The Case of the Sick Statesman With a Bullet in His Belly

Albert B. Lowenfels, MD


March 23, 2010

Treatment of Gunshot Wounds -- Then and Now

At the beginning of the 19th century, effective treatment options for a complicated injury involving abdominal organs and the spine were unavailable. Toward the end of the century, when President Garfield, the 20th president of the United States, suffered a similar injury after being shot at close range by an assassin, treatment proved ineffective and attempts to remove the bullet led to infection, probably hastening the president's death.[2]

Today, treatment of gunshot wounds involving both the spine and an abdominal organ has improved and it is likely that with our current diagnostic and therapeutic measures, Hamilton would have survived. Prehospital treatment would have included spine immobilization (although recent evidence has question its value)[3,4] and intravenous fluid replacement. Because Hamilton experienced loss of sensation to the lower extremities, a physician would immediately have suspected injury to the spinal cord, and the presence of abdominal tenderness would have made visceral injury highly likely. These clinical suspicions would have been confirmed by computed tomography scans, which would have disclosed the position of the bullet. Laparotomy would have located and controlled the bleeding from the liver. Careful exploration of the small and large bowel would be obligatory -- the combination of a bowel and spinal injury greatly complicates case management.[5] An additional spinal operation might be necessary, especially if the spine was unstable, if the bullet had lodged within the spinal canal, or if there was a dural tear.[6,7] Although Hamilton probably would have survived, it is unlikely that he would have regained function of his lower extremities: the prognosis for full recovery after spinal cord injury has shown little improvement over the past two centuries.


We have Hamilton to thank for restoring the credit of the young country, for extensive contributions to the widely influential federalist papers, and perhaps above all, for spearheading the founding of our first national bank. His portrait on the face of our $10 bill reminds us of his vital role in the successful founding of our country. [Editor's note: Hamilton's tenure on the $10 bill may be short lived. The US Department of the Treasury announced in June 2015 that a newly redesigned $10 bill will feature the face of a yet-to-be-selected woman. In keeping with that theme, the US Treasury is asking the American people to share ideas, symbols, and designs for the new $10 note that reflect what democracy means to them. You can share your ideas on Twitter using #TheNew10 or by visiting the Treasury website.]


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