j.;'-^;v.Vo6VAri.".\'-t>,v ? j;>> » > LIBRARY OF CONGRESS. e^ap — (immi^ ^"^ — Shelf -^--^^^-ij" UNITED STATES OF AMERICA. > J > - - 5> > > >€> • ^ :» ^m ^ii m- i? j»>>^ ^3 iS^i .- fl^r c^ #^ r^ '^: ^ ^ u-< SB o : ;3 oj o o 5 ^ ^ "a; 5 =* cS +^ > oi is 0) ^'-C :x !3 a> OS CO tif^ ^ postmortem examination. The course of the bullet was wholly without the peritoneal cavity. As will be seen by the engraving, the course of the missile after it entered the body of the President fol- lowed the line of an irregular, nearly S-shaped curve with its convex surface directed to the back of the 101 President, and passing to the left and gradually down- ward to its termination. A consideration of this fact will show at once how impossible it was to obtain any information concerning the course of the bullet, or its location in the body by any examination made from the outside of the body. No probe could be passed through the wound in the body of the verte- bra, (even if it had been considered advisable to attempt such a proceeding), and the purulent mate- rial formed in the w^ound as the result of, bacterial action, gradually by the action of gravity dissected its w^ay dow^nw^ard toward the right iliac fossa, and formed a false channel or sinus, which misled the surgeons, and made them suppose the bullet lay in that part of the body. The carious condition of the body of the first lumbar vertebra found to exist at the time of the postmortem w^as quite sufficient to account for the septic condition of the President during life. It may here be remarked that the spinal canal of the first lumbar vertebra was not opened by the bullet in its course through the body, nor were there any gross anatomical lesions found in the spinal cord at the time it was examined. It should be remembered, how^ever, that the weapon with which the President was shot was an English revolver of what is commonly called the "bulldog pattern," that was capable of throwing a bullet with great propulsive force ; and crushed and splintered the porous cancellated bony tissue in its passage through the body of the vertebra. The lacerated condition of the cancellated struc- ture of the first lumbar vertebra doubtless con- tributed largely to the production of the septicemic condition, which was in no wise due to lack of proper or sufficient drainage. More favorable circumstances for its production than existed m the comminuted and softened cancellous tissue, with its open venous sinuses bathed m ichorous pus could scarcely be imagined. Dr. William White (-Review of some of the more Important Surgical 102 Problems of President Garfield's Case," p. 15, 1882) : "The fact that drainage was thorough and com- plete, and that no portion of the unfavorable symp- toms was due to failure in this respect, was fully — ♦J o. oo QJ tc oc O So o & a o cc „ oS-3 cc 0) cn O > t< O o3t3 • a o 3^ established by the absence of purulent collections, either along the track of the ball or in the passagj caused by the burrowing of the pus. There was no time previous to the first operation (July 24) at 10-6 which the accumulated pus did not pass freely out ot the original wound. Its exit was favored by grav- itation after the two incisions had been made' which brought the external openings to a lower level and enabled them not only to drain the lumbar and'iliac regions but also to carry away any discharge that might have come from the fractured vertebra." Anti- septic treatment was employed throughout the case as carefully as it was possible to do so, and drainage tubes were used until it was evident that their use was unnecessary." ^ In attempting to reply to the above mentioned ques- tions, much time and labor have been spent in review- ing the various authorities on this subject. The con- sensus of opinion of all the great masters of the art of surgery is to the effect that these injuries are almost necessarily fatal. Dr. Lidell, justly esteemed as one of our most experienced of American military surgeons, says {American Journal of the Medical Sciences, Vol. 48, p. 317) : "Leaving out of the calcu- lation such fractures as involve the spinous processes alone, the writer has never seen a case of gunshot fracture get well, and he might add that he has never seen life prolonged for a month after the inflic- tion of that injury." In Circular No. 6, Surgeon-General's Office, 1865 (is^sued during our Civil War), it is reported that of 187 recorded- cases of gunshot fracture of the verte- brae, all but seven proved fatal ; six of these were fractures of the transverse or spinous apophyses. It is well known that fractures of the vertebral pro- cesses are not especially fatal injuries, and that a large proportion of them recover. Many of these have been recorded under the general head of frac- tures of the vertebrae, but evidently have no bearing on the case in question. Dr. Demme, ("Military Surgery," 1868) says: "Extensive injuries or lodg- ment of balls in vertebrae or in the cord give rise to death or incurable paralysis." Professor Gross ("Treatise on Military Surgery," 104 Vol. 2, p. 82) says: "Gunshot wounds of the verte- bra3, with lesion of the spinal cord, are nearly always, if not invariably fatal. Of twenty-two cases of this kind in the English army in the Crimea, not one E3 O SB —I tn ^^ O a^ i +^ '-' '. 03 recovered. Even when the bones alone are affected the danger is generally very imminent, most of the patients thus affected dying in a short time." Professor P. S. Connor (Ashhurst's International Encyclopedia of Surgery, 1882, Vol. 2, p. 203) says: 105 "The prognosis of vertebral injuries, aside from the less severe forms of contusions and fractures of the processes, especially the spinous, is very grave, death usually resulting from lesion of the cord, from sep- tic infection, from caries with abscess, or from asso- ciated wounds of a viscus or large vessel. As was declared by Ollivier, in gunshot cases the accidents are graver and death generally more rapid than in those otherwise caused. Of the thirty- two cases of verte- bral fracture among the British soldiers in the Crimea, all proved fatal except four, which were either fractures of the transverse processes in the neck, or of the spinous processes only, and in the French army, 181 died out of 194 (93.3 per cent.). In the war between Prussia and Hanover in 1866, there were eight cases with six deaths. Of 628 cases tabulated by Otis, 349 or 55.57 per cent, ended in death, the mortality according to locality having been : For the cervical region 70 per cent. (63 out of 90) ; for the dorsal region 63.5, (87 out of 137) ; and for the lumbar region, 45.5 per cent. (66 out of 145) ; but in almost all probably, of the non-fatal cases, the fractures affected only the processes." In the Wien Medicin Wochen, No. 47, 1881, Pro- fessor Max Schuller, after giving a complete history of President Garfield's case concludes as follows : ''Taking into consideration all the circumstances connected with this gunshot wound, it is evident that the determination of the direction taken by the missile by probing would have been extremely diffi- cult, and had it been possible, would have been accompanied by great danger to the patient. Among the symptoms which presented themselves immedi- ately after the receipt of the injury, only the pain and disturbance of insensibility in the lower extrem- ities, gave an indication of the true course of the bullet. If, however, the supposition had been enter- tained that the vertebral column was wounded, the question of the indication for treatment would not have been different from that instituted by the 106 attending surgeons." He then continues : "To pre- vent sepsis in gunshot injuries, and to bring to a. successful issue such a wound as that received bv _.::..::yi^-..';:f>. /■ •1 ''-.\ 02 >i •> < ■2 ; ; V- •3 : , •: •», \_ • s ; 1/ Diagram of posterior surface of body of President Garfield. 1. Point ot eiiti aiice of bullet. 2. Location of bullet when found during the post- mortem examination. ^ President Garfield, is one of the most difficult achieve- ments, and can not always be accomplished, even with the most careful and assiduous application of aseptic surgery." ^ tv ^ "^ s Fold-out Placeholder This fold-out is being digitized, and will be inse future date. Fold-out Placeholder This fold-out is being digitized, and will be inserted at future date. 107 Dr. John Ashhurst (No/^th American Revieiv, Decem- ber, 1881, p. 594) says: "Looking at the whole case from beginning to end, I do not see that the treat- ment could have been altered in any way to the advantage of the illustrious patient ; nothing was done that should have been omitted, and nothing was left undone that could possibly have been of benefit." Dr. J. Marion Sims (North American Revieiv, De- cember, 1881, p. 300) says : "The President's sur- geons did all that men could do, all that the present state of science would permit, and all that could have been done, even if they had first ascertained the course and direction of the ball." "Our whole med- ical literature does not contain a single well authen- ticated case of recovery from such a wound." "He had not the least chance of recovery under any circumstances or any treatment." Dr. John T. Hodgen (Ibid, p. 610) says: "In reviewing the history of the case of President Gar- field, I can find no reason for adverse criticism of any part of the management." Finally, while it is difficult and perhaps impossi- ble for any one to give a dispassionate judgment, in a case in which we were so deeply and personally interested as in that of the President, yet it is the deliberate conviction of the writer (as it was of all the surgeons in charge of the case) that the Presi- dent was mortally wounded when he received the fatal shot. Freely confessing our errors of diagnosis, yet we believed that no different course of treatment could have saved his life. I know that I speak only the truth when I say that no wounded man ever received more tender, loving and devoted service, not only from his surgeons but also from the faithful friends who nursed him through his long and weary illness. We gave him this cheerfully and would have sacrificed even our lives for him, if by so doing we could have saved his. We would have done this- not only because he was President, but because we^ 108 loved the man. Poor patient, uncomplaining, suf- fering President. How our hearts ached for him ; Member of Congress, Senator, President, stricken down at the time when he had received in rapid suc- cession the highest honors his country could bestow, he passed through days, weeks and months of suffer- ing, through the valley of the shadow of death, to that heavenly country, where there is neither sorrow, nor suffering nor pain. We can not understand why such things should be. We can only bow in humble submission to the will of Him who ruleth all things hoth in heaven and earth, and who doeth all things, well. THE END. ^n -^^.^±x:r , ■s c mi "' ^ .^ ^-^^^^ ■ V -CC ^..c-> S^.«^ ^•ce^ ^JF t S<^i^fci C «r Co r^^^ c > c ^ C C -^c cc ^1 C( ^rm^>'.^ c c CO:: XCT' CCc re: ^ ^-< <: c