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Civil War Medicine
Death to Dust: What Happens to Dead Bodies? Second Edition

Treating President Lincoln's Fatal Head Wound

By Alfred Jay Bollet, M.D.
From: Civil War Medicine: Challenges and Triumphs
©Galen Press, Ltd., Tucson, AZ, 2002

        On April 14, 1865, John Wilkes Booth shot President Abraham Lincoln in the back of the head with a .41-caliber bullet fired from his single-shot Derringer pistol. Lincoln and his wife were attending a play at Ford's Theater in Washington, D.C., that night. Booth chose a moment with loud laughter from the audience, which obscured the sound of the pistol. The assassin immediately dropped the empty Derringer and used a hunting knife to severely slash the upper arm of Maj. Henry R. Rathbone (who was also in Lincoln's box). Booth then jumped down to the stage.
        Assistant Surgeon Charles A. Leale, one of two army surgeons in the audience, was the first to reach the president. Leale, who was in charge of the officer's ward at Armory Square Hospital, had obtained special training in head wound treatment at New York's Bellevue Hospital under Dr. Frank Hastings Hamilton. Leale noted that Lincoln was not breathing and, because he had seen Booth brandishing a bloody knife as well as Major Rathbone's bleeding arm, he thought at first that Lincoln must have been stabbed. He loosened Lincoln's collar and shirt but, finding no stab wound and seeing blood on his shoulder and an enlarged right pupil (an indicator of increased intracranial pressure, known as a "blown pupil"), he then suspected a head wound. When Leale palpated the back of Lincoln's head, he felt the ball's entry wound. When he tried to probe the wound with his fingertip, feeling for the bullet, he dislodged a blood clot and Lincoln began to breathe again.
        Leale did not find the ball under the scalp or when he probed the skull wound as far as his fifth finger reached. He noted in his reports to the surgeon general and to a Congressional investigating committee that the skull wound had smooth edges. This indicates that his finger did not penetrate deeply, since the fracture of the inner table of the skull would have had sharp beveled edges and would have injured his finger. (Indeed, the autopsy revealed such changes in the inside layer of the bone of the skull.)
        Dr. Charles S. Taft, the second army surgeon to reach the President's box, also noted that one pupil was large and the other very small, but he recorded that the left was widely dilated and the right was contracted. Both surgeons realized that the bullet had entered the brain from behind and thought that it had probably blasted pieces of the skull into the right orbit, since the right eye was protruding and discolored. Both agreed that the wound would be fatal.
        Lincoln was tenderly carried across the street to a rooming house and laid diagonally across the small bed, semi-sitting with a wedge of pillows under his head and shoulders. At about 1:00 a.m., three hours after being shot, Lincoln experienced an episode of general twitching, with arm spasms which tended to turn his palms down (pronate them). Afterwards, his pupils became fixed, dilated, and non-reactive to light. These findings can be interpreted as meaning that Lincoln was now decerebrate and progressing rapidly toward death.
        At about 2:00 a.m., Surgeon General Joseph Barnes used a silver probe to investigate the wound and to keep a clot from forming; later he introduced a porcelain-tipped Nélaton probe deep into the bullet track. The probe hit something solid, but there was no mark of lead on it and Barnes concluded that it had struck a piece of bone. No further attempts were made to find the bullet. The wound continued to ooze blood and brain tissue. Lincoln's breathing became intermittent and finally ceased altogether at 7:22 a.m. on April 15.
        Lincoln's body was removed to the White House and placed on his bed in the "Lincoln bedroom," where Dr. Joseph J. Woodward of the Surgeon General's Office performed an autopsy beginning at noon; it was limited to the head. (Two weeks after performing the autopsy on President Lincoln, Dr. Woodward autopsied the body of John Wilkes Booth aboard The Montauk, a Federal monitor.) Woodward thought that the ball, which had fallen out when the skull was opened, had lodged above the left eye, but Surgeon General Barnes recorded that he thought the ball had probably lodged above the right eye.
        President Lincoln's family physician, Dr. Robert King Stone, was also present at the autopsy. His handwritten notes and a diagram of some of his observations were found and published almost exactly 100 years after the event. His description is very similar to Woodward's: he states that the bullet was lodged in brain substance on the left side. These contradictions have never been resolved. As Dr. John K. Lattimer, the most detailed and informed reviewer of these observations, pointed out, all those involved in the care of President Lincoln and in the autopsy were extremely upset, under severe emotional stress, and had marked sleep deprivation by the time of the autopsy.
        Woodward recorded that the bullet had entered the back of the head (the occipital bone) and passed through the entire length of the brain and through the right lateral ventricle (a brain cavity normally filled with spinal fluid); both ventricles and the track of the ball through the brain tissue were filled with clotted blood and contained several small bone fragments. There was a thick subdural clot on the surface of the brain. The roofs of both eye sockets (the orbital plates) were fractured and fragments of bone pushed up into the brain.
        Debris found inside the head included the flattened ball, a sharp-edged disk of metal sheared from the ball, a burnt cloth patch that had been wrapped around the ball in the Derringer, large sharp-edged disks of bone from the inner table of the skull, and numerous small sharp fragments of thin (cancellous) bone from the plates of the skull. These fragments were photographed and preserved. According to experienced coroners, orbital plate fractures are frequent after bullet wounds to the head. They probably occur because of the pressure changes resulting from distortion of the skull as a result of the impact of the bullet and displacement of intracerebral tissues.
        The treatment of President Lincoln's head wound was the typical approach during the Civil War and for a long time afterward. Since the bullet had penetrated the entire length of the brain from back to front and there was extensive hemorrhage into the tissue and ventricles within the brain, there was no hope of recovery. Such wounds were virtually always fatal during the Civil War, and most still are today. The attempts to find the bullet were routine at the time, although the Surgical Section of Medical and Surgical History contains descriptions of twenty cases in which the bullet was allowed to remain in the cranium. However, in most of the cases, there was considerable or total disability, usually accompanied by convulsions or paralysis, and most patients died within a few years of the injury.
         By the end of the 1800s, with x-rays to help locate the missile, surgeons knew that trying to remove a bullet deeply embedded in the brain caused too much harm and they would leave it there, sometimes with good results. While the attempts to find the bullet in President Lincoln's head were harmful, no one really believes they affected the outcome.