Mouth-to-mouth (MTM) resuscitation is a foundational first-aid technique used to restore breathing in someone who has stopped inhaling or exhaling. While the act of breathing air into an unresponsive person may seem like an ancient practice, the modern, standardized method used globally is a surprisingly recent invention. The history of artificial respiration is long, but its scientific validation and adoption as a public health measure did not occur until the mid-20th century. This period established MTM as a reliable intervention, paving the way for the development of modern cardiopulmonary resuscitation (CPR).
Early Attempts at Resuscitation
Before the modern era, attempts to revive unresponsive individuals focused primarily on physically manipulating the patient’s body to move air in and out of the lungs. Early documented attempts, such as one in Scotland in 1732, used mouth-to-mouth breathing to revive a coal miner, but this method was not widely adopted. The Paris Academy of Sciences recommended mouth-to-mouth for drowning victims in 1740, but the practice soon fell out of favor.
From the mid-19th century through the first half of the 20th century, manual compression methods dominated resuscitation practices. Techniques like the Silvester method involved placing the patient on their back and rhythmically raising and lowering their arms. The Schafer method required placing the patient prone and applying pressure to the back. These methods incorrectly assumed that simply moving the chest walls was enough to provide adequate ventilation.
Historical practices were often ineffective, including the use of bellows to force air into the lungs or attempts to stimulate the patient with tobacco smoke enemas. The adoption of manual methods, despite their low efficacy, was partly due to the belief that exhaled air was toxic and the fear of disease transmission. The critical flaw in these techniques was that they failed to address the most common cause of obstruction: the patient’s own tongue blocking the airway.
The Scientific Validation of Rescue Breathing
The modern era of mouth-to-mouth resuscitation began in the 1950s with a scientific re-evaluation that proved its effectiveness. Anesthesiologists Dr. James Elam and Dr. Peter Safar were the primary figures who demonstrated the technique’s superiority over manual methods. Dr. Elam, in 1954, was the first to experimentally prove that a rescuer’s exhaled air contained enough oxygen to maintain adequate ventilation in a patient.
The collaborative work of Elam and Safar, beginning around 1957, was groundbreaking. They demonstrated that the major obstacle to successful artificial respiration was an obstructed airway, not a lack of oxygen in the rescuer’s breath. Their research established the “head tilt/chin lift” maneuver as the necessary first step to open the airway, integrating this concept into the first two steps of the “ABCs” of resuscitation: Airway and Breathing.
Safar published definitive research in 1958 showing mouth-to-mouth ventilation was significantly more effective than manual methods. By 1957, the United States military had already adopted the method. The National Academy of Sciences officially endorsed the head-tilt and direct mouth-to-mouth ventilation technique as the preferred method of artificial respiration for adults and children in 1957.
Institutional Adoption and Public Training
Following the scientific validation, the process of integrating mouth-to-mouth into public health guidelines began immediately. The technique was combined with external chest compressions, developed by Drs. Kouwenhoven, Jude, and Knickerbocker, to create Cardiopulmonary Resuscitation (CPR) in 1960. The American Medical Association and the American Red Cross officially sanctioned the use of the head-tilt and mouth-to-mouth technique in 1958.
The American Heart Association (AHA) began publicizing the combined technique, issuing its first formal set of CPR guidelines in 1966. The American Red Cross formally endorsed CPR in 1962 and began expanding training to the general public. The widespread adoption of the technique was accelerated by the development of the first realistic training manikin, the “Resusci Anne,” in 1960.
This training device allowed instructors to teach the technique to laypersons without the complexity associated with older manual methods. The public promotion of rescue breathing, sometimes referred to as the “Kiss of Life” campaign, successfully replaced the outdated manual techniques. Public education campaigns in the 1960s and 1970s cemented mouth-to-mouth as a standard first-aid skill globally.
Modern Changes to Resuscitation Protocols
Since its initial adoption, resuscitation science has continually refined the practice of MTM and its role within CPR. The original protocol, known as A-B-C (Airway, Breathing, Compressions), prioritized opening the airway and administering rescue breaths before beginning chest compressions. Research showed that a delay in starting chest compressions significantly lowered survival rates, especially for victims of sudden cardiac arrest.
This evidence led to a major change in the guidelines in 2010 by the AHA, shifting the sequence to C-A-B (Compressions, Airway, Breathing). The C-A-B sequence emphasizes immediate chest compressions to circulate the oxygen that remains in the victim’s bloodstream. This change also addressed the reluctance of many bystanders to perform mouth-to-mouth on a stranger, resulting in a simpler, “hands-only” CPR recommendation for untrained lay rescuers dealing with adult cardiac arrest.
Hands-only CPR, which omits rescue breathing, is now the preferred method for most adult cardiac arrests when performed by a layperson. However, rescue breathing remains a fundamental part of resuscitation for specific scenarios, such as drowning, drug overdose, and for victims whose cardiac arrest is likely due to a breathing problem, including children and infants. This evolution reflects an ongoing effort to simplify the process for bystanders while maximizing the chance of survival.