August 9, 2012 by EmerJencyWEBB
The Assassination Attempt
At 9:20 AM on July 2, 1881 James A. Garfield, 20th President of the United States, arrived at Baltimore and Potomac Railroad station in Washington D.C, with his sights set on a leisure filled Independence Day weekend at his alma mater, Williams College in Massachusetts. He was 49 years old at the time, and less than four months into his term as President. Garfield was a self made man from Ohio, the son of an impoverished widowed mother who excelled in academic pursuits. He was admitted to practice law in 1861, and subsequently elected to serve in both the Ohio State Senate, and the U.S. House of Representatives for a total of 9 terms prior to his Presidential bid.
As Garfield made his way through the waiting room at the train station with his Secretary of State James G. Blaine, two gunshots rang out from behind.
The man firing the shots was a crazed self-proclaimed lawyer and theologian named Charles Guiteau. By all accounts, Guiteau was a lunatic. His obsession with the President began prior to his election, when he wrote a speech (that he handed out at the Republican National Committee meeting that year) championing the Republican candidate. After Garfield was elected, Guiteau believed he should be rewarded a consulship to Paris for his efforts. He stalked members of the White House, with failed attempts to contact the President on many occasions, and was even thrown out of the White House waiting room due to frequent loitering. Enraged, he decided to seek vengence and assassinate Garfield.
The weapon fired was a .44 caliber Webley British Bulldog pocket-revolver with an expensive ivory handle, purchased after borrowing money from a relative. It was a nice weapon, he thought, to display in a museum after the shooting. The first shot grazed Garfield’s right shoulder, leaving only a “flesh wound”. The second shot, however, found it’s mark and hit the President in the back. The bullet entered 4 inches right of the 12th “dorsal” or thoracic vertebrae. At the time of the shooting, up until the President’s death, the path of the bullet was unknown. It was not until autopsy that his physicians knew the true extent of his wounds.
Interestingly, in attendance at the station was Abraham Lincoln’s son, Robert Todd Lincoln, who was Garfield’s Secretary of War. This was the second Presidential assassination he was forced to endure. Lincoln summoned help from area physicians, who quickly made it to the depot. The man who ultimately took charge, Dr. Willard Bliss (pictured below) immediately surmised the damage. The patient’s general appearance was described as “prostrate” as he lay on the floor bleeding. He was pale and clammy, and his first recorded vital signs revealed a feeble heart rate of 40, with respirations 12-14 per minute.
Immediate interventions included the use of “restorative agents” (a commonplace procedure at the time) in the form of brandy as well as “spirits of ammonia”, in attempts to rouse the patient from his feeble state. At around the same time, the President’s gunshot wound was probed with both unsterile fingers by multiple physicians, as well as a Nélaton probe to a depth of 3 inches in attempts to find the bullet. We can see from the above, how little medicine had changed in the 16 years following Lincoln’s death.
The decision was made to move the President to the White House for further care (there was no hospital in D.C. at the time). By the time he left the train depot, his pulse had improved to the 60′s.
At the White House, the President’s team of physicians was solidified, with Dr. Bliss assuming charge, to include Drs. Barnes (Surgeon General), Hayes and Agnew who provided surgical consultation, Reyburn who provided vital sign checks and notetaking, and Woodward who was tasked with providing the daily new briefs released to the public. News of the President’s condition soon spread across a distraught nation.
19th Century Medical Care
The President’s condition had actually stabilized after transfer. His primary complaints regarded pain in the legs and feet, as well as paresthesias. He was also frequently nauseated and continued to have intermittent vomiting episodes which never truly subsided until he died. For symptomatic relief, he was given hypodermic injections of “sulphate of morphia” for pain, and compounds of bismuth for nausea. These became a frequent necessity throughout the remainder of the President’s care.
On July 4th, 1881 instead of enjoying the Independence Day festivities, President Garfield was having his wound continually examined by his bedside physicians. Surgeons Hayes and Agnew were summoned for consultation, and proceeded to probe the wound with their fingers, multiple probes, and “flexible bougies” to no real value. He endured all this without the use of anesthetic. Discussions were made about deeper dissection and exploration at this time, but were abandoned as Garfield’s condition was looking somewhat improved.
Note must be made here that germ theory and surgical application of antisepsis propagated by Lister in 1867 and described by many physicians prior, including Semmelweis, were not generally adopted by American physicians at the time the President was shot. This was an era when surgeons commonly used unclean instruments, dressed in street clothes, and used ungloved/unwashed hands to explore open wounds. It wasn’t until 1890, almost a decade after the President’s death, that gloves were first used during surgery by Halsted at Johns Hopkins.
Although Garfield’s physicians claimed July 23rd as the date of Garfield’s first “rigor” with a temperature spike to 104, he had well documented fevers throughout the first month beginning as soon as July 4th. Pus was also first noted to ooze from the wound on July 8th but was described as “laudable pus”, an event deemed to be encouraging. This idea of good pus or “pus bonum et laudabile” was propagated from the time of Galen, and was believed to encourage wound healing.
Garfield continued to display signs of septicemia throughout the ensuing months, with multiple eruptions of “pus-sacs” and pustules at the site of the bullet wound, in his axillae, on his trunk. He even developed a suppurative parotitis on the right side of his face, which formed an abscess cavity requiring frequent drainage by his physcians and ultimately led to spontanous drainage of pus from his right ear canal and into his mouth via Stenson’s duct. In mid August, his surgeons noticed increased induration and signs of an internal fistulous tract with abscess pockets tracking from the entry wound to his “right iliac fossa”. The pocket was probed to a depth of 12.5 inches, and a large drainage tube was sewn into place to encourage continued drainage of this deep site.
The President also suffered from debilitating nausea and vomiting, which ultimately led physicians to start “nutritive enemas” on Aug 15th and continuing to his death to supplement his caloric intake. These consisted of egg yolk, bouillon, whiskey, and tincture of opium. He became profoundly dehydrated and notes were made of increasing tenacious oral secretions. At the time of his death, he had lost nearly 80 lbs due to severe malnutrition, falling from 210lbs to 130 lbs.
Alexander Graham Bell and the “Induction Balance”
An interesting piece of this story revolves around another figure in American history, Alexander Graham Bell. On two attempts in late July and early August while attempts at bullet location were being made by Bliss and the other physicians, Bell was asked to provide assistance with the use of an “induction balance” to locate the ball. It was basically a metal detector. The balance worked wonderfully in Bell’s lab, but in clinical use, failed miserably (thwarted, perhaps, by the metal spring bed frame the President was lying on).
His published accounts reveal Bell’s distress and consternation that the device ultimately failed, but also display the fervent intensity he threw into his experiments in effort to save the President’s life.
Transfer of the Critically Ill Patient
In early September, the counsel of physicians deliberated on moving the President from Washington. The D.C summer involved sweltering heat (which was partially relieved by the application of a rudimentary air conditioner set up in his room), and the stench of the surrounding marshland wafting into the President’s window, which they believed could make his condition worse. Garfield also desperately wanted to change his surroundings, as he had lain in a sickbed for nearly 2 months at this point. On September 5th, Bliss and his cohorts determined the risks of staying in D.C. far outweighed the risks of patient transfer and actually produced a well-orchestrated removal of the President from the White House by ambulance, to a specially equipped train car, and ultimately to a cottage on the Jersey Shore where he could enjoy the benefits of fresh air and the sight of the sea. This was most likely the only peace Garfield enjoyed during his convalescence. Of note, during the trip, the doctoring did not stop. Multiple vital sign measurements were taken throughout the journey, and the train’s speed was increased and decreased in response to the President’s comfort.
The Death Knell
Over the next two weeks, the President’s condition continued to deteriorate. He grew weaker by the day, developing terrific coughing spells. Notes were made of the increased production of “mucopurulent” sputum and concern for lobar pneumonia. He was also hallucinating heavily at times, his mental status waxing and waning with increased delerium.
On the night of September 19th, an attendant heard Garfield gasp. Upon entering the room, the President was holding his chest and exclaimed “Oh my!…what pain I have here”. Dr. Bliss was summoned immediately, but could not provide much in his patient’s last hours. His breathing became “stertorous”, his eyes rolled backwards. Bliss felt for a pulse, and listened for a heart beat. The President had finally died, 80 days after being shot by his assassin.
The Autopsy of a President
Shortly after death, an autopsy was performed where the path of the bullet and the damage created was finally recorded.
It was found that the ball, after fracturing the right eleventh rib, had passed through the spinal column in front of the spinal cord, fracturing the body of the first lumbar vertebra, driving a number of small fragments of bone into the adjacent soft parts, and lodging below the pancreas, about 2 1/2 inches to the left of the spine and behind the peritoneum, where it had become completely encysted.
“Official Bulletin of the Autopsy on the Body of President Garfield,” September 20, 1881.
The immediate cause of death, however, was deemed to be due to hemorrhage from a splenic artery aneurysm, likely formed by damage from the bullet itself as it traveled to it’s resting place. They also found a “long suppurating channel extended from the external wound, between the loin muscles and the right kidney, almost to the right groin.”. At the time of life, the physicians believed this area was the tract the bullet actually took. He was also noted to have evidence of bilateral pneumonia.
The question brought up by many as we look back on the care of President Garfield is: Was this a non-lethal wound made lethal by unsterile surgical practices and poor nutrition? It’s hard to say. These practices certainly didn’t help, and likely contributed to the President’s septic state. Repair to a damaged splenic artery is a wholly separate affair, and likely not able to be accomplished in 1881. Imagine how Garfield’s care would differ in your Emergency Department and in your ICU 130 years later.
It is interesting to read the accounts of Bliss and Reyburn years after the President died. Reyburn readily admits antiseptic practices took place, but in the same breath defends their cleanliness, going into great detail about dressings soaked in carbolic acid, daily linen changes, and wound irrigation with carbolic acid solutions. They even turned him frequently to prevent bedsores. His accounts, however, were published nearly a decade after the assassination, after weathering scathing editorials in newspapers and medical journals regarding substandard care. In most of his manuscript, Bliss (I believe) purposefully neglects most of the medical details and instead fills his pages lauding the President for suffering his ailments with dignity and poise. Interestingly, Bliss also petitioned the U.S. government for payment of services rendered to the President. The amount asked for totalled $91,000 for all services, with $25,000 claimed personally by the lead physician. Only $6,500 was approved and collected.
The President was laid to rest in Cleveland, OH on September 26th 1881. His death and preceding illness were tragic, but they remain a fascinating time-piece to explore the workings of 19th century medicine.
(The references used will be published shortly in the comments section below. Have a look at some of these first hand accounts of the President’s care, they are amazing.)