88 V»v*;VJiV^ ;n ?;w.r m -tSo, *€ flR4 UNITED STATES OF AMERICA WASHINGTON, D.C. B19574 FOROEI) llESPIIt AT ICL\. BY GEO. E. FELL, M.D., F.R.M.S., OF BUFFALO, N. Y. LATE PRESIDENT OF THE AMERICAN SOCIETY OF MICROSCOPISTS, PROFESSOR OF PHYSIOLOGY AND MICROSCOPY MED. DEP'T NIAGARA UNIVERSITY, ETC. An Address delivered before the Buffalo Medical and Surgical As- sociation, January5, iSqt. Reprinted from the "Journal of the American Medical Association," March 7, 1891. CHICAGO: Printed at the Office of the association 1891. WA \8S>\ FORCED' RESPIRATION. It may be well to premise what I have to say by calling attention to the difference in the mean- ing of the terms used. We understand by arti- ficial respiration, an artificial method of breathing for an individual; but since forced respiration has been used, with such remarkable results, it seems to me terms should be employed which would be distinctive, and some time ago I made a suggestion to the profession which seems to have been quite universally adopted, to the fol- lowing effect: Auto-respiration: respiration by the individual for himself. Deep Respiration: forcible respiration by the individual himself. Artificial Respiration: this we understand to be that produced by the methods which have been suggested by Sylvester, Howard, Marshall Hall and others, in which movements of the limbs of the patient and pressure are made so as to draw the air into the lungs. In many instances arti- ficial respiration cannot be depended on to furnish a sufficient supply of air to the lungs. Forced Respiration: those measures by which air is forcibly passed into the lungs. CI do not advocate forcibly withdrawing it, because I think it to be an unphysiological method.) At the late Berlin Congress Professor Horatio C. Wood, of the University of Pennsylvania, the 2 only American, I understand, who delivered an address before the Congress, spoke about John Hunter and others having devised an appara- tus for the purpose of breathing for an individ- ual where it was necessary to do so. I will quote from Professor Wood's address on " Anaes- thesia " his remarks in this connection, which will indicate that some of the brightest lights of medicine have considered the subject of forced respiration, but have not demonstrated its value ; but, through the failure of their efforts, rather relegated it to the field of impracticable methods. The use of what may be called "forced" respiration by the physiologist so naturally suggested a similar practice in man, that the celebrated John Hunter in- vented for the purpose an apparatus which consisted of a bellows so constructed that when it was extended one compartment drew in air from the lungs, whilst the other drew air from the atmosphere ; and when it was closed the process was reversed, the fresh air being thrown into the lungs, the foul air into the atmosphere. In 1867, Richardson, of London, invented an apparatus more elegant and portable, although identical in principal with that of John Hunter's ; but I have not found that either Hunter or Richardson treated by forced artificial respiration an actual case of disease or poisoning. In 1875 {Boston Medical Journal, Vol. xxi.) Dr. John Ellis Blake reported a successful case of aconite poison- ing, in which life was apparently saved, although there was no pulse for over three hours, by artificial respira- tion, with the use of oxygen. In this case Marshall Hall's method was at first used, but later a small rubber tube was connected directly with a copper reservoir of condensed oxygen, the other end of the tube terminating in a small nozzle, which was inserted in one nostril. Four hundred gallons of oxygen were thus used, but how far the force of the compressed gas was employed to dilate the lungs is not very clear; and it is somewhat doubtful whether this case should be considered as one of forced respiration. The first physician to use forced respiration in actual human poisoning, with a clear idea of its value and power, so far as my reading goes, was Dr. George E. Fell (International Medical Congress, Washington, 1877). 3 It is plain that the bellows constructed by John Hunter and by Richardson are unnecessarily complex and faulty in principle. There is no need whatever of drawing the air out of the fully filled lungs. Every phvsiologist knows that when the muscular system is completely para- lyzed by woorari or even by death, that the chest-walls have sufficient elasticity to force air out of the lungs, and all ordinary laboratory apparatus for artificial res- piration is based upon this fact. For forced artificial respiration in man, an ordinary bellows of proper size is all that is required for the motive power. The real difficulty—the point to be especially investi- gated and studied—is as to the connection between the bellows and the lungs. Hunter and Richardson simply placed a tube in one nostril, closing firmly the other nostril and the mouth of the subject. Dr. Fell at first used a tracheal tube, the insertion of which, of course necessitated the performance of trache- otomy. In one case, however, a simple mask covering the mouth and nostrils was a perfect success. I have had no opportunity of trying the apparatus on the living, but have made a series of experiments upon dead bodies, which have demonstrated that usually a face-mask is all that is necessary for the performance of artificial respira- tion. Before using the mask the tongue should be well drawn forward, and if necessary fixed in this position by an ordinary piece of suture silk run through it, which can be held in the hand of the operator. If in any indi- vidual case the mask fails, an intubation tube may be in- troduced into the larynx. I do not believe that it is ever necessary to perform a tracheotomy. Dr. Fell's apparatus consists of a pair of foot-bellows (the bellows have always been used by hand power), by which air is forced into a receiving chamber, which is connected with an apparatus for warming the air, and a valve which can be opened and shut by a movement of the finger. This valve in turn leads to the tracheal tube. When the valve is opened the air rushes through the chamber into the lungs and expands them ; the finger is lifted, the valve shuts, the lungs contract; and so the respiration goes on. I have no doubt that this app#atus is efficient in practice, but it is open to the serious objec- tion of being unnecessarily complex and costly. A much simpler, cheaper asd probably equally effici- ent1 apparatus may consist simply of a pair of bellows of proper size, a few feet of India rubber tubing, a face- mask, and two sizes of intubation tubes. There should 4 also be set in the tubing a double metal tube, with open- ings so placed that their size can be so regulated by turn- ing the outer tube (similar to that commonly found in the tracheal canula of the physiological laboratory), so that it is in the power of the operator to allow for the escape of any excess of air thrown by the bellows. I suppose this whole apparatus could be prepared at a very small cost, and it seems hardly necessary to point out its probable value in various narcoting poisonings, and in other accidents in which death is produced by a temporary paralysis of the respiratory centres. The proper use of it could be taught to persons without special medical skill, so that it ought to form a part of not only the surgeon's outfit, but might be of" great service in life-saving stations, about gas-works, etc I will comment on Prof. Wood's article later on. My first operation of forced respiration, was not made upon the spur of the moment. I had thoroughly considered it, for fully a year, but when the opportunity did present it was a re- markable one, and P took advantage of it. Shortly after that first operation I made a series of notes upon what I believed to be the value of the op- eration. These were made in my note-book in the year 1887. I then said that I believed forced respiration would accomplish more than any method of artificial respiration, either in cases of drowning, or even in cases of shock— in cases of asphyxia of whatever nature. I am glad to state now that I am more than ever satisfied of the truth of those statements. In the last case which I will report here to-night, the demonstration will bear this out. I should like to enter somewhat into the in- teresting experiences which I have had since making my first operation, and the trials and tribulations to which I have been subjected in the promotion of the measure ; but I presume that any one who makes an operation possessing '1 do not agree with Dr. Wood, reasons given further on. F. 5 so far reaching an import as does forced respira- tion, will probably have a like experience. I made my first operation in July, 1887, and saved a life which I had thought there was no possi- bility of saving. When I made tracheotomy in that case I felt that I was making the operation upon a cadaver, and worked accordingly. When the man gave evidence of life, I was as much surprised as any one present. I rightfully be- came quite enthusiastic over the operation. When some time afterward, I went to Pittsburgh as Treasurer and Custodian of the American So- ciety of Microscopists, to attend the annual meet- ing of that Society, it was suggested that I might explain my methods to some of the physicians there. Some of Pittsburgh's ultra-conservative physicians, however, thought it was just as well to let me go to Washington, where I was intend- ing to read a paper on the subject, " for fear there might be some under-hand business about it." Then, some of our Buffalo physicians intimated that what I had done was nothing novel; the operation was an old one, said they ; dogs had been treated {killed) by forced respiration ever since vivisection came to be utilized in the med- ical colleges. I was well aware of that, but I had never been taught in medical college that forced respiration would save even a dog's life, much less the life of a human being. And this was the teaching of the world at that time. I knew that my apparatus was original in its conception, practicability and results, and took steps which assured this fact. As a further fact, to show what even at the present time the teaching is, and to indicate the necessity of repeatedly pre- senting this subject to the profession, I will merely state, that if you will turn to the last " Blakis- ton's" "Visiting List," you will find, under 6 "Marshall Hall's ready method in asphyxia," that the directions are to " avoid the immediate removal of the patient, as it involves a dangerous loss of time; also the use of bellows or any forcing instrument.'" This is what the medical profession was taught to believe at the time • I made my first operation. I was treading upon the accepted principles of the profession, and liable to severe censure had I failed in my first operation. Well, as stated, I went to Pittsburgh, and the conservatism of the profession showed itself there by refusing to listen to what I had to say upon the subject. When later, I went to Washington, I was not heralded by any fore-runners, was ac- quainted with but very few individuals at the In- ternational Congress, and it was with the great- est difficulty that I had an opportunity to read my paper at all; and what was the most peculiar feature of the whole circumstance was, that, even among a class of men supposed to possess the highest medical knowledge, not any of them saw the point which presented in that first case of forced respiration, in which I breathed for a man two and one-half hours with a tube in his neck. They did not grasp that point. And I now make the statement, without fear of contradiction, that there was not a paper presented at the Inter- national Congress at Washington which had a farther reaching import, if to save human life is desirable, than that little paper on "Opium Poisoning," which I presented—a paper embody- ing in it demonstrations which would alter and advance one of the greatest medical practices of the day, a practice of wide application. It demonstrated what was before not practically ac- cepted in medicine, that we could force air into the lungs for an almost unlimited period without 7 danger to the delicate lung tissue. Dr. Vanden- burgh, of Columbus, Ohio, a disinterested ob- server, speaks of it as " one of the most interest- ing and valuable therapeutic discoveries of the day." When I managed, however, to read my paper at Washington, they did me the kindness (?) not to publish it in the proceedings. After I had saved my third life, however, by forced respira- tion, and the world could not question methods which were so positive in their demonstrations, and so undeniably original, there not being a similar case on record, I had a discussion with the Chairman of a Section, and also with the Secreta- ry-General of the International Congress, and from that discussion, which can be produced if it should be necessary, it was evident that my paper either was not carefully read, or the princi- pal point conveyed by it was not grasped by the members of the committee. In my first case, a man had taken 20 grains of morphia. After two and a half hours of forced respiration with the apparatus his life was saved. That is, after the dilatation of asphyxia had taken place, and all known methods had failed. In the second case (not mine), a man had taken 8.24 grains of morphia. This case occurred in Vienna, Austria, two months after my first case. After four and a half hours of forced respiration, that is, you must note, after artificial respiration had failed to do any good, the patient was saved by forced respiration. In the third case (my own), a man had taken 2 ounces of laudanum. It had been demonstrated that artificial respiration would not save him. He was dying. Then we began with forced respiration, and after fourteen and one-half hours 8 with the new apparatus which I had devised, his life was saved. That was by tracheotomy But the fourth case came. A man had taken 2 ounces of laudanum, had severed the anterior jugular vein, and had lost a large amount of blood. For twenty-one and one-half hours con- tinuously applied forced respiration kept him alive until he could breath for himself, and then in a few hours he asked that it be applied again. He is now living in the southern part of the States, in good heal^i. In this case was demon- strated a very interesting point which has not been brought out prominently, which is, that in a case of great loss of blood from haemorrhage it does very little good to inject ether or brandy into the peripheral capillaries, unless you can in- ject it into, or proximally to a large vein, where you know it will be taken into the circulation. The patient laid in bed nearly two months merely because the ether and brandy which had been in- jected into the chest produced a gangrenous con- dition of the tissue. The fluid was not carried off by the capillary circulation, and the muscles of the chest sloughed away, down to the ribs. In the thigh, where injections had also been made, owing to the same cause existing, a weak or very slow capillary circulation, an abscess formed, and a cup of pus was removed on the first incision. This demonstrated very interestingly the neces- sity of care in the employment of hypodermic medication where there is excessive haemorrhage. Following these interesting cases, came a series in which the results were not so successful. An old gentleman, 80 years of age, had taken 1 ounce of laudanum. At the hospital artificial respration was used, the hospital physicians gave him up. Then forced respiration kept him alive for some twelve hours after that. 9 One of my most interesting cases was a little child, 18 days of age, of one of our prominent citizens, which had accidentally been given i grain of morphia by a physician of the homoeo- pathic school. The little one took the whole of the poison, equivalent to about eighty doses, and came under the influence of it. It was given about a quarter to one. I was called at five o'clock. Without proper apparatus I went to work and made tracheotomy, a most difficult undertaking in one so young ; but I succeeded in getting down to the trachea. I then with a small catheter inserted into the trachea, kept up forced respiration, with bellows and valve, with the result that the little one, which was markedly cyanosed, became of a natural hue, the blood be- came oxygenized, and it breathed for itself a short time. The bowels moved and the evidence was strong that the child might live. But owing to the long time during which the asphyxiated condition had lasted through the influence of the poison, it was too much to expect that we could retain the vital condition of the tissue of the brain for a sufficient time, as was demonstrated by the heart failing to act some four hours after the forced respiration was begun, when death supervened. This was one of the most striking demonstrations I ever had of the value of forced respiration. Again, it is usually conceded that when you can obtain no pulse at the wrist and no heart ac- tion on auscultation, that an individual is (nearly) dead. This condition existed in one instance which occurred. It was a case of opium poison- ing. 'The day before this case presented, I was about to make tracheotomy and carry out my op- eration in another case, when I noticed indica- tions that the patient would probably live with- IO out it; we waited, and he did pull through. without the operation. The next day I had the case referred to. I waited until there was no pulsa- tion at the wrist, and could detect no heart action on listening over the chest-wall. I then made tracheotomy. The blood was markedly venous, but upon passing oxygen into the lungs it be- came oxygenized and red, and furthermore, the heart action became distinct, and the pulse again was present at both wrists. But after an hour the heart again ceased beating. I had waited a little too long before beginning the forced respira- tion. After this I demonstrated another method, by which we could perform forced respiration without tracheotomy, and the first application of it oc- curred in trying to keep alive a still-born infant by passing a tube into the mouth and compressing the nostrils; I succeeded in keeping it alive for a number of hours. Owing, however, to compres- sion of the brain produced in labor wThich ex- isted, there was evidently no chance for the child to live, and I gave up the attempt. So long, however, as the forced respiration was kept up, the heart continued to beat. Then came another case which demonstrated, also, that life can be kept up by forced respira- tion without tracheotomy. A man had taken 2 ounces of laudanum. One of the physicians2 present called attention to the dilatation of the pupils as an indication of the very near approach of death. I had begun to make the operation for tracheotomy, but found the blood markedly venous. I stopped, and inserted the tube-of the apparatus in the mouth, closed the nostrils and forced air into the lungs through the mouth, and had the satisfaction of seeing the blood in the - Dr. Carlton C Fredericks. II neck turn from a dark purple to bright scarlet, indicating that there was sufficient heart action to carry the oxygenized blood through the sys- tem, and demonstrating the valuable fact that through the mouth and the nostrils sufficient air could be made to pass to the lungs for a time to retain life without the necessity of tracheotomy. This subject seemed to have a mania for com- mitting suicide by taking laudanum, and after- ward took 2 ounces of laudanum and about 5 or 6 grains of morphia ; I repeated the operation of tracheotomy, and again saved him. Upon mak- ing a third attempt he was sent to the asylum, and is now, I believe, cured of his peculiar habit. Another case presented in which a young woman took 2 ounces of laudanum ; by breathing for her four hours with the face-mask alone, her life was saved, i. 2£&