history of cardiopulmonary resuscitation history of cardiopulmonary resuscitation the history of cardiopulmonary resuscitation (cpr) can be traced as far back as the literary works of ancient egypt (c. 2686 – c. 2181 bce). however, it was not until the 18th century that credible reports of cardiopulmonary resuscitation began to appear in the medical literature. mouth-to-mouth ventilation has been used for centuries as an element of cpr, but it fell out of favor in the late 19th century with the widespread adoption of manual resuscitative techniques such as the marshall hall method, silvester's method, the shafer method and the holger nielsen technique. the technique of mouth-to-mouth ventilation would not come back into favor until the late 1950s, after its "accidental rediscovery" by james elam. the modern elements of resuscitation for sudden cardiac arrest include cpr (consisting of ventilation of the lungs and chest compressions), defibrillation and emergency medical services (the means to bring these techniques to the patient quickly). earliest descriptions elijah resuscitating the son of the widow of sarepta, 1819 painting by louis hersent the earliest references to cpr can be found in ancient egyptian literature of the old kingdom of egypt, in which isis resurrected osiris (her slain brother and husband) with the breath of life. other early references from the iron age can be found in the bible. for example, according to the genesis creation narrative, god breathed life into the nostrils of the first man. later - according to the first book of kings - the prophet elijah (the disciple and protégé of elijah) resuscitated a phoenician boy in the city of zarephath. this is the first instance of resurrection of the dead recorded in the bible. in the second book of kings, elisha successfully performed mouth-to-mouth resuscitation on another apparently dead child, this time in the village of shunem. renaissance burhan-ud-din kermani, a physician in 15th century persia, described his approach to the treatment of ghashy (cardiac and respiratory insufficiency), which involved moving the victim's arms and expanding and compressing the left side of the chest. in 1667, robert hooke performed an experiment that refuted galen’s hypothesis that death would ensue if the lungs ceased to expand and contract. his test subject was a dog in which he made cuts in the chest wall, diaphragm, and pericardium. he determined that "the motion of the lungs without fresh air" contributed nothing to the life of the animal, but rather it was the continuous supply of fresh air that was necessary to preserve life. 18th century a device for the administration of a tobacco smoke enema, consisting of a smoking pipe attached to a pig's bladder, with a cone for insertion into the rectum artificial ventilation significant advances in resuscitation were made in europe during the age of enlightenment. for example, in 1732, scottish surgeon william a. tossach used mouth-to-mouth resuscitation to resuscitate james blair, a coal miner in alloa, scotland who had been apparently dead for 30 to 45 minutes. the patient recovered and returned to work a few days later. this case — which was witnessed by a crowd of nearly 400 people — is considered to be the first modern documented account of successful cpr in an adult. tossach published an account of this case in 1744. english physician john fothergill (1712 - 1780) discussed tossach’s experience in a paper he published the following year. the first organized effort to respond to sudden death was in 1767, when a group of citizens in amsterdam formed the society for the recovery of drowned persons (srdp). the srdp recommended a range of resuscitation techniques, including mouth-to-mouth ventilation, warming the victim, removing water from the lungs by positioning the victim's head at a lower position than the feet and applying manual pressure to the abdomen, stimulating the victim by means such as rectal fumigation with tobacco smoke, and bloodletting. within four years of its founding, the srdp claimed to have saved over 150 patients by using these methods. by 1773, similar organizations had been formed in hamburg, venice, milan, padua, vienna, and paris. in hamburg, an ordinance was passed in 1769 which allowed notices to be read in churches describing how to use these methods to rescue people who were drowned, strangled, frozen, or overcome by noxious gases. english physician thomas cogan (1736 – 1818) was living and practicing in the dutch republic at that time, having just earned his medical degree from leiden university in 1767. impressed by the accomplishments of these organizations, he returned to london where in 1774 he and a group of prominent citizens (including william hawes and frederick bull) founded the society for the recovery of persons apparently drowned (which later became the royal humane society). following the successes of these organizations, similar organizations soon sprang up in many large cities in europe and the united states, all with the goal of successfully resuscitating victims of sudden death or cardiac arrest. these rescue societies of the 18th century were the precursors of today's emergency medical services. defibrillation in 1775, danish physician peter christian abildgaard conducted experiments on electrical shock on animals. he found that applying an electric shock to the head of a hen rendered it apparently lifeless, but that it could be revived by applying another shock to the chest. he repeated this experiment several times on the same test subject, successfully resuscitating it each time. the hen even laid an egg a couple of days later. in 1792, english physician james curry (1763 – 1819) noted that the important difference between absolute death and apparent death was that in the former, "the vital principle is completely extinguished", while in the latter "it only lies dormant, and may again be roused into action, and the person thereby completely restored to life and health". curry performed experimental work on external defibrillation in small animals, and even described two successful cases of human resuscitation by this means. he used two electrodes — one above the right clavicle and the other over the lower left chest. 19th century illustration of silvester's method of performing artificial respiration. from the surgeon's handbook on the treatment of wounded in war, by friedrich von esmarch, 1878. artificial ventilation in 1856, english physician marshall hall (1790 – 1857) described a new method of providing artificial ventilation of the lungs, which involved rolling the victim from the prone (inspiratory) to the lateral (expiratory) position at a rate of sixteen times per minute. henry robert silvester (1828 – 1908) soon noted several important shortcomings inherent in hall's technique. chief among these were 1) that the resulting inspiratory and expiratory volumes were quite small, 2) that repeatedly rolling a lifeless body from prone to lateral was likely to cause significant injury to the cervical spine and face, and finally 3) that the risk of pulmonary aspiration of gastric contents was unacceptably high using hall's method. in 1858, silvester proposed a new method of artificial ventilation in which the victim is laid in the supine position, and their arms are raised above their head to aid inhalation and then pressed against their chest to aid exhalation, with this sequence repeated several times per minute. silvester's method received a great deal of attention, and was advocated by many prominent physicians of that era, including friedrich von esmarch. chest compressions in 1868, john d. hill of the royal free hospital described the use of sternal compression at a rate of twelve times a minute to successfully resuscitate three patients who had no carotid pulse and no audible heart sounds. in these three cases, the chest compressions appear to have served primarily as a means for the inhalation of ammonia from a sponge held close to the nostrils of the patient. in 1877, rudolph boehm at the university of dorpat reported the use of external cardiac massage to resuscitate cats after chloroform-induced cardiac arrest. in 1892, friedrich maass — a surgical resident at the university of göttingen — was the first to describe the successful resuscitation of a patient using external cardiac massage. maass became the first proponent of external chest compression as an effective means of assisting circulation, rather than ventilation alone. 20th century illustration of the schäfer method of resuscitation, from encyclopædia britannica, 1911 illustration of the holger nielsen method of resuscitation. norway, circa 1955. artificial ventilation main article: mouth-to-mouth resuscitation demonstration of mouth-to-mouth ventilation by dutch boy scouts at the 11th world scout jamboree, 1963 although the use of mouth-to-mouth ventilation as a resuscitative technique dates back virtually to the beginning of recorded history, it seems to have fallen out of favor in the late 19th century with the widespread adoption of silvester's method (the chest-pressure and arm-lift technique). silvester's method remained the most widespread method of resuscitation from its description in 1858 until the first decade of the 20th century, when some other innovative approaches to the problem of sudden death gained some recognition. for example, certain jujutsu techniques (referred to as kuatsu) were being used with some degree of success in japan at that time. the shafer method became popular after it was described by edward albert sharpey-schafer (1850 – 1935) in 1904. that in turn was replaced by the holger nielsen technique, first described in 1932 by danish triple olympic medallist holger nielsen (1866 – 1955). the shafer method and the holger nielsen technique were both manual methods, similar to silvester's method except that the victim was laid in the prone instead of the supine position. the mostly forgotten technique of mouth-to-mouth ventilation finally came back into favor in the mid-20th century, beginning with its "accidental rediscovery" by james elam (1918 - 1995). in 1946, during a poliomyelitis epidemic in minnesota, elam — an anesthesiologist — resorted to mouth-to-mouth ventilation on many occasions to successfully rescue paralyzed patients when their mechanical ventilators failed. based on this experience, elam and his team performed a series of experiments in the early 1950s using pharmacologically paralyzed human volunteers to demonstrate that this technique could effectively maintain adequate levels of oxygen and carbon dioxide in the blood. in 1956, elam met peter safar (1924 – 2003) — also an anesthesiologist — and persuaded him to join the effort to convince the world that ventilating the lungs with expired air was effective as part of a resuscitative technique. safar performed further experiments on human volunteers, comparing silvester's method with the holger nielsen method and the mouth-to-mouth method of artificial ventilation. by 1957, the experiments of elam and safar had conclusively demonstrated that the mouth-to-mouth method was superior to these older methods of artificial ventilation. an ad hoc panel comprising many eminent authorities on methods of artificial respiration was convened on march 8, 1957. after carefully considering the evidence available at that time, the opinion of the panel was unanimous that — for infants and small children — the mouth-to-mouth method was preferable to the rocking method, back-pressure arm-lift, and other manual methods. based on this recommendation, the mouth-to-mouth ventilation technique was endorsed that year by the national research council, united states armed forces, and the american red cross. the american medical association followed suit in 1958. that year, elam served as a medical adviser on the instructional film rescue breathing, which demonstrated and publicized this new life-saving technique. in 1959, elam (together with danish anaesthetist henning ruben, the co-inventor of the ambu bag) wrote an instructional booklet entitled rescue breathing, which was distributed throughout the united states. organizations such as the american red cross began to provide training at local chapters in the proper administration of artificial respiration. the familiar "resusci anne" training mannequin was introduced in norway and the united states in 1961. designed by norwegian doll maker asmund s. laerdal, "resusci anne" featured a lifelike face that was based on the death mask of a french girl who drowned in the seine river in the late 1880s. chest compressions while the cessation of respiration is an obvious sign of sudden death, the cessation of circulation — and particularly the rhythm of the heart — is not as easy to detect. for this reason, the appreciation of artificial circulation as a key factor in resuscitation lagged considerably behind the obvious need for artificial respiration. although closed chest massage had been described in 1892 by friedrich maass, its benefit was not widely recognized until