“Is it cancer?” For doctor and patient alike, the question begs a moment of truth that, emotionally, neither wants to face. This may have been how “spin doctoring” actually got its start. It happens thousands of times day, but on one day in particular, Oct. 22, 1884, the person asking was the most famous living American of the Civil War era, Ulysses S. Grant, and his physician, Dr. John Hancock Douglas, lied. So began a case that left behind a “death mask,” a preserved section of the tumor that killed the only American president to die of cancer, and the most intimately documented record of any illness, perhaps, of anyone, ever.
Grant already was in pain when his cancer surfaced in the summer of 1884. On the previous Christmas Eve he had slipped on ice in front of his New York City brownstone and severely hurt his leg. He needed crutches for months, and limped until his last days. But even more troubling was his swindling at the hands of a business partner, Ferdinand Ward, who absconded with $150,000 Grant had borrowed from William H. Vanderbilt to temporarily prop up the Marine Bank of Brooklyn, N.Y. Grant was bankrupted on March 6, 1884. Ironically, it was these sorrowful circumstances that created the time and the necessity for him to write his renowned memoirs, which ultimately restored his family’s inheritance. His longtime aide-de-camp, Adam Badeau, always thought that the business humiliation caused Grant’s cancer, harking to the ancient humoral supposition that all malignancies were rooted in melancholy, i.e., too much black bile.
As they had done since the first year of his presidency, the Grants vacationed at their summer cottage in the oceanside resort of Long Branch, N.J., when “the fatal malady first made its appearance in General Grant’s throat,” Julia Dent Grant, the general’s wife, recalled in her memoirs. Biting into a peach, Grant thought something had stung his throat. Possibly, the tumor pushed through the hypoepiglottic ligament at that moment. Water hurt like fire, and the pain persisted. Dr. Jacob Mendez Da Costa, who was visiting next door, made enough of an examination to urge that the general immediately see Dr. Fordyce Barker, Da Costa’s own physician in New York. But Grant, characteristically unflappable, waited four months before taking the advice, and by then, Barker was preparing to leave for Europe. On referral, Barker’s associate, John Douglas, took the case, renewing an acquaintance with the general that went back to 1862 at Fort Donelson—one of Grant’s and the Union’s first notable victories. Douglas even noted the hour: 11 a.m., Oct. 22, 1884. “On examination,” Douglas later wrote, “I found the velum [the soft palate] inflamed, of a dark, deep congestive hue, a scaly squamous inflammation strongly suggestive of serious epithelial trouble.” Leukoplastic tissue might have indicated infection, but the redness meant something worse. The tongue had swelled and hardened on the right side.
“When I had closed my preliminary examination,” Douglas later wrote, “the effect it had produced upon me was undoubtedly depicted upon my face, for the first and only question he asked me was, ‘Is it cancer?’ Fumbling to hide the grim reality, Douglas said, “The disease is serious, epithelial in character, and sometimes capable of being cured.” Later, he admitted, “I avoided the use of the word ‘cancer.’”
For the next nine months, Douglas saw Grant almost every day, sometimes twice a day, and near the end, 24 hours a day. The general’s throat became so sore that eating was almost impossible. In November, several teeth were extracted, partly to aid viewing the tumor through clinched jaws, and possibly, Douglas hoped, to remove an irritation that he suspected had provoked the disease. As aide-de-camp Badeau noted: “I shall always recall his figure as he sat at the head of the table, his head bowed over his plate, his mouth set grimly, his features clinched in the endeavor to conceal the expression of pain, especially from Mrs. Grant, who sat at the other end. He no longer carved or helped the family, and at last was often obliged to leave before the meal was over, pacing the hall or the adjoining library in his agony.”
Douglas must have considered a surgical option, as he called in the leading authority on such an operation, Dr. George F. Shrady, who had authored “Ligation of the Lingual Artery near Its Origin, as a Preliminary Procedure in the Extirpation of Cancer in Diseases of the Tongue” in 1878. Shrady also served as secretary of the New York Pathological Society and editor of the Medical Record, which he had founded in 1866. He offered no surgical alternative, but thereafter regular bulletins on the general’s condition appeared first in his journal. Apparently, neither physician thought Grant should be admitted to the New York Cancer Hospital—the first facility of its kind in the United States—which had opened in 1884.
For Grant, suppressing pain was the most medicine could offer at the time. When Barker returned, he and Douglas first prescribed “salacin” (salicin, used since 1829 to treat rheumatoid arthritis, caused painful stomach-lining irritation until Felix Hoffman developed a buffering process that produced aspirin in 1899). It did little; so next, they tried the first localized anesthetic—cocaine—supposing its tongue-numbing effect would help. Grant had a camel hair brush to apply a 4 percent solution as needed. This helped immediately, but gradually the pain crept up and at one horrible moment during an application, the brush tip came off. “Perfectly impassive,” according to Douglas, Grant waited for him to remove the brush with forceps.
Facing a future of disease, pain, and death
Badeau described Grant as sitting “for hours propped up in his chair with his hands clasped, looking at the blank wall before him, silent, contemplating the future; not alarmed, but solemn at the prospect of pain and disease, and only death at the end.” When the agony lessened, Douglas used various anodynes, including Listerine, and dusted the throat with the topical antiseptic iodoform (triiodomethane), but gave laudanum orally or morphine by injection during crises.
Douglas called in consulting physicians and ordered a biopsy on Feb. 18, 1885. Dr. F.C. Riley, one of Barker’s surgical associates, took a pea-sized section and immediately turned it over to the pathologist, Dr. George R. Elliott. After hardening the tissue in alcohol, Elliott made razor cuts for microscope slides. He stained the slices with haematoxylon and eosin, which allowed him to easily see the enlarged nuclei stained blue from the haematoxylon and the shrunken cytoplasm stained pink from the eosin. He cleaned the specimens with oil of clove and mounted them on Canada balsam.
Under a Hartnack microscope with a magnifying power of about 500, Elliott observed that irregularly shaped epithelial cells had formed into concentric globes, indicating rapid growth. He also noted that the blood vessels had decidedly thick walls. These findings were consistent with “a diagnosis of epithelioma of the squamous variety,” which Elliott regretfully concluded was “the nature of the malady afflicting our esteemed Ex President.”
Shrady printed the full pathology report in the Medical Record on March 14, but he must have briefed reporters a week or so after Elliott’s letter came in. The New York Sun ran “General Grant Mortally Ill. His Disease a Cancer from Which He Cannot Recover” on March 1, and the same day, the New York Tribune told the story as “General Grant’s Suffering: Little Hope of Recovery. The Cancer of the Tongue Speedily Becoming Worse.” Both newspapers attributed the disease to smoking, the Sun noting that Grant had taken his last cigar on Nov. 20, while the Tribune mentioned that the doctors had restricted Grant to a half of one cigar after each meal. Three months later, when reporters peering through a window saw Grant smoking, they accused the doctors of malpractice. But by then Shrady thought another cigar, after thousands before, made little difference. (Then as now, medicine accepted the link between smoking and cancer without being able to explain why most smokers don’t get cancer.)
Grant felt better or worse, day by day. Old friend Mark Twain’s visit in March must have brought cheer, but on that occasion he also introduced the Grants to German sculptor Karl Gerhardt (1853-1940), who asked permission to take a plaster impression of the general’s face for a bust. Probably because Mark Twain vouched for Gerhardt, Grant accepted. Later, ownership of the first terra cotta cast—mistakenly thought to be a death mask—became an object of contention between the artist and Grant’s wife. She won, after Twain paid off Gerhardt, and she eventually donated the mask to the Smithsonian Institution.
‘Fighting again as Shiloh’
Nearly everyone expected death would come in early April, including Grant, who wrote to Shrady that “I am ready now to go at any time. I know there is nothing but suffering for me while I do live.” He had profuse salivation and a spasmodic cough, along with a falling pulse, which the physicians unsuccessfully tried to elevate with injections of brandy, but then resorted to five drops of digitalis every five hours, adding atropine at night. The patient also received morphine injections and continued taking his tea of “Pyrosphosphate of Iron, Protoiodine of Mercury, with Codeia . . . Coca and Red Clover.” Grant fell into semiconsciousness, and as the New York World reported, imagined he was “Fighting Again as Shiloh.”
Another crisis came on April 7, when Grant hemorrhaged. Fresh blood “came in great mouthfuls . . .” Then, incredibly, he began feeling better. He subsisted thereafter on a liquid diet of “Bovinine [beef bouillon], milk, and eggs,” and improved so dramatically that some of his friends, especially ex-Sen. Jerome Chaffee, doubted that he had cancer. By the end of April, Grant resumed work on his memoirs, which would ultimately restore his family’s fortune, and made real headway. Volume one went to the press on May 23, and he forged ahead, writing in pencil, on the second. At night, he slept sitting up between two leather chairs, fearing he would choke to death if he lay flat.
Move to Saratoga Springs
Douglas worried about his patient’s difficult breathing and agreed that a move from New York City to a cottage that real estate developer Joseph Drexel had offered on Mt. McGregor, near Saratoga Springs, N.Y., might be beneficial. On June 16 the Grant household, along with Douglas and Shrady, traveled to the house, which had a lovely view of Vermont’s Green Mountains.
There, though he could no longer speak, Grant continued work on his memoirs. He communicated with his physicians by writing notes on a pad he kept in his robe pocket, mentioning constipation, heartburn, spitting up blood, weakness, and weight loss. (These notes—several hundred of them—became keepsakes for the two physicians.) Grant wondered if he would die by hemorrhage or strangulation or exhaustion. Still, he remained stoic. He had once weighed 195 pounds, but by July 5 had fallen off to 130. The next day, he mentioned that “the pain left me entirely so that it was enjoyment to lie awake; but I got the enjoyment from the mere absence of pain.” He never mentioned pain again.
To whatever extent a person can will off death, Grant seemed able to postpone his until he finished the last lines of his memoirs on July 19. He wasn’t satisfied, thinking he had left out too much between the crossing of the James River in June 1864 and Robert E. Lee’s surrender at Appomattox, but at least it was done—and entirely in his own hand. He took his last walk the next day, and he slept once again in a bed, instead of being propped up in the leather chairs.
After 13 months of suffering, Grant died quietly shortly after 8 a.m. on July 23, 1885. Douglas recorded the night of July 22: “As the hours drew on, the symptoms of dissolution grew. The respiration quickened, the pulse became small and very frequent, the limbs finally became cold, the respiration shallower and quicker, the pulse too frequent to be counted . . . He was alert and in no pain.” Grant’s last note, written to Julia a few days before his manuscript was finished and kept in his pocket to the end, told her to look after “our dear children.” Julia was so distraught that she could not even attend the funeral ceremonies in New York City on Aug. 8. Years later, when she wrote her own memoirs, she concluded her life’s story with Grant’s death: “For nearly thirty-seven years, I, his wife, rested and was warmed in the sunlight of his loyal love and great fame, and now, even though his beautiful life has gone out, it is as when some far-off planet disappears from the heavens; the light of his glorious fame still reaches out to me, falls upon me, and warms me.”
A nation draped in black
Grant’s funeral procession, from City Hall in New York City up Broadway to Riverside Park, teemed with 60,000 mourners, including unit upon unit of Union and Confederate veterans. Union Generals William Sherman and Philip Sheridan, and Confederate Generals Joseph Johnston and Simon Buckner were the honorary pallbearers. The New York Times reported, “Broadway moved like a river into which many tributaries were poured . . . There was one living mass choking the thoroughfare from where the dead lay in state to the grim gates at Riverside open to receive him . . . From Fourteenth Street to the top of the hill—pavements, windows, curb, steps, balcony, and housetop teeming . . . All walls and doorways were a sweep of black . . .” Sherman wrote, “Such a funeral never before occurred in America and never will again.” Indeed, no event in American history saw so large a public turnout before, and would not again until the Armistice celebration in 1918.
Grant remained in a temporary tomb in Riverside Park until a grand edifice was completed in 1897 with more than $600,000 in donations from around the world—the largest public fundraising effort anywhere to date. Julia joined him there in 1902. Douglas suffered a stroke in 1888 and died four years later, almost penniless, in Washington, D.C., on Oct. 2, 1892. Shrady continued editing the Medical Record and practicing medicine; he died in 1907 of sepsis following a gallstone attack. His son, sculptor Henry Merwin Shrady, labored for 20 years to complete the gigantic equestrian statue of Grant that sits at the foot of the U.S. Capitol, and died two weeks before its dedication in 1922.
The “artifacts” of Grant’s last days—Karl Gerhardt’s terra cotta “death mask,” now in the Smithsonian’s collections; some 200 notes written by Grant to Douglas, now at the Library of Congress; and the pea-sized tumor biopsy Elliott prepared for the pathology report on Feb. 19, 1885, now at the National Museum of Health and Medicine at Walter Reed Army Medical Center in Washington, D.C.—are but a short distance from the sculpture that shows Grant, not as president, but as the soldier who saved the Republic.
Terry Sharrer is curator of the Division of Science, Medicine, and Society at the Smithsonian Institution’s National Museum of American History. He lives in Hamilton, Va.
How Would Grant Fare Today?
Even today, squamous cell carcinoma at the base of the tongue remains a difficult disease. Frequently patients don’t seek treatment until the cancer is already at an advanced stage, with metastatic spread to the lymph nodes. Only 15 percent of patients today with stage-IV tumors like Ulysses S. Grant’s could be expected to survive for five years. But if Grant were alive today, what might be done differently?
The first question would be: “Was Dr. George R. Elliott’s pathology report on Grant’s tumor accurate?” Indeed, it was. Recently, a group of pathologists at the Armed Forces Institute of Pathology at Walter Reed Army Medical Center in Washington, D.C., reexamined a preserved section of the tumor using a microscope that allowed all five to view the tissue simultaneously. Because malignant squamous cells are relatively easy to identify under a low-magnification microscope such as the one Elliott would have used, the pathologists at Walter Reed concluded that they had nothing significant to add to Elliott’s statement of Feb. 19, 1885.
The Civil War had been a good instructor for surgical techniques, but Grant’s tumor was probably too advanced for resection, then or now. If it had been detected earlier, removing half of the tongue (hemiglossectomy) might have worked, but the blood vessels, nerves, and lymph nodes in the neck area have always tested the surgeon’s skill. Douglas and Shrady very likely would use radiation therapy today, but they might argue over whether external beam irradiation with an iridium implant, or the implant alone, would be the better alternative. Radiation therapy, of course, was unknown in Grant’s lifetime; its first use to treat cancer came in January 1896.
If a president’s doctor today knew Grant’s history with whiskey and cigars, the physician might have a chance of early-stage discovery, when surgery could be curative. But Grant’s cancer can still be as intractable at present as it was 119 years ago—as intractable as former President Ronald Reagan’s Alzheimer’s disease.
But just as new ideas like the concepts of germ theory were emerging in medicine when Grant died in 1885, gene theory today may bring about a significant medical transformation in a not-too-distant future. For some cancers, gene-expression analyses already exist (for use in clinical research) that define the molecular origin and individuality of the disease, suggesting that no two people ever have the same cancer. Indeed, two tumors in one patient are unlikely to be genetically identical. Gene expression analysis, eventually, may accurately stage a tumor, indicate novel and precise targets for chemotherapy, and predict likely outcomes for both treatments and adverse events. When that hope becomes history, the 21st century may well claim one of its greatest achievements.—T.S.