From reviving the living to raising the dead; the making of cardiac resuscitation

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Soc. Sci. Med. Vol. 47, No. 9, pp. 1341±1349, 1998 # 1998 Elsevier Science Ltd. All rights reserved Printed in Great Britain S0277-9536(98)00212-3 0277-9536/98 $19.00 + 0.00

FROM REVIVING THE LIVING TO RAISING THE DEAD; THE MAKING OF CARDIAC RESUSCITATION JATINDER BAINS* Registrar in Psychiatry, Psychiatric Unit, Prince of Wales Hospital, High St, Ranowick, Sydney NSW 2031, Australia AbstractÐCardiac arrest (the process of the heart ceasing to beat) and cardiac resuscitation (the attempt to restart the heart) were created in the surgical theatres of the early to middle twentieth century, in response to the cardiac arrests which were being caused by the ``theatre'' doctors themselves. These patients were young and healthy (a consequence of the preselection surgery involves), cardiac resuscitation was trying to revive the living. The paper explores the intimate relationship between cardiac arrest and cardiac resuscitation. By the use of historical and Latourian sociological analysis the paper also reveals how cardiac resuscitation was made into the emblematic medical event it is today, a process which has been so complete that it has become, in many senses, an ``obligatory passage point to death'', that is, in order to die one must pass through cardiac resuscitation. The outcome of this is the changed nature of cardiac resuscitation, no longer attempting to revive the living, cardiac resuscitation now attempts to raise the dead and dying, and at this it fails. Despite the remarkable success of cardiac resuscitation as a fact, the paper argues that it is a failure as a technique, paradoxically the more successful a fact it became, the more it failed as a procedure. The paper explains this apparent contradiction and the resistance to anomalies, by showing how cardiac resuscitation was created simultaneously inside and outside medical science, from its very start being a social and scienti®c fact with a vast network of stabilising allies. # 1998 Elsevier Science Ltd. All rights reserved

Key wordsÐcardiac arrest, resuscitation

INTRODUCTION

THEATRICAL BEGINNINGS

Cardiac resuscitation is more than any medical event, emblematic of modern Western medicine. We are all familiar with it, not least through the numerous and sensational depictions on television dramas such as E.R and Casualty. It is the supreme medical emergency having priority over all other medical manoeuvres and ailments, even sanctioning junior doctors abruptly leaving consultant ward rounds without fear of chastisement. The paper will demonstrate how the fact of cardiac resuscitation has been created and through this analysis show how the fact has been able to resist the threat of anomalies. Cardiac resuscitation (the process of attempting to restart the arrested heart) is always preceded by cardiac arrest (the process of the heart ceasing to beat e€ectively). Thus the analysis will also consider the nature of the relationship between these two interlinked events, for they cannot be seen in isolation. Cardiac resuscitation is a modern event that did not exist until the mid twentieth century. To begin with this paper will examine the process by which this medical emergency was created.

``Surgeons and anaesthesiologists in this country are facing the bare fact that they must resuscitate several thousand men, women and children yearly. They must also remember that if these people had not an operation, instrumentation, or an anaesthetic, it would actually not be a problem. The patient can not be blamed'' (Dinsmore, 1958).

*Author for correspondence.

The early twentieth century was a period when surgeons were becoming more adventurous. Developments in other ®elds of medicine, such as anaesthetics and medical physiology had made it possible for a greater number of complex procedures to be performed, and as a consequence operative procedures were becoming more technical and of greater duration. A combination of these factors, particularly the use of anaesthetic agents (Bailey, 1947) such as chloroform and ether led to the increasing occurrence of a hitherto little identi®ed event; the heart would suddenly cease to beat (Stephenson, 1958; Beck and Rand, 1949). These early cardiac arrests occurred in surgical theatres and for several reasons this unique location provided a suitable environment for their recognition. Firstly, they were being caused by the theatre doctors (surgeons and anaesthetists), either through the procedures being performed, or by the use of anaesthetic agents; the cardiac arrest was an iatro-

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genic problem. Secondly, the close observation of the patient necessary to recognise a failing heart was present as the patient was being carefully monitored by the anaesthetist (initially by manual palpation of the carotid pulse and later by the use of a cardiac monitor). Thirdly, the cardiac arrest was an unforgettable event (Primrose, 1935 and Glenn, 1953). Part of the reason for this was that the patients did not tend to be old or particularly ill, as such people were, and still are, generally considered too high a risk for a surgeon to place under his knife. Indeed these early cardiac arrest victims tended to be young (often children) having relatively trivial procedures (Primrose, 1935 and Stephenson, 1958) and therefore not expected to die. Increasing numbers of these dramas was concentrated in the intimate world of the surgical theatre, ``few emergencies being remembered so vividly'' (Stephenson, 1958). The cardiac arrest was iatrogenic in nature, caused predominantly by the theatre doctors and uniquely ``theatrical'' in its aetiology, recognition, and in the signi®cance attached to it. Hence it is of no surprise that its management was surgical. When such an emergency occurred, the impending death of the usually young patient would be to a surgeon, his responsibility. He would be compelled by his training, his compassion for the patient and his sense of guilt, to act. The operation in progress had often exposed the heart via incisions in the abdomen or chest (Stephenson et al., 1953), making it easy to manipulate either directly or through the diaphragm. If not, the chest or abdomen was opened (Stephenson, 1958). This procedure, openchest cardiac massage, was in keeping with the surgeon's training for it was a manual act, and congruent with the notion of the heart as a pump. By the early 1950's it had become customary for a surgeon to make an attempt at resuscitation in the event of cardiac arrest. The technique of openchest cardiac massage was a success, it maintained oxygenation to the brain, and the heart would return to a normal rhythm, either spontaneously or with direct de®brillation. The reason for this success was that the cardiac arrest could be diagnosed instantaneously (a consequence of cardiac monitoring in theatres) and massage could be started immediately as the surgeon had the necessary skill and equipment readily at hand. The most important factor in the success of the technique was that generally the patients were young and did not have any underlying heart or lung problems (Stephenson, 1958), a consequence of the preselection surgery necessitates. These early emergencies were true dramas, the actors being the unfortunate patient, the surgeon and the anaesthetist, performed on the stage of the hospital theatre, theatrical beginnings indeed. How then, did this event leave the boundaries of the theatre and enter the remainder of the hospital

and beyond? Surgeons themselves perceived the cardiac arrest as solely the concern of theatre doctors (Nicholson, 1942 and Kay, 1951). It was however of particular interest for a speci®c group of surgeons for whom the heart was of special signi®cance; the cardiothoracic surgeon (Cooley, 1950 and Stephenson et al., 1953). To these surgeons the cardiac arrest embodied many fascinating problems: what keeps the heart beating normally, and can it be paced when the rhythm strays from this norm?, why does it suddenly stop and can this be induced therapeutically?, when it does stop how can it best be restarted? (Stephenson, 1958) It was this interest in the cardiac arrest, in addition to its dramatic nature which led cardiothoracic surgeons to collect data on the event. In 1953, the cardiac arrest registry was collated by Hugh Stephenson, Professor and chairman of the department of surgery at the University of Missouri School of Medicine and associate in charge of the cardiovascular program. Cardiac arrests were found to be ``occurring with increasing frequency at sites in the hospital remote from the operating theatre'' (Milstein, 1963), and increasing in frequency with tremendous magnitude, ®ve fold in the previous ®ve years. Stephenson was ``studying an epidemic!'' (Stephenson et al., 1953). If one looks for cardiac arrests they will be found as everyone will have a cardiac arrest when they die, for the heart ceasing to beat was the de®nition of death, and to large measure still is. It is therefore of no surprise that Dr Sykes (of the Royal Postgraduate Medical School of London) found that ``in the 3 years before 1959 there are records of 20 patients who had cardiac arrests. . .In the 4 years after the introduction of the (resuscitation) services there are records of 263 cardiac arrests occurring in 231 patients'' (Sykes, 1964). It was the publication of Stephenson's data in 1953, with the emphasis that the cardiac arrest should be a concern for all doctors, as unlike other emergencies it extended ``into every realm of medicine'' (Stephenson, 1958), that helped sensitise the profession to the concept of the cardiac arrest, and that it should be taken seriously (Beard, 1964, Stahlgren and Angelchick, 1960). CLOSING THE OPEN CHEST

From the 1930's the Edition Electric Institute had been working on methods of reducing the death rate from electrically induced cardiac arrest amongst its linesmen, with William Kouwenhoven (a retired dean of engineering at Johns Hopkins) heavily involved in this research. In 1958 Kouwenhoven and Guy Knickerbocker (a fellow engineer) began work on a portable de®brillator in order to overcome this loss of personnel. While engaged on this project the technique of closedchest cardiac massage (CCCM) was eventually ``discovered'' during work on experimental dogs and

Cardiac resuscitation

then translated through the assistance of James Jude (resident surgeon on the Johns Hopkins cardiac unit) into a procedure that was tried on human subjects, when they would arrest during cardiothoracic operative procedures (Timmermans, 1995). The technique involved massaging the heart externally by pressing on the ``closed'' chest. This work led to the Johns Hopkins Group publishing the ®rst 20 cases in the what is now regarded as the landmark article ``Closed-chest cardiac massage'' (Kouwenhoven et al., 1960). Up till 1960 open-chest cardiac massage (OCCM) was the only available method of massaging heart. Today the closed form of cardiac resuscitation is familiar to every doctor and many members of the general public. Cardiac resuscitation is now a fact in the Latourian sense, a fact that has been made by enrolling individuals, institutions, nature itself, and by the ®ghting trials of strength. When these allies are made to act as one they form a closed ``black box'' (Latour, 1987). An example of such a process is seen in the manner by which the open chest style of resuscitation was gradually replaced by the closed. In retrospect it seems obvious that the closed system of heart massage would win over its rival as it is simply better. If the open system had won it would now seem equally obvious that this was inevitable. But the future is not obvious. How and why did the advocates of CCCM win over their rivals? Advocates of CCCM needed to convince their opponents, the medical profession and others of the importance and value of their technique, they had to persuade these other agencies to ``fetch it, seize upon it for (their) own motive'' (Latour, 1988). Jude (as mentioned earlier, a surgeon himself) diminished CCCM's association with electric pylons and portrayed the technique as having developed from the same surgical lineage as the open technique, increasing the association with OCCM. This linking of the two methods was further ampli®ed by highlighting how the techniques could be seen as complementary, as evident in the following statement by Kouwenhoven: ``We have met many doctors who are strongly in favour of OCCM. I have suggested to them, if they were not convinced they would do a satisfactory job while they are waiting for the equipment to open the chest. They should apply external massage and at the same time arti®cial respiration. Under these circumstances, the heart and the brain will be kept viable until they are ready to proceed to thoracotomy'' (Timmermans, 1995).

Such association would help to displace (translate) the intentions of the advocates of OCCM, by adopting their projects, while adding to them an element that would strengthen both the advocates of CCCM and OCCM. Latour states, ``to win we have only to bring the enemy where we are sure we will be stronger'' and ``a force even a small one, applied to the strategic places could bring victory''. His example is the use of the laboratory in defeating the

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microbe, for in the laboratory the microbe is attenuated (Latour, 1988). CCCM can be commenced with greater haste than OCCM as ®rstly, there is no delay in waiting for equipment and secondly, the procedure itself is far less time consuming to initiate (even when the equipment has arrived, the doctor still has to wait until he has gained access to the heart before beginning massage). In addition, the necessity of equipment (at least a scalpel) is a weakness of OCCM and a strength of CCCM. Whilst a surgeon with his training may not be too reticent about opening a patient's chest, many other doctors would be somewhat shy of this invasive manoeuvre. This would make it more dicult to ally them to the procedure. The advocates of OCCM would for this reason not even try to convince other nonmedical personnel, and certainly not members of the public to cut into the chest and grab the heart of victim, who was quite possibly known to them. Jude and Kouwenhoven had no such concerns and so the potential number of allies was for them almost limitless, as Kouwenhoven put it ``anyone, anywhere, can now initiate cardiac resuscitation procedures. All that is needed are two hands'' (Kouwenhoven et al., 1960). In the same year as the publication of the ``Closed-chest cardiac massage'' article it was translated into Finnish and a year later into Spanish. The Johns Hopkins Group went on to publish extensively in di€erent medical and technical journals. A handbook centred on CCCM was made by Jude and distributed to 11 states, Canada and Puerto Rico. The technique was also promoted by wallet-size cards. Between 1960 and 1966 Kouwenhoven alone gave at least 53 talks and demonstrations to various distinguished medical audiences on the bene®ts of CCCM and external de®brillation. One of these talks (St. Louis, 1961) was attended by 5000 physicians and the team won the Hektoen Gold Medal for best exhibit and was featured in TIME Magazine. Kouwenhoven and his sta€ made numerous training ®lms (winning an award from the British Medical Association), and set up training programs (Timmermans, 1995). The advent of closed-chest cardiac massage is of little value if nobody knows about it, the Johns Hopkins team were ``raising the world''. The advocates of CCCM had captured others' interests, moved ``the leverage point from a weak to a strong position'' and begun to ``move the world with a lever'' (Latour, 1983). Dr Flagg, a surgeon, responded swiftly following one of Kouwenhoven's talk at the National Resuscitation Society on March 10 1961. He believed it was ``a grave error for surgeons, who had no experience or only one case, to close the door on the life saving possibilities of open-chest cardiac massage under suitable conditions. By denying this demonstrable truth, the value of CCCM (was) bound to su€er'' (Timmermans, 1995). Three

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years later in 1964 Dr Sykes of the Royal Postgraduate Medical School, advised that CCCM should precede OCCM (Sykes, 1964). In 1966 Mr. Harley, a consultant thoracic surgeon at the United Cardi€ Hospitals advocated OCCM because of its ``inherent advantages'' but again only after the closed form had failed to resuscitate (Harley, 1966). To Stephenson (eight years later in 1974), it was unfortunate ``that the training of physicians in the techniques of open, direct cardiac compression (had) considerably diminished with the advent of closed-chest compression techniques'', and recommended that ``every physician, particularly the surgeon, should have the ability to e€ectively open the chest and adequately maintain arti®cially by compressing the heart''. To him the ``two techniques of closed-chest and open-chest cardiac massage (were) not in themselves competitive, but there are situations in which one technique may be preferable to the other'' (Stephenson, 1974). Dr Beard (of the National Heart Hospital) declared in the Section of Anaesthetics of the Proceedings of the Royal Society of Medicine that the greater ``opportunity of success'' in the treatment of cardiac arrest was ``due largely to the work of Jude and his coworkers who have so powerfully advocated the closed-chest compression'' (Beard, 1964). There had been a trial of strength and as Stephenson lamented the diminishing of skills in OCCM, closed-chest cardiac massage had gone from strength to strength. The black-box was closing, and with it the chest. MAKING A MIRACLE

``Since scienti®c facts are made inside laboratories'', or in this case theatres, ``in order to make them circulate you need to build costly networks inside which they can maintain their fragile ecacy. If this means transforming the world into a laboratory, then do it'' (Latour, 1983). The advocates of cardiac arrest and resuscitation aimed to create such a network. The construction of the fact of cardiac resuscitation, just like the victory of the closed over the open system of cardiac massage, depended on uniting elements by the formation of allies (by interesting others, moving the leverage point from a weak to strong position and raising the world). The previous section has shown how active the advocates of the closed form were (they ``so powerfully advocated the closed-chest compression'') in making allies of doctors, including doctors that had been their adversaries. Foes such as Stephenson now promoted CCCM, having a detailed chapter on CCCM in the 1969 edition of his text. Other groups of doctors were also persuaded by being made to have an interest in the cardiac arrest, to want to seize it, to desire it (Latour, 1988). A cardiac arrest may be caused by renal impairment and itself cause renal impairment. This would o€ course be of particular interest to renal physicians and renal surgeons. The

cerebral anoxia associated with cessation of blood supply to the brain can cause permanent neurological damage if resuscitation is successful but not suf®ciently swift, in this case interesting neurologists, helping to enrol groups of doctors to the cause (Stephenson, 1969). Advocates of the heart highlighted that any doctor may ®nd himself dealing with a cardiac arrest, as the emergency did not respect boundaries of speciality. It was up to him to ensure he had a plan of action that would ensure that he would be able to cope with the situation, and hence revive the patient. Stephenson recommended that all juniors at least, and perhaps all doctors should carry penknives in their white coats, so that there would be no delay if they needed to open the chest to gain access to the heart (Stephenson, 1958). A mental state of readiness was being created, so that all doctors would be continually on guard for the ever present threat of cardiac arrest. Doctors were not the only segment of the population successfully persuaded. The Johns Hopkins Group did not make their discovery public in the medical press, instead they chose the media of television. In November 1959 the American television show ``Medicine 59'' depicted the method. On the 15th November the Baltimore Sun reviewed the television show, its science journalist writing: ``the method, which in time may become a standard part of all ®rst-aid courses, keeps blood ¯owing to the brain, preventing brain damage. It may also cause the heart to start beating again''. Initial training programs included non-medical rescue services such as the ®re-®ghting teams. A ®re-®ghter resuscitated a patient 4 days after receiving training, the event being reported in the Baltimore New Post on 24 May 1960. As mentioned earlier (p. 3) following a presentation in St. Louis the Johns Hopkins Group received publicity in Time Magazine. In 1973 cardiac pulmonary resuscitation was taught to members of the general public and is now familiar to most members of the public (Timmermans, 1995). Advocates lobbied for money to research this new killer and related phenomena, and were very successful. In 1964, $500,000,000 of grants were given to cardiac arrest and resuscitation research in the United States. The cardiac arrest had become a subspecialty (Stephenson, 1964). There were calls for the medical curriculum to train medical students in the management of cardiac arrests. Hospital management were asked to ensure that all doctors were pro®cient in handling cardiac arrests by running courses (Beard, 1964). Hospital management were also encouraged to organise cardiac arrest committees to ensure that doctors were organised into cardiac arrest teams (Jude and Elam, 1965), arrest protocols (Stephenson, 1964) and e€ective communication systems established (Stephenson, 1969). It was up to them to ensure that each hospital had a ``hospital plan of action'' (Stephenson,

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1958, Julian, 1961, Johnson, 1963, Shaw et al., 1964). Research, training, hospital committees are part of establishing the machinery of cardiac resuscitation. However, cardiac resuscitation had a mechanical machine of its own, the ``arrest trolley''. The hospital theatre was a good place to have a cardiac arrest. The patient's heart was being continuously monitored and the sta€ had the skill to perform a thoracotomy. However the equipment was not always readily available, hence the creation of the cardiac arrest tray (Cooley, 1950, Glenn, 1953). Soon the cardiac arrest tray was given wheels (Stephenson, 1958, Stephenson, 1969) to ensure the equipment to diagnose and treat a cardiac arrest was mobile and present shortly after the onset of a cardiac arrest. They were to be deployed at strategic places around the hospital, and no patient would ever be more than two to three minutes away from these high-tech machines (Sykes, 1960). The advocates called for these to become common place in every hospital. They were to be a visible reminder of the omnipresent threat of cardiac arrest, and therefore were sometimes draped in red sheets (Stephenson, 1964). Very soon the machine was given an engine (the arrest trolley was incorporated into an ambulance) facilitating its exit from con®nes of the hospital (Kernohan and McGucken, 1968, Stephenson, 1969). Both the training of the public in cardiac resuscitation (Stephenson, 1969) and the building of a mobile machine extended the range of cardiac resuscitation from the theatres to the hospital and beyond, it was now possible to be resuscitated almost anywhere. The design and contents of the machine were not arbitrary, they dictated what could and should be done following a cardiac arrest. This in conjunction with stricter arrest protocols and education of the profession and public alike facilitated the standardisation of the cardiac resuscitation. Moreover, the machinery of the cardiac arrest trolley importantly linked together numerous diverse interests. It linked the designer, the manufacturers, the doctors who would use it, the hospital management who had to buy it, allying them all to the cardiac arrest and its treatment. These scripts, protocols, trolleys can be regarded as ``boundary objects'' facilitating heterogeneous interactions between the distinct social worlds linked to them (LoÈwy, 1994). This process of construction included the actual rebuilding and reorganisation of the hospital. The lay out of the hospital had to be designed to allow the rapid mobilisation of equipment and personnel. Doctors' quarters were not be too far from the hospital and lifts needed to be capable of being commandeered in the event of an arrest. The wards too, needed to be designed so that the nursing sta€ could monitor every patient's heart trace by looking at a centrally placed monitor (Stephenson, 1974). Patients' rooms were designed so that cardiac resus-

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citation equipment ®tted neatly and conveniently away into a wardrobe by the head of the bed (Stephenson, 1974). In this as in the move of the cardiac arrest out of the hospital the related rise of cardiology as a discipline is of considerable relevance, in particular the creation of coronary care units (Corday and Vyden, 1967). A cardiac arrest now occurred amongst a public which believed it was a problem, and with a government that invested money in its research and treatment. It occurred in hospitals around the world which had the cardiac arrest and resuscitation built into their design and had a ``hospital plan of action''. Cardiac arrests were treated by doctors who were trained and mentally alert to the problem and assisted by the ``arrest'' trolley. Without this construction, erected by the heart doctors, cardiac arrest and resuscitation could not exist. The section so far has examined how cardiac arrest and resuscitation was created, but not directly addressed two related questions. Firstly, how were allies enrolled? Much of this is evident from what has been described earlier. The advocates worked very hard enrolling numerous diverse allies as outlined above. The result was a set of allies which included the anaesthetists, surgeons (in particular cardiothoracic surgeons), cardiologists, physicians in general (internal) medicine and all the other groups that have been mentioned. As a lobby such a collective is formidable, especially in an era when the heart was growing in prestige. The greater emphasis on the heart, heart traces, cardiology, heart transplant surgery and the aggressiveness of post-war medicine (particularly American), meant that the medical profession and the public was more receptive to the notion of cardiac arrest and resuscitation (Fleming, 1997, Fye, 1996, Pernick, 1988). Perhaps the most important ally enrolled was time itself. In order to successfully revive a patient resuscitation needs to be commenced within three minutes. Cardiac resuscitation had to take priority over all other emergencies, it could not wait (Jude and Elam, 1965), for ``as time ¯ies the neuron dies'' (Turk and Glenn, 1954). Time, or the ``time factor'' (Stephenson, 1969) legitimated the place of cardiac resuscitation as the supreme emergency, and hence the need to construct a system around it. If cardiac resuscitation was to be attempted, it had to be attempted quickly, and that necessitated the construction of an elaborate extensive network, which in turn stabilised the fact. The second question is very much related to the ®rst, why did doctors want to treat the cardiac arrest? Again much of the answer has been discussed. The early cardiac arrest were in fact iatrogenic and occurring in theatres, where the theatre doctors were obligated to act. However the construction was also facilitated by the psychological need cardiac resuscitation ®lled, and the promise of wondrous possibilities. This need and promise had

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been successfully created. It was cardiothoracic surgeons who spoke of the profession being given a weapon, a tool to use when a patient became suddenly unwell; when previously they had to impotently watch as their patient passed away, ``the death certi®cate (being) soon ®lled out''. ``The physician need no longer have the despair of inability to meet the challenge of sudden unexpected cardiac arrest'' (Jude, 1961). Claude Beck, a heart surgeon, recounted in 1956 the miraculous tale of a 65 year old physician who collapsed on the way out of the hospital, the victim of a cardiac arrest. ``The man was dead''. Following open chest massage ``beads of perspiration appeared on the forehead of the patient as life was restored'' (Beck et al., 1956). His heart like many others was ``too good to die'' (Corday and Vyden, 1967). Cardiac resuscitation could cure death, restore life (Johnson, 1963), accomplish ``the desired reversal of the process of death'' (Stephenson, 1958). Indeed, cardiac resuscitation itself was ``best de®ned as the restoration of life after death'' (Southworth, 1959). Death had been reduced from a ®nality to a mere factor, the ``death factor'', and the death factor in coronary artery disease was ``small and reversible''. Accounts of cardiac resuscitation in the media echoed similar sentiments; ````Dead''. He Revives only to Die Again'' (New York Times, Feb 16 1953), ``Girl ``Dies'', Then Lives 22 Hours'' (New York Times, Feb 18 1953) and ``She Was Dead for 50 Minutes'' (Reader's Digest May 1955). ``The veil of mystery (was) being lifted from heart conditions, and the dead (were) being brought back to life'' (Beck et al., 1956) ARRESTED DEVELOPMENT

I explained earlier how time or the ``time factor'' was used to help create cardiac resuscitation and is crucial if a patient is to be successfully revived. Hence there is no time delay between the diagnosis of a cardiac arrest and the commencement of closed-chest cardiac massage. I cannot think of another situation in medicine in which the treatment of an ailment is instantaneous. In addition if a diagnosis of cardiac arrest is made cardiac resuscitation must usually be attempted. This is again because of the time factor, following diagnosis there is no time to spend in considering alternatives, action has to be immediate. Because of these two reasons a cardiac arrest is often followed by resuscitation and if resuscitation is in progress a cardiac arrest has always taken place. The cardiac arrest and cardiac resuscitation are temporally so closely linked that the distinction between them is often blurred. The two processes seem to merge and form one event (which in a sense is actually the case). Thus neither cardiac arrest or cardiac resuscitation when used in the technical sense convey the full meaning of the event (which involves both pro-

cesses). This understanding is evident in the manner that doctors who are regularly involved in these events discuss them: did the patient arrest?, how did the arrest go, did the patient make it?, were you at the arrest?, arrests, they never work? The time factor has also resulted in the illusion that cardiac arrests are sudden. Most cardiac arrests are far from unanticipated for they usually strike the unwell and dying, in other words they are expected. It is the instantaneous and dramatic response to the cardiac arrest that helps create the deception of suddenness. The consequence of this merger between cardiac arrest and cardiac resuscitation is highly signi®cant. In a general hospital a cardiac arrest will usually be followed by cardiac resuscitation. If a person collapses in the street, and a passer-by diagnoses a cardiac arrest, closed-chest massage will be commenced. The default position is to activate the cardiac resuscitation machine. This machinery can only be halted in certain situations. The victim of the cardiac arrest may die alone and when the body is found it is obvious that he is dead. The ``discoverer'' of the patient may be unfamiliar with cardiac resuscitation or unwilling to act, or the dicult decision ``not to resus'' the patient, should he have a cardiac arrest has been made in advance (as is the case with cancer patients in hospital, patients in hospices, and patients in the community who have made such decisions). After such a ``not for resus'' decision has been made the patient is allowed to die, and the machinery of cardiac resuscitation is not activated. He is allowed to reach death without having to pass through cardiac resuscitation. Nonetheless it is not uncommon for such patients to receive resuscitation, for the nurse on duty may be inexperienced of have forgotten the patient's ``resus'' status, and having diagnosed a cardiac arrest be then bound to commence cardiac resuscitation or the victim may die in public and therefore be resuscitated by a passer-by or para-medic. Additionally the ``not for resus'' is often not made even when it is clearly appropriate. This can be because there has not been enough time, the patient having arrested shortly after admission. It may be because it is easier not to make the decision which often involves an awkward conversation with the patient and relatives. Sometimes entire wards of patients which perhaps should be ``not for resus'' are allowed to receive cardiac resuscitation. I have worked for a consultant who cared for a ward of patients in the very end stages of dementia. The consultant however was clear that all his patients should be for resus as ``not for resus'' decisions can result in the patients level of care being lowered. It is clear that the default position is for the patient to pass through the machinery of cardiac resuscitation, it has become such a successful fact that the route to death is often to travel through its gates, it is

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becoming in many senses an obligatory passage point, an obligatory passage point to death. Associated with this is a change in the nature cardiac arrest and resuscitation. The theatrical cardiac arrest was the arrest of the young ®t surgical heart Ð cardiac resuscitation to revive the living. The further it was driven (and wheeled) the more successful a fact it became, linking a greater number of diverse allies. Paradoxically the more successful it became as a fact, the more unsuccessful it became as a technique. Stephenson (1958) found the success rate to be 30.2% in theatres and 21.1% outside and Turk and Glenn (1954) cited ®gures of 23.7% and 15% respectively. Jude et al. (1961) in a series of 118 patients found that 64% of patients who had cardiac arrests in theatre or the recovery room survived to leave hospital, compared with 9% of those who had su€ered cardiac arrests outside the theatre environment. The explanation for this is simple, the nature of the cardiac arrest had changed, it was no longer the arrest of the ®t heart in theatres. Cardiac resuscitation was becoming an obligatory passage point to death and hence its clientele was the dying individual and the diseased heart (Baringer et al., 1961) cardiac resuscitation now attempted to raise the dead. There is now an 18% chance of resuscitation being attempted inappropriately (King et al., 1994) and a 89% chance of failure (Berger and Kelley, 1994 and Tunstall-Pedoe et al., 1992). The fact of cardiac resuscitation is an immensely successful creation, and a remarkable failure. The above studies have generated anomalies, they revealed cardiac resuscitation was not working as well as expected. Cardiac resuscitation was thought to be able to reverse death, but the research showed a disappointing miracle rate, a mismatch between theory and observation. In 1992, the results of the BRESUS study was published, a study comparable in size to Stephenson's Registry. The authors concluded: ``Since this study was initiated in the mid-1980's there have been developments which promise better results in the future. Widespread deployment of ambulances with trained sta€ and de®brillators is changing the potential for resuscitation out of hospital. Increasing awareness of remediable de®ciencies in the training of hospital sta€ led the Resuscitation Council to promote British (and potentially European) guidelines for standardising resuscitation procedures and hospital training. Following the recommendation of the Royal College of Physicians, hospitals are setting up resuscitation committees, appointing resuscitation training ocers, and auditing their results by using simpli®ed record forms derived form this study. Compared with other life saving interventions hospital resuscitation is seen to be cost e€ective and a procedure where improved speed of reaction, training, and competence should produce improved results'' (Tunstall-Pedoe et al., 1992).

In 1963 the British thoracic surgeon B. Milstein had echoed virtually identical sentiments (Milstein, 1963). These heart doctors did not blame the fact (their fact) but instead they criticised the training of

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doctors and called for increased speed of reaction, improved education, making the arrest more even more of a fact. Why is it that, for the heart doctors the ®gures did not reveal failure, what explains the stability of cardiac arrest and resuscitation? The above statistics would cause concern in most procedures, especially given the cost involved. The answer to this question is evident from the preceding analysis. Watching the closure of the black-box has shown the immense number of diverse allies both within and outside what is known as science, the construction of the ``scienti®c'' and ``social'' fact of cardiac arrest and resuscitation went hand in hand (the distinction between them being as a consequence rather arbitrary). ``The exactness of a science does not come from within. It, too comes from the strength of the agents with whose fate it has managed to become linked'' (Latour, 1988), and cardiac arrest and resuscitation have become linked to numerous agents, the linking a€ording stability. Additionally, normal science is practised in manner which is intended not generate anomalies. When they are generated, the fact itself is rarely questioned, instead there is assumed to be a need for more detailed studies, re®nements in observational techniques or further articulation of theory. This is seen in the earlier quotation calling for improved training, speed of reaction and competence. These doctors did not see the failure, they did not see the failure because in their terms there was no failure. There was simply discrepancy between theory and observation, a discrepancy that could be corrected by improving the delivery of cardiac resuscitation (Kuhn, 1962). The analysis has also shown how the ``scienti®c fact'' was taken up by varying thought collectives (groups of people bound by a shared ``thought style''), whether they be cardiologists, general physicians or hospital management. When a ``scienti®c fact'' elaborated by one thought collective is adopted by a second, it is translated into the thought style of the second. This ``translation'' is, however bound be imperfect because the thought style of the second is at least in part incommensurable with the thought style of the ®rst. Some things may be lost but others gained in translation (LoÈwy, 1994). Its advocates spoke of the heart that was too good to die, of restoring life and raising the dead (p. 6). Doctors today do not speak in such terms, but do speak in similar ones. I have on numerous occasions said to the relatives of a patient who has died despite cardiac resuscitation, ``he died suddenly, we did all we could, we did try to revive him, but it was too late''. Cardiac resuscitation sanctions death, legitimates it, makes it acceptable, for it has been fought to the very end. When talking to the relatives of patients, discussing the fact that their relative should not be for resuscitation, I have been surprised that some relatives have insisted in maintaining the cardiac arrest status. The reason has

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usually been that they wanted the highest level of care for their relative, they wanted to do everything they could for them. All of us have been made allies. The deep and emotional penetration of the cardiac arrest and resuscitation into society outlined above, explains the strength and resilience when faced with anomalies; we, experts and laymen alike, have a need for the process, a need that has been successfully created. This need prevents its destruction, and hence anomalies do not threaten its existence, the way anomalies can threaten less secure facts. Cardiac resuscitation legitimates death, these days many people cannot die, as I have said, unless they undergo cardiac resuscitation, it is becoming an obligatory passage point to death. However in order to die one needs to receive cardiac resuscitation, to die without it is to have been robbed of the chance of life, of being raised from the dead. AcknowledgementsÐI would like to thank Dr Andrew Cunningham (Cambridge Wellcome Institute for the History of Medicine) for his expert guidance during the preparation of this paper and Ms Michaela Perry for her kind support.

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