Walt Whitman’s poem sings the praises of life as a metaphor for the long and fascinating history of cardiopulmonary resuscitation…
I sing the body electricWalt Whitman Leaves of Grass 1855 1.
The armies of those I love engirth me and I engirth them,
They will not let me off till I go with them, respond to them
The story has its roots in myth and religion but in the 19th century and 20th century, we see its development and refinement. For centuries, breath was the sign of life and the respiratory component was the only measure of it 2 . Then near the end of 18th century, the breath came to be associated with the concept of resuscitation.
The treatment of the airways in 18th century was advanced by two important Scottish pioneers: the obstetrician William Smellie, with the introduction of the endotracheal tube in 1763, and the physician John Hunter with his studies using bellows to resuscitate dogs. In 1776 with the presentation of an article, ‘Proposal for the recovery of people apparently drowned’ , to the Royal Society of London, Hunter demonstrated how lack of oxygen leads to cardiac dysfunction.
At the end of this century, the foundations of resuscitation were laid with rescue societies, forerunners of the modern ambulance and emergency medical services. The first was born in 1767 as the Society for Recovery of Drowned Persons in the Netherlands 4. It was soon followed by the Royal Humane Society in London and others in New York, Philadelphia and Boston.
But the prime driving force , according to Dr. Fye 5, in the development in the science of resuscitation was the discovery of nascent electricity and its corollary experiments. The first was conducted by the Italian scientist Luigi Galvani, who observed the contraction of the legs of frogs and of people after electrocution.
The first use of electric shock as a resuscitative experimental method involved a child, Sophie Greenhill, in 1776. As reported by The Humane Society of London 6, the girl fell from a window and was ‘picked up by a man in a state of apparent death.’ A Mr. Squires applied electricity to various parts of the body but only when he applied it ‘through the chest’ did he feel ‘a small pulse, and within a few minutes the child began to breathe with great difficulty.’ 6
Writing in 1776, John Hunter in a review of the article ‘Proposal for the recovery of people apparently drowned” remarked, ‘Electricity is a useful tool and should be used where others have failed … it is likely that this is the only method that we have to stimulate the heart in an instant’ 7 . It was a space-age statement, considering that it had been quoted thirty years before publication of romantic novel Frankenstein by Mary Shelley. The novel narrates the resuscitation of a dead person with electric shock.
However it was experiments on dogs in 1850 by Dr. Carl Ludwig and Dr. Mauritius Hoffa 8 that led to the discovery that electrical stimulation was capable of causing ventricular fibrillation.
The foundation for the restoration of circulatory function with the use of direct cardiac massage was laid by the 19th century German anatomist Moritz Schiff when he attempted to counter the two potential fatal side effects of the ‘new’ chloroform: cardiac and respiratory arrest. Schiff’s views on the influence of the nervous system on the blood stream and how CPR maintained the ‘nutrition ‘ 9 of the myocardium would be acknowledged and used many years later.
In 1872, surgeon Thomas Green described 10 six successful resuscitations out of seven attempts following cardiac arrest from chloroform. In these cases, a galvanic battery permanently installed in his operating room was used. A few years later, the Scottish physiologist John A. Mac William, before an audience of the in 1887 International Medical Congress, showed how the ventricular fibrillation could be interrupted by application of shock 11.
In 1899, the physiologists Geneva Jean Luis Prevost and Federico Batelli demonstrated 12 that electrical discharges could cause arrhythmias that return the heart to normal rhythm: for the first time, the effectiveness of defibrillation on animals was proven.
It was in the 20th century, the ‘short century’, that the principles of resuscitation would be fully developed.The work of Moritz Schiff on open chest cardiac massage succeeded with the physiologists Starling and Lane in 1902 13 with trans-diaphragmatic cardiac massage and with Inglesburd in 1904 will be the complete recovery of the patient.
The missing insight would be supplied in 1906 when Dr. George W. Criley and Dr. David H. Dolley were attempting to resuscitate dogs. They realized that the key to the recovery of their dog patients was preventing them from incurring ischaemic brain injuries.
In terms of ventilation, the Irish anaesthesiologist Ivan W. Magill in front of problems to ventilate the veterans from World War I while they were undergoing facial surgery in 1919 he invented the endotracheal flexible tube, scissors for intubation , the anaesthetic spray for intubation , the straight blade laryngoscope and other resuscitator devices.
In the years preceding the Second World War, New Zealand anaesthesiologist Robert R. Macintosh improved intubation techniques with his namesake curved blade laryngoscope.
Finally, in 1953 the German engineer Holger Hesse and the Danish anaesthesiologist Henning Ruben invented the first self-inflating balloon, marketed by AMBU®. AMBU® was the company that created them and that today is the abbreviation for this device. In the same century, the Guedel cannula was invented by US anaesthesiologist Arthur Guedel.
We have seen much progress in terms on defibrillation and circulation. In 1936 professor of Physiology Carl J. Wiggers demonstrated to the American Physiological Society the combined use of defibrillation with cardiac compressions in an attempt to increase the chances of success.
In 1940, together with Dr. René Wegria discover that the ventricular fibrillation could be induced in the heart during a precise period called the ‘vulnerable period‘. The future cardiac pacemaker science was deduced from these researches.
In 1957, thirty years after the beginning of his studies, the American engineer William Bennet Kouwenhoven in experiments on dogs developed the (second) external defibrillator used on human beings. The year before, the Harvard cardiologist Paul Zoll made the same discovery.
But William Bennet Kouwenhoven, with Guy Knickerbocker and James Jude of Johns Hopkins University, accidentally discovered another tremendously important thing. In their studies on the defibrillation of dogs, they applied paddles with pressure on the chest of the dog and obtained a femoral pulse. In 1960 they demonstrated 14,15 the effectiveness of the technique of the ‘closed-chest cardiac massage’ in 20 clinical cases of intra-hospital arrest. The survival rate was 70% .
A technique already described 16 by British dentist John Hill in 1868 and resumed several times in history that the group Kouwenhoven was perfected in order to be able to compress the heart without damaging the chest and abdominal structures.
An effective technique with a misnomer is ‘cardiac massage’‘, the term used by the cardiac surgeon Claude Beck in 1947 . He described 17 massaging the heart of a boy with his hands for 45 minutes in ventricular fibrillation and subsequently performed the defibrillation with an internal electrical defibrillator developed by the scientist and friend James Rand.
The external defibrillator already became known, thanks to Dr. Zoll then used direct current (DC) thanks to the discoveries of Bernard Lown in the early 1960s, showing that the direct current was equally effective and safer 18. The first portable version was realised in 1965 by Irish Professor of cardiology James Francis Pantridge and Dr. John Geddes 19 (installed on ambulance Belfast it weighed 70 kg and was connected to the battery of the vehicle). Only three years later, a 3-kilogram portable version became available. In 1980, thanks to the research of Dr. Levi Watkins and Dr. Vivien Thomas , the first implantable cardioverter defibrillator (ICD) was marketed.
Taking a little step back to the past , during the 1946 polio epidemic in Minnesota, physician James Elam applied mouth-to-mouth respiration on an affected child. As he described it ‘I sealed my lips around his nose and his lungs inflated. In four breaths, he was pink.20’. He had come across the technique the previous night when reading a book on the history of neonatal resuscitation.
This episode guided his subsequent research with the physician Dr Peter Safar. Together they demonstrated the effectiveness of their technique of artificial mouth-to-mouth respiration. It was promoted in 1958 by JAMA as an ‘easily learned, lifesaving procedure in both emergency conditions and in the field 21‘.
From their work spreading ideas to the scientific community and to the general public arose the need to introduce manikins for training in ventilation techniques. The first manikin was called ‘Miss Sweet Breath’ and invented by Roger Mehalek in 1959. He was a Red Cross volunteer in Kalamazoo, Michigan. The second manikin was designed by Safar and the Norwegian toymaker Asmund Laerdal. It become the most famous in the world: CPR Annie was a manikin with human features and size.
However, the formal connection between the ventilation techniques of Helam and Safar and the cardiac massage and defibrillation procedure of Kouwenhoven and Jude took place in September 1960 at the annual meeting of the Maryland Medical Society, where they were presented for the first time together. It was the birth of modern CPR.
During the world tour to promote to the public the newly-formed CPR Safar, Kouwenhoven and Jude assigned director David Adams to produce an educational video. Thus was born ‘The Pulse of Life’, a 27-minute movie in which for the first time the letters A (for ‘airways’), B (‘breathing’), C (‘circulation’) were emphasised as an aide to students to remember the sequence for resuscitation. The defibrillator arrived on the scene in 1965, thanks to professor Pantridge, who formed the first coronary care unit in Belfast Mobile (MCCU). Professor Pantridge reported 22 in 1967 that of 312 patients treated by the MCCU staff over 15 month-period , half had heart attacks in progress and 10 were rescued with a cardiac arrest in progress. All 10 were resuscitated and admitted to the hospital, an amazing achievement. The foundations of modern chain of survival had been laid 23.
200 years since the birth of the first rescue company (August 1767) with the “System Belfast” of Professor Pantridige 22 and the discoveries of Jude, Helam, Safar and Kouwehowen the foundations of modern CPR had been laid.
Today, as yesterday, the promise remains the same: to save ‘hearts too good to die’ 24.
Francesco Adami, University of Pisa (Italy)
- Whitman W. Leaves of Grass.1855.
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myths behind the history