Cameos of Terror – Four US Presidents and a Senator

The assassinations of four American Presidents and the brother of one of them were fore-plays of today's indolent, terrorist war. It is unrewarding to quibble about whether they were acts of terrorism or anarchy. Their reasons and effects were exactly the same. Impossible demands were placed on doctors who suddenly found themselves managing catastrophic events involving a President or a Senator when and where they occurred. Of course, surgeons who became involved were also placed in highly-visible positions of extreme difficulty. It is informative to examine how they handled those challenges and with what degree of success. Drs Trunkey and Farjah have analysed the Presidential killings in great detail, from medical and surgical standpoints.[1] What any surgeon could, or could not possibly accomplish in those circumstances becomes very obvious. My interest here concerns the “terrorist” nature of these killings and the ominous surgical implications of the gunmen's means and methods of attack.

To the extent that the assassins employed stealth, premeditation and dedication, and all must have known that they were liable to capture and severe retribution soon after their acts, they exhibited many characteristics of modern “suicide” bombers. Each was driven by absolute conviction of the merit of exterminating a public figure. One, who was intent on killing Robert Kennedy, may not have succeeded. Despite many conspiracy theories, all but one of those blamed seemed to have acted in isolation.

Three of the five victims, Lincoln and both Kennedys, died from massive injuries to the head with no chance of recovery. I am much less optimistic than Drs Trunkey and Farjah in estimating the chances of salvage in the cases of Garfield and McKinley. With no antibiotics available and the available surgical techniques and operators, I doubt that surgery of that era could have succeeded with their abdominal injuries. Perhaps they may have been saved by expert, modern care but that possibility becomes irrelevant when the nature of their wounds and the available resources are considered. Due to the particular circumstances of each attack, the initial resuscitation and surgical attention the victims received were inadequate or useless in every case. All of the intending assassins had political or quasi-political intent and all of them were experienced with weapons. Every victim was well aware of security needs and their own vulnerability. Three of the Presidents had lived through the Civil War and knew of its social implications.

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Abraham Lincoln (1809–1865)

Lincoln had been the object of numerous death threats from Southerners who didn't want slavery abolished. John Booth was familiar with the theatre and a popular enough actor to command an income similar to that of the President. In the interests of preserving slavery, he conspired with others to kill Lincoln, the Vice President, the Secretary of State, the Secretary of War and General Ulysses Grant whenever the opportunity presented.

During an evening performance at Ford's Theater in Washington, D.C., Booth shot Lincoln through the back of the head. Booth had chosen a moment during a play when he could approach the presidential box without much difficulty. He left the theatre by vaulting over the rail of the box onto the stage in front of a stunned audience. Despite fracturing his left fibula, he fled to a waiting horse but later needed surgical attention by Dr Samuel Mudd, who gave assistance without telling anybody what he had done.

The first doctor on the scene was a 24 year old army surgeon, Charles Leale. He instituted first-aid measures of some sort and attempted to open the scalp wound with his finger to remove clots in the hope that it would relieve pressure on Lincoln's brain. Three other doctors soon arrived on the scene and repeatedly probed the wound with bare fingers (there were no surgical gloves in those days) to try to find the bullet. Lincoln rapidly became moribund and died early next morning.

An autopsy performed in the White House showed that the bullet had passed from behind Lincoln's left ear to the front of his brain. It has recently been suggested that he might have survived that injury with more aggressive surgical care but that is unlikely in view of the extent of the injury and the inevitable amount of reactionary brain swelling. If, miraculously, he had survived then, or if he survived today with modern treatment, it is certain that Lincoln would have been vegetative at best. All concerned probably acted reasonably. What the various surgeons did to the wound with their bare fingers was scarcely ideal practice but it didn't affect the outcome because it could not have produced useful relief of compression of the brain by haemorrhage.

Booth was captured a couple of weeks later and shot through the neck by Sergeant Thomas Corbett who, in 1858, was sufficiently disturbed about the numbers of prostitutes on the streets of Boston that he, in disgust, had cut off his testicles with a pair of scissors. After attending a prayer meeting, he then spent a month in the Massachusetts General Hospital to recover from his injury. He was later committed to an asylum but escaped and was not found again until the shooting of Lincoln.

Booth had fancied himself as a killer of tyrants. His motives were quite simple. It was a purely political murder. When cornered, he was given several opportunities to surrender peacefully but rejected them all. Corbett's wound to Booth's neck defied any contemporary surgical care. He suffocated on the porch of a Virginia farmhouse as a result of a spinal injury.

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James Garfield (1831–1881)

Garfield was shot by Charles Guiteau who believed that the President favoured another Civil War. Guiteau was convinced that he had God's approval to assassinate Garfield who was in Washington on his way to a college reunion on 2.7.1881. Guiteau approached from behind and fired two shots into Garfield's back. One wound was superficial and did no real harm. The other took a complicated course through several upper abdominal organs.

First on the scene was Dr Smith Townsend, the district health officer, who probed the major back wound thoroughly with his unwashed finger (again, before rubber gloves were invented), hoping to find the bullet, but he failed to do so. The President was then transferred to the White House in a shocked state. At his own request, he was placed in the care of a Dr Bliss.

Some hours later a naval surgeon, Dr Wales, also examined the wound with his bare fingers and concluded that the bullet had passed through the liver and lay in the abdominal cavity somewhere. Half a dozen other curious doctors repeated the performance and nodded their heads wisely, no doubt, but none of them was able to find the bullet with a finger. At least two of them were highly experienced surgeons. Why they wanted to know where the bullet was, rather than what damage it had produced, is unclear. It seems that no exploratory operation was planned.

For a couple of months, Garfield slowly improved. During that period, Alexander Graham Bell, the Scottish inventor of the telephone, offered to construct a machine which might locate the bullet by an auditory reflection-signal, presumably an early form of ultra-sound. Finally, Bell gave up despite many tests and was forced to withdraw, probably gratefully, when the President suddenly deteriorated. With increasing evidence of deep infection in his chest and in his abdomen, he suddenly died. Autopsy showed pockets of pus and massive haemorrhage around a ruptured artery.

Guiteau was hanged nine months later, insisting that God had told him to kill Garfield. All the doctors who attended Garfield submitted huge accounts to the U.S. Government and all were promptly paid in full. A half-hearted enquiry into the size of the accounts was suddenly aborted by order of the succeeding President.

As with Lincoln, it is widely agreed that repeated, unhygienic examination of Garfield's wound could well have introduced a mortal infection but it is unlikely that he could have survived his wounds, anyway, when nobody was anxious to undertake an exploratory operation on a President who seemed to be improving. He certainly had no expert nursing care but that would scarcely have hastened his death. Clearly, his management failed to meet ideal standards but it did not affect the outcome.

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Integrated terrorist activities were clearly apparent in that era. Three months before Garfield died, Tsar Alexander II of Russia was killed by a hand grenade thrown by an anarchist. In the following 20 years, anarchists killed Garfield, the President of France, the Empress of Austria and the King of Italy. During the investigation of the King's death in 1898, a note was found naming six world leaders whom anarchists planned to kill. The first three on the list were already dead. The fifth was President William McKinley.

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William McKinley (1843–1901)

Like Garfield, President William McKinley had a distinguished record during the Civil War and was believed to be popular. Because Leon Czolgosz was dedicated to world anarchy, he shot the President twice on September 4, 1901, in Buffalo City, New York. There was a superficial injury to the right upper chest and a deep wound of the upper abdomen. Quickly on the scene was a Dr Hall, accompanied by two medical students. They saw much external bleeding and somehow took the President to a nearby hospital which was ill-equipped to handle any surgical emergency. Other surgeons soon arrived, some of them experienced in gunshot wounds during the civil war.

For some reason, they decided unanimously that Dr Matthew Mann, an obstetrician and gynaecologist, should be in charge of surgical management. There may have been some conflict of opinion between the various surgeons present about that choice but it transpired that the least-appropriate surgeon ended up as the leader of the team of operators. With inadequate instruments, poor lighting and unhelpful assistance, exploration of the President's upper abdomen showed a large tear of the stomach.

Rubber gloves were available and reasonable sterility was possible but there was already much soiling of the cavity by spilled stomach contents. Some reports referred to other injuries of the colon and kidney, but no mention was made of surgical attention to those organs. Because of the nature of the wound, it is unlikely that the availability of antibiotics could have contributed favourably to the outcome.

Dr Mann repaired the stomach, at least, and the President was taken to a nearby house for convalescence. No fewer than eight experienced nurses were allocated to McKinley's care, such an over-abundance being related, perhaps, to the quite inadequate nursing of President Garfield.

Intensive care appropriate to 1901 included adrenalin, nutrient enemas of egg and whiskey, oxygen, and water, camphor and nitro-glycerine by mouth. The surgeons agreed to McKinley's request for cigars before he abruptly died on the eighth day after his operation. An autopsy showed that extensive infection involving all the upper abdominal organs.

Czolgosz was executed a month later. It was generally agreed that surgical management was undertaken in an inappropriate place by an inappropriate surgeon with multiple assistants who were of doubtful help to the surgeon. Whether or not the injuries to the colon and kidney affected the outcome, it seems that Dr Mann had been handed a poisoned chalice, perhaps because nobody wanted the responsibility for managing the President's wounds. Again, all practitioners involved in McKinley's care submitted extravagant accounts which were paid in full but without haste.

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John F Kennedy (1917–1963)

President Kennedy opposed Communism while Lee Harvey Oswald embraced it as practiced in Cuba. He had originally planned to kill President Richard Nixon but no opportunity had arisen. Among several conspiracy theories, the usual interpretation of the situation is that, while working at the Texas School Book Depository in Dallas, Oswald learned that Kennedy was to visit the city and pass-by the Depository. He decided to kill him to demonstrate his dedication to Communism.

On 22.11.1963, Kennedy and his wife were in the back seat of an open car moving slowly through the middle of a large crowd. Governor John Connally and his wife were sitting in front. It is now generally accepted that, at 12.30 P.M., Oswald fired three shots from the sixth floor of the Depository. The first carbine bullet missed the group altogether. The second hit Kennedy in the neck and then struck Governor Connally. The third bullet struck the back of the President's head. He was taken to nearby Parkland Hospital within five minutes.

The first doctor concerned was a surgical resident, Dr Carrico, who found Kennedy in extremis with extruded brain tissue and heavy bleeding. Although appropriate resuscitative measures were applied and several specialists were soon available, Kennedy was pronounced dead 30 minutes after his injury. An autopsy showed massive, irrecoverable damage to the right half of his brain. There was also a deep wound on the right side of his neck which obstructed his airway.

Although Dr Carrico had noted both entry wounds, the neck injury was not originally identified by the Parkland Hospital staff but nothing could have saved Kennedy's life.

Governor Connally recovered from his multiple injuries.

Shortly after the President was attacked, Oswald shot and killed a policeman who attempted to capture him. He was arrested shortly after in a movie theatre. Two days later, in the busiest part of a Dallas police station, a nightclub owner, Jack Ruby, shot Oswald in the chest and he died during an exploratory operation.

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Ruby was a minor criminal with Mafia connections, who often carried a handgun. He was apprehended after he had shot Oswald in what became the first-ever, live, TV broadcast of a homicide. His motive remains unclear. One theory is that Ruby and Oswald had originally collaborated in planning to kill a Kennedy. Ruby was sentenced to death but successfully appealed and had a new trial pending when he died of cancer. He, John Kennedy and Oswald all died in Parkland Hospital, Dallas.

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Senator Robert F Kennedy (1926–1968)

Sirhan Sirhan attempted to assassinate Senator Robert Kennedy, the U.S. Attorney General and brother of President John Kennedy, just after the Senator had won the Californian Presidential Primary on June 5, 1968. It was in a crowded kitchen corridor through which Kennedy was leaving the Ambassador Hotel after addressing supporters. As he passed slowly through a packed corridor, Sirhan fired into the crowd around the Senator. Three or four of the shots struck Kennedy, apparently from in front. One struck his clothing, one or two entered his right chest superficially and another hit his head.

The first doctor on the scene, Stanley Abo, found a wound behind Kennedy's right ear with a powder burn indicating a very close range shot from behind. He probed the wound with a bare finger in an attempt to allow free exit of blood and reduce the pressure of bleeding on Kennedy's brain before he was quickly transferred to the closest hospital.

With no neurosurgeon available there, he was then rushed to The Good Samaritan Hospital where surgeons found more wounds – one in the right armpit and another a few inches below it. At operation, neurosurgeons removed blood clots and fragments of bullet and bone from Kennedy's shattered brain but he died within 24 hours. Autopsy confirmed a huge injury to the right side of Kennedy's brain and brain stem but the shots that struck the right side of his chest had not injured him mortally.

Sirhan had fired eight shots. Some of those shots struck bystanders. Mystery surrounds the fact that an armed guard close behind Kennedy had also fired a shot but his weapon was never checked by the police and the assassination-scene photographs were destroyed or lost before Sirhan's trial.

The shot that killed Kennedy entered the back of his head and had been fired at almost point-blank range but, according to all those interrogated, Sirhan had only fired from in front of Kennedy. Unless Kennedy had turned through almost 90 degrees at the instant he was shot, and there is no evidence for that, it is difficult to see how Sirhan's shot could have been responsible for Kennedy's mortal injury. It is even more difficult to see how the guard's shot could be disregarded as the fatal one.

Not surprisingly, the autopsy pathologist's report was carefully worded:

“Until more is precisely known…the existence of a second gunman remains a possibility. Thus, I have never said that Sirhan killed Robert Kennedy.”

That comment begs several questions: Did the security guard in fact fire the deadly shot? Was the shot deliberate and who else might have wanted Kennedy dead? Was the guard aiming at Sirhan? Why were details and materials of the police enquiry hidden or lost? The enigma persists.

Sirhan confessed to the killing but then claimed no memory of the event. As with John Kennedy, conspiracy theories about Robert Kennedy's assassination persist. At Sirhan's trial, the question was repeatedly raised as to whether the shot which killed Kennedy could possibly have come from Sirhan's gun but there was no confident answer. The security guard was cleared of involvement.

Given the autopsy report's wording, Sirhan's original death sentence was commuted to life imprisonment. Since then, he has applied unsuccessfully for parole on at least thirteen occasions. He is presently in a Californian State prison with a further chance of parole in 2011. His diaries, though confused, repeatedly suggest that his reason for attacking Kennedy was the latter's support for Israel in the 1967 Six-day War.

The provisional title of the manuscript of origin is: “War Surgery – a partnership of heroes.” John Wright MB; FRACS; FACS is the sole author and holds sole copyright. At present, it is being processed for publication later this year by “Australian Military History Publications”, Sydney, Australia.