How Did Lincoln Die?

Threat of assassination may seem the greatest risk a president of the United States must take upon entering office, but history suggests that, until recently, a Chief Executive’s life was threatened more by his post-assault medical treatment than by his assassin’s bullet. There have been at least eleven attempts on the lives of American presidents, four of them successful. John F. Kennedy was shot with a high-velocity bullet that destroyed his brainstem, an instantly fatal injury that rendered any medical treatment useless. The three other victims did not immediately suffer fatal wounds.

Both James Garfield and William McKinley received sub-standard medical care after being shot, which probably contributed more to their deaths than the wounds themselves. Garfield, who was shot in 1881, died of sepsis, an infection that may result from any wound, but, in his case, most likely resulted from a series of unsterile wound probes by his doctors. It is curious that, while Garfield’s doctors took every other antiseptic measure throughout the case, they explored the wound with naked fingers 14 times, repeatedly engaging in a practice thoroughly condemned by medical texts of the day.

McKinley’s death 20 years later also appears to have been the result of his doctors’ poor judgment. The surgeon who attended him, Dr. Mathew Mann, was an obstetrician-gynecologist who had never operated on a gunshot victim and should have declared himself unqualified. Dr. Herman Mynter, the first surgeon on the scene, was responsible for the hasty appointment of Dr. Mann. Mynter decided that the surgery must be performed as soon as possible, and Mann lived nearby. However, the time it actually took to begin operating would have been sufficient to bring the wounded president to one of the most advanced medical facilities in the country, the Buffalo General Hospital, which owned one of the first X-ray machines and employed doctors who were well-qualified to perform the procedure. Instead, McKinley was taken to an ill-equipped, unlit room in the Exposition Hospital and, like Garfield, he died of sepsis.

After having discovered the quality of medical care given to these two American presidents, I thought it reasonable to investigate the care of their predecessor, Abraham Lincoln. Many details of the event that took place on the night he was shot are obscured by misleading and contradictory accounts, but a consensus of various sources maintains certain facts.

On the evening of April 14, 1865, five days after General Lee surrendered his exhausted army, Abraham Lincoln attended a performance of Our American Cousin at Ford’s Theater in Washington. He arrived late, at approximately 8:15 P.M., and the play was briefly halted to welcome his entrance. Lincoln was accompanied to the President’s box with his wife and his guests, Miss Clara Harris and her fiancé, Major Henry R. Rathbone. At around 10:00, John Wilkes Booth, who frequently performed at Ford’s Theatre and had a close rapport with most of the staff, walked into the theater’s main entrance and approached the ticket taker, Joseph ("Buck") Buckingham, whom he knew very well. Jokingly, Booth asked him, “You’ll not want a ticket from me?” Buck laughed and told his friend, “Courtesy of the house.” Booth headed up the stairs to the dress circle.

Sometime between 10:15 and 10:30, he entered the president’s box. Lincoln, his attention temporarily diverted from the stage, was sitting with his head tilted forward and to the left, probably watching a musician in the orchestra. Standing about four feet behind the president, Booth pulled the trigger of his derringer and Lincoln’s head dropped to his chest.

The first doctor to reach the wounded president was Charles A. Leale. He was the assistant surgeon of United States Volunteers and only 23 years old. The remainder of this account of Lincoln’s death is taken mostly from a report Leale rewrote from notes he made the day Lincoln died and submitted to the Congressional Assassination Committee in 1867. Directly after Leale saw Booth leap onto the stage, wave a dagger, and hurry toward the exit, the doctor heard shouts for a surgeon. Leale made his way to the president’s box. “While approaching the president, I was told that he had been murdered, and I sent for some brandy and water.” He arrived at the box and saw Major Rathbone standing at the door. Lincoln was sitting on a high-backed armchair with his head leaning toward his right side, supported by Mrs. Lincoln. Miss Harris was at the left and behind the unconscious president.

When the surgeon reached Lincoln, he found him paralyzed, with his eyes closed. Leale placed his finger on the right radial pulse, but felt no movement. With assistance, Leale immediately placed Lincoln in a recumbent position, and, in the process, his hand came in contact with blood on Lincoln’s left shoulder. He thought that perhaps the president had been stabbed with the dagger, but found no wound. Continuing to examine the patient, Leale noticed that the pupils were dilated, and he discovered a large clot of blood about one inch below the superior curved line and an inch and a half to the left of the median line of the occipital bone in the back of the skull. He passed the little finger of his left hand through the hole made by the ball. Lincoln “was then apparently dead,” Leale wrote in his report, but, when he removed his finger, blood oozed out, and Mr. Lincoln “soon commenced to show signs of improvement.”

There is some question about what occurred next. Leale’s account of the assassination submitted in 1867 made no mention of resuscitation, but, in 1909, he delivered an address in New York in which he gave a detailed description of practicing mouth-to-mouth resuscitation on Lincoln after he probed the wound. It is strange that Leale did not include this in his first account, which omitted no other important details of the president’s treatment. I am more inclined to give credence to this earlier version, recorded in Leale’s own hand on the day that Lincoln died.

In any event, this resuscitation, if it actually occurred, was directly followed by the arrival of an Army surgeon, Dr. Charles S. Taft, and Dr. A. F. A. King of Washington, at which point the three doctors agreed to remove the stricken president. Leale was asked to put Lincoln in a carriage to take him to the White House, but he refused, fearing that Lincoln would die if placed upright. Instead, Lincoln was taken across the street to the nearest house, which belonged to a Mr. William Petersen, and was placed on a bed—diagonally, because he was too tall to fit lengthwise. Leale asked that everyone leave the room, with the exception of “the medical gentlemen.” After undressing the patient, Leale found that the president’s lower extremities were quite cold “to a distance several inches above his knees.” He sent for the surgeon general, J. K. Barnes, the family physician, Robert K. Stone, and the commander of the Armory Square Hospital, D. W. Bliss. The moment that Dr. Stone arrived, Leale gave control of Lincoln's care over to him. (Dr. Bliss is unique in being the only surgeon to participate in the care of two assassinated presidents; he helped preside over President Garfield’s post-assault care 16 years later. The quality of his conduct in that case and that of his colleague Dr. Weiss, an anatomist, prompted one reporter’s acid comment: “If ignorance is Bliss, ’tis folly to be Weiss.”

When Lincoln was first laid in bed, a “slight ecchymosis of blood” (a spot from a rupture) was noticed on his left eyelid, and the pupil of that eye was dilated. At 11:00 P.M., the right eye began to protrude, and this was followed by an increase of the ecchymosis, until it encircled the right orbit. The wound was kept open by the surgeon general with a silver probe. Dr. Taft remarked that at 11:30 a twitching of the facial muscles of the left side set in and continued for about 15-20 minutes, and “there was artificial heat to the extremities.” At 1:00 A.M., “spasmodic contractions of the muscles came on,” and “at about the same time, both pupils became widely dilated and remained so until death.” Presumably at this moment, Lincoln became decerebrate—brain dead.

At 2:00 A.M., a doctor’s aide arrived with a Nekton’s probe, and an examination of the wound was made by the surgeon general. The probe was driven about two and a half inches when it hit a foreign substance. This was passed, and then the probe felt another hard substance, which was at first thought to be the ball. However, when the probe was removed without a lead stain, the obstacle was thought to be another piece of bone. The probe was introduced a second time, and the ball “was supposed to be distinctly felt by the Surgeon General.” Taft accounts for the ball’s not making any mark on the probe by explaining that it “was afterwards found to be of exceedingly hard lead.” Following the probes, “nothing further was done, except to keep the wound free from coagula.” Taft remarks on the “great difference in character of the pulse whenever the orifice of the wound was freed from coagulum,” and adds that, “while the wound was discharging freely, the respiration was easy, but the moment the discharge was arrested from any cause, it became at once labored.”

During the night, doctors counted pulsations, and at 6:50 A.M. respirations ceased for some time. Lincoln lived about 30 minutes longer, during which time Reverend Phineas Gurley said, “Let us pray,” and everyone knelt beside the bed. At 7:22 A.M., Lincoln “breathed his last.”

Ford’s Theatre Museum, where the weapon is currently kept, gave me a detailed description of the gun that Booth used to assassinate Lincoln. It is a single-shot muzzle-loading Philadelphia derringer with a percussion cap. Its total length is 5 27/32 inches, but the barrel is only 1 15/16 inches long. The interior diameter of the barrel is 0.4375 inch, making the gun a .44-caliber pistol (caliber refers to the barrel and/or bullet diameter in inches). The derringer shot a round lead ball. Usually, a gun fires a bullet or ball of approximately the same caliber, but the pathological examination of the ball that killed Lincoln suggests that Booth used a .41-caliber ball in his .44 derringer.

The National Museum of Health and Medicine currently owns the ball that killed Lincoln. On April 6, 1971, the ball was examined. It weighed 6.314 grams and was found, by spectroscopy, to be principally lead. Its weight was not the same as at the time Booth shot it, for three reasons: the lead had corroded, and the corrosion was easily rubbed off in handling the ball; it had a small hole drilled into it prior to 1941 for mounting at an exhibition; and most significantly, part of the ball had been broken off by the skull when it entered the president’s head. This fragment was found during the autopsy, but was later lost. The ball was flattened by the impact of the shot; in 1971, it was measured at 13.3 mm in diameter at its widest and 12.1 mm at its narrowest point and was 7.2 mm from front to back.

The most widely accepted current theory that attempts to describe the extent of tissue damage incurred by a missile states that its wounding capacity is proportional to its kinetic energy, which may be calculated with the formula: KE = ½ mv 2 . In other words, the kinetic energy of a missile is proportional to the missile’s mass times the square of its velocity. The kinetic energy, and therefore the wounding capacity, of a bullet is much more dependent on its velocity than on its mass. If a bullet’s mass is doubled, its kinetic energy is doubled; if a bullet’s velocity is doubled, its kinetic energy is quadrupled.

The derringer fired by Booth had a very low muzzle velocity—around 400 feet per second, which is about that of most of today’s air guns. To calculate the ball’s kinetic energy, the only further measurement needed is its mass. Since the ball was weighed after a significant amount of its volume had been lost, it seems sensible to estimate its original mass using the density of lead and the volume of a .41-caliber sphere, which would have been 6.7 grams.

From this, it can be calculated that the kinetic energy of the missile that killed Lincoln was 36.7 foot-pounds. Today, this magnitude of kinetic energy is associated with guns of a much lower caliber. A .22-caliber short revolver, for example, produces approximately 48 foot-pounds of kinetic energy. A pathologist describing the wound of a twenty-year-old male who shot himself in the head with this type of gun noted that the bullet entered the brain in the right temporal lobe and perforated the left parietal lobe before lodging in the left occipital region. The bullet’s track was straight and cylindrical, tapered at the entrance and lodgment areas, and about three centimeters wide in the middle. This wide area is the result of cavitation, a phenomenon common to missile wounds. Lower-velocity bullets will normally produce little or no cavitation, while high-velocity ones transfer more of their kinetic energy to the tissue and produce large temporary and permanent cavities. A temporary cavity is formed when the missile’s kinetic energy separates the soft tissue around where it strikes, producing a wide opening for a fraction of a second before the tissue recedes back toward its normal position. If the tissue does not recede completely, a permanent cavity is formed.

The shape and size of this cavity also depend on variables other than kinetic energy, such as yaw—the wobbling motion of a bullet—and the effect of secondary missiles that form when the bullet’s kinetic energy is transferred to bone, which fragments and itself becomes projectiles. When the bullet enters tissue, it chisels out a cavity much larger than its own diameter. A ball cannot produce yaw because it has no longitudinal axis to wobble on, and no secondary missiles were formed in Lincoln’s injury because, other than entering the occipital bone, the ball encountered only soft brain matter. The occipital bone that was hit was driven like a plug and found in the autopsy about two and a half inches down the missile track. The hole made in the bone, wrote a witness to the autopsy, “was as cleanly cut as if done with a punch.” The absence of yaw and secondary missiles combined with the ball’s low velocity should have rendered the effect of cavitation in Lincoln’s wound minimal, and indeed, the autopsy report seems to indicate the ball’s having made a fairly clean, narrow track.

Curiously, there are two completely different versions of the autopsy report. The autopsy itself was performed by Assistant Surgeon J. Janvier Woodward, who hand-wrote a description the day Lincoln died. According to him, “the ball entered through the occipital bone about one inch to the left of the median line and just above the left lateral sinus, which it opened. It then penetrated the dura mater, passed through the left posterior lobe of the cerebrum, entered the left lateral ventricle and lodged in the white matter of the cerebrum just above the anterior portion of the left corpus striatum, where it was found. . . .”

Dr. C. S. Taft, who was present, but did not participate in the autopsy, wrote an entirely different report: “The calvarium was removed, the brain exposed, and sliced down the track of the ball, which was plainly indicated by a line of coagulated blood extending from the external wound in the occipital bone, obliquely across from the left to right through the brain to the anterior lobe of the cerebrum, immediately behind the right orbit. The surface of the right hemisphere was covered with coagulated blood. After removing the brain from the cranium, the ball dropped from its lodgement in the anterior lobe. . . .”

The last sentence of this version may explain why there was a discrepancy as to where the bullet lodged; it fell out after the brain was removed, perhaps before the doctors could get an accurate view of its location. It is odd that Taft describes the track of the ball as “plainly indicated,” since Woodward obviously had an entirely different view. Both versions do agree that the two orbital plates were fractured, an occurrence common in gunshot wounds to the head.

The procedures used to treat Lincoln were obviously very different from what would have been done today. From the start, his doctors were probably doing more harm than good. Dr. Leale’s comment about first inserting his finger into the wound—"I believe that he would not have lived five minutes longer if the pressure on the brain had not been relieved and if he had been left that much longer in the sitting posture"—reveals a total misunderstanding of the patho-physiology of brain trauma. Although intracranial pressure may have been high, the sort of probe that Leale delivered could have easily ruptured blood vessels that had not been hit by the ball. The blood that “oozed out” almost certainly resulted from fresh bleeding. After this type of low-velocity missile enters the brain, the tissue behind the ball will swell, closing up the track of the ball. A probe of this sort will therefore cause an increase in intracranial pressure, adjusting to the sudden increase in volume. When the finger is removed, whatever oozes out has been caused by a broken clot or perhaps a broken blood vessel.

When Lincoln’s doctors again entered the wound with a porcelain Nelaton’s probe to locate the ball, the surgeon general encountered a foreign object about two and a half inches down the track that was “easily passed” until the tip of the probe came in contact with the ball itself. More damage could easily have been incurred here. Furthermore, it was not necessary to remove the missile. Today, the ball would have been left alone, unless it was easily accessible.

The question is: How many of these hazards were known in 1865? Surgical case records at New York Hospital from the early 1860s describe treatments of injuries of an invasive nature similar to Lincoln’s. In most of these cases the doctors did very little for the patients. On December 4, 1862, a man was wounded by a buckshot “which entered outside of the left orbit exterior to globe of eye, and passing, backwards, downwards and outwards, lodged probably in the neighborhood of the mastoid portion of the temporal bone.” The doctor made an opening behind and a little below the ear and, at a depth of three-quarters of an inch, reached the abscess and evacuated the contents. A few small pieces of bone were felt but could not be removed. Little else was done, and in less than a month the patient healed and was discharged. Another patient was wounded by a ball that entered near his right eye. The direction of the ball was backward and a little downward. “On passing a probe, it goes in about two inches but cannot detect the ball.” After three more weeks in the hospital, the patient was discharged while the ball was never found. The doctor’s only treatment was to “order a poultice.”

There were several other incidents of gunshot wounds to the brain from the case histories dated 1859-1862. In fact, most of these wounds were found to be non-fatal—largely the result of the low-kinetic-energy missiles that were in use. The New York Hospital Archives reveal only one head wound admitted during the Civil War that underwent “passing a probe.”

In none of these cases did the doctors report using their fingers or any other device to “relieve the pressure” on the brain. In fact, there were many doctors who explicitly warned against the practices that were administered to Lincoln. When Leale first probed Lincoln’s wound with his unsterile finger, he was inviting sepsis, and had Lincoln lived long enough, his wound would have become infected. Then, as now, infection was an issue. Around 1860, the discoverer of chloroform anesthesia, Sir James Y. Simpson, issued a survey to surgeons and found that, of 2098 amputations in hospital practice, 855 (40 percent) died, while only 226, or 10 percent, of the same number of patients died from amputations performed outside hospitals. Simpson concluded that “a man laid on the operating table in one of our surgical hospitals is exposed to more chances of death than was the English soldier on the battle of Waterloo.” During the Civil War, 110,000 Union soldiers died from wounds or were killed in action, while 224,000 died from disease; the figures for Confederates were roughly proportionate.

It was clear to almost everyone that something was flagrantly wrong with the hospitals and medical practices of the time. Ignaz Semmelweis, a Hungarian doctor working in Viennese maternity wards, attempted to address the problem. Everyone knew about the high incidences of fatal puerperal fever among postpartum women in maternity wards and that the lying-in wards attended by medical students and doctors had higher fatality rates than those attended by nurses.

Semmelweis observed that the doctors came straight from dissecting tables to these wards, and, around 1846, he began to insist that all who came from the dissecting rooms wash their hands in chlorinated lime. Incidences of puerperal fever fell dramatically.

Most doctors did not heed Semmelweis’s warnings, but there were medical men in this country who supported his assertions. Oliver Wendell Holmes in fact had already published an article advising physicians to wash their hands in calcium chloride after attending women with puerperal fever. At around the same time, Louis Pasteur, studying fermentation, had discovered that it could not take place without germs. Eventually, he drew the first clear analogy between fermentation and septicemia. But Pasteur was not a doctor, and his principles were not applied to medicine and surgery until Dr. Joseph Lister read them and formulated a technique for performing antiseptic surgery.

The importance of antiseptic measures had been realized by many doctors by the time of Lincoln’s assassination. Still, this was a minor concern and wasn't a contributing factor in Lincoln’s demise. Tissue damage incurred by the probe was likely much more harmful, and it, too, was an imprudent procedure, given the standards of the time. Some doctors had known this as early as the 1820s. Dominique Jean Larrey, the surgeon-in-chief of the imperial armies of France under Napoleon, was emphatically opposed to this type of probe: “And I repeat this,” he wrote, “if foreign bodies pass beyond the inner table of the skull into the substance of the brain, it is better to leave the patient to the results of expectant treatment than to attempt to explore the interior of this pulpy organ, as we have seen some practitioners do.”

John K. Lattimer, the author of the 1980 study Kennedy and Lincoln: Medical and Ballistic Comparisons of Their Assassinations, wrote extensively on the topic of Lincoln’s murder, and his is the most detailed account of the president’s medical treatment. There are several points in Lattimer’s book that I would question. Most important, he asserts that “there seems to be no reason to disagree with those who have stated that Lincoln could not possibly have survived this wound, even in modern times. . . .” He argues that “the principles of aseptic techniques and the concept of germs as the cause of wound infections were unknown in Lincoln’s day; while occasional Civil War soldiers were reported to have recovered from bullet wounds of the brain, these were rare exceptions.”

As we have seen, the role of germs in wound infections certainly was known in Lincoln’s day. Lister did not publish his first papers until two years after the President’s assassination, but his theories on the spread of infection by germs had been established two decades earlier. As for Lattimer’s other assertion, research indicates that during the Civil War many soldiers as well as civilians did survive gunshot wounds to the brain. Among the cases I reviewed at New York Hospital, more patients survived these wounds than did not!

Another point Lattimer uses to support his case is that the autopsy “does not take into account the further damage which is now known to result from the momentary creation of a large cavity in the brain when it is traversed by a missile traveling at the speed of a bullet.” This is true for many of today’s high-velocity bullets, but not of the slow-moving lead ball that killed Lincoln. Evidence for the derringer’s extremely low muzzle velocity is shown, in that the ball “lodged in the white matter of the cerebrum,” a fact uncontested in all of Lincoln’s autopsy reports. The brain’s gelatinous consistency can impede only the very slowest missiles. The ball’s kinetic energy would have been too low to form much, if any, of a cavity.

With all the speculation as to the correct path of the ball, I assert that, regardless of whether it lodged above the right or left orbit, Lincoln’s wound was not necessarily fatal. There are two errors in Lattimer’s comment that “it is surprising that, if the bullet had indeed traversed the central part of the brain stem, damaging it directly as it would if it crossed the midline, respirations could be maintained at all.” First, if the bullet had damaged the brainstem directly, it would have been impossible for Lincoln to have lasted nine hours; he would have died instantly. Second, if the ball crossed the midline of the brain, it didn’t traverse the brain stem. If the ball entered just above the left lateral sinus (a fact uncontested in Woodward’s autopsy report) and traveled across the brain to lodge above the right orbit, it would have passed above the brainstem.

It would, of course, be unfair to hold Lincoln’s doctors completely responsible for his death. It was then very difficult to understand the extent of this type of injury, and devise a procedure to treat it. Although excessive probing did probably have a negative effect on Lincoln's condition, there was still the problem of raised intracranial pressure, for which there was no known treatment in 1865.

Nevertheless, there were doctors in Lincoln’s day who knew better. If the principles of Larrey and others had been heeded, the doctors would never have probed as they did. There are reasons to believe that, today, Lincoln’s life could have been saved. The damage incurred by the ball was significant but not devastating, and many people have survived wounds of a greater force.

When defending the constitutionality of the Emancipation Proclamation, Lincoln used a metaphor that is both ironic and relevant to this article: “Often, a limb must be amputated to save a life. The surgeon is solemnly bound to try to save both life and limb; but, when the crisis comes, and the limb must be sacrificed as the only chance of saving the life, no honest man will hesitate.... In our case, the moment came when I felt that slavery must die that the nation might live.”

In the days before antiseptic surgery, Lincoln had foreshadowed his own demise. His efforts to preserve the life of the nation had been successful at the cost of its strongest limb.