Wednesday, March 23, 2016

1750-1950: Methods of Manual Resuscitation

When the Humane Society was established in 1774 to help victims of drownings, various methods were used to breathe for those not breathing on their own.  There were success stories, and therefore the society was able to thrive.

Some of the methods used we might find laughable, because they had nothing at all to do with breathing, such as rubbing a feather on the nose, or blowing smoke up the anus.  Yet we must understand the limitations of knowledge at the time.  (You can read about the methods used by the Humane Society by clicking here)

For example, people from the year 2015 might read about how the American Red Cross once recommended mouth to mouth breathing and cringe, saying something like, "Ewe, they did that?"  As you can see by the history below, mouth to mouth breathing was once recommended by the Humane Society, but went out of fashion due to hygienic concerns.  By the 1960s it was back in vogue.  Mouth to mouth breathing would be debated once again in 2000, with many organizations no longer recommending it.  

And, who knows?  Like mouth to mouth breathing once made a come back, so too might any of these obsolete methods.

The general recommendation of the humane society and other similar organizations was to pull the victim away from danger first: out of the water, away from electric current, away from poisonous air, etc.

If the victim was not breathing, the airway should be cleared (such as of mucus and water), and one of the methods of manual resuscitation (artificial breathing) should be started right away.

As soon as possible a second person should notify (by word of mouth or by phone) a physician and/ or rescue team.  

During the 19th century, older methods of artificial resuscitation came under question, mainly due to the safety of performing, and on their effectiveness. Various physicians performed experiments on their own, and as the provided evidence that their method was more effective, the newer method was adapted.

Some of the more common methods of manual resuscitation are listed here:

1.  Simple methods to excite the breathing:  Simple methods come from the ancient world, and since never disproved to initiate breathing, were among the various recommendations of the original members of the Humane Society.  This can bee seen through the wrods of Frederick Killick in his 1893 article, "Resuscitation of the apparently drowned," in Dominion Illustrated Monthly:
Excite the nostrils with snuff, hartshorn and smelling salts, or tickle the throat with a feather, etc., if they are at hand. Rub the chest and face warm, and dash cold water, or cold and hot water alternately on them. If there be no success, lose not a moment, but instantly... (10, page 173)
Once these efforts have failed, it was time to move on to the preferred method of artificial respiration.  The authors in this case recommend the Marshall or the Howard method, both of which are described below. (10, page 173)

2.  Mouth to mouth method:  As noted in a booklet by the Lungmotor Company: 
As commonly practiced by Life Savers, the Rescuer grasps the victim's tongue between his teeth and blows into his mouth. This is too unsanitary to be considered, except to state that it is more likely to fill the victim's stomach with air than, it is to expand the lungs, and to call attention to the danger o£ transmission of dread diseases thereby, namely, Syphilis, Tuberculosis, etc., etc. (1, page 8)
Surely this method was used from time to time, although, because it was seen as unhygienic, it was not recommended. I would imagine this method, or a variation of it, was more likely to be used to save the life of a boy or girl, or a newborn infant, as opposed to a perfect stranger.

No. 2 —Dr. Hall's System of Artificial Expiration
3.  Dr. Marshall Hall's Method (postural method/ ready method):  (18, page 2) (17, page 74) Dr. Marshall Hall (1790-1857) was an English physician (10, page 171).who recommended a method of resuscitation in an 1856 article in The Lancet called "Asphyxia, it's rationale and its remedy."  (11, page 17)

His method was later recommended to the Humane Society.  (11, page 17)

In 1857 he published an article in the Lancet called "Prone and Postural Respiration in Drowning," whereby he criticized the methods used by the Humane Society in favor of his own method.  (17, page 74)

Mickey S. Eisenberg, in his 1997 book "Life in the Balance, explained that Hall "believed that too much valuable time was lost in transporting the victim; that restoratoin with warmth without artificial ventilation was dangerous and too time consuming; that exposure to fresh air was eneficial; and that in the supine position, the victim's tongue and larynx fell back and blocked the airway." (17, pages 74-75)

Dr. Marshall was the first to recommend clearing the throat (clearing the airway) as the first step of artificial resuscitation. He thus recommended clearing the throat by placing the "patient on the floor or the ground with the face downward, and one of the arms under the forehead in which position all fluids will more readily escape by the mouth, and the tongue itself will fall forward leaving the entrance into the windpipe free.  Assist this operation by wiping and cleansing the mouth." (10, page 173)

A thorough description of what the method entailed can be found in the 1862 edition of the U.S. Army Medical Departments "Hand-book of Surgical Operations" by Stephen Smith, as noted here: (9, page 45)
"Turn the body gently, and completely, on the side and little beyond, and turn then on the face (prone); alternating; repeating these measures deliberately, efficiently, and perseveringly, fifteen times in a minute only (when the patient reposes on the thorax; this cavity is compressed by the weight of the body, and expiration takes place; when he is turned on the side, this pressure is removed and inspiration occurs).  When the prone position is resumed, make equitable but efficient pressure along the spine; removing it immediately before rotation on the side (the first pressure augments the expiration, the second commences inspiration)"  (9, page 45)(also see 10, page 173)(also see 15, page 347)
As noted by Killick:
By placing the patient on the chest the weight of the body forces the air out (expiration).  When turned on the side this pressure is removed and air enters the chest (inspiration). (10, page 173)
Eisenberg also explained that Dr. Hall referred to his method as the "ready method" because "no equipment or complicated training were required.  (17, page 75)

It is obvious the disadvantages to this method.  For one thing, it would entail more than one person to perform.  One, or possibly more, would be needed to turn the patient, and another to "attend solely to the movements of the head, and of the arm placed under it." (10, page 173)  It may also be noted that while this method was recommended by army physicians after an anesthetic was given, it would be next to impossible to perform any lengthy operation on such a patient.

Marshall's Method was among the main recommendations until the Sylvester method was introduced, and became obsolete after the Schaefer method was introduced.   

As a side note here, along with recommending clearing the airway, Dr. Marshall Hall was also the first to recommend cooling the patient as opposed to warming him.  Perhaps this is why, in the Army's "Hand-book of Surgical Operations," Smith noted that just after the anesthetic was given, and prior to initiating artificial respiration (Marshall,  Silvester, or Howard), to do the following: 
"...the patient's tongue was drawn forward with forceps or a tenaculum, fresh air admitted to the door or windows, or induced by a fan...  (9, page 45)
This was a notable recommendation by Marshall, because at that time the recommendation was to keep the patient warm, often by placing the victim by the fire. (11, page 17)  Once the patient wakes up, Smith recommends giving the patient brandy and ammonia. He then mentions a newer method introduced by Dr. Silvester. (9, page 45)

4.  1858: Dr. Henry R. Silvester's Method:   (Sometimes his name is spelled Sylvester) Silvester criticised Hall's method in favor of his own in an article published in The British Medical Journal in 1858 called "A NewMethod of Resuscitating Still-born Children, and of Restoring Persons Apparently Drowned orDead."

This entails laying the patient on his back and providing rhythmic traction on the patient's arms.  According to Smith, the method goes something like this:
Fig 59 — Artificial Respiration—Inspiration
These figures represent Silvester's method. (15, page 345)
It consists of laying the patient on his back, drawing the tongue forward, then carrying the arms slowly upward over the head, thus elevating the ribs by means of the pectoral muscles, and inducing respiration; the arms are then brought down to the side of the chest and slightly compressed against it; these movements are to be repeated slowly as by the other methods." (9, page 45)(also see 10, page 174)
When used on a drowned victim, the Lungmotor Company recommends that because this method does not remove water from the patient's lungs, water should be removed prior to its use. (1, page 7) When performed in a controlled setting,  Killick recommended the following:
Draw forward the patient's tongue, and keep it projecting beyond the lips; an elastic band over the tongue and under the chin will answer the purpose, or a piece of string or tape may be tied round them; or by raising the lower jaw, the teeth may be made to retain the tongue in that position (10, page 174)(also see 15, pages 345-6)
In his 1858 article, Silvester noted his method had many advantages, such as: (17, pae76)
  1. It could be performed while victim was in a warm bath
  2. It's easier to perform than Hall's method
  3. It allows for more air to enter the lungs (17, page 76)
Criticism of this method was that it was hard to perform and there were stories of victims who survived but had broken ribs and ruptured livers.  It was also hard to keep the tongue from blocking the airway, and depth of breaths (tital volume) were less than ideal, or so later physicians like Dr. E.A. Schaefer proved. (12, page 754)
The position of the patient and operator as well as the modus operandi,
are well depicted in figure 14  It consists of producing contraction of
the thorax by means of the operator's knee.  (19, page 75)  As usual,
there were probably more than one versions of this method.  Perhaps
a safer method would be so simply apply pressure to the chest by
placing the hands on the chest and applying pressure by force of
the upper body.  Either way, this method would be close in design
to modern chest compressoin. 

5.  1869:  Dr. Benjamin Howard's Method (Direct Method): (17, pages 78-79)  Dr. Howard was an American physician (10, page 171) who recommended  in 1871 (18, page 15) a method that entailed the following, as noted by Dr. Edward Schaefer in a 1904 report (Schaefer would later perfect Dr. Howard's method):
The only method of artificial respiration which is perfectly simple to apply, and which effects a sufficient exchange of air per minute, is that of intermittent pressure upon the lower part of the thorax. The introduction of this system, although it had been suggested by Erichsen and others, is due to Dr. Howard (1869). By Howard's method the patient in a case of drowning is first turned face downwards and the back is pressed upon two or three times to force out water from the lungs, after which he is turned face upwards. The operator is then directed to grasp the lower part of the chest and to press gradually forward with all his weight for three seconds, then with a push to jerk himself back and wait three seconds, repeating this eight to ten times a minute.
This method is simple, can be performed by one operator, and is fairly efficient so far as air-exchange is concerned. The drawbacks are (1) that the tongue is the face-up position tends to fall back and block the passage of air through the pharynx; (2) that there is risk of rupturing the liver (which is enormously swollen in asphyxia); (3) that there is risk of breaking the ribs if the operator is heavy and powerful, and if the patient be advanced in years. (12, page 754)(also see 15, pages 346-7)
He initially recommended his procedure in an 1869 five page pamphlet "Plain Rules for theRestoratoin of Persons Apparently Dead from Drowning."  The pamphlet set for some simple rules for performing artificial respiration, including: (17, pages 78-79)
  1. Set patient on his back
  2. Open the airway
  3. Kneel astride the patient and perform his procedure to breathe for victim
  4. His method should be continued for up to two hours (17, page 78-79)
So that was the Howard method.  It was modified by Dr. Schaefer. First, however, Dr. Schaefer noted the following regarding the drawbacks of the Howard method:
These drawbacks are avoided by keeping the patient in the face-down (or prone) position during the whole operation. The tongue then tends to fall forwards, and the weight of the operator's body being communicated through his hands, which are placed over the lower part of the back (lowest ribs), compresses the thorax and abdomen in such a way that the pressure is diffused over a considerable area, and is less localised than by the method described by Howard. This produces greater efficiency and reduces the risk if injury to ribs or viscera to a minimum. The muscular exertion required is only that needed to swing the upper part of the body backwards and forwards on the hands about twelve or thirteen times a minute, the operator kneeling by the side of or across the patient. The pressure is gradually applied and gradually released. The amount of air exchanged by this method per minute is greater than that yielded by any other which has been tried, and may even exceed the ordinary rate of exchange of the individual. It is perfectly simple and easy of application by boy, woman, or man.  (12, page 754)
Eisenberg quotes Howard from an 1877 article in The Lancet, in an article titled "The more usual methods of artificial respiratoin. With demonstrations of the 'direct method' of the author": "This method is called the 'direct method' because byit the few things neded to be done are, simply, done.  The tongue needs holding forward -- it is held; the ribs, pressing -- they are pressed.  It is so simple tht a Harbour policeman, after a single lesson, has done it as well as I.. can do it.  Adjunctive measures as friction, electricity, insufflation, or even tracheotomy, can be used simultaneously." (17, pages 80-81, 275)

This method was generally not accepted due risks of broken ribs and ruptured liver, which may explain why this author can find only a few descriptions nor pictures of the procedurs. (18, page 2)

6.  Ventilation (insuflation) with bellows:  It must be noted here that inflating lungs using bellows or other similar devices was referred to as insuflation prior to the term positive pressure being used in the 1950s.  Dudley Wilmon Buxton, in the 4th edition of his book "Anaesthetics, their uses and administration," explains the following: (16, page 347)
Professor H. C. Wood regards all the methods of artificial respiration mentioned as imperfect and inferior to  the following plan: A pair of bellows has a length of India rubber tubing attached to it. A face mask and two intubation tubes of different sizes are also in readiness. In the tubing "there should also be set a double tube, with an opening similar to that commonly found in the trachea cannula of the physiological laboratory, so that the operator can allow the escape of any excess of air thrown in by the bellows." Professor Wood gives the following directions for employing the apparatus: "In using this apparatus, the mask should be first tried, care being exercised to see that the tongue is well drawn forward and held in place by a thread through it, and that the epiglottis is kept open." If the face-piece does not succeed, intubation should be at once performed. In the use of either the face-piece or of intubation, the lungs should be slowly but thoroughly expanded by each stroke of the bellows. Care must be taken that only sufficient force is used to expand, not to rupture, the air-vesicles. The use of oxygen as the perflating gas greatly enhances the value of the method. The patient's body temperature should be maintained. Forced respiration is of especial value for persons with rigid chests. (15, page 347)
Buxton says that mouth to mouth breathing can also be used.  A method he does not describe is "infuflation" using a tracheostomy, although this technique is mentioned by others.

Gradually, this method, or variations of it, would become the preferred method of artificial respiration in the controlled setting, such as by caregivers in hospitals, ambulances, etc. Gradually the bellows were replaced with one of mechanical resuscitators (such as the Lungmotor or Pulmotor), and ultimately devices like the bag-valve mask AMBU-bag, and intermittent positive pressure breathing and mechanical ventilators of the 1950s and 1960s.

Fig. 1. This illustration shows Schaefer method first movement (inspiration)  
7.  The Edward A. Schaefer (Shafer) Method (Prone-Pressure Method): A committee was formed in 1899 by the Royal Medical Chirurgical Society and in 1903 Professor Edward A. Schaefer provided a report where he recommended a new method of resuscitation which was basically just a modification of the Howard Method.  (18, page 2)

The "new method" was introduced to the American Medical Society in 1908 by Professor Schaefer, and he referred to it as the Prone-Pressure Method. (1, page 7)(3, page 11) (4, page 53) The Schaefer method was recommended by two commissions in the United States.  In 1909 it was recommended by the Royal Society of Medicine.   Regardless, the Royal Humane Society, among others, continued to recommend Silvester's Method. (17, page 2)

Fig 2 -This illustration shows Schaefer method second movement (expiration)
The advantage over Howard's method is that the patient is prone, so that the tongue falls out of the way of the airway.  (17, page 3)  Another advantage was the this new method, when compared with other methods of manual respiration, provided the best tidal volumes, as per studies performed by Schaefer on conscious human beings. Although later studies by others on apneic (not breathing) human beings refuted the evidence, claiming that the Schaefer method resulted in the same tidal volumes, if not less, than the other methods. .  (15, page 4)

The Prone Pressure Method entailed the following as described in an August, 1913, entry in The Colliery Engineer:  (4, page 53)
  1. Pulling the patient away from danger
  2. Laying the victim on his stomach (prone position)
  3. Place victims arms above his head
  4. Turn victim's face to one side so the mouth and nose are not blocked by the ground
  5. Operator then kneels, straddling the victim and facing the victim's head (figure 1)
  6. Operator finds the landmarks of floating ribs (lowest ribs) and pelvis
  7. Operator places hands over lowest ribs (but not over pelvis)
  8. With arms straight, the operator swings forward slowly so that the weight of the body is gradually brought to bear upon the subject as shown in figure 2.  This produces expiration.  
  9. Immediately swing backward to remove pressure, but leave hands in place (as is shown in figure 1).  Through their elasticity, the chest walls expand, and the lungs are thus supplied with fresh air (inspiration)
  10. After 2 seconds, swing forward again.  Thus repeat deliberately 12-15 times a minute the double movement of compression and release -- a complete respiration in 4-5 seconds, the operator following the rate of his own deep breathing -- swinging forward with each expiration, and backward with each inspiration.  (4, page 53)(also see 15, pages 344-345)
This method was shown by various experiments to be superior to the Silvester Method due to the following reasons: (3, page 11)
  • Greater simplicity and ease of performance
  • Absence of trouble from the tongue falling back and blocking the air passages.
  • Little danger of injuries the liver or breaking the ribs if pressure be gradually -- not roughly -- applied
  • Larger ventilation of the lungs (3, page 11)
During the first 20 years of the 20th century various mechanical resuscitators were introduced to the market, such as the Bratt's Apparatus and the Lungmotor.  In 1907 the first mechanical ventilator was introduced to the Pulmotor, and quickly gained fame through stories reported by the media.  Rescue crews were equipped with one or more of these mechanical resuscitators.  Once on the scene, manual resuscitation was stopped and mechanical resuscitation started.  Of course the mechanical device was generally credited with saving the patient, regardless of whether this was true or not.

However, B.L. Wilson, who was responsible for the Pulmotor crew in Baltimore in 1922, noted the following:  (2, page 258)
Every policeman should be taught the "prone method" of resuscitation, so that while waiting for the pulmonator he could do his part in helping to bring some poor person back to life. The police are usually the first on the scene, and if they were equipped with pulmonators more lives could be saved in Baltimore than at present." (2, page 258)
The prone pressure method remained the most recommended method of manual resuscitation in the years that followed.  This, and all similar methods, were phased out in favor of mouth to mouth breathing, as a new method called cardiopulmonary resuscitation, gained favor during the 1950s and 1960s.  (14, page 539)

8.  Horseback riding on victim's chest:  This was never a recommended method of resuscitation, although I found it interesting that it was even brought up.  I'll leave a description of it to S. J. Meltzer:
Several years ago in a conversation which we had in London, Professor Schafer remarked that "if he were now confronted with the task of resuscitation he would kneel astride over the subject and perform the simple motions of horseback riding without employing his hands and arms at all." (17, page 3)
There is no further data that this technique was ever used. It is, however, comical that a respected physician would make such a comment, if that's all it was.

9.  1909:  Mouth to mouth breathing:  Yes, once again a physicians toyed with the idea that the best method of breathing was mouth to mouth breathing.  This time it was Dr. Robert H. Woods, an Irish throat surgeon.  He noted that this method was simple to do and could be started immediately upon finding the victim.  However, because the Schaefer and Silvester methods were so well thought of at the time, his "voice was stifled," according to Eisenberg. (17, page 82)

The Holger Nielson method became the most commonly recommended
method during the 1940s and 1950s until CPR was invented. Posters
like this were commonplace around water or other such places of danger.
They were also seen where artificial resuscitation training took place.
10.  1932:  The Holger Louis Nielson Method (back pressure-arm lift method):  Colnel Holger Louis Nielson (1866-1955) was a Danish army officer (16) (17, page 83) who devised a technique that was a combination of the Silvester and the Schafer methods. According to Mickey S. Eisenberg in his 1997 book "Life in the Balance:"
His original plan was to have two rescuers -- one to perform prone pressure on the lower back to cause exhalation while the other lifted the arms above the victim to facilitate inhalation.  But this method was rejected by the Danish Red Cross in 1930 because it required two rescuers Back to the drawing board.
Nielson's breakthrough came when he visited a masseur for relief from rheumatic pains in his shoulders and noticed that when the masseur pressed down on his shoulder blades, he experienced a forceful expiration.  This experience led him to suggest one rescuer positioned at the head of the victim, who alternates pressure on the upper back for expiration and lifts the arms for inhalation.  Nielson described his prone back-pressure arm lift methods in 1932, and presented physiological data to support the superiority of the method. Tidal volumes of 450 to 1750 milliliters were measured in relaxed, hyperventilated subjects, much better performance than other methods of artificial ventilation. (17, page 82)
By 1953 his method was the preferred method of the International Red Cross.  Of course use of the method was short lived, as by the end of the 1950s a better method was devised called Cardiopulmonary Resuscitation (CPR).  (17, page 82)

11.  1942: Emerson Method:  During WWII Jack Emerson joined V. Ray Bennett and Forrest Bird in the quest to invent a device that allowed pilots to fly higher and out of harms way. What he ended up inventing was a better method of artificial resuscitation, replacing the Shafer method.  Richard Branson described this method. (20, page 568)
This technique placed the patient in the prone position and alternately raised and lowered the patient's hips. The hipbones were grasped and lifted upward to create inspiration and drainage of fluid out of the lungs. When the hips were lowered, exhalation occurred. (20, page 568)
This method replaced the Shafer technique, and was commonly used until the mid 1940s when mouth to mouth breathing was preferred.

Peter Safar asked doll maker Asmund Laerdal (1913-1981) to make  a training
manikin to be useful for training people his new method.  Laerdal wanted to
make the manikin look like an unconscious person, although he didn't want
it to be scary.  At a relative's house he saw a death mask of a lady named
Annie who drowned herself.  Impressed by her "enigmatic yet peaceful gaze,"
he made the face of the manikin in he image.  Laerdal amply named the manikin
"Resusci-Annie."  Laerdal said he did not name the manikin after the person
he modeled the face after, but the first line of successful dolls that he made:
The Annie Dolls. (17, page 102)
12. 1954:  Mouth-toMouth breathing (expired-air resuscitation):  Back again, and it quickly becomes popular this time around.  In 1949 Anesthesiologist James Elam (1918-1995) attempted to use mouth to mouth breathing to save the life of a young boy, and it worked.  He learned about this method while reading "historical accounts of newborns."   (9)

Subsequent experiments by Dr. Elam in 1954 and Safer in 1958 proved that none of the previously used methods of artificial breathing (listed above) provided a deep enough  breath to be effective.  (6, page 590-591)

He also proved by his experiments that all of the previous methods of artificial respiration barely provided respiration at all, and they all also provided a very low amount of inspired oxygen to the patient.  As there is 21% oxygen in inspired air, there is only 16% in expired air.  Both the Schafer, Silvester and Nielson methods generated far less than 16 percent  (17, page 92).

By the 1950s there was a device that could measure the amount of inhaled oxygen that was absorbed into the blood and bound onto a hemoglobin molecule.  A normal human arterial oxygen saturation was shown to be about 98%. During experiments Elam performed in 1952 he proved that "total arterial oxygen saturatoin could be maintained at 100 percent. During experiments with the Schafer and Nielson methods, the oxygen saturation fell to 70 percent. (17, page 92)

Slowly but surely the various organizations in America and Europe accepted expired-air resuscitation as the preferred method of artificial respiration.  The organization that was slowest to adapt it was the American Red Cross.  However, due to the "ever growing body of scientific data," in 1958 the American Medical Association approved of the method, followed shortly thereafter by the American Red Cross.  (17, page 93, 101-102)

Expired-air respiration would ultimately gain "worldwide recognition and application (after the) publication, in 1959, of the National Academy of Sciences - National Research Council 'Statement on Emergency Artificial Respiration Without Adjunct Equipment'," according to Dr. Peter Safar (1924-2003) in 1966. (7, page 155)

Safar continued to work on mechanisms to deal with the various concerns regarding mouth to mouth breathing, mainly:
  •  Preventing the tongue from falling back and blocking the airway
  • The issue of poor hygiene and the fact that most people considered it to be gross
To deal with the former, he invented what was referred to as a Safar S-Tube that was inserted through the oral opening into the pharynx.  On the opposite end (the end sticking out of the mouth) was a mouthpiece, whereby the rescuer would provide breaths.  The S-Tube, thereby, acted as both an oral airway and as a means of providing ventilations.  (6, page 590-591)

Considering most bystanders wouldn't have such a device, he created a method called the chin lift jaw thrust, whereby the chin was lifted, and the jaw thrust forward.  The simple technique is still used to this day.

During the course of the 1950s a technique called CPR would be devised, and the only of the above methods to survive was, ironically, mouth to mouth breathing.  It's ironic how mouth to mouth breathing has come full circle. In the early 2000s it would once again come into question.

  1. "Drowning: Historical-Statistical Methods of Resuscitation," no author nor editor listed, Published by Lungmotor Company, Boston, Massachusetts, 1920
  2. "Pulmotor advertises gas company," Gas Age, volume 29, 1922, New York, Robbins Publishing Company Inc. 
  3. Cannon, Walter Bradford, George Washington Crile, Joseph Erlanger, Yandell Henderson, "Report of the Committee on Resuscitation from Mine Gases," Technical paper number 77, Department of Interior, Bureau of Mines, Joseph A. Holmes, Director, 1914, Washington, Government Printing Office
  4. "Schaefer Method of Resuscitation," The Colliery Engineer, August, 1913, Volume XXXIV, August 1913 to July 1914, Scranton, PA, International Textbook Co., page 53 (no author or editor listed)
  5. Hughes, Martin, Roland Black, "Advanced Respiratory Critical Care,"  2011, New York, Oxford University Press; material from section 3.1: "Invasive Ventilation Basics: Development of Invasive Ventilation (history)."
  6. Agasti, T.K. "Textbook of Anesthesia for Postgraduates," 2011, New Delhi, Jaypee Brothers Medical Publishers, page 590
  7. Safar, Peter, "Exhaled air ventilation and cardiopulmonary resuscitation," published in the following: Gordon, Archer S, editor, "Cardiopulmonary Resuscitation: Conference Proceedings," May 23, 1966, Washington D.C., National Research Council, pages 35-45
  8. Donahue, Mary, "History of Lifesaving," DeAnza Collegge,, accessed 8/10/13
  9. Smith, Stephen, "Hand-Book of Surgical Operations," 1862, New York, U.S. Army Medical Department, republished in 1990 in "The American Civil War Surgery Series, No. 8," U.S., Norman Publishing 
  10. Killick, Frederick H., "Resuscitation of the apparently drowned," The Dominion Illustrated Monthly, February, 1893, Montreal and Toronto, Vol. II, NO. 1, pages 171- 175 *Once the patient's natural breathing has been restored, the author recommends a variety or methods of warming the patient, such as "hot flannels, bottles, or bladders of hot water, heated bricks, etc... on restoration of life, a teaspoon of warm water should be given.  And then, if the if the power of swallowing have returned, small quantities of wine, warm brandy-and water, or coffee should be administered. The patient should be kept in bed, and a disposition to sleep encouraged." These passages can be found on pages 174-175 in the section "Treatment after natural breathing has been restored."
  11. O'Connor, W.J., "Founders of British Physiology: A biographical dictionary, 1820-1885,"  Chapter 2: Physicians, 1820-1835, 1988, U.K., Manchester University Press
  12. Schafer, E.A., "On the methods of artificial respiration," "Report of the seventy forth meeting of the British association for the advancement of science held at Cambridge in August 1904," 1905, London, John Murray,  page 754-755
  13. Gordon, Archer S., "History and Evolution of Modern Resuscitation Techniques,"  published in the following: Gordon, Archer S, editor, "Cardiopulmonary Resuscitation: Conference Proceedings," May 23, 1966, Washington D.C., National Research Council, pages 7-31
  14. Howarth, Glennys, Oliver Eaman, editors, "Encyclopedia of Death and Dying," 2001, New York, Routledge, page 539
  15. Buxton, Dudley Wilmot, "Anaesthetics, their uses and administration," 4th edition, 1907, Philadelphia, P. Blakiston's Sons and Co. 
  16. "Holger Nielson Method," Merriam Dictionary,,, accessed 8/19/2013
  17. Eisenberg, Mickey S., "Life in the Balance: Emergency Methods and the Quest to Reverse Sudden Death," 1997, New York, Oxford University Press
  18. Meltzer, S. J., "History and analysis of the methods of resuscitation," Medical Record: A Weekly Journal of Medicine and Surgery, July 7, 1917, Volume 92, Number 1; Thomas L. Stedman, editor, Medical Record, Volume 92, July 17, 1917 - December 29, 1917, New York, William Wood and Compay
  19. Guilford, Simeon.Hayden., "Nitrous oxide; it's properties method of administration, and effects," 1887, Philadelphia, Spangler and Davis, Printers
  20. Branson, Richard,  Branson, Richard D, "Jack Emerson:  Notes on his life and contributions to Respiratory Care," Respiratory Care, July 1998, vol. 43, no. 7, pages 567-71
Furhter reading:
  1. Knott, Arthur Reynolds, "Lie Saving and Artificial Respiration," 2nd edition, 1915, no city or publisher noted in book
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