Civil War CPR: Resuscitation and Artificial Respiration in the 1860’s

The shocking sight of Buffalo Bills safety Damar Hamlin lying unresponsive on the field at a recent NFL game and the heroic success of trainer Denny Kellington’s use of CPR to revive him have made headlines. Considering the recent discussion around CPR, we at the National Museum of Civil War Medicine have decided to publish this piece (long in the works and originally scheduled for publication later this year) discussing the history of resuscitation. 

While this post is intended for educational purposes and should not be taken as medical advice, we recommend that everyone able consider taking CPR and First Aid training. You may be the next to save a life. 

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 people who were drowning 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.[1] 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.[2] 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.[3]

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, and that 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.[4]

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,[5] which appears to have been the main motivator behind Dr. Henry Fraser Campbell’s method of resuscitation.[6] 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 the patient’s 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.[7]

One of the primary reasons surgeons required training in artificial respiration and resuscitation was the possible overdose of the patient by anesthesia. 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.

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.”[8] 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.

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 5^th 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].[9]

In another case, Hall’s Ready Method was abandoned. Private Abraham Boyd, a Confederate also wounded at Gettysburg, was undergoing an operation at General Hospital #1 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.[10]

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 the President’s 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.[11]

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.[12]

For a time where mouth-to-mouth was rarely practiced, Dr. Leale was desperate enough to try:

I leaned forcibly forward directly over his body, thorax to thorax, face to face, and several times drew in a long breath, then forcibly breathed directly into his mouth and nostrils, which expanded his lungs and improved his respirations.[13]

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

Modern CPR is a last-ditch effort to save a patient, and mortality is high. Even in the best conditions, most patients who undergo CPR will not survive. CPR gives the best possible chance of survival, 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.

As with much of the medical history in this era, resuscitation and artificial respiration was in a transition period. The humoral school of medicine was on the wane as the scientific method proved its ineffectiveness, but in the years following the school’s collapse and preceding the advent of germ theory, there was no clearly superior approach to medicine. There was still much to learn, and that process required doctors to work with what they had, even if it was only rarely effective.

About the Author

Kyle Dalton is the Membership and Development Coordinator at the National Museum of Civil War Medicine. He is also a summa cum laude graduate of the Catholic University of America in Washington, DC, where his paper Active and Efficient: Veterans and the Success of the United States Ambulance Corps was awarded the Zeender Prize for best history thesis. In his spare time Kyle writes and maintains a website on the lives of common sailors in the eighteenth-century: BritishTars.com.

Sources

[1] Hall, Dr. Marshall, M.D., F.R.S., “Asphyxia: Its Rationale and its Remedy,” The Lancet, April 12, 1856, pages 393-394, Princeton University via HathiTrust Digital Library, accessed April 13, 2022, <https://babel.hathitrust.org/cgi/pt?id=njp.32101074830520&view=1up&seq=401&skin=2021>; Hall, Dr. Marshall, M.S., F.R.S., “The Ready Method in Asphyxia,” The Lancet, October 25, 1856, pages 458-459, Princeton University via HathiTrust Digital Library, accessed April 13, 2022, <https://babel.hathitrust.org/cgi/pt?id=njp.32101074830538&view=1up&seq=464&skin=2021>.

[2] Hall, “Asphyxia,” 393.

[3] Hall, “Ready Method.”

[4] Silvester, Henry R., B.A., M.D., “A New Method of Resuscitating Still-Born children, and of Restoring Persons Apparently Dead,” The British Medical Journal, No. LXXXI, July 17, 1858, pages 576-579, University of Illinois at Urbana-Champaign via HathiTrust Digital Library, accessed April 13, 2022, <https://babel.hathitrust.org/cgi/pt?id=uiuo.ark:/13960/t3nw71645&view=1up&seq=586&skin=2021>.

[5] “Narcotic Poisoning” in The Retrospective of Medicine, W. Braithwaite editor,Vol. XXXV, January-June, 1857, London: Simpkin, Marshall, and Co., page XX, Harvard University via HathiTrust Digital Library, accessed April 13, 2022, <https://babel.hathitrust.org/cgi/pt?id=hvd.32044102974409&view=1up&seq=24&skin=2021&q1=marshall%20hall%27s%20ready%20method>.

[6] 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>.

[7] Campbell, Henry Fraser, M.D., “Article XI. Caffeine as an Antidote in the Poisonous Narcotism of Opium,” in Southern Medical and Surgical Journal, Vol. XVI, No. 5, Augusta, Georgia, May 1860, page 238, via Augusta University, accessed April 13, 2022, <https://augusta.openrepository.com/bitstream/handle/10675.2/920/SMSJ.1860.issue5.pp.321-400.pdf?sequence=20&isAllowed=y>.

[8] Chisolm, A Manual of Military Surgery Prepared for the Use of the Confederate States Army, Richmond: Ayres & Wade, 1863, Page 75, Thomas Jefferson University, accessed April 13, 2022, <https://jdc.jefferson.edu/milsurgcsa/1/>.

[9] Wood, Surgeon Charles S., “Case 1277,” The Medical and Surgical History of the War of the Rebellion, page 895, via HathiTrust Digital Library, accessed April 13, 2022, <https://babel.hathitrust.org/cgi/pt?id=uc1.31822000922120&view=1up&seq=1081&skin=2021&q1=hall%27s%20method>.

[10] Ibid, Acting Assistant Surgeon W.S. Adams, “Case 1276.”

[11] Leale, Charles A., M.D., “Lincoln’s Last Hours,” Military Order of the Loyal Legion of the United States, 1909, via Project Gutenberg, accessed April 13, 2022, <https://www.gutenberg.org/files/24088/24088.txt>.

[12] Ibid.

[13] Ibid.