Lister had come to America to spread his gospel. Philadelphia was the first leg of an extensive cross-country tour. A genuinely humble man, he took pains to praise the medical advances made in the United States, singling out anesthesia as the greatest gift “ever conferred upon suffering humanity.” At times, his remarks bordered on pandering, as when he described American surgeons as “renowned throughout the world for their inventive genius, boldness, and skill in execution.” Lister spoke for three hours that afternoon, linking germs to infection and demonstrating his techniques. To those who worried about the time and effort involved, he assured them it was well worth the trouble. “It is the close attention to these minute details that renders this system so absolutely certain and safe,” he said. And to those who questioned the science behind it, he linked himself directly to Pasteur. “The germ theory of putrefaction is the foundation of the whole system of antiseptic surgery,” Lister declared, “and if this theory is a fact, it is a fact of facts that the antiseptic system means the exclusion of putrefactive organisms.”
Few minds were changed. Some in the audience grumbled about Lister’s complicated instructions, while others fretted that carbolic acid might irritate their hands. Mostly, though, there was bewilderment that anyone should listen to an Englishman spouting the theories of a Frenchman about the dangers of particles too small for anyone to see.
Lister’s Philadelphia presentation did not go entirely unnoticed, however. In the audience that day was an apothecary’s apprentice from New Brunswick, New Jersey, named Robert Wood Johnson. Inspired by the science of the presentation, the young man imagined a future in which Lister’s ideas would be the norm for operating rooms, doctors’ offices, and medicine cabinets across the land. Joining with his brother and a few friends, he would begin a company producing sterile bandages for a market that barely existed: Johnson & Johnson.
—
Welch and Halsted were two of the thousands of young American physicians who visited Europe in these years in search of better clinical and laboratory training. One historian described this migration as the largest “movement of professional men over so great a distance…in the annals of human experience.” Previously, such visits were limited to cities like Paris, London, and Edinburgh. But times had changed. Those seeking the latest techniques in bacteriology, pathology, and surgery now flooded the labs and clinics of Leipzig, Vienna, and Berlin. Welch began his two-year odyssey through Central Europe in 1876. It was expensive—he, unlike Halsted, wasn’t wealthy—and it meant learning German. Welch adapted rather well, commenting with his usual fussiness about everything from the food (heavy and monotonous) to the local medical students he met (arrogant and condescending) to the alien street life (“You can see the original Shylocks in the shape of Polish Jews who are swarming here”). What most impressed him, however, was the German passion for evidence-based science. “Don’t be alarmed,” Welch wrote his sister. “I do not expect to [settle here] but I do think that the condition of medical education [in America] is simply horrible.”
Welch was particularly taken by Germany’s embrace of Lister. “You must go to [Leipzig] if only for a couple of days,” he urged a friend. “Such results as they have there are simply astounding to me—42 successive cases of amputation of the thigh [without] one death. If you are not a convert to Lister, you [are] stubborn to fact.”
Welch returned to New York in 1878 determined to spread the word. Ignoring these breakthroughs was more than an affront to science, he believed; it was a brazen attempt by parts of the medical community to prevent new and better ideas from taking hold. Welch turned first to his medical school professors at P&S. Offered a lowly, unpaid lectureship in pathology, he replied that a successful course required an actual laboratory, which the college didn’t have and was unwilling to build. Welch then approached his friends at Bellevue, with modestly better results: a small stipend was promised, along with three bare rooms for a laboratory and $25 worth of supplies. Begging and borrowing, Welch collected his own specimens by combing the local marshes for frogs. That fall, with half a dozen Bellevue students and an equal number of “antique microscopes,” he offered the first pathology course at an American medical school.
It proved an instant success. As word spread that the European-trained Welch was offering a pathology course with a laboratory component, medical students from across the city clamored to get in. A few months later, a new offer arrived from P&S. Lab space had been found; an alumni group would provide the supplies; and a modest salary was attached. Given the school’s powerful reputation, it seemed a perfect fit for Welch, a recent alumnus. “We’ve got to get you back,” he was told. “We must have pathology here.”
Welch was sorely tempted. The offer meant that two major medical schools now recognized pathology as a discipline worth pursuing. It was a heady moment for the son of a country doctor, not yet thirty years old, who had returned from Europe with few prospects for academic success. But Welch turned down the offer. “I felt I would be a traitor after all that they had done for me at Bellevue if I abandoned them, so I declined very reluctantly,” he recalled.
While immensely popular with medical students and the house staff, Welch earned mixed reviews from Bellevue’s senior physicians, some viewing him as “a laboratory man,” unable to do “anything practical.” One episode is particularly revealing. Upon learning that Germany’s Robert Koch had isolated the tubercle bacillus, Welch explained its momentous implications at his next lecture, drawing bursts of applause. Word of this reached Alfred Loomis, a Bellevue faculty don and president of the elite New York Academy of Medicine. A few days later, Loomis openly mocked the discovery in the hospital’s packed amphitheater. “People say there are bacteria in the air, but I cannot see them,” he said, peering dramatically into space. Welch wisely let it pass. He wasn’t about to pick a fight he couldn’t win. “That’s too bad,” he told the student who reported the remark to him. “Loomis is such a nice man.”
As Welch gained a modest foothold at Bellevue, William Halsted began his own journey to Central Europe. Returning to New York City in 1880, he took on several jobs before settling primarily at Bellevue, where he and Welch, formerly acquaintances, became fast friends. Like other young surgeons, Halsted faced a senior staff bitterly divided over Germ Theory and antisepsis. At one end of the spectrum stood Frank Hamilton and his allies, conceding nothing to these “foreign ideas.” In the middle were those like James Rushmore Wood, a founder of Bellevue Medical College, who had begun his surgical career before anesthesia existed and could amputate a leg in nine seconds. Wood wasn’t opposed to Lister per se. He conspicuously washed his hands before operating because he believed in personal cleanliness, not because he supported—much less understood—what Germ Theory implied. As a result, Wood made no attempt to sanitize his instruments, or the operating table, or the patient’s wound—and few in the audience seemed to mind.
At the other end of the spectrum were surgeons like Stephen Smith, who had met Lister during his American tour in 1876 and was among his early converts. Smith had come to Germ Theory the hard way—by watching dozens of his patients survive the operation only to die shortly thereafter of infection. “We may summarize the conditions regarded as essential to success as follows,” he wrote of his new surgical routine: “A clean operator; clean assistants; a clean patient; clean instruments; clean dressings.”
Frank Hamilton viewed Smith’s methods as “demented,” and some shunned Smith entirely. Walking through the hospital, he could hear the mocking cries of “There’s a bacillus, catch him!” The conflict led Halsted to worry whether he could continue to practice at Bellevue—a place, he fretted, “where the numerous anti-Lister surgeons dominated and predominated.” This was an exaggeration. The lecture notes of Bellevue medical students in these years show a fair number of faculty endorsing Germ Theory and antisepsis. “Pasteur has demonstrated that 212 degrees heat destroys germ life,” read a typical student entry. “To [prevent] poison in the bl
ood use carbolic acid about wound and in room freely—metastatic abscesses should be opened early and washed out.”
What troubled Halsted were the methods of the old guard—surgeons who held instruments in their teeth, passed unwashed artery clamps from patient to patient, and closed wounds with catgut discolored by filth. Refusing to work in the same operating space used by these men, Halsted got permission to build a private surgical tent on the hospital lawn, personally raising the $10,000 it would cost. “The floor was of maple laid almost as finely as a bowling alley,” Halsted recalled. There were “large and numerous portholes [for] ample light. Water, hot and cold, and gas were piped to the tent and patients were rolled [in] on a platform.” It was, some believed, the most sanitary operating room in the country.
In 1880, controversy surrounding Joseph Lister and his methods was largely unknown to Americans beyond the medical profession, but this was about to change. Less than a year after Halsted’s return from Europe, a political tragedy of epic proportions struck the United States, bringing esoteric terms like Germ Theory and antisepsis into the national dialogue in an unimaginable way.
11
A TALE OF TWO PRESIDENTS
On the morning of July 2, 1881, an assassin named Charles Guiteau approached President James A. Garfield in Washington’s main railroad depot and fired two shots at point-blank range from a snub-nosed revolver. Convinced that he had been responsible for Garfield’s victory, and demanding an ambassadorship in return, the deranged Guiteau exacted his revenge. One bullet grazed the president’s arm; the other entered his back, missing the spinal cord but breaking two ribs before settling behind the pancreas. Those who first attended him thought the wound to be fatal, as did Garfield himself. “Doctor, I am a dead man,” he told a physician at the scene. Only forty-nine, he’d just taken office in March.
The assassin’s bullet, we know today, did not cause Garfield’s death. It had lodged in fatty tissue, skirting vital organs and major arteries. Had the responding physicians been followers of Joseph Lister, or had they done nothing more than make Garfield comfortable, he almost certainly would have survived. Instead they searched clumsily for the bullet, inserting unwashed fingers and filthy probes into the open wound. Rushed back to the White House, the new president appeared to rally; in truth, the fatal damage likely had been done.
The lead physician was Doctor Willard Bliss, a family friend. (His hopeful parents actually named him Doctor.) Though Bliss spoke boldly of his ability to handle the case, Secretary of State James G. Blaine, Garfield’s political confidant, was less certain. Blaine had been standing alongside the president when the shooting occurred. Taking charge, he summoned two of the nation’s top surgeons to the White House—David Hayes Agnew, sixty-three, a professor at the University of Pennsylvania Medical School, and Bellevue’s Frank H. Hamilton, now sixty-eight. “The President, while doing well, is still in a very critical condition,” Blaine telegraphed Hamilton on July 3. “It would do much to relieve Mrs. Garfield’s anxiety to have you here to consult with the attending Physician. Will you come by first train?” Hamilton left for Washington that evening.
He and Agnew examined Garfield the following day—July 4—without pausing to wash their hands or clean their instruments. The problem, Hamilton told reporters, was that “the ball seems to have entered the liver and remains in the abdominal cavity beyond the reach of detection.” Actually, Hamilton had no idea where the bullet lay, and wouldn’t find out until the autopsy was performed. Worse yet, he threw caution to the wind. “The President is getting better,” he assured the nation. “The chances are all in his favor.”
Hamilton furthered this fantasy by returning to Bellevue. With Garfield’s condition now “stable,” a full recovery was predicted. “Dr. Hamilton’s Views: No Danger of Pyaemia or Other Complications—The President’s Life Safe,” the New York Times declared. But when Garfield didn’t recover—he got progressively worse—Hamilton was summoned back to Washington. At a tearful private meeting on July 23, he recalled, Mrs. Garfield begged him to remain by her husband’s side, and he dutifully agreed. “From this moment until the death of the President,” he wrote, “my time and thoughts were given wholly to the sufferer in the White House.”
No stone was left unturned. In attempting to cool down Garfield’s sweltering bedroom, a group of engineers designed what one historian has called “the country’s first air conditioner”—a huge fan “that forced air through cheesecloth screens soaked in ice water.” With the X-ray machine yet to be invented, Garfield’s advisors invited Alexander Graham Bell to try to find the bullet believed to be responsible for Garfield’s grave condition with a primitive metal detector called the “induction balance.” It didn’t work. What had caused Garfield’s reversal? Some blamed the presidential mansion, then in awful disrepair. The pipes leaked, the floors were rotted, and rodents had the run of the place. Surrounded by swampland, it often stank of sewage. In one of the more bizarre episodes of the assassination drama, Garfield’s doctors, suspecting dangerous “miasmas” to be the cause of his troubles, brought in a sanitary engineer to inspect the plumbing, cesspools, and local marshes for dangerous odors. His report, never made public, confirmed the worst: the White House was a deadly mess. “The President,” said one alarmed physician, “is now in much greater danger from the pestilential vapors of the Potomac flats than from Guiteau’s bullet.” What influence, if any, this had on the future course of events is not known. But three weeks later, Garfield was moved by train to a house on the New Jersey Shore, where “the cool breezes of the sea coast” allowed “air of the right kind to [filter] into the invalid’s chamber.”
There is no evidence, however, that his treatment changed course. In an era before antibiotics, there was little to be done once a massive bacterial infection set in beyond draining the pus and easing the pain, which meant morphine, alcohol, and nourishment through the rectum, since Garfield could hold down little of the food he ingested. Still, the cheerful updates kept appearing. “I regard his case as making good progress toward an almost assured recovery,” Hamilton announced on August 1. Two days later, he publicly applauded Garfield’s medical team—himself included—for its heroic efforts on the president’s behalf. “I have had a great deal of experience with gunshot wounds in the course of my life, having seen many thousands of them,” he stated, “and I think I may safely say that I have never seen a case more judiciously managed.”
Not everyone agreed. As the weeks passed without a sighting of the bedridden Garfield, rumors spread that he might indeed be suffering from pyaemia, or blood poisoning. If true—if something this serious had so long escaped detection—“it does not give a happy impression of the acuteness of the doctors around the President,” remarked the New York World. But Dr. Hamilton’s resolve remained rock solid through the crisis, and his sterling reputation helped ease the doubts. Many physicians—including several Bellevue colleagues—lined up loyally in support. “The case,” said Alfred Loomis, “could not possibly be progressing more favorably.” As late as September, with Garfield now hovering near death, most newspapers still expressed confidence in Hamilton, calling him “the prince of surgeons” and “a model gentleman.” A typical headline read: “The President’s Best Day: His Condition Growing More and More Hopeful.”*1
Garfield died on September 19 at the oceanfront home in Elberon, New Jersey. Ravaged by multiple infections, “his ribs stuck out, his arms and legs resembled matchsticks and his face appeared skeletal.” He had lost close to one hundred pounds in ten weeks. The autopsy listed the cause of death as a “secondary hemorrhage” near the path of the bullet but noted, without further comment, two enormous abscesses (or collections of pus), one “in the vicinity of the gall bladder,” the other “between the loin muscles and the right kidney.”
The findings were controversial. And their publication seemed to accomplish what Joseph Lister’s Centennial Exhibition address had failed to do five years before: ignite a full-scale debate ove
r the value of antiseptic surgery. For some, the abscesses clearly indicated pyaemia, which raised serious doubts about the care that President Garfield had received. Writing in the prestigious Boston Medical and Surgical Journal, Dr. John Collins Warren Jr., a rising star in the profession, took direct aim at Hamilton’s methods. “We might criticize the introduction of the finger of several surgeons into the wound,” he wrote, adding: “These examinations were not in accord with prevailing present theories.”
Even those who had stood solidly behind Garfield’s doctors during the crisis seemed shaken by the death. Perhaps other approaches could have been tried; perhaps more could have been done to reverse the downward spiral. “The collision of opinion on [Lister’s methods] is exemplified by the varying practices of surgeons working in the same hospital everywhere,” wrote the New York Herald Tribune, “and the fair-minded observer is indeed puzzled to know on which side he should take his stand.”
Others, however, mocked Hamilton as a fossil in his own institution. “If Garfield had been a ‘tough,’ and received his wound in a Bowery dive,” a doctor sniffed, “he would have been brought to Bellevue Hospital in an ambulance, operated on without fuss or feathers, and would have gotten well.” Furious, Hamilton replied that dressings dipped in carbolic acid had been applied to Garfield’s wound. What he couldn’t comprehend was that antisepsis required precise daily effort—it couldn’t be done casually, hit or miss. There was no compensating for the single thrust of a germ-ridden finger. The slightest deviation could be fatal. At his murder trial that fall, Garfield’s soon-to-be-hanged assassin refused to accept blame for the president’s death, shouting: “Nothing could be more absurd….Garfield died from malpractice.” Sadly there was truth to what he said.
Whatever goodwill Garfield’s doctors had earned from their vigil at the failing president’s bedside vanished instantly when word leaked out regarding the size of the bill each man sent Congress. “For professional services as consulting surgeon and physician,” Hamilton’s read, “rendered to the late President of the United States, James A. Garfield, Deceased, from July 3, 1881, to September 19, 1881, inclusive, Twenty Five Thousand Dollars, $25,000.” Hamilton justified the sum (worth close to $600,000 in 2016 dollars) by claiming to have led each consultation and surgical procedure “until the hour of Mr. Garfield’s death,” and remaining, “as was my duty, to take part in the autopsy.” But his tone-deaf explanation only made things worse. “Sir, the bill you have submitted…is exorbitant in the extreme,” an anonymous “Friend of the late President” wrote him, and he wasn’t alone. The public response proved so hostile that a special congressional committee was formed to investigate “the Expenses of the Last Illness and Burial of President Garfield,” with an eye toward lowering the bill. The majority recommended the sum of $15,000, noting that a surgeon of Hamilton’s standing often earned that much overseeing a serious case, while the minority, furious over both the bill and Garfield’s medical treatment, opposed the majority’s recommendation as “excessive.” In the end, Congress cut the fee to $5,000, including expenses. Hamilton returned to Bellevue a bitter, humbled man.
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