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Cardiopulmonary resuscitation is an important life saving first aid skill, practised throughout the world. It is the only known effective method of keeping someone who has suffered cardiac arrest alive long enough for definitive treatment to be delivered (usually defibrillation and intravenous cardiac drugs). In 1954, James Elam was the first to demonstrate experimentally that cardiopulmonary resuscitation (CPR) was a sound technique, and together with Dr. Peter Safar he demonstrated its superiority to previous methods. Peter Safar wrote the book ABC of resuscitation in 1957. In the U.S., it was first promoted as a technique for the public to learn in the 1970s
There were some techniques to keep people alive developed in the 18th century, but it was well in to the 20th century before Elam and Safar discovered and published the truly effective method known as CPR. Safar conducted research on existing basic life support procedures including controlling a person’s breathing airway by tilting back his or her head with an open mouth; and using mouth-to-mouth breathing. He combined these with a procedure known as closed-chest cardiac massage to become the basic life support method of CPR.
Throughout his life Safar was hesitant to take credit for “inventing” CPR. The way he saw it, he merely brought to light effective procedures that humans had already discovered, putting them together into what he called “the ABCs”—maintaining a patient's Airway, Breathing and Circulation. He worked hard to popularize the procedure around the world and collaborated with Norwegian toy maker Åsmund Laerdal to create “Resusci Anne,” the CPR training mannequin. Laerdal now is a medical equipment manufacturer.
Safar also created the first guidelines for community-wide emergency medical services, or EMS; he founded the International Resuscitation Research Center (IRRC) at the University of Pittsburgh, which he directed until 1994; and he was nominated three times for the Nobel Prize in medicine.
First attempts at resuscitation in the 18th Century
The Enlightenment, starting around 1750, was a remarkable time in human history; a time of scientific discovery, political democracy, and a growing belief that humans could unravel the mysteries of the universe. All scientific principles were challenged and explored, including the mystery of death itself, and whether it could be reversed, postponed or even stopped altogether. In this climate, it was inevitable that the concept of resuscitation would become the focus of study and work by interested scientists of the age.
The first city to teach and promote resuscitation was Amsterdam, located in the heart of the European Enlightenment and also a city of canals—therefore a city with many drownings – as many as 400 per year. Death from cardiac disease was still not prevalent and sudden deaths were mostly from accidents.
In August 1767 a few wealthy and civic-minded citizens in Amsterdam gathered to form the Society for Recovery of Drowned Persons. This society was the first organised effort to respond to sudden death.
Within 4 years of its founding, the society in Amsterdam claimed that 150 persons were saved by their recommendations. Their techniques involved a range of methods to stimulate the body. The members of the society recommended:
- Warming the victim
- Removing swallowed or aspirated water by positioning the victim's head lower than feet
- Applying manual pressure to the abdomen
- Respirations in to the victim's mouth, either using a bellows or with a mouth-to-mouth method (mouth-to-mouth or mouth-to-nostril respiration is described including the advice that "a cloth or handkerchief may be used to render the operation less indelicate")
- Tickling the victim's throat
- 'Stimulating' the victim by such means as rectal and oral fumigation with tobacco smoke. This may seem very unusual in modern times, however it may have been that the nicotine was enough of a stimulant to engender a response in the “almost” dead
- Bloodletting
The first four of these techniques (or variations of them) are still in use today, whereas the last three are now out of line with modern medical thinking. However, regardless of the scientific merit of these techniques, it started a collective belief that resuscitation was possible, and the suddenly dead could be revived.
Following successes of this first society, rescue societies soon sprang up in most European capitals, all with the goal to find a way of successful resuscitating victims of sudden death. This theory proved so popular that Hamburg, Germany passed an ordinance in 1769 providing notices to be read in churches describing assistance for drowned, strangled, and frozen persons and those overcome by noxious gases, probably the first example of mass medical training. The Royal Humane Society in London (no connection to the animal welfare organization in the United States), founded in 1774, served as the model for societies in New York, Philadelphia, and Boston. These rescue societies of the 18th century were the precursors of today’s emergency medical services.
For the next 150 years, scientists (not to mention quite a few quacks) advocated literally hundreds of resuscitation techniques. Some were even partly effective especially for respiratory emergencies. For example, the back pressure-arm lift method (“out goes the bad air, in goes the good air”) taught to countless thousands of Boy Scouts until the late 1950s could occasionally have saved a drowning victim, as in drowning, the initial problem is a cessation of respirations and for the first 5–10 minutes the heart is still beating and if the victim can be extracted from the water and be induced to breathe the outcome may be good, but the technique was of no benefit for cardiac arrest as it did nothing for circulation, which it is now known, is the key factor to address in these victims.
Modern Resuscitation
Scientists and doctors started to try and address the problem from many different sides including developing new medications, devising new surgical techniques and identifying risk factors. Doctors James Elam, Peter Safar and Archer S. Gordon set to educating the world about rescue breathing, preventive measures and trying to discover a way to treat acute cardiac arrest.
Gordon initially did not support rescue breathing until he performed a study of his own using pediatric patients, reproducing Elam's results. Safar had also been working on the feasibility of rescue breathing, so they agreed that a concerted effort would be much more valuable than each working separately and possibly reproducing each others' work.
Prior to the 1950s, the accepted method of resuscitation was the chest-pressure and arm-lift technique that was shown to be ineffective by Safar and Elam. In 1954, Elam was the first to demonstrate experimentally that exhaled air ventilation was a sound technique. Elam and Safar (and later Gordon) performed many experiments demonstrating the superiority of the rescue breathing technique. The problem then became one of popularizing the method.
Organizations such as the American Red Cross provide training at local chapters in the proper administration of artificial respiration procedures. The Red Cross has been teaching this technique since the mid-1950s. For example, in Kalamazoo, Michigan, volunteer Roger Mehalek introduced a breathing trainer called Miss Sweet Breath 1959, a plaster and plastic training mannequin he created.
In New York, then State Health Commissioner, Herman Hilliboe was impressed with the technique. He commissioned Elam to write the instructional booklet titled "Rescue Breathing," which was distributed nationally in 1959. The success of the booklet spurred Elam to produce films demonstrating this new life-saving technique.
By 1960, rescue breathing had been adopted by the National Academy of Science, American Society of Anesthesiologists, Medical Society of the State of New York and the American Red Cross as the preferred method of resuscitation.
Several key discoveries and understandings were required to treat the problem, which would take decades to work out, and even now is not 'solved'. Doctors speak of the natural history of diseases as a way to understand how therapy alters the usual progression of a disease. For example, the natural history of breast cancer may be measured in months but treated with surgery or chemotherapy the disease can be measured in years or even cured. Sudden cardiac arrest is a disease with an extremely rapid natural history, measured in minutes, with an inexorable outcome. But when treated with CPR the course of death can be extended (CPR will delay the dying process) and if treated with timely defibrillation death can be aborted.
The modern elements of resuscitation for sudden cardiac arrest are cardiopulmonary resuscitation (CPR in turn consists of mouth-to-mouth ventilation and chest compression), defibrillation and emergency medical services (the means to bring these techniques to the patient quickly).
Mouth-to-mouth Ventilation
For a long time before it was formalised, it had been known by doctors and midwives that mouth to mouth resuscitation could be useful in bringing a lifeless newborn around. In 1946, during the middle of a Polio outbreak, an anesthesiologist, James Elam, applied this principle to an older child in an emergency situation. Elam described the event in his own words as "I was browsing around to get acquainted with the ward when along the corridor came a gurney racing - a nurse pulling it and two orderlies pushing it, and the kid on it was blue.
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