One oft-heard speculation regarding the President Lincoln’s assassination goes something like this: “We have such better medical care now! Lincoln would’ve definitely survived…wouldn’t he?” Just type “would Lincoln have survived today” in any search queue and you will find yourself awash in forums discussing the differences in firepower between now and the 1860’s, myths about Lincoln’s doctors, and assertions that trauma care is so advanced, that Lincoln would have survived and resumed official duties if he had been shot with the same caliber weapon today. Faced with these opinions, tried to use the medical evidence to get to the bottom of this conundrum.
In order to better illustrate what trauma care looks like today, I will use the 2011 shooting of Representative Gabrielle Giffords (D-AZ) as a case study. In the 911 call made just after the shooter fled, those at the scene (some of them doctors) stated that Representative Giffords “had been hit” but that she was breathing and conscious. First responders were at the scene within five minutes, and all victims were quickly evacuated. While medical records are not available to the public, one can assume that Rep. Giffords received standard pre-hospital care, which involves assessment of the airway, respiration, and circulation. She was immediately taken to the University Medical Center in Tucson where Dr. Randall Friese performed the initial evaluation. This is where the story dramatically diverges from Lincoln’s. Rep. Giffords was conscious, could respond to simple commands such as “squeeze my hand,” “hold up two fingers,” and “wiggle your toes,” and could open her eyes spontaneously. All of these signs pointed to the fact that her injury was markedly less severe than President Lincoln’s.
One of the major predictors of recovery from traumatic brain injury is a high score on the Glasgow Coma Scale. This scale measures motor response, ability to open the eyes, and verbal response to quantify consciousness after head trauma. Unlike Rep. Giffords, we have no record of the President’s precise responses. However, the physician who initially evaluated him reported that he was unconscious, with his eyes closed, his breathing intermittent and raspy, and his pulse undetectable. This presentation would lead to a very low score on the Glasgow scale, which is indicative of worse prognosis and higher mortality. Even though his doctors were not trained in modern resuscitation techniques, the fact that the President responded so poorly to stimuli after his injury reveals that he had a slim chance of recovery even in light of medical advances.
Once in hospital, Rep. Giffords underwent a decompressive craniectomy to reduce her intracranial pressure and thus lessen her chances of cerebral herniation. Over the next few weeks, she had further surgeries to fix her shattered eye socket and remove pieces of bone that the bullet had displaced into her brain. She was also put into an induced coma in order to spare her brain from the overwhelming metabolic demands associated with central nervous system injury. The congresswoman was eventually discharged to a rehabilitation facility to undergo intense therapy in the hope that she could regain some of her lost motor and speech abilities. Had Lincoln been shot today, he would most certainly have received the same level of surgical and hospital care.
Another key difference between Rep. Giffords injury and the President’s is that the trajectory of the bullet, as well his symptoms, are disputed within the primary literature. Dr. Leale, the first on the scene, reported that “…the pupil of that eye [Left] was slightly dilated, and the right pupil was contracted; both were irresponsive to light.” However, one of the other physicians on the scene, Dr. Taft, reported the exact opposite. Additionally, the autopsy reports are unclear on where the bullet finally lodged in the President’s brain. Did it stop posterior to the left eye or did it cross the midline and come to rest posterior to the right eye? Doctors present for Lincoln’s autopsy testified to both trajectories. How can we, nearly 150 years after his death, reconcile these stark discrepancies? The fact is we can’t. With testimony from physicians on the scene differing so much about such a crucial fact, we cannot know how the bullet traveled through Lincoln’s brain. This is one of the essential pieces of information that would allow us to judge whether or not the President could have survived the same injury if presented with current medical care. Dr. Blaine Houmes, an ED physician and Lincoln expert, stated that, “…if you only read one or two of the reports, in theory Lincoln could have survived, particularly today with our medical care. But if you read all the others, there's no way he could have survived, due to the severity of the injury.”
Of those who have attempted to speculate on his potential survival, opinions are split. Nearly all investigators agree that his wound was just too severe for him to have survived in any circumstance. Dr. Houmes explains that, “Today if you treat someone with an injury like Lincoln had, despite all of our advances, despite all of our equipment, despite all the drugs we're able to give, and the procedures available, if you look in the medical literature, the fatality rate is still 100 percent.” In contrast, Dr. Thomas Scalea, of the University of Maryland’s R. Adams Cowley Shock Trauma Center, believes that it would not be out of the ordinary to see people with gunshot wounds like Lincoln’s who survive. “We probably see a dozen gunshot wounds to the head each year where people survive. He had a non-fatal injury by 2007 standards.” This assertion, based on the idea that the bullet stayed on the left side of Lincoln’s brain instead of crossing to the right, makes sense. Even though the number of people who survive such an injury is not high, it is not inconceivable that he would have survived. However, if the bullet crossed the midline and entered the right half of his brain, as Dr. Houmes believes, then his survival would be much less likely.
Retrospective diagnosis or prognosis presents many challenges, including source credibility and agreement. Additionally, it is difficult to interpret medical terminology used in the past, since it isn’t often standardized and very easily could mean something totally different than it does today. Ultimately, we will never know if Abraham Lincoln could have survived his injuries today, and what that would have meant for the country. All we can do is wonder, and see how alternate history buffs tell the story the way it might have happened.