Assassination Medicine

Twice during my tenure as President Reagan’s White House physician, I accompanied him to performances at Ford’s Theatre. Each time I found myself looking up at the flag-draped box where Booth shot Lincoln and wondering what I would have done had I been one of the doctors who rushed to the President’s aid. Could the medical techniques that had saved Reagan’s life after he was shot in 1981 have helped Lincoln? What about Garfield, McKinley, or Kennedy? Nothing, I have concluded, could have saved Lincoln or Kennedy; Garfield and McKinley are another story.

Booth fired his one-shot derringer pistol an inch away from the back of Lincoln’s head; the bullet went through the President’s brain and lodged behind his left eye. Charles Leale, a young Army doctor who reached Lincoln minutes later, managed to restore his breathing and had him moved to more comfortable quarters across the street, but Lincoln never regained consciousness. Today we could replace fluids and blood and put him on life-support systems to keep him breathing. We could certainly prolong his life. But the likelihood that he would ever have regained anything like his normal capacities is slender indeed.

The rifle shots Lee Harvey Oswald fired at John F. Kennedy’s limousine on November 22, 1963, did their work even faster than Booth’s derringer. Entering the base of Kennedy’s neck while his right arm was raised to wave to the crowds, the bullets opened a massive gaping wound on the back of his head. The President was moribund when he arrived at Parkland Memorial Hospital shortly after 12:30 P.M. At 1:00 P.M. he was pronounced dead.

But modern medicine could certainly have saved the life of James Garfield. On July 2, 1881, Garfield entered a Washington railroad station en route to Williams College, his alma mater. His only guard was a local policeman, and as the President walked toward his train, Charles J. Guiteau, an unbalanced lawyer and evangelist, fired two bullets from an English bulldog .44-caliber revolver. One pierced Garfield’s sleeve; the other hit him in the back close to his spine.

Garfield was carried to the second floor of the station, and his boyhood friend Dr. D. W. Bliss was called to the scene. Dr. Bliss gave the President half an ounce of brandy, a dram of spirits of ammonia, and began searching for the bullet with his little finger and a long silver probe. Within an hour Garfield was moved to the White House in a horse-drawn ambulance. From his symptoms it appeared that he was hemorrhaging internally and could not survive the night. But the President rallied, and the next morning Dr. Bliss appointed two Army surgeons and three civilian doctors to help look after him.

The surgeons determined that none of the President’s internal organs had been hurt and agreed to keep a sharp eye out for signs of infection. On July 23 Garfield developed a chill and his temperature shot up to 104 degrees. His doctors traced the problem to pus found in the channel the surgeons had created with their probes. When this was cut open and cleaned out, the President did feel some relief, but on August 18 a swelling in the parotid gland began discharging pus through his mouth and ear. By early September he seemed well enough to be moved by special train over tracks laid to the door of a cottage by the sea in Elberon, New Jersev. There, however, the fever returned, and on the night of September 19 he died.

In Garfield’s day doctors would probe gunshot wounds in the belief that if they could remove the bullet everything would be fine. Today we know a hot bullet is self-sterilizing. Garfield’s real problem was the ill-advised, ill-directed poking with nonsterile instruments by every doctor who entered the sickroom and thought he could do a better job than the one before. All that meddling introduced more bacteria into Garfield’s body.

Garfield’s physicians never found the bullet that killed him, even after they shot at cadavers in an effort to reproduce the wound. Alexander Graham Bell joined the search, using a telephone-like receiver as a metal-detecting device. When the doctors finally located the bullet during an autopsy on Garfield’s body, they found it lodged in the back muscle—a far less dangerous place than they had thought. During his trial Charles Guiteau claimed he hadn’t killed the President, the doctors had. He was probably right.

Today we would put a sterile dressing over President Garfield’s wound, make sure nobody touched it, and immediately administer antibiotics to treat any infectious bacteria that might have been carried into the wound, either by bits of fabric from his clothes or by debris from the bullet itself. Then we’d hustle him into the armored limousine that would be waiting outside the station, and dash for the nearest hospital. Once inside the emergency room, we’d check the President’s appearance, pulse, and blood pressure and start putting blood and other fluids back into his body intravenously to reduce shock. We’d monitor his heart with an electrocardiogram. We’d give him a broad-spectrum antibiotic to prevent the onset of infection. We’d do a red-blood count to see if he was still losing blood, and a white-blood count to see if any infection had already developed and would need treatment. We’d use an X ray to locate the bullet, but once we found it we might decide to leave it alone, since removing it would require anesthesia and surgery—procedures that could create more problems than the bullet itself. Next we would check for any intra-abdominal damage by doing what is called a four-quadrant tap: we’d insert a hollow needle into the four different quadrants of his abdomen to see if we obtained air, blood, or intestinal contents. This would tell us whether the bullet had ruptured a blood vessel, perforated the intestine, or cut the liver. If we wanted to get still more information, we could do an X ray, CAT scan, MRI, or even exploratory surgery to determine if all the organs were intact. We would have President Garfield back at work in a few weeks.

William McKinley’s injury was more serious than Garfield’s, but I believe he, too, could have been saved by modern medicine. On Friday, September 6, 1901, the fiftyeight-year-old President was at the Pan-American Exposition in Buffalo, New York, where he planned to give a speech. In the crowd was a slim twenty-eight-year-old anarchist named Leon Czolgosz holding a .32-caliber IverJohnson revolver wrapped in a dirty handkerchief. The assassin fired two shots, hitting President McKinley in the chest and abdomen. An ambulance arrived in minutes, and the President, bathed in blood, was taken to the exposition’s emergency hospital, which was little more than a first-aid station.

In a state of severe shock, McKinley was laid out on a table. One of the bullets had merely grazed his ribs, but the other had opened up a serious wound in his abdomen. Dr. Mathew D. Mann, a prominent Buffalo surgeon, was summoned. Although conditions in the small room were far from ideal, Mann, along with three assistant surgeons, decided to operate immediately. The afternoon light was failing and the electric lighting was so poor that one of the doctors used a hand mirror to reflect the rays of the setting sun into the President’s abdominal cavity.

The surgeons determined that the bullet had perforated the front and back wall of McKinley’s stomach. They sutured the tears and cleaned out the peritoneal cavity as best they could. Although they were invited to use an early X ray machine on display at the exposition, they turned down the offer, and they never found the bullet. The doctors eventually closed the incision without drainage and covered it with a sterile dressing.

McKinley was carried unconscious to the nearby home of the exposi. tion’s president and put in a bedroom on the second floor. On September 12 he took a turn for the worse, and his physicians gave him violent purgatives to cleanse his system. Early the following morning he suffered a physical collapse. He revived once more before losing consciousness, but at 2:15 A.M. on Saturday, September 14, 1901, President McKinley died.

Today we would treat his gunshot wound with careful attention to the perforation of the stomach and intestinal tract. What’s worrisome is the possibility of digestive juices leaking from the pancreas into the abdominal cavity, so we’d insert a sterile drain to carry away any pancreatic fluid, blood, or infectious material.

As McKinley was recovering from his operation, we would give him intravenous fluids to make sure he was adequately hydrated, and we’d correct any imbalance in his electrolytes. Since no specific cause of McKinley’s death was found during a careful autopsy, I believe he probably died from a low potassium level. We know he lost potassium during repeated enemas and laxatives, and physicians back then were unaware of the need to replace this vital mineral. With modern treatment McKinley could have resumed his regular duties in three to four weeks.