Keywords
Cermak - assassination - colitis
On February 15, 1933, Franklin Delano Roosevelt was in Miami returning from a fishing
trip in the Bahamas. As he passed through Miami, Roosevelt planned to give a short
speech and meet, informally, with Chicago Mayor Anton Cermak. Roosevelt stopped at
the Biscayne Bay Park after 9 pm and gave his 1-minute speech while sitting in his
car. After the speech, Cermak approached Roosevelt's car and sat with the president-elect
discussing the financial future of Chicago. As Cermak was leaving Roosevelt's car,
several shots were fired by a lone gunman attempting to assassinate Roosevelt. Roosevelt
was uninjured, but Cermak and four other bystanders were stuck by errant bullets.[1] Cermak was taken to Jackson Memorial Hospital where he died 19 days later.[2] This study will review Cermak's health prior to the shooting and also the care he
received during his stay at Jackson Memorial.
Background
Anton Cermak was a Czech immigrant that rose to power in Chicago politics in the environment
of the major financial depression of the early 1930s. ([Fig. 1]) He was born in 1873, came to the United States with his parents when he was 1 year
old, and moved to Chicago at the age of 16 years. He began his political career as
a member of the Democratic Party in 1902 when he was elected to the Illinois House
of Representatives. He defeated a Republican incumbent and became the mayor of Chicago
in 1931[3] ([Fig. 2]).
Fig. 1 Anton Cermak (1933).
Fig. 2 Cermak sworn into office as the mayor of Chicago (April 7, 1931).
Cermak's History of Intestinal Disease
Cermak's History of Intestinal Disease
Cermak's political career was challenged by frequent severe intestinal symptoms, which
were called colitis. The first public report concerning Cermak's health was in 1918,
when newspapers reported that he was ill with “a severe cold.”[4] The press attributed his illness to “overwork.” On August 18, 1925, Cermak became
sick while fishing near Hayward, WI. He was admitted to a local hospital due to “severe
cold with intestinal trouble.”[5] He was transferred to St. Anthony's Hospital in Chicago the following day, where
his temperature was 104F. He was diagnosed with “influenzal infection of the intestine”
and cared for by Dr. Frank J Jirka, Cermak's son-in-law, and Karl Meyer, MD, a noted
Chicago surgeon.[6] Two days later, his condition worsened as he continued to spike temperatures, but
his symptoms eventually resolved and he was discharged without complication.[7]
[8]
Cermak was diagnosed again with “intestinal inflammation” in February of 1929 and
spent time recovering in Miami Beach Florida.[9] By the middle of April, he had not improved and traveled to Baltimore, MD, to be
admitted to the Johns Hopkins Hospital.[10]
Cermak did well for nearly a year but was sick again in the spring of 1930 and 1931
when he returned to Miami each time for rest and recuperation.[11]
[12] After being elected the mayor in April of 1931,[13] Cermak's illness returned and his son-in-law, Dr. Jirka, encouraged him to take
a significant break from his work to avoid a “serious breakdown.”[14]
Cermak's recovery was again short-lived because he was back in Florida on January
11, 1932, this time resting at a relative's home at Miami Beach.[15] He was suffering from a “severe cold and intestinal inflammation” and “confined
to bed.”[16]
[17]
Cermak was admitted again to St Anthony's Hospital in Chicago on July 6, 1932, with
severe fatigue. He was described by Dr. Jirka as “rundown” and was discharged 10 days
later, and he recovered from his “attack of indigestion.”[18]
[19]
[20]
Meeting Roosevelt in Miami
Meeting Roosevelt in Miami
When Cermak became the mayor, Chicago was in significant financial distress and in
need of federal support. Cermak planned to meet with Roosevelt to discuss federal
programs that might support Chicago's needs.[21] In February of 1933, Cermak agreed to meet James Farley (chair of the Democrat National
Party), in Miami, to discuss Roosevelt's support of Cermak's efforts in Chicago. The
mayor also planned to meet Roosevelt in Miami to confirm Farley's promises.[20] Roosevelt was returning from a Caribbean fishing trip in early February and was
passing through Miami for a brief stop as he traveled back to New York.[22]
[23] Roosevelt arrived in Miami on the evening of February 15 and was to be driven by
his security team to Biscayne Bay Park where he would make a brief speech and then
proceed by train to New York. Given the limited time that Roosevelt was to be in Miami,
it was suggested that Cermak meet Roosevelt just after the short speech ([Fig. 3]).
Fig. 3 Franklin Delano Roosevelt, Presidential portrait (1933).
Roosevelt arrived at the park after 9 pm and his car stopped in front of the large
crowd that had been waiting for the president-elect to deliver his speech. Roosevelt
sat on the top of the back seat of his convertible to give his 1-minute speech around
9:40 p.m. After the speech, Cermak, who was sitting with other dignitaries just steps away
from the convertible, moved to the running board to shake hands and speak with the
president-elect. After speaking with Roosevelt, as Cermak moved away from the convertible,
Giuseppe Zangara fired five shots in an attempt to assassinate Roosevelt.[24]
Assassin
Giuseppe Zangara, an often unemployed bricklayer, was born in Italy, came to the United
States in 1923, and became a naturalized citizen in 1929. He was sitting in the fifth
or six throw of seats, 20 feet from Roosevelt when he fired his revolver.[25] Lillian Cross and Tom Armour were private citizens sitting next to Zangara, who
disrupted his aim and were given credit for saving the future president's life.[26] Five individuals were hit by bullets including Mayor Cermak, but Roosevelt was not
injured. Zangara ([Fig. 4]) was immediately apprehended and later told police that he wanted to kill kings,
presidents, and all capitalists.[27] Cermak fell after being stuck in the right flank by a single bullet. He was able
to stand with assistance and helped into Roosevelt's car, which quickly drove 20 city
blocks to Jackson Memorial Hospital.
Fig. 4 Giuseppe Zangara, mugshot Florida Department of Corrections.
Jackson Memorial Hospital
Jackson Memorial Hospital
When Cermak got to the hospital, he was noted to have an entrance wound on the right
chest, just below the tip of the scapula. The physicians stated that the bullet had
traversed the right lung, the right diaphragm, and the liver. The trajectory of the
bullet was posterior and downward, and it was detected by X-ray in the 11th thoracic
vertebra. By 2 a.m., the physicians taking care of Cermak issued a statement that
the mayor had an expected 50% mortality but they were not recommending immediate surgery.
He was afebrile with a heart rate of 88 beats per minute and was breathing comfortably
at 24 breaths per minute.[28]
At approximately 20 hours after the shooting, Cermak was described by his physicians
as “very satisfactory.” Again his vital signs were stable (pulse of 88 beats per minute,
respiratory rate of 22 breaths per minute, temperature of 99°F), and his pain from
the bullet injury was diminishing. Plans for an operation were again delayed since
the mayor was stable and the bullet location was not causing harm.[29] They thought the kidney was spared and again suggested that the diaphragm and the
liver had been traversed.[30]
Two physicians, well known to Cermak, joined the team of doctors who were taking care
of the mayor. The first was Dr. Frank J. Jirka, who had recently been appointed the
Director of the Illinois Department of Public Health. The second was Dr. Karl Meyer,
the head of the Cook County Hospital and a surgeon with extensive experience with
abdominal operations.[30]
[31]
[32]
At 10:30 p.m. on February 16, the mayor had stable vital signs (pulse rate of 96 beats
per minute, temperature of 99.6°F, and respiratory rate of 20 breaths per minute)
despite the fact that he had developed heart block on his EKG (electrocardiogram).
The physician team worried about “weakening of the heart” and the possibility that
the mayor might develop pneumonia.[33] His condition improved on February 17, when vital signs were stable, and he was
able to speak to his family. The surgeons confirmed that the bullet went through the
tip of the right lung in its path from lateral to medial, but they were convinced
that Cermak would recover barring complications such as pleural effusion or empyema.[34]
[35]
By February 18, the mayor had improved sufficiently to sit up in bed and talk to reporters
for the first time since the shooting. His doctors including, his son-in-law, continue
to be cautious, stressing that complications could still cause a setback. By all accounts,
Cermak appeared to be starting to emerge from danger.[36] February 19 and 20 were similar days, marked only by a low-grade fever of 100F each
day.[37]
[38]
Cermak Develops Colitis
Cermak's condition started to deteriorate on February 21. In the evening, he developed
a fever of 101F, rigors, and abdominal pain associated with a heart rate of 108 beats
per minute and respiratory rate of 30 breaths per minute. The physicians stated that
the cause of decline was “colitis.”[39] By the following day, the abdominal pain from the colitis was somewhat improved,
but his loose stools continued. His heart rate was 130 beats per minute, and he was
described as exhausted.[40]
During the night of February 22 and the following morning, Cermak became hemodynamically
unstable, with hypotension and decreased urine output, and was presumed to be in “shock.”
His blood pressure was sufficiently low and therefore his heart rate could not be
measured for three minutes. He was given intravenous dextrose (1,500 mL of a 10% glucose
solution) and caffeine as a “stimulant” to raise his blood pressure. During this crisis,
the doctors briefly thought Cermak had died. He responded to this resuscitation, and
by the afternoon of February 23, his vital signs and renal function had stabilized
and improved.[41] The physicians continued to worry about his respiratory function and planned to
use an oxygen tent if his respiratory rate increased further.[42]
February 24 was a stable day, but on February 25, the mayor had worsening cardiopulmonary
function.[43] The physicians no longer predicted survival but simply said Cermak would “live through
the night.” He was placed in an oxygen tent and received his first blood transfusion
along with his daily glucose infusion. His gastrointestinal symptoms persisted, and
the physicians continued to call this condition colitis. Blood donors were sought
since daily transfusions were anticipated.[44]
On February 26, the mayor was diagnosed with an infection in his right lung, which
was confirmed by X-ray in the setting of decreased breath sounds on auscultation.
According to his physicians, it was unclear if this represented a posttraumatic abscess
or pneumonia.[45] Cermak was stable on February 27, his breathing slightly less labored, and he was
temporarily removed from his oxygen tent.[46] His downhill course continued on February 28 when his infiltrate on chest X-ray
doubled in size. When the mayor's respiratory rate reached 40 breaths per minute and
he was gasping for air, he was placed back in the oxygen tent.[47] Despite some encouraging words from his physicians, there was clear evidence that
Cermak deteriorated on March 1 and 2. He was moved from the oxygen tent to an oxygen
room to guarantee his high-flow oxygen.[48] The colitis was still present, his respiratory rate continued at 30 breaths per
minute, and hiccups started on March 2.[49]
On March 3, Cermak's abdominal pain and distension worsened and was accompanied by
persistent shortness of breath and right shoulder pain. The physicians were concerned
about empyema or right subphrenic abscess. He was taken to the operating room on March
4 for a needle aspiration of a right chest plural effusion. The aspirate was smelling
foul; therefore, a chest tube was placed, which drained bloody serous fluid described
as a “gangrenous process” in the right lung.[50]
[51] On the same day in Washington, DC, Roosevelt was inaugurated at the 32nd President
of the United States[52] ([Fig. 5]).
Fig. 5 Franklin Delano Roosevelt and Herbert Hoover riding to Roosevelt's first inaugural
address (March 4, 1933).
Cermak spent the March 5 getting transfusions and intravenous fluids for worsening
heart rate and low blood pressure, but by 12:05 a.m. on March 6, he was in a coma.[53] Attempts at resuscitation included neoarsphenamine (an arsenic preparation used
to fight gangrene).[54] The mayor died at 6:57 a.m. on the morning of March 6.[55]
Aftermath
Zangara was originally indicted for attempted murder, but the charge was changed to
murder following the death of Cermak. After a speedy trial, where Zangara admitted
that he was trying to kill Roosevelt, he was convicted and sentenced to death. Zangara
was executed by electric chair in the Florida State prison, Raiford, FL, on March
20, 1933.[56]
The other four individuals injured on February 15 recovered from their wounds. Mabel
Gill was shot in the abdomen, required a laparotomy for her wounds, and was discharged
from the hospital on March 23, 1933, after a complicated course.[57] William Sinnott, a former New York police officer, and 22-year-old Russell Caldwell
both recovered from bullet injuries to the head. Margaret Kruis, a 23-year- old dancer,
had a minor injury to her hand.[58]
[59]
Autopsy
The Cermak autopsy was attended by nine doctors. The conclusion by the doctors was
that the gunshot wound initiated a downhill course that triggered severe colitis.
They stated that the bullet had injured the lung and diaphragm, which caused hemorrhage
and cardiac failure. The colitis was triggered by the systemic stress of the bullet
injury. The colitis progressed to ulcerative and then toxic colitis, resulting in
right colon perforation and gangrene above and below the right diaphragm.[60]
The summary of the autopsy was presented at the trial of Zangara. The physicians made
it clear that the gunshot wound was the cause of death because it initiated a cascade
of events culminating in colitis, colon perforation, and peritonitis. There was concern
that the assassin would attempt to say that the bullet injury was nonlethal and the
doctor's mismanagement caused the eventual death. This was the attempted defense that
Charles J. Guiteau used when he was tried for the assassination of President Garfield.[61] Despite the apparent consensus among the physicians, as shown by their signatures
on the autopsy report, there was disagreement as to the importance of the colitis
in the mayor's course. Several newspaper reports appeared in the month following Cermak's
death, which shed a different light on the cause and effect of the gunshot wound.
On March 30, Dr. Meyer stated that the mayor would certainly have healed his chest
wound had he not developed colitis.[62] This opinion was corroborated on April 1 by Dr. Frederick Tice, a physician attending
the autopsy, when he stated that “The bullet wound was not directly responsible” for
Cermak's death.[63] Both physicians claimed that the mayor was “rundown” in an overall weakened state,
which contributed to his difficulty in fighting these complications. The state's attorney,
N. Vernon Hawthorne, who tried the case that led to the execution of Zangara, took
issue with these opinions. He sent a public letter to Dr. Meyer, attached a copy of
the autopsy, and reminded the surgeon that the stated cause of death was the bullet
wound.[64] Meyer attempted to backtrack his comments under pressure from the state's attorney,
but he still maintained that the final cause of death was from complications of the
colitis.[65]
Analysis of Cermak's Care
Analysis of Cermak's Care
Cermak was shot with one bullet that entered his back just below his right scapula
and lodged in the body of T11 vertebra. There is evidence that it traversed the right
pleural cavity, the right lung, and the right diaphragm before it lodged in the spine.
Although the autopsy and news reports state that the lung was punctured, traversed,
and collapsed, there is no mention of a right-sided chest tube early in the management.
Given that chest tubes were commonplace in the 1930s, it is very likely that his pneumothorax
was small and stable and therefore not treated with a tube.[66] He had a chest tube place just before his death for an empyema.
Cermak stabilized quickly after the shooting and steadily improved over these first
5 days. The clinical course is consistent with the described injury. A gunshot wound
to the right chest, right diaphragm, and dome of the liver would not require intervention
if the pneumothorax was small and the bleeding minimal. After 5 days of improvement,
the mayor developed gastrointestinal symptoms consistent with his history of colitis.
The mayor had fever, abdominal pain, rigors, and diarrhea, and the autopsy described
ulcerative and gangrenous colitis. Given the mayor's long history of colitis, it is
likely that he developed an exacerbation of existing ulcerative colitis as he recovered
from the gunshot wound.
The gastrointestinal symptoms worsened during his hospital course, similar to toxic
colitis. Late in his hospital course, the mayor developed hiccups and right shoulder
pain likely as he perforated his right colon and formed a subphrenic abscess. If his
bullet wound injured the right diaphragm, a subphrenic abscess could easily necessitate
into the right chest, resulting in the need for drainage of the foul-smelling pleural
fluid just prior to his death. His autopsy findings align with his clinical course,
suggesting that he developed toxic colitis and perforation of the right colon with
subphrenic abscess. Two of the physicians attending the autopsy explicitly state that
the colitis, colon perforation, and peritonitis caused the mayor to die, not the gunshot
wounds.
Management of Ulcerative Colitis in the 1930s
The medical management of ulcerative colitis was largely supportive in the 1930s.
Patients with severe diarrhea were often dehydrated and benefited from intravenous
hydration, as did Cermak. Otherwise, there was no proven medical treatment of ulcerative
colitis at the time of Cermak's illness.[67] The use of sulfonamides was evaluated for patients with ulcerative colitis in 1942,
and corticosteroids were not used to treat ulcerative colitis until 1950.[68]
[69] Once a patient developed toxic colitis, the mortality was extremely high, and emergency
total abdominal colectomy was not considered. Occasionally, surgeons used diverting
ileostomy as urgent treatment in the toxic patient and would follow with colectomy
only if the patient stabilized.[70]
Alternate Hypothesis to Explain Cermak's Course
It has been suggested that the real reason for his colon perforation was a missed
bullet injury to the right colon. In his book titled “The Five Weeks of Giuseppe Zangara,”
author Blaise Picchi asked several Miami surgeons to review Cermak's hospital course
as chronicled by the newspapers of the day. After their review, the surgeons hypothesized
that when the bullet passed through the right diaphragm, it injured the right colon,
leading to subphrenic abscess, peritonitis, and death.[71] Although this explanation is possible, it ignores many of the details of the 19-day
clinical course. This alternate explanation implies that Cermak survived a bullet
wound to the colon without surgery for 19 days in the preantibiotic era. In addition,
it is unlikely that a bullet injury to the colon would present with diarrhea. Picchi's
Miami surgeons also failed to review Cermak's long history of colitis requiring several
hospital admissions prior to the shooting.
Summary
Anton Cermak sustained a gunshot wound to the chest from an assassination attempt
originally meant for the president-elect, Franklin Delano Roosevelt. Cermak was taken
to Jackson Memorial Hospital in Miami where he died 19 days later. He was treated
nonoperatively for a penetrating chest wound. As he was recovering from a nonlethal
gunshot wound, he developed severe ulcerative colitis, a disease he had been hospitalized
for many times in the past. He died of complications of toxic colitis, which included
right colon perforation, right subphrenic abscess, and peritonitis.
