Will Hadden for redOrbit.com – Your Universe Online
The assassin ascends the stairs to the private balcony where his unsuspecting prey is waiting.
The prey watches the performance below him, oblivious to his own approaching doom. He knows nothing until he hears the firing of a derringer, and by then it’s too late.
The shot rings out. The crowd screams. The assassin flees.
And by the next morning, the President is dead.
Abraham Lincoln, 16th President of the United States, was shot in the back of the head by John Wilkes Booth on April 14th, 1865, mere days after the end of the long and bloody Civil War.
As the 150th anniversary of Lincoln’s death nears (April 15th), one can’t help but wonder: Would the President have survived if he’d had access to today’s medical technologies? Would modern science have any impact on his chances for survival?
But first: The nature of the fatal injury
Almost immediately after being shot, Lincoln was rushed from Ford’s Theatre to a nearby house and treated for his injury.
However, in 1865 there was little in the way of medicine, technology or trauma care for something as severe as Lincoln’s fatal wound, said Dr. Allen Sills, a neurosurgeon at Vanderbilt Hospital in Nashville, Tennessee.
“There was no way to monitor intracranial pressure, there was no way to image the brain and the array of medications that were available were extremely limited,” Sills said. “I think that traumatic injuries to the brain were treated probably treated much like traumatic injuries to other parts of the body where physicians and surgeons tried to stop the bleeding and give general supportive care and hope for the best.”
According to Lincoln’s autopsy report, the bullet entered Lincoln’s skull through his occipital bone “about one inch to the left of the median line and just above the left lateral sinus, which it opened.”
From there, the bullet tore into Lincoln’s dura mater, worked its way through the cerebrum’s left posterior lobe and entered the left lateral ventricle.
The bullet finally came to rest in the white matter of the cerebrum above the anterior portion of the left corpus striatum.
This caused Lincoln’s brain to compress against the inside of his skull. Like tissue anywhere else in the body, the brain naturally swells after sustaining a traumatic injury.
However, while an injured arm or leg can freely expand without restriction, the brain can only swell so much due to the skull surrounding it.
“You have to think of the brain as existing inside a closed box, that’s what the skull really is,” Sills said. “The skull really can’t expand, it’s not elastic at all and it’s very rigid. So, when the brain is injured and it starts to swell, it causes a dramatic increase in the pressure inside the skull.”
To ease this pressure, the doctors treating Lincoln repeatedly probed his wound to remove the blood and thereby keep the pressure down. This only prolonged the inevitable and didn’t affect his long-term chance for survival, Sills said.
The bleeding finally stopped due to the extremely high pressure in Lincoln’s brain tissue, which in turn caused his brain to fail entirely and ultimately led to his death.
But what if this were to happen today?
If Lincoln were alive in 2015, he would find himself privy to numerous developments in medicine and science.
In the last few decades alone there have been multiple breakthroughs just in the field of neurosurgery and how the brain is treated, from CAT scans to metabolic suppression, Sills said.
“Probably the biggest innovations in the last two to three decades have been our ability to measure intracranial pressure continuously,” he said. “Additionally we have a much greater range of medications we can use to decrease pressure in the brain and to decrease the amount of energy the brain is requiring at any given time.”
Besides being able to medicate and image the brain to look for structural damage, Sills said the understanding of the variables affecting each patient’s survival has also evolved during the past few years.
So, with all that in mind, what would happen if Lincoln were shot today in the exact same way as on that fateful night in 1865?
The first step, said Sills, would be to secure Lincoln’s airway by placing a breathing tube directly down his windpipe.
“When the brain has a severe injury, respiration and control of respirations can become very irregular, and that actually contributes to a worsening of the injury,” he said.
The second reason for this is so doctors can help decrease the pressure in the brain by manipulating the ratio of oxygen and carbon dioxide in the body, which helps ease the swelling of brain tissue.
Once this was done, doctors would stabilize and continuously monitor Lincoln’s blood pressure and while at the same making sure enough blood was flowing to the brain in spite of the injury.
Lincoln would then be given medicine and treatment to ease the intracranial pressure, then undergo a CAT scan to determine if surgery was needed “immediately, on a delayed basis or not at all,” Sills said.
However, Sills noted that surgery isn’t very common in most cases of penetrating brain injuries from gunshot wounds.
“Surgery is not extremely common because the nature of the injury doesn’t lend itself to the need for surgery, but that’s obviously decided on a case-by-case basis,” he said.
Even when patients survive such injuries, Sills said many of those patients will suffer from disabilities. These can range from loss of vision to loss of speech or movement, but the deficiencies, if any, are determined by how much of the brain is damaged by the incoming bullet.
Despite the advantages of modern technology and medicine, Sills said that Lincoln probably still wouldn’t have survived his traumatic gunshot wound.
Lincoln was shot at close range in the back of the head with a .44 caliber bullet. This fact, coupled with the path carved by the bullet through his brain, means that not even modern science could have saved Lincoln’s life.
And even if he’d lived, Lincoln certainly wouldn’t have resumed his duties as president.
“I think based on the descriptions that we have, that even if he had been literally across the street from a modern major trauma center, this would have likely been a fatal injury. But, if he had survived, there would have been significant disability that he would have incurred,” Sills said.
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