The Cincinnati Lancet & Observer

Soon after the announcement by Marshall Hall of his "Ready Method" in asphyxia, communications appeared in the journals containing reports of cases to the effect that the process in them had been successfully employed. Like reports have since greatly multiplied, consisting of some cases of asphyxiated adults, but for the most part of asphyxiated new-born children, in which resuscitation followed more or less quickly the application of the new method. In these cases, the process would seem to have accomplished all that could be desired; and if, in accordance with the expressed view of some of the reporters, the children could not have been restored by any other means, then the question is settled, a true advancement has been made in the discovery of a treatment by which children that were doomed under former methods may be saved. Nevertheless, for one, I am not thus sanguine, and propose the question: Which method, the Marshall Hall or the mouth to mouth, is the more entitled to our confidence in the asphyxia of new-born infants?

It may be remembered that the case of the asphyxiated new

Read before the Cincinnati Medical Society.

VOL. III., No. 1.-1.

born child is not just parallel with that of the asphyxiated adult. The first has never respired. The chest has never been expanded; the air vesicles have never been opened. The chest and lungs then do not possess that elasticity or resiliency which would be so important an element in successfully carrying on the "rotation process." It would be difficult to understand how, under it, the first expansion of the lungs could take place; when the child is turned on its face, the lungs being already compressed, the capacity of the chest could be thereby but little, if any, diminished; and when turned upon the side and a little beyond, as directed, it could be but little, if any, increased. Whether here there be any ingress and egress of air has yet to be determined by experiment. This test, instituted, as is well known, by Marshall Hall at St. George's Hospital, was in reference to adults. This peculiarity, then, of the new-born child can but constitute a serious impediment to the successful performance of the rotation process. But it possesses characteristics which render it a very suitable subject for the mouth to mouth operation its small size admits of its being placed in any position that may best suit the convenience of the practitioner; its small mouth is easily encompassed by his mouth, and the force of his breath is entirely sufficient to expand its delicate lungs; and the child, accustomed as it has been to imperfectly arterialized blood, is readily quickened into life by contact with its air vesicles of air no purer than the breath of the practitioner; moreover, no real difficulty is here experienced in the falling back of the tongue.

If the two processes be compared in reference to the qualities ready, easy of performance, and effectual in the purpose, it is plain that the old plan is as ready as the new, since by it the child is treated "instantly and on the spot ;" that ease of performance pertains almost as much to the one as to the other (since no apparatus or complicated maneuvre is required in either case), and if there be here a slight difference in favor of rotation, it is not such as to influence the mind of the practitioner in deciding which process to pursue.

The great point is, which is the most effectual in the purposethe accomplishment of artificial respiration. Under the new method, there are no indications whereby it may be known whether the air enters the lungs or not, until waiting for evidences

of increased vitality on the one hand, or the cessation of all signs of life on the other. Under the old method, there are direct, immediate, and unmistakable signs that respiration is being effected: the thorax expands, the air is heard and felt to enter the lungs; the thorax contracts, and the air is heard and felt to escape. Such evidences are conclusive; when present there is respiration, and there is no occasion that they should ever be wanting.

I propose now to consider the question in the light of cases occurring in practice. I will take it for granted that the cases published as favorable to the new method are familiar to the profession, so as to render it unnecessary to reproduce any of them here.

Mrs. C, third confinement, July 22, 1855. I found the child presenting by the feet. Labor steadily advanced till the body of the child was expelled, when an interval of at least a quarter of an hour elapsed before the head followed, during which time the circulation through the cord was completely obstructed. The child was born apparently dead, though the hand applied to the chest detected a very feeble pulsation of the heart. Artificial respiration by the mouth to mouth process was immediately resorted to, under which the action of the heart became more vigorous. After persevering for several minutes, there was a feeble respiratory gasp; then, after a considerable interval, there was another gasp. These respiratory acts continued to be repeated at long intervals, artificial respiration in the mean time being kept up and the circulation thereby maintained. An hour passed before the child could maintain its respiration unassisted. In the course of another hour there was a perfect restoration of vitality. Mrs. B, multipara. Confined November 6, 1855. week previously she was taken with flooding, which continued more or less until true labor pains set in; after which there was no more flow. In this case there was prolapsus of the cord before the head, and my efforts were unavailing to keep it above the brim. The usual consequences followed: the cord was compressed, its pulsations grew faint and finally ceased; the child was born to all appearance lifeless. Examination, however, revealed the important fact that the heart was still pulsating, though so feebly as to be just perceptible, and so slowly that the lengthened interval excited my apprehension that each beat would be the last. With the loss of as little time as possible, I commenced artificial

respiration (by the usual method), the effect of which was soon manifested on the circulation: the action of the heart was increased until it came up to the standard of a healthy breathing infant; the surface changed from pallor and lividity to the healthy complexion.

But it seemed that vitality was to be maintained only so long as I persevered in inflating the lungs; for on suspending the operation there was no spontaneous respiratory effort, and the circulation became speedily feeble. However, after keeping up the process at least half an hour, I was greeted by a respiratory gasp. There was a recurrence of gasps at first at long intervals, and afterwards more frequently, until respiration was established.

These cases, I am aware, contain nothing peculiar. They are merely examples of asphyxiated new-born infants relieved efficiently by the method which the profession has been taught to recognize as the sine qua non in such conditions. I relate them that they may be placed in apposition with the cases published in the journals as favorable to the "Marshall Hall Method." And if it be claimed that in the latter cases resuscitation could not have been brought about by other than the "Ready Method," I think it may with equal propriety, at least, be claimed that my cases could not have been restored by other than the mouth to mouth method. Indeed, my firm conviction is, that, when these births occurred, had I known of this new method, and resorted to it, and trusted it to the exclusion of the old process, these children would never have breathed. The asphyxia was so profound, and the tendency to complete death so rapid, that nothing less than the prompt and free exposure of the air vesicles to the air, as obtained by this process, would suffice.

I shall now reproduce some cases in which both methods were employed.

Mrs. C, primipara; foot presentation, with descent of the cord, which latter was pulseless. I had no expectation of saving the child, and announced to the friends that it would be born dead. With no more delay than the average, delivery was completed. The child was small, and evidently not less than six weeks premature. There was nothing about it to indicate to the casual observer the presence of life, but by a careful examination the heart was ascertained not to have ceased its action—the pulsa

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