EXCERPTS 
FROM 
OPINIONS OF DISTINGUISHED MEDICAL 
MEN IN THIS AND OTHER COUNTRIES 
JUSTIFYING THE TREATMENT 
OF THE LATE PRESIDENT 
GARFIELD, 
TOGETHER 
With a letter in reply to the resolution of the Special 
Committee of the House of Representatives 
referring' to the expenses consequent 
upon his illness and death. 
WASHINGTON, D. C. 
GIBSON BROTHERS, PRINTERS. 
1882. EXCERPTS. 
British Medical Journal, July 9, 
“ The distinguished patient could not be under ' 
cal care than is to be found in Washington. The vast experi- 
ence gained during the war of the rebellion in the United 
States has diffused an immense amount of knowledge concern- 
ing gunshot wounds and their treatment among army surgeons 
in that country, and several of the most eminent among them 
are connected with the casef &c. 
British Medical Journal, August 20, 1881. 
“ The surgical treatment has been severely criticised in some 
quarters, very unfairly, as it seems to us, inasmuch as the attacks 
upon the course pursued have been made without an oppor- 
tunity of personal observation of the case, and without making 
any allowance for the difficulties in which the surgeons in at- 
tendance upon it have been placed.” * * * “ So far as the 
facts which have been, successively announced in the official 
bulletins are concerned, nothing has been mentioned which has 
been inconsistent with what might be expected to take place in any 
case of a bullet wound, in which a bone has been struck and 
the bullet so diverted that it has been caused to pursue a deep 
and tortuous course in muscular tissues, and to pass out of reach 
of observation or detection by the surgeons.” 
Same Journal, December 17, 1881. 
“ After analyzing the statements of Drs. Hammond, Sims, 
Ashurst, and llodgen, in the North American Review for 
December, 1881, we fully concur with Dr. Sims in the pre- 
vious assertion made by him that the wound of the late Presi- 2 
dent was as certainly mortal as the wound of President Lin- 
coln. The difference was only one of time?'* 
New York Medical Journal, November, 1881, 
Says, regarding English criticisms on the long and painful 
conflict of surgery with the injury dealt to our lost President: 
“ Truly the modern art of surgery in all its fulness—not the 
mere individual capabilities of the little knot of men who stood 
as its representatives—was brought to bear upon this case,” &c. 
“ Also, if any of Dr. Bliss’’ questions as appended by him to 
his account of the case in the Medical Record of October 8, 
1881, chn be so answered as to show that in any respect the 
conduct of the case could, without the light thrown upon it by 
the autopsy, have been better carried out, we trust that such an- 
swer will be brought forward speedily and boldly. We have 
nothing but praise for the surgeons as regards their actual 
management of the case?’ 
Boston Medical and Surgical Journal, September 8, 1881. 
“ A lenient judgment must, however, be invoked for the phy- 
sicians who have borne the task of an attendance, the trying 
nature of which can be easily understood, and we ought to con- 
gratulate ourselves that no change has taken place in the per- 
sonnel of the President?s medical staff.” 
Same Journal, September 22, 1881. 
“No one, we believe, is in a position to say that the wound 
was not from the beginning of a necessarily fatal character, or 
that other measures than those taken could have averted the 
result we all deplore.” 
Boston Medical and Surgical Journal, September 22, 1881. 
“ It is plain, and is generally acknowledged, that no good and 
much harm would have resulted from any serious attempt to 3 
extract the ball, even had it been possible to determine its 
exact situation.” 
Medical Record, August 13, 1881. 
“In the light of the facts that are furnished the public it is 
easy to understand the extreme caution of the surgeons as to 
probing the wound.” 
Same Journal, August 6, 1881. 
“ We take pleasure in affirming again that the treatment of 
the President is thus far beyond criticism, and it is fair to sup- 
pose that so long as the present medical staff remains in attend- 
ance nothing will be left undone to insure the comfort, safety, 
and recovery of the illustrious patient.” 
Same Journal, August 20, 1881. 
“ As might have been expected, the management of this case 
has been open to much criticism by the secular press. It is to 
the credit of the profession, and especially of the gentlemen in 
charge of the case, that so little can be said concerning what 
might have been done and what was not done. Despite the 
journalistic prescribers in some of our leading dailies, the peo- 
ple have continued to maintain a confidence in the attending 
and consulting surgeons which is as gratifying as it is necessary. 
There seems to be, justly, but one sentiment entertained both by 
the prof ession and’ the public regarding the judicious manner 
in which this case has been treated from the beginning T 
Same Journal, September 24,1881. 
“It is, we believe, the general verdict of the profession that the 
late President received all the aid which medical science, intelli- 
gently applied, could f urnish. Looking back upon the case, 
even with the light of the autopsy before us, it is impossible 
for any one to say that any different mode of treatment would 4 
have saved the President; and furthermore, we may claim that 
medical art prolonged for months a life which might otherwise 
have ended in a few days or weeks. We believe that this can 
be truthfully said, and that it will be echoed and endorsed by 
the medical profession.” 
/Same Journal, September 26,1881. 
“ No means of more thorough exploration of the wound could 
have been safely employed.” 
Drs. Sims, Ashurst, and Ilodgen in the North American 
Review “ frankly acknowledged that the wound was essentially 
fatal; that the error of diagnosis was, under the circum- 
stances, unavoidable; that the treatment was in accordance 
with accepted principles in surgery, and that in reality nothing 
more could have been done to prolong the life of the lamented 
sufferer.” 
Cincinnati Lancet and Clinic, Septembei 24, 1881. 
“No blame can be attached to the surgeons in attendance 
upon tire President for abstaining from instrumental interfer- 
ence with a view of locating the ball. * * * What skill 
and science could do was done. The surgeons in attendance 
merit the gratitude of our people alone; there is nothing 
deserving of reproach.” 
Pacific Medical and Surgical Journal, San Francisco. 
“He was in able hands, well known to the profession in 
Europe as well as in America.” 
Canada Lancet, September 1, 1881. 
“ Everything is being done for the patient that can be done. 
Every confidence is very justly reposed in his medical advisers, 
and, come what may, there can be no cause for blame attached 
to them'' 5 
Medical News and Abstract, Philadelphia, October, 1881. 
The publication in the current number of the American 
Journal of the Medical Science of the official report of the 
autopsy upon the body of President Garfield will, we trust, 
while satisfying the legitimate curiosity of the profession and 
of the laity, at the same time effectually and permanently quiet 
the unfriendly criticism of the surgical treatment of the case in 
which part of the daily press has so freely indulged and from 
which, we regret to observe, some medical journals, without 
full knowledge of the case, have not thought proper to abstain. 
“ The discoveries of the autopsy, taken in conjunction with 
what is known of the clinical history, will at once make ap- 
parent to the profession the good common sense, admirable 
conservatism, and sound surgical treatment and judgment 
which have characterized the management of the case from 
first to last, and although the non-medical mind may be slower 
to comprehend the questions at issue, it will not be long before 
the same conviction forces itself upon the people at large. 
“ We know beyond the possibility of a doubt that no human 
skill could have averted the fatal result; but we find, more- 
over, that even in the searching light of the careful and 
thorough post-mortem examination it is difficult, if not impos- 
to suggest any modification of the treatment, even in 
minor points, which would have made it better adapted to the 
exigencies of the case.” 
* * * * * * 
From this general consideration of the history of the case, 
viewed in the light thrown upon it by the details of the autopsy, 
we may safely conclude : 
1st. That the treatment at the time of the reception of the 
injury, immediately subsequent to it, was that rendered proper 
by the condition of collapse which then existed. 
2d. That on reaction taking place, a sufficient, thorough, and 
careful examination was made with the finger and the probe. 
3d. That when the consulting surgeons were called in and 
found that this had been done, they very properly, and in ac- 6 
cordance with well-established and universally-recognized rules 
of surgery, refrained from repeating that examination. 
4th. That even if these rules had been disregarded and such 
examination had been made, it would have determined nothing 
of practical importance as regards the subsequent treatment. 
5th. That wherever pus accumulations had taken place, 
they were properly opened by free incisions made at the most 
dependent portions. 
6th. That these incisions drained not'only the course of the 
abscess, but communicated freely with that portion of the spine 
which had been penetrated, and, therefore, with the track of 
the ball; and the completeness of the drainage is shown by the 
absence of pus accumulations either in the locality traversed by 
the ball or in the iliac or lumbar regions. 
7th. That the damage done to the cancellated tissue of the 
lumbar vertebra was sufficient in itself to explain the septic 
state of the system, which in time, and independent of the ball, 
(which proves to have become harmless,) would have destroyed 
the life of the patient. 
College and Clinical Record, Philadelphia, October, 1881. 
“ The careful methods of exploration pursued by the attend- 
ing surgeons will commend themselves to the attention of the 
profession and the public as full commensurate with the impor- 
tance of this celebrated case. The study of the autopsy will bring 
to the mind of the most sceptical a thorough and persuasive vin- 
dication of his careful, conscientious, and indefatigable medical 
attendance—a vindication that was not deemed necessary by 
those who had honestly placed their faith in their skill and dis- 
cretion during the many weeks of suffering through which their 
distinguished patient so uncomplainingly struggled.” 
Medical Press and Circular, (London]) October, 1881. 
“ The general verdict of the profession is that the President 
received all the aid which medical science, intelligently applied, 7 
could furnish. It is held that, looking back upon the case by 
the light of the autopsy, it is impossible for any one to say 
that a different line of treatment than that pursued would have 
saved the President’s life, and further, that medical art pro- 
longed the life which otherwise might have endedin afezo days.” 
Virginia Medical Monthly, September, 1881. 
“ The President’s condition is a subject of such deep inter- 
est to every American that we are not surprised at the eager- 
ness so generally manifested by the medical press to speculate 
as to the result. We have seen many ridiculous descriptions 
and surmises on the subject put in print by doctors, who, in this 
instance, manifest no greater intelligence than the laity, as to 
the nature of the wound. By such a course the profession 
lays itself liable to have further odious epithets and taunts 
thrown at it. Not one of the six distinguished medical men 
now in attendance upon the President has yet been able to 
trace the track of the ball, or to locate its present position with 
satisfactory definiteness to warrant them in announcing an 
opinion—although these gentlemen are the only surgeons who 
have ever had an opportunity of examining the wound. * * * 
Whatever may be the result now, even if fatal, we would 
feel resigned as we would live in the belief that everything 
had been done for the restoration of the President that human 
skill could accomplish.” 
Annates H Hygiene Publique et de Medicin Legale, Paris, 
Fevrier 1882, 
Contains an account of the post-mortem and remarks “ that 
treatment was fully justified by the results.” 
In its Rondon letter, says: “When, however, the suppuration 
of the gland ceased to form new points of pus, then again hope 
became buoyant that his magnificent constitution, his high cour- 
Philadelphia Medical Times, October 8, 1881, 8 
age, judicious nursing, and consummate medical skill, all com- 
bined, would bring him through ultimately. * * * The 
medical management of the case has never been hostilely criti- 
cised, in my hearing at least—nothing, but whatever occurs 
the public of Great Britain will ever feel that in a terrible 
emergency the medical profession has acquitted itself with dis- 
tinguished skill, and has deserved well of all?' 
Extracts from a Review of some of the more important 
Surgical Problems of President Garfield's Case, by J. 
William White, M. D., Demonstrator of Surgery and 
Lecturer on Operative Surgery in the University of 
- Pennsylvania, Surgeon to the Philadelphia Hospital, 
Fellow of the American Surgical Association, etc. Phil- 
adelphia, 1882. 
Its motive is to be found in the fact that numerous articles 
which have from time to time appeared in both the medical 
and the lay press, seem to indicate that in the minds of many in- 
telligent people, within and without the profession, there is still 
much misconception regarding several important points in the 
case of the late President Garfield. 
In bringing together the facts which I shall mention I have 
especially consulted the official report, published in the Ameri- 
can Journal of the Medical Sciences for October, 1881, and 
have carefully perused the excellent articles of Drs. Ashhurst, 
Hunt, Sims, Hodgen, Shrady, Weise, Kumar, Sehussler, Fi- 
gueria, and others, as well as the editorials and criticisms of the 
medical press of this and foreign countries. 
The points which it seems worth while to consider, on ac- 
count both of their general surgical interest, and of the mis- 
conception alluded to, and which may be taken up seriatim, 
are as follows: 
1. Did the relative positions of the patient and assassin at 
the time of the shooting afford any indication of the course of 
the ball as revealed at the autopsy ? 9 
2. Was it probable that at any time the ball could have 
been detected or located by the use of probes ; and if so, should 
such an endeavor have been made ? 
3. Did the subjective symptoms indicate anything more 
serious than nerve injury or spina] concussion; or, in other 
words, did they furnish reliable material for diagnosis ? 
4. Was the subsequent treatment in any way whatever hurt- 
ful or defective, or could it have been modified with advantage, 
if the exact character of the injury had been known ? 
5. What was the immediate cause of death ? 
6. Was the wound necessarily a mortal one ? 
“Occasionally,1 when the trunks of nerves are directly in- 
jured (not divided, but violently pushed aside,) the wound will 
be accompanied with intense pain, but none will be experienced 
locally; the pain which is felt will be referred far away from 
the tract of the projectile to some distant part to which the 
nerves are distributed. * * * Less rare cases are those in 
which pain is not only felt in the wounded limb, but reflex pain 
is also felt in the opposite uninjured limb,” &c. 
“Nerve injuries may also cause pain which, owing to inex- 
plicable reflex transfers in the centres, may be felt in remote 
tissues outside of the region which is tributary to the wounded 
nerve. 
“ In Case IV, Hutchinson’s Series, p. 313, the median and 
ulnar nerves being injured, there was pain in the unhurt hand. 
Pirogoff, p. 384, has similar instance from injury to the right 
brachial plexus. 
“ In two cases wounds of one leg seemed to the patient to 
be truly in the other.”3 
So far as I know all the diagnoses of spinal injury which 
were claimed to have been made in different parts of the coun- 
try first appeared after the publication of the autopsy, and this 
is rather to the credit of their authors than otherwise, as cer- 
tainly no one having merely those symptoms submitted to him 
1 Gunshot Injuries, their History, Nature, and Treatment by Surgeon-Gen- 
eral T. Longmore, London, 1877, p. 145. 
2 Injuries of Nerves by S. Weir Mitchell, M. D., Philadelphia, 1872, p. 193. 
2 Ibid., p. 146. 10 
in a similar case to-day would be justified in asserting the ex- 
istence of a fractured vertebra or a grave injury of the cord. 
Prof. Kumar, of Vienna, after a lengthy criticism of the case 
in the light of the clinical history and the autopsy, wrote:1 
“ Evidences of paralysis in the region of the lower extrem- 
ities were never noticeable ; the only symptoms of disturbance 
of nerve function were those already mentioned—hyperesthe- 
sia of the skin of the feet and ankles and of the right half of 
the scrotum—which at the end of the first week had entirely 
disappeared. From all these symptoms no conclusion as to the 
course of the ball could be drawn.” 
Lid ell says : 2 
“ The general symptoms of gunshot fracture of the spine are 
not essentially different from those which are present in other 
forms of that injury, and they are referable mainly to paraly- 
sis, either partial or complete, (but commonly the latter,) of all 
the muscular apparatus supplied with spinal nerves given off at 
or below the seat of fracture.” 
Hamilton3 wrote in 1865 : 
“ In a few cases a ball has been known to pass through the 
side of the body of one of the vertebrae, leaving a round hole 
or a lateral furrow, without coming in contact with the spinal 
marrow or the blood-vessels. It is not probable that we shall 
be able to diagnosticate such a case clearly during the life of a 
patient, and if we were able to do so we do not see what bene- 
fit could be derived from any surgical operation.” 
Legouest4 says: 
“ It is always very difficult, if not impossible, to be assured 
that the bodies of the vertebrae are injured when there are no 
symptoms of a lesion of the spinal marrow. The surgeon in 
most of these cases is constrained to leave them to the efforts 
of nature, watching for the appearance of those accidents which 
may accompany the presence of foreign bodies, and which are 
1 President Garfield’s Verwundung, von Primararzt Dr. Kumar, Wiener 
medizinische Blatter, November 10, 1881. 
3 American Journal of the Medical Sciences, vol. xlviii, p. 311. 
3 Military Surgery, p. 338, quoted by Dr. Hunt. 
4 Treatise on Military Surgery. 11 
aggravated in such cases by the importance of the organs in 
the neighborhood of the wound.” 
Agnew1 says of fractures of the vertebrae : 
“ Except in fractures of the spinous processes, where the 
damaged part is entirely accessible to the touch, we cannot 
affirm the existence of such an injury with any degree of cer- 
tainty. The presence of certain symptoms following a sufficient 
cause furnishes ground for supposing the existence of a frac- 
ture, and yet these may all be present without any injury of 
the kind. The prominent symptom is paralysis.” 
Authorities to this effect might be multiplied indefinitely, 
but the question hardly admits of dispute. 
If, then, a study of the positions of the wounded man and 
his assailant was without diagnostic value; if probing to any 
extent was strongly contraindicated, and could not possibly have 
resulted in anything but harm ; and if the subjective symptoms 
were not distinctive, or were positively misleading, it is evident 
that the materials for definitely determining the character of 
the injury were altogether wanting. Much has been written 
in regard to “ mistaken diagnosis,” even by gentlemen who in- 
tended to defend the management of the case; but it has al- 
ways seemed to me that this did not fairly state the situation. 
An “absence of diagnosis” on account of a total lack of neces- 
sary evidence would have more nearly expressed it, and every 
surgeon of experience knows how frequently and how unavoid- 
ably this occurs. 
The laceration of the cancellated structure of the first lum- 
bar vertebra doubtless contributed largely to the production of 
the septicaemic condition, which was in nowise due to lack of 
proper or sufficient drainage. More favorable circumstances 
for its production than existed in the comminuted and softened 
cancellous tissue, with its open venous sinuses, bathed in ichor- 
ous pus, could hardly be imagined.2 
1 The Principles and Practice of Surgery, Philadelphia, 1878, vol. i, p. 825. 
2 “ A long, interrupted, and sinuous shot-wound, with several fractured 
bones in its course and terminating in the neighborhood of the abdominal 
cavity, necessarily presents every facility for unhealthy suppuration, the for- 
mation of secondary abscesses, the retention of pus, and all their accompany- 
ing inseparable and unavoidable evil consequences.”—Kumar, op. cit. 12 
The fact that drainage was thorough and complete, and that 
no portion of the unfavorable symptoms was due to neglect in 
this respect, was fully established by the absence of purulent 
collections either along the track of the ball or in the passage 
caused by the burrowing of the pus. There was no time pre- 
vious to the first operation at which the accumulated pus did 
not pass out of the original wound, but its exist was favored 
by gravitation after the two operations which brought the ex- 
ternal openings on a lowel level, and enabled them not only to 
drain completely the iliac and lumbar regions, but also to carry 
away any discharge that may have come from the fractured 
vertebra. 
Prof. Max Schuller, of Berlin, after a careful review of all 
these points, wrote :1 
“ Even if a suspicion of the wound of the spine had arisen, 
the problem of treatment, which the attending surgeons were 
endeavoring with the greatest skill to solve, would have under- 
gone no alteration.” 
The treatment was cautious, but thorough, and no indication 
was overlooked or disregarded. Wherever collections of pus 
took place, they were properly opened by free incisions made 
at the most dependent portions. These incisions drained not 
only the course of the abscess, but communicated freely with 
that portion of the spine which had been penetrated, and, there- 
fore, with the track of the ball, and the completeness of the 
drainage was shown by the absence of pus accumulations either 
in the locality traversed by the ball or in the iliac or lumbar 
regions. The treatment also as regards the other complica- 
tions, the parotitis, bronchitis, dyspepsia, etc., was in the most 
marked degree careful and judicious, and, indeed, may be said 
to have prolonged the life of the patient for many weeks. 
As to the immediate cause of death, it was, as has been 
stated, the rupture of an aneurism of the splenic artery. The 
ball itself had become encysted, and had given rise to no 
1Deutsche medizinische Wochenschrift, No. 47, p. 634. 13 
damage whatever, after the moment of its lodgement, but the 
injury to the cancellated tissue of the lumbar vertebra was suf- 
ficient to explain all the septicemic symptons, and in time 
would doubtless of itself have proved fatal. 
6. In attempting to reply to the sixth and last question, as 
to whether or not the wound was necessarily a mortal one, 
much time and labor has been spent in a review of all the au- 
thorities bearing upon the subject. It may be said at once 
that in the whole range of surgical literature, civil and military, 
no similar case, followed by recovery, has ever been recorded, 
and this statement is made with the full knowledge that it has 
been asserted that such recoveries are not infrequent. In some 
instances these erroneous assertions may have been due to ne- 
glect properly to classify the cases, which are often very im- 
properly reported. Of course, it is well known that fractures 
of the vetebral processes are not especially fatal injuries, and 
that a large proportion of them recover. Many of these are 
recorded under the general head of fractures of vertebrae, but 
evidently have no bearing upon the case in question. 
What Lidell1 does say, is that— 
“ In the British army, during the Crimean war, there oc- 
curred ten cases of gunshot wounds with/ractf t/re of vertebrae., but 
without lesion of the spinal cord, of which six died and four 
recovered so far as to be invalided ; there also occurred twenty- 
two cases of gunshot wounds with fractures of the vertebra? 
and lesion of the spinal cord, all of which died.” 
On the very same page Dr. Lidell, who is truly described as 
one of the most experienced of our militry surgeons, says: 
“ Leaving out of the calculation such fractures as involve 
the spinous process alone, the writer has never seen a case of 
gunshot fracture of a vertebra get well, and he might add that 
he has never seen life prolonged for a month after the in- 
fliction of that injury.” 
“ Attempts at extraction are dangerous and often-useless,” 
and that “ only when when paralysis exists will it be necessary 
1 American Journal of the Medical Sciences, vol. xlviii, p. 317. 14 
or prudent even to make incisions, or to search in the simplest 
manner for the foreign body or for spiculae of bone.” 
“ In the Surgeon-General’s Report, No. 6, one hundred and 
eighty-seven examples of gunshot fracture of the vertebrae are 
reported, of which one hundred and eighty died, and of seven 
which recovered not one was a fracture of the body of a ver- 
tebra.”1 
Demme2 says : 
“ Extensive injuries or lodgment of balls in vertebrae or in 
the cord give rise either to death or incurable paralysis.” 
Gross3 says: 
“ Gunshot wounds of the vertebrae, 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 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.” 
No instance of complete recovery after the latter injury was 
met with, and in those here alluded to, the actual seat of the 
fracture was in every case doubtful. No perforating wound 
with recovery is mentioned at all. 
Space will not permit a more extended consideration of this 
subject, but I may add that, in addition to the authorities 
already quoted, the excellent writings of Alcock, Ballinger, 
Bell, Bird, Chevalier, Clowes, Cole, Demme, Guthrie, Hall, 
Hutchinson, Longmore, Ran by, Thompson, and Williamson 
have been consulted, and with a similar result. 
No undoubted instance of recovery after a compound com- 
minuted or perforating gunshot fracture of the body of a ver- 
tebra has ever been recorded. 
The explanation of this fact is apparent to every one who 
carefully considers the nature of such an injury, the grave and 
manifold dangers which encompass it, ami the almost infinitesi- 
1 Medical Record, 1867, vol. ii, p. 401. The italics here are Dr. Hamilton’s. 
2 Military Surgery, edition of 1868. 
3 Treatise on Surgery, vol. ii, p. 82. 15 
mal chance which the patient has, if he escape one or two or 
them, of avoiding them all. 
In support of the foregoing statements, both as to the nec- 
essary fatality of the wound and as to the absolute correctness 
of the treatment in the President’s case, it would be easy to 
adduce almost unlimited confirmatory evidence. The leading 
medical journals of the world have strongly and unequivocally 
upheld these views, and, indeed, it may be said that they have 
been maintained by every writer who has discussed the subject 
and who is entitled, by special study or experience, to speak 
with authority. 
I shall confine myself now, however, to quoting the testi- 
mony of three eminent members of the profession in this 
country : 
•‘Looking at the whole case from beginning to end, I do not 
see that the treatment 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.”1 
“ The President’s surgeons 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 at first ascertained the 
course and direction of the ball. Our whole medical literature 
does not contain a single well-authenticated case of recovery 
from such a wound.” “ He had not the least chance of recov- 
ery under any circumstances or any treatment.”2 
“ In reviewing the history of the case of President Garfield 
I can find no reason for adverse criticism of any part of the 
management.”3 
In conclusion, it may be asserted that, after careful consider- 
ation and thorough seach through the records of this and sim- 
ilar cases, and after the opportunity of deliberate comparison 
thus afforded, the following facts appear to be incontrover- 
tible : 
1. It was never possible at any time or by any method to as- 
1 Dr. John Ashhurst, Jr., in North American Review, December, 1881 p 
594. 
2 Dr. J. Marion Sims, Ibid., p. 600. 
8 Dr. John T, Hodgen, Ibid., p. 610. 16 
certain definitely and safely the precise character and extent of 
the President’s wound. 
2. Any attempt in this direction further than was made by 
the attending surgeons would in all probability have resulted 
fatally at once, and their steadfast resistance to extraordinary 
influence in favor of operative interference entitles them to 
great credit. 
3. The treatment, which was directed to meeting the indica- 
tions as they arose, was in every respect that which it would 
have been necessary to adopt had it been possible fully to de- 
termine the exact nature of his injuries. 
4. Life was prolonged for an unusually protracted period by 
the careful and skilful attention which the distinguished patient 
received. 
5. Death resulted from the secondary effects of the wound 
upon structures far beyond the reach of surgical interference. 
6. No undoubted instance of recovery from such a wound 
is to be found recorded in surgical literature. 
Copied from the New York Medical Gazette of January 21, 
1882. 
EDITORIAL THE TREATMENT OF THE LATE PRESIDENT’S WOUND. 
In the JFzen Medicin Wochen, No. 47, 1881, Prof. Max 
Schuller, after giving a complete history of the late President’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 difficult, and, if it had been possible, would have 
been accompanied by great danger to the patient. It is prob- 
able that the track of the bullet through the muscular tissue it 
traversed was so irregular, and the tissue itself so torn by the 
projectile fired at so close range, that an immediate attempt to 
follow in the direction of the ball would have been futile. 17 
Among the symptoms which presented themselves immediately 
after the receipt of the injury, only the pain and disturbance of 
sensibility in the lower extremities gave an indication of the 
true course of the bullet.” 
“This disturbance of sensibility in both lower extremities 
would scarcely have occurred without a lesion of the cord (either 
by extravasation and pressure upon the dura or a direct injury 
of a light grade of the substance of the cord) above the point 
of origin of the nerves distributed to these members. If, how- 
ever, the supposition has been entertained that the vertebral 
column was wounded, the question of indication for treatment 
would not have been different from that instituted by the at- 
tending surgeons.” 
“ To prevent sepsis in gunshot injuries and to bring to a suc- 
cessful issue such a wound as that received by President Gar- 
field, is one of the most difficult achievements, and cannot always 
~be accomplished, even with the most careful and assiduous ap- 
plication of antiseptic surgery}'1 
Dr. Schuller has fallen into the error of supposing that ner- 
vous sensation or pains can always be traced to some specific 
lesion of the nervous system ; while nothing is better estab- 
lished than that such sensations are often wholly unreliable as a 
means of exact diagnosis. The literature of nerve injuries is 
replete with examples which illustrate the truth of this state- 
ment. Lesions of the ganglionic system, where there is no lesion 
of the nerves of common sensation or of motion, often cause 
reflex pains and paralysis in one or both extremities or in other 
parts of the body. Ordinary colic, or distention of the stomach 
by gas, may cause pains in various parts of the body ; and if 
the disturbance or lesion of the ganglionic nerve is persistent, 
(as it would be in case of its being traversed by a ball,) the re- 
flex pains would necessarily be persistent. There was no posi- 
tive evidence, therefore, furnished by the pains, first in the right 
foot and then in the left, that they were not caused by such an 
injury, and especially since these pains only lasted a short time. 
“ It is true, also, as shown by Mitchell, that an injury of the 
spinal nerve is not always expressed by pains in that part of the 18 
body which corresponds to its distribution. The author relates 
the case of a man who, being wounded by a ball in his right 
thigh, felt pain only in the left thigh; and in another case 
cited by him an injury of the right sciatic nerve caused paraly- 
sis of the right arm and only paresis of the right thigh. But 
in a matter so well known to medical men it is unnecessary to 
cite examples. We do not deny that the rule is otherwise, so 
far as lesions of nerves of common sensation are concerned, but 
the exceptions are so frequent as, in the total absence of other 
evidence but a temporary, symmetrical pain in the lower ex- 
tremities, to justify the inferences made by the surgeons in the 
case of the late President. 
“It is certain, also, that in case it were to have been neces- 
sarily inferred from the pains in the feet that the spine had 
been injured, it could not indicate whether it was simply a con- 
cussion, the ball having glanced off in some other direction, or 
an actual penetration of the spine, the ball remaining embedded 
in that structure, or a complete perforation the ball be lodged 
at some point remote from the spine. It would determine, in 
short, nothing-of any practical importance ; as Dr. Schuller 
justly says, it would not have changed the indications of treat- 
ment, or to use his exact language, 1 the treatment would, not 
have been different from that instituted by the attendants' ” 
“While we were writing, the British Medical Journal for 
December 27, 1881, came to hand, and we find in it a very 
full expression of opinion on this subject by its editor. He 
thinks that during the first 24 or 48 hours after the receipt of 
the injury some further exploration might properly have been 
made, but it is evident from his statements that he was not 
well informed as to the extent of the explorations which were 
actually made by Drs. Wales, Bliss, and Woodward. He 
does not doubt that the splenic artery was injured, nor does he 
think that any exploration, however thoroughly made, could 
have averted the fatal result; and in this conclusion he declares 
himself in accord with the opinions of Drs. Sims, Ashurst, 
and Hodgen, as expressed in their several papers published in 
the December number of the North American lieview. 19 
“ When, therefore,” says the editor of the aforementioned 
journal, “the injury came in the form of a severe gunshot 
fracture of two ribs, and the perforation of the vertebral column, 
not to mention the other accompanying lesions, the chances 
of escape became infinitesimal that the wound might be 
strictly regarded as a fatal one. . No particular mode of surgi- 
cal treatment, no amount of skilled nursing and attention to 
hold out a reasonable hope of being able to avert the fatal re- 
sult. Professional skill, devotion, and extreme watchfulness, 
might prolong life, as we believe they did to its utmost tether 
in the President'1s case, but either in the form of blood-poisoning, 
or if not in that, in the form of exhaustion, or in some other 
manifestation of the kind, the fatal end was sure to follow. 
We have expressed regret that the early exploration of the 
wound was not more complete, in the belief that the diagnosis 
and prognosis would have been rendered clearer, had it been, 
and that some of the passing complications which ensued might 
probably have been evaded; but it never occurred to us, when 
once the true nature and extent of the lesions were fully ex- 
posed at the examination after death, that the exploration 
could have exerted such an influence as to stop the final result.” 
As the editor of the British Medical Journal alludes to the 
matter of placing the patient in the same position in which he 
was when the ball was received before proceeding to probe, 
but naively remarks that, owing to the shock this may not 
have been possible in the President’s case, we take the liberty 
of suggesting to him that this rule, given in the writings of 
certain surgical authors, was never intended to apply to any- 
thing but muscular wounds, and especially wounds of the ex- 
tremities, in which a restoration of posture does occasion- 
ally cause a restoration of the channel made by the ball, and 
which would otherwise be obliterated by the action of the 
muscles as sliding valves; but even in these cases it is seldom, 
as all army surgeons know, of any value. No surgeon of ex- 
perience, of reputation, nor who has ever given the subject a 
moment of thought, has ever advised this to be done in the 
case of a gunshot wound of the belly or any of the large 20 
cavities; for the reason that it could be of no possible use— 
the channel through the viscera could not thus be restored. 
This is especially true in case the ball has entered the abdomen. 
The intestines, especially after being wounded, are in constant 
motion ; and to think of restoring the channel of the ball by 
this method is simply puerile, and its mention is unworthy a 
medical student. 
If the ball had passed through the liver, whose position is 
changed by every degree of inflection of the body, the diffi- 
culties would be the same. There are other reasons, also, why 
surgeons have never taught that, in case of an abdominal 
wound, such as that suffered by the President, the patient 
should be put again upon his feet; namely, first, that if the 
intestines have been perforated the effect of this would be to 
hasten and make certain the escape of their contents into the 
peritoneal cavity, and thus vastly increase the danger of a 
fatal result; second, there may be, for aught we can know, a 
concealed hemorrhage, which would be necessarily increased by 
such a change of position; and, third, that the patient is almost 
invariably suffering under such extreme prostration from the 
shock that to maintain him in an erect position until the prob- 
ing was completed and the ball extracted would be simply im- 
possible or promptly fatal. 
Surgeons have, therefore, always enjoined perfect rest in the 
horizontal posture from the first moment after the accident, 
and they are not likely hereafter to teach any other doctrine, 
or to disturb the viscera with probes after belly wounds, in any 
position of the body. No one has yet followed these absurd 
and dangerous suggestions, or if he has, he has taken good care 
to conceal his results. 
The London Lancet for September 24, 1881, concludes a 
somewhat lengthy review of the President’s case, as follows: 
“ The fact that life had been so long preserved is the best evi- 
dence in favor of the surgeons.” 
We wish to add to these rather desultory remarks a word or 
two more in reference to the question of the practicability of in- 
troducing probes or drainage tubes into the track of the wound. 21 
It is a matter of fact, capable of the easiest demonstration, 
that the course of the ball was not straight. These are the 
known facts denied by no one. The ball struck the eleventh 
rib about three inches from its anterior extremity; then the 
twelfth rib near its posterior extremity; then the fibro-carti- 
lage between the last dorsal and first lumbar vertebra, near the 
root of the transverse process, from which point it passed for- 
ward and downward, emerging from the front of the first lum- 
bar vertebra only a little to the left of the centre ; and here 
was again deflected to the left, until it became lodged under 
and below the pancreas, two or three inches to the left of the 
spine. Tn this course it had suffered, as any one may demonstrate 
on the skeleton, four marked deflections ; first, on the eleventh 
rib ; second, on the twelfth rib ; third, as it entered the spine ; 
fourth, as it emerged from the spine. Such being the actual 
fact, to have carried a probe or drainage tube through its chan- 
nel would have been impossible. But admitting that the chan- 
nel had been straight, every surgeon knows that such channels 
in the cavity of the belly do not remain open for the conven- 
ience of the surgeon, and, as we have already stated, they can- 
not be re-established. It is, to our mind, evidence of the lack 
of knowledge and experience in surgery for any man to say 
that he could carry a probe safely among the vital tissues to 
the depth of seven or ten inches; and (as in the President’s 
case it must have been carried) behind the kidney, between the 
liver and colon, or behind both to the spine, and through the 
spine to the seat of the ball. 
J/k Garfield had a very broad chest, and It is quite probable 
that the distance of the ball as found in a straight line was 
twelve inches. Whoever talks of cutting or probing for the 
ball, or of satisfactorily draining it through drainage tubes, 
seems to us to talk nonsense; and we are not surprised there- 
fore that the almost unanimous expression of the medical pro- 
fession at home and abroad is that the surgeons pursued the 
only course which presented any chance of saving or of pro- 
longing the life of the patient. Washington, JD. C., February 2, 1882. 
Hon. E. B. Taylor, 
Chairman of the Committee for Auditing Claims for Ser- 
vices and Expenses Growing out of the Illness and 
Burial of the late President of the United States, 
James A. Garfield: 
Sir : Attention having been called to the expressed wish of 
your Committee, as set forth in the resolution, requesting of 
those persons whose services to the late President Garfield are 
to come before you for consideration an estimate of the value 
of those services, I have the honor to state that, after a full 
conference with the medical gentlemen associated with me in 
attendance upon the President, 1 am requested by them to ex- 
press their earnest desire to meet the wishes of the Honorable 
Committee, while yet, as a matter of delicacy, they beg to be 
relieved from presenting bills to Congress for services ren- 
dered. 
It is believed that it would be more satisfactory to the Com- 
mittee, to Congress, and to the American people, to present to 
your Committee a statement of the services rendered in their 
endeavor to promote the comfort and preserve the life of the 
President, leaving the matter of compensation to your Com- 
mittee, than to present an itemized bill. 
This opinion is one of most earnest conviction, in view of the 
fact that the physicians have no claim against the United 
States, and that the action of Congress in the matter of com- 
pensation for their services is a recognition that they were ren- 
dered to the President of the United States, and not simply to 
the man, James A. Garfield. 
My permanent counsel consisted of Surgeon-General J. K. 
Barnes, U. S. A., Surgeon J. J. Woodward, U. S. A., and Dr. 
Robert Rey burn, all of Washington, D. C. 
It is proper to state that all these gentlemen gave daily per- 23 
sonal attention to the President, and Drs. Woodward and Rey- 
burn alternated night service, one of them being immediately 
with me each night until September 17, 1881. 
After the President arrived at Elberon, at his request the 
number of physicians attending upon him was reduced, and 
these gentlemen retired from the case. They were, however, 
called to Elberon immediately after the death of the President 
to assist in conducting the autopsy. 
The distinguished counsel from Philadelphia and New York 
city, Drs. D. Hayes Agnew and Frank H. Hamilton, were 
summoned to Washington on the night of July 3d, 1881, and 
arrived the following morning, remaining in consultation during 
that day. They were again summoned July 23d, and from 
that date gave alternate personal service of from three to four 
days each, until the death of the President. 
It is perhaps unnecessary for me to state that all the physi- 
cians in attendance during the periods above-named virtu- 
ally gave their entire time and attention to the case of the 
President, and I am glad to be able to say that the whole his- 
tory of surgery shows no such striking instance of harmonious 
and self-sacrificing devotion to the care and comfort of a patient 
as was displayed by the medical gentlemen in consultation with 
me. 
As surgeon in charge of the case, I was for eighty (80) con- 
secutive days constantly on duty, from the time the President 
was wounded until his death. This service included day and 
night attendance, which required the abandonment of my pri- 
vate practice, and so seriously impaired my health as to prevent 
me from resuming my full professional duties until about the 
1st of January, 1882. Dr. D. S. Lamb, of Washington, ac- 
complished as an anatomist and pathologist, was selected to 
perform the autopsy, and called to Elberon for that purpose. 
The skilful manner in which he performed this delicate service 
fully justified the selection made. 
I desire in this connection to pay a just tribute to the untir- 
ing and devoted services of those who performed the immediate 24 
duty of nursing the President during his illness, viz : General 
Swaim, Colonel Rockwell, Dr. Boynton, Mrs. Dr. Edson, Mr. 
O. C. Rockwell, and Steward Wm. T. Crump, whose health 
was seriously, and it is believed permanently, impaired by his 
continuous and exhausting duties. 
Last, but not least, I desire to specially mention the faithful 
services bf President Garfield’s family servant, Daniel Scroggs, 
(colored.) 
Therefore, the compensation for services rendered in the case 
of the lamented Garfield, which so keenly touched the sympa- 
thy of all and engaged their anxious solicitude, is respectfully 
submitted to your deliberate judgment. 
I have the honor to be, very respectfully, your obedient ser- 
vant, 
D. W. BLISS. [Copied from the “ National Republican” of July Uh, 1882.] 
DR. BLISS’S AUTHORITY. 
The following correspondence will show exactly the authority under which Dr. 
Bliss went into the case, and that he assumed charge of the treatment of the late 
President at the express desire of Mrs. Garfield. The letters of Secretary Lincoln 
and ex-Secretary Hunt distinctly set forth the facts, and their clear and concise 
statements are sufficient to refute the misrepresentations ancl attacks made by Sen- 
ator Vest and others on July 3d, 1882 : 
1329 F Street Northwest, Washington, D. 0., May 22, 1882. 
Hon. Robert T. Lincoln, 
Washington, D. C.: 
Dear Sir : As one of the medical advisers of the late President Garfield I take the 
liberty of addressing you briefly upon a matter of both public and private interest. 
Certain statements made by parties of presumable credence in a portion of the press 
of the country are calculated to inspire some minds with doubt as to whether the 
wishes of General Garfield and his wife, together with those of their nearest friends, 
were respected and followed in the selection of professional gentlemen who had 
charge of the case during his illness. 
May I ask you to furnish me with an outline of the circumstances connected with 
this part of the case as far as they came under your own observation? By so doing 
you will aid in setting at rest some minor yet vexatious questions, the discussion of 
which tends to pervert and even distort the history of a labor which was by all re- 
garded as a patriotic duty. 
You will thus add greatly to the esteem in which you are held by myself and my 
associate counsel. Yours, very truly, D. W. BLISS. 
War Department, Washington, May 23, 1882. 
Dear Sir: I have your note of yesterday, asking me to furnish you with an outline 
of the circumstances, so far as they came under my observation, connected with the 
selection of the professional gentlemen who attended upon President Garfield during 
his illness. In compliance with your request I give you such a statement, made as 
brief as possible. 
When the President was shot my carriage was at the door of the railway station, 
and within a few seconds thereafter I hurried it off to bring you, the utmost speed 
being, of course, enjoined upon the driver. You were very soon at the station, the 
President having been, I think, borne to an upper room before your arrival. I do 
not recall that anything which happened led me to think that any physician was 
present before your arrival; certainly, there was none whom I knew. You at once 
took charge of the President, acting with other surgeons who came quickly to his 
help. Then followed his removal to the White House, and the anxious hours of the 
afternoon, during which a large number of surgeons (some of whom I knew person- 
ally, some only by name, and some being entirely unknown to me) were in attend- 
ance. During the night, as I recall it, this attendance had largely ceased, and 
when I left the house at dawn I was informed by you that there would probably be 
no information to give as to the outlook until after a general consultation, which had 
been appointed for 8 o’clock in the morning. I returned about 9 o’clock, and not 
not long, perhaps an hour after that, all the members of the Cabinet being assem- 
bled in one of the chambers, the large number of medical gentlemen in attendance 
upon the President became the subject of conversation, all assenting to the neces- 
sity of the number being reduced at once, for obvious reasons. It appeared in the 
conversation that the only surgeon known to those present in the room to have been 
summoned in the case was yourself, and also that there were persons among the 
many anxious friends of the President who would not have probably chosen you as 
one of his medical attendants. It was therefore thought best to have the suggestion 
made to Mrs. Garfield of the propriety of her selecting one or more surgeons to 
attend the President, and of the consequent cessation of the attendance of the others. 
For the purpose of communicating with her, General Swaim and Colonel Rockwell 
were sent for to the room and requested to make the suggestion I have made. Inas- 
much as you were, as far as I know, the only surgeon summoned directly by any one 
near the President, personally or officially, and had been in consequence up to then 
in principal charge during what had come to seem a very long time, I felt it my duty 
to request General Swaim and Colonel Rockwell at the same time to say to Mrs Gar- 
field that if the attendance of Doctor Bliss was not agreeable for any reason, and it 
was thought best to have him retire, any embarrassment should be felt in effect- 
ing this, I trusted that, as I had summoned him, a mere suggestion might be made 2 
to me, and that I would see that his attendance ceased without embarrassment to 
any one. 
I am now uncertain whether these two gentlemen went on their piission and re- 
turned, or whether, without going, they were able to give us the information, which 
they at once did, that Dr. Bliss had been selected to take charge of the case with such 
assistance as he should desire. 
In pursuance of further conversation among all the gentlemen in the room, based 
on this information, it was thought best that the Secretary of the Navy and myself 
should go to Dr. Bliss and tender him the asssistance of the Surgeon-Gen- 
eral of the Navy and Surgeon-General of the Army, with any other assist- 
ance which he might ask, and which it was in our power to afford him. 
The Secretary of the Navy and myself at once went to your room and tendered 
you this assistance. You replied that you would much like to have the aid and 
counsel of the Surgeon-General of the Army; that for reasons which you men- 
tioned you would not ask the assistance of the Surgeon-General of the Navy ; that 
further, for reasons which you gave us, you would like the assistance of Surgeon 
Woodward, of the Army, and of Dr. Reyburn, of this city. I therefore formally 
advised the Surgeon-General of the Army that you were the surgeon in charge of the 
case, and directed him to place himself in attendance with you, and to instruct Sur- 
geon Woodward, of the Army, also to place himself in attendance. I do not now recall 
the exact circumstances which resulted in the summoning of Dr. Agnew and Dr. 
Hamilton, but I remember that we were all anxious for their presence, so that noth- 
ing should possibly be left undone which might contribute to the recovery of the 
President. 
I believe the foregoing answers your inquiry as completely as I am able to do from 
my own knowledge. Very truly yours, 
ROBERT T. LINCOLN. 
Dr. D. W. Bliss. 
Washington, May 24, 1882. 
Dear Sir : I was at the railroad station in this city when President Garfield was 
shot. I saw him in less than a minute afterward. He lay on the floor of the recep- 
tion room. In a few minutes he was removed to a room upstairs. I then saw 
Secretary Lincoln. He told me he had sent immediately after the shot for you. I 
expressed my gratification at his having done so, for I had perfect confidence in 
your skill, judgment, and experience. Soon after this, I saw you approach the mat- 
tress where the President was lying. You uncovered the wound, inserted a small 
probe into it, spoke with the patient, gave him brandy, and exercised entire control 
of the case. Afterward, other surgeons came about the bed ; but you were in entire 
and unchallenged control of the case. You remained so all that day, and the friends 
of the President and the other surgeons acquiesced in your doing so. 
Next morning something was said among the Cabinet about the presence of so 
many persons in and about the sick room. It was deemed expedient to reduce the 
number of surgeons. This conclusion was communicated to Mrs. Garfield, and she 
was requested, as I understood, to state whether your direction and supervision of 
the case was undesirable to her. I was told she said that this arrangement was en- 
tirely in accordance with her wishes. You were then requested to select such sur- 
gical assistance as you desired. You mentioned the gentlemen who acted with you 
afterward. The Secretary of War and myself conferred with members of the Cabi- 
net after this interview, and we proposed that the Surgeons-General of the Army 
and Navy should be added to your corps. The suggestion was approved by our col- 
leagues. It was then communicated to you. You were pleased with the recom- 
mendation of Surgeon-General Barnes, but you objected to the Surgeon-General of 
the Navy on personal grounds. I did not urge him further on you. 
Afterward the members of the Cabinet suggested that Drs. Agnew and Hamilton 
be added to the corps as consulting surgeons. This proposition was conveyed to 
Mrs. Garfield and met her approval. It was afterward submitted to you and you 
approved it promptly and cheerfully. 
These facts occurred when things were fresh and your control of the case was as- 
sured and exercised in the presence of the President’s family and friends, with the 
knowledge of the world and with their acquiescence. 
It is an insult to the truth to set up at this date the pretence that you in any man- 
ner intruded into the control of the case. It is at least a mean reward for your skil- 
ful, unceasing, and heroic devotion to your distinguished patient. 
I am, dear sir, with the highest consideration, 
Your obedient servant, WILLIAM H. HUNT. 
Dr. D. W. Bliss, Washington.