Famous assassinations: Who could doctors save today?

Dr. Terry Housinger, a general surgeon at the Billings Clinic, tackled the topic of famous assassinations at a meeting of the History of Medicine Club, offering his audience of medical students and doctors a chance to reflect on the evolution of trauma care.

After describing the circumstances surrounding each famous assassination, Housinger offered his opinion on whether modern medicine could have saved those high-profile victims if the attack had occurred in Billings today.

Here's the gist of what Housinger gleaned from the historical record:

Julius Caesar

• The circumstances: As a military leader, Caesar transformed Rome into an empire that stretched across Europe. But political opponents feared his power as a statesman.

On March 15, the Ides of March, in 44 B.C., Caesar was lured to the Senate by Roman aristocrats who hid knives under their togas.

William Shakespeare's play "Julius Caesar" helped make his murder one of the most talked-about assassinations in history, Housinger said.

"The first blow went into his shoulder and his neck, so it may have gotten a major artery there," Housinger said. Caesar started spurting blood all over, according to historical accounts.

"And then everybody just had at it."

Caesar was stabbed many times - some accounts say more than 20 times while others claim 75 to 100 times - and left to bleed to death.

• Today's outcome: No chance. If he had been stabbed in an alley in Billings that many times and left to bleed, he wouldn't have survived today, Housinger said. Caesar had too many big wounds and lost too much blood.

Abraham Lincoln

• The circumstances: The first assassination of an American president came on the night of April 14, 1865, when Lincoln attended a performance of the comic melodrama "Our American Cousin" at Ford's Theater in Washington, D.C.

As part of a conspiracy plot, John Wilkes Booth, an actor, shot the president from the rear of the presidential box, leapt to the stage and cried, "Sic semper tyrannis" ("Thus always to tyrants"), Virginia's motto.

• The weapon: Booth's single shot, at a distance of less than 5 feet, came from a .44-caliber derringer, a short stubby weapon. The derringer had a medium muzzle velocity, a measure of the speed of a bullet as it leaves the barrel, of 900 feet per second. It also had a relatively low muzzle energy of 350 foot-pounds.

In comparison, today's high-powered rifles get into the 3,000 range for muzzle energy.

• The wound: The bullet entered from behind the left ear and penetrated deep into Lincoln's skull.

• Medical attention: "At the scene, they did a form of CPR," Housinger said.

Because Lincoln stopped breathing shortly after he was shot, a couple of medical students tried to do an early form of cardiopulmonary resuscitation. "CPR, the way they did it, was basically where they were pushing on his diaphragm from below and they were pulling up his arms," Housinger said. "They actually got some respirations."

One of the physicians who was there kept pulling the clot out to minimize the damage caused by swelling.

"Their thought at the time, maybe one of the things they learned from Civil War trauma, was they wanted to keep pressure off the brain. They would pull the clot off so he could freely bleed."

Lincoln moaned frequently and moved a little bit in his upper extremities but showed few other signs of life. He was carried to a nearby house.

"There was a lot of hand wringing done in the next portion of his care. About 10 hours later, he died," Housinger said.

In addition to the bleeding and tissue damage from the gunshot, the injury probably caused the brain to swell severely enough to cause the brain to herniate, or bulge downward, pushing the brain stem down toward the spinal column, which can cause death by stopping the body's control of basic functions such as breathing or heartbeat.

• Today's outcome: In Billings, with good neurological care, Lincoln might have survived. He probably could have been decompressed, relieving the swelling by using drugs or opening a portion of the skull to relieve pressure. The operation might have required removing a portion of the brain.

If he survived, he would have been in a minimal vegetative state at best, Housinger said.

James A. Garfield

• The circumstances: Four months after taking office, Garfield was assassinated by a disappointed job seeker. Garfield was the fourth president to die in office and the second to be assassinated.

He was shot on July 2, 1881, as he stood in a railroad station waiting to take a train to his 25th class reunion at Williams College. The assassin, Charles J. Guiteau, stepped out of the crowd and fired two shots.

• The weapon: Garfield was shot from a distance of less than 5 feet with a .44 caliber pistol.

• The wound: The bullet passed within 3 to 4 inches of the president's spinal column. It broke through the 11th rib of Garfield's back on the right side, causing injuries to the liver and soft tissues.

• Medical attention: Wound probing.

Despite horrendous casualties during the Civil War, surgeons learned very little about trauma care from the war because there was no systematic method of evaluating the results of specific procedures.

"We didn't learn diddly squat from the Civil War. People weren't of a mode to study how you could better take care of somebody who is badly injured. They just did stuff," Housinger said.

Every doctor had his own ideas about treatment.

"One of the things these guys all did was they wanted to probe the wound. I don't have any idea of what they thought they were going to do by probing the wound, but, by God, they did it. They stuck their fingers in it and probed for the bullet. Everybody was hung up on finding the bullet," he said.

Today, a bullet is often allowed to remain in place because digging around for it can cause more damage.

"They closed his wounds. That was about it," Housinger said.

Garfield was tachycardic, having a very rapid heartbeat, and tachypneic, having abnormally rapid breathing.

On Sept. 19, 80 days after he was shot, Garfield died of sepsis, a widespread inflammation that happens when the body's normal reaction to an infection goes into overdrive. The inflammation can cause dramatic changes in body temperature, blood pressure, breathing and heart rate, and it can spiral into multiple organ failure.

Garfield had abscesses, pockets of infection, throughout his abdomen, where his body had tried to wall off the infection in an attempt to contain it.

As Garfield struggled against death, he also became severely malnourished, dropping from 220 pounds to 130 pounds.

"He had any number of wound probings, not just that first night, but on down the way. Everybody needed to stick their finger in," Housinger said.

At the time, there were no surgical gloves or antibacterial soaps.

• Today's outcome: Doctors would have been able to treat his injuries and infection and been able to offer nourishment intravenously or through tube feedings.

"This was a no-brainer. It would have been an unreasonable death by today's standard," Housinger said.

William McKinley

• The circumstances: McKinley was six months into the start of his second term when he was shot by an assassin and Theodore Roosevelt assumed the presidency.

On Sept. 5, 1901, McKinley was shaking hands with people in a receiving line at the Pan-American Exposition in Buffalo, N.Y., when he was shot twice by Leon F. Czolgosz, a deranged anarchist.

• The weapon: McKinley was shot at point-blank range with a .32-caliber revolver. The revolver had a muzzle velocity of 780 feet per second. The bullet had a fairly low energy of 130 foot-pounds.

• The wound: The bullet hit McKinley's left upper abdomen and passed through his stomach.

• Medical attention: At first, McKinley was taken to a clinic on the exposition grounds, then to a hospital in Buffalo, where they operated to close his stomach wounds.

Although the surgeon had some experience with trauma, his primary doctor, an obstetrician-gynecologist, knew nothing about gunshot wounds, Housinger said. McKinley also had two other doctors, famous cronies who were friends of the exposition's director.

Although they closed the holes in his stomach, they failed to debride him. After a gunshot wound, surgeons debride soft-tissue wounds, removing dead or dying tissue, metal or bone fragments and other contaminants such as pieces of clothing, hair or skin.

As high-velocity projectiles penetrate the body, they cause shock waves that disrupt and destroy tissues as far as several inches from the bullet's path. Failing to debride a wound increases the risk of infection and likelihood of complications including gangrene and death.

The doctors tried to look around to find the bullet, but, when McKinley's pulse became feeble, they quickly finished up the operation. In their haste, they probably missed a number of injuries, Housinger said.

McKinley died nine days after the shooting, probably from sepsis and pancreatitis, an inflammation of the pancreas caused by injuries to the pancreas that the doctors overlooked. The pancreas secretes digestive enzymes and produces several important hormones that regulate blood glucose levels.

McKinley also leaked digestive acids from the stomach into his abdomen and probably leaked pancreatic enzymes, which can digest the surrounding body tissue.

"Throughout the whole time he was trying to get over his illness, they gave him whiskey, and they gave him cognac and more whiskey and they gave him strychnine and then they gave him digitalis and quinine and they gave him more whiskey.

"That was pretty much it. I don't know where people came up with the idea this was going to help him. There was absolutely no science here, whatsoever, that I could see," Housinger said.

• Today's outcome: "We would have had him out of the hospital in a week, 10 days max," Housinger said.

Surgeons would have treated his wound, recognized which organs were injured and debrided his abdomen and pancreas.

Archduke Franz Ferdinand

• The circumstances: The assassination of the archduke touched off World War I, one of the bloodiest and costliest wars in modern history.

On June 28, 1914, crowds had gathered in Sarajevo, the capital of the Austrian province of Bosnia, to see Archduke Francis Ferdinand, heir to the Austria-Hungary throne. A man jumped on the running board of the royal touring car and fired a pistol.

Two shots hit Ferdinand, and one hit his wife, Sophie, duchess of Hohenberg. The assassin was Gavrilo Princip, a Serb nationalist.

When Austria-Hungary declared war on Serbia a month later, military alliances drew the rest of Europe into the fight.

• The weapon: Princip fired a .22-caliber handgun from a distance of several feet. It had a muzzle velocity of 700 feet per second and energy of 75 foot-pounds.

• The wound: A bullet entered the side of the archduke's neck and nicked his jugular vein, which drains blood from the head and brain back to the heart. The archduke bled profusely.

• Medical attention: "His treatment at the scene - various and sundry screams and exhortations," Housinger said.

"Nobody did just the simplest thing on the planet. Nobody put a finger on it. He basically bled to death right at the scene."

• Today's outcome: "Most of us now would have enough sense, I don't care if you're Joe Civilian or the finest trauma surgeon on the planet, you know you can stop bleeding by putting direct pressure on it," Housinger said.

John F. Kennedy

• The circumstances: Kennedy, the youngest man ever to be elected president, was barely past his first 1,000 days in office when he was shot as he rode in an open limousine during a motorcade through Dallas on Nov. 22, 1963.

The limousine raced to the nearby Parkland Hospital. Kennedy never regained consciousness, and within two hours of his death Vice President Lyndon B. Johnson was sworn in as the 36th president. Lee Harvey Oswald, who was charged with the murder, was shot two days later by Jack Ruby, a Dallas nightclub owner.

• The weapon: The 6.5 mm rifle had a muzzle velocity of 2,200 feet per second and energy of 2,800 foot-pounds. Kennedy was shot at a distance of about 200 yards.

• The wound: One shot entered the back of JFK's head. Another shot passed through his larynx.

• Medical attention: He arrived at Parkland Hospital after a 15-minute limousine ride. At the time, the program of Advanced Trauma Life Support training for emergency resuscitation and stabilization of seriously injured or ill patients did not exist. But Kennedy was given full ATLS-style trauma care.

The ATLS training program, developed by the American College of Surgeons, simplified and standardized the treatment approach to trauma patients. The premise of ATLS is to treat the greatest threat to life first.

The memory aid, or mnemonic, ABCDE, sets the order of handling injuries. A stands for airway; B for breathing; C for circulation and bleeding control; D for disability or a neurological evaluation of brain function; and E for exposure and environment, meaning the patient is safe from environmental hazards.

Doctors intubated Kennedy through the wound the bullet had caused in his trachea by placing a tube into the trachea to protect his airway and provide a means for mechanical ventilation. There was no heart or respiratory activity.

• Today's outcome: "The bullet tore his skull apart completely," Housinger said, noting that JFK would have no chance of surviving today.

The Rev. Martin Luther King Jr.

• The circumstances: In spite of King's emphasis on the use of nonviolent resistance to achieve racial justice, the Baptist minister and Nobel Peace Prize winner often became the target of violence.

He was stabbed in New York City and stoned in Chicago, and his home in Montgomery, Ala., was bombed. On April 4, 1968, at the age of 39, King was shot by James Earl Ray, an escaped convict, as King stood on a motel balcony in Memphis, Tenn.

• The weapon: King was killed with a single shot from a distance of 100 yards with a .30-06, a high-powered rifle with a muzzle velocity of 2,500 feet per second and energy of 2,900 foot-pounds.

• The wound: The bullet entered from the right side at an angle and took out King's jaw along with his jugular vein, which drains blood from the head, and carotid artery, which supplies blood to the head.

• Today's outcome: "If someone had shot him on the operating table, we couldn't have saved him," Housinger said.

Robert F. Kennedy

• The circumstances: After his brother John F. Kennedy's assassination in 1963, Robert Kennedy served as a U.S. senator from New York from 1965 to 1968. He was assassinated in Los Angeles in June 1968 while campaigning for the Democratic nomination for president.

His assassin, Sirhan Sirhan, is serving a life sentence in California.

• The weapon: RFK was shot three times from just inches away with a .22-caliber handgun, a very low-energy weapon that had a muzzle velocity of 1,095 feet per second and an energy of 77 foot-pounds.

• The wound: The main bullet wound was behind his ear.

• Medical attention: RFK was still breathing at the scene, where he was given comfort measures. At the first hospital, which was nearby, there was no neurosurgeon, so Kennedy was transported to another hospital 20 minutes away.

Shortly after he got there - about one to 1½ hours after the shooting - surgeons did a craniotomy on him and decompressed him, opening a portion of his skull to relieve pressure and control bleeding. They found significant brain injury from the slug and bone fragments. The swelling caused Kennedy's brain to herniate.

• Today's outcome: With no delay in treatment, doctors today might have saved Kennedy, but he would have had poor quality of life.

"He probably would have lost a lot of motor function and may have had trouble breathing," Housinger said.

Doctors would have had to deal quickly with the swelling and would probably have left parts of his skull open to relieve pressure.

Contact Donna Healy at dhealy@billingsgazette.com or at 657-1292.