On the morning of April 17, 1769, a woman named Anne Wortman was found lying facedown in a shallow Amsterdam canal, not breathing and without a heartbeat.

But when two bystanders — Andrew de Raad and Jacob Toonbergen — came upon her, they were convinced she wasn't yet dead and could be resuscitated. First, they rolled her back and forth over a log, which was a common resuscitation practice at the time. Then they brought her to an apothecary, who rubbed her with ammonia, blew tobacco smoke into her rectum, breathed into her mouth through a handkerchief, and tickled the back of her throat with a feather.

Against all odds, Wortman came back to life — and eventually, her case gave rise to the modern science of resuscitation.

resuscitation has quietly become a mundane reality

We're now at a point where resuscitation has quietly become a mundane reality, with millions of people certified in CPR and automatic defibrillators installed in thousands of public buildings. But how did we get here — and what does the future of resuscitation look like?

David Casarett, a hospice physician and professor at the University of Pennsylvania medical school, recently explored all sorts of aspects of resuscitation — from the weird history to the intriguing experimental science to the overlooked ethical concerns — in his new book Shocked: Adventures in Bringing Back the Recently Dead. He spoke with me to share some of the most notable things he's learned about the topic.

1) People once tried tickling, barrel-rolling, and smoke-blowing as resuscitation techniques

Around the time of Wortman's resuscitation in 18th century Europe, Casarett says, people began systematically trying to bring back the recently deceased. Most of their methods were ineffective — and oftentimes, downright bizarre.

"If you look through the list of things that people thought might be helpful, it involved everything from putting people’s feet in boiling water, to rolling them back and forth over a barrel, to tickling them with a feather, to beating them with whips, to draping them over a trotting horse, to blowing smoke in various orifices — which I write about in more detail, maybe, than most people want to read," Casarett says.

The main two approaches were a bit less strange, and philosophically opposite: "There was a feeling, among drowning victims especially, that the best approach was to warm them up. You put them in front of a fire, you put their feet in hot water, you climb into bed with them," Casarett says. "And at the same time, there was something known ominously as the 'Russian Method.' It involved putting people in ice or snow."

Although neither approach was exactly right, they also weren't totally off. "What's interesting is that there’s actually a little bit of science behind both of them. It is easier to restart someone’s heart if that heart is warm," he says. "But the colder you are, the lower your metabolism is, so you’re able to tolerate longer periods of not having a heartbeat."

2) Mouth-to-mouth and electrocution go back hundreds of years

In addition to the ineffective and bizarre methods most commonly used, though, Europeans hit on a couple of useful ways to bring back the recently dead at a surprisingly early date.

Sometime during the 1760s, a group called "The Society in Favour of Drowned Persons Here in Amsterdam" printed a set of resuscitation guidelines that said "let one of the assistants, applying his mouth to that of the drowned, closing the nostrils with one hand, and pressing the left breast with the other, blow with force, and endeavor to inflate the lungs." Although the technique didn't become widely used for some time for centuries, the Society appears to have discovered mouth-to-mouth resuscitation.

Casarett also found that electrocution — one of the chief methods we use today to restart a stopped heart, through the use of defibrillators — is older than many people think. "Some of the earliest reports of resuscitation using electricity came from the 18th century," he says.

In 1774, for instance, a report by the British Royal Humane Society — another organization devoted to promoting resuscitation — details how, after a woman named Ms. Greenhill fell out of a window and became unconscious, she was taken to London's Middlesex Hospital, and repeatedly shocked by a surgeon named Mr. Squires. After he tried applying wires to various places on her body, he tried her chest, which caused her to begin breathing again and eventually wake up.

3) Automated external defibrillators are probably the most important invention ever for bringing people back to life

When it comes to the modern science of resuscitation, Casarett says, the most important thing for people who've suffered a cardiac arrest is to try getting their heart restarted as soon as possible, before extensive brain damage occurs due to a lack of oxygen. This damage beings occurring about three to five minutes after the heart has stopped, and though CPR can keep some blood flowing through the body, it can't restart the heart.

"The latest, greatest development towards this goal is the automated external defibrillator [AED], which are now turning up in places like bus stations, train stations, and shopping malls," he says. These devices automatically detect a person's heartbeat (or lack thereof) and effectively allow anybody to administer the crucial shock to get it restarted.

How much of a difference do they make? Casarett writes of one study that found that someone who suffers a cardiac arrest outside a hospital and only gets CPR has a 9 percent chance of surviving. Someone who's treated with an AED, on the other hand, has a 24 percent chance of survival.

"Think of how ubiquitous ATMs are, and that would give you an idea of how many AEDs we need out there," Casarett writes.

4) You no longer need to do mouth-to-mouth for CPR

If there's not an AED around, CPR is still the best option. But one big thing has recently changed in CPR guidelines.

"It was thought for a long time that it ideally included both breathing for that person — mouth to mouth — and also chest compressions. But people are beginning to realize now that it’s mainly the chest compressions that matter," Casarett says. "And so there’s a move to encourage hands-only CPR, for two reasons: that’s where most of the benefit is, but also because there’s this 'ick' factor associated with mouth-to-mouth that prevents a lot of people from even trying CPR."

For people trained in CPR, guidelines still suggest doing mouth-to-mouth as well as chest compressions, because it can make a slight difference. But for untrained people (or people who got training a while back and are rusty), experts say simply doing chest compressions at a rate of 100 per minute (about the tempo of the Bee Gees song "Stayin' Alive) is the way to go.

5) We might be able to figure out suspended animation from lemurs

The next step in resuscitation, Casarett says, is prolonging the amount of time someone can survive without a heartbeat, without suffering brain damage. "Right now, it's about five minutes," he notes. "But what if you can extend that time from ten minutes to twenty, or thirty, or even an hour? You have to buy time, so that rather than trying to hurriedly resuscitate someone in the field, you could load them into an ambulance and take them into an ICU."

If you say 'suspended animation' to most people, they think science fiction, and they laugh," he says. "But in fact, that’s where a lot of the really neat science is going these days." One theoretical method of doing that, he writes, is suspended animation : essentially, putting someone's life on pause. "





Some of it involves research into animal species that hibernate, to understand the physiological changes that allow them to survive in this state. For the book, Casarett visited the Duke Lemur Center , where scientists are studying how lemurs — the only species of primate to hibernate — use hormones to put themselves into hibernation seasonally, then wake themselves up in the spring. It's still a ways off, but it's possible that this sort of basic research could help us figure out if suspended animation for humans is a real possibility.

6) Freezing a human body is really, really hard

Casarett also attended a conference for cryonauts — people willing to spend thousands of dollars to have their bodies frozen after they die, so they might someday be revived as medicine progresses in the future.

The main problem with this seemingly simple idea? "You’d think that freezing a person would be pretty easy," Casarett says. "But it turns out that the sheer physics of freezing someone and having them come out in one piece make it really, really difficult."

One problem is that the formation of ice crystals alters the balance of fluids inside and outside of cells. Another is that ice expands by about 9 percent in volume as it freezes, so the water inside cells wreaks havoc on their architecture as it crystallizes.

"Just taking somebody who’s died, then freezing them, and thawing them — forget bringing them back to life — that’s going to be really difficult to do while maintaining the structural integrity of their organs," Casarett says. The best we've done so far is freeze extremely small bits of tissue, like corneas and heart valves.

7) There are all sorts of ethical issues tied up in resuscitation

In February 2013, Casarett writes, an 87-year-old woman named Lorraine Bayless collapsed and died at a retirement home in California. Her case became infamous because the nurse who called 911 was told to perform CPR — and refused, citing facility policy that dictated she was only permitted to wait with the resident until trained responders arrived. An outpouring of criticism ensued.

But Bayless, it turns out, had said she'd wanted to die a natural death — something that's becoming ever more rare in our society.

"It’s gotten so that CPR has become the default: if you have a cardiac arrest, no matter where you are, unless you’ve explicitly told people not to resuscitate you and have a bracelet, you will get it," Casarett says. "Think of the message from the American Heart Association: 'You can save a life.' If somebody has a cardiac arrest in front of you, the thinking goes, not only can you save them, but you should save them. It’s a moral obligation."

'we keep bringing people back to life, but we're not making them any healthier'

In reality, though, things aren't so simple. "It’s easier to restart somebody’s heart than to cure whatever caused that heart to stop in the first place," Casarett says — something he knows well from his hospice work. "We keep bringing people back to life, but we’re not making them any healthier."

He writes about a patient whose heart he restarted, only to see him survive unconscious at the ICU for 18 days. This exacted an enormous emotional toll on his family. It also exacted huge financial costs on our medical system, of the sort we're still not comfortable talking about. At the same time, there are thousands of cases where the availability of AEDS and CPR being the default treatment, he says, have led to people living longer, healthy lives — and by nature, it's impossible to diagnose each case in the instant when CPR is still a possibility.

"I think one of the big challenges of all this is that we’ve gotten much better at bringing people back from the dead than we are at talking about whether it’s a good idea," he says. "If we were as good at having those uncomfortable family discussions about goals, and preferences, and quality of life, we'd be much more capable of sorting out some of these difficult cases."