A mortally wounded American president and the quest to find his assassin’s bullet unexpectedly opened up a potentially new era of medical diagnostics in the late nineteenth century. In this episode, learn about the assassination of James Garfield and how the controversy surrounding his medical care led Alexander Graham Bell to develop an “induction balance” that could locate a piece of metal inside a human body. This is the first part of a two part series called “Sound and Light.” Also included — a new #AdamAnswers about … hiccups! All this and more in Episode 22 of Bedside Rounds!

Sources:

• Bell AG. Upon the electrical experiments to determine the location of the bullet in the body of the late President Garfield; and upon a successful form of induction balance for the painless detection of metallic masses in the human body, Retrieved from: https://archive.org/details/uponelectricalex00bell
• Paulson G. Death of a president and his assassin–errors in their diagnosis and autopsies. J Hist Neurosci. 2006 Jun;15(2):77-91.
• Trunkey D, et al. Medical and surgical care of our four assassinated presidents. J Am Coll Surg. 2005 Dec;201(6):976-89. Epub 2005 Jun 16.
• Reyburn R. Clinical history of the case of James Abram Garfield. JAMA. 1894;XXII(13):460-464.
• Steger M et al. Systemic review: the pathogenesis and pharmacological treatment of hiccups. Aliment Pharmacol Ther. 2015 Nov;42(9):1037-50

Transcript

This is Adam Rodman, and you’re listening to Bedside Rounds, a tiny podcast about fascinating stories in clinical medicine. This is the first two-parted I’ve done, and I’ll be exploring an exciting period in the late nineteenth century where it seemed that new diagnostic tools based on sound, and then light, would revolutionize not only medicine, but how we saw the world. So for this episode, called “The Assassination”, we’re starting with sound; it’s about how a single gunshot, a mortally wounded president, and the search for a bullet promised a new era of medical diagnostics. 

Our story starts on a hot and steamy morning on July 2, 1881. Washington, D.C., was quite literally still a swamp, teeming with mosquitoes and malaria, so recently-elected president James Garfield must have been very eager to escape the city for his 25th class reunion at Williams College in Massachusetts. Garfield was waiting for his train at the old Baltimore and Potomac Depot, only a short walk from the White House. Charles Guiteau, a delusional office-seeker who was very likely suffering the effects of neurosyphilis, approached Garfield from behind and shot him twice with a 0.44 caliber revolver. The first bullet grazed the president’s arm, but the second hit him squarely in the back. Garfield collapsed onto the tiles.

Medical assistance reached Garfield within four minutes — impressive even by today’s standards. Fortunately, we know more or less exactly what happened thanks to Drs. Bliss and Reyburn, the two esteemed DC surgeons who led care for the president,, and who both who published their medical notes in full and first-hand accounts in JAMA a decade after the assassination. Dr. Doctor Willard Bliss in particular had cared to the first slain U.S. president, Abraham Lincoln, and quickly asserted his dominance in the case, even forbidding Garfield’s private physician from providing care. And you heard right — Dr. Doctor — Doctor was his first name, the 19th century equivalent of naming your child “Armani”. 

In any event, the district health officer, Dr. Smith Townsend, was nearby and reached the president’s side within four minutes. Townsend found him on the ground, barely conscious and bleeding copiously from his back. Brandy and aromatic spirits were produced to rouse the president, and Garfield immediately reported to him a “prickling sensation” in his right lower extremity — paresthesias, possibly signifying a spinal cord injury. Examining the wounded president, he noted the bullet’s entry, 2.5 inches beside the vertebrae, and inserted his pinky finger into the wound to try and identify the track of the bullet. Garfield was helped upstairs to an empty room, and within an hour a gaggle of doctors, including Dr. Doctor Bliss, had arrived, all of them attempting to probe for the bullet with their fingers or unsterilized surgical instruments — Bliss even got his probe stuck behind the broken 11th rib and had to apply considerable force to remove it. Garfield, I should note, was awake and not anesthetized for any of this. 

Garfield was taken to the White House, which was quickly converted to a field hospital. Things initially looked bleak — the president bled constantly from his wound, and he had a raging fever. But after several days, the bleeding spontaneously stopped, his temperature returned to normal, and his vital signs otherwise stabilized. Garfield’s sense of humor returned, and buoyed by these improvements, asked Reyburn his chances of survival, to which he responded, “Mr. President, your injury is formidable [but] in my judgment, you have a chance for recovery.” 

Reyburn then recounted:

He placed his hand upon my arm, and, turning his face more fully toward me, said, with a cheerful smile: ” Well, Doctor, we’ll take that chance.”

By mid July, with the president gradually improving, his doctors started to focus on tracking down the bullet. Reyburn writes how each doctor “examined the wound with great care,” though one must wonder the definition of great care since what had been a small entry wound now stretched over a foot. Still, Garfield’s team argued violently — privately, but also in competing and increasingly public bulletins that were published across America — about the location of the bullet. Drs. Bliss and Reyburn had become convinced from their exploration of the bullet tract that the bullet must be located somewhere in the president’s right.

Where is the bullet? became a rallying cry across the nation as a patriotic public hoped for the president’s improvement. The doctors found themselves inundated with suggestions. Reyburn recollects:

”Every crank and vendor of patent medicines in the country seemed to think himself called upon to offer to cure the President. One man gravely suggested that the President’s body should be inverted for some hours in order that the bullet might gravitate downwards, and thus aid in its removal. Another sent a drawing of a machine composed of a rubber tube and an air-pump. The rubber tube was to be introduced into the wound until it came in contact with the bullet, then the air-pump was to be attached to it, and by suction the bullet removed. I wish now I had retained some of the most absurd of these missives, but at the time of receiving them we were too busy to appreciate either their absurdity or comicality.”

But why the obsession with finding a bullet? I’m no surgeon, but if my patient were improving on his own, with a small, uninfected entry wound and no signs of internal injury, I’d probably call it a day. But the medical standards of the day warned against blood poisoning by the metals of the bullet, and the standard of care remained removal.

With traditional medical methods of finding the bullet dimming, the doctors turned to one of these inventors, none other than Alexander Graham Bell, inventor of the telephone.

Wired communication seems very quaint today, but it was brand new when Garfield was shot. The telegraph had been invented only 35 years before, and had already dramatically shrunk the world — the first transatlantic cable had been laid in 1858, and the east and west coasts of the United States had been linked in 1861. As if this were not miracle enough, only 6 years before the assassination, Alexander Graham Bell had sent the first audio message over a wire, summoning his assistant Watson. 

While we don’t have that original recording, the Smithsonian was able to recreate Bell’s voice from a wax plate from this era:

This new “telephone” fascinated the public in America and Europe. Soon he held very public demonstrations where Bell would lead separate groups in Salem and Boston singing Aud Lang Syne together. The mass commercialization of the telephone was yet to come, but the public certainly understood its importance. The next year in 1877, the phonograph was invented, a way to definitively store sound — something that for millennia had been characterized by its very impermanence. The taming of sound was downright revolutionary, so when Simon Newcomb, the physicist at the naval observatory, publicly suggested that using electrical induction, like in a telephone, might help locate the bullet, Bell contacted him immediately and traveled down to Washington, the next day.

A fastidious scientist, Bell published detailed accounts of his development of an electrical induction machine, and his experiments testing it, a “lab report” that is surprisingly readable even today. He recalled from his experiments on a telephone that when a piece of metal was introduced into the electrical field surrounding the apparatus, a click was made as the field was interrupted. He also recalled that he had seen a giant “induction coil” in London several years earlier that could produce an electrical field over an entire person. He realized that if he could combine these two inventions, he could pass an electrical field throughout the president’s body and listen for interference from the bullet. With some calibration, he could essentially triangulate the exact point of a piece of metal in a human body. 

Time was of the essence, so Bell arrived with none of his equipment and scavenged what he could from the Smithsonian, and within a few days he had built a prototype of his “induction balance”. He and his assistant tested the apparatus by clasping bullets in their palms and their teeth and running the probe over, listening for the tell-tale click sound over the phone. This test successful, they fired bullets into large slabs of meat. Again, with the probe held over the meat, a faint clicking was heard on the earpiece. For the final experiment, he recruited one Lieutenant Simpson, a civil war veteran who carried a bullet still inside him. With the probe slowly placed over the Lieutenant’s body, he heard a very faint faint clicking sound. Moving the probe around, he realized he was “hearing” the bullet. After adding a condenser to make the click much more noticeable, Bell was ready for the president.

On July 26th, Bell arrived at the White House and wheeled his invention in the president’s bed room. Bliss helped prop Garfield up for examination. Notably, as Bliss had determined that the bullet was on the right, he only allowed Bell to examine this side. The room was deathly quiet, save for the gentle blowing a makeshift air conditioning system the Army Corps of Engineers had set up. Bell slowly moved the probe over Garfield’s body. For a long time, nothing. And then finally, some faint clicks. The doctors were ecstatic, but Bell was not convinced. The clicks didn’t seem to be coming from just one place, and the next day he discovered that Garfield was in fact lying on a spring mattress, also a very recent invention and thus slipping through Bell’s instructions to remove all metal from the room.

Bell went back to tinkering and progressively improving his balance, testing on multiple civil war veterans with known bullet wounds, and on August 2nd he returned to the White House, again examining only Garfield’s right side. But even without the metal wires in the mattress, he was unable to hear the telltale click of a bullet. 

Not that it mattered. By August 2nd, even if Bell had found the bullet, it would be the least of Garfield’s problems. Reyburn’s notes show that the president was again septic by the first time Bell examined him. His wound was clearly infection, and new pockets of pus-filled abscesses popped up all over his body, requiring constant lancing. As it became increasingly clear that the president was not long for this world, he was moved to his cabin on the New Jersey Shore, where he died on September 19th, 1881, surrounded by his family.

The autopsy found that the doctors had been completely wrong about the location of the bullet. In fact, it had completely missed all of his vital organs and was lodged in fatty tissue on the left side of his back. What the doctors had thought was the track of the bullet was actually a sinus tract, and they had completely prevented Bell from examining the left side of his body. 

Clearly, by today’s standards, Garfield’s wound would have been survivable, and honestly, probably not a major procedure. The controversy that raged after his death, however, was that the President’s wounds were very likely survivable by the medical knowledge available in the 1880s. Even Guiteau, the assassin, got in on this argument, which might be my favorite murder defense of all time: “The doctors killed Garfield, I just shot him.” Needless to say, the jury did not find this convincing, and he was hanged.

But he had a point. His doctors were terrified that the bullet had perforated his intestines, and as the poor man worsened, they placed him on enemas of beef bouillon, egg yolks, milk, whiskey, and of course, opium. Accordingly, the president’s weight dropped from 210 lbs before the shooting to 135 at the time of his death. But probably even more controversially, even at that time, was the repeated exams with unwashed hands and surgical instruments. Germ theory had been described in the 1860s by Koch and Pasteur, and had already gained widespread acceptance. Joseph Lister had then demonstrated that carbolic acid could sterilize surgical tools and decrease mortality in surgery. His methods had been accepted across Europe, and though he had toured America lecturing several times in the 1870s, American surgeons had not yet adapted all his methods. Reyburn admitted as much with his retrospectoscope, writing, “It must be remembered that the technique of antiseptic, or more properly speaking, aseptic surgery was not so thoroughly appreciated or carried   out by operating surgeons in 1881 as it is in 1892”

As for Bell, despite the president’s death, he was hailed as a hero, and he continued to work on his induction balance. Only a month after the president’s death, he held a public demonstration where he identified the bullet in the cheek of a civil war veteran, Calvin E. Pratt.

The legacy of the induction balance itself is more circumspect. The tool obviously had great promise in medicine, especially battlefield medicine. It was based on a scientific understanding of basic science, and perfected over dozens of meticulously documented experiments. It was the doctor’s tool of a new, scientific age — clean, painless, and safe, contrasting dramatically with the doctors and their dirty fingers. There’s no question the the induction balance presaged future medical technologies by decades — MRI scanning also uses similar electrical principles, and ultrasonography uses sound to identify interior structures in the body. Ultimately, though, a new technology rendered it quickly obsolete — the X-ray, which we’ll talk about in part 2. But within months of its invention in 1896, it was used to successfully locate buckshot in a hand. 

But Bell’s induction balance still lives on as the metal detector. So the next time you see someone beach combing, or you walk through security at an airport, know that that metal detector is a direct descendent of the quest to find President Garfield’s missing bullet.

That’s it for this episode! But wait — it’s time for a #AdamAnswers, where I answer your questions about medicine, no matter how silly. Since my parents are currently visiting me in Botswana, I have this joint question from my mother and my wife:

• What causes hiccups? And from my wife — what makes them stop?

So hiccups — or singultus, their medical name, which means in Latin “to be caught in the act of sobbing” — are very common, and remarkably poorly understood. They’re usually benign and self-limiting — but chronic hiccups exist, and the longest duration was apparently 69 years and 9 months. The hiccup itself is a rhythmic contraction of the diaphragm, powered by a primitive reflex arc. The evolutionary purpose isn’t totally understood, but the dominant explanation is that they’re a vestigial holdover from our amphibian ancestors who would need a reflex to switch between air-lung breathing and water-grill breathing.

As for what causes it — well, anything that affects that very long reflex arc. The most common is distension of the stomach, either from fizzy drinks, a large meal, or “air eating,” which people do when they’re nervous. However, since anything that affects the reflex arc can do it, strokes, brain tumors, and head trauma have all been identified as causes of hiccups. That being said — the full list would take almost an entire episode to list out. 

Now for the treatment. Let’s start with acute hiccups. Dr. Steger, the author of the systematic review on the subject, which you can find in the shownotes, lists a variety of interventions including, and I’m quoting, ice water, carotid massage, smelling salts, “intra-nasal application of vinegar,” “induced fright,” and “induced vomiting.” While all of these are plausible and seek to interrupt the reflex arc, he points out:

“Many of these ‘remedies’ have not been tested and some appear to have been invented ‘purely for the amusement of the patient’s friends’.”

I also have to read this aside from him:

“Rectal massage and sexual stimulation have also been reported to help; however, we recommend that this kind of recommendation is reserved for carefully selected patients!”

As for chronic hiccups, there have actually been randomized controlled trials on the subject, and beyond treating underlying causes, the current first line medication is baclofen, followed by gabapentin and pregabalin. 

So there you have it, my mother and my wife! If you have any questions about medicine, no matter how trivial or how profound, tweet them to me @AdamRodmanMD.

That’s it for the show! Thanks for listening; part two of Sound and Light will be out next month. In the meantime, I’m working on some fun collaborations with my friend and fellow podcaster Dr. Jim Siegler over at Brain Waves podcast, which I highly recommend. So listen for that soon! If you like Bedside Rounds, please rate and review us on iTunes! It’s the best way we have to get word out — besides, you know, telling a friend. I’m on twitter @AdamRodmanMD, and we are on facebook at facebook.com/BedsideRounds; please come by and say hi! Listen to our entire catalog on our website at www.bedside-rounds.org, or on iTunes, Stitcher, Google Music, or wherever fine podcasts are found. 

All of the sources are in the shownotes and on the website.

And of course, as always while I am actually a doctor and I don’t just play one on the internet, this podcast is intended to be purely for entertainment and informational purposes, and should not be construed as medical advice. If you have any medical concerns, please see your primary care provider.