doctors at lincoln's bedside

[Leon Greene]

(02-25-2018 05:37 PM)JMadonna Wrote:  

(02-25-2018 01:47 PM)Steve Wrote:  According to medical texts at the time, trepanning was seldom useful for treating penetrating bullet wounds to the head/brain. And the few patients who did survive had bullet wounds to the front of the brain, not the back as Lincoln had.

I find it hard to believe that they didn't try because it was not recommended in a medical text at the time. I read where a couple of doctors tried giving Lincoln brandy for his head wound. This makes me question their actual competency.

Who was the doctor in charge of this group? Did he make the decision to do nothing? Or was there no one in charge and no one wanted to take responsibility?

Medicine and surgery in the 1860s - then, as now - did not have universally accepted protocols for various injuries. Treatment of battlefield wounds was evolving, and many techniques had been imported from surgical care during the recent Crimean War. A book published in 1870 reviewed the surgical techniques and outcomes during the Civil War. (The Medical and Surgical History of the War of the Rebellion, Part I, Volume II, Surgical History, Joseph K. Barnes, George A. Otis, Washington, Government Printing Office, 1870)

Regarding trepanning, or trephining, the book reports:

"One need not revert fifteen years in surgical literature to be convinced that an unfounded dread of the impossibility of an exit for the secretions of the wound were then considered proper indications for trepanning. The ample information which one of the most zealous advocates of trepanning, one who was an excellent surgeon as well as a truthful man, I mean Percivall Pott, has given us in regard to the effects of trepanning, leaves no doubt as to the theory that the access of air increases suppuration. In most cases of simple contusions, in which he trephined on account of the formation of pus internally, very little pus was found at the first operation; yet the symptoms were generally aggravated, and trepanning, was resorted to a second or third time, and not until the secondary operations were great quantities of pus disclosed. Thus, as usual, one mistake brought about another, and one ill-advised use of the trephine rendered its repetition necessary. The main symptoms which seemed to demand trephining, for the majority of surgeons addicted to the trephine, consisted in the stupor or insensibility of the patient. It really requires no small degree of firmness of conviction of the danger of the trephine to see a patient, not only for days but weeks, in a state of greater or less stupor or insensibility without resorting to the operation, when, sometimes, complete consciousness is restored immediately by a successful elevation of the depressed bone, or the removal of extravasated blood. It is not enough to remind one that patients with typhus often remain for weeks in a still deeper stupor, and yet gradually resume the use of their mental faculties; nor is it sufficient to recall the innumerable cases where trepanning, notwithstanding the apparent success of its purpose of elevating depressed bone, or removing extravasations, did not influence the restoration of consciousness, but where this was only gradually regained by means of an antiphlogistic treatment. One must have observed as often the successful cure of head injuries, without trepanning, to be enabled to acquire such accuracy of observation, as nearly every physician possesses in regard to fever patients. Would not every one be called a miserable quack now-a-days, who would give a typhus patient musk, camphor, or serpentaria on account of stupor? It will not be long before no favorable estimate will be had of any surgeon who will use the trepan on account of comatose conditions alone. The campaigns of 1849 and 1850 have, happily, given many young surgeons the opportunity to convince themselves, with their own eves, that one may look on a condition of semi-stupor for weeks without resorting to the trepan." (pp. 153-154, emphasis mine)

The technique is used today - often called creating "burr holes" - to release intracranial pressure most often caused by bleeding or infection. But the indications for its use in 1865 weren't carefully defined; hence, not used on President Lincoln. In addition, his wound was so massive the doctors probably realized that he was beyond help. Furthermore, the majority of cases of bullets penetrating the skull and brain were either fatal or caused total and permanent disability.

In the cases reviewed in this book, 2514/4350 (58%) patients with a gunshot wound to the cranium died (p. 307). Of all operations reported and described for a gunshot wound to the cranium, 220/900 (24%) were the trepanning technique (p. 309). Results of trepanning were reported for only 196 of those patients; 110 (56%) died.

Interestingly, this huge post-Civil War text referenced above did not include any mention of Lincoln's gunshot wound.

I suspect that your last suggestion was correct - no one wanted to take responsibility for this rather gruesome technique that had a very high death rate.