A Review of the Surgical Aspects of the Case of President McKinley

     The report of the Medical Staff in attendance upon the late President McKinley has been given out and, in its scientific aspects at least, is before the profession for discussion. The latter, true to its instincts of justice, has refrained, with a few exceptions, from commenting upon the case until all the facts were placed before it. Where adverse criticisms have been made prior to the issuing of the report, these have not been favorably received by the profession at large, and, it is fair to say, have brought the reverse of credit to those who have uttered them.
     Briefly stated, the case is about as follows: The illustrious patient was the subject of a perforating gunshot wound of the stomach, the missile entering the latter near the greater curvature, and emerging, as nearly as could be made out, at a point about opposite the wound of entrance. Its further course was not determined either at the operation or autopsy.
     The wounding took place within the grounds of the Pan- [704][705] American Exposition at Buffalo, and the emergency hospital set up within the grounds was available for the immediate care of the case. Unfortunately the arrangement and equipment of this hospital was such as to adapt it to minor surgical emergencies only. The operating room was located upon the ground floor, with no overhead light, and the only available source of natural light was from windows upon one side, and that the west side of the building. The difficulties arising from insufficient light were further enhanced by the time of day at which the shooting took place, as the sun was low in the horizon, and the light failed almost completely before the operation was completed. The absence of a reception ward evidently necessitated placing the patient at once upon the operating table in the operating room, and there undressing him; else it is difficult to understand this somewhat unusual course of procedure. The difficulties of the operation were still further increased by the want of such important instruments as retractors. Even the small curved needle which was employed for suturing the opening in the posterior wall of the stomach was supplied from the pocket case of one of the surgeons present at the operation. Nor could the operator in the case be held responsible for the lack of suitable instruments, inasmuch as he was summoned to the exposition grounds without the slightest hint as to the reason for the call, the first intimation of which was given him as he entered the hospital, by another surgeon, who said to him, “The President has been shot and we are waiting for you.”
     The subsequent steps in the case are all set forth in the detailed report. In the light of the surgery of to-day it is difficult to conceive how any other course could have been pursued than that of immediate operation, particularly in view of the location of the wound, the probability that the stomach was involved, the fact that in all probability the latter contained food, and finally the fact that the patient did not fall, but remained standing or sitting for a sufficient time to favor leakage of the stomach contents; all of which considerations presented the positive indications for opening the abdomen at the earliest possible moment and repairing the damage done to the contained viscera.
     The preliminary injection of morphine and strychnine had much to do with the promptness with which the patient passed under the influence of the anesthetic, as well as the fact that the operation was well borne. This, as well as other important pre- [705][706] liminaries to the contemplated operation, was attended to pending the arrival of the surgeon, who, in the absence from the city of the Surgeon-in-Chief of the Exposition, had been selected as the operator in the case. All of which goes to show that the necessity for prompt operative interference was not lost sight of for a single moment, and that even the short consultation spoken of in the report was more a matter of form and courtesy than of actual need, since there could scarcely be two opinions on this point. Indeed, one has yet to hear, from the medical profession the world over, a single word of adverse criticism upon this point from any whose opinion is entitled to respect.
     The choice of an anesthetic was a consideration that required some thought, since in operations of this character many surgeons would have chosen chloroform rather than ether as being the most convenient and less likely to be followed by vomiting. The element of safety was certainly on the side of the latter, and the event proved that the choice was a wise one. The ether was well borne, and anesthetization was complete in nine minutes, facts which speak for a skilful [sic] anesthetist.
     The usual rule of including the bullet wound in the incision was followed and with the result of finding a piece of cloth along the track of the bullet, and of coming at once upon the opening in the anterior stomach wall. Equally good judgment was displayed in enlarging the opening sufficiently to permit of digital exploration of the interior of the stomach, since only through this maneuver could the presence or absence of the missile in the stomach itself, or of food, be determined.
     The choice of silk as suture material is mentioned only to be commended, and the usual method of a double row of practically continued sutures is looked upon by surgeons of to-day as ensuring a water-tight jointure of the serous surfaces with far greater certainty than the interrupted sutures of a decade ago, and still employed by many surgeons.
     The absence of the missile in the stomach made it absolutely necessary to reach its posterior wall. In order to accomplish this in the most expeditious manner possible the omentum and transverse colon were drawn out of the abdominal wound and the gastro-colic omentum divided between two ligatures to the extent of about four inches. This very practical and rapidly executed expedient enabled the operator to bring the stomach into the operation wound, and gave ready access to the bullet wound in [706][707] its posterior wall, which was closed in the same manner as the anterior wound.
     The use of a simple saline solution to flush the parts as they appeared in the field of operation was a precautionary measure, since the examination of the interior of the stomach disclosed the presence of considerable liquid, more or less of which must have escaped during the manipulation.
     Taking all things into consideration the decision arrived at by the surgeons present, after satisfying themselves that the transverse colon had not been wounded, not to attempt to follow the bullet into the tissues behind the stomach, was a wise one. Most especially is the course followed to be commended when the age of the patient, and the fact that he was already suffering considerably from shock, are taken into account. Further, the evisceration essential to such a procedure must of necessity not only have increased the already existing shock, but have heightened the probability of infection.
     There seems to have been some difference of opinion as to the necessity for drainage. One of the surgeons present was in favor of a gauze or wicking drain leading from the site of the wound in the posterior wall of the stomach. The operator, however, with the concurrence of the other surgeons, “decided against this, as being unnecessary.”
     Without question the decision arrived at was warranted by the intra-abdominal conditions as they existed at the close of the operation. So far as could be ascertained there had been no escape of stomach contents prior to opening the abdomen, and what little soiling had occurred during the manipulation had been promptly corrected by hot saline solution. The openings in the stomach had been closed in the most approved manner, there was no probability of the occurrence of hemorrhage requiring the presence of a tell-tale drain, the location of the wound of the stomach almost precluded injury to any other portion of the alimentary canal, and the utmost aseptic care had been exercised throughout. So far as the injury to the viscera was concerned, therefore, there could be no question as to the wisdom of omitting that which was unnecessary, and which might possibly prove harmful.
     The only point which can possibly arise in connection with the question of drainage will turn upon its probable influence, had it been employed, upon the changes which took place in the tissues along the course of the bullet subsequent to its escape [707][708] from the stomach. In the light of the autopsical findings the suggestion forces itself upon one that the evil effects of the necrosis which occurred in the bullet track might have possibly been lessened by drainage, but whether drainage in an anterior direction would have served any good purpose is far from certain. He would be a bold critic who, in view of the favorable course pursued, would have made the assertion during the first week of the case that drainage should have been instituted, and even at the present time the inquiry as to where the drainage should have been made would be pertinent to such criticism.
     The further steps of the operation call for but very little comment. The removal of tissue likely to become necrotic in the track of the bullet was followed by closure of the operation wound by silkwormgut sutures.
     As to the cause or causes of death, there must necessarily be differences of opinion. In summing up the pathological findings upon autopsy it is stated, in addition to the gunshot wound of both walls of the stomach disclosed by the operation, that the superior aspect of the left kidney had been injured by the bullet. The other changes found consisted in “extensive necrosis of the pancreas; necrosis of the gastric wall in the neighborhood of both wounds; fatty degeneration, infiltration and brown atrophy of the heart muscle; slight cloudy swelling of the epithelium of the kidneys.”
     The extensive necrosis of the pancreas which, in all probability was an important factor in the cause of death, must have been due either to direct injury or occurred as an after-effect from infection. The necrosis of the gastric wall at the site of the bullet wounds is not so easily explained from the surgical standpoint. One thing at least seems certain: it was not due to any error of operative technique. Even the ligature and division of the gastro-colic omentum, which was made in order to gain access to the posterior wall of the stomach, cannot be held responsible for this complication, as has been suggested, for the reason that the blood supply to the stomach itself is complete and perfect without reference to the vessels of the gastro-colic part of the great omentum, the blood supply of which, the vasa epiploica, is derived chiefly from the arteria gastro-epiploica sinistra. In other words, the stomach does not depend to the slightest extent upon the vessels of the gastro-colic omentum for its blood supply, but rather the reverse, the blood supply of the omentum being derived from the vessels which supply the stom- [708][709] ach. That there was an almost complete absence of repair at the site of the sutures was evident; that this was entirely independent of the technique employed was equally apparent.
     Pending the completion of the report of the bacteriologist in the case it would be manifestly improper to state a definite opinion as to the causes of the necrosis of the retroperitoneal structures. That the normal structures in the neighborhood of a pancreas the seat of extensive necrosis present similar although less advanced conditions those who have had experience in such cases will not hesitate to aver. How much this may have been favored by the traumatism to which the tissues were subjected by the passage of the bullet, or to what extent infection carried to these tissues may have lent its aid in bringing about the final result are questions which, for the present, at least, must remain sub judice.