The President And The Pancreas

How Did The Pancreas Play A Crucial Role In The Assassination Of The 20th President Of The United States?

James Garfield was born in a log cabin and into abject poverty on November 19, 1831. He never knew his father, Abram, who died when James was an infant. He spent his childhood on a frontier farm in Cuyahoga County, Ohio helping his nearly penniless mother, Eliza. Always studious, he ultimately enrolled in Williams College and paid his way through school by working as the school janitor. He graduated with honors in 1856 and then studied the law on his own, passing the Ohio bar exam in 1861.

At around the same time, he threw himself into politics as an enthusiastic abolitionist, joining the newly formed Republican party campaigning for Abraham Lincoln. When southern states began secession from the Union, he urged the federal government to respond with force. He himself organized the 42nd Ohio Infantry and distinguished himself in battle during the Civil War at Middle Creek and Chickamauga, rising to the rank of Major General. He resigned from the Army in 1863 to take a seat in the US House of Representatives, winning the election without even campaigning.

He served 9 terms as a successful Congressman, becoming an expert on financial matters by serving as chairman of the House Committee on Appropriations. In 1880 he was elected to the Senate. That same year, he campaigned for Secretary of the Treasury, John Sherman (a fellow Ohioan and son of the famous General) for the Republican nomination at the Chicago Presidential convention. After 35 ballots failed, Garfield himself was nominated as a dark horse candidate and won! In November 1880, in a close election (he won by fewer than 10,000 votes) he was elected the 20th President of the United States.

On July 2, 1881, while waiting for a train in Washington's Baltimore and Potomac train station with Secretary of State James Blaine and his two teenage sons, Garfield was shot in the back twice by Charles Guiteau with a .44 caliber British pistol. Remember that this was more than 20 years before the establishment of the Secret Service. Guiteau was a man known in Washington circles as mentally disturbed and paranoid, and he stalked the President for weeks after Garfield denied his application for a consulship in Paris.

One bullet grazed the President's arm and shoulder but the second tore through his back, cutting through his first lumbar vertebral body (sparing his spinal cord), and then continuing right to left before piercing his pancreas and coming to rest adjacent to his splenic artery, remaining embedded within the pancreas.

Guiteau was rapidly apprehended as he ran for the Sixth Street exit and dragged away by police. Smith Townsend, a local physician, emerged from the crowd and was the first physician on the scene. He found the President in shock, covered in blood. He gave him an ounce of brandy as a stimulant along with one drachm (or dram; 8 drams to an ounce) of aromatic ammonia spirits. Garfield was moved to the less public second floor of the building and was carefully laid on a mattress on the floor. He continued to bleed. Robert Lincoln (Abraham Lincoln's son and Garfield's Secretary of War) summoned D. Willard Bliss, his close friend and a military surgeon to the scene.

Bliss found two wounds, a shallow flesh wound of Garfield’s left shoulder and a more ominous one four inches to the right of the 12th thoracic vertebrae. He tried to explore the latter injury with his finger to trace the path of the bullet. He felt the shards of Garfield’s 11th rib but not the bullet. In short order 8 surgeons joined Bliss and Townsend at the scene, including Robert Reyburn, Professor of Surgery at Howard University. They agreed with Garfield's request to take him back to the White House.

He was given morphine and atropine, continued to vomit, had heart rates up to 158, his temperature fell and he was not expected to survive the night. Once back at the White House, urgent calls went out to the country's best surgeons and two surgeons, D. Hayes Agnew from University of Pennsylvania and Frank Hamilton of Bellevue Hospital arrived in Washington on July 4.

Both surgeons examined him and probed the wound with their fingers. Neither thought surgery would be beneficial. Shockingly, the President's condition improved by the end of the first week after a stormy first 2 days. Agnew made a larger incision to help with drainage at the fourth week and large amounts of pus drained from the wound. Bliss continued to be worried about not removing the bullet and asked Alexander Graham Bell to try and find it. Bell brought his newest invention to the White House, a metal detector, and was convinced the bullet was lodged somewhere in the right side of the abdomen (it wasn't).

Drains were placed deep into the wound cavity and appeared to function. The wound track continued to be manually and instrumentally probed.

By the sixth week, Garfield's condition had worsened, he no longer was able to eat, he had lost 80 pounds, and the surgeons resorted to nutritive enemas. They consisted of one egg yolk, an ounce of bullion, a half-ounce of whisky, one-and-a-half ounces of milk, 2 drachms of beef peptonoids and 10 drops of tincture of opium. The concoction was warmed to 100°F. Peptonoids were preparations extracted from beef pancreas. These too did not help and finally the President and his wife had had enough.

They decided that perhaps the best care would be exposure to the salty sea air in Elberon, NJ (near present-day Long Branch) and a specially-designed rail car was used to bring Garfield to a beach cottage there. He died peacefully on September 19, 1881.

More than 100,000 people came to see Garfield’s body lying in state in the Capitol Building Rotunda, and another 150,000 attended his funeral in Cleveland, Ohio. The new president, Chester A. Arthur, declared days of national mourning.??

An autopsy was performed revealing the true cause of death to be overwhelming sepsis related to a large abscess in the retroperitoneum, extending from the pancreas (where the bullet was found) down to the pelvis. The splenic artery appeared to have been injured but this was contained. In addition, another abscess was found near the gallbladder likely related to cholecystitis.

Whatever happened to Charles Guiteau?

On October 14, 1881, Charles Guiteau was formally indicted for the murder. Throughout the trial, Guiteau exhibited behavior so bizarre that it only gave credence to the defense team’s contention that their client was insane. He often cursed and insulted everyone in the room, including his own attorney and the judge. His final claim was that "the doctors killed Garfield, I only shot him!" He was found guilty on January 25, 1882 and he screamed that "God would avenge this outrage!" He was hanged on June 30, 1882.

Did Guiteau Have A Point That Garfield's Doctors Killed Him?

There actually was some truth to this. The surgical practice of the day was that “all foreign bodies, such as pieces of clothing, spiculae of bone,… should be removed from the track of the wound as soon as discovered, and the bullet itself should be extracted if its removal can be effective without the infliction of serious additional injury.” The problem was that germ theory had only just started being accepted in America in 1881. The practice of antisepsis was far from uniform and bacteria in wound infections had only just been described in 1878 by Koch. Washing hands and surgical instruments was certainly not standard practice at the time.

The President's convalescence and care were the fodder of daily newspaper reviews, often scathing. By two weeks into his care, criticism of Bliss and his team was mounting across the country. Many surgeons denounced the decision to either probe the President's wounds or not to. Headlines blared "Ignorance Is Bliss" often. Pointed criticism was that the President would have lived had he just been left alone. A later review in 1881 however concluded that "with an injury such as this it is a marvel he lived so long."

Legacy

Despite his very short term in office, President Garfield did in fact have a hand in nearly every issue of national importance. He helped refinance the national debt (saving taxpayers millions of dollars); nominated a professed successful abolitionist to the Supreme Court; pushed forward key issues in civil rights; and most importantly rooted out corruption in civil service. He was best known for going head-to-head with a powerful political patronage boss from NY, Roscoe Conkling, and winning. Unfortunately, a presidency that could have been highly productive was cut short, and Garfield's presidency was reduced to a tantalizing "what if" as Ira Rutkow wrote in his 2006 biography. Garfield did however leave the office better than he found it and physicians throughout the USA quickly adopted antisepsis principles after his death.

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