Primum non nocere
In The USA, the medical and surgical care provided to a sitting president is the very best available.  My overall purpose in a series of posts is to illustrate and report on changes in American Medical care in the past 150 years (the last three percent of recorded history) I am anchoring the several posts required, with the carefully documented status of the care delivered to President Garfield.
Only 135 years ago, in 1881, James Garfield, the sitting President of The United States, died subsequent to a modest gunshot wound because of the lack of science-based knowledge in medical and surgical care of wounds and infections. 
Four months after President Garfield’s inauguration, a deranged assassin left the wounded president in a bitter behind-the-scenes struggle for power. Sitting Presidents of The USA, have nearly immediate attention of the very best and knowledgeable physicians and surgeons in the World.  A team of selected, prominent physicians administered shockingly inept treatments, to a disastrous effect. What happened over the next two months, the desperate and ultimately failed attempt to save the president is the subject of a new book by author Candice Millard. It’s called “Destiny of the Republic: A Tale of Madness, Medicine and the Murder of a President.” I reviewed this book earlier this year.
In 2011, REBECCA ROBERTS, NPR host, interviewed Candice Millard. This post relies heavily on the NPR review.
“July 2, 1881 … Charles Guiteau, a deranged former lawyer and evangelist who believed Garfield owed him an ambassadorship, stepped out of the shadows and shot the president once in the arm and once in the back. Garfield seemed at first as if he might recover, but then, his doctors got involved…”
“To get a better feel for the story, Candace Millard and I took a field trip.
We’re here at the National Museum of Health and Medicine.”
“CANDACE MILLARD: This is the section of President Garfield’s spine that was removed during the autopsy. And it shows – specifically, you can see there’s a red pin that goes – and it’s a plastic pin – that goes through the spinal column showing where Guiteau’s bullet went through.
ROBERTS: Also, looking at it, the way the bullet went through the body of the vertebra instead of through where the spinal cord comes up, he could have survived this bullet wound.
MILLARD: Yes, absolutely. The bullet didn’t hit the spinal cord. It didn’t hit any vital organs. And, you know, at this time, 16 years after the Civil War, there were a lot of Civil War veterans walking around with bullets inside of them. In fact, one of the detectives who took Guiteau to the district jail after he shot Garfield had a bullet in his head that he’d been walking around with since the Civil War. And so, you know, the problem was the president received a lot of medical care and the wrong kind. In fact, the first time this wound was examined was on the floor of the train station.
ROBERTS: And what eventually killed the president?
MILLARD: Infection. So this examination went on for day after day after day for more than two months. In the end, 12 different doctors inserted unsterilized fingers and instruments in this wound in the president’s back searching for this bullet. In fact, they made the track down the right side that they thought was the track of the bullet, but their own fingers and instruments made it, and it filled with pus. And so he went from this, you know, six-foot-tall, 210-pound vigorously healthy man to 130 pounds in less than three months.
ROBERTS: So looking from here – and I’m trying to orient my spine to the president’s here on the table – if the bullet went through to the left side of his body, his doctors at the time were pretty convinced it was on the right side. And, in fact, one of the interesting, sort of subplots in your book is Alexander Graham Bell trying to rush to readiness more or less a metal detector to track the path of the bullet, but he wasn’t allowed to look in the right place.
MILLARD: That’s right. So the doctor who took over his medical care, Dr. Doctor Willard Bliss – whose first name was Doctor strangely – Dr. Bliss believed and had publicly stated that the bullet was on the right side. At first, he thought it was in the liver, and everyone believed that the president would die that night. And when he survived, they said, well, it must be near the liver, but it’s still a danger to him, and so that’s why we need to find it, and that’s why they continued to probe for it. This 14 years before the invention of medical X-rays, so they really don’t have any other way to look for it. And that’s when Alexander Graham Bell stepped in with his induction balance, which was basically a metal detector which he connected to a telephone receiver.
And had he been able to find this bullet, and had they been able to see, it had done all the damage it was going to do. It was no longer a danger to the president, the medical care was. Had he been able to stop that early enough before the infection was too great, the president almost certainly would have survived. So what happened, when they did the autopsy – and the doctors who had taken care of the president were there – they realized immediately how wrong they were. And one of the surgeons who had worked with Bliss stepped forward at this, you know, incredibly painful, emotional autopsy and ran his little finger down the spine and slipped his finger into that hole where you see that pin right now, and he said, we were wrong. We made a mistake. And he walked out the door.
MILLARD: So this is one of the most difficult-to-accept aspects of this story. Joseph Lister, who was a renowned British surgeon, had discovered antisepsis 16 years earlier. He’d had dramatic results in his own surgical lab, and he had begged American doctors to sterilize their hands and instruments. And he had warned them if they didn’t, they ran the very real risk of killing their patients.”
“Unfortunately, many of the most experienced, most respected doctors in the United States dismissed antisepsis. They thought it was useless, maybe even dangerous. And the doctors who were treating the president, you know, the fact that he was president, they thought, we’re not going to take any chances. We’re going to use the most traditional medical methods of the time. I think had he been just an average man, he would have had a better chance of surviving.
ROBERTS: It’s ironic, because the fact that he was the president also pushed people forward scientifically. Alexander Graham Bell tried to perfect the induction balance, but at the same time, it led his doctors to cling to older ways.
MILLARD: That’s right. You know, this – you know, people forget that this was a tremendous tragedy at the time, an incredible loss to the country. But one of the good things that came out of it was that antisepsis immediately was accepted and adopted in the United States after Garfield’s death. Because after the autopsy results were released, Americans understood right away that their president didn’t have to die, and they understood why he did. You know, Dr. Bliss was disgraced, publicly disgraced in newspapers and medical journals. And it was a tremendous advancement in medical science.”
1881: a sitting President… modest gunshot wound… no X-ray… infection and sepsis…no anti-sepsis technique… inept management. This was American Medicine only 135 years ago. ccr
Addendum by the author:
The delivery and distribution of medical and surgical care in The United States is among the greatest issues in American lives in 2016. This is from “a first-person history” perspective if you will allow me a running start of about seventy years before I was born.
Enormous amounts of energy and efforts are spent quarreling over the logistics of the delivery of modern medical knowledge. You need to be aware of my experience of a wide variety circumstances, resources, regulations and economics of which I have had first hand experience:
In my opinion, what has been lost in the heat of the discussion, is what should be a celebration for the explosion of scientific knowledge (and mostly), the implementation of radical improvements in the quality of science-based medical care. This essay will catalog some of these. However, our nation has delivery problems, including, (but not limited to) an indefensibly high infant mortality rate, for example, in spite of these advances. (1) Infant mortality rate is an important index of a nation’s health.
Allow me to set the time-frame I wish to review.
Consider the last 50,000 years: Allow me to define one generation of humans to be 25 years.
The history of mankind is written in the lives of two thousand generations  of your ancestors. I am going to review and compare changes in care of the most recent six of these 2000 human generations. [Sapiens; Harari]
The last 150 years, 1865-2015, is the last 0.3% and 1965-2015, the last 0.1% of human history. I will cite some relatively recent medical failures and scientific discoveries that have radically improved our medical care in an amazingly short segment of history.
References and Citations:
Suggested Viewing: THE KNICK (2014 – )
All Critics | Top Critics
AVERAGE TOMATOMETER 94%
AVERAGE AUDIENCE SCORE 96%
liked it: SERIES INFO
Medical drama set in the 1900s charts the exploits of the staff and patients at a New York hospital, where they try to maintain their reputation for quality care while struggling to keep the doors open.more
Creators: Jack Amiel , Michael Begler
Starring: Clive Owen , Andre Holland , Eve Hewson
Suggested Reading: The Flexner Report: ― 100 Years Later
Thomas P. Duffy, MD Yale J Biol Med. 2011 Sep; 84(3): 269–276.
Published online 2011 Sep.
The Flexner Report of 1910 transformed the nature and process of medical education in America with a resulting elimination of proprietary schools and the establishment of the biomedical model as the gold standard of medical training. This transformation occurred in the aftermath of the report, which embraced scientific knowledge and its advancement as the defining ethos of a modern physician. Such an orientation had its origins in the enchantment with German medical education that was spurred by the exposure of American educators and physicians at the turn of the century to the university medical schools of Europe. American medicine profited immeasurably from the scientific advances that this system allowed, but the hyper-rational system of German science created an imbalance in the art and science of medicine. A catching-up is under way to realign the professional commitment of the physician with a revision of medical education to achieve that purpose.
 Primum non nocere is a Latin phrase that means “first, do no harm.
 This author has been a Professor at The George Washington University Medical Center since 1974. Colleagues of the Medical Associates have frequently attended to The President and The President’s Family.
 Candice Millard, DESTINY OF THE REPUBLIC; A Tale of Madness, Medicine,and the Murder of a President
339 pp. Doubleday. also Audiobooks
Charles Clanton Rogers, MD, FACR, Emeritus Professor, GWU