Could Modern Medicine Have Saved Lincoln?

What is more extraordinary than what might have happened to Lincoln if he were treated in the 21st century is what did happen to him in the middle of the 19th.

Lincoln received a version of cardiopulmonary resuscitation that is eerily similar to what is standard today. His medical care -- first in the theater, then at a boardinghouse across the street -- focused largely on brain decompression, one of the chief therapeutic goals in modern treatment of head trauma.

The first physician to attend Lincoln was Charles Augustus Leale, a 23-year-old Army surgeon sitting 40 feet from the presidential box, assigned to attend the performance in case of a threat to the president's health.

CPR protocol calls for an "ABC" assessment of the patient -- airway, breathing, circulation. Leale reported that when he arrived, Lincoln's breathing "was intermittently and exceedingly stertorous" (snore-like). He could feel no pulse in the president's wrist. He explored the head wound, probing it with a pinkie finger and dislodging a clot -- after which Lincoln's breathing "became more regular."

Over the next 20 minutes, with the help of two other physicians, Leale resuscitated Lincoln.

They placed him on his back. Leale straddled him on his knees, opened Lincoln's mouth, depressed the tongue "and made a free passage for air to enter the lungs." They manipulated his arms in a version of artificial respiration. At one point Leale "forcibly breathed directly into his mouth and nostrils . . . and improved his respirations."

Incredibly, at one point Leale applied "intermittent sliding pressure under and beneath the ribs" and "stimulated the apex of the heart." That was an early form of "external cardiac massage," although its purpose was not to circulate blood directly but to spur the heart to do so.

Once Lincoln moved to his deathbed (which he fit in only diagonally because of his height), his pulse and breathing periodically slowed, a consequence of bleeding and swelling of the brain.

High "intracerebral pressure" causes an automatic slowing of the heartbeat called the Cushing reflex, named after the 20th-century neurosurgeon Harvey Cushing. It also pushes the brainstem, which controls respiration, against the hole at the base of the skull where the spinal cord connects to the brain. Lincoln's dilated left pupil, noted by Leale in the theater, was also evidence of this threatened "brainstem herniation."

The doctors relieved the pressure by taking clots out of the wound and probing it with a metal instrument. But those temporizing measures eventually failed.

Today, paramedics would "scoop and run" with Lincoln. Studies have shown that almost nothing done in the field, other than driving fast, increases survival of victims of head trauma. Doctors would put a breathing tube down his trachea as soon as he arrived at the hospital. He would be given intravenous fluid that is far saltier than blood, which would slightly shrink his brain, relieving pressure. He would get a quick physical exam and a CAT scan of his head -- all in 10 minutes.

In Lincoln's case, the images would have revealed large pools of blood that surgeons could have taken out. They would probably remove much of one side of the skull and leave it open but covered. The piece of bone would be "banked" for replacement if he survived.

If that was not enough, surgeons could try other maneuvers. Two used at the Shock Trauma Center, and largely developed there, are opening the abdominal cavity -- which, curiously, lowers intracerebral pressure -- and standing the unconscious patient's bed vertical, which enlists gravity to the task.

In the intensive-care unit, a modern Lincoln would face myriad hazards, including infection, kidney failure and uncontrolled bleeding. If he survived them, the Everest of rehabilitation would lie ahead.

But people do make it, Scalea said. About one a month, in Baltimore.