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Here is the report of Garfield's doctors [4a]:
It was found that the ball, after fracturing the right eleventh rib, had passed through the spinal column in front of the spinal canal, fracturing the body of the first lumbar vertebra, driving a number of small fragments of bone into the adjacent soft parts and lodging below the pancreas, about two inches and a half to the left of the spine and behind the peritoneum, where it had become completely encysted.
The immediate cause of death was secondary hemorrhage from one of the mesenteric arteries adjoining the track of the ball, the blood rupturing the peritoneum and nearly a pint escaping into the abdominal cavity. An abscess cavity, 6x4 inches in dimensions, was found in the vicinity of the gall-bladder, between the liver and the transverse colon, which were strongly adherent. It did not involve the substance of the liver, and no communication was found between it and the wound. A long suppurating channel extended from the external wound between the loin muscles and the right kidney almost to the groin. This channel, now known to be due to the burrowing of pus from the wound, was supposed during life to be the track of the ball.
A non-physician, writing in 1901, explained some of the problems confronting
Garfield's surgeons [4b]:
A 44-caliber revolver bullet fracturing the rib, then crashing through the body of a lumbar vertebra and driving a number of fragments into the soft parts, thence lodging behind the pancreas, makes a wound and condition not to be despised by even the boldest and deftest of modern operators. Moreover, President Garfield was a stout man, which would have increased the difficulties. Were such a bullet promptly located [start page 313] to-day by the X-Rays, any experienced and conscientious surgeon would hesitate as to his course. If he elected to remove the bullet, again he would be embarrassed to know whether it were best to choose the anterior or posterior route. A laminectomy is a comparatively simple operation in a thin subject, but to reach the body of a vertebra, much less go anterior to it, as would have been necessary to have recovered the ball and removed the spiculae of bone driven forward by it, in a patient of President Garfield's build, would have taxed both the anatomical knowledge and surgical daring of the greatest of his surgeons, the gifted Agnew. If the anterior route were chosen, one has only to think of the important vessels and nerves superimposed on the bullet, and almost in contact with it. By either, anterior or posterior route, the danger from hemorrhage would of necessity have been great.
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