Good Samaritan surgeon wrongly accused of contributing to President Lincoln's death: an experimental study of the President's fatal wound.

BACKGROUND: When President Abraham Lincoln was shot in the back of the head at Ford's Theater in Washington, D.C., on April 14, 1865, he was immediately rendered unconscious and apneic. Doctor Charles A. Leale, an Army surgeon, who had special training in the care of brain injuries, rushed to Lincoln's assistance. When Doctor Leale probed the wound in Lincoln's thickened scalp, feeling for the bullet, he dislodged a blood clot, and Lincoln began to breathe again. However, Lincoln progressively deteriorated and died at 7:22 AM on April 15, 1865. During the postmortem examination of Lincoln's body, numerous secondary missiles of bone and metal were found in the track of pultaceous brain tissue, extending completely through the brain to the front of the skull. In February 1995, an article in a popular magazine alleged that Doctor Leale had caused further (fatal) damage to Lincoln's brain by thrusting his finger into the brain through the bullet hole. The article alleged (wrongly) that most bullet wounds of the brain incurred in Civil War times were not fatal. STUDY DESIGN: The following study demonstrates that it is impossible to introduce even the tip of the little finger through a hole in the skull resulting from a .41-caliber bullet fired from a derringer. In our study, a .41-caliber derringer was used to fire bullets into numerous fresh skulls; the bullet holes all had razor-sharp edges and were much too small to accommodate a fingertip. RESULTS: Thus, the allegation that President Lincoln's brain was damaged further because Doctor Leale thrust his finger through the bullet hole into the brain parenchyma is not valid. In this study, experimental data are presented to demonstrate the foregoing point. CONCLUSIONS: The wound made by John Wilkes Booth's derringer ball in Lincoln's brain was devastating; it was clearly the cause of his death. Good Samaritan surgeon Leale has been falsely accused of contributing to Lincoln's death.

Experimental duplication of the important physical evidence of the lapel bulge of the jacket worn by Governor Connally when bullet 399 went through him.

By duplicating the wound to the neck of President Kennedy, which caused bullet 399 to turn sideways, and having it then hit a Connally-type rib cage with shirt and jacket, we reproduced the right-sided bulge of the jacket worn by Connally, with lapel eversion, which is so significant in frame 224. The extensive damage to his shirtfront was from the hail of rib fragments and soft tissue, exactly as described with his own shirt. Our tumbling bullet then went on to fracture a radius and be recovered intact except that it was somewhat flattened and bent and had lead extruded from the rear, as did bullet 399. Fragments of this lead were scraped off on the ragged bone-ends of some of our fractured radiuses, just as with Governor Connally's radius. It is believed that this duplication of the jacket and lapel bulge of Governor Connally, which occurred dependably, when we reproduced the circumstances at Dallas, confirmed this very important detail in this technical demonstration of the findings in the shooting of President Kennedy and Governor Connally. The bulge and the lapel eversion of the jacket worn by Governor Connally, starting in Zapruder frame 224, does indeed establish, beyond any shadow of a doubt, the exact moment when bullet 399 went through him. The right arms of both men were seen to react simultaneously, immediately thereafter. It also permits us to establish that there was plenty of time (three and one-half seconds) between the first two shots (frames 160 to 224) and even more time (five seconds) between the last two shots (frames 224 to 313), for Oswald to reload, reacquire his target (the head of President Kennedy) plus two full seconds to lock onto it. If the bullet does not traverse the neck of President Kennedy, it does not cause Governor Connally's jacket and lapel to bulge. The lapel bulge is a very important bit of actual physical evidence in establishing the fact that one bullet hit both men and that Oswald had plenty of time to hit the President, first in the neck and then in the head. These experiments confirm the mechanism of the lapel bulge and the behavior of the bullet.

Long-term followup of 207 patients with bladder exstrophy: an evolution in treatment.

Between 1945 and 1985 a total of 207 patients (male-to-female ratio 2:1) was treated at our institution for exstrophy of the bladder. Primary anatomical bladder closure was performed in 137 patients, of whom 42 (31 per cent) eventually required urinary diversion. Primary urinary diversion was the initial treatment in 70 patients, including ureterosigmoidostomy in 40, ileal conduit in 17, colon conduit in 11 and cutaneous ureterostomy in 2. Secondary urinary diversion was necessary in 35 patients and included continent diversion in 7. Primary anatomical bladder closure, done within 72 hours of birth and followed by staged reconstruction of the bladder neck, was the most successful surgical regimen for the treatment of bladder exstrophy. Acceptable urinary continence was achieved in 82 per cent of our patients with this approach. However, multiple procedures often were required to achieve continence.

Tissue expansion of underdeveloped scrotum to accommodate large testicular prosthesis. A technique.

A contracted empty scrotum in a young man will not accept an artificial testis satisfactorily using any of the standard techniques. Previous operative scars, as from a failed orchiopexy, have often added to the difficulties. Greatly enlarging the scrotum by gradual distention of a tissue expander implanted in the contracted side has been successful in overcoming this problem, both cosmetically and functionally.

Primary closure of bladder exstrophy: long-term functional results in 137 patients.

Between 1945 and 1985, 207 patients were treated at our institution for exstrophy of the urinary bladder. Primary anatomical bladder closure was performed in 137 patients. In 97 patients treated prior to 1975, bladder closure was performed at a median age of 1 year and continence in this group was only 16%. Forty patients treated after 1975 underwent closure at a median age of 72 hours followed by staged reconstruction of the bladder neck. Continence in this group was 82%; however, the average number of surgical procedures was five as compared with two in the first group. Early bladder closure and staged reconstruction can achieve acceptable urinary continence, but multiple surgical procedures may be required.

The treatment of ureteral obstruction in Gardner's syndrome: renal autotransplantation.

We report a case of successful renal autotransplantation for the treatment of ureteral obstruction owing to retroperitoneal desmoid tumors in Gardner's syndrome. Our patient has survived 2 years postoperatively and represents to our knowledge the only long-term success recorded.

Prune belly syndrome: 35 years of experience.

Between 1949 and 1984, 50 children with the prune belly syndrome were treated at our institution. The modes of evaluation and treatment, and the long-term results are discussed.

Fertility prospects for children with cryptorchidism.

One hundred forty-five men had undergone surgical correction of cryptorchid testes between 1936 and 1968. Eighty percent of 100 patients with unilateral cryptorchidism and 35% (16/45) of patients with bilateral cryptorchidism had reported fertility after 12 or more years of follow-up. There was no significant difference between the fertility rates of patients treated with or without preoperative human chorionic gonadotropin. These data serve to challenge other published series and the popular assumption that there is an inherent bilateral testicular defect in most patients with unilateral cryptorchidism.

A urethral lengthening procedure for epispadias and exstrophy.

A procedure to lengthen the urethra is described, which involves the tubularization of the top layer of the foreskin, maintains a good vascular supply and requires only 1 anastomosis. The short natural urethra, with whatever functional capability it may have, also is tubularized and dropped back to form the proximal urethral segment. This technique has worked well and gives a satisfactory cosmetic result.

Bone marrow acid phosphatase in prostate cancer: an assessment by immunoassay and biochemical methods.

Comparisons of the bone marrow and serum acid phosphatase values obtained by counter-immunelectrophoresis and the Roy biochemical test were made in 72 patients with and in 13 patients without prostatic cancer. The counter-immunoelectophoresis test, when positive at more than 1 international unit per liter, showed only 4.4 per cent falsely positive results. The Roy biochemical test, which used sodium thymolphthalein monophosphate as the substrate, had 65 per cent falsely positive bone marrow acid phosphatase levels. Conflicting reports regarding the value of bone marrow acid phosphatase determinations in patients with prostatic cancer result from the use of non-specific substrates in biochemical methods for measurement and from the trauma incidental to bone marrow aspiration, which releases many non-prostatic acid phosphatase enzymes. The use of immunoassay such as counter-immunoelectrophoresis minimizes this source of error.

The unheralded hazard of ureterosigmoidostomy.

Patients with ureterosigmoid urinary diversions always have some anal leakage of a malodorous mixture of feces and urine, especially at night or when passing gas. They obtain limited continence only by consciously keeping their buttocks tensed toegher. Their unusually high elimination frequency weds them to a bathroom for the rest of their lives. The universal prevalence of this truly severe burden of liquid fecal incontinence, which a patient is asked to bear after ureterosigmoidostomy diversion, is not well recognized and should be clearly revealed to the patient before a choice of procedure is made.

Improved life expectancy for children with exstrophy of the bladder.

Life-table techniques demonstrate a 98% ten-year survival, a 96% 20-year survival, and 91% 35-year survival of children with exstrophy of the bladder. These figures represent a vast improvement over the earlier figures, due in large part to technical advances that have been made in areas of surgery, anesthesia, and antibacterial and metabolic therapy.

The exstrophy support team: a new concept in the care of the exstrophy patient.

The concept of the exstrophy support team is reported. It has extended the care of children with exstrophy into a lifelong continuum of effective assistence, not just by way of medical and surgical interaction but through knowledgeable and sympathetic coordination. There has been a spectacular improvement in over-all lifetime survival and much greater patient interest and appreciation with better followup and maintenance so that we can help quickly and effectively when problems arise. Now that we have achieved an increased longevity for these patients, we must be able to assure them the best possible quality of life.

Delayed development of the scrotum in exstrophy.

Early attempts at orchiopexy should be avoided in children with exstrophy, since the testes will often descend spontaneously by puberty. In many cases the scrotum will grow much larger and will become pendulous by puberty. In a patient with a rudimentary scrotum orchiopexy will only result in fixing the testes in an abnormally high position owing to the lack of a sac into which to place them. If the scrotum develops later the testicles will probably be unable to descend further. Scrotal skin should not be used for urethroplasty operations in children with exstrophy and special techniques should be applied if it is necessary to repair hernias in these patients. In the child with partially descended testes but with only a small patch of wrinkled scrotum efforts may be undertaken to increase scrotal size by topical hormone treatment (or by injections) before the onset of puberty to help fertility and emotional development.

Bone marrow acid phosphatase in prostate cancer: an assessment by immunoassay and biochemical methods.

Comparisons of the bone marrow and serum acid phosphatase values obtained by counterimmunoelectrophoresis and the Roy biochemical test were made in 72 patients with and in 13 patients without prostatic cancer. The counter-immunoelectrophoresis test, when positive at more than 1 international unit per liter, showed only 4.4% falsely positive results. The Roy biochemical test, which uses sodium thymolphthalein monophosphate as the substrate, had 65% falsely positive bone marrow acid phosphatase levels. Conflicting reports regarding the value of bone marrow acid phosphatase determinations in patients with prostatic cancer result from the use of non-specific substrates in biochemical methods for measurement and from the trauma incidental to bone marrow aspiration, which releases many non-prostatic acid phosphatase enzymes. The use of immunoassay such as counter-immunoelectrophoresis minimizes this source of error.

Group psychotherapy on a children's urology service.

This paper describes an ongoing program, in a large metropolitan hospital, of weekly group meetings for hospitalized children on the Babies Hospital Urology Service, led by a pediatric psychiatrist and a psychiatric social worker. The purpose of the program is to help children cope with the multitude of fears and anxieties that can arise in the course of hospitalization. Although not described in detail, corollary weekly group meetings are also held with parents of the children. The authors describe the format of their meetings with child patient groups, whose composition is, by its nature, a constantly changing one. Examples are excerpted from typical group sessions, indicating the kinds of problems that surfaced and how they were dealt with. Ways in which group interaction and support contributed to the positive results of such meetings are also shown. The authors suggest that their program can be utilized in a variety of hospital settings.