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Science and Medicine: Could Lincoln Have Survived?

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David Brown
Washington Post Staff Writer
Tuesday, May 22, 2007; 12:00 PM

If Ford's Theatre had been in Baltimore, if the patient had been taken to the city's Shock Trauma Center, and if 1865 were 2007 ... Abraham Lincoln might have survived the gunshot wound to his head.

In their annual examination with the flexible retrospectoscope, medical experts last week took on the case of Abraham Lincoln for the 13th Historical Clinicopathological Conference, sponsored by the University of Maryland School of Medicine and the Veterans Affairs hospital.

Washington Post staff writer David Brown discussed their findings on Tuesday, May 22 at Noon ET.

A transcript follows.

Read more about the findings here: Could Modern Medicine Have Saved Lincoln? (Post, May 21)

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David Brown: Greetings readers and chatters. This is the chat about the presentation last Friday in Baltimore that examined the issue of how Abraham Lincoln would have been treated if he had been shot today, and posed the question whether he might have possibly survived.

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Vienna, Va.: Has the University of Maryland considered doing a study on the effect of the type of automatic weapon that would have been used if Booth had been the shooter today? What would it have meant if Lincoln's whole row had been taken out?

David Brown: This was an intellectual exercise, not a study or an experiment. I think there is a general belief, however, that if Lincoln had been shot with a high-velocity, large caliber bullet, as President Kennedy was, there would have been no doubt about the inevitable mortality of the injury.

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Burke, Va.: Hi David,

Don't take this the wrong way, but what is the real purpose of going through 'what if' exercises like this? While a testament to the incredible medical advances that have taken place since then, esp. the last 30-40 years or so and an interesting exercise, it just seems to be a waste of time. Seems like the medical community did all they could with the knowledge and equipment they had at the time.

David Brown: The main purpose, I think, is that it is interesting. Secondary reasons are that it is entertaining and it is also a vehicle to tell people in the audience (and the newspaper) a little something about medical care and physiology. How many people knew before this that if you "decompress" the abdominal cavity of many trauma patients you lower their intracerebral pressure? (I sure didn't). The historical "what-if" speculation, I agree, is pretty pointless, but it, as well, is a vehicle for explaining what did happen and what the effect of a historical event was. The U of Md./VA presentation had a historian talk about presidential success and invalidity; unfortunately I couldn't get into that in the story.

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Washington, D.C.: This is all speculation. Does anyone really know exactly what damage had been done to Lincoln's brain?

David Brown: No one knew for sure, as he was unconscious (beyond saying, obviously, that it had done enough damage to render him so). But neuroanatomy is very well understood (although there is some individual variation), so it is possible to say with some assurance what generaly modalities and functions were likely damaged by the bullet.

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Bethesda, Md.: Forcing someone to live with such possible brain damage, pain, and incapicity is terrifying... The thought makes me want to have a living will tatooed on me that states: administer nothing except pain killers and oxygen. When will doctors cease trying to prolong life at any cost?

Do doctors consider being alive in any condition preferable to letting someone die? If so, let the doctors get themselves in a condition that makes the doctor end up permanently brain damaged and incapacitated.

David Brown: This raises an interesting question: Would the country tolerate a president who has as standing "do not resuscitate" (DNR) order on record? Would his or her physicians follow it?

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Alexandria, Va.: It seems logical that modern advancements in medicine may have proffered a different outcome for Mr. Lincoln.

Why is this news?

David Brown: It's not news. It's just interesting to think about and talk about. After all, you're here!

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Pau, France: The report stated that the bullet stopped before it reached the frontal lobe. What would have happened had it been a modern bullet?

David Brown: It would have gone through the frontal lobes and out the frontal bone, much like the bullet that killed JFK. He lost a significant amount of brain matter throught he exit wound. The cavitary shock-wave of high-velocity bullets is apparently also much greater than with a low-velocity one like Booth's, and causes a comensurately large amount of indirect damage. Or so I am told.

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Brookfield, Conn.: My son -- a high school senior -- rightly suggests that the issue requires not only an updating of medicine, but also of the weapon used to assassinate Lincoln. He astutely noted that the contention so far is whether 21st century medicine could heal a wound from a 19th century weapon. Assuming Booth had a modern gun and slipped through today's security, what then?

David Brown: It's pretty amazing that Booth, who helped arrange the attempted simultaneous assassination of at least three people (Lincoln, Johnson, Seward) would go after the most important target with a single-shot, muzzle-loading pistol and a knife. There were repeating revolvers and breach-loading weapons available in 1865, so his tools were outdated even then. But then it is also amazing that the assigned bodyguard for POTUS was next door in a bar drinking. It was a different era in more ways than one!

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Washington, D.C.: The plot that resulted in the death of Lincoln had multiple cells and multiple targets, and is believed to have included people within Lincoln's own government and possibly cabinet. There are many people who believe that the doctor who was assigned to attend to Lincoln's health that night actually caused his death by pushing the bullet deeper into the president's brain. Is your research just a tricky form of propaganda to present a whitewashed version of events without ever addressing the assassination controversy?

David Brown: There's been a lot of speculation over the years about whether the probing of the wound made things worse and hastened Lincoln's death. The discussion last week by Dr. Thomas Scalea, of Maryland's Shock Trauma Center, suggested that by keeping the wound open it allowed for periodic decompression of Lincoln's brain. In fact, in the physicians' accounts of the 9 hours of Lincoln's medical care are several descriptions of how his breathing and pulse slowed but then returned to normal (for a while) after the wound was probed or blood clot from it was removed. That would support the theory that the probing might have prolonged Lincoln's life, not shortened it. Of course, in the process of decompression, the probing may have caused further injury that led to further brain swelling, which was almost certainly the thing that ultimately led to his death. (Dr. Scalea also thinks blood loss was a major contributor, as brain and scalp injuries bleed profusely). So it may all have been a wash.

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Frederick, Md.: You stated the Charles Leale was "...assigned to attend the performance in case of a threat...".

This is untrue, he came to Ford's Theatre to see the President, he took time off from his duties specifically to see the President.

According to an article that Dr. Leale wrote in 1909.

I am a volunteer for the NPS at Ford's Theatre and have done several first person interpretations of Doctor Charles Leale

David Brown: As I said in my e-mail to you, you may be right and you undoubtedly know more about the events of the night than I do. My source was an article in the journal Resuscitation (v. 45 (2000) 3-5) that states: "He had been specifically assigned to the theater that night during the performance of 'Our American Cousin' due to the presence of the presidential party." I have not checked to see what they base that assertion on.

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Tallahassee, Fla.: If President Lincoln had survived his injuries, would he have eventually been able to resume his responsibilities as President of the United States, or would he have been disabled in shape, form or fashion?

David Brown: At the time of Lincoln's death (and for nearly a century after) there was no constitutional provision to provide transfer of presidential power to the vice president while the president was still alive. Presidential historian Steven Carson, who works at the Woodrow Wilson house historical site in Washington, spoke about this at the session last week. The lack of provisions for presidential disability allowed Edith Wilson, Woodrow Wilson's wife, to apparently assume much of her husband's power for more than a year, after Wilson had a stroke.

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Vienna, Va.: Fascinating discussion, Dr. Brown, though it's hard to see someone effectively serving as president with such injuries. Vice President Johnson would have still had to take over.

Would President Garfield, shot in 1881, have survived with today's medicine?

David Brown: There's a very interesting article in the Journal of the American College of Surgery (vol. 201, No. 6, December 2005) called "Medical and Surgical Care of Our Four Assassinated Presidents". Can't go into the details, but it does note:"Lack of the following might have led to Presidents Garfield's and McKinley's death: access to adequate and prepared hospital resources, such as instruments, lighting, andnursing staff; sterile surgical environment; and care delivered by physicians with extensive experience in traumatic injury. . . . Lincoln and Kennedy received excellent care by any standard, and Garfield and McKinley might well have survived their injuries had they received better care."

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Washington, D.C.: Are you surprised to see so many comments attacking both the study and the methods used to create it? Why do you think people get so upset about it?

David Brown: People love to attack from a safe distance.

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Washington, D.C.: I know this is off the track a little, however I was very interested in you comment about the bodyguard next door drinking. What was the fallout for that dereliction of duty?

David Brown: Great, great question for which I don't have an inkling of an answer. Boston Corbett, the soldier who disobeyed orders and killed John Wilkes Booth took his story on the road in later years, I have read. But the absent bodyguard---what was the rest of his life like? There's a novel in there someplace.

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Frederick, Md.: David,

Based on readings I have done, didn't the round transverse both hemispheres of the brain? Whether he could have been saved or not, I would expect a poor quality of life. No, I'm not a doctor, and I didn't sleep at a Holiday Inn Express last night.

David Brown: My understanding is that the bullet did not cross the midline so it did not enter both hemispheres. However, it caused damage in the right hemisphere, the one it didn't enter. There was bleeding under the dura (the thick covering of the brain) there, which actually caused Lincoln's right eye to bulge visibly. The thing that mystifies me the most is the report in the autopsy that "Both the orbital plates of the frontal bone were fractured and the fragments pushed up towards the brain." How the think cone-shaped bone of the eye sockets were fractured by this injury is not well explained if the bullet didn't get that far forward in the head. Dr. Scalea also couldn't explain it.

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Bowie, Md.: I remember Issac Asimov wrote something along the line of:

William Henry Harrison might have survived his pneumonia, but no one could have survived the constant attention of a team of doctors of the period.

Is this a reasonable assessment?

David Brown: The same has been said of George Washington's treatment for a tonisillar abscess, or retropharyngeal abscess. Many observers believe he was essentially bled to death--therapeutically.

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Washington, D.C.: Not that anyone would rush to exume his remains, but is the bullet still in Lincoln's brain and skull?

David Brown: Lincoln's casket is covered with concrete. It will never be opened. It was opened twice after his death, I believe. The second time was (I think) very early in the 20th century. I remember reading an article in Life Magazine in the early 1960s about a man who had witnessed that opening when he was 12 years old. Anyway, I believe the bullet and some bone fragments are in the National Museum of Health and Medicine (former Army Medical Museum) in Washington. But I could be wrong.

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Falls Church, Va.: It has been speculated based on personal diary entries and physical attributes, that Lincoln suffered from what is today known as Marfran's Disease. If that was a true diagnosis, as evidence leads us to believe, it is said that he would have had perhaps another 5 years to live at best anyway. Could you comment on that please?

Rachel

David Brown: Yes, there is some belief that Lincoln has Marfan syndrome, and some believe that there are hints from a photograph suggesting he had aortic regurgitation, a serious heart defect that can arise from a stretching of the aorta from Marfan. But I do not believe there is any consensus on this. There was talk about trying to do genetic analysis of some material from blood-stained cuffs of one of the physicians, but I don't believe this has been done. I'm sure the answers are all on the web.

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Rockville, Md.: I would think that even a low caliber round such as the one used by Booth would still cause massive trauma to the brain tissue. Also, in reading "Manhunt, the 12 Day Chase for Lincoln's Killer," they state that the round travelled through both hemispheres and came to rest behind his right eye. There isn't much to save and still have a good quality of life at that point is there?

David Brown: The autopsy report says, in part: "The ball entered through the occipetal bone about an inch to the left of the median line . . . and lodged in the white matter of the cerebrum just above the anterior portion of the left corpus striatum, where it was found." So that would suggest it was in the left hemisphere the whole way.

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David Brown: I think we're out of time. This chat confirms my impression that there is a lot of interest in medical history out there. Thanks for listening.

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