Monday, May 21, 2007

Abrham Lincoln's Medical Woes in the News - Part II

Many thanks are due to my good friend Guy Hasegawa, Pharm.D., for bringing another recent and interesting article about Lincoln to my attention. In the Washington Post this morning (21 May 2007) is a report about how medical experts took on the case of Abraham Lincoln's assassination at the 13th Historical Clinicopathological Conference, sponsored by the University of Maryland School of Medicine and the Veterans Affairs hospital:

Could Modern Medicine Have Saved Lincoln?
By David BrownWashington Post Staff Writer
Monday, May 21, 2007

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

If he had lived, he would at the very least have been partially blind, unsteady on his feet, numb in certain regions of his body and inarticulate. Nevertheless, he might have been able to think and, after much rehabilitation, communicate.

What that might have meant to the United States at the dawn of reunification after the Civil War -- well, the string of imaginary events can be unspooled forever.

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

Previous exercises have sought to diagnose illness or determine cause of death of famous people with incomplete medical records. They include Alexander the Great (typhoid fever complicated by Guillain-Barre syndrome), Ludwig van Beethoven (syphilis) and Edgar Allan Poe (rabies, a diagnosis now generally discredited). This year's attempted not to solve a mystery but rather to address an extreme hypothetical -- what might have happened to one of the country's greatest presidents if time travel were possible.

"We probably see a dozen gunshot wounds to the head each year where people survive. He had a non-fatal injury by 2007 standards," said Thomas M. Scalea, a surgeon and the director of the Shock Trauma Center.

Though almost all previous analyses have called Lincoln's wound unsurvivable under any circumstance, Scalea believes evidence to the contrary is in plain view. Lincoln survived for nine hours.

Lincoln was shot about 10:25 p.m. on April 14, 1865. He lived long past the "golden hour" when stabilization of vital functions -- principally, respiration and blood pressure -- is essential.

Throughout the night his condition waxed and waned, until brain swelling and blood loss tipped him inevitably toward death, which occurred at 7:22 a.m. the next day.

During that night, which ended with Secretary of War Edwin Stanton's memorable comment "Now he belongs to the ages," definitive medical care would have been possible if Lincoln had lived in another age.

"For him to have lived today would not be an extraordinary thing," Scalea said.
John Wilkes Booth, the assassin, shot the 16th president with a muzzle-loading derringer pistol. The bullet -- apparently a .41-caliber slug fired from the .44-caliber weapon -- pierced the lower rear part of the skull, called the occipital bone, and traveled roughly straight forward. It tore a path through the left side of the brain, including through the fluid-filled lateral ventricle. But it did not hit the brainstem, which controls such essential functions as breathing, did not cross the midline, and stopped before entering the frontal lobes, the seat of reason and emotional control.

What is more extraordinary than what might have happened to Lincoln if he were treated in the 21st century is what did happen to him in the middle of the 19th.

Lincoln received a version of cardiopulmonary resuscitation that is eerily similar to what is standard today. His medical care -- first in the theater, then at a boardinghouse across the street -- focused largely on brain decompression, one of the chief therapeutic goals in modern treatment of head trauma.

The first physician to attend Lincoln was Charles Augustus Leale, a 23-year-old Army surgeon sitting 40 feet from the presidential box, assigned to attend the performance in case of a threat to the president's health.

CPR protocol calls for an "ABC" assessment of the patient -- airway, breathing, circulation. Leale reported that when he arrived, Lincoln's breathing "was intermittently and exceedingly stertorous" (snore-like). He could feel no pulse in the president's wrist. He explored the head wound, probing it with a pinkie finger and dislodging a clot -- after which Lincoln's breathing "became more regular."

Over the next 20 minutes, with the help of two other physicians, Leale resuscitated Lincoln.
They placed him on his back. Leale straddled him on his knees, opened Lincoln's mouth, depressed the tongue "and made a free passage for air to enter the lungs." They manipulated his arms in a version of artificial respiration. At one point Leale "forcibly breathed directly into his mouth and nostrils . . . and improved his respirations."

Incredibly, at one point Leale applied "intermittent sliding pressure under and beneath the ribs" and "stimulated the apex of the heart." That was an early form of "external cardiac massage," although its purpose was not to circulate blood directly but to spur the heart to do so.
Once Lincoln moved to his deathbed (which he fit in only diagonally because of his height), his pulse and breathing periodically slowed, a consequence of bleeding and swelling of the brain.
High "intracerebral pressure" causes an automatic slowing of the heartbeat called the Cushing reflex, named after the 20th-century neurosurgeon Harvey Cushing. It also pushes the brainstem, which controls respiration, against the hole at the base of the skull where the spinal cord connects to the brain. Lincoln's dilated left pupil, noted by Leale in the theater, was also evidence of this threatened "brainstem herniation."

The doctors relieved the pressure by taking clots out of the wound and probing it with a metal instrument. But those temporizing measures eventually failed.

Today, paramedics would "scoop and run" with Lincoln. Studies have shown that almost nothing done in the field, other than driving fast, increases survival of victims of head trauma. Doctors would put a breathing tube down his trachea as soon as he arrived at the hospital. He would be given intravenous fluid that is far saltier than blood, which would slightly shrink his brain, relieving pressure. He would get a quick physical exam and a CAT scan of his head -- all in 10 minutes.

In Lincoln's case, the images would have revealed large pools of blood that surgeons could have taken out. They would probably remove much of one side of the skull and leave it open but covered. The piece of bone would be "banked" for replacement if he survived.

If that was not enough, surgeons could try other maneuvers. Two used at the Shock Trauma Center, and largely developed there, are opening the abdominal cavity -- which, curiously, lowers intracerebral pressure -- and standing the unconscious patient's bed vertical, which enlists gravity to the task.

In the intensive-care unit, a modern Lincoln would face myriad hazards, including infection, kidney failure and uncontrolled bleeding. If he survived them, the Everest of rehabilitation would lie ahead.

But people do make it, Scalea said. About one a month, in Baltimore.

1 comment:

bcfears said...

Your emphasis on the doctors, their technique and expertise, should serve well to reinforce the idea that Civil War doctors knew what they were doing and were (largely) competent in their jobs. I've read about the poor quality of health care on battlefields and in hospitals-- I'm sure we all have.

This is a point of view that I can no longer hold.

I had the great opportunity to listen to a talk by George Wunderlich a couple of years ago and if he can't change your opinion of the Civil War doctor, no one can. His thesis that Civil War doctors and surgeons "got it right" and saved lives using techniques taken for granted today is well grounded and supported.

Your article reinforces the fact that the doctors had the training and ability to handle trauma cases despite the fact that Lincoln died.

Keep up the good work and good writing.