STILLBIRTH-RESUSCITATION AFTER TWO HOURS

AND FIVE MINUTES.

BY ROBERT BATTEY, M.D.,

GEORGIA.

B

MRS. W., aged thirty-five, three years married, primipara, medium stature, very fleshy, in excellent general health, and at full term, was aroused at midnight on Wednesday by very slight uterine pain and copious discharge of liquor amnii. She was seen at 6 A. M. Thursday. The waters were still draining away at intervals and freely; there was, however, no pain, and had not been since the first discharge, but only a "sense of discomfort," as she expressed it, in the pelvis. The os was open to the size of a silver quarter dollar, and very high up, so as to be difficult to reach. The presentation could not be made out satisfactorily. The next twenty-four hours were passed in comparative comfort; little or no pain was complained of, and labor did not progress at all, although the waters continued to be discharged at intervals. At 9 A. M. of Friday (thirty-three hours) the os was slowly dilating, the uterus had settled down in the pelvis, and a female child was discovered to be presenting by the breech, with the sacrum to the right acetabulum.

The labor went on slowly, pains moderate and well borne. The breech and abdomen of the child came lazily through the vulva, when, at 3 P. M., the pains having ceased, the arms were brought down, and the head turned out of the vagina with some delay and great difficulty, because of the obesity of the mother. The child was still and deeply cyanosed, the cord was pulseless, the heart-beat was very feeble and irregular, there was no effort at respiration. By the old mouth to mouth method the lungs. were inflated without loss of time, the mouth and throat of the

child having been previously cleared of mucus. A spray of cold water was repeatedly dashed in the face and upon the chest, but not the slightest respiratory movement could be elicited. Artificial respiration was attempted successively by the several

methods of Marshall Hall, Sylvester and Harvey Byrd, and continued for fifteen minutes, but the trachea and larger bronchii were so clogged with mucus that the air could not be made to enter the lungs satisfactorily by either of these methods.

The surface of the body was now becoming quite cool and livid; there was no respiratory impulse whatever, and the heartbeat had not been perceptible at all for some minutes. The child seemed to be entirely and hopelessly dead, and would have been so pronounced had not repeated experience shown the successful resuscitation of stillborn babes after a much greater lapse of time, and under circumstances apparently the most hopeless. A nurse was deputed to surround the body and limbs of the child with hot flannels, and change them every four or five minutes so as to maintain an excessive surface temperature, whilst the attention of the writer was directed to the complete and rhythmical inflation of the lungs, mouth to mouth, the nose of the child being compressed between thumb and finger.

In ten minutes' time the pulsations of the heart could be feebly discerned, but they were extremely slow, not more than ten or twelve to the minute. The pulsations, however, increased gradually in frequency and force, until, after the lapse of an hour, a fair normal standard of circulation was reached. The aëration of the blood by the artificial inflation of the lungs had progressed so favorably that the face and head were assuming comparatively a natural, florid color, though the ears, lips, and limbs were still quite livid. Now, for the first time, a single deep breath was drawn, and in ten minutes more another. The inflation by the mouth was diligently continued, the mucus rattling loudly in the air-passages all the while, portions of it being forced up into the nasal passage by the inflation, and expelled from time to time from the nose during artificial expiration. The long interval between the natural breaths gradually shortened, until the respiration becoming two per minute the inflation by the mouth was discontinued, and, finally, after the lapse of two hours and five minutes by the watch the breathing became regular and rhythmical. In fifteen minutes more the aeration of the blood was complete, the lividity was all gone, and the surface presented only the intense redness produced by the diligent application of the heated flannels.

The cord was now ligatured and divided. The child was well anointed with lard and wrapped in warm flannels, and was

allowed to rest without further toilet. It moaned at intervals as if in distress, but the action of the heart and lungs was normal. It nursed the mother repeatedly, took catnep tea, and slept fairly well. At midnight, however, the respiration became embarrassed with bronchial mucus, which accumulated more and more, and, finally, a pinkish sanguinolent froth issuing from the mouth and nostrils, the child died in asphyxia at one A. M. of Saturday, ten hours from its birth.

This case is brought before the Section, not on account of any novelty in the asphyxia or its treatment, but simply in the belief that it teaches a practical lesson of value which is not so generally accepted by the profession as it ought to be, namely, a lesson of patience and long perseverance in the use of means of resuscitation in the stillborn.

It is true that our standard authorities all enjoin the use of means to this end, and some even go so far as to inculcate maxims of patient perseverance; but none, as far as opportunity for reference at command of this writer is concerned, hold out any confident hopes of success when the heart has ceased to beat, and after so long a period as two hours has elapsed.

Dr. Tyler Smith, in his work upon Obstetrics, says: "It is seldom that a child can be restored after the cessation of these centric movements-gasping-notwithstanding that the heart will frequently beat for some time after they have ceased. . . Artificial respiration is not of so much value in congenital as in other forms of asphyxia, from the fact that the foetal lung has never been distended with air."

Cazeaux says: "The lapse of half an hour, an hour, or even more, from the time of delivery, is not sufficient cause for despair, since a number of facts may be mentioned going to prove that children have been in an asphyxiated condition for an hour, and were afterwards restored to life. Long-continued silence of the heart, the entire absence of pulsations at the præcordial region, frequently determined at intervals, is the only sign which can be regarded as destructive of all hope. The heart is the ultimum moriens, and I do not believe that efforts to restore its pulsations, whenever once completely extinguished, have ever been crowned with success."

Ellis, in his Manual of the Diseases of Children, quotes the statement of Maschka: "An infant may be an hour or more

without breathing, and still be saved." Bedford, in his Clinical Lectures, says: "Permit me here to remark that the faculty of resisting asphyxia, that is, of living without breathing, is very much greater in the new-born infant than in the adult, so that if a child should not breathe for half an hour or more after birth, it should not be abandoned as dead and beyond remedy. Cases are recorded in which resuscitation has been accomplished by some of the means just alluded to, and more particularly artificial respiration, even after asphyxia had continued for a long time. Another important fact is this: a newly-born infant affected with asphyxia should not be considered dead because its heart has ceased altogether to beat; for it has been demonstrated by Brachet of Lyons, Josat, and others, that life may be restored after the pulsations of the heart have ceased for more than five minutes."

Playfair, in his late work upon Midwifery, says: "In other cases the child, instead of being turgid and livid in the face, is pale, with flaccid limbs, and no appreciable cardiac action; then the prognosis is much more unfavorable. . . . Encouragement to persevere in our endeavors to resuscitate the child may be derived from the numerous authenticated instances of success after the lapse of a considerable time, even an hour or more."

In Smith on Diseases of Infancy and Childhood, we find the following: "The action of the heart, previously slow, becomes quicker by the artificial respiration, and I am confident that I have been able to produce pulsations by this method, when the heart had ceased to beat, and death, to all appearance, had occurred. . . . Artificial respiration should be continued for ten or fifteen minutes, in cases in which no action of the heart can be detected, by pressing the fingers under the ribs, when, if there are no signs of returning animation, the case is hopeless. . . . In one case, in which pulsations in the cord had ceased from ten to fifteen minutes before birth, in consequence of its prolapse, I employed artificial respiration nearly a quarter of an hour before there was any appreciable pulsation, but by perseverance the child was restored."

Dr. Condie, in his work upon the Diseases of Children, tells us: "In those cases in which the child is born without any indications of life, its face swollen and livid, its body flaccid, and no pulsation is perceptible in the cord or at the heart, notwithstanding there is but little hope that resuscitation can be

effected, it is nevertheless proper that suitable efforts should be made and persevered in during a reasonable time for the establishment of respiration. . . . In no case of asphyxia in a newborn infant should we hastily pronounce success impossible.... It is, indeed, amazing the length of time that new-born infants can survive without breathing, not merely for half an hour or an hour; but, as Dr. Maschka has shown, for a much longer period, even under circumstances the most unfavorable. A series of cases in proof of this are collected in the Gazette Hebdomadaire for December 1, 1854."

In the January, 1860, number of the American Journal of the Medical Sciences, Dr. Condie, in a highly commendatory notice of a lecture on Suspended Foetal Animation, delivered in University Medical College by Dr. T. Gaillard Thomas, of New York, remarks: "According to the lecturer, when, in cases of stillbirth from asphyxia, there is no perceptible action of the heart, little or no hope of resuscitation is to be entertained. This is not our experience; we have known entire recovery to ensue in a very large number of instances, when proper measures have been promptly resorted to, and sufficiently long persevered in, when not the slightest action of the heart could be detected."

In the present instance, the results obtained might at first. sight appear barren and unprofitable, inasmuch as the child had sustained such vital injuries as to cause death in ten hours, notwithstanding the resuscitation. Such a view, however, seems hasty and ill-judged. The fact that the resuscitation was successful in such unpromising circumstances should but give us the more courage and determination in those cases where less serious injuries have occurred. Besides, who shall estimate the value to the mother of the consciousness of a maternal triumph in having borne a living instead of a dead child, though she may be called upon to part with it in a few short hours? She is enabled to recognize it truly as her offspring; to feel that it is indeed and in truth a living soul; to fasten her affections upon it; to fold it to her bosom; to nurse it from her breast. If her faith so dictate, she may call in the priestly offices, too, have it baptized, received into the fold of her church, and thus made fit for heaven, where she may hope to set it as a jewel in her crown for all eternity. Surely these are abundant recompenses for our diligent endeavors, and ought to stimulate us to adopt fully the motto nil desperandum.