Cardiopulmonary resuscitation: Lessons from the past

Cardiopulmonary resuscitation: Lessons from the past

The Journal of Emergency Medicine, Vol. 9, pp 503-507, 1991 Printed in the USA. Copyright 0 1991 Pergamon Press plc CARDIOPULMONARY RESUSCITATION: L...

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The Journal of Emergency Medicine, Vol. 9, pp 503-507, 1991

Printed in the USA. Copyright 0 1991 Pergamon Press plc

CARDIOPULMONARY RESUSCITATION: LESSONS FROM THE PAST Joseph Varon,

MD,

and George L. Sternbach,

MD, FACEP

Emergency Medicine Service, Stanford University Medical Center, Stanford, California Reprint Address: Joseph Varon, MD, Pulmonary and Critical Care Medicine Section, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030

0 Abstract - One of the most startling ideas of modern medicine is that “sudden death” may be reversed; however, thii idea was not reached easily. In its earliest forms, cardiopulmonary resuscitation (CPR) is probably as old as the human being. The evolution of CPR represents, as does the evolution of medicine as a whole, a history of human error and human discovery. Although it is common to ascribe the development of CPR to Kouwenhoven and colleagues at Johns Hopkins Hospital, in fact they refined and popularized a method that had been evolving over several millennia. This paper reviews the most important advances in resuscitation prior to the 20th century.

(2-4). Our purpose is to present some of the historical bases of modem CPR prior to the 20th century.

ANCIENT MEDICINE The earliest documents of medical history, the Egyptian papyri, carry the history of medicine back about four thousand years. Nevertheless, there is evidence of basic conceptualization of resuscitation attempts before this (3). The remarkable red ochre drawing of a mammoth in the Pindal cave in Spain, presumably of the Paleolithic period, showing a leaf-shaped dark area where the heart should be, may depict the first attempt by humans to relate disease and death to the heart. At that time a supernatural orientation to health and disease was fundamental. Intruded spirits had to be driven out by magico-religious formulas. Some authors have postulated that resuscitative efforts consisted of yelling, crying, making loud noises, and even beating the patient in order to “wake-up” the victim (3). This speculation regarding life in prehistoric times, however, has been based on the analysis of those interpreting evidence such as Paleolithic art. It was only with the advent of written records that any true interpretation of early medical practice was provided. Many centuries later, in Egyptian mythology, Isis, the healing goddess, is depicted as breathing into her husband Osiris’s mouth, thereby restoring him (3,4). A similar case is cited in the Bible by the prophet Elisha,

0 Keywords - cardiopulmonary resuscitation; CPR; history of medicine

INTRODUCTION Resuscitation from death is not an everyday event but is no longer a rarity. Sudden cardiac death accounts for 400,000 to 600,000 deaths each year in the United States (1). One of the most startling ideas of modem medicine is that such “sudden death” may be reversed; however, this idea was not reached easily. The development of cardiopulmonary resuscitation (CPR) is frequently cited as occurring in the 1950s. In particular, the descriptions by Kouwenhoven, Jude, and Knickerbocker in the early 1960s are viewed as being seminal for closed chest compressions. However, the history of CPR is far longer than this. In its earliest forms, CPR is probably as old as the human being

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who relates the apparent revival of a dead child (5). These appear to be the first documented cases of artificial ventilation. It is known that Hebrew midwives of about 1300 BC utilized the expired air method for resuscitation of newborns (4). The inversion method of resuscitation was developed in Egypt 3500 years ago. The patient was hung by the feet, with chest pressure applied to aid expiration and pressure release to aid inspiration (6). Despite its lack of success, this method found continued use until the 18th century. Most early discoveries in resuscitation involved pulmonary physiology, with emphasis in ventilation. The Greek physician Galen began the research in artificial ventilation, around 177 AD, by using bellows to inflate dead animal’s lungs (7,B). He had teleological explanations for much of what he observed. Unfortunately, Galen made many mistakes, especially concerning the internal organs. For example, though there is normally no direct connection between the right and left heart chambers, Galen “found” openings in the dividing septum to fit his theoretical system in which blood had to pass from one side to the other (3). For many centuries thereafter, no one challenged Galen’s medical concepts. During the Middle Ages, beliefs regarding resuscitation, as in many other fields, came to constitute an amalgam of the pagan traditions of the invading barbarians with the classical traditions of the defunct Roman Empire and the Christian religion. Medieval physicians were of the opinion that the heart was the seat of the life spirit; therefore, if the heart became diseased, the outcome would be fatal. Resuscitation attempts in these years included the use of amulets, holy oil, and other elements of supematuralism and superstition (3).

MODERN MEDICINE Agreement is general that the 16th century marks the beginning of the modem era in medicine. It was a century of struggle and conflict, an almost constant battle between the vested doctrines of the past and new ideas. This period of time is characterized by extensive research in the physiology of blood flow and the integration of ventilation and circulation in CPR. Andreas Vesalius (1514-64) described a technique of breathing into a tube that had been placed in an animal’s trachea (7,9-l 1). . . . In order to revive the animal to some extent, one must attempt to open the trunk of the arteria aspera. Into it a cannula of thin or thick caliber should

be introduced. One blows into it so that the lung raised as the animal is inhaling . . . (10)

Around the same time Phillipus Aureolus Paracelsus, a native of Switzerland, was thought to practice “occult sciences” when he recommended the use of bellows in cardiac arrest victims (9,12). He had developed considerable interest in astrology and alchemy. His writings are a strange mixture of intelligent observation and mystical nonsense, of humble sincerity and boasting megalomania. He allied medicine and chemistry with the mystical doctrines of the cabala. To the surprise of many physicians of that era, in 1543 he performed a tracheostomy on a pig and inserted a tube into the trachea, then blowing down the tube (4). For more than three centuries his discoveries were severely criticized. Renouard, in 1856, described Paracelsus as follows: . . . He was a barbarian, an ignorant, who despised all the sciences, for the sole reason that he was ignorant of them all . . . (12)

In 1628, William Harvey published the first modem accurate description of circulation (13). Harvey differed from his forerunners in that his approach was not merely speculative, but experimental and quantitative. He demonstrated the necessity of blood flow for the existence of life, and proposed that if circulation was reestablished an arrested victim could be resuscitated. Prior to his discoveries there were believed to be two closed systems of circulation, the natural, containing venous blood, and the vital, containing arterial blood and spirits. The lungs were regarded as bellows which “fanned and cooled” the vital blood (14). Harvey observed that a resuscitated heart seemed to respond to the movement of the atria. His experiment on a pigeon was described as: . . . after the heart had stopped movements, I laid my finger moistened and warmed with sputum on the heart. When through this stimulation it had, so to speak, raised its vitality, I saw the heart and auricles

move, contract and relax, and so to speak, it was as if it were called back from death to life . . . (10) Harvey’s discovery of the circulation of the blood encountered violent opposition and even resulted in a falling off of his personal medical practice. On the other hand, there was acceptance of his discovery, and almost immediately two logical conclusions were drawn from the new information: the possibility of injecting medicaments intravenously, and the possibility of trans-

Cardiopulmonary Resuscitation: Lessons from the Past

fusing blood. Frederik Raysch (1638-1731) was one of the many scientists who made a small but substantial contribution to modern CPR when he described and perfected the method of injecting blood vessels (15). At a time in which the predominant emphasis was on aspects of circulation, respiratory physiology was also slowly developing. John Mayow, in 1674, for the first time identified oxygen as essential for animal life. He applied the name Spiritus Nitro-Aereus (the term “oxygen” was to be formulated by Lavoisier in 1775) and proposed it to be:

. essential to life as it is to fire, and it is which by chemical action changes the dark venous blood to the colour of red in arterial blood . . . (16) In the 17OOs, drowning and near-drowning accidents were very important public issues. Interest in aggressive treatment of these victims was great (17). The Humane Societies developed, first in Amsterdam, then in London, and finally in the United States. These societies were concerned with the causes of sudden death, procured books and manuscripts on drowning and resuscitation, and kept records of successfully as well as unsuccessfully resuscitated patients (4,17). In 1744, Tossach described the successful use of mouth-to-mouth resuscitation in a coal-miner overcorned by toxic fumes (45).

He breathed into the coal miner’s mouth after pinching the nostrils and immediately felt six or seven . . (4) quick beats of the heart

The Dutch Humane Society, in 1767, recommended the following approach to resuscitation of a drowning victim:

Keep the victim warm, remove swallowed or aspirated water, give mouth-to-mouth respiration and perform insufflation of smoke of burning tobacco into the rectum . . (18)

John Hunter (1728-1793), a Scottish physician, performed artificial respiration with double chambered bellows. Hunter was the key figure in the transformation of surgery from a mere craft into an experimental science, and was a firm believer in resuscitation (4,19). He had determined the “vital properties” of blood, one of the most “essential liquids in the animal economy” (12). He dismissed emetics and phlebotomy as means of resuscitation and in place of them recommended air insufflation into the trachea (10).

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Resuscitation continued to be a matter of constant research. Several attempts were undertaken in the following years. The first application of compression of the thorax was performed by John Hovard (1736 1790). Hovard, however, eventually abandoned his method, since he had the misfortune of breaking several ribs of a rather important person during a demonstration in front of police inspectors (10). In 1775, Squires of London gave the description of a possible cardiac arrest with successful electric defibrillation of a 3-year-old child who had an apparent death after falling from a one-story height (20). . . he tried the effects of electricity. Twenty minutes elapsed before he could apply the shock, which he gave to various parts of the body in vain; but upon transmitting a few shocks through the thorax, he perceived a small pulsation; in a few minutes, the child began to breath with great difficulty, and after some time she vomited. A kind of stupor, occasioned by the depression of the cranium, remained for several days, but, by proper means being used. her health was restored . (4) Around the same time the Humane York described the use of electricity attempts

Society of New in resuscitation

as:

. . . a most powerful agent, a very proper remedy in all cases the machine should be made to excite powerfully, otherwise the attempt to use it will be a loss of time . . . (17)

In 1783, DeHaen described a manual method of resuscitation known as the “chest-pressure, arm-lift” (7). Several decades later, in 1858, John Balassa successfully resuscitated an 18-year-old woman with closed cardiac massage with a technique similar to that described by DeHaen (21). That same year, Silvester, a British physician, proposed a method of artificial ventilation in which the victim was placed in the supine position with the arms folded on the chest. In a cycle of 12 times per minute the operator knelt at the head of the victim, then grasped the arms just above the wrist and drew them first upward, then replaced them with vertical downward pressure for expiration (22). How prevalent were resuscitation efforts as part of medical practice during the 19th century is unknown. However, there is at least one dramatic account of the attempt to apply basic CPR techniques in the case of the assassination of Abraham Lincoln in 1865. This is found in the records of Charles Augustus Leale, an army surgeon and the first physician to attend Lincoln

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in the presidential box at Ford’s Theater. He initially discovered the lethal head wound, and removed the clot overlying it, attempting thereby to relieve “the pressure on the brain” (23).

unsuccessful attempts with artificial respiration, a resection of the ribs was carried out and the heart exposed. The heart, indeed, became firmer after massage, fibrillated; normal contractions, though, no longer occurred . . . (10)

. * . As the president did not then revive, I thought

mode of death, apnoea, and assumed my preferred position to revive by artificial respiration. I knelt on the floor over the President, with a knee on

of the other

each side of his pelvis and facing him. I leaned forward, opened his mouth and introduced two extended fingers of my right hand as far back as possible, and by pressing the base of his paralyzed tongue downward and outward, opened his larynx and made a free passage for air to enter the lungs. I placed an assistant at each of his arms to manipulate them in order to expand the thorax, then slowly to press the arms down by the side of the body, while I pressed the diaphragm upward: methods which caused air to be drawn in and forced out of his lungs . . . I also with the strong thumb and index fingers of my right hand by intermittent sliding pressure under and beneath the ribs stimulated the apex of the heart . . . Convinced that something more must be done to retain life, I leaned forcibly forward directly over his body, thorax to thorax, face to face, and several time drew in a long breath, then forcibly expanded his lungs and improved his respiration . . . (23) A few years later, John Hill, a London surgeon, discribed three patients who arrested after undergoing chloroform anesthesia, successfully resuscitated with the technique that became the standard method for many years: . . . the left hand was placed firmly across the front of the chest, the fingers resting over the fifth, six and seventh costal cartilages of the right side, while the tip of the thumb lay on the second piece of the sternum, and the muscular part of the hand on the corresponding cartilages of the left side. The right hand was now crossed over the left, and a forcible pressure was made; the hands then being suddenly removed, the chest was allowed to expand its own elasticity. These movements were repeated 3 times in a quarter of a minute . . . (24) In 1874, Moritz Schiff, a Frankfurt physiologist, performed the first open-chest cardiac massage in a series of dogs (4,6). Boehm was simultaneously investigating closed chest resuscitation techniques in chloroforminduced cardiac arrest in cats (4). A few years later, Niehans performed unsuccessful open chest massage in a man (6). * . . A 40-year-old-man was operated for a goiter. Before the start of the operation, cardiac arrest. After

Attempts to improve ventilation techniques and patency of the airway were tried. Based on the old concepts of Paracelsus, Friedrich Trendelenburg, in 187 1, developed a tracheotomy tube with an inflatable cuff (25). This was followed by the development of an orotracheal tube with an inflatable cuff designed by Eisenmenger in 1893 (4). By the end of the 19th century, CPR, in any modality, was a common practice. Franz Koenig described a one-handed precordial compression that was successful in resuscitating six patients in 1893 (26). The advances of the 19th century had made the doctor a far happier man than was his predecessor. His powers to reverse some cases of cardiopulmonary arrest had grown out of all recognition (27,28).

DISCUSSION Every day thousands of persons perform CPR. Most of them do not realize the efforts that were required in order to achieve this basic technique. The evolution of CPR represents, as does the evolution of medicine as a whole, a history of human error and human discovery. The development of modem medicine cannot be viewed as representing a smooth curve of progress. Although it is common to ascribe the development of CPR to Kouwenhoven and colleagues at Johns Hopkins Hospital, in fact they refined and popularized a method that had been evolving over several millennia. Medical systems of earlier times are instructive both in their similarities to, and their differences from, the medicine of today. Although the role of the heart in sustaining life may have been recognized as far back as prehistoric times, the earliest advances in resuscitation involved largely the application of airway and ventilatory techniques. Even in these areas, however, progress came slowly. Before scientific advance of an orderly fashion was possible, a tradition of the application of scientific methods of observation had to be developed to replace the establishment of dogma based on superstition, mysticism, and magic. Science had to evolve, from the dogmatic environment in which Paracelsus was denounced in the most violent of terms for the application of basic ventilation techniques. Although there was a degree of practical wisdom inherent in early medical practice (even in prehistoric and Biblical

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times), it is unwise to ascribe scientific basis to the magical and superstitious beliefs that dominated medical thinking. Another intellectual hurdle requiring clearance was the unquestioning adoption of teachings of acknowledged early masters of medicine. The principles espoused by Galen, for example, were frequently erroneous. Such was his prestige, however, that many of even his most errant doctrines remained unchallenged for centuries. The most critical contribution of modem medicine to the theory of resuscitation was the accurate description of the circulation of the blood by Harvey. Even this discovery, however, was met with opposition, and it required many years for its widespread incorporation into accepted medical thought. The understanding of circulatory dynamics led to the development of various techniques to artificially maintain the circulation of the arrested individual through external stimulation. Another major advance that has its origins in the 18th and 19th centuries was the application of electri-

cal current to the fibrillating heart. Although early beliefs regarding the effects of electricity bordered on the mystical, refinement in application eventually resulted in the appropriate use of electrical current in ventricular fibrillation. The advances of this century in resuscitation have involved the condensation and application of knowledge and practice gathered over the past several thousand years. Illustrative of these advances was the case of former President Dwight D. Eisenhower, successfully resuscitated from 14 episodes of ventricular fibrillation over the course of the week of August 16 to 24, 1968 (28,29). These resuscitations stand in contrast to the rudimentary efforts made in the case of Abraham Lincoln (though Lincoln’s injury was undoubtedly fatal in any event). Eisenhower was the beneficiary of a body of knowledge that had grown substantially since the efforts upon his predecessor in the White House more than a century before, but also benefitted from the explosive progress that had been made in reversing sudden death.

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