The History of CPR: From Ancient Practices to Modern Guidelines

Depiction of a CPR class in 1960. Not a historical photo.

The History of CPR

In communities across United States, and around the globe, Cardiopulmonary Resuscitation (CPR) is recognized as a critical, life-saving intervention. From workplace safety training to high school health classes and advanced protocols used by paramedics, the coordinated steps of chest compressions and rescue breathing are widely understood as the first line of defense against sudden cardiac arrest. Yet, this seemingly straightforward procedure, now grounded in rigorous scientific evidence, has a surprisingly long, complex, and often bizarre history. The journey from ancient resuscitation rituals to the standardized guidelines we follow in 2025 is a captivating story of observation, innovation, scientific breakthroughs, and the persistent human desire to snatch life back from the brink of death.

Understanding this history not only highlights how far medical science has come but also underscores the profound impact of the discoveries that led to the effective techniques we rely on today. Let's embark on a journey through time to explore the fascinating evolution of CPR.

Whispers from Antiquity & Early Resuscitation Efforts (Pre-18th Century)

The desire to revive the apparently dead is as old as humanity itself. While not CPR in any modern sense, ancient texts contain accounts that hint at resuscitation attempts. Perhaps the most cited is the biblical story of the prophet Elisha apparently reviving a boy, described as placing his mouth on the child's mouth. However, for centuries, attempts to restore life were based more on superstition, guesswork, and rudimentary observations than any understanding of physiology.

Early methods were incredibly varied and often ineffective, sometimes even harmful:

• Inflation Attempts: As far back as the 2nd century, the Greek physician Galen reportedly tried, unsuccessfully, to inflate a dead animal's lungs using bellows. This idea of forced ventilation would reappear sporadically over the centuries.

• Stimulation Methods: Believing life could be shocked or stimulated back into a body, various methods were employed. These included flagellation (whipping the victim), applying heat or cold, and vigorously shaking or rolling the body.

• Inversion & Rolling: Hanging victims upside down or rolling them over barrels was thought to help clear airways or stimulate the body.

• Fumigation: Perhaps one of the most peculiar methods involved attempting to stimulate the victim internally via rectal or oral fumigation, most notably using tobacco smoke blown through a tube or bellows. This was surprisingly common for a time, particularly for drowning victims.

These early efforts, while well-intentioned, suffered from a fundamental lack of knowledge about how the heart, lungs, and circulation actually worked.

⌛1700s. The Enlightenment & Organized Humane Efforts

The 18th century saw a shift towards more organized and slightly more rational approaches, particularly driven by the increasing number of drowning incidents in European cities.

• Humane Societies: In 1767, the "Society for the Recovery of Persons Apparently Drowned" was founded in Amsterdam, followed soon after by similar organizations like the Royal Humane Society in London. These groups aimed to promote standardized resuscitation methods.

• Mouth-to-Mouth Reappears: The Paris Academy of Sciences, in 1740, officially recommended mouth-to-mouth resuscitation for drowning victims. This marked a significant step towards recognizing the importance of breathing, though the technique would fall in and out of favor over the next two centuries, often due to aesthetic objections or doubts about its effectiveness.

• Manual Methods: As mouth-to-mouth faced resistance, various manual techniques emerged that focused on manipulating the chest and abdomen to force air in and out of the lungs. Methods developed by Dr. H.R. Silvester (lifting the arms above the head and pressing them against the chest) and later Holger Nielsen (prone position with arm lifting and back pressure) became standard practice and were taught well into the 20th century.

• Electricity's Spark: The late 18th and 19th centuries also saw growing fascination with electricity and its potential biological effects, with some early suggestions about using electrical shocks to restart the heart.

While these methods represented progress, they still lacked the coordinated approach to circulation and ventilation that defines modern CPR.

⌛1900s. The Early-20th Century Development: The Birth of CPR

While the combination of chest compressions and rescue breathing as we know modern CPR wasn't fully established within the 1900s, however the discoveries during this period laid important groundwork.

• Early 1900s: Dr. George Crile's research confirmed that external chest compressions could restore circulation in dogs. He also reported a successful case of closed-chest cardiac massage in a human. However, this non-invasive technique did not become widely adopted at the time, and open-heart massage remained the standard.

• 1924: The American Heart Association (AHA) was founded on June 10, 1924, in Chicago, Illinois. It was initially formed by six cardiologists as a professional society for doctors focused on the heart.

• 1933: Researchers at Johns Hopkins University, led by electrical engineer William Kouwenhoven, accidentally rediscovered the effectiveness of external chest compressions. They found that applying pressure to a dog's sternum provided sufficient blood circulation to the brain to keep the animal alive until defibrillation could restart the heart. This discovery, confirmed in over 100 dogs, was a significant step towards modern CPR techniques.

• 1947: While not directly related to chest compressions or mouth-to-mouth resuscitation that we typically associate with CPR today, Dr. Claude Beck performed the first successful use of an electric defibrillator on an exposed human heart. This was a crucial advancement in the treatment of cardiac arrest, demonstrating the potential to restore a normal heart rhythm using electrical shocks.

⌛1950s. The Mid-20th Century Revolution: The Birth of Modern CPR

The 1950s marked a turning point, driven by pioneering research that finally combined the essential elements of resuscitation based on scientific understanding.

• Electric defibrillator: The first successful use of an electric defibrillator on an exposed human heart was performed in 1947 by cardiothoracic surgeon Dr. Claude Beck in Cleveland, Ohio. This device was not portable, as it was used during an open-chest surgery in a hospital setting.

• Breathing Rediscovered (1950s): The long-debated effectiveness of mouth-to-mouth resuscitation was conclusively proven. Anesthesiologists Dr. James Elam and Dr. Peter Safar conducted critical research demonstrating that expired air from a rescuer contained sufficient oxygen (around 16-17%) to keep a victim oxygenated. Crucially, Dr. Safar refined the technique by incorporating the essential step of opening the airway using the head-tilt/chin-lift maneuver, preventing the tongue from obstructing airflow. Safar’s work, often summarized in his concept of the "ABC of Resuscitation" (Airway, Breathing, Circulation), laid the groundwork for effective ventilation.

• Circulation Solved (Late 1950s): Simultaneously, a breakthrough in maintaining circulation occurred at Johns Hopkins University. Electrical engineer Dr. William Kouwenhoven was working on developing external defibrillators. His research fellow, Guy Knickerbocker, made a serendipitous observation during experiments on dogs: applying the heavy defibrillator paddles firmly to the dog's chest caused a temporary rise in blood pressure, even when the heart was in fibrillation. Knickerbocker shared this observation with Dr. James Jude, a cardiac surgeon. Jude immediately grasped the significance – forceful, rhythmic pressure on the outside of the chest could squeeze the heart and manually circulate blood.

• Putting It Together: The Johns Hopkins team rigorously tested external chest compressions, first on animals and then, starting in 1959, on human patients. They found they could maintain significant blood flow and dramatically extend the window for successful defibrillation. Their landmark paper published in the Journal of the American Medical Association (JAMA) in 1960 detailed their success. When these external chest compressions were combined with the airway and breathing techniques championed by Safar and Elam, modern CPR as we know it was born – a coordinated effort to provide both ventilation and circulation.

⌛1960s: Standardization, Training, and the AHA

The groundbreaking discoveries of the 1950s needed to be translated into standardized practice and widespread training.

• The three doctors who are credited with discovering that combining mouth-to-mouth breathing and chest compressions was an effective treatment in 1960 were Dr. Peter Safar, Dr. William Kouwenhoven, and Dr. Archer Gordon. These doctors were closely associated with the American Heart Association (AHA) and their work was instrumental in the development of CPR guidelines that the AHA would later champion.

• The AHA Steps In: The American Heart Association played a pivotal role. Recognizing the significance of these breakthroughs, the AHA started a program in 1960 to train physicians in closed-chest cardiac resuscitation. In 1963, under the leadership of cardiologist Dr. Leonard Scherlis, the AHA established its CPR Committee and formally endorsed CPR.

• Setting Standards: The first National Conference on Cardiopulmonary Resuscitation and Emergency Cardiac Care was held in 1966, bringing together experts to establish the first standardized CPR guidelines. This marked the beginning of a regular process of reviewing scientific evidence and updating recommendations.

• Training Dissemination: The AHA, often collaborating with organizations like the American Red Cross, began developing training materials and programs to teach CPR not only to healthcare professionals but also, eventually, to the general public. The development of lifelike training manikins, such as the famous "Resusci Anne," was instrumental in enabling effective hands-on skills practice.

• Portable defibrillator: In 1965, while working as a consultant cardiologist at the Royal Victoria Hospital in Belfast, Northern Ireland, Pantridge developed the first portable defibrillator.

Refining the Recipe: The Evolution of CPR Guidelines

CPR guidelines are not static. They have undergone significant evolution over the past six decades, driven by ongoing research aimed at optimizing effectiveness and improving survival rates. International collaboration through ILCOR (International Liaison Committee on Resuscitation) ensures that guidelines worldwide are based on the latest and best scientific evidence. Key evolutionary changes include:

• Compression-Ventilation Ratios: Early guidelines often used a 5:1 or 15:2 ratio. Recognizing the paramount importance of blood flow generated by compressions, the ratio for single-rescuer adult CPR was standardized to 30:2 in 2005 to maximize compression time and minimize pauses for breaths.

• Compression Rate: The recommended speed has increased over time. Early guidelines were less specific or suggested slower rates (~60/min). Research showed faster rates improved outcomes, leading to recommendations of 80-100/min, and finally settling on the current standard of 100-120 compressions per minute.

• Compression Depth: Guidelines became more specific about how deep to push. The current recommendation for adults is at least 2 inches (5 cm) but no more than 2.4 inches (6 cm) to ensure effective compression without causing unnecessary injury.

• Emphasis on Quality Compressions: Beyond rate and depth, guidelines increasingly emphasize allowing full chest recoil between compressions (letting the chest fully expand to allow the heart to refill) and minimizing interruptions to chest compressions for any reason (like rescue breaths or rhythm checks). The concept of "Chest Compression Fraction" (the percentage of time during resuscitation that compressions are actually being performed) emerged as a key quality indicator.

⌛1980s: The Defibrillation Difference: Integrating AEDs

While CPR keeps oxygenated blood flowing, it doesn't usually restart a heart stuck in a fatal rhythm like ventricular fibrillation (VF). That requires defibrillation – an electrical shock.

• From Manual to Automated: Early defibrillators were large, manual devices operated only by highly trained medical professionals. The major breakthrough came with the development of Automated External Defibrillators (AEDs). These portable, user-friendly devices analyze the heart rhythm automatically and guide the user (even laypersons) through delivering a shock if needed. The first truly AED designed for public use was developed in the late 1970s by the Cardiac Resuscitation Company. This unit was launched under the name Heart-Aid.

• Public Access Defibrillation (PAD): The advent of AEDs led to the concept of Public Access Defibrillation in the 1990s, advocating for placing AEDs in public locations like airports, schools, gyms, and workplaces.

• Integral Part of CPR: AED use is now fully integrated into CPR training at all levels and is recognized as a critical link in the Chain of Survival. Early CPR combined with rapid defibrillation provides the best chance of survival for victims of VF cardiac arrest.

Simplifying for Action: The Advent of Hands-Only CPR

Despite decades of CPR training, bystander response rates remained stubbornly low, often due to hesitation about performing mouth-to-mouth ventilation.

• Evidence for Compressions: Research emerged showing that for witnessed sudden cardiac arrest in adults, chest compressions alone (Hands-Only CPR) were nearly as effective as conventional CPR with breaths in the first few minutes. This is because, initially, there is still residual oxygen in the victim's blood, and circulating that blood is the immediate priority.

• Lowering Barriers: Recognizing this, the AHA and other organizations launched campaigns around 2008 promoting Hands-Only CPR for the public. The simple steps – Call 911, then Push Hard and Fast in the center of the chest – were designed to be easier to remember and perform, encouraging more bystanders to act immediately without the perceived barrier of rescue breaths.

• Important Caveats: It's crucial to note that conventional CPR with breaths is still recommended for trained responders and is considered essential for children, infants, and victims of unwitnessed collapse or respiratory arrest (like drowning or overdose), where oxygen depletion is the primary problem.

CPR in 2025 and Beyond

Today, CPR guidelines reflect decades of research and refinement. The core principles focus on high-quality chest compressions (rate 100-120/min, depth 2-2.4 inches for adults, full recoil, minimal interruption), coordinated with rescue breaths in conventional CPR (30:2 ratio), immediate activation of emergency services, and rapid use of an AED.

The future of CPR likely involves continued refinement of techniques, wider implementation of CPR feedback devices to improve quality during resuscitation, enhanced dispatcher-assisted CPR programs, leveraging technology like mobile apps for training and AED location, and ongoing efforts to increase public awareness, training rates, and willingness to act, while also addressing disparities in care.

Conclusion: A Legacy of Life-Saving Innovation

The journey of CPR from ancient rituals and misguided practices to the evidence-based protocols of today is a remarkable testament to scientific inquiry, medical innovation, and dedicated pioneers. What was once a mystery shrouded in fear and ineffective techniques has transformed into a standardized, teachable skill that empowers millions worldwide to intervene during life's most critical emergencies. The development of mouth-to-mouth resuscitation, external chest compressions, standardized guidelines, AEDs, and Hands-Only CPR represents countless lives saved and families kept whole. Appreciating this history reminds us of the power of persistent research and the profound impact that learning and performing CPR correctly can have. It is a legacy worth learning, preserving, and acting upon.