How Did Lincoln Die?

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Curiously there are two completely different versions of the autopsy report. The autopsy itself was performed by Assistant Surgeon J. Janvier Woodward, who hand-wrote a description the day Lincoln died. According to him, “the ball entered through the occipital bone about one inch to the left of the median line and just above the left lateral sinus, which it opened. It then penetrated the dura mater, passed through the left posterior lobe of the cerebrum, entered the left lateral ventricle and lodged in the white matter of the cerebrum just above the anterior portion of the left corpus striatum, where it was found. . . .”

Dr. C. S. Taft, who was present but did not participate in the autopsy, wrote an entirely different report: “The calvarium was removed, the brain exposed, and sliced down the track of the ball, which was plainly indicated by a line of coagulated blood extending from the external wound in the occipital bone, obliquely across from the left to right through the brain to the anterior lobe of the cerebrum, immediately behind the right orbit. The surface of the right hemisphere was covered with coagulated blood. After removing the brain from the cranium the ball dropped from its lodgement in the anterior lobe. . . .”

The last sentence of this version may explain why there was a discrepancy as to where the bullet lodged; it fell out after the brain was removed, perhaps before the doctors could get an accurate view of its location. It is odd that Taft describes the track of the ball as “plainly indicated,” since Woodward obviously had an entirely different view. Both versions do agree that the two orbital plates were fractured, an occurrence common in gunshot wounds to the head.

The procedures used to treat Lincoln were obviously very different from what would have been done today. From the start his doctors were probably doing more harm than good. Dr. Leale’s comment about first inserting his finger into the wound—"I believe that he would not have lived five minutes longer if the pressure on the brain had not been relieved and if he had been left that much longer in the sitting posture"—reveals a total misunderstanding of the pathophysiology of brain trauma. Although intracranial pressure may have been high, the sort of probe Leale delivered could have easily ruptured blood vessels that had not been hit by the ball. The blood that “oozed out” almost certainly resulted from fresh bleeding. After this type of low-velocity missile enters the brain, the tissue behind the ball will swell, closing up the track of the ball. A probe of this sort will therefore cause an increase in intracranial pressure, adjusting to the sudden increase in volume. When the finger is removed, whatever oozes out has been caused by a broken clot or perhaps a broken blood vessel.

When Lincoln’s doctors again entered the wound with a porcelain Nelaton’s probe to locate the ball, the surgeon general encountered a foreign object about two and a half inches down the track that was “easily passed” until the tip of the probe came in contact with the ball itself. More damage could easily have been incurred here. Furthermore, it was not necessary to remove the missile. Today the ball would have been left alone, unless it was easily accessible.

The question is, how many of these hazards were known in 1865? Surgical case records at New York Hospital from the early 1860s describe treatments of injuries of an invasive nature similar to Lincoln’s. In most of these cases the doctors did very little for the patients. On December 4, 1862, a man was wounded by a buckshot “which entered outside of the left orbit exterior to globe of eye, and passing, backwards, downwards and outwards, lodged probably in the neighborhood of the mastoid portion of the temporal bone.” The doctor made an opening behind and a little below the ear and, at a depth of three-quarters of an inch, reached the abscess and evacuated the contents. A few small pieces of bone were felt but could not be removed. Little else was done, and in less than a month the patient healed and was discharged. Another patient was wounded by a ball that entered near his right eye. The direction of the ball was backward and a little downward. “On passing a probe, it goes in about two inches but cannot detect the ball.” After three more weeks in the hospital, the patient was discharged while the ball was never found. The doctor’s only treatment was to “order a poultice.”

There were several other incidents of gunshot wounds to the brain from the case histories dated 1859-1862. In fact, most of these wounds were found to be nonfatal—largely the result of the low-kinetic-energy missiles that were in use. The New York Hospital Archives reveal only one head wound admitted during the Civil War that underwent “passing a probe.”