Medical Treatment of President McKinley

     The President was of a nervo bilious temperament and took on fat (fatty infiltration), becoming quite obese. This condition of the body tells of a forceful, if not rapid, heart that sooner or later causes cardiac hypertrophy, dilation and fatty degeneration as well as infiltration. We are told that when nervous he had a very rapid heart.
     Such a body was wounded at short range and he fell, or would have fallen had he not been supported. That tells us that the heart’s action was arrested. He was shot at 4:07 p. m. and the pulse record at 4:45 p. m. was 84. (We quote from the official record). The ball entered the abdomen at the left of the median line about half way between the left nipple and the umbilicus, taking a downward, backward and outward direction. At 4:30 p. m. he was given hypodermically .01 gm of morphine and .002 gm of strychnine. He had no particular pain and soon was under the influence of the opiate. (Why was it given)? At 5:29 the operation began under ether. The incision began at the ribs and was nearly parallel with the median line of the body. The stomach was wounded twice, the ball passing through the great curvature, slightly wounding the kidney and, it is thought, the pancreas. At 5:38 p. m. .002 gm strychnine was again given. At 5:55 the respiration was 32, pulse 84, both of good character. At 6:09 the pulse was 88; at 6:20 it was 102, fair, respiration 39. At 6:22 was administered 1.50 gm of brandy. At 6:48 the pulse was 124, the tension good, but quick; respiration 36. At 6:50 the operation was completed. At 7:01 the pulse was 122 and the respiration 32. At 7:17 there was given .04 of morphine. At 7:32 the patient was removed to the private residence of Mr. Milburn. In suturing the stomach, part of its contents escaped into the abdomen, but was carefully mopped out. We are told that introducing the arm into the cavity had a bad effect upon the pulse. The pulse at this time was 127, temperature 100.6 and respiration 30. At 8:28 he was given .016 gm of morphine. There was slight nausea. During the night he slept at intervals, vomited occasionally, but rallied satisfactorily; occasional slight pain. An enema of salt solution was given and retained; slept free from pain.
     Second day, 6:00 a. m., temperature 102, pulse 110, respiration 24; expelled gas in large amount; saline enema. [396][397] During forenoon .01 gm morphine was given. At 1:15 p. m. saline enema 500 c. c. As the pulse was rising .06 gm fl. ext. digitalis was given hypodermically. At 6:30 p. m. the patient complained of intense pain in the epig[?]stric region, and .08 gm morph. sulph. was given. He was very restless, after sponging rested again. Now pulse 130, temperature 102[.]5, respiration 29. During the day the digitalis, morphine and saline enemas were kept up at regular intervals. (How much and how often record does not tell). At 10:30 comatose [sic] 4 gm was given with enema. At 11:15 p. m. stool, greenish colored fluid, fecal matter.
     Third day, restless, confused, a little chilly. Digitalis was continued. (How much and how often record does not state). At 7:45 strychnine, .002 gm was given. At 8:20 pulse strong and of good character; at 8:30 the record states that the pulse was 132, temperature 102.8, respiration 24. There was some oozing and the bullet track was syringed with peroxide of hydrogen. At 10:40 enema of Epsom salts, glycerine [sic] and water brought away some gas and small stool; at noon another. Pulse 128, temperature 101, respiration 27. At 4:45 he was given a teaspoonful of water and an enema of sweet oil, soap and water. That produced a slightly colored fluid, some fecal matter and mucus[.] After this he had a small quantity of water and at 6:20 a nutritive enema of egg, whiskey and water, which was partly retained. Digitalis and strychnine were both given during the evening. At 9:00 p. m. pulse was 130, temperature 101.6, respiration 30. During the day 420 c. c. of urine was passed. The urinalysis showed [a] specific gravity of 1.026, with strongly acid reaction, with but a mere trace of albumin and no sugar. Indican, however, was abundant. The other constituents were normal. Microscopic examination showed a few small, finely granular casts and many large crystals of uric acid and bacteria.
     Fourth day, Monday, Sept. 9, the bulletins at 6:00 and 9:30 [a]. m., 3:00 and 9:30 p. m. recited that the President’s condition steadily improved throughout the day. His pulse dropped from 120 to 112 and his respiration rose from 26 to 28, temperature remaining practically constant at 101, varying but .2 of a degree. Codeine was substituted for morphine, and the digitalis and strychnine were stopped. Nutritive enemas were given at 3:20 a. m. and 4:30 and 10:00 p. m. Following a small dose of calomel and a high enema of oxgall he had a large, partly formed stool. The third urinalysis showed a decrease in indican and uric acid crystals and no other important changes.
     Fifth day, Tuesday, Sept. 10. The President passed the most restful night since he was shot. On awakening his mind was clear and he was cheerful. The nutritive enemas were kept up and water was given by the mouth. The only medicine was one dose of cod. phos. .015 gm. In the evening the dressings of the wound were examined and it was thought best to remove four stitches and separate the edges of the wound. There was a little slough near the bullet track an inch wide. The separation extended down to the muscle. Otherwise the surfaces were healthy but not granulating. The parts were packed with iodofom [sic] gauze and closed with adhesive straps.
     Sixth day, Wednesday, Sept. 11. The President rested well and took beef juice with great satisfaction. His temperature stood at 100.2 all day, pulse was regular at 116, but rose to 120 at night. The blood count was, leucocytes [sic] 9752; red cells 3,920,000. At 10:00 a. m. the wound was redressed and [397][398] seemed to be doing well. The patient slept much during the day and seemed comfortable. The rectum would not contain the enemas. The fourth urinalysis showed a larger quantity (750 c. c.), an increase in albumin, indican and cylindroid cells, but no other change.
     Seventh day. The President now seemed at his best and his condition appeared to justify the most favorable prognosis. The beef juice was continued with the addition of a little chicken broth. He also had some whiskey and water. At 8:30 a. m. he was given chicken broth, a very small piece of toast; and a small cup of coffee. He ate but a little of the toast. The only unfavorable symptom was the rapid pulse, but it was known that it was naturally high and easily excited. [Nervous tobacco heart]. At noon the pulse weakened and an infusion of digitalis, 8 c. c, and strychnine, .002 gm, was given. In spite of this the pulse went to 130 and grew weaker. At midnight, however, the unfavorable condition was improved. The fifth urinalysis showed the indican to be decreased and the earthy phosphates to be much increased.
     Eighth day. At midnight the pulse was fairly good, 132. Strychnine and whiskey were given at intervals and hypodermics of camphorated oil. At 2:50 a. m. his condition gave rise to the gravest apprehension, and his heart did not respond to stimulation. At 10:00 a. m. two pints normal salt solution were given under the skin and one pint containing adrenalin [sic]. At 3:00 p. m. nitroglycerin and camphor were injected at various times, together with brandy and strychine [sic]. At 3:30 p. m. his pulse grew weaker and at 5:00 oxygen was administered. At 6:30 p. m. the last bulletin was issued, saying that unless the profound depression could be relieved his death must shortly supervene. At 10:00 the President lost conciousness [sic] and the oxygen was discontinued. He became weaker and weaker and died at 2:15 a. m., September 14, 1901.
     The post mortem showed necrosed tissue along the track of the bullet and at the top of the left kidney. In this region was a large, irregular cavity, “the walls of which were covered with a grey, shiny material, in which were found fragments of nercrotic [sic] tissue.” The heart “was covered with a well developed panniculus.” It was soft and flabby. The mitral valve admitted three fingers. [Two fingers only can be admitted through the normal mitral valve. This shows dilation]. The muscular tissue was infiltrated with fat, also showing fatty degeneration and brown atrophy.
     In reading the above abstract of the official record, the inquiry arises, why an enema was not given before the operation, and also why morphine and strychnine were given before the operation. These are anti-dotal drugs and if one was indicated the other was not. The old idea of digitalis was followed, and the case did better when its use was stopped. The frequent enemas must have annoyed and weakened the patient. He did not need nourishment. The gases could have been drawn off with a catheter. The giving of calomel was a sad mistake; the same can be said of the food by mouth and the castor oil on the seventh day and at noon of the eighth.
     The medical treatment of this case savored of the old, old school. We have wondered what would have been the result had he been given staphisagria after the operation, and small amounts of water, leaving the bowels alone. What have our surgeons to say?
     This case is a striking illustration of the fact that the most brilliant operation [398][399] may fail when the medical management is not equal to the surgical. We cannot overlook the fact that the weakened tobacco heart made the subject a bad one.
     The small doses of medicine given show a progress in old school therapeutics, but they are still guided by contraria. It is to be regretted that modern scientific medicine (Homœopathy) could not have been summoned to help save the life of such a great and good man.