To the Editor:-The review of Juvin and Desmonts [1] is excellent, especially with respect to French contributions to internal cardiac massage. However, two pioneers are missing.

Firstly, Janos Balassa (1814–1868) should be mentioned, who, in 1858, successfully performed cricothyrotomy followed by chest compressions during a case of asphyxia from laryngitis. [2–4]

Secondly, Rudolf Eisenmenger (1871–1946) published, in 1903, a device for suction and pressure on the abdomen (and lower chest) to promote breathing and circulation. [5] He was the first to propose active compression-decompression cardiopulmonary resuscitation (ACD-CPR) and a device (Lautenschlager, Munich, Germany) to do so, which was later named Biomotor. [6] With his device at least one successful resuscitation in cardiac arrest is documented. [7] Animal experiments in 1929 showed the device to generate not only blood pressure, but also blood flow, as evidenced by carbon dioxide exhalation and transport of intravenously injected dye to all parts of the body. [8] Eisenmenger worked on and published information about ACD-CPR from 1903 until 1942. [9] He thus upheld external cardiac resuscitation in the "dark age" between World Wars I and II. Although the device was used as a ventilator in several hospitals, few contemporaries took the idea of ACD-CPR seriously. [6] In 1994 Smithline et al., [10] using a Hayek Oscillator (Breasy Medical, London, UK) as a substitute for the Biomotor, confirmed his findings.

Katharina P. Koetter, M.D.

Neurological Critical Care Unit; Leopoldina-Hospital; Schweinfurt, Germany

Wolfgang H. Maleck, A.R.Z.T.

Anesthesiology; Klinikum Ludwigshafen; Ludwigshafen, Germany

(Accepted for publication January 14, 1999.)

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Robicsek F, Littmann L: The first reported case of external heart massage. Clin Cardiol 1983; 6:569-71
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Koetter KP, Maleck WH, Petroianu GA, Ghisoiu S: Eisenmengers biomotor-predecessor of active-compression-decompression cardiopulmonary resuscitation, Proceedings of the Fourth International Symposium on the History of Anaesthesia. Edited by Schulte am Esch J, Goerig M. Lubeck, Drager, 1998, pp 405-20
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Smithline HA, Rivers EP, Rady MY, Blake HC, Nowak RM: Biphasic extrathoracic pressure CPR. A human pilot study. Chest 1994; 105:842-6