Could Abraham Lincoln have survived the point-blank shot to the head he suffered in 1865 if he'd had access to 21st-century medical care? And, presumably, a medevac helicopter to whisk him to an operating table in Baltimore?
Thomas A. Scalea and his colleagues say yes, the 16th president could have recovered from John Wilkes Booth's attack at Ford's Theater in Washington.
Scalea, the director of Maryland Shock Trauma Center, the downtown facility that has revolutionized the care of people who have suffered gunshots, accidents and other serious injuries, said the injuries that killed Lincoln are far from the worst he has seen in a decade treating gun injuries in Baltimore.
He and others will present their findings today on Lincoln's injury to 350 medical students, faculty and alumni at the University of Maryland School of Medicine's 13th annual historical clinicopathological conference, which each year looks at a medical issue from history.
"This could be a recoverable injury, with a reasonable expectation he would survive," Scalea said.
The assassin's weapon was relatively impotent compared to the firepower now on the streets.
"He needed surgery, modern-day life support and the appropriate level of intensive care," he said.
Scalea and others will discuss how the brain injury - a small pistol ball lodged in Lincoln's skull above and behind his left eye - would be treated today. This in contrast to the primitive methods employed in 1865, where surgeons, lacking X-ray technology, plumbed the injury with a metal probe, and one stuck his finger in the wound.
Relying on National Archives medical records, which include detailed accounts from the president's medical team on April 14-15, 1865, Scalea noted that Lincoln's frontal lobes, which govern cognition, appeared to have survived the attack.
The bullet, a round ball fired from a small derringer, entered the back of Lincoln's skull and traveled nearly all the way through his head, cutting through the left lateral lobe, which governs voluntary muscle movement, and the lateral ventricle, a horseshoe-shaped cavity filled with fluid.
The bulled lodged just above and behind the left eye socket, which cracked and quickly filled with fluid.
If Lincoln were flown to Shock Trauma with those injuries, a radiological CT scan of his brain would be performed first. Then a portion of his skull would be surgically removed to relieve pressure from his swelling brain, and the blood clotting would be cleaned out, Scalea said.
Meanwhile, to ease the brain's burden, the president would be hooked up to a mechanical respirator to take over his breathing. Intravenous fluids would provide nourishment and hydration.
Removing the bullet would risk more injury and would not be attempted, Scalea said.
If all went well, Lincoln's blood loss should be stemmed and his condition stabilized in a few hours or a day.
Lincoln's actual care was much different.
A young Army assistant surgeon named Charles A. Leale happened to be at the theater that night, where a comedy, Our American Cousin, was playing.
Leale rushed to the president's side and found him comatose. He could not detect a pulse, so he pulled the president to a sitting position to find the injury. He spotted blood on Lincoln's shoulder, according to a record prepared for today's presentation.
Assuming a stab wound to the shoulder, he had Lincoln's shirt and coat cut away but found no wound there. Feeling around the head, he soon discovered a blood clot on the back of the president's head. He pulled the clot out and stuck his little finger into the smooth, round hole there.
He gave the president a small amount of brandy and water and decided to move him to a house across the street because it was determined that he would not survive a stagecoach trip to the White House.
There, the president was laid diagonally across a bed that was too short for his lanky frame. Bottles of hot water were piled around his legs and abdomen, which were by then cold.
A silver shaft was used to probe the bullet hole and keep the wound open. The president lingered without regaining consciousness for about nine hours.
Secretary of War Edwin Stanton was keeping a vigil as the doctor felt for a pulse as dawn broke. "At 6:40 am the pulse could not be counted ... at 7:20 am the President breathed his last," the official report noted.
Philip A. Mackowiak, professor and vice chair of the University of Maryland Department of Medicine, who organizes the annual clinicopathological conferences, said the clinical record is complete enough for surgeons to make a good appraisal of the president's care and prognosis.
"And we can ask, could they have done more? Should they have done less? ... History teaches us a number of things, including humility," Mackowiak said.
There's general agreement among faculty doctors who have read the record that Leale did well, given the circumstances and medical knowledge at the time. If they traveled in time back to 1865, they said, they probably couldn't have saved him.
"In the 1860s, Lincoln had a fatal injury," Scalea said.
The modern prognosis predicts more than a vegetative state - and conceivably, the patient might recover enough to return to the White House to carry on the work he foresaw in his second term, healing the divided nation's war wounds.
"Would he be 100 percent? No," Scalea said. "Brain injuries are an unpredictable thing."
Mackowiak initiated the series of historical patient conferences at the School of Medicine. The first forum focused on poet Edgar Allan Poe, who was born the same year as Lincoln and who seemingly died of alcohol-related causes after being found deliriouson a Baltimore street in 1849.
In past conferences, the doctor said, the cause of death was the question, with perplexing medical cases such as conqueror Alexander the Great and composer Ludwig van Beethoven. The point of today's exercise is whether a historical figure could have been saved with modern medical doctors, techniques and technologies.
"Nobody has dealt with this 'What if?' scenario before," Mackowiak said.
The conference will be held at Davidge Hall, a neoclassical structure built in 1812, when Lincoln was a boy on the prairie.
To add political context to the medical narrative, a writer on the presidency, Steven Lee Carson, will speak on the consequences of Lincoln's death.
In the end, Scalea said, holding Lincoln's case up to modern light is more than a parlor game. The official government protection plan is to bring the president to Shock Trauma, he said, if the president is shot in Maryland.
"Here is something, an event that altered world history, and maybe we'll take a minute to reflect on what it's really all about," he said.
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