American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

“On the Shoulders of Giants”: Primum non nocere, Hubris, and the Death of President James A. Garfield

As the U.S. celebrated Presidents’ Day in February, I was reminded of the death of President James A. Garfield.

James A. Garfield was president for less than four months before he was shot in 1881 by the delusional and grandiose Charles Guiteau. Garfield’s death, while tragic in itself, was made even more tragic by the fact that it was, by all accounts, preventable. Even worse, experts have concluded that the president’s death was actually caused by the treatment he received from his physicians.

Garfield was shot twice by his assassin—once in the arm and once in the back. The shot in the back we now know was not fatal, as the bullet did not hit any vital organs. Rather, it lodged in the retroperitoneum behind the pancreas.

Within minutes, doctors converged on the fallen president, using their dirty, unwashed fingers to poke and prod his open wounds. Twelve different doctors inserted unsterilized fingers and instruments into Garfield’s back to probe for the bullet. The first attempt at retrieving the bullet was conducted right on the manure-stained train station floor. It’s hard to imagine a more germ-infested environment.

American doctors at the time rejected the concept of Lister’s germ theory and the associated Listerian practices of cleansing wounds and instruments with antiseptics and hand washing. Rather, they subscribed to the miasma theory—the theory that bad air caused disease and illness, not microbes.

Garfield’s primary surgeon was Dr. D. Willard Bliss, a uniquely arrogant and ambitious man. For him, there were no second opinions. For an excruciating 80 days, Bliss probed Garfield’s wounds with unsterile instruments as his condition worsened. In an effort to locate the bullet still lodged in the president, Bliss even called on Alexander Graham Bell to use a primitive metal detector to scan the President’s body for the location of the bullet. In an unparalleled demonstration of hubris and arrogance, Bliss stated that the bullet was on the right side, and he would only let Bell examine that part of the president’s body. In fact, the bullet had gone to the left.

President Garfield died on September 19, 1881.The autopsy confirmed Bliss’ ignorance and that it was sepsis from multiple abscesses, not the bullet, that caused the President’s death. Immediately before his hanging, Charles Guiteau even remarked, “Yes, I shot him, but his doctors killed him.”

Some good came from this tragedy, though, most notably the widespread acceptance of antiseptic principles. But the lesson here is not one of surgical infectious disease. It is one of humility. We must humble ourselves in the practice of our beloved profession. No man is perfect. To help our patients to the best of our ability, we must often acknowledge what we do not know and seek help from others when it is needed. Only then can we ensure that we “first do no harm.”