculiarities of the foetal circulation. 
 
 Every infant (except perhaps those that are swiftly born, with the pre- 
 cipitation of a single pain,) comes into the world in a state of partial or 
 
29 
 
 incipient apnoea. Venous blood predominates over the arterial, and exerts 
 its sedative influence upon the brain and nervous centres, and of this ar- 
 rangement, when not sufficient in degree to render the child still-born, we 
 observe the utility, in that it prepares the delicate and susceptible nervous 
 system of the infant to withstand the shock, by light, sound, touch, tem- 
 perature, &c, so suddenly to be impressed upon it, as it emerges from the 
 silence and darkness of the uterine cavity, into the light and noise of the 
 external world. If the keen susceptibilities of the infant, instead of being 
 thus obtunded by the sedative influence of unserated blood, were to be ex- 
 alted by the presence of oxygen circulating through and stimulating the 
 nerve-centres, then we should not be surprised to see every new-born 
 child ushered into the world with a convulsion. 
 
 That children always are born in the conditibn of incipient apncea, is 
 plain. At birth, and for a certain period — varying in different cases — 
 prior to it, the circulation of blood through the placenta has in part, or 
 wholly ceased ; this we know, for the foetal pulse, felt in the cord, no 
 longer reaches the placenta. And while this proof is wanting, the same 
 thing may be inferred, for it can hardly be otherwise but that the con- 
 tractions of the uterus, especially towards the end of labor, as when the 
 head is expelled, must interfere very materially with the circulation and 
 aeration of blood in the placenta. 
 
 Now, from the instant at which the placental circulation, and hence the 
 placental respiration, ceases, until the pulmonary respiration begins — and 
 it may be a period of moments or minutes, sometimes of a quarter or half 
 an hour — during that time the infant is in a condition of, at first incipient, 
 but gradually increasing apnoea. 
 
 As in the case of the adult, the non-arterialized blood could not per- 
 meate the pulmonary capillaries, so in the infant the same kind of blood 
 cannot pass the placental tufts. It therefore accumulates in the placenta, 
 then in the umbilical arteries, then in the aorta, then in the right ventricle, 
 (via ductus arteriosus,) and the whole foetal heart, (since its cavities com- 
 municate,) thus becomes congested. The congestion and distension, how- 
 ever, we should suppose to be greater on the right side of the heart, than 
 on the left, for the reason that the obstruction to the circulation first be- 
 gan in those channels which admit blood to How from the right ventricle. 
 Indeed this must be the case, for the foetal heart has continued to pump 
 blood in the same direction since the circulation was obstructed in the 
 placenta, as it did before, hence the greatest accumulation is between the 
 obstruction and the heart, viz : in the umbilical arteries, aorta, ductus 
 arteriosus and right ventricle. Now this distension of the heart and ac- 
 cumulation of blood within the right ventricle, within certain limits, is 
 normal. It is, — if I may be allowed the simile, — but the preparatory fill- 
 ing of that great cardiac syringe which is to empty itself by injecting the 
 lungs, through the pulmonary arteries, when the first respiratory move- 
 ment of the chest takes place. 
 
 But when, from delay xhiring delivery ; from premature separation or 
 obstruction of blood in the placenta, or from other causes, the condition of 
 apnoea has been developed to its full extent, and the right ventricle, and in- 
 deed the whole heart, so excessively distended as to stop its action — then 
 we have the child in the condition known as il still born/' The congested 
 heart can now no longer be relieved by emptying itself through the pul- 
 monary arteries, for the reason that there occurs no inspiratory act. The 
 
30 
 
 brain and nervous centres, especially the sensori-motor ganglia of the medulla 
 oblongata, which preside over the muscular motions of the chest, being as it 
 were poisoned and narcotized by the accumulation of highly carbonized and 
 unserated blood, no longer respond to the action of external impressions 
 made upon the peripheral sentient nerves, in the manner to excite as they 
 should do, the reflex movements of the muscles of the chest, whereby the 
 thoracic cavity is dilated, and a vacuum formed in the lungs for the re- 
 ception of blood from the distended right ventricle. In such cases, how- 
 ever, when not gone too far, and in others of more frequent occurrence, 
 where the derangement exjsts in a less degree, Nature has provided proper 
 means to remedy the difficulty — to relieve the distended right ventricle — to 
 diminish the amount of black blood circulating through the nervous centres 
 — a remedy more appropriate than the surgeon's puncture — than bleeding 
 from the jugular — more certain than the " Ready method " of Marshall 
 Hall ; and more potent than the electric battery of Sutton — in fact a remedy 
 that the practitioner is finally compelled to resort to after all others have 
 failed, viz : depletion through the umbilical arteries. As if, therefore, to en- 
 sure the maintenance of the heart's action, and the safety of the child's life 
 during the exigencies of birth, nature has provided two avenues — a double 
 means, whereby the engorgement of the right ventricle may be relieved, 
 viz : through the pulmonary arteries, and through the unligated cord. 
 If the distension should be so excessive, from whatever cause, as not to be 
 entirely righted through the establishment of the pulmonary functions, and 
 thus leaving some embarassment of the general circulation, the equilibrium 
 may still be restored, and completely, by umbilical hemorrhage when the 
 cord is divided at birth. 
 
 Now since we cannot be aware, from any clinical symptoms, of the exact 
 condition of the pulmonary and cardiac organs, respecting the quantity of 
 blood in them, and can by no means, that I am aware of, learn exactly how 
 much or how little should be suffered to escape from the cord ; would it not 
 be far better, especially remembering how soon even a breathing child 
 can be brought into a condition of asphixia by premature ligation, as in the 
 case by Eberle ; and bearing in mind also, that the real necessity for ligating 
 the cord, does not exist — under these circumstance I ask, would it not be 
 far better to leave the matter entirely in the hands of nature, and totally 
 abandon so dangerous, so unnecessary, and often so fatal a practice as placing 
 a ligature upon the umbilical cord. 
 
 Having now shown in what manner the untimely ligation of the funis 
 may injuriously influence those most important vital organs — the heart and 
 lungs — in the establishment of their new functions, I think it is not surpriz- 
 ing that " certainly in some, and probably in not a few, the operation has 
 been a direct cause of death." Thus we leave our third proposition. 
 
 In reviewing what has now been said, and to sum up the whole matter, 
 the conclusions at which we feel justified in arriving are these : 
 
 1st. That ligation of the umbilical cord in the human infant is unneces- 
 sary. This, for the following reasons : 
 
 a. Because the operation is not required at the birth of any other animal. 
 
 b. Because the imagined necessity for it (viz: to prevent hemorrhage), does 
 not exist, as distinctly appears from a knowledge of the formation of the 
 cord, and of the structure of its component vessels ; as well as from the nu- 
 merous recorded cases, in which no ligature was applied, and yet no fatal 
 bleeding followed. 
 
31 
 
 c. Because to ligate for cleanliness' sake is superfluous. 
 
 d. Because it is unreasonable to attach to the process of reproduction in 
 woman, so glaring an imperfection, as that the birth of a single child can- 
 not be safely completed without a strand of thread upon the umbilical cord. 
 
 2d. That ligation of the umbilical cord at child-birth is in many cases 
 injurious. This for the following reasons : 
 
 a. Because, as shown in the text, it may justly be considered as the 
 cause of secondary hemorrhage from the umbilicus. 
 
 b. Because by preventing that flow of blood which should naturally take 
 place from the umbilical vein and thus giving rise to congestion of the Liver — 
 it produces infantile jaundice, and probably also causes bchlerema. 
 
 c. Because — by interfering with dessication of the cord, and thus pre- 
 venting its separation — it gives rise to ulceration of the navel, and, as a not 
 unfrequent occurrence, erysipelas , fungoid, excresence, fyc. 
 
 d. Because by maintaining the funial vessels in a state of congestion and 
 distension from unnaturally retained blood — it causes the inflammation of 
 those vessels and also hinders their normal obliteration — thus laying the 
 foundation for umbilical phlebetis, erysipelas, jaundice, pyemia, fyc. 
 
 e. Because — by preventing a normal escape of blood when the cord is 
 divided and thus causing hepatic hyperoemia and congestion of the portal 
 circulation — it may lay the foundation for that innumerable list of fatal 
 infantile affections which so often appear to originate in congestion of 
 the portal blood vessels. 
 
 3d. That certainly in some, and probably in not a few, the operation of 
 ligating the funis has been directly fatal. This for the following reasons : 
 
 a. Because numerous cases of death, in which the fatal result was as- 
 cribed to ligation, have been recorded by the highest obstetrical authorities. 
 
 b. Because, it can be seen how the operation in the cases of still-born 
 children, maintains the right ventricle in a state of distension, (otherwise 
 relieved by bleeding from the hypogastric arteries) and thus effectually pre- 
 vents the renewal of the heart's action when it has stopped ; or renders the 
 stoppage complete when it is about to cease. 
 
 c. Because, in many instances, the removal of the ligature, has saved the 
 life of the infant, when all other remedies had failed. 
 
 Management of the Cord without Ligation. 
 
 I now propose, in conclusion, to suggest some practical directions for the 
 proper management of the cord without ligation. 
 
 Supposing the ligature to be dismissed, it only remains in practice, with 
 regard to the management of the funis, to consider its division and dress- 
 ing. Concerning the former, the questions that naturally occur to us at the 
 bedside are : When shall we divide it 1 At what time relative to birth, 
 respiration, and its own pulsation ; how shall it be separated; by what instru- 
 ment ; and, where or at what point, shall the division be made ? 
 
 First, with regard to the time of separation. It is a general rule, I be- 
 lieve, with all the authorities on obstetrics, that the cord should be tied 
 and cut only after respiration is established, or when the pulsations of 
 the umbilical arteries have ceased, or become very feeble. 
 
 Now, when we consider tying and cutting together-, such a rule may be 
 
32 
 
 all very good and necessary, but when we cut without tying, I believe no 
 such restriction will be required. The application of the ligature, under 
 certain circumstances, has been known to do great harm, but there is no 
 instance where any such result has followed division of the cord, when 
 practiced alone. Even in those instances where it has been violently 
 broken at the first moment of birth — and perfectly regardless either of the 
 child's respiration, or the pulsation of the umbilical arteries — even in 
 these, there has been no evil result in consequence. Indeed, I cannot 
 conceive how the simple division of the funis, at almost any time after 
 the child is once in the external world, can be injurious. The infant 
 either breathes after delivery, or it is (if not dead) "still born." If it 
 breathes, we allow the cord to be divided; if it is still born, we emphati- 
 cally enjoin its division; for do not — as shown on a former page — do not 
 practice and theory agree in proving, that no remedy is so effectual in 
 establishing the respiratory function in a new born child, when it is 
 absent, as the division of, and bleeding from, the funis. To let the cord 
 remain imcut, when there is no pulmonary respiration, under the suppo- 
 sition that oxygen is being supplied, through the funis, by the placental 
 respiration, is irrational, for the circulation in the placenta and in the pla- 
 cental end of the cord, has already ceased. 
 
 The immediate result, and indeed the only one, of cutting the cord, is 
 bleeding, and sometimes even not this. Now how does loosing blood 
 from the cut end affect the child? If respiration is established, it seems 
 to have no material effect, except perhaps, to completely relieve that en- 
 gorgement of the heart and greater bloodvessels, which had been partially 
 remedied by the reception of blood, through the pulmonary arteries, into 
 the lungs. But if the breathing is not established; if the condition of 
 apncea — which to a limited extent always exists at birth — is excessive, so 
 that black blood predominates in the infant circulation, thus paralysing 
 the nervo-muscular apparatus, and preventing the movements of the chest, 
 as well as distending the right ventricle; under these circumstances, the 
 loss of blood following division of the cord, cannot but be salutary and 
 tend to restore the inanimate child. 
 
 Really, therefore, we can discover no reason, either by theoretical 
 speculation, by observation of animals, or by bedside practice, why a rule 
 should exist, prohibiting division of the cord, (though it should prohibit 
 its ligation,) until the breathing function has been established. The fact 
 is, the cord may be cut, so far as respiration is concerned, either before or 
 after it, provided there be no tying. 
 
 As regards cutting the cord while its arteries pulsate, we are somewhat 
 in a quandary. Without reasoning on the matter, we are naturally averse 
 to the operation of severing a funis, while its vessels beat with any degree 
 of vigour; but instinctive aversions or inclinations must not be allowed 
 as guides for practice. At the same time, however, I think it may be 
 seen, when we examine the subject rather more closely, that there really 
 are some grounds, though, perhaps, inconclusive ones, why a strongly- 
 beating cord should not be divided. 
 
 Upon reflection, we are first led to ask : Is it strictly natural and proper 
 that the cord should pulsate, and pulsate strongly, and throughout all, or 
 a greater part of its length, after the child is expelled. We think not. 
 
 In some children at birth, we can feel no pulse, in any part, from the 
 navel to the placenta; while in others the pulsation is distinct and vigorous 
 
33 
 
 throughout the whole length; while again — and this is the larger class of 
 cases — it will be felt to beat more or less strongly, and for a shorter or 
 longer distance from the umbilicus, in various degrees, between these two 
 extremes. It is not to be supposed — so I imagine — that all of these con- 
 ditions, some of them so dissimilar and opposite, can be considered 
 strictly normal, and in accordance with the designs of nature. 
 
 The length and strength of the umbilical pulsation — if I may so ex- 
 press it — depends upon the length and character of the labor ; and further, 
 between the longest labors and the shortest — between the easiest and the 
 hardest — there is doubtless a happy medium — not easy to define, which 
 we should call natural labor. 
 
 Now, the condition of the funis, as regards its pulsation, observed in 
 these natural labors, is its natural condition, and in this condition it may 
 always be divided, without hesitation, when the child is born. The con- 
 dition referred to, however, as I will immediately endeavor to explain, is 
 not that in which the umbilical pulse is strong and persistent through a 
 good length of the umbilical cord. 
 
 The stoppage of the arterial beat in the funis, is caused by obstructed 
 circulation in the placenta. But this obstruction does not become com- 
 plete until very near the close of labor, although it may have begun to 
 take place simultaneously with the earlier uterine pains. In natural labor, 
 when the placental circulation has ceased, there yet remains a certain 
 period which it is proper should elapse before the delivery is finished; and 
 it is during this period that the pulsation of the arteries in the umbilical 
 cord ceases. If the time is unusually long, the child will be delivered, 
 (most likely still-born, which is unnatural,) without any pulsation in the 
 cord whatever; if it is unusually short, as in very sudden deliveries, the 
 child will come into the world with a cord pulsating, and strongly, from 
 end to end, which is also unnatural; while if the time elapsing be no 
 more or less in duration than it should be, then we shall receive the child 
 with its cord pulsating but feebly, and only towards its umbilical end. 
 
 Now, to prove that it is desirable and proper for a certain length of 
 time to pass, after the placental circulation has ceased, before the child is 
 delivered, we need only refer to facts already mentioned. We have en- 
 deavored to show that the condition in which nature designed a child 
 should be born, is a state of partial suffocation, of approaching apnoea, of 
 semi-unconsciousness; for there are, at least, two important results that 
 attach to such a condition; first, the heart of the infant becomes congested — 
 distended with blood — preparatory to injecting the lungs, when the first 
 inspiration occurs; and second, the predominance of black venous blood 
 in the circulation of the child, prepares — by its sedative action upon the 
 brain and nervous system generally — the delicate sensibilities of the in- 
 fant to withstand the shock of the violent impressions so suddenly to be 
 made upon it at the moment of expulsion. Of course, a third result, of 
 such a state of partial asphixia, is cessation, either complete or incom- 
 plete, of the umbilical pulse. 
 
 Now, while these are the natural circumstances under which a child 
 should be delivered, it cannot be otherwise, but that those births which oc- 
 cur under different circumstances, are tm-natural. 
 
 The labor, therefore, that takes place so rapidly, and of which especially the 
 last stage is so rapid, that delivery is completed almost, or quite as soon as 
 the placental circulation is obstructed — in that labor there has been unnat- 
 
34 
 
 ural haste, one result of which is, that the umbilical cord,' instead of having 
 its pulse enfeebled, preparatory to separation, beats as strongly, throughout 
 its whole length, as it did before the child was expelled. 
 
 Admitting such a condition to be a deviation from the natural course of 
 things, and supposing a child to be born, whose cord pulsates vigorously 
 almost from end to end, we recur to the question, shall it be divided or not? 
 That such cords can be divided without any manifest ill consequence, ex- 
 cept perhaps an unusual amount of hemorrhage, though not sufficient to en- 
 danger life, is beyond doubt. This is proven by the cases of sudden de- 
 livery, in which there has been accidental rupture of the cord. We do not 
 however recommend the practice. Our own custom is, to wait until the 
 pulsation becomes feeble, or else, (as in those cases, where from some ex- 
 traneous cause, the separation of mother and child is absolutely necessary,) 
 to divide the cord where its beat is already extinct, i. e., below the pulsa- 
 tion. No matter if it is eight or ten inches from the navel, the remaining 
 part can be cut off after the pulsation has ceased. 
 
 Now, about the only reason that occurs to us, why a pulsating cord should 
 not be cut, is simply this : we believe it to be natural, (as just explained,) in 
 the process of parturition, that the labor should be so far prolonged after cir- 
 culation has ceased in the placenta, as that the child shall not be expelled until 
 its umbilical arteries either beat but feebly, or not at all; and it is therefore 
 our object in a case where the child is born too rapidly, and in whom the 
 funial pulse is yet full and strong, to imitate nature as far as possible, and 
 not divide the funis until the pulse is feeble or moderated, as it naturally 
 would have been, with less haste in the delivery. Perhaps the best way of 
 all, if it were practicable, and it sometimes is — would be to prevent the too 
 rapid expulsion of the child, so that the cord shall have ceased to pulsate 
 before birth ; for it probably takes much longer to quell the umbilical pulse 
 when respiration is established, than it does when, in utero, the action of 
 the foetal heart is being enfeebled by accumulation of black blood in the 
 vessels. 
 
 Next, with regard to the mode of division, the instrument to be used, &c. 
 
 To tear and pull the cord in twain, or to bite it and pinch it, however 
 near they approach to the " natural" are not methods to be employed in 
 practice. But perhaps even these are more eligible, certainly safer, than 
 sharp cutting instruments.* To sever the cord with a sharp pair of scissors, 
 is by all means bad practice and should be abandoned. 
 
 Perhaps the first necessity of the unfortunate ligature, grew out of the 
 employment of such instruments. To pinch the cord in two, between the 
 
 *Since in animals the cord is usually broken by force — by traction or pulling from 
 the abdomen — and while it is generally true that the means employed by nature for 
 the accomplishment of any particular end, commonly answer the purpose better 
 than the means substituted by art, it might be worth while to enquire whether there 
 is not, in addition to the mere separation of the cord, some other useful and indirect 
 result attained by traction of the funis at birth. In this connection the following 
 questions occur to us. Does the traction referred to, assist in establishing respiration 
 and causing a full expansion of the lungs ; whether by drawing the adominal wall 
 in an anterior direction — thus inviting the viscera of the abdomen to follow, and so 
 facilitating the downward movement of the diaphragm — or by some impression 
 through the nerves, causing reflex movements of the muscles concerned in respira- 
 tion ? Again, what effect does the pulling the funis have — by stretching it, and also 
 to some extent, the attached hypogastric arteries — upon the circulation, upon the 
 amount of hemorrhage, and upon the umbilical pulse ? 
 
35 
 
 finger and thumb nail, would perhaps be a ligitimate method of separation, 
 but it is by no means easy to accomplish, as any one can prove, by trying 
 it for himself. The best, and at the same time most scientific proceeding, 
 would be, I should think, to employ a small ecraseur. Such an instrument 
 made specially for the purpose, might be constructed to fit easily in the 
 pocket without inconvenience. It would prevent that supposed liability to 
 hemorrhage which is so generally dreaded, almost or quite as effectually, as 
 "biting" itself. But in the absence of such an instrument our practice 
 is, to use a dull pair of blunt pointed pocket-scissors, and hack through the 
 cord, not at one cut, but by a sort of nibbling process. Should there be 
 no bleeding, or but little, nothing further will be required. But if it should 
 bleed too much — an occurrence that has not yet happened to us — then the 
 cut end may be scratched, scraped and pinched between the thumb nail and 
 end of the index ringer — a sort of digital biting — until the hemorrhage is 
 controlled. An undue amount of bleeding might be further arrested by 
 pinching the cord above the end, at various points, between it and the navel, 
 But none of these proceedings will generally be necessary. 
 
 It should here be remembered that in forming an opinion as to what 
 really is an excessive bleeding, and what is not, we are not to judge from 
 the amount of blood lost, but by its effect upon the child. Some infants 
 are much more plethoric than others ; and the ability to lose blood, and to 
 be benefited by it, is very different, in different individuals. No matter 
 what the quantity of blood lost, so long as there is no pallor of the face, so 
 long as the respiration is good and the cry strong, I should have no fears 
 that the hemorrhage was excessive. For one who is timid of blood, my 
 advice is, to cut the cord and place it in a cloth out of sight, but where 
 it can be easily reached, and then watch the countenance of the child. 
 While there is ruby on its lip, and the cheek is scarlet; while the outcry 
 is vigorous and the respiration strong, no fears need be had, that the cord 
 is oozing too much. 
 
 As regards the point at which separation should be made, this is imma- 
 terial, provided pulsation is extinct. When, as before remarked, it is ab- 
 solutely necessary to remove the child in haste, while the arteries are 
 beating violently, we usually cut below the pulsation and then, after it has 
 ceased, remove so much of the remaining cord as may be desired, at our 
 leisure. Exactly how much need be left, is perhaps, not particular, though 
 for cleanliness' sake, if for no other reason, it might be desirable, to leave 
 as little as possible. 
 
 As relevant to the matter of managing the funis without ligation, it may 
 not be inappropriate in this place, to indulge a few remarks on the subject 
 of dressing. We do this, especially with a view of dissenting from the or- 
 dinary practice of applying the abdominal bandage and wrapping the cord 
 in a greased rag ; — both of which, so far from doing good, are actually hurt- 
 ful to the child. The ill effects of such a mode of dressing are in particu- 
 lar, these : 
 
 1st It interferes with the process of dessication ; and so prolongs the time 
 at which the cord should separate from the umbilicus. A funis that is first 
 folded in a greased rag, and then wrapped under a bandage, so that evapo- 
 ration of its fluid parts is prevented, cannot possibly dry as rapidly as it 
 would do, if left exposed to the air, and in immediate contact with the hot 
 skin of the child. 
 
 The slower the cord dries, the longer will it be in separating, and the 
 
36 
 
 greater liability will there be to inflammation, ulceration, &c., of tbe navel, 
 and their consequent sequelae. Moreover, when drying of the cord is pre- 
 vented, and it remains an unusually long time attached to the umbilicus, 
 putrifaction begins to take place, as any one can testify who has had occas- 
 ion to observe the odor given off under such circumstances. And it is not 
 impossible that from this putrifaction, may result, in some cases, blood 
 poisoning; as evidenced by erysipelas of the navel, umbilical phlebetis, py- 
 emic abscesses, &c. But in addition to preventing evaporation and drying 
 of the cord, the ordinary mode of dressing is injurious, 
 
 2d. Because it gives pain to the child. And what is worse, it is often 
 for this pain, and this alone, (often mistaken by nurses for colic) that the 
 infant is made to swallow all sorts of nauseous drugs and teas, in the way 
 of laxatives, anodynes, carminatives, &c. 
 
 The pain we refer to is caused in the following manner. The cord in 
 drying necessarily contracts and becomes shorter, but when, as often hap- 
 pens, its distal end becomes fixed, by sticking to the binder, which last is 
 also immovable, it cannot be otherwise but that the force of its contraction 
 should be exerted equally upon the umbilical end, thus pulling the funis 
 from the navel and causing pain. Furthermore it will be observed, when 
 the dressing is dismissed and the cord left free to dry, that the latter often 
 curls in a complete semi-circle round the navel. When therefore, within 
 the binder, we maintain it in a fixed, straight position, it necessarily follows, 
 that the power and disposition to curl being resisted, reacts with equal force, 
 only in the opposite direction, upon the navel, and so causes pain. And 
 again, while the remains of the navel string is fixed in an immovable binder, 
 we must remember that the navel itself is in perpetual motion from the 
 action of the diaphragm, hence a '' see-saw" motion is kept up at the root 
 of the umbilical cord, by each respiration — a motion that must necessarily 
 be painful to the child ; and that might always be prevented by leaving 
 the cord free to move with the abdominal wall in which it is rooted. 
 
 The agony suffered by the infant, when the old dressings are being re- 
 moved and new ones applied, as is recommended to be done a second and 
 even a third time by high obstetrical authority, and especially when the 
 stiffened funis is in part or wholly raised to a position at right angles with the 
 abdomen, which is often required to be done in renewing the application — 
 under these circumstances, the agony suffered by the infant can be better 
 imagined than described, as is evident from its lamentable and trembling 
 cries. 
 
 The binder, we believe, is generally applied in new-born infants to give 
 support to the abdomen. But in a healthy child, where there is no arrest 
 of development of the muscles, and no unusual opening at the umbilicus, 
 it surely cannot be necessary for such a purpose. 
 
 When any such abnormal conditions do exist, let them be diagnosed and 
 the proper remedies applied. But that every new-born child should be so 
 imperfectly developed as to require the support of artificial appendages- 
 from such an admission, " angels and and ministers of grace defend us." 
 
 Besides the support afforded by it, I believe there has been no other use 
 attributed to binding the infant's abdomen with a bandage. 
 
 Failing, therefore, to discover any real use for the appliances ordinarily 
 employed in dressing the navel-string, and believing those appliances to be 
 in reality rather hurtful than useful, the practice that I now invariably re- 
 sort to is the following; : 
 
37 
 
 The cord having been divided in accordance with the principles already 
 laid down, and hemorrhage having ceased, we endeavor, by gentle means, 
 to squeeze out the blood and fluid portion of the gelatinous matter con- 
 tained in it. This can be best accomplished by holding the root firmly 
 with the thumb and finger of one hand, while with those of the other we 
 force out the blood by a kind of milking operation, much in the same way 
 that it is sometimes squeezed out of leeches. This precaution is perhaps 
 only desirable in the cords that are very thick and loaded with gelatinous 
 matter, and which otherwise take a long time to dry, and in those where 
 the vessels are large and filled with blood. 
 
 Having been thus treated, and having already become flaccid and rib- 
 bon-like, it is simply suffered to remain, without any dressing whatever, 
 hanging downwards and resting on the abdomen of the child. Of course 
 the squeezing out of blood, &c, is not to be thought of while the cord is 
 yet pulsating. Under the latter circumstances it may be left, and of any 
 length, until our visit on the following day. Then, however, it may easily 
 be cut off short, by simply raising the skirt and applying the scissors or 
 ecraseur, and without giving the least pain or uneasiness to the infant. 
 
 I always deem it best on the second day to shorten the remaining por- 
 tion of the cord to something less than an inch in length, just enough to 
 turn down flat over the rim of the umbilicus. A funis treated in the man- 
 ner now described is, at first, left in a condition very different from the 
 stiff, turgid, and glistening state in which it is generally observed after 
 ligation in the usual way ; and at a later period, instead of presenting itself 
 in the form of a projecting spike-like process an inch or inch and a half 
 long, as we find it when dressed in the ordinary fashion, it is observed to 
 be short, flat, and with its broad surface resting on the abdomen, is often 
 curled snugly round the umbilicus. 
 
 In applying the diaper, caution should be given to the nurse not to dis- 
 turb the navel, and in fitting clothes upon the child it should be noticed 
 that the waistbands, especially if they are at all tight, should come suffl- 
 crently high up on the body as not to press upon the umbilicus. In short, 
 the one great principle to be observed in managing the cord after separa- 
 tion, is, to let it alone. 
 
 The advantages of this mode of management are, that dessication and 
 separation take place rapidly ; that pain to the child is avoided ; that the 
 risk of ulceration, inflammation, and erysipelas of the navel, is less- 
 ened ; and last, but by no means least, the accoucheur can in one moment, 
 by simply raising the skirt, easily examine the umbilicus at every visit, 
 without at all incommoding the infant, or even waking it, if asleep. This 
 last is an advantage which every obstetrician who has witnessed the cries 
 of the infant when undergoing examination of, and removal of dressings 
 from the umbilicus, must, I think, appreciate. 
 


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