August 3, 2012 by EmerJencyWEBB
April 14, 1865 marked the first successful assassination attempt on a sitting U.S. President. Abraham Lincoln was 56 years old at the time, starting his second term as President. General Lee’s army surrendered to Grant five days prior on April 9th, and it appeared the American Civil War was finally coming to a close. The day reportedly started well with Lincoln’s Secretary of Treasury to actually comment, “I never saw Mr. Lincoln so cheerful and happy”. In good spirit, the First Lady decided to treat Lincoln that evening to a well known comedy of the day entitled “Our American Cousin” at Ford’s Theater.
John Wilkes Booth, at 26 was an american actor and Confederate sympathizer whose growing disdain for the Union, the President, and his policies could no longer be contained. He had actually been contemplating the kidnapping or murder of the Lincoln well before the fateful night, but until then, none of his plans had actually been completed to fruition. On the morning of April 14th, he reportedly wrote to his mother, “Our cause being almost lost, something decisive and great must be done”. It was by coincidence that he learned of the planned attendance of Lincoln to the play that evening. This was his stomping ground, a place he knew well as an actor, having recently performed on the stage he would later be famous for jumping onto while fleeing the President’s box.
Just after ten o’clock that evening, the President, his wife, and their guests Major Henry Rathbone and his fiancé Clara Harris, were enjoying the play in the Presidential Box. Booth was one door separated from the party, spying through a peephole he had fashioned. A single actor, Harry Hawk, was on the stage and delivered one of the funniest and now most infamous lines of the play (“Don’t know the manners of good society, eh? Well, I guess I know enough to turn you inside out, old gal; you sockdologizing old man-trap!”). At the height of audience laughter, Booth drew his .44 caliber single shot Deringer pistol, burst into the box from behind, and fired a single round into the President’s head.
The ball, a .41 caliber missile, entered the back of the head one inch left of midline behind the left ear. It traveled through the scalp, occipital bone, left transverse venous sinus, and ultimately penetrated the dura to enter the brain. Based on autopsy results at the time, the bullet coursed through the left lateral ventricle and finally came to a stop in the left frontal white matter above the anterior corpus striatum. Secondarily, both orbital plates of the frontal bone were fractured.
The first physician who made it to the President’s side was a 23 year old newly minted army physician named Charles Leale, who happened to be in the audience. He found Lincoln sitting in his armchair, his head slumped to the right. A rudimentary primary survey was performed where Dr. Leale noted the President was, “…profoundly comotose” with agonal respirations and a non-palpable right radial arterial pulse. Bystanders helped lower Lincoln to the floor, and this is where Leale first noted blood on the left shoulder. He immediately ordered assistants to check for a wound at this site (he thought the President had been stabbed), but quickly found the wound to the head. He also reported pupillary asymmetry that he noted was concerning for “brain damage”.
Leale probed the wound with his pinky to find that the bullet had entered the skull. Exiting the hole, he cleared a large clot, and almost immediately noted improvement in respiration. In his account, Leale is describing a Cushing Reflex to increased intracranial pressure. The pathophysiology of this response was not described formally at the time, but he quickly learned that improving outflow from the skull also improved his patient’s condition. He repeated this maneuver several times while transporting Lincoln across the street to a house where more medical men would gather to tend to the dying President.
Dr. Leale also employed rudimentary cardiopulmonary resuscitation of the day with arm maneuvers and diaphragmatic pressure to simulate a normal bellows respiration, artificial respiration with mouth to mouth breathing, and “intermittent sliding pressure” by his hand under the costal margin to stimulate the heart.
Other techniques reveal the not so modern state of medicine at time, as Dr. Leale asked for brandy and administered a small amount into the mouth of the comatose President.
The President’s personal physician Dr. R. K. Stone, as well as the Surgeon General Joseph K. Barnes, and his assistant (and future surgeon general) Charles Henry Crane joined Leale and took over care at his request. By this time, the President had developed significant orbital ecchymosis and proptosis of the right eye. Barnes probed the depth of the wound with a Nelaton’s probe several times to locate the ball.
The probe itself was invented in 1862, and it’s sole purpose was to stratify hard objects encountered as tissue or foreign (specifically lead bullets). It had an unglazed porcelain tip (see pic above) that once in contact with a bullet, would be scuffed black by lead and confirm location. Whether they actually came into contact with the missile is not apparent. Reportedly the tip of their probe did not mark black, but they were still confident they felt bullet.
At that time, the medical crew continued clearing clots from the wound, but nothing more was to be done. They waited for the inevitable.
Lincoln became increasingly bradycardic, with agonal respirations until his last breath around 7 AM the next morning. Below you can see observations by time period taken by bedside physicians:
At 7:20 AM, on April 15th, 1965 the 16th President of the United States was pronounced dead with his physicians unable to find a pulse in the carotid or bilateral radial arteries.
Hope you found this piece of American history and medicine interesting. Links to resources used will be provided in the comments section below once I have compiled them all into list form.