The Late President McKinley

     No Sovereign, no President, no man in any country outside the British Empire was so highly respected and so much beloved by the citizens of Canada as the late William McKinley—“without reproach in life or fear in death, Christian knight, twenty-fifth President of the United States” (Jour. A. M. A.). While we all deeply sympathize with the citizens of the United States in the appalling calamity which has befallen them, our chief aim as medical journalists is to consider the illness and death of Mr. McKinley in their surgical aspects. We have purposely abstained from giving minute particulars or making any comments until full information was at hand. There is now such an abundance of literary material at our disposal that we are only able to give a brief synopsis of the most important articles on the subject which has been published.
     We publish in this issue a detailed account of the case, as nearly complete as possible, with the limited amount of space at our disposal. First, we give an abstract of the very interesting narrative by Dr. Nelson W. Wilson, the sanitary officer of the Pan-American Exposition, published in the October issue of the Buffalo Medical Journal, edited by Dr. Wm. Warren Potter. The other portions of our report are taken chiefly from the bulletins issued daily, and from the official report of the physicians and surgeons as given to the medical press, including the remarks on the operation. We omit many details as to treatment, urinalyses, blood examinations, and other matters.
     Of course, many criticisms came from all parts of the world. Most of the unfriendly and even unjust criticisms appeared in the medical and lay press of New York City. The most unfriendly medical criticism appeared in the Record. The first question that arises is: Was early operation advisable? The results of non-intervention in cases of perforating wounds of the abdominal cavity during the wars, from the time of the American civil war to that of the Spanish-American and the Anglo-Boer wars, have been so satisfactory that masterly [633][634] inactivity on the battlefield is approved of by such authorities as Senn, Nancrede and Parker, of the United States, and MacCormack, Treves and others, in Great Britain. It has been pointed out, however, by the surgeons whom we have named, and others, that rules which apply to military surgery are not the best in civil practice. One of the chief reasons for this statement is the fact that the modern rifle ball is small, conical, travels with great velocity, and cuts like a knife, with little or no bruising. The ordinary pistol ball, on the other hand, is usually larger, rounder, travels with less velocity, makes a larger and more ragged opening, with much more bruising. We are glad to be able to say that there is a general consensus of opinion that immediate operation in this case was the right procedure.
     Was the operation properly performed? All will probably agree that the operator showed great skill and good judgment, so far as he went. Should he have gone further, and learned more about the direction and condition of the bullet-track and surrounding structures? It was deemed advisable, chiefly on account of the President’s condition, not to spend any further time in making such an investigation. We firmly believe that the operator exhibited that virtue not always possessed by surgeons—he knew when to stop. All the evidence goes to show that further search would have done no good, and might have caused death on the operating table.
     Was the patient properly treated after the operation? The only adverse criticism in this connection was the statement that a mistake was made in the administration of solid food on the morning of the seventh day. According to the bulletin, he had “chicken broth, a very small piece of toast, and a small cup of coffee. He did not care for the toast, and ate scarcely any of it.” We know now that the little bit of toast was not the cause of the serious symptoms which appeared on the afternoon of that day. The physicians apparently thought it did not agree with him, as they decided to give him no more solid food for some time. As this is rather a small matter we think we can dismiss it, and state without reservation that the after treatment of the patient was good.
     Were the surgeons and physicians justified in taking such a favorable view of the case on the 5th, 6th, and 7th days? The [634][635] grave charge made against them is, that they showed too much optimism. If they erred in this respect, as in a certain sense they did, we think the error was on the right side. An atmosphere of optimism in a sick chamber is better than one of pessimism. Optimism, however, is distinctly wrong when it leads to carelessness or negligence, and worse still when, connected with it, there is a concealment of facts. In this case there was neither carelessness, negligence nor concealment. The surgeons were as frank and truthful as possible. Let us consider some of the facts. At 3.30 p.m., the day after the operation, we find the following: “The President continues to rest quietly; no change for the worse. Pulse, 140; temperature, 102.2°; respiration, 24.” On the fifth day we find: 9 a.m., “The President’s condition this morning is eminently satisfactory to his physicians. If no complications arise a rapid convalescence may be expected. Pulse, 104; temperature, 99.8°; respiration, 26. In the afternoon some stitches were removed, and at the same time some foreign material carried in by the bullet.” Full particulars were given in the bulletin. We find on the sixth day: 9 a.m., “The President rested comfortably during the night. Decided benefit has followed the dressing of the wound last night. His stomach tolerates the beef juice well and it is taken with great satisfaction. His condition this morning is excellent. Pulse, 116; temperature, 100.2°.”
     On the morning of the seventh day we are told: “The President seemed at his best. The time for peritonitis and sepsis had passed. The bowels had moved, and gas passed freely. The tongue was clear, and the appetite increasing; and he seemed to be able to digest food. There was no pain nor tenderness in the abdomen, and he was able to turn easily and to sleep on his side. The urine was steadily increasing. His spirits were good and his mind clear, while his pulse, though frequent, was strong and of good quality, and the temperature low.”
     We think these records showed so many good features in the way of improvement that the physicians had good reason to hope for recovery, although the patient could hardly be said to be out of danger. Drs. Mann and Park, who incurred the chief responsibility, state positively that at no time were they free from anxiety. [635][636]
     The British Medical Journal (friendly in all its criticisms) says: “In abdominal cases the character of the pulse and its frequency are, it is no exaggeration to say, of greater consequence and import than all other signs.” That statement is correct, although we are not quite so certain that another statement—“The pulse-rate was never even moderately satisfactory”—is exactly right. When, after an abdominal section, the rate of the pulse steadily increases from day to day for five or six days, we can generally say, without much, if any, consideration of other signs, that the patient will die. This is especially true when it also becomes weaker. But when a pulse drops from 140 to 104 in five days, and at the same time becomes stronger in character, we think it may be considered, at least, moderately satisfactory. When, at the same time, with this marked improvement in the pulse, there is a decided improvement in almost every other direction (as ordinary signs go after abdominal sections), we think there are fair grounds for a favorable prognosis. It should be remembered that the President’s pulse was naturally fast, or at least, had been so for years.
     While we express such an opinion, we must, at the same time agree with the London Lancet, when it says: “In no part of the body are sinister surprises more likely to be met with than in the abdomen. Patients who have progressed, and are progressing, most favorably cannot be considered to be out of danger until they have ceased to be patients. Great as is our knowledge to-day of the injuries of the abdomen, many as are the resources of the surgeon, skilful [sic] as may be his operations, yet there are elements in any case of abdominal injury which may render in vain all his knowledge, his resources, and his skill.”
     Many stories were circulated as to mutual recriminations between the surgeons after the President’s death. We are happy to say that all such statements were absolutely without foundation. Mynter, who arrived first, gave way to Mann, who operated. Park, who, as director-general of medical matters at the Exposition, should have performed the operation, was twenty-five miles away, and only arrived when the operation was nearly finished. Yet Mynter and Park worked cheerfully and faithfully with Mann and the other surgeons and physicians in their untiring efforts to save the [636][637] life of their patient. The coterie of devoted men who attended President McKinley were as fine a body of scientific and practical surgeons and physicians as could be gathered together in any part of the world. Bitter is our disappointment at their failure; but great is our respect for their bravery, their skill, and their care in the treatment of their distinguished patient. They have earned the gratitude, not only of a great nation, but also of the whole civilized world.