Modern cardiopulmonary resuscitation (CPR) procedures originated in the eighteenth century, but fell out of favour as the success rate was very low.
(1) The early nineteenth century was seen as a time of great progress in the development of medical science, of which resuscitation techniques were no exception. Notably, surgeons would open the chest and use their own hands to pump the heart). However, it took pioneers like Elam and
Kouvenhoven a century and a half later to revive techniques similar to those utilised today.
In particular, the lives of millions of people were saved, in 1960, when Kouvenhoven showed that ‘anyone, anywhere can initiate cardiac resuscitation procedures’.
(2) Now, modern CPR techniques and protocols have been established to treat the 120,000 cardiac arrests which occur in the UK each year.
(3) If CPR is started immediately after cardiac arrest survival rates double or even triple, compared with almost certain death three hundred years previously.
{4} Kouvenhoven’s prediction has become reality. This essay will discuss how CPR came to be an accepted procedure.
The earliest known recording of resuscitation is in the bible: (5)
‘And the soul of the child came into him again and he revived’ (3)
It went on to influence the attitudes of people towards CPR for centuries. The revival of the child was viewed as being caused by God and only he had the power to give life. Therefore, for a mortal to attempt this would be seen to contradict God’s will, a grave blasphemy.
(5,6)
Prior to the Enlightenment, resuscitation was viewed as an immoral act in most societies.
(6)
Very early in the sixth century it was known that animals who had sustained neck injuries could be saved by creating a hole in the trachea. This rudimentary version of a modern day tracheotomy demonstrates that there was now a limited understanding of the importance of maintaining a clear airway in order to sustain life.
(5) However it was not understood that these findings could be applied in human.
(5) Attitudes did start to change and there are reports of Paracelsus, who in 1530, realised the importance of artificial breathing techniques and used fireside bellows to ventilate the lungs.
(5) Bellows were seen as being superior to blowing directly into the mouth because, at that time, it was improper to touch another’s mouth even to resuscitate.
(7) Indeed, physicians would rarely come into contact with their patients, physical treatment reserved for surgeons and apocetharies. In addition to this social barrier, bellows were viewed as being better because expired air was seen as being depleted of oxygen and thus of little use.
The Enlightenment was a crucial turning point in the development of CPR as rational humanism brought a decline in the belied in providence. Indeed, Newtonian scientific method influenced the belied that humans were able to influence what happened to a patient, reviving some who would have previously died by misadventure (such as those who had drowned) with the new awareness of the scientific mechanisms underlying these events.
(6) Of vital importance was the new understanding that in learning about the mechanisms of living, near deaths could be reversed. (6) The establishment of the
Amsterdam Rescue Society in 1767 is further evidence of a change in attitude. It was a society which made an organised attempt to overcome sudden death. A person whose work directly influenced the development of the Rescue Societies was Tossach. He advocated blowing directly into the mouth in order to artificially respire for the unfortunate patient.
(3,5)
Amsterdam, at that time, was a thriving, mercantile city, where ideas were traded as readily as goods.
(6) Due to its proximity to water, drowning was a leading cause of death. In 1767

there were as many as 400 deaths per year.
(6) The Amsterdam Rescue society had remarkable results and reported that 150 people had been saved within the first 4 years.
(6)
By clearing the airway, it was discovered that the patient was far more likely to recover consciousness. It is important to note that around the middle of the eighteenth century, although there were attempts being made to save those who experienced drowning, little could be done if a person had sustained a cardiac arrest.
(8) It was not appreciated that these causes could be reversed.
Methods utilised by the Amsterdam Rescue Society were cruder in the eighteenth century.
Barrel rolling was used where an individual was turned upside down then rolled on a barrel based on the understanding that a clear airway would result in a more favourable outcome.
(5) Other means of ‘reanimating’, as it was seen at that time, included placing the individual upside down on the back of a horse for a period of time.
(8) At the time the society had a list of guidelines and there were financial incentives for those who managed to successfully revive a person.
(5)
In addition to these physical methods, electricity was utilised in the late eighteenth century.
It had been discovered only a quarter of a century earlier and in this time of great discovery there were already reported cases of it possible therapeutic use.The Humane Society in
London described the case of a 3 year old girl called Sophie Greenhill.
(8) In 1775, she fell from a window and there were no signs of life. When she was rushed to hospital multiple electrical shocks were applied in different regions of her body 20 minutes following the accident. It was noticed that following shocks to the chest wall the heart restarted and she began to breathe. She went on to make a full recovery with no neurological damage. (8)
After great interest and progression in the 18 th century, there was a period of time when few advances were made until the development of anaesthesia.
(7) Anaesthesia had been introduced in 1847 and in the period following this many operations began to take place.
(7)
Initially physicians had not appreciated the dangers of excess doses of chloroform and began to observe many patients suffering cardiac arrest.
(7) Therefore, it became imperative to find a solution to restart the circulation. This was a major problem and there were reports of surgeons beginning to forego anaesthesia altogether because this risk was so high.
(7) Moritz Schiff was interested in this subject and was studying cardiac arrest during anaesthesia in animals.
(1) He found that the heart would stop prior to the respiratory effort therefore concluded that direct massage of the heart through opening the chest wall would be of use.
(1) Schiff wrote:
‘if one opens the thorax whilst air is slowly blown into the lungs and compresses the heart rhythmically with the hand to squeeze out the blood…, one can restore the heart as long as eleven and a half minutes after it has been arrested.’ (1)
Many surgeons now had an improved understanding of the sequence of events in a cardiac arrest and were armed with a radical treatment to correct it. In fact, surgeons were reported to be so fond of this technique that some began to carry scalpels outside of the hospital in order to assist people who became gravely unwell.
(9)
Throughout the early 1900’s open cardiac massage was seen as the best way to maintain the circulation during cardiac arrest. Therefore if this happened outside of a hospital, chances of survival were slim. During this time there were great developments in

defibrillation. This resulted from a number of events. A large electricity company funded research because it wanted to find out how to prevent accidental electrocution.
(5) In 1947,
Beck reported the first successful resuscitation using a defibrillator.
(5)
James Elam, an American physician, is seen as the pioneer of mouth to mouth resuscitation.
In the midst of a polio outbreak in 1947, he was faced with a 3 year old child who had stopped breathing.
(6) At the time mouth to mouth resuscitation was seen as an old fashioned and ineffective technique because the expelled air was thought to contain too little oxygen. Throughout the development of CPR an aspect which was very poorly understood was the value of breathing into another person’s mouth. Tossach had reported successful cases using this method in 1732, however this work was later disregarded.
(5) Elam described going into ‘total reflex behaviour’ after having read about the technique the previous night.
(6) The boy recovered and Elam became passionate about the value of mouth to mouth resuscitation.
(6) It is intriguing that techniques which were dismissed led to the progression of CPR techniques.
Safar, in 1959, conducted research aiming to understand more about airway management and pioneered the importance of performing the jaw thrust during resuscitation.
(5) Safar and
Elam joined forces and developed mouth to mouth resuscitation. This was combined with an ingenious ABC system, designed to simplify CPR and also to make it easier to perform. It allowed CPR to move from the hospital to the community. This is where 50% of cardiac arrests occur therefore a larger number of people can be saved.
(3)
One of the landmark papers which sealed the development of CPR was the work of
Kouvenhoven. He demonstrated that sternal compression was sufficient to maintain perfusion.
(10) A century previously John Hill had described a version of closed chest compression however in 1838; the successful outcome was reported as resulting from ammonia which had been placed under the nostrils.
(1) Therefore it seems likely that at that time the role of chest compression, although performed, was attributed to another cause.
(1)
Closed chest compression was not seen as effective compared to a surgeon’s approach of opening the chest. Kouvenhoven combined chest massage, ventilation and defibrillation which had been slowly developed over the last two centuries. Kouvenhoven spent many hours performing CPR on cadavers and found the correct level of sternal pressure which would compress the heart. In particular he showed that using closed chest massage was sufficient to maintain perfusion and prepare the heart for defibrillation.
(9)
After reading Kouvenhoven’s work, a physician working in Kansas called Hughes Day, realised its significance and applied this experimental work clinically.
(9) He also introduced defibrillators to his hospital but found that many patients continued to die. Although
Kouvenhoven’s technique was good, there were huge delays and treatment was not started in time.
(9) This, too, was a problem recognised in Dundee Royal Infirmary. Stewart and his colleagues developed the first cardiac arrest trolley.
(11) This shows that the need to deliver
CPR urgently was appreciated and efforts were being made to render this process as easily as possible. (11) Desmond Julian was another researcher who was able to help overcome the time that it was taking to deliver CPR. In 1961 very few people, even working in hospitals, were competent to perform the technique.
(9) In 1961 he wrote
‘Many cases of cardiac arrest... could be treated successfully if all medical, nursing and auxiliary staff were trained in closed chest cardiac massage’. (9)

This reflects a change in attitude towards CPR. Previously, skilled surgeons had only been seen as capable of performing cardiac massage but now it was recognised that every member of staff was able to learn this procedure.
Julian’s work indicated the importance of CPR’s application outside of a hospital setting.
Despite the great advances which were being made in hospitals, a vast proportion of victims did not have access to a hospital nor a medical professional.
(10) Thus, it was accepted that large scale public awareness campaigns were needed in order to reduce mortality figures.
(15)
1965 heralded the next stage in the widespread availability of cardiac resuscitation in the community. 50% of deaths due to cardiac arrest occur outside of hospital, therefore it is essential that CPR is available to help this group of patients.
(3) Over the last 50 years with the introduction of public health campaigns, defibrillators in public places and the development of the paramedic service CPR has now become widely practiced in the community.
(5)
Modern media, particularly television and the printed press have done much to improve awareness of CPR techniques. Recently, the British Heart Foundation have conducted a
‘hands only CPR’ advertising campaign with former footballer Vinnie Jones.
(12) The multimedia campaign was designed to raise awareness of a simplified version of CPR without mouth to mouth resuscitation. This advert resulted from research which found that
1 in 5 people may not be put off performing mouth to mouth resuscitation or any type of
CPR upon finding a collapsed person due to fear of contracting infection.
(12) This campaign highlights the huge advances that have occurred in the last 200 years; public awareness and knowledge of the technique has sky-rocketed and there is recognition that more should be done to improve success rates of the technique. However, some limitations present two hundred years ago exist today. For example, there is still a feeling that it is ‘improper’ to breathe into another’s mouth. As the British Heart Foundation’s campaign illustrates, many are still wary of contagion risk or stigma.
(12) It would seem that the internet, particularly social media, have thus far been under-utilised as a way of disseminating information to the public. Young people in particular should be targeted so that the technique continues to save more lives.
CPR has been slowly developed over the last 300 years with the work of many scientists and physicians. Dating back to biblical times, attempts have been made to save life. The major turning point in the development of modern day CPR procedures was the establishment of organised rescue societies because these allowed people to become more aware of resuscitation techniques. These rescue societies were early versions of the current paramedic services. Problems associated with anaesthesia urged a major push to find effective ways to deal with this clinically and contributed vastly. However, it did mean that surgical methods were in use. The last significant turning point was in the mid 1950’s leading to Kouvenhoven realising that CPR could be delivered effectively by any person. This has continued to be developed and now it could be argued that every person has some awareness of the value and techniques of CPR. More are able to use these to save those who would once face a certain death. In addition, there has been a vast advance in knowledge and recognition that the public needed to be made aware and be able to conduct this technique. In the future, we shall see whether this increased awareness can help to raise the probability of recovery from sudden cardiac arrest.

References
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(2) Kouwenhoven W,B., Jude J,R., Knickerbocker G,C. Closed chest cardiac massage. JAMA
1960;1960(173):1064-7.
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