Civil War CPR

[kyle.dalton]

Engraving from Dr. Marshall Hall, "Asphyxia: Its Rationale and its Remedy," The Lancet, April 12, 1856, pages 393-394, Princeton University via HathiTrust.​

Cardiopulmonary resuscitation (CPR) is a fairly new invention, but far from the first effort to revive trauma victims whose breathing had ceased.

Early European efforts at resuscitation focused primarily on drowning victims and stillborn children. Several societies in eighteenth century Europe were formed to develop methods of resuscitation and train others on how to use them. Some of their techniques are familiar to us today, like mouth-to-mouth. Some are rather foreign, like sticking a bellows in the mouth of a patient or bleeding them. It is from this era and these societies that the infamous use of a tobacco enema was suggested for drowning victims.

In the years immediately preceding the Civil War, new and more effective techniques were introduced in England, and at least one found widespread use among Civil War surgeons.

Dr. Marshall Hall introduced his "Ready Method of Resuscitation" in the British medical journal The Lancet in 1856. Hall criticized previous methods proposed by the Royal Humane Society, which delayed treatment by advising that victims be carried "to the nearest house" before treatment was administered and laid on their back without taking the tongue into consideration. As anyone who has taken CPR classes today knows, the tongue may block airways and prevent breathing, and if CPR is necessary it must be performed immediately.

Hall's Ready Method of Resuscitation called for the patient to be laid on their stomach with their wrist placed under their forehead. He advised against using bellows for artificial respiration as "the violence used by them is apt to tear the delicate tissues of the lungs." He believed laying the patient down on their stomach was enough to push air from their lungs through the weight of their own body. Attendants would then rock the patient onto their side "rather more than the quarter of a circle…and inspiration-effectual inspiration-will take place!" The process was to be repeated until the patient was breathing on their own. In a follow up paper, Hall suggested also using ammonia as smelling salts, massaging the limbs, and splashing the face of the patient with cold water.

Engraving from Dr. Marshall Hall, "The Ready Method of Asphyxia," The Lancet, October 25, 1856, Vol 2, page 458, Princeton University via HathiTrust.​

Two years later Dr. Henry R. Silvester offered his own method of resuscitation. After experimenting on the lung capacity of a cadaver using Hall's Method, Silvester found that the air capacity of the lungs was not increased, so Hall's Method relied on what air was already present in the lungs of the patient. Instead, Silvester proposed laying the patient on their back, then lifting the shoulders to allow the head to drop back (thus freeing the tongue). The arms would be crossed over their body and the rescuer would press on their chest. Assistants would then raise and lower the patient's arms to open the lungs.

J. Edgar & Louise S. Monroe Library, Special Collections & Archives, Loyola University New Orleans via GIPHY.​

The intentions of their European counterparts for reviving drowning victims and stillborn children were used by American physicians, sometimes with success. It was also applied to narcotic overdoses, which appears to have been the main motivator behind Dr. Henry Fraser Campbell's method of resuscitation.[1] This was the first American answer to new English techniques. Campbell proposed arranging the patient in a sitting position with one assistant holding the head up. Two others would stand on each side raising their arms and slightly lifting them before lowering them and pressing them "close against the sides of the Thorax so as to compress the chest." Meanwhile, the doctor would hold the tongue down with the handle of a spoon (like a modern tongue depressor) or his fingers to keep the airways clear. Dr. Campbell was a strong advocate of caffeine as a stimulant, and at least once used a hypodermic injection of caffeine in conjunction with his method. Campbell would later serve as a surgeon in Richmond for the duration of the war.

Hypodermic needle, National Museum of Civil War Medicine collection, 2009.012.001.​

While traumatic capital amputations were rare in the Antebellum Era, they were the most common surgical operation of the conflict, meaning that surgeons were administering general anesthesia on an unprecedented and staggering scale. At least eighty thousand surgeries were performed under anesthesia in the North alone. Though overdosing was rare, it was inevitable when being applied in so many cases. Anesthesia overdose became the primary reason surgeons required training in artificial respiration and resuscitation.

In early versions of his Manual of Military Surgery, Dr. J.J. Chisolm said nothing about resuscitation. By 1863, Chisolm had seen enough of anesthesia to advise his fellow Confederate surgeons that in the case of anesthetic overdose "artificial respiration is to be instituted by either Marshall Hall's ready method, by Sylvester's, or by that of Prof. Campbell, of Georgia." It is difficult to say which of these methods found the most traction among Confederate doctors, but U.S. sources are quite clear. Silvester's method is mentioned nowhere in the voluminous Medical and Surgical History of the War of the Rebellion's case notes, nor is Campbell's. In the section detailing efforts to revive overdose patients, Hall's Ready Method is specifically named more than half a dozen times.

Modern CPR is a last-ditch effort to save a patient, and mortality is high. Even in the best conditions, a majority patients who undergo CPR will not survive. CPR gives the best possible chance of survival to patients already in dire straits, especially with the aid of an automatic electronic defibrillator (AED). The surgeons of the Civil War had neither the benefit of modern CPR nor AEDs.

Hall's Ready Method was employed in overdose cases, but rarely with any success. Surgeons appear to have combined it with other techniques, including the ill-defined "artificial respiration" which may have included bellows, mouth-to-mouth, or versions of Campbell's and Silvester's methods, likewise with low success rates.

But some patients did pull through. Private Samuel R. Green of the 5th​ New Hampshire was wounded in the leg on the second day of Gettysburg and underwent an amputation at a field hospital. Assistant Surgeon Charles S. Wood wrote in his report:

Out of the hundreds of cases in which I have administered chloroform this is the only one accompanied by any unpleasant symptoms; here the patient sunk under its use, was apparently dead, and respiration and circulation both ceased. But by the continual use for some ten or fifteen minutes of Marshall Hall's ready method he was restored and the operation was proceeded with. The cause was evidently inattention on the part of the administrator [of the chloroform].

In another case, Hall's Ready Method was quickly abandoned. Private Abraham Boyd, a Confederate soldier also wounded at Gettysburg, was undergoing an operation at a general hospital in Frederick, Maryland when "pulsation in the brachial artery was noticed to be running down rapidly, and the respiratory movements of the chest and abdomen were observed to have ceased." Hall's Method was "kept up for about half a minute" when the attending surgeon Dr. R.F. Weir decided to "open the larynx" and induce respiration through "compressing and relaxing the chest and abdominal walls," perhaps a version of Silvester's Method. After two more minutes, breathing returned to normal and the pulse was perceivable. Recognizing that the surgery was too risky to proceed, Dr. Weir sent Boyd back to the ward to recover.

The most famous case of resuscitation is that of President Lincoln on the night of his assassination. Dr. Charles Leale happened to be in the audience at Ford's Theater the night Lincoln was shot and was lifted to his box to attend him almost immediately after the attack. Remembering the event decades later, Dr. Leale knew the case was hopeless:

The history of surgery fails to record a recovery from such a fearful wound and I have never seen or heard of any other person with such a wound, and injury to the sinus of the brain and to the brain itself, who lived even for an hour.

Even so, Dr. Leale tried his best to extend the president's life. He appears to have used Silvester's Method:

I…assumed my preferred position to revive by artificial respiration. I knelt on the floor over the President, with a knee on each side of his pelvis and facing him. I leaned forward, opened his mouth and introduced two extended fingers of my right hand as far back as possible, and by pressing the base of his paralyzed tongue downward and outward, opened his larynx and made a free passage for air to enter the lungs. I placed an assistant at each of his arms to manipulate them in order to expand his thorax, then slowly to press the arms down by the side of the body, while I pressed the diaphragm upward: methods which caused air to be drawn in and forced out of his lungs.

During the intermissions I also with the strong thumb and fingers of my right hand by intermittent sliding pressure under and beneath the ribs, stimulated the apex of the heart, and resorted to several other physiological methods. We repeated these motions a number of times before signs of recovery from the profound shock were attained; then a feeble action of the heart and irregular breathing followed.

Though Lincoln's wound was indeed mortal, Dr. Leale bought him a few more hours.

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[1] Another potential motivator was Dr. Campbell's anger at Marshall Hall for allegedly plagiarizing his work. Campbell, Henry Fraser, M.D., A Claim of the Priority in the Discovery of the Excito-Secretory System of Nerves, Augusta: McCafferty's Office, J. Morris Printer, 1857, via the Internet Archive, accessed April 13, 2022, <https://archive.org/details/66131050R.nlm.nih.gov/page/n5/mode/2up>.