APPARATUS EOR TRANSFUSION 
Asphyxia in New-born Children 
Considered from a Medical and a Legal 
Stand-point. 
PAPERS READ BEFORE THE NEW YORK OBSTETRICAL SOCIETY 
J. C. GARRIGUES, M.D. 
BY 
tieprinted from the American Journal of Obstetrics and Diseases of 
Women and Children, Vol. XI., No. IV., October, 1878. 
NEW YORK: 
WILLIAM WOOD & CO., 27 GREAT JONES STREET. 
1878. APPARATUS FOR TRANSFUSION. 
" In presenting a transfusion apparatus to the society, I do 
not lay claim to any originality. The chief characters of the 
instrument I am going to show you are found in that sub- 
mitted as early as 1853 to the French Academy of Sciences 
by Mathieu, that of Roussel, of Geneva (Switzerland), which 
took a prize at the International Exhibition of Vienna, and 
Playfair's improvement on Aveling's apparatus. My only 
merit, if merit there be, consists in calling Tiemann & Co.'s 
attention to the subject, and in helping them in certain details 
of the construction. 
Construction.-The instrument is essentially a diminutive 
Davidson's syringe. It consists of two rubber tubes united by 
a rubber bulb with two metal cup valves opening the same 
way. At one end of the instrument is a tin plunger, at the 
other a nickel-plated stop-cock and canula. The canula is 
of small calibre, tapering, probe-pointed, and flexible. 
Operation.-A healthy individual, preferably a strong 
man, is bled, if possible in an adjoining room, and about eight 
or ten ounces drawn into a perfectly clean vessel. Whilst the 
blood is collecting, it is stirred or whipped continually with a 
silver fork or a wooden stick, by which process the fibrin is 
made to coagulate separately on the implement used for 
whipping the blood. This separation takes about five minutes. 
Next the whipped blood is strained once or twice through a 
perfectly clean piece of old linen, into a vessel standing 
in another vessel with lukewarm water (at about 105°). If 4 
Apparatus for Transf usion. 
there be no warm water at hand, it may be dispensed with, 
for the blood may lose 30° before any untoward symptom 
due to its loss of temperature appears. If possible, the 
syringe should be warmed, and then tilled by compressing the 
bulb until the blood flows through the canula, when the 
stop-cock is turned. 
The next stage is to open a vein on the patient, most con- 
veniently one at the elbow bend (never on the neck, in order 
to avoid the danger of air being absorbed.) If none be visible, 
they can be made so by compression above. The skin that 
covers the vein is lifted up in a fold, and an incision made 
perpendicularly to the vein. In order not to lose the vein, if 
by chance the canula should slip out, it is advisable to pass 
a probe or a double thread under it. The best way of opening 
it is to lift its anterior wall with a pair of fine forceps or a 
hook, and make a nick in it with a pair of fine scissors. Thus 
a minute flap is formed, under which the point of the canula 
is easily introduced. If these instruments are not at hand, the 
vein may simply be slit open with a lancet, care being taken 
not to perforate the posterior wall. Before introducing the 
canula, the operator convinces himself, by pressing slightly 
on the bulb, that all air has been chased from the syringe. 
The most important of all is to inject slowly, in order to 
avoid dilating the right side of the heart, and stopping the 
free flow from other veins, and in order to give the blood time 
to be purified in the lungs. The bulb ought to be compressed 
so slowly that the fluid scarcely forms a stream, but comes 
almost in drops. Thirty seconds are not too much, and three 
seconds are the shortest time for each compression. The bulb 
contains about three drachms, but by moderate pressure about 
two drachms only are expelled from it, and consequently, by 
counting how often it is emptied, we may calculate how 
much blood has been injected. The quantity to be used must 
depend on the supply at hand, on the amount of blood lost, 
and on the time elapsed since the loss, for the quantity lost is 
in a very short time replaced by lymph and water, and over- 
filling the vessels is dangerous. In most cases four to six 
ounces will do, but eleven have been injected with success. 
If a resistance be felt in working the bulb, the operator must 
first ascertain that it does not come from compression of the 
vein. If this is not the case, the resistance is probably due to 
overfilling of the right side of the heart. Therefore he must 
interrupt the operation or end it altogether, according to cir- 
cumstances. The same rule applies when dyspnea or other 
unpleasant symptoms appear. 
After the operation the wound is dressed as after phlebotomy. Apparatus for Transfusion. 
5 
As often as the instrument is used, it must be completely 
separated, in order to clean it. Even the fittings must be 
t:iken off by undoing the wires. Else a little blood will be 
left between the interior part of the fittings and the wall 
of the bulb, where it will dry and corrupt. Neglecting this 
precaution has caused acute septicemia and death. 
It will be seen that the operation here described is the 
indirect transfusion of defibrinated human blood. 
The indirect transfusion presents great advantages over 
the direct. The blood-donor need not see the patient, nay, 
not even come into the sick-room, where sometimes he faints, 
so that no blood can be obtained from him. No canula is 
introduced into his veins, which exposes him much less to dan- 
gerous consequences. 
The use of defibrinated blood presents also great advantages 
over the use of the entire blood. The danger of injecting coag- 
ula which may put an end to the patient's life is avoided, and 
the operator can work at his ease. By being whipped, the 
blood is delivered from carbonic acid and saturated with 
oxygen. Numerous experiments have proved that defibrinated 
blood is quite as efficacious in every respect as the entire blood. 
According to the repeated investigations of Panum, Pon- 
fick, and Landois (1875), it does not seem justifiable to inject 
blood from animals into the vessels of man. 
It will be known to the society that Dr. T. Gaillard Thomas 
and others have successfully injected milk into the veins of 
patients (see the American Journal of the Medical Sciences, 
January, 1876). The instrument may, of course, be used for 
this substance as well as for defibrinated blood. 
Bulb apparatus, in general, are preferable to syringes with 
a piston, because this rarely fits when the syringe is not con- 
stantly used. All instruments of glass and hard rubber are 
also apt to break. 
A special advantage in the method proposed is that the 
whole apparatus is filled with blood before it is introduced. 
Thus the trouble of chasing the air from the canula after 
introduction is avoided. The instrument is so small and 
light that it easily can find room in the obstetric bag, and, 
accordingly, always be at hand. It is easily managed even 
without skilled assistance, and is not likely to get out of order. 
Finally, it is so cheap that every practitioner can afford to 
buy it, and as transfusion may enable him to save life when 
all other means fail, some instrument for its performance 
ought to form a part of the obstetric apparatus. " Asphyxia in Children 
Considered from a Medical and a Legal Stand-point. 
Case.-(flydramnion, brow presentation, forceps delivery, 
large child, cord compressed, deep asphyxia, inspiration two 
and a half hours after birth, death seven hours after birthf 
u Mrs. B., 37 years old, has borne two children, eight and 
three years ago. No miscarriage. Both children were very 
large, bnt were born without instrumental help. 
The last menstruation began on the 26th of April. Each 
menstrual period lasts generally six or seven days. The move- 
ments of the fetus were felt for the first time four months 
later. When I first saw her, about a month before her con- 
finement, I diagnosed hydramnion on account of the uncommon 
prominence of the abdomen, the very marked fluctuation, and 
the quantity of water that could be felt between the fetus and 
the uterine wall. The vaginal examination did not reveal any- 
thing abnormal. During the latter half of her pregnancy, she 
suffered much from back-ache, which became so intense during 
the last sixteen days that she could barely move. When I was 
called, February 2d, 1878, true pains had already been present 
for twenty-four hours, and had been shooting dowTn for two 
hours. ' I saw her at 5.30 a.m. The abdomen was uncommon- 
ly distended with water. The fetal heart beat 120, and the 
sounds were unusually clear, extending from the level of the 
umbilicus down all over the left side. As this seemed to be 
contrary to hydramnion, I examined very carefully, and was 
able to exclude twins by making out the configuration of the 
whole body, a diagnosis that was corroborated by the absence 
of any heart-sound in other parts of the abdomen. The un- 8 
Asphyxia in New-born Children considered 
commonly clear and extended sounds are easily accounted for 
by the uncommon size of the child. The os was about an inch 
from side to side, and scarcely a linger breadth wide in the 
antero-posterior direction. The cervical canal had the length 
of the third phalanx of the index. 
The vertex was felt presenting. As the pains continued 
without forwarding the delivery, 1 gave her at three separate 
times fifteen grains of hydrate of chloral with an interval of 
twenty minutes, and later a fourth dose. She had some sleep, 
and the pains became better. At 9.30, the fetus had 
turned on its long axis, so that the back with the heart-sound 
was found in the right side. At 10.15, the os was as large as 
a silver dollar, when I ruptured the bag with a wire above the 
os, but in spite of the great quantity of liquor amnii present, 
only a couple of ounces escaped. The brow was then found 
presenting-both eyes, the nose, and the nostrils were felt above 
the horizontal branch of the left os pubis, the whole anterior 
fontanelle in front of the right ilio-sacral symphysis. I tried in 
vain to change the presentation into a vertex presentation, by 
pressure on the lower part of the forehead with two fingers. 
The heart-sounds became weaker, and the fetus made violent 
movements, like a seal in its little tank in a zoological garden. 
At the same time the mother suffered intensely. I therefore 
gave her chloroform and applied the forceps to the head, which 
was still at the superior strait. This was at noon. It was 
rather difficult to get the large head down. It bent and turned 
in the forceps, and emerged in the R. O. A/ position. 
The face was violet. It was very difficult to make the large 
shoulders follow. An assistant pressed the uterus powerfully 
down, whilst I pressed on the head from side to side, and 
finally hooked a finger into the posterior axilla. As soon as 
the head advanced somewhat, a loop of the umbilical cord 
appeared compressed between the neck and the right branch 
of the pubic arch. The head had a normal form, and the 
forceps had left no mark on it, except a small scratch on the 
back of the nose. . 
The child, a boy, was born in a state of profound asphyxia. 
Only a few slow and feeble beats of the heart showed that life 
was not extinguished. The child was entirely flaccid, the 
face violet, and the hands and feet blue. The cord was as 
thick as my thumb. I ligated it immediately and severed it. 
Compression of the womb was kept up by an assistant, and 
the placenta expelled by Crede's method. She lost about a 
pint of blood, and there appeared even some little arterial 
blood, probably due to laceration of the imperfectly dilated 
cervix. from a Medical and a Legal Stand-point. 
9 
Whilst others took care of the mother, I bestowed my whole 
attention on the child in order to restore it to life, and I had 
the opportunity to try most of the means recommended for 
this purpose. I slapped its buttocks, shook it, rubbed it, 
put it in a warm bath, and threw cold water over it alter- 
nately. Next I tried Sylvester's method, alternately lifting 
the arms along the sides of the head, and pressing the elbows 
against the hypochondria. Then I covered the face with a 
piece of linen, with a hole corresponding with the mouth, com- 
pressed the nose and the abdomen, and blew through the 
mouth, but found that the air scarcely entered the lungs. 
After that, I introduced a flexible catheter through the larynx. 
No fluid could be withdrawn, but the insufflation of the lungs 
was easily performed and kept up for two hours, whilst the 
child was constantly covered with hot cloths. The pulsations 
of the heart were brought up to 120, and were of normal 
strength, but, two hours and a half having elapsed without a 
single other sign of life, I was about to give up the case as 
hopeless, when it made the first respiratory gasp. Encou- 
raged by this I went on with the insufflation, combining it with 
other stimulants, such as vapor of ammonia, tickling the interior 
of the nose with a feather, and the introduction of lumps of 
ice into the rectum, and the frequent application of ice and hot 
cloths alternately to the abdomen, this last measure, which 
had a very marked effect, being suggested to me by Dr. Stub. 
During the first hours the progress was very slow : at 2.30 p.m., 
the boy made the first inspiration, and at 4 o'clock he had 
only come to five double inspirations in the minute-that is to 
say, two inspirations followed one another immediately, and 
then there came a pause of about ten seconds before the next 
double inspiration occurred. At 5 o'clock, he made eight 
double inspirations. Now I ceased inflating the lungs, and 
during a whole hour he respired alone through the catheter. 
The short pause became longer, so that the respiration 
approached more the normal rhythm. In order to give him 
the benefit of warmed air, I held the end of the catheter in 
my open mouth. Several times the catheter was withdrawn 
in order to try if any fluid could be aspired, but it brought 
up only a little blood, probably due to a slight abrasion caused 
by the introduction of the instrument, or perhaps to the 
asphyxia itself, a state in which the lungs become filled with 
blood, and ruptures take place. 
At 6 p.m., I withdrew the catheter and left it out, the 
respiration lost in frequency, being only six or seven double 
inspirations per minute, and had a stertorous sound. Twelve 
minutes later he opened both eyes. The conjunctiva covering 10 
Asphyxia in New-born Children considered 
the sclerotica was injected. Suddenly he ceased breathing al- 
together. I reintroduced the catheter and repeated insufflation, 
but now he could only be brought to make a few gasps, the 
pulsation of the heart grew weak, and at a quarter past seven, 
seven hours after birth, he died. 
He weighed 11 pounds, his length was inches, the cir- 
cumference of the head 15 inches, and that of the shoulders 
The placenta measured 8 inches in length by 7% in trans- 
verse diameter. It was covered with blood-clots. The mother 
had very slight parametritis, and has been out walking every 
day this last fortnight. 
Commentary.-My object in publishing this case is to im- 
press upon the mind of all who may not know it, that if only 
the heart beats, the life of the child may be saved even if spon- 
taneous respiration does not appear for hours. Many may be 
ignorant of the fact, as many text-books on obstetrics are apt to 
lead the practitioner into error on this point. The most recent 
German work, Spiegelberg's voluminous treatise,1 gives only the 
advice not to despair of success immediately even in the worst 
cases. Stadfeldt,2 professor at the university of Copenhagen, 
says that half an hour or an hour may elapse before respiration 
becomes regular. Playfair3 speaks of the numerous authen- 
ticated instances of success after the lapse of an hour or more. 
Older writers, however, such as Nsegele and Siebold, give more 
trustworthy information by stating that children have been 
revived, although they did not respire for two or three hours. 
1 regret that I withdrew the catheter before the child respired 
quite normally and tried to cry, for from the great progress it 
had made, I feel confident that it would have been entirely 
restored to life, so as to be able to respire without any help, to 
cry and to move freely, even though perhaps it might have 
died after a few days, as is so often the case with children born 
in a state of asphyxia. 
The hydramnion was probably due to the large size of the 
fetus. As often happens, it produced an unfavorable presenta- 
tion and prolapse of the umbilical cord, which again was the 
cause of the asphyxia. The latter probably commenced when 
the fetus made such violent movements, and its heart-sounds 
became weaker. The forceps was first applied after this, and 
the entirely normal configuration of the head and absence of 
any kind of impressions on it show that the asphyxia could not 
be due to compression of this part. 
Generally, we find the mouth, the throat, the larynx, and 
1 Spiegelberg, Lehrbuch der Geburtshiilfe. 1878, p. 675. 
2 Stadfeldt, Det mekaniske Misforhold, 1872. 
3 Playfair, Midwifery, London edition, II., 256. from a Medical and a Legal Stand-point. 
11 
even the deeper parts of the air-passages more or less filled 
with aspired liquor amnii. The absence of fluid in this case 
can easily be explained by the brow presentation. The mouth 
was pressed against the wall of the uterus, and thus the fluid 
was prevented from entering, in spite of the efforts at respira- 
tion made by the child. 
As for the comparative value of the different means employ- 
ed to induce respiration, as on former occasions, I found the 
insufflation of air through an elastic catheter to give better 
results than anything else. Of the other means used, the irri- 
tation of the mucous membrane of the nose by a feather and 
by the vapor of ammonia, and that of the skin by momentary 
application of ice, had the most marked effect. An electric 
apparatus was not at hand. It might, perhaps, have been well 
to let some blood escape; but the opinions are much divided 
on that subject. Spiegelberg1 goes so far as to condemn even 
the tying of the cord, because by it the chi d loses the blood 
retained in the placenta, which is its due. 
Cases like the one I have submitted to you present a great 
medico-leg al interest. I suppose that there is no member of 
this Society who will not agree with me that this child lived 
seven hours after its birth. 
Where circulation, respiration, and motion are present, no 
man with the physiological knowledge of our age will deny the 
existence of life. But it has not always been so, and there are 
still countries in which this child would have been declared by 
law not to have lived. A double interest attaches to the ques- 
tion, what is to be regarded as a living child : on the one hand, 
the criminality of maltreating the child, on the other hand, its 
capability of inheriting and transmitting property to others 
depends on its being alive. 
As it is likely that the opinion of the members of this Soci- 
ety would be more frequently asked, and have more weight than 
that of many others, it may perhaps not be altogether super- 
fluous to make ourselves acquainted with the perplexities of a 
question that at first sight must seem so exceedingly simple to 
everybody acquainted with laws of physiology. The laws 
of different ages and different countries are at variance as to 
the conditions required of a child in order to be able to inherit. 
The Roman law required that it should be perfectly alive, but 
it needed not to have made its voice heard.2 In France, a 
capitulary of King Dagobert prescribed that it should live an 
hour and be able to see the four walls and the ceiling of the 
chamber. This law was altered by Louis IX., who ordered 
1L. c., p. 672. 
2 Beck, Medical Jurisprudence, 12th ed. Philadelphia, 1863, I., p. 412. 12 
Asphyxia in New-born Children considered 
that it should cry. The present French law requires that tho 
child shall be born viable, and the interpretation of the word 
life and born alive is complete and perfect respiration. 
According to Scotch law, the child must cry.1 Thus in Scot- 
land and in France our child would be declared not to have 
lived, and consequently not be able to inherit. The English 
law, influenced by the Roman law, is much more in accordance 
with science. 'Crying,' says Blackstone, 'is the strongest 
evidence of life, but it is not the only evidence." Coke says, 
' Crying is but a proof that the child was born alive, and so is 
motion, stirring, and the like.' In the case of Fish, or Fisher 
vs. Palmer, in 1806, in which action was brought ten years 
after the birth of the child, it neither cried nor moved nor 
showed any symptoms of life ; but while in a warm bath, there 
twice appeared a twitching and tremulous motion of the lips. 
Denman thought it had not been alive, but two other physi- 
cians declared that it had been, and so found the jury.3 Dun- 
lope lays down the right principle that, where there is power 
of being affected by stimuli (other than galvanic or electric), 
this, in common sense, must be held to constitute vitality. 
In several cases of alleged infanticide, the English judges, in 
charging the jury, said that a child may be born alive and live 
for some time without breathing. In fact it would appear that 
breathing is regarded as only one proof of life ; and the law 
will therefore receive any other kind of evidence which may 
satisfactorily show that a child has lived.4 A child that is born 
alive, or has come entirely into the world in a living state, may, 
by the English law, inherit and transmit property to its heirs, 
even although its death has immediately, and perhaps from 
morbid causes, necessarily followed its birth.6 Although 
the mere warmth of the body would not be evidence of live 
birth, yet the slighest trace of vital action, in its common and 
true physiological acceptation-such as crying, breathing, pul- 
sation, or motion-observed after entire birth and separation 
from the mother, would be deemed in English law a sufficient 
'Beck, 1. c., p. 417. 2 lb., p. 413. 3 Beck, 1. c., p. 414. 
4 Taylor : Principles of Medical Jurisprudence, 2d edition. Philadelphia, 
1873, II., p. 324. 
6 Taylor, II., p. 206.-It is to be noted, however, that in prematurely born 
children, the time elapsed since the conception of the child makes a difference. 
After six months of pregnancy, it is enough to prove that the child is born 
alive, but children born within the first six months after conception are pre- 
sumed to be incapable of living, and therefore cannot take and transmit pro- 
perty by descent, unless they actually survive long enough to rebut that pre- 
sumption. In such a case, therefore, the medical expert will not only have to 
answer the question if the child is born alive, but if it is born viable, that is to 
say, if it would be able to continue life. (See Chancellor Walworth in the case 
of Marcellis v. Thalhimer, Taige Chancery Reports, Vol. II., p. 35.) from a Medical and a Legal Stand-point. 
13 
proof of the child having come into the world alive? In the 
case of Brock vs. Kelly, tlie only sign of life was pulsation 
of the cord. The question of its having been alive or not 
came up twenty years later. At the time of its birth, it was 
declared alive by Dr. Freeman. Dr. Tyler Smith supported 
his opinion, considering that the fact that pulsation was ob- 
served in the umbilical cord after delivery was physiologi- 
cal proof that the child was not born dead. On the other hand, 
Drs. Lee and Ramsbotham gave their opinion that nothing less 
than breathing could establish the fact of live birth. The child, 
therefore, in their judgment, was not born alive. The chan- 
cellor decided that proof of breathing was not necessary, and 
held that there was sufficient legal evidence of life after birth 
in the pulsation observed by the accoucheur? 
That life may be prolonged even for a considerable time 
without breathing appears from a case observed by Bon chut. 
During twenty-three hours, feeble but distinct pulsations of the 
heart were heard at long intervals, but there was no motion of 
the ribs. Attempts to induce respiration failed. The post- 
mortem examination showed that the lungs had not received any 
air? In a case which occurred at Turin, in 1818, the Cesarean 
operation was performed after the death of the mother. Motion 
of the child's head and feet were discovered during and after 
the operation ; it opened its hands, which were closed ; blood 
sprang out of the umbilical cord on being cut, and pulsations 
were felt in the cord, the carotid arteries, and the region of the 
heart; water being poured on its head in administering baptism, 
a motion of the bps and mouth was perceived, and an impres- 
sion which produced an inspiration; the natural heat remained; 
aftei- having lived about thirteen or fourteen minutes, some 
drops of blood came from its nose, it became pale, stretched its 
limbs, closed its eyi s, and died. During the procedure pending 
before the senate of Turin, some distinguished members of the 
medical faculty proposed the question, whether the child had 
been alive, to the faculty of Strasburg, which declared that it 
was born alive. > 
In this country, no case of the kind has come before the 
courts, except one in this State, in 1830 (Marselis vs. Thalhimer), 
in which there was no proof at all of the child having been 
born alive. It was claimed that, upon establishing the fact of 
birth, the legal presumption was that the child was born alive. 
The court decided, of course, that the existence of life at birth 
was to be proved by the party seeking benefit from it.4 But if 
1 Taylor, II., p. 209. 
4 Beck, 1. c., IL, 422. 
2 Taylor, II., p. 210. 
3 Taylor, 1. c., p. 213. 14 
Asphyxia in New-born Children. 
cases should come up, the decisions of the English courts would 
be considered the law. 
However this may be, we are not jurists, but physicians, and 
it is for us only to testify if, in a given case, the child was born 
alive. The term born implies, that it has come entirely out of 
the body of its mother. If any part of it is still contained 
within the cavities of the mother, it is not considered by law 
as born. As to the term alive, we should stand on strictly 
scientific ground, and not repeat the errors committed by men 
who, in other respects, range among the best of our profession, 
such as Denman, Ramsbotham, Orfila, Dubois, Pelletan, 
Roux, etc. As long as active motion goes on, such as pulsa- 
tions felt or heard in the heart, pulsation of the cord after the 
child has been entirely expelled from the body of its mother, 
the faintest respiratory gasp, or a movement of the lips or the 
eyelids or a limb, life is not extinct, and according to the wise 
laws which this country has inherited from England, any mal- 
treatment of the child is a crime, and it has the right of inlier-, 
iting and transmitting property. 
As practitioners we should use every effort to make the child 
cry, this being, to the popular mind, the convincing proof of its 
being alive, which will perhaps save even the trouble and ex- 
pense of a lawsuit, and which also gives hopes of keeping it 
alive, but as witnesses we must remember that life may be 
manifested in many other ways. In my case, the undertaker 
sent me a certificate for a still-born child, which, of course, I 
refused to sign. The cases alluded to above show that the 
question may come up ten or twenty years after the death of 
the child. It is, therefore, an imperative duty to be very exact 
in all our statements in such cases."