by Dana Sterner
Archaic yet Modern
Most health care providers can recall their first CPR class. Some providers can even brag about doing CPR in their sleep they have performed, or taken the acronym so many times. But most of us just dread the idea of sitting through or teaching another CPR session. Yet hundreds of years ago CPR, ABC, or CAB held no significance, and resuscitation techniques were poorly understood by the medical community. Most physicians and scientists held the belief that expired air did not have enough oxygen for effective ventilation, and that whipping an unconscious person would stimulate breathing. Although that idea and procedure may sound very archaic, many of those earlier techniques have historical roots in modern medicine.
A Historical Comparison
The Greek physician Galen, around 160 AD concluded that blowing air into an animal’s larynx through a reed would inflate its chest (1). Today we use tracheal tubes mostly made of plastics, but that idea along with other primitive techniques laid the foundation for what we practice today. In the 1500’s a fireplace bellow was often used to blow hot air into the mouth or nostrils of the unconscious, an archaic technique, but a technique similar to the modern ambu bag – BVMs (2). Flagellation, a common practice of the time, consisted of whipping the unresponsive person into responsiveness(3). Fortunately we practice a more docile technique - “shake and shout”. During this early period the importance of warming the body was well understood, an idea we hold today. But their procedures were unconventional involving hot ashes, burning excrement, or placing hot water directly on or in the body as an attempt to restore life (3).
The remarkable case of Anne Green
According to an Oxford study in the British Medical Journal, a remarkable case involving resuscitation measures occurred in 1650 when a young woman Anne Green was sentence to hang. Hangings were often a slow death by strangulation, so it was not uncommon for family or friends to pull on the swinging body, or strike the individual with severe blows to quicken the execution. Anne Greens family and friends pulled and tugged on her so hard that the executioners made them stop for fear of the gallows breaking. Anne was left to hang for an additional 30 minutes before they cut her down. Pronounced dead she was taken to Oxford University for anatomical dissection. The next day when the casket was opened one of the physicians heard a rasping noise coming from her throat. On further assessment a weak pulse and shallow breathing were noted. The physicians quickly turned their energy toward resuscitation. Prying her teeth open they poured a hot liquid down her throat not something we would do today, but they unknowingly established an airway similar to our current head tilt jaw lift. Fortunately for Anne Green the physicians choose heat methods over flagellation. There were no medical standards at the time, and the heat method for resuscitation was utilized in different ways: person to person heat transfer, rubbing the extremities, bandaging the extremities tightly, applying hot bandages to the chest wall as well as administering warm enemas to heat the bowels. All these resuscitation methods were used on Anne Green as well as bloodletting and throat tickling with a feather to stimulate a cough or vomiting. Their limited knowledge of the cardiopulmonary system, and their questionable techniques saved Anne Green who was later exonerated from her crime, and lived an additional 15 years giving birth to three children (4).
Historical Credits
History credits the ancient Greeks for the initial understanding of pulse rate in correlation to breathing(5). But, it was not until 1707 with the invention of the stop watch that changes in pulse rate could be accurately measured. The Reverend Stephen Hales in 1733 was the first to note that pulse varied with respiration, and around that same time mouth to mouth resuscitation was recommended by the Paris Academy of Sciences (5). But mouth to mouth was considered unsanitary, and the danger of disease transmission was a concern – even then. Others felt it filled the victim’s stomach with air verses expanding the lungs, leaving surreal attempts at resuscitation to continue. The inversion method, rolling the unresponsive person on a barrel in an attempt to force air in and out of the lungs was commonly used as well as hanging an unconscious person upside down to clear or stimulate the airway (3). Another method called fumigation, blowing smoke into the victim’s rectum, was practice until 1811. Many physicians believed that the intestines retained life longer, and if heated, or stimulated could revive life (3). But as one method was discredited another method soon took its place. The trotting horse method was introduced that same year in an effort to resuscitate drowned victims. Drowning held a high death rate at the time (3). Lifeguards would place a drowned victim sideways on a horse and run the horse up and down the beach. The bouncing motion created an alternating compression and relaxation of the chest cavity. The idea of chest compressions was widely held, but the technique still needed work. In 1856 the roll method proposed by Marshal Hall suggested rolling the unconscious person from side to side 16 times a minute while applying pressure to the persons back in the prone position(2). This technique was widely accepted as well as the observation that the tongue would fall back and occlude the airway, thus giving way to the tongue stretching method. The tongue stretching method was described as holding the victim’s mouth open while pulling the tongue forcefully and rhythmically (3). Still another method by Henry Silvestre 1883 is described as placing the victim supine, raising their arms to the sides of their head, holding the arms temporarily, then bringing them back down and pressing against the chest (2). The movement was to be repeated 16 times per minute. The idea of counting compressions along with rescue breathing continues today.
Present day
Advances in resuscitation continued to be gradual until the 20th century when heart disease outpaced drowning victims (3). In 1956 Peter Safar was the first to combine the idea of A (Airway) B (Breathing) C (chest compressions), and wrote the book ABC of Resuscitation in 1957 (2). He demonstrated on paralyzed human volunteer’s that rescuer exhaled air could maintain adequate oxygen levels in the non-breathing victim (3). He also showed that even lay people could effectively perform mouth to mouth breathing to save lives. That same year a Norwegian doll maker named Asmund Laerdal of Laerdal Company was asked to design, and manufacture a mannequin for CPR training (6). Resuscitation Anne was born.
The A-B-C system for CPR was later adopted by the American Heart Association who initiated standards for CPR training in 1974(6). These initial CPR standards have seen a lot of changes over the years even a new acronym in 2010; CAB- Compression, Airway, and breathing(7). It would be easy to say - the rest is history, but one question remains. How antiquated will our procedures sound - 100 years from now.
References
1. Stoller JK. The history of intubation, tracheotomy and airway appliances. Respiratory Care Volume 1999;44:595-603
2. Cooper, JA, Cooper JD, Cooper JM. Contemporary Reviews in Cardiovascular Medicine History, Current Practice, and Future Direction. Circulation 2006; 114:2839-2849
3. Third Facility of Medicine, Charles University CPR History timeline. Retrieved August 10, 2014.
4. Miraculous deliverance of Anne Green, An Oxford Case. British Medical Journal volume 285 December 1982 p1792-1794
5. Billman GE. Heart rate variability – A historical Perspective. Frontiers in Physiology Retrieved August 10, 2014.
6. Laerdal, History Laerdal yesterday and today Retrieved August 10, 2014.
7. Field, J.M., F.M. Hazinski, Sayre MR et al; 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science Part 1: Circulation Retrieved August 10, 2014.
Dana Sterner RN, has worked as a community CPR and first aid instructor as well as a health care provider instructor for BLS, ACLS and PALs for almost 25 years where she has seen a lot of changes.
Archaic yet Modern
Most health care providers can recall their first CPR class. Some providers can even brag about doing CPR in their sleep they have performed, or taken the acronym so many times. But most of us just dread the idea of sitting through or teaching another CPR session. Yet hundreds of years ago CPR, ABC, or CAB held no significance, and resuscitation techniques were poorly understood by the medical community. Most physicians and scientists held the belief that expired air did not have enough oxygen for effective ventilation, and that whipping an unconscious person would stimulate breathing. Although that idea and procedure may sound very archaic, many of those earlier techniques have historical roots in modern medicine.
A Historical Comparison
The Greek physician Galen, around 160 AD concluded that blowing air into an animal’s larynx through a reed would inflate its chest (1). Today we use tracheal tubes mostly made of plastics, but that idea along with other primitive techniques laid the foundation for what we practice today. In the 1500’s a fireplace bellow was often used to blow hot air into the mouth or nostrils of the unconscious, an archaic technique, but a technique similar to the modern ambu bag – BVMs (2). Flagellation, a common practice of the time, consisted of whipping the unresponsive person into responsiveness(3). Fortunately we practice a more docile technique - “shake and shout”. During this early period the importance of warming the body was well understood, an idea we hold today. But their procedures were unconventional involving hot ashes, burning excrement, or placing hot water directly on or in the body as an attempt to restore life (3).
The remarkable case of Anne Green
According to an Oxford study in the British Medical Journal, a remarkable case involving resuscitation measures occurred in 1650 when a young woman Anne Green was sentence to hang. Hangings were often a slow death by strangulation, so it was not uncommon for family or friends to pull on the swinging body, or strike the individual with severe blows to quicken the execution. Anne Greens family and friends pulled and tugged on her so hard that the executioners made them stop for fear of the gallows breaking. Anne was left to hang for an additional 30 minutes before they cut her down. Pronounced dead she was taken to Oxford University for anatomical dissection. The next day when the casket was opened one of the physicians heard a rasping noise coming from her throat. On further assessment a weak pulse and shallow breathing were noted. The physicians quickly turned their energy toward resuscitation. Prying her teeth open they poured a hot liquid down her throat not something we would do today, but they unknowingly established an airway similar to our current head tilt jaw lift. Fortunately for Anne Green the physicians choose heat methods over flagellation. There were no medical standards at the time, and the heat method for resuscitation was utilized in different ways: person to person heat transfer, rubbing the extremities, bandaging the extremities tightly, applying hot bandages to the chest wall as well as administering warm enemas to heat the bowels. All these resuscitation methods were used on Anne Green as well as bloodletting and throat tickling with a feather to stimulate a cough or vomiting. Their limited knowledge of the cardiopulmonary system, and their questionable techniques saved Anne Green who was later exonerated from her crime, and lived an additional 15 years giving birth to three children (4).
Historical Credits
History credits the ancient Greeks for the initial understanding of pulse rate in correlation to breathing(5). But, it was not until 1707 with the invention of the stop watch that changes in pulse rate could be accurately measured. The Reverend Stephen Hales in 1733 was the first to note that pulse varied with respiration, and around that same time mouth to mouth resuscitation was recommended by the Paris Academy of Sciences (5). But mouth to mouth was considered unsanitary, and the danger of disease transmission was a concern – even then. Others felt it filled the victim’s stomach with air verses expanding the lungs, leaving surreal attempts at resuscitation to continue. The inversion method, rolling the unresponsive person on a barrel in an attempt to force air in and out of the lungs was commonly used as well as hanging an unconscious person upside down to clear or stimulate the airway (3). Another method called fumigation, blowing smoke into the victim’s rectum, was practice until 1811. Many physicians believed that the intestines retained life longer, and if heated, or stimulated could revive life (3). But as one method was discredited another method soon took its place. The trotting horse method was introduced that same year in an effort to resuscitate drowned victims. Drowning held a high death rate at the time (3). Lifeguards would place a drowned victim sideways on a horse and run the horse up and down the beach. The bouncing motion created an alternating compression and relaxation of the chest cavity. The idea of chest compressions was widely held, but the technique still needed work. In 1856 the roll method proposed by Marshal Hall suggested rolling the unconscious person from side to side 16 times a minute while applying pressure to the persons back in the prone position(2). This technique was widely accepted as well as the observation that the tongue would fall back and occlude the airway, thus giving way to the tongue stretching method. The tongue stretching method was described as holding the victim’s mouth open while pulling the tongue forcefully and rhythmically (3). Still another method by Henry Silvestre 1883 is described as placing the victim supine, raising their arms to the sides of their head, holding the arms temporarily, then bringing them back down and pressing against the chest (2). The movement was to be repeated 16 times per minute. The idea of counting compressions along with rescue breathing continues today.
Present day
Advances in resuscitation continued to be gradual until the 20th century when heart disease outpaced drowning victims (3). In 1956 Peter Safar was the first to combine the idea of A (Airway) B (Breathing) C (chest compressions), and wrote the book ABC of Resuscitation in 1957 (2). He demonstrated on paralyzed human volunteer’s that rescuer exhaled air could maintain adequate oxygen levels in the non-breathing victim (3). He also showed that even lay people could effectively perform mouth to mouth breathing to save lives. That same year a Norwegian doll maker named Asmund Laerdal of Laerdal Company was asked to design, and manufacture a mannequin for CPR training (6). Resuscitation Anne was born.
The A-B-C system for CPR was later adopted by the American Heart Association who initiated standards for CPR training in 1974(6). These initial CPR standards have seen a lot of changes over the years even a new acronym in 2010; CAB- Compression, Airway, and breathing(7). It would be easy to say - the rest is history, but one question remains. How antiquated will our procedures sound - 100 years from now.
References
1. Stoller JK. The history of intubation, tracheotomy and airway appliances. Respiratory Care Volume 1999;44:595-603
2. Cooper, JA, Cooper JD, Cooper JM. Contemporary Reviews in Cardiovascular Medicine History, Current Practice, and Future Direction. Circulation 2006; 114:2839-2849
3. Third Facility of Medicine, Charles University CPR History timeline. Retrieved August 10, 2014.
4. Miraculous deliverance of Anne Green, An Oxford Case. British Medical Journal volume 285 December 1982 p1792-1794
5. Billman GE. Heart rate variability – A historical Perspective. Frontiers in Physiology Retrieved August 10, 2014.
6. Laerdal, History Laerdal yesterday and today Retrieved August 10, 2014.
7. Field, J.M., F.M. Hazinski, Sayre MR et al; 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science Part 1: Circulation Retrieved August 10, 2014.
Dana Sterner RN, has worked as a community CPR and first aid instructor as well as a health care provider instructor for BLS, ACLS and PALs for almost 25 years where she has seen a lot of changes.
