Could Modern Trauma Care Have Saved Abraham Lincoln?

(University of Maryland School of Medicine News - May 18, 2007)

Could President Abraham Lincoln survive a gunshot wound from an assassin’s bullet if it had occurred in 2007 instead of 1865, due to modern advances in trauma care? If so, what would have been the impact on history?

Those questions were the focus of the 13th annual Historical Clinicopathological Conference (CPC) sponsored by the University of Maryland School of Medicine and the Veterans Affairs (VA) Maryland Health Care System in Baltimore.

Held in historic Davidge Hall, this annual conference is devoted to the modern medical diagnosis of disorders that affected prominent historical figures. More than 300 alumni, faculty members, students and local history buffs attended the CPC, which was one of the School of Medicine’s bicentennial and graduation events.

President Lincoln sustained a massive head wound after the bullet from John Wilkes Booth’s derringer entered the back of his head and stopped just behind his left eye, destroying the left side of the brain in the process.

At the conference, Thomas M. Scalea, M.D., physician-in-chief at the R Adams Cowley Shock Trauma Center at the University of Maryland Medical Center and director of the Program in Trauma at the University of Maryland School of Medicine, explained how Lincoln would be treated at Shock Trauma, home of the world’s first dedicated trauma center, which opened in 1968.

"There is little question that President Lincoln would have been disabled," says Dr. Scalea. "However, I believe if he had been brought to the Shock Trauma Center in 2007, his survival, while not guaranteed, would have been a very reasonable expectation."

Dr. Scalea says modern emergency medical care would involve rapid transport to a qualified trauma center, may have included airway management in the field, and would certainly have involved fluids and other supportive measures.

Immediately upon arrival at Shock Trauma, sophisticated technology such as a CT scan would be used to image the wound and doctors would give medications to reduce the effects of brain swelling. Lincoln also would have undergone a surgical procedure to remove accumulated blood and reduce pressure on his brain. While nothing could undo the bullet’s damage, Dr. Scalea says efforts could be directed to prevent further damage, known as secondary brain injury. He adds that advanced respiratory care, early nutrition and frequent re-imaging would all be utilized. Monitoring to measure brain pressure and/or cerebral blood flow might also be helpful.

But beyond survival, would Lincoln have been able to communicate, relate to his environment or make meaningful decisions? Dr. Scalea observes that the frontal lobes of Lincoln’s brain were spared. Since these lobes are home to language, emotions and problem solving, he says Lincoln’s cognitive abilities would have remained intact.

"The issue would have been his ability to express his ideas because of severe damage to other parts of the brain," says Dr. Scalea. He says that with modern rehabilitation, unavailable in the 1860’s, Lincoln may have been able to communicate. "We have all seen people make a seemingly miraculous recovery," he says. But he cautions, "Brain injury is very hard to predict."

Lincoln died within 10 hours of being shot on April 14, 1865. U.S. presidential historian Steven Lee Carson explored the question of whether there would have been chaos if Lincoln had lived. Carson is a lecturer, author, playwright and editor as well as a commentator for radio and television who has spoken at the White House and the Kremlin.

He points out that the Constitution had no provision for presidential disability or incapacity in 1865. The 25th Amendment, proposed by the 89th Congress 100 years later and ratified in 1967, describes the process by which the president is declared unable to discharge the powers and duties of office and how the vice president becomes acting president.

Carson says Edwin M. Stanton, Lincoln’s Secretary of War, took over the government for about 24 hours because there was initial concern that there might be an attempt to assassinate Vice President Andrew Johnson as well. These fears were fueled, in part, after Secretary of State William H. Seward and his family were attacked in their home on Lafayette Square across from the White House on the same night Lincoln was shot. A Booth accomplice was indeed assigned to assassinate the vice president, but got drunk instead. The man was later hanged with the other conspirators. Johnson was sworn in as president.

The Lincoln case is a departure from past conferences, when the name of the famous person whose death was being analyzed was kept secret until the end. In Lincoln’s case, the details of his assassination are so well known, organizers decided to reveal his name in advance.