Wednesday, April 27, 2016

1792: The first attempts at neonatal resuscitation

Fig. 1 -- Represents the box-wood tube.  One end was inserted
into the infants airway.  The caregiver would lace his mouth
over the other end (bottom of the figure in the photo) and provide
breaths to the child.  Bellows may also be connected to the tube.
(14, page 77-78, 196)
Perhaps among the first attempts at artificial respiration were performed on a stillborn child. The mother and father waited patiently for nine months, a perfectly formed child was born, but it wasn't breathing.  Frantic attempts were made to excite breathing.

More often than not such attempts failed, but every so often there was success, which brought great joy and excitement, just enough to motivate the next generation to make such efforts given the same frightful situation.

Some methods used to excite a newborn's first breath included: (1, page 77) (2, page 13)
  1. Talking to the baby
  2. Rubbing the baby's chest 
  3. Shaking the baby
  4. Tickling the baby
  5. Blowing in the baby's face
  6. Warming the baby with warm blankets
  7. Applying moderate friciton to the body by rubbing 
  8. Slapping the baby on the back or heels
  9. Patting the baby on the back
  10. Squeezing the rib cage
  11. Hugging the baby
  12. Performing mouth to mouth respirations, what was called inflating the lungs
  13. Inserting a tube into the airway and breathing for the child that way 
  14. Suctioning the baby's airway (not available until 1937)
  15. Performing gentle chest compressions or abdominal thrusts
  16. Tickling the nose with a feather
  17. Tickling the arm pits, temples, stomach
  18. Dunking the child up to the neck in warm water
  19. Other gentle stimilation
Over time, and by trial and error, better methods were developed. By the end of the 19th century a basic form of neonatal resuscitation was taught to medical students, nurses, midwives, and members of societies such as the Humane Society. In fact, the report references and quotes Curry. 

A good example can be found in James Curry's 1815 book "Observatoins on Apparent death:"
WHEN a still-born Child appears in every respect perfect, and especially when, from the circumstances of the labour, there is reason to believe that the Child has not been long dead, measures may be taken for recovery, with very great hopes of success. With this view, the Lungs should be diligently inflated, and the heat of the body kept up, by the application of Warm Flannels, or by putting the Feet and Legs, or the whole Body up to the chin, into Warm Water. Moderate frictions with the Naked Hand, and gentle agitations, may also be used; and Stimulating Remedies applied to the Nose, Temples, and Pit of the Stomach. (1, page 77-78)
If these efforts did not work, then the physician or midwife would move on to the next stage of the resuscitation attempt, which would involve inserting tubes into the airway and breathing for the baby.  An example of this is noted by Curry:
If the Wooden Tube (Fig. 1.) be not at hand, the female Catheter (an instrument which every Practitioner in Midwifery is presumed to carry constantly about with him) will answer tolerably well for inflating the Lungs in this case: in defect of it, a joint of reed, the barrel of a qiull, or a piece of still paper or a card rolled up, may be; —one end being introduced into the Mouth, and the Assistant blowing into the other with his breath,* until the Lungs are expanded; then gently pressing the Chest;—and repeating this, so as to imitate Natural Respiration.
The recommendation by the Humane Society was similar, although the 1823 report of the Society suggested that bellows should be used to breathe for stillborn infants instead of the mouth.

Curry notes that in "some cases which have come within my knowledge prove, that Still-born Children may be recovered even after an hour or more has elapsed." His explanation for this is as follows: 
There are several reasons for believing, that the Vital Principle is not so soon destroyed here, provided the warmth of the body be kept up, as when Respiration has been established for a length of time, and then interrupted: for the new-born Infant which has either not respired at all, or had its breathing suspended very soon after birth, seems in a state of susceptibility somewhat resembling that which annually takes place in certain Animals, as the bat, frog, dormouse, &c, from the influence of the Winter's cold; the one requiring only the restoration of that warmth by the return of Spring, the other the application of Air to the Blood stagnating in its Lungs, to restore the Circulation, and with it the balance of functions necessary to Life. 
His theory is actually quite interesting considering anatomical pathology was only in its infancy during this era.  Over the ensuing years better wisdom improved the steps of neonatal resuscitation.  However, it wouldn't be until the 1980s that the technology was available to save the lives of infants not so perfectly formed.

References:
  1. Curry, James, "Observations on Apparent Death from drowning, hanging, suffocation by noxious vapours, fainting-fits, intoxication, lightning, exposure to cold, & etc., and an account of the means to be employed for recovery. To which are added the treatment proper in cases of poison, with caution and suggestions respecting various circumstances of sudden danger," 2nd edition, 1815, London (the 1st edition was published in 1792)
  2. "The Forty Ninth Annual Report of the Royal Humane Society, For the Recovery of  Persons Apparently Drowned or Dead," 1823, London, 
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