The President’s Case

     THE sad crime that laid our President low and for a time seemed to threaten his life has occupied so much attention that we have felt that the medical profession of the country would be interested in knowing the details of the President’s injury and the subsequent course of the case, not from the more or less distorted statements of the secular press, but to as great an extent as might be under the circumstances from the members of the profession who have been in actual touch with the case. The following notes are from a special correspondent sent to Buffalo to consult the surgeons in charge and as far as possible obtain information at first hand:
     The Wounds.—The President’s case is a striking example of how little pain may be inflicted by bullet wounds and how little conscious of their infliction the wounded person may be. The wounds were received from a distance of less than three feet. The first shot penetrated the abdomen, wounding only soft tissues, and the President seems not to have felt it at all and not to have realized what had happened. This first shot, after penetrating the anterior abdominal wall, seems to have followed a course somewhat downward and outward. The President’s assailant was carrying his right arm across his chest as if it were in a sling and as he straightened it to fire the general direction of the arm was downward. This circumstance perhaps accounts for the fact that the diaphragm was not wounded, although the wound of entrance of the bullet was about two inches to the left of the umbilicus and about on a level with it (standing position).
     After the first shot the revolver, as is usual with weapons of this form, kicked upward so that the second bullet hit the sternum toward its left edge and near the articulation with the fourth rib. This bullet did not even penetrate the skin, but made only a discolored, bluish, bruised mark and was found later in the President’s clothing. This bullet did not hit a button or other hard substance in its passage through the waistcoat and shirt, but fortunately seems to have been one of those weak-charge cartridges that sometimes are found among ordinary commercial revolver ammunition. The revolver used was of 32 calibre, of the variety known as bulldog, i.e., with very short barrel, which favored the concealment of the weapon when carried in the hand.
     There are different accounts as to how the President acted after the second shot. Practically all bystanders agree in saying that he was very little disturbed for a few moments while he stood facing the would-be assassin. Then a look of anxious surprise came into his face and, as those near grappled with his assailant, Mr. McKinley turned somewhat pale to those beside him. The shock and pain of his wounds had thus far been so little that he had to ask those around him if he were shot. When assured that he was, one of his first thoughts seems to have been for Mrs. McKinley, and he asked a secret-service man near him whom he knew very well to see that the news be broken gently to her.
     After a few moments the sight of blood and the excitement affected him, and he became weak and had to be supported. He reclined on a chair for a few moments until the Exposition ambulance could be summoned by telephone.
     The Emergency Hospital.—Within ten minutes after the President was shot he was in one of the ambulances provided for emergency cases and was on his way to the Emergency Hospital on the Exposition grounds near the West Amherst gate. The director of the Pan-American Exposition Medical Department is Dr. Roswell Park. He had remarked more than once to the staff of the little hospital on the grounds that, while their small operating-room was unsuited for major operations and might never be needed for so serious a purpose, circumstances might arise in which it would be necessary to do important surgical work. There was no anticipation then of how grave and weighty an occasion would arise to test the perfection of the operating arrangements. The little operating-room, about 12 by 20, was to be the scene of the most important operation of recent years. Though small, it is reasonably well lighted and is thoroughly business-like in its air of absolute simplicity and cleanliness. How thoroughly aseptic everything about the little room was can be best judged from the post-operative course of the President’s case. Great credit it would seem, now that the apportioning of commendation is in order, is due to the house staff, Drs. Hall and Zittel, and to the head nurse, Miss Walters, for the perfect condition that fortunately had been maintained.
     As soon as the President arrived he was put on the operating-table, but without removing the stretcher on which he had originally been carried to the ambulance. This stretcher remained under him until after the operation was completed and served for his retransfer to the ambulance when he was moved to the home of Mr. Milburn. Dr. Roswell Park, the medical director, was at once summoned, but it was found that he was out of the city, operating at Niagara Falls. From there he came later by special train, arriving before the end of the operation. Considerable difficulty was experienced in finding Dr. [401][402] Mann. He was in a barber’s chair when the urgent summons finally reached him, and left the shop, he said, with his hair only half cut.
     The Operation.—As soon as it was found that Dr. Roswell Park could not come at once, Dr. Matthew D. Mann was summoned by President Milburn of the Exposition. He arrived at the hospital at five minutes after five. The President had been wounded at 4:07 p. m., so that practically an hour had elapsed. Very naturally this hour of waiting seemed very long for the President. Nothing was being done nor was there the slightest inkling of what would be done. The only sign of impatience manifested by the patient came at this time. He asked if others did not find the wait intolerably long.
     All delay was over as soon as Dr. Mann arrived. Examination showed that, while the wound in the thoracic wall was only a superficial bruise, that in the abdomen had penetrated the abdominal cavity. The President’s condition was good; there was as yet no rise of temperature, the pulse was running slightly over 100 and the patient was evidently suffering slightly from shock. There had been two or more almost fainting spells and one-thirtieth of a grain of strychnine was given as a stimulant. A sixth of a grain of morphine was administered to quiet some restlessness due to the delay. The presence of a penetrating wound of the abdomen seemed to Dr. Mann sufficient indication for at least an exploratory laparotomy. As the events show, this was an extremely wise conclusion. Mr. McKinley at once accepted the doctor’s opinion in the matter and expressed his entire willingness to submit to whatever treatment might be deemed necessary.
     Nineteen minutes after his arrival, that is, at 5:24 p. m., Dr. Mann made his incision. The President had been given ether while the surgeons’ personal preparations were making, and he took it very quietly and without excitement. The opening of the abdomen at once disclosed the fact that laparotomy was of vital necessity and that every moment of delay while waiting for surer indications for surgical intervention would have been precious moments lost while infectious material was being absorbed. The stomach had been penetrated and some of the stomach contents were already extravasated into the abdominal cavity.
     An opening was found in the anterior wall of the stomach in the neighborhood of the greater curvature. This opening was in the upper half segment of the stomach. Its position, small size and sharp inverted edges, and the contraction of that viscus served to keep it tightly closed. That on the posterior wall was larger and more irregular, but its edges were also inverted and the amount of leakage of gastric contents was not large. No bacteriological examination of this small amount of extravasated matter was made.
     It was about three hours before his wound was received that the President had taken his lunch. It was fortunate that that meal was taken at Niagara Falls, where, according to tradition, at least lunches are not prone to be excessive in quantity. Though it was so long after lunch, the President’s stomach was found about half full. The edges of the wound were repaired with Lembert sutures. The posterior wall of the stomach was then exposed by turning the organ upward and backward, avoiding any contact with the intestines, and a wound corresponding to that in the anterior wall was found. This was sutured as the other one. All extravasation was now at an end. No other visceral wounds could be found. There was practically no hemorrhage. The abdomen was thoroughly flushed out with sterile normal salt solution. As the bullet had not been found during the course of the rather lengthy manipulations (the patient was under ether about an hour and a half), further search for it was deemed inexpedient. The apparent direction of this bullet was, as has been said, away from the median line. There was no danger [402][403] that it had injured the body of a vertebra, as in Garfield’s case, and the fact that there was no noticeable hemorrhage seemed to indicate that it had lodged in the muscles of the back, where it might well remain without doing any harm.
     The question of using the Roentgen rays to locate the bullet is still open. Unless the ball gives rise to symptoms of irritation, however, the President will not be disturbed and the use of the Roentgen rays will be postponed until he is well on the road to convalescence. So far there has not been the slightest indication that the bullet is causing any trouble, and the indications are entirely for expectant treatment.
     We here append the temperature chart prepared from the special bulletins of the case. It is to be noted that the temperature was taken by the rectum until Tuesday morning. This makes the earlier readings a trifle over ½º F. higher than they would have been if taken by the mouth.
     A Cutaneous Abscess.—There was a thrill of apprehension on Wednesday morning at the announcement that a second operation had been performed on the President late Tuesday night. This was not an operation, but only a dressing of the incision. For forty-eight hours before the President had been complaining of some tenderness in the neighborhood of the wound and this had not only persisted, but increased. It was thought better to investigate the cause for this discomfort. A small superficial collection of pus along the edge of the wound was found to be forming. It was noticed by Dr. Mann, who called the attention of the assistant surgeons to it while making his incision, that a small portion of clothing had been carried into the abdominal wound. It did not reach the abdominal cavity, but was found near the bottom of the fatty layer of the abdominal wall. The shreds of clothing were removed as carefully as possible, but it is a well-known experience that portions of such material are liable to be left in the wound. This Dr. Mann considers to have been the origin of the superficial suppuration that was found to exist. The collection of pus was evacuated without in any way disturbing the coaptation of the wound edges and the wound was redressed as before. As a result of the relief thus afforded the President passed a more comfortable night on Tuesday and was in excellent spirits on Wednesday, asking for the paper and wanting to talk more than the attending surgeons considered good for him. Feeding by the mouth was begun on Tuesday morning and was well borne. Since Wednesday all nourishment has been given in this way, and the rectal alimentation of the first few days, which was fortunately always satisfactorily retained and absorbed, has been discontinued.
     The Outlook.—As we go to press all the surgeons in attendance are agreed that danger of peritonitis is over. There is, however, still some danger of sepsis. Wounds in civil life differ from those in military life in the greater after-danger of septic involvement. Revolver cartridges are more liable than are rifle cartridges to have been handled frequently, to have been carried in dirty pockets, and to have come in contact with various forms of infectious materials that may prove of serious consequence when buried in the tissues. Moreover, revolver cartridges are covered with a coating of grease and this encourages an accumulation of manifold microbic material some of which may prove to be of virulently infectious nature. Rifle bullets are practically always sterilized by the intense heat developed by the powder at the moment of their discharge. Their rapid progress through the air while in a heated condition still further serves to cleanse them of any extraneous material that may chance to have accumulated on their surfaces. This cleansing process is very effectually begun by the rifling of the rifle barrel through which the bullet forces its way. All of these favorable factors are lacking in the case of the revolver bullet, and so it is possible that in any given case such a bullet may carry infectious material with it into the tissues. If this were in small amount Nature might effectually wall it off and no serious consequences result. On the other hand, such infectious material might lie seemingly dormant for days, but really slowly gathering strength by multiplication, and when its toxins were elaborated in sufficient amount they might paralyze protective chemotaxis and produce a septic condition.
     Blood-counts made by Dr. Eugene Wasdin demonstrated the absence of leucocytosis. The differential count of leucocytes showed no departure from normal and the usual number of red cells was present. Thus the evidence derived from the blood-counts indicates the absence of any sepsis.
     There is nothing in the President’s condition at the present moment to hint at such an unfavorable possibility. He is recovering rapidly from his wound without a single disturbing symptom. He has not had any peritonitis and the danger from that is past. The disturbance of pulse and temperature noted for forty-eight hours after the operation and that were a source of no little disquiet to those who did not realize all the conditions were due to three principal factors, (1) the shock of the wound itself, (2) the shock due to the manipulation of the stomach and intestines during the operation, and (3) the disturbance of the nervous system and the shock incident to the intra-abdominal manipulations, all having been necessarily done in close proximity to the solar plexus. Dr. Mann refers most of the immediately subsequent disquiet to solar plexus irritation. This is now a thing of the past and every sign points to assured speedy and complete recovery. If the President were younger by twenty years it would be possible for him to be up and around in ten days. As it is his reaction all through the course of the affection has been that of a man much younger than his years. There is, then, really very little danger of sepsis developing and its possibility is held out by the surgeons merely in order not to seem too sure of the distinguished [403][404] patient’s recovery, for, after all, stranger things have happened than a turn for the worse in cases that have apparently progressed as favorably as this.
     Older surgeons would still fear from the secondary manifestations of wounds. For the military surgeons of a quarter of a century ago there would still be (at least for nine days after a bullet wound) some danger from secondary hemorrhage, for instance. As is well understood now these so-called secondary complications were really due to gradually developing septic conditions. As to secondary hemorrhage, there having been no primary hemorrhage, the danger in this respect seems more or less imaginary. The fact that the attending surgeons look to the possible development of sepsis as the only complication to be feared now shows that we have not departed as far as might seem from the point of view of older surgeons.
     The possibility of such a retained bullet finding lodgment beside an artery and by pressure absorption opening the vessel and causing hemorrhage was formerly seriously entertained by the surgeons of a generation ago. It is now generally conceded that it was never the mechanical factor of pressure alone that worked harm in such cases; there was always the accessory element of septic material present on the bullet and producing preliminary tissue changes. The dangers to be feared, then, are all concentrated in the word sepsis, and for those who fear to tempt fate by too good a prognosis this is the rational method of giving hostages to fortune.
     Besides the question of sepsis there remains, of course, the doubt whether the bullet may not have found its way after its course in the abdomen through the diaphragm and so be lodged in the pleural cavity. This is, as is well known, a very frequent lodgment for bullets that penetrate the stomach. The possibility of this was a great source of uneasiness to the attending physicians for the first two or three days. But there has never been any, even the slightest, interference with respiration. There has been no pain nor diaphragmatic discomfort, and now the question of the pleural cavity as the resting-place of the bullet is dismissed from all minds. As said when describing the wounds, the weapon seems to have been directed somewhat downward when the first shot was fired and this fortunate circumstance spared subsequent pleural complications and the serious sequelæ that would be almost sure to have followed sooner or later.
     The Prisoner.—Owing to all that has been said in sensational journals about the prisoner as a typical criminal he comes into the medical aspects of the case. It will be hard for the criminologists to bring him under any of their classifications of innate criminality. He has a young foreign-looking face that even now, with its week’s growth of beard topped by unkempt hair, is not unpleasant. He has none of the irregular features so often suggested as typical of the born criminal. There are no hints of supraciliary ridges. His eyes are normally set and of normal size. His ears do not project more than normally and they are equal in size and set at the same level. The jaw is a little heavy, but there is a suggestion of weakness about the lips. Those in immediate custody of him in Buffalo consider him a rather ordinary-looking young foreigner, without any of the facial traits they are so accustomed to see in habitual criminals or those imprisoned for violence.