Damn Near Killed Him

WARNING: The following contains graphic descriptions of medical procedures and bodily functions.

When United States President James Garfield awoke on the second of July, 1881, he would have been surprised and dismayed to learn that only a few hours later he would be shot in the back, by Charles Guiteau, a habitual loser and fantasist. Guiteau shot Garfield in apparent retaliation for being denied a position as consul in Paris, a position for which Guiteau — who did not speak French — was entirely unqualified. That morning Garfield would have been equally surprised, and even more dismayed, to learn that he would survive after the shooting for a period of close to three months, and would be fed for much of that time solely by the introduction of various foods to his lower bowel, through his rectum.

On that July morning, Guiteau’s bullet, fired from a .442 “British Bulldog” revolver — purchased for its looks, on the basis that it would look better in a museum¹ — glanced off Garfield’s rib, passed through the spinal vertebrae from right to left, narrowly missing severing the spinal column, and lodged in fatty tissue in Garfield’s back. On its way, the bullet missed all major organs, but shattered bones and damaged the intestines². Garfield immediately collapsed, and was soon surrounded by a throng of concerned citizens, staff, and doctors. He is reported to have responded to one encouraging onlooker with considerable sangfroid, “I thank you doctor, but I am a dead man.”³

Historians disagree on the seriousness of the wound, with some arguing that Garfield’s injury was entirely survivable, and others holding that his eventual death from infection was inevitable⁴. Garfield’s condition and treatment became something of a cause celebre, and daily updates were published in major papers. At the time of the assassination, hopes of Garfield’s survival were high, as his health rallied after the initial shock. Papers wrote of an expectation of full recovery. But these hopes were dashed in the coming weeks as his condition worsened, and by mid-August the President, gravely ill, could not hold down food⁵. In addition to the depredations of massive infection, which filled Garfield’s body with vast abscesses filled with pus, the President, unable to eat, began to starve. In this situation, with a starving patient who could not be fed by any conventional means, the decision was made to feed Garfield by a more unusual rout: rectally.

At this juncture we must meet the President’s doctor, the architect of this programme of rectal feeding, and the hero, or perhaps villain of this story. An acquaintance of Garfield’s youth, who had happened to be on the scene of the attempted assassination, Dr. D. W. Bliss had from that moment commandeered charge of the President’s care⁶. Bliss, like most surgeons of his day, had served in the American Civil war, where he distinguished himself. At the time of the assassination he was employed as superintendent of a Washington D. C. hospital⁷.

Dr. Doctor Willard Bliss

The “D.” and “W.” in “Dr. D. W. Bliss” stand for “Doctor” and “Willard” respectively, making Bliss’s full name “Doctor Doctor Willard Bliss, M.D.”. He’d acquired this aptronym from his parents by way of homage to the physician who attended his birth, Dr. Samuel Willard⁸.

There are several ambiguities in the explanation of how Bliss happened to become the chief physician to President Garfield, and Bliss’ own explanation of the matter, as given to a biographer soon after Garfield’s death, seems a little too neat:

“When the President had fully reacted, had had several hours of rest, was cheerful and competent to attend to any ordinary business, I presented the matter of his professional attendance to him, Mrs. Garfield being present… …He replied: I desire you to take charge of my case. I know of your experience and skill, and have full confidence in your judgment.”⁹

Bliss also volunteered the following somewhat dubious quote from President Garfield’s wife, Mrs. Lucretia Garfield:

“I want to say to you, doctor, that you shall not be embarrassed in any way in your future treatment of this case.”¹⁰

In fact, contra Mrs. Garfield’s purported assurance, in the days and weeks after the President’s death, many experts and laypeople called into question the appropriateness of Bliss’s treatment of Garfield, and Bliss’s conduct during the period of Garfield’s slow passing¹¹. It was claimed that he bullied the other doctors, jealously guarded the President’s favour, and refused to consider alternative courses of treatment. Chief among latter-day targets of criticism was the unsanitary conditions of Bliss’ treatment of Garfield, and the fact, which became apparent during autopsies, that it was massive infection of the wound, and not the bullet itself, which ultimately caused the President’s death¹².

Joseph Lister, a pioneer of sanitary practices in medical treatment, had toured the United States in 1876 — five years before the assassination — and his methods were gaining slow acceptance among American surgeons¹³. But germ theory was still little-understood, and there was by no means unanimous support for this new idea that postulated that diseases were caused by miniature, invisible animals. Among those who were yet to be convinced was Dr. Doctor Bliss.

It is important to understand this in the context of the prevailing attitudes of 19th-Century medicine. The profession was, at the time, engaged in a kind of turf war with an emerging rival discipline, homeopathy. In modern days medicine tends to have the best of this dispute, on the basis that, for all its faults, medicine generally works, while homeopathy patently does not. But in the 19th-Century medicine did not have this advantage, and indeed suffered from the fact that while homeopaths were at least doing nothing, “regular” doctors were cutting people open with unsterilised knives and feeding them toxic patent cures.

One of the belligerents in this war, the American Medical Association, had issued a “consultation clause” in its articles of membership, which held that should any member of the Association consult with a homeopath, they would be expelled from membership, and their license to practice would be revoked. Even more controversially, any Association member who then consulted with this colleague who had been so struck off, would similarly face expulsion.

Bliss, in earlier years, had been expelled from the District of Columbia Medical Society for violating this clause. He had consulted with his colleague and friend, Dr. Cox, who had previously been suspended from the Society for associating with a homeopathic practitioner¹⁴. Bliss had also attracted some opprobrium for promoting a “quack” medicine, “Cundurango”, a preparation of the bark of a Ecuadorian vine¹⁵. At the time of Garfield’s shooting, Bliss had only shortly regained his earlier standing in the Society, having recanted his support for his former colleague.

Label for bottle of “Cundurango”

Lister’s radical theories about the causes of disease and the importance of sanitary techniques were viewed with some skepticism and scorn by the medical establishment, and modern historians have speculated that his earlier censure made Bliss reluctant to swiftly embrace the new theories. Therefore Bliss took no care at all to ensure the cleanliness of various implements and digits inserted into Garfield’s wound in the course of attempting to locate the bullet¹⁶.

Perhaps it would have been impossible for any doctor’s treatment to withstand the public scrutiny in the aftermath of the popular President’s death. The high publicity of the case meant that every facet of Bliss’ care was available for examination and cross-examination. But while Bliss’ treatment of Garfield was questioned in almost every other respect, his decision to feed the President rectally seems to have been entirely uncontroversial. Indeed, he was drawing on a practice that was relatively common at the time — it was used in the feeding of the mentally ill in asylums¹⁷ and was considered (but for the most part not used) for force-feeding of hunger-striking suffragists¹⁸.

We are lucky, in these latter days, to have detailed information about the precise programme followed in this case, as Bliss published a pamphlet on the subject one year after Garfield died.

The pamphlet is titled “Feeding Per Rectum: As Illustrated in the Case of the Late President Garfield, and Others”¹⁹. It provides an enthusiastic endorsement of the method, as well as notes on the practice’s use throughout history, and a detailed explanation of the schedule of feeding to which the late president was subjected.

Collection of contemporary syringes including enema apparatus

If this practice was uncontroversial at the time, it also seems to have been little-understood. Bliss’ notes indicate that in Garfield’s case there was a degree of experimentation with the exact mixture used for the President’s meals. For the first four or five days of the programme, the yolk of an egg was included in the mix, but this was discontinued on account of an undesirable side-effect: “annoying and offensive flatus”. Bliss next experimented with fresh cow’s blood, but with a similar result — it was apparent from the “volume of offensive gasses” and “the character of the ejecta”, that the blood simply rotted in the President’s rectum. The odour was apparently strongly detectable throughout the entire residence.

The recipe that eventually met with approval from the Presidential rectum is recounted in faithful detail in Bliss’ pamphlet:

“Beef Extract. — Directions. — Infuse a third of a pound of fresh beef, finely minced, in 14 ounces of cold soft water, to which a few drops (4 or 5) of muriatic acid and a little salt (from 10 to 18 grains) have been added. After digesting for an hour to an hour and a quarter, strain it through a sieve and wash the residue with 5 ounces of cold water, pressing it to remove all soluble matter. The mixed liquid will contain the whole of the soluble constituents of the meat (albumen, creatine, etc.), and it may be drank cold or slightly warmed.”²⁰

In addition to two ounces of this preparation, administered 4-hourly day and night, Garfield also enjoyed “2 drachms of beef peptonoids”, “5 drachms whiskey”, and on occasion, several drops of “deodorised tincture of opium”. A “drachm” here is a unit of measurement from the now obsolete avoirdupois system, and was equal to 60 “grains”, or more helpfully, about a teaspoon. The opium, it seems, was not explicitly for pain relief, but rather for its effect of suppressing muscle movement in the bowels. This helped with the “retention” of the beef enema.

“Peptonoids” are a preparation of a cow’s pancreatic gland, which Bliss prepared himself to a recipe not supplied in his pamphlet. This appears to involve the inoculation of beef broth with the secretions of the pancreas, in the hope that the digestive enzymes would survive and multiply. Their inclusion in the enema was thought to supply a digestive capability otherwise absent from the lower bowel.

Bliss devotes a good deal of his pamphlet to assuring readers of the efficacy of his method of feeding. He asserts a historical pedigree for the practice reaching back to the ancient Greek physician Galen, as well as recounting several cases of patients surviving, and even regaining health, on a rectal diet over periods of several months or even years.

Bliss makes particular mention of two very unusual examples. He describes treating a “distinguished gentleman”, whom “[f]our hours after receiving an injection of broth composed of Beef Peptonoids, he declares that he distinctly recognises the taste of Peptonoids in the mouth.” Bliss also makes passing reference to an occurrence described in an 1827 medical journal. The patient, in severe gastrointestinal distress, had been administered — in accordance with 19th-Century medical orthodoxy — an enema of mixed oil and turpentine. The doctor then relates the following:

“Just as I came in, a quantity of stercoraceous [a word which here means “a faeces-like substance”] was ejected from the stomach, very offensive and strongly impregnated with turpentine and oil, floating on its surface. The enema had been twice administered through the night — No motion from the first, but the second produced two or three stools, when vomiting of a fluid, similar to that passed per anum, came on, and on comparing the two I could perceive no difference — they were both dark green with flakes of faeces floating on their surface.”²¹

This vivid episode is referenced for a very clear reason: As Bliss himself notes in his pamphlet, there is no mechanism by which nutrition, other than sugars and amino acids, can be absorbed by the lower bowel. To explain how patients were nourished for long periods solely by rectal feeding, Bliss invokes the notion of a “reversal of peristaltic action”. In other words, the lower bowel drawing up the food into the small intestines.

Contemporary accounts of Bliss’ programme of feeding describe the “excellent results” of the beef enemas²². And Bliss makes a compelling argument for their effectiveness: Digestive enzymes from a cow’s pancreas to aid in the metabolisation of the enema, a collection of successful case studies, historical precedents, and a purported method by which these observations might concur with anatomical orthodoxy.

But, in fact, both the contemporary onlookers and Bliss himself were, for the most part, mistaken. Although it was a popular technique at the time, studies in later years would demonstrate that Bliss and his co-practitioners were engaged in a largely futile pursuit. The lower bowel simply does not absorb food in the way they believed. The rectal feeding, besides providing hydration and perhaps some small amount of calories from available sugars, was effectively useless.

By the end of the 19th Century, the reign of the beef enema was coming to an end. A 1913 article describes rectal feeding as both “universally practiced” and “nearly useless”²³. In that study they examine several historical articles purporting to demonstrate the effectiveness of rectal feeding, and prove that in every case, flawed methodologies make their data invalid. In their own research, the authors find little evidence of absorption of nutrition from the lower bowel. They dismiss the concept of “reverse peristalsis”. The episode that Bliss referenced, of a patient vomiting the contents of their enema is now understood not as a reversal of normal operation of the bowel, but rather caused by that normal operation being impeded. Fecal vomiting occurs in rare cases, and is caused by obstruction of the bowel, which results in normal peristalsis forcing digested material from the intestines to be returned through the mouth²⁴.

But rectal feedings did not pass swiftly into the annals of medical history. A 1926 study which involved administering nutrient enemas to “four healthy medical students” (presumably volunteers), found ambiguous and contradictory results²⁵. A 1943 journal article claimed “no unanimity of opinion exists regarding their value”²⁶. The results of their study are complex, both supporting and rejecting various kinds of nutrient enema. They concur with earlier studies though, in their conclusion that the kind of beef broth preparations favoured by Bliss were likely to be of little practical value.

The end of the nutrient enema was precipitated largely by improvements in tube-feeding techniques. Tube feeding, in which a tube is passed down a patient’s throat into the stomach or duodenum, had been known since the seventeenth century, but these were crude techniques with risks of severe adverse effects. From the early twentieth century, several advances in this technology led to the quiet obsolescence of rectal feeding²⁷.

Bliss’ reputation never recovered from the death of the President and the public excoriation of his competence that followed. He struggled to work, and fought to receive the compensation he had been promised for his time treating the President. He was attacked in the press, and vilified by some of the doctors who had assisted in the case. Historians have suggested that some of this vituperation was driven by professional rivalry — two of Garfield’s family doctors were homeopaths who had been, by dictum of the American Medical Association’s consultation clause, excluded from participating in the President’s care²⁸. This exclusion must have rankled, and perhaps provided motivation for their assassination of Bliss’ character in the public press.

In the year following the president’s death, Bliss published not only his pamphlet on rectal feeding, but another work, titled “Excerpts from opinions of distinguished medical men in this and other countries justifying the treatment of the late President Garfield”²⁹. These opinions, cherry-picked as they were, paint a picture of Bliss’ treatment as entirely orthodox, the case as intractable, and Garfield’s death as inevitable³⁰. In much later years, a clinical history of Garfield’s case, published by the last surviving member of the team of doctors who tended the President, would also defend Bliss’ treatment:

“It is the common lot of physicians to sacrifice their comfort, health, and even
their lives for the welfare of their patients, and Dr. Bliss showed these characteristics of the true physician in a marked degree during his care of the President. In performing that duty he sacrificed a most lucrative private practice, permanently injured his health and shortened his life, and as a reward for these labors was treated with a depth of ingratitude, that perhaps may be equalled, but certainly has never been exceeded in modern history.”³¹

Bliss died of a stroke in 1889, at the age of 63, a little more than 7 years after the death of the President³², having never fully recovered his health or reputation. In his own eyes, he was a hard-working physician who did the best he could for a gravely ill patient. But in the eyes of the public, he was an incompetent quack whose malpractice slew a beloved president.

The truth is now lost to history. From the vantage of over a hundred years of progress, and unfettered by anyone who would contradict us, we are free to exonerate or condemn Bliss as we choose, and to take from his story what we can. Bliss makes a convenient target for homilies on the horrors of nineteenth-century medicine, and the benefits of sanitary medical practice. These can be found in abundance³³ ³⁴ ³⁵. But it is hard not to feel, for all that it was ultimately futile, and even perhaps deadly to his charge, Bliss’ care for the dying President was genuine, and that he was moved to do his best. He wrote, describing the moments after the death of the man he had tended for three torturous months:

“I cannot describe this scene. The vital spark had gone. No human skill or courage of heart could longer avail. The once magnificent physique, which had been so constantly and tenderly watched, lay untenanted before us. There was no sound — not even of weeping. All hearts were stilled.”³⁶

Contemporary lithograph of the scene of Garfield’s deathbed

Dr. Doctor Bliss lived at a precarious time in medical history, when the faint rosy fingers of a dawning empiricism were just beginning to lift the dark night of medical ignorance. It was a time of grand theories, and the era of snake oil — the homeopathy that had misled and maligned Bliss, as well as germ theory which would revolutionise medicine. Great advances in medical science were born and lived alongside utter follies. To sift, as Bliss must have tried to do, the nuggets of truth from the sands of mistaken beliefs and outright frauds, is a task at which we all struggle. Bliss was given a choice: His patient was hungry, and unable to eat. Bliss saw that need, and responded with the best tool his age had provided him. The choice Bliss faced was one we all face — to retreat into inaction, baffled by the unknowable, or to act, with imperfect knowledge and only hope that we are doing our best.

References

1: Elman, Robert (1968). Fired in Anger: The Personal Handguns of American Heroes and Villains. Garden City, NJ: Doubleday & Company.

2: Official Bulletin of the Autopsy on the Body of President Garfield

3: The life and public services of James A. Garfield … including full and accurate details of his eventful administration, assassination, last hours, death, etc

4: Ackerman, Kenneth D. (2003). Dark Horse: The Surprise Election and Political Murder of James A. Garfield. New York, New York: Avalon Publishing. ISBN 0–7867–1396–8.

5: See 3.

6: See 4.

7: Whitman, Walt; Miller, Edwin Haviland (2007). The Correspondence: Volume I: 1842–1867. New York, NY: New York University Press. p. 91. ISBN 0–8147–9421–1.

8: How Doctor Bliss Got His Name

9: See 3.

10: See 3.

11: Peskin, Allan (1978). Garfield: A Biography. Kent, Ohio: Kent State University Press. ISBN 0–87338–210–2.

12: See 2.

13: Joseph Lister and his 1876 tour of America

14: Deppisch, Ludwig, M.D. (2007). The White House Physician: A History from Washington to George W. Bush

15: Bliss, D.W., M.D. Boston Med Surg. J 1871; 85:41–43 Cases of Cancer Treated with Cundurango

16: Murder of a President: Who’s who.

17: Kai Sammet. Avoiding violence by technologies? Rectal feeding in German psychiatry, c. 1860– 85. History of Psychiatry, SAGE Publications, 2006, 17 (3), pp.259–278.

18: A History of Force Feeding: Hunger Strikes, Prisons and Medical Ethics, 1909–1974

19: Feeding Per Rectum: As Illustrated in the Case of the Late President Garfield, and Others

20: See 19.

21: Journal de médecine de Québec [Tome 2] (Avril 1827)

22: See 3.

23: Short, A. Rendle and Bywaters, H. W., Amino-Acids and Sugars in Rectal Feeding

24: Wilkins, Lippincott Williams & (2007–07–01). Portable Signs and Symptoms. Lippincott Williams & Wilkins. ISBN 9781582556796.

25: Nature 118, 858–859 (11 December 1926) Rectal Alimentation

26: Arch Dis Child. 1943 Mar; 18(93): 22–27. The Nutrient Enema

27: The History of Nonsurgical Enteral Tube Feeding Access

28: https://books.google.co.nz/books?id=IqvuhJ6kAqkC

29: Bliss, D.W., Excerpts from opinions of distinguished medical men in this and other countries justifying the treatment of the late President Garfield

30: See 29.

31: Reyburn, Robert, M.D. Clinical history of the case of President James Abram Garfield

32: Baxter, Albert (1891). History of the city of Grand Rapids, Michigan. Munsell & Company.

33: The Inept Doctor Who Killed President Garfield

34: How Doctors Killed President Garfield

35: The Unnecessary Death by Incompetence of a President

36: Bliss, D.W. The Century Magazine, 1881. The Story of President Garfield’s Illness, as Told by the Physician in Charge

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