RESUSCITATION

 and

ARTIFICIAL RESPIRATION

Artificial repiration is defined as "an emergency procedure for maintaining a flow of air into and out of a patient`s lungs when the natural breathing reflexes are absent or insufficient"(1).

POSITIVE PRESSURE VENTILATION

  MOUTH-to-MOUTH RESUSCITATION

In Italy, in the 1400s, newborn babies who failed to breath spontaneously were given mouth-to-mouth resuscitation by midwives(2). In 1732, William Tossach, a Scottish surgeon, resuscitated a coal miner by means of mouth-to-mouth(3), and the method became widely used in adults in the 1740s(4). With the coming of the "germ theory", mouth-to-mouth resuscitation was abandoned in the 18th century(5) - with a move to the use of bellows to force air into the lungs(6).

  BELLOWS

Paracelsus (1493-1541) attempted resuscitation by bellows(7). Andreas Vesalius (1514-1541) used bellows to resuscitate an asphyxiated dog(8) - preceded, clinically, by Paracelsus. In the 1600s, Rev Henshaw used a system of church organ bellows, adjusting the atmospheric pressure within a sealed chamber(9).  Robert Hooke, in 1667, inserted bellows into a dog`s trachea, opened the chest (causing the lungs to collapse), blew air into the lungs, and kept the animal alive -but Hooke`s experiment was merely a repeat of that of Vesalius(10) - both of whom had been preceded by Rev Henshaw. Bellows were one of the recommended methods of the Dutch Society for Recovery of Drowned Persons in 1767(11) and were advocated by Charles Kite of the British Humane Society in 1788(12). Bellows continued to be used(13), but in the early 1800s, reports appeared of cases in which the lungs of victims had been punctured(14) and identification of complication of barotrauma - damage to the ear, the air-filled spaces within some of the bones of the skull, caused by changes in pressures(15) - led to the bellows method being abandoned(16). In 1829, Leroy d`Etialles demonstrated that over distention of the lungs by bellows would kill an animal(17) - adding nothing to the clinical experiences, which had identified the cause.

   FUMIGATION 

Fumigation (by which smoke was blown into a bladder and then into the rectum) had been used by native American tribes for years - before the method was introduced into Britain in 1711(18). But, it is claimed the method was abandoned after Benjamin Brodie reported, in 1811, that through experiments on animals he had discovered that 4 ounces of tobacco would kill a dog and 1oz would kill a cat(19). In fact, Brodie wrote, in 1811, "a single drop [of emphyreumatic oil, a constituent of tobacco] injected into the rectum of a cat occasioned death in about five minutes; and double the quantity administered, in the same manner, to a dog was followed by the same result"(20). Thus, Brodie did not use tobacco smoke, and different amounts were required to kill a cat or a dog. Not only that but Brodie was aware of the dangers of fumigation - before he undertook the animal experiments - and wrote "We may have taken warnings from the fate of the Red Indians of America"(20).

Positive Pressure Ventilation was abandoned, and, instead, attention turned to indirect artificial ventilation by manual means(21).

MANUAL METHODS of RESUSCITATION

  "ROLLING METHOD"

Since the 1700s, victims were rolled back and forth over a barrel with pressure applied to the back and chest(22). In 1831, Dalrymple suggested side-to-side compression of the chest of the victim(23). In 1856, Marshall Hall, an animal experimenter, is claimed to have made three contributions to resuscitation:

1. to have developed a manual method of resuscitation - rolling the victim from stomach to side 16 times per minute(24) - preceded by Dalrymple 25 years earlier(25);

2. to have contended that lying the victim in a suprine position - on the back, or face-up - could cause the tongue to drop back(26) - preceded centuries before in inversion of victims of drowning(27), and in use of the "barrel method" since 1700(28);

3. to have deemed that time was lost in transporting victims from the scene(29) - preceded over 70 years earlier by Charles Kite, who wrote maintaining "recovery of the apparently dead is the length of time that elapsed before the proper remedy is applied"(30).

  CHEST PRESSURE

Inversion in response to drowning was practiced by the Ancient Egyptians(31) and the native South American Indians treated sufferers of drowning by hanging the victim upside down from a tree(32). The latter was observed by an explorer, Pia, and as a result of his report, inversion was introduced into Europe in the 1700s(33). In 1770, life-savers began to use stanchions, to which a drowned person was attached with the ankles tied together and the head raised and lowered to expel swallowed water(34). In 1785, Charles Kite published "An Essay on the Recovery of the Apparently Dead", with 125 cases of successful resuscitation of drownings(35) - preceding - by 10 years - his own animal experiments of 1795, in which animals were rendered insensible by enforced submersion in water(36). Since 1773, pressure of the chest of the victim had been part of the "barrel method"(37). Clinical manual ventilation by applying pressure to the chest and abdomen had been described in 1829(38) .

With positive pressure ventilation being abandoned after 1829, one of the methods of artificial ventilation which was adopted was inversion of a drowning person and the application of pressure to the chest of the victim(39).

In 1878, closed chest massage was described by Boehm(40), who squeezed the chest of a dead cat, causing a rise in blood pressure - preceded by numerous examples of where pressure on the chest had resuscitated human victims.

  "PRONE-PRESSURE METHOD"

In 1899, Prof (later Sir) Edward Schafer conducted drowning experiments on dogs and developed a "prone pressure method"(41). The method was not introduced, clinically, until 1907(42) - involving placing a drowning person face down and pressure by the palms was applied to the small of the back(43) - and became popular in Europe(44) and used throughout the world until the 1960s(45).

However, the chest pressure method - devised from Boehme`s animal experiments - and the prone pressure method - devised from Schafer`s animal experiments - were both unsatisfactory in treating a victim "whether his state is due to drowning, electrocution, or general anaesthetic"(46). 

POSITIVE PRESSURE VENTILATION

  ENDOTRACHEAL INSUFFLATION

Artificial ventilation experiments in the 19th century(47) had been preceded by a method in the 10th century - by which victims were resuscitated by inserting a tube down the throat(48); and by Jacob Ben Asher, who referred to the method in the 14th century(49).

Endotracheal intubation was tried in the 1700s, and used systematically in the mid-1800s by Depaul to resuscitate new-born babies. In 1898, Eisenberger described a cuffed endotracheal tube. Around this time, a  Dr Fell used his own device to maintain ventilation in drug-overdosed patients, and Joseph O`Dwyer developed his method which he used in 100 diphtheria patients(50). The two ideas were combined into the "Fell-O`Dwyer apparatus", which Rudolph Matas and Parham used and showed, in 1898, how to intubate and ventilate a patient(51).

Tuffier, in the early years of the 1900s, conducted experiments to try and determine safe levels of "positive pressure ventilation". In America, in 1909, Meltzer and Aver, of the Rockerfeller Insitute in New York, described endo-tracheal insufflation (blowing air into the lungs), providing information of its experimental and clinical use(52). Both had been preceded by clinical application of the method.

  CHEST EXPANSION METHOD

Liet Col R Viswananthan, through his work on warm cadavers and anaethetised patients, devised a technique aimed at "expanding the chest rather than squeezing the already contracted lung"(53) - as in the animal experiments conducted by Schafer - and showed that Schafer`s method was unsatisfactory in victims who been electrocuted, drowned, or under deep anaesthesia. Comparing the amount of air collected in a re-breathing bag, the average amount for his method was 836cc, whilst with Schafer`s method, it was 278cc. Viswanthan`s article on his method appeared in the `Lancet` in 1945(54).

  MOUTH-to-MOUTH RESUSCITATION re-introduced

Re-introduction of mouth-to-mouth resuscitation dates from 1946 with the revival of a patient by James Elam(55), who, in 1954, declared that mouth-to-mouth would work well with amounts of oxygen(56) and published an account of his work on paralysed patients - establishing the chin lift and jaw thrust method(57).

In 1958, Peter Safar demonstrated the advantage of expired breath ventilation, in a paper on "Venticular efficacy of mouth-to-mouth artificial respiration: airway obstruction during manual and mouth-to-mouth artificial respiration" in the `Journal of the American Medical Association`(58), and on "Comparison of mouth-to-mouth and mouth-to-airway methods of artificial respiration with chest pressure arm-lift methods", published in the `New England Journal of Medicine`(59). In 1959, Safar reported that manual ventilation was ineffective(60) - thus discrediting Schafer "prone pressure" method - based on drowning experiments on dogs(61). By studies of anaethetised and paralysed adult patients, Safar noted that the tongue commonly obstructed the air way, and reported on this in 1959(62). Safar, later, performed animal experiments into the effects of resuscitation on the brain, and the effect of hypothermia(63). Any animal experiments which may have been conducted on animals into assessing obstruction during mouth-to-mouth resuscitation would have been of no clinical benefit - as the anatomy of the upper airway of animals differs from that of humans(64).

Refs:

1. Martin,E A. Concise Medical Dictionary. 4th ed. Oxford University Press. 1994.

2. Harris,SB. The Skeptic. vol 1. no 2. 1992.

3. Fisher,J. 1977. 16th May. cited on website: www.paediatric-emergency.com/Arreslx4.htm

4. Wallace,M J. A History of Resuscitation. website: www.gene.ucl.ac.uk/hester/CPRhistory.html

5. Baxter,D et al. website: www.paracadem.com/events/mirrorpages_March99/page10.html

6. Luckhardt,AB. British Medical Journal. vol 285. 1952.

7. Harris,S B. 1992. The Skeptic. vol 1. no 2. pp24-31.

8. ibid.

9. Morrison,D S. Kirkby,R D. on website: www.quackwatch.com/01QuackeryRelatedTopics/HBOT/hm01.html

10. Garrison,F H. History of Medicine. W B Saunders Co Ltd. 1929.

11. Luckhardt,AB, British Medical Journal. vol 285. 1952.

12. Harris,SB. The Skeptic. vol 1. no 4. 1992.

13. Perkins,J F. Handbook of Physiology. American Physiology Society [pub]. 1964.

14. Harris,SB. The Skeptic. vol 1. no 4. 1992.

15. Baxter,D et al. website: www.paracadem.com/events/mirrorpages_March99/page10.html

16. Harris,SB. The Skeptic. vol 1. no 4. 1992.

17. d`Etailles,L. 1829. cited by: Keith,A. Lancet. vol 1. 1909.

18. Dworkin,G M. Evolution of Resuscitation. 8th January 1999.

19. Brodie,B. 1811. cited by: Keith,A. Lancet. vol 1. 1909.

20. Brodie,B. 1811. Lancet. quoted/cited by: Livemore,A A. Anti-Tobacco. (pub later by Robert Bros). 1882.

21. Baxter,D et al. website: www.paracadem.com/events/mirrorpages_March99/page10.html

22. Wallace,M J. A History of Resuscitation. website: www.gene.ucl.ac.uk/hester/CPRhistory.html

23. Karpovich,P V. Adventures in Artificial Respiration. Associated Press. 1953.

24. Hall,M. Lancet. 1. 1856.  

25. Karpovich,P V. Adventures in Artificial Respiration. Associated Press. 1953.

26. Hall,M. Lancet. 1. 1856.  

27. Hughs,J T. British Medical Journal. vol 285. 1982.

28. Wallace,M J. A History of Resuscitation. website: www.gene.ucl.ac.uk/hester/CPRhistory.html

29. Hall,M. Lancet. i. 1856.

30. Kite,C. An Essay on the Recovery of the Apparently Dead. 1785. 

31. Hall,M. Lancet. 1. 1856.

32. Collins Warren,J. 1912. Ann Med Hist. vol 2. 1912.

33. Hall,M. Lancet. i. 1856.

34. Brodie,B. 1811. cited by: Keith,A. Lancet. vol 1. 1909.

35. UK Resuscitation Council. Basic Life Suffort. website: www.resusc.org.uk/pages/bls.htm

36. Collins Warren,J. Ann Med Hist. vol 2. 1912.

37. Dworkin,G M. Evolution of Resuscitation. 8th January 1999.

38. Brodie,B. 1811. cited by: Keith,A. 1909. Lancet. vol 1.

39. Baxter,D et al. website: www.paracadem.com/events/mirrorpages_March99/page10.html

40. UK Resuscitation Council. Basic Life Suffort. website: www.resusc.org.uk/pages/bls.htm

41. Beddow-Bayley,M. Clinical Discoveries. NAVS. 1961. 

42. Royal Lifesaving Society of Canada. website: www.lifesaving.ca/About%20us/history%20EN.htm

43. Heimlich Institute. website: www.heimlichinstitute.org/pr990916.htm

44. Gordon,A et al. 1950. JAMA. vol 144. pp1455-1456

45. Heimlich Institute. website: www.heimlichinstitute.org/pr990916.htm

46. Viswanathan,R. Lancet. 24th February 1945.

47. Martin,L. Historical Perspective on Pulmonary Medicine. 1996.

48. Fisher,J. 1977. 16th May. cited on website: www.paediatric-emergency.com/Arreslx4.htm.

49. Luckhardt,AB. British Medical Journal. vol 285. 1952.

50. Grannis,F W Jnr. website: www.smokinglungs.com/theop1a.htm

51. Fuke,N et al. cited IN: Japanese Association for Disaster Medicine. vol 4. no 1. abstract.1999.

 52. Grannis,F W Jnr. website: www.smokinglungs.com/theop1a.htm

53. Viswanathan,R. Lancet. 24th February 1945.

54. Beddow-Bayley,M. Clinical Discoveries. NAVS. 1961.  

55. Coulston,A S. Cardiac Arrest. website: httl://home.inreach.com/dmrn_hrt/arrest.htm.

56. Elam,J O et al. 1954. cited on: www.gene.ucl.ac.uk/users/hester/CPRhistory2.html.

57. Elam,J O et al. New England Journal of Medicine. 1954. 

58. Safar,P. JAMA. vol 167. 1958.

59. Safar,P. et al. NEJM. vol 258. 1958. pp671-677.

60. Safar,P. et al. J Appl Physiol. vol 14. 1959. 

61. Wallace,M J. A History of Resuscitation. website: www.gene.ucl.ac.uk/hester/CPRhistory.html

62. Safar,P et al. J Appl Physiol. vol 14. 1959.

63. Becker,L B et al. Annals of Emergency Medicine. November 1997.

64. UK Resuscitation Council. Basic Life Suffort. website: www.resusc.org.uk/pages/bls.htm