Surgeries of US Presidents Reveal History of Secrecy and Scrutiny

November 5, 2024, is the day voters in the US will select their president for the next 4 years. However, despite the attention that political advertisements, news media channels, and late-night talk show hosts have placed on the election, the health of the president can be a very private topic.

In this historical retrospective, an overview of six sitting US presidents who underwent operations during their times in office is provided, along with how the surgical management of each case impacted American history.

President James Garfield’s Assassination

James A. Garfield (1831–1881; 20th US president, 1881) was shot by an assassin on July 2, 1881, as he and his family were boarding a train at the Baltimore and Potomac Railroad Station in Washington, DC, en route to a summer vacation.¹ Charles Guiteau, an American with psychosis and delusions of grandeur, believed that he had been politically slighted after what he considered to be his substantial efforts contributing to President Garfield’s victory in the election.

In reality, Guiteau had done little, if any, effectual campaigning and had been banned from the White House for his constant harassment of the president. On July 2, 1881, Guiteau emerged from the crowd of well-wishers at the railway station and shot President Garfield twice with a revolver. The first bullet grazed the president's shoulder, and the other struck him in the upper back. 

US Secretary of War Robert Todd Lincoln (son of President Abraham Lincoln) called for surgeon D. Willard Bliss, MD, to care for the president. Dr. Bliss’s initial examination of President Garfield reported, “The president was deathly pale, almost pulseless…a very feeble pulse of about 40 beats per minute, and a marked pallor of the face; skin cold and covered with a clammy perspiration.” 

Dr. Bliss explored the wound with his finger to trace the path of the bullet and felt the shards of the president’s 11th rib but not the bullet. When he guided a probe into the wound, it could only be passed 3 inches before it stopped.

During the first day after his injury, President Garfield was tachycardic, hypothermic, and had persistent emesis. Dr. Bliss and his team did not expect him to survive the night. The physician made urgent calls to surgeons David Hayes Agnew, MD, from the University of Pennsylvania in Philadelphia, and Frank Hastings Hamilton, MD, from Bellevue Hospital Medical College in New York City, New York, to lend their expertise to the dire situation.

Both physicians arrived in Washington and re-examined the president, including probing the wound with their unwashed fingers. The wound began to discharge “healthy looking pus,” and on one occasion, discharged a shard of bone and some bits of clothing. By this point, the president had developed jaundice and was having daily fevers.

The surgeons continued to explore the wound daily with unsterile instruments and inserted a 2-inch surgical drainage tube to facilitate source control. The tube initially passed to 4 inches, then progressively deeper up to 12 inches toward the iliac fossa. The president, unable to take nutrition by mouth, was treated with warm nutritive enemas consisting of egg yolk, bullion, whiskey, milk, and opium. 

Weeks of arduous attempts to locate the bullet, including using Alexander Graham Bell’s newly invented metal detector, widened the 3-inch wound into a 20-inch-long incision, beginning at the president’s ribs and extending to his groin. It soon became a superinfected, “pus-ridden, gash of human flesh,” and the president experienced a 120-pound weight loss during his illness.

President Garfield was taken to his beach cottage in New Jersey to convalesce, and he died on September 19, 1881, nearly 80 days after the shooting. During the president’s autopsy, it was discovered that the bullet had traversed the pancreas and passed through the body of the first lumbar vertebra but spared the spinal cord, with a large retroperitoneal abscess tracked to the iliac fossa. He was noted to have a ruptured splenic artery aneurysm and perforated gallbladder. 

President Garfield’s ultimate cause of death was ruled to be hemorrhagic shock without resuscitation, inadequate nutritional support, unchecked sepsis from the injured area, and bronchopneumonia.

President Grover Cleveland’s Oral Tumor

Grover Cleveland (1837–1908; 22nd/24th US President, 1885–1889 and 1893–1897) took office during a tumultuous economic period: The “Panic of 1893,” which included an economic depression, widespread unemployment, and massive bank closures. Adding to this stressful time for President Cleveland, he discovered a sore inside his left hard palate, on the side where he chewed his cigars.

A clandestine surgery was scheduled for July 1, 1893, aboard his friend Elias Benedict’s yacht, the Oneida.^2,3 The surgical team included William Keen, MD, and Joseph Bryant, MD, while dentist Ferdinand Hasbrouck administered anesthesia using a combination of cocaine and ether. During the 90-minute operation, the surgeons extracted approximately one-third of the president’s maxilla, and a prosthodontist fashioned a vulcanized rubber implant for him. The tissue sample was sent to William H. Welch, MD, at Johns Hopkins in Baltimore, Maryland, who diagnosed a maxillary carcinoma. 

President Cleveland recovered well after the operation and resumed regular speaking addresses in August. However, on August 29, journalist E. J. Edwards published an exposé on the secret operation in the Philadelphia Press. The president flatly denied the report and Edwards was widely discredited. Rival papers labeled him a “disgrace to journalism” and a “calamity liar.”

It was only in 1917 that Dr. Keen published the full account of the operation in the Saturday Evening Post. Dr. Keen regretted Edwards’ mistreatment, and he said hoped to “vindicate Mr. Edwards’ character as a truthful correspondent.” 

President William McKinley’s Assassination

William McKinley (1843–1901; 25th US President, 1897–1901) was assassinated while attending the 1901 Pan-American Exposition in Buffalo, New York.⁴ President McKinley’s early term was known for its pro-industry and protectionist policies that led to a rapid economic expansion and brought the US out of a recession. However, these policies caused a growing economic divide and were harmful to many working-class citizens.

On September 6, 1901, President McKinley arrived at the Temple of Music, a concert hall and auditorium built for the event, where he was greeted with a reception line. Leon Czolgosz, a 28-year-old American anarchist who sympathized with the impoverished working class, had been waiting in the receiving line and shot the president with a revolver that was concealed in a handkerchief. President McKinley was rushed to the exposition’s hospital building. 

Matthew D. Mann, MD, a gynecological surgeon and dean of the University of Buffalo Medical School, was called upon to oversee the president’s care. Unfortunately, Roswell Park, MD, a premier surgeon in Buffalo with extensive experience in trauma and gunshot wounds to the abdomen, wasn’t available to operate on the president because he was out of town in Niagara Falls performing a radical neck dissection.

Dr. Mann decided to proceed with an exploratory laparotomy in the makeshift operating room of the expo hospital building. The sun was setting, and mirrors were used to guide the little remaining sunlight into the surgical wound. Electric lights were available at the exposition but not brought into the hospital. 

Dr. Mann primarily closed the anterior and posterior gastric perforations with fine silk sutures. The bullet track proceeded into the retroperitoneum and could not be fully exposed. Dr. Mann made the decision to stop his search for the bullet, as he believed that further retroperitoneal injury could not be successfully repaired even if it was found and, therefore, assumed that further time under the anesthetic would be detrimental. The decision not to drain the lesser sac has been criticized by contemporary surgeons. 

The president survived for another 8 days after the shooting. During that time, several prominent physicians traveled to see him, including Dr. Park and Charles Heber McBurney, MD, of Columbia University in New York City. 

On September 13, gangrene had developed on the walls of the president’s abdomen and brought on severe sepsis. The president died the following day.

During the autopsy, both the anterior and posterior gastrotomy repairs were intact. However, the wound extended to involve retroperitoneal fat and a “considerable area of the pancreas,” the superior pole of the left kidney, the inferior aspect of the spleen, and the posterior aspect of the descending colon. Areas of the wound cavity had “gray slimy material with necrotic tissue.”

In the fallout from President McKinley’s death, the US Secret Service, whose original purpose was to control counterfeiting and other financial crimes as a bureau within the US Treasury Department, was expanded to provide protection for the president, vice-president, and their families.

President Dwight D. Eisenhower’s Crohn Disease

Dwight D. Eisenhower (1890–1969; 34th US President, 1953–1961) had a long-standing history of abdominal issues before he assumed the presidency.^5,6 In 1923, several episodes of lower abdominal pain led to an appendectomy, with histology demonstrating “chronic catarrhal appendicitis.”

In 1938, he was admitted to the hospital with another major episode of abdominal pain and intestinal obstruction, but the obstruction resolved, and he avoided a laparotomy. In the spring of 1956, President Eisenhower experienced another episode of abdominal pain with radiographic evidence of “regional enteritis,” which prompted a short admission at what is known today as the Walter Reed National Military Medical Center in Bethesda, Maryland.

On the evening of June 7, 1956, President Eisenhower was attending a gala for the White House Press Photographer’s Association emceed by entertainer Bob Hope. Shortly after midnight, the president developed progressive abdominal pain and vomited over a liter of bilious fluid. He was transferred to Walter Reed, where a series of radiographs demonstrated a small bowel obstruction. A nasogastric tube was placed, and a surgical team was assembled, including Leonard D. Heaton, MD, FACS (commander of Walter Reed), Isidore Schwaner Ravdin, MD, FACS (military), Brian B. Blades, MD (academic), and John H. Lyons, MD (private). 

Serial radiographs showed no improvement in the obstruction, and the president was scheduled for surgery. On June 9, he underwent an exploratory laparotomy through a right paramedian incision. Following 30 minutes of adhesiolysis, the surgeons found a 30–40 cm area of fibrotic inflammation and stricture in the terminal ileum. The surgical team decided to bypass the obstructed segment with an internal ileo-transverse colostomy.

The decision to perform a bypass was not contested at the time of surgery, but it has been widely discussed by surgeons since then. According to reports, President Eisenhower had told Dr. Heaton that he was planning to run for a second term in office, and Dr. Heaton likely chose an internal bypass operation for rapid, complication-free recovery so the president would be ready for the rapidly approaching re-election campaign. 

The press was updated hourly with significant detail, which was, before this time, unprecedented in the history of presidential illness. The president had an uneventful postoperative recovery. His nasogastric tube was removed on postoperative day 5, and he was discharged from Walter Reed in just under 3 weeks. President Eisenhower had no further symptoms or issues associated with Crohn disease for the remainder of his life.

President Lyndon Johnson’s Gallbladder

Lyndon B. Johnson (1908–1973; 36th President, 1963–1969) experienced an episode of right subcostal pain in September 1965 while vacationing at his ranch in Texas.⁷ He consulted with his physician George Burkley, MD, who ordered an oral cholecystogram, which confirmed cholecystitis. The president also was incidentally found to have concurrent bilateral nephrolithiasis.

James C. Cain, MD, a well-known gastroenterologist at the Mayo Clinic in Rochester, Minnesota, and the longtime personal physician of the president, was consulted for evaluation of the cholecystitis. Dr. Cain recommended a cholecystectomy be performed at the Mayo Clinic. 

President Johnson did not want to travel to Minnesota, and instead suggested that a Mayo surgical team travel to Washington, DC. Two prominent Mayo surgeons, George A. Hallenbeck, MD, and Donald C. McIlrath, MD, FACS, were recommended to perform the president’s operation. Ormond Culp, MD, FACS, a urologist from the Mayo Clinic, also was consulted to evaluate his nephrolithiasis. 

The surgeons met with President Johnson, along with his cardiologist John Willis Hurst, MD, and his operation was planned with two important pieces of information: the president wanted to know how long he would be incapacitated by the anesthesia; and he wanted his operation scheduled for a Friday, so that he could recover over the weekend and be well enough to address the press on Monday morning. 

President Johnson’s operation was performed on Friday, October 8, 1965, at the Bethesda Naval Hospital in Washington, DC. An open cholecystectomy using a “bottom-up” approach and a right ureterolithotomy was performed through a right subcostal incision, with an operating time of approximately 2 hours. 

The president had an uncomplicated postoperative course and was able to address the press the following Monday as he had hoped. On postoperative day 12, he posed for an infamous photo where he lifted his shirt to expose his incision, and the press at the time asserted this action to be “unpresidential.” Nevertheless, President Johnson claimed he posed for the photo to avoid speculation of a cancer diagnosis.

He was discharged on postoperative day 17 and resumed his typical duties.  Unfortunately, President Johnson would later develop a small incisional hernia at his surgical drain site, which was repaired by Dr. Hallenbeck in November 1966. 

President Ronald Reagan: Two Terms, Two Operations

Ronald W. Reagan (1911–2004; 40th President, 1981–1989) was operated on twice during his presidency. The first operation was to treat a 1981 assassination attempt, while the second was an operation for colon cancer. 

On March 30, 1981, 70 days after taking office, President Reagan exited the Hilton Hotel in Washington, DC, after addressing members of the American Federation of Labor and Congress of Industrial Organizations labor union.⁸ John Hinckley Jr., emerged from the crowd and fired six shots from a revolver at the president.

The sixth shot ricocheted off the armored limousine and hit President Reagan in the left chest. He was pulled into the limousine by the US Secret Service and taken emergently to George Washington University Hospital in Washington, DC. He walked into the hospital under his own power, and then collapsed in the emergency department. 

Joseph Giordano, MD, FACS, assumed care for the president who was hypotensive with a systolic blood pressure of 80 mm Hg on arrival. Examination of his chest revealed a 1.5 cm gunshot wound in the left posterior axillary line at the fourth intercostal space with no exit wound. A chest tube was inserted into the left hemithorax, and a total of 2,275 cc of blood was drained. Breath sounds became audible, but brisk bleeding continued.

The president was taken to the OR for a left anterolateral thoracotomy, which revealed approximately 500 cc of clotted blood. The major intrathoracic structures were intact, and the bullet was retrieved 2.5 cm from the pericardium. A peritoneal lavage was negative, and total operative time was 105 minutes. 

President Reagan reportedly quipped to his surgeon, “Please tell me you’re a Republican.” Dr. Giordano is said to have replied, “Today, Mr. President, we’re all Republicans.”  The president was discharged from the hospital on postoperative day 12. 

One of the other victims of the shooting, White House Press Secretary James Brady, was left permanently disabled and became a staunch advocate for gun control, leading the passing of the eponymous Brady Handgun Violence Prevention Act, which mandated federal background checks on firearm purchases.

President Reagan’s next operation occurred in the first year of his second term. In March 1985, Reagan’s stool tested positive for occult blood, and his hemoglobin had been falling over several months.⁹ On July 12, a colonoscopy revealed an ulcerated tumor in his cecum, with biopsy demonstrating carcinoma. 

Prior to his operation, Vice-President George H. W. Bush was sworn in as acting president under the 25th Amendment, and this was the first time in US history that the amendment was enacted.

On July 13, a surgical team consisting of Dale W. Oller, MD, FACS, Lee Smith, MD, and Bimal Ghosh, MD, FACS, performed a right hemicolectomy. The operation lasted 2 hours and 52 minutes, and final pathology revealed a T2N0MX adenocarcinoma arising in a 5 cm tubulovillous adenoma of the cecum. He had an uneventful postoperative course and was discharged on postoperative day 6. 

While President Reagan’s perioperative period was uncomplicated, it did mark an interesting historical precedent as the first enactment of the 25th Amendment (Section 3). 

As demonstrated by these six cases, operations performed on US presidents are complicated, and the surgical care of presidents is undeniably influenced by political situations. The president often embodies the “health of the nation,” and the surgical care is high profile yet sometimes mired in secrecy and scrutiny.

Acknowledgment

The authors would like to acknowledge Theodore N. Pappas, MD, FACS, for his superb contributions to the field of surgical history, several of which are cited in this article.  

Dr. Brendan Lovasik is a clinical fellow in transplant surgery at Washington University in St. Louis, Missouri. 

References

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