Learning to Breathe: The History of Newborn Resuscitation, 1929 to 1970. Rachel McAdams Submitted in fulfilment of the requirements for the Degree of Doctor of Philosophy. University of Glasgow Faculty of Law, Business and Social Science (October 2008) 2 Abstract The history of newborn resuscitation in the twentieth century presented thus far in the writings of practitioner-historians describes a ‘hands-off’ attitude to newborn care prior to the 1950s. These practioner-historians tend to recount a positivist narrative with the rapid expansion of newborn care after WWII and the eventual logical uptake of endotracheal intubation and positive pressure resuscitation as the most effective method for treating asphyxia neonatorum. This thesis challenges this positivist narrative my examining the resuscitation of the newborn in Britain and America during the interwar period through to the late 1960s. It uncovers a much more complex and non-linear narrative for the development of newborn resuscitation during the twentieth century, uncovering some interesting themes which the practitioner-histories have not addressed. These themes include the interactions between neonatal and fetal physiologists and their research with clinicians and clinical practice, and the role of new groups of clinicians, the paediatricians and anaesthetists, in newborn resuscitation during this period. Many of the practitioner-histories ridicule what they deem to be ‘failed’ resuscitation techniques, seeing them as ‘deveiations’ from the eventual widespread adoption of positive pressure methods. My analysis of both the clinical and scientific debates surrounding both the use of positive pressure methods and some of these ‘failed’ techniques provides a more complex and detailed story. Two techniques in particular, intragastric oxygen and hyperbaric oxygen, provide useful case-studies to reflect on the factors which influenced the development of newborn resuscitation during the twentieth-century. One important factor which is analysed in detail is the formation of a network of scientists and clinicians with a shared interest in the neonate, which emerged during the 1950s. This ‘neonatal network’ has been identified and mapped, and its actions are discussed in detail. The thesis argues that the neonatal network played a fundamental role in directing neonatal research and care during the 1950s and 1960s. The case of newborn resuscitation is used to highlight the interactions of the network members. 3 The history of newborn resuscitation is used to reflect on some wider themes of late-twentieth century medicine. It highlights the divided role of the post-war academic clinician, who was responsible for both clinical care and research. It also illustrates common trends such as the move towards super-specialization in medicine, the increasingly technological nature of medical care and the growing authority of science in the clinic. The research has analysed a variety of sources including the archives of the Ministry of Health, Medical Research Council, Scottish Home and Health Department, the Neonatal Society and National Birthday Trust Fund. Oral histories have been used to map the relationships forged between key actors. A variety of published resources, including journal articles, textbooks and conference proceedings, have also been studied to track both the changes in neonatal care and changes in the physiological understanding of the newborn. 4 Table of Contents Table of Contents....................................................................................................4 List of Figures .........................................................................................................6 Acknowledgements.................................................................................................8 Candidate’s declaration ..........................................................................................9 Introduction ...........................................................................................................10 Writings on the history of newborn care in the twentieth century.......................14 Writings on late twentieth-century medicine ......................................................21 Aims and Methodology......................................................................................26 Chapter outline..................................................................................................28 Chapter 2 ..............................................................................................................31 The obstetrician and the resuscitation of the asphyxiated newborn (late C19th - 1920s) ...............................................................................................................31 ‘Save the babies’: the wider context of the early twentieth century ...................37 The birth of fetal and neonatal physiology, 1927-1946......................................40 Yandell Henderson: applying physiology to the resuscitation of the newborn44 Nicholson J Eastman’s ‘Foetal Blood Studies’...............................................46 Joseph Barcroft ventures into neonatal physiology........................................51 Henderson’s continued adventures in respiration..........................................54 Barcroft builds the foundations of neonatal physiology, 1938-1946...............56 Resuscitation of the newborn, 1929-1945: A scientific approach?........................62 The introduction of ‘modern’ and ‘scientific’ resuscitative methods during the interwar years ................................................................................................65 Reviewing newborn resuscitation in the 1930s ..............................................70 A physiologically informed approach to newborn resuscitation?....................76 Newborn resuscitation in the 1940s...............................................................81 Chapter 3 ..............................................................................................................84 Who owns the neonate? The obstetrician, paediatrician, and anaesthetist, and the role of each in newborn resuscitation in the mid-twentieth century.......................84 Anaesthetists and newborn resuscitation in interwar Britain and America.....85 Anaesthetists and newborn resuscitation after WWII.....................................91 A role for paediatricians in newborn care?.....................................................96 Chapter 4 ............................................................................................................111 Oxygenating the newborn ...................................................................................111 Positive-pressure inflation: face-mask versus endotracheal tube .......................120 Positive-pressure resuscitation during the interwar years............................120 Positive pressure ventilation after World War II ...........................................128 Chapter 5 ............................................................................................................142 Neonatal mortality after WWII and the identification of the asphyxiated newborn ........................................................................................................................142 Neonatal physiology after World War II ...........................................................149 Geoffrey Dawes (1918-1996).......................................................................152 Kenneth Cross (1916-1990).........................................................................157 The neonatal network and the birth of neonatology.........................................161 5 The Neonatal Society ......................................................................................171 The neonatal network and newborn resuscitation during the early 1960s ..........173 Chapter 6 ............................................................................................................188 A medical misadventure? The rise and fall of intragastric oxygen ......................188 The rise to popularity of intragastric oxygen....................................................189 The gradual decline of intragastric oxygen......................................................205 Chapter 7 ............................................................................................................220 The Hyperbaric Oxygen Controversy..................................................................220 Hyperbaric oxygen and the resuscitation of the asphyxiated newborn............220 Reactions to Hutchison et al’ s paper...............................................................226 Ministry of Health and Medical Research Council become concerned about the controversy......................................................................................................233 The physiologists publish their research .........................................................243 The MRC Conference on Hyperbaric Oxygen and the Respiratory Disorders of the Newborn, 7 th January 1965 .......................................................................247 The controlled animal and clinical trials are published. ...................................255 A Second MRC Special Meeting .....................................................................265 Chapter 8 Discussion and conclusions ...............................................................271 A