The Case of the President and the Surgical Lesson of the Hour

     THE attention of the entire professional and, for that matter, the lay world has been fixed for the past week upon the case of President McKinley, and the grave problems involved in the prognosis of penetrating wounds of the abdomen and perforating wounds of the stomach.
     The day has gone by for serious discussion of the necessity for promptly opening the abdomen in every case of penetrating wound of its cavity, occurring in civil life at least, with the view of repairing the damage inflicted upon its contained viscera by the perforating missile.
     That the members of the surgical branch of the profession, whose judgment is at all worth having, have looked with the fullest approval on the course pursued by those who are in immediate attendance upon the President, goes without saying. The recognition of the fact that prompt operative interference held out the very best, if not the only chance, stands out as the pivotal point upon which every consideration of the case must turn. The surgeons met the first question at issue, namely, as to whether or not [421][422] the missile had invaded the peritoneal cavity, by immediately placing the patient upon the operating-table in the Emergency Hospital and enlarging the wound of entrance in order to at once and satisfactorily clear up this point. This having been decided in the affirmative, the next enquiry naturally arose as to what damage had been done to the important viscera. Here, again, a thorough investigation cleared up this vital point. There was no guess-work about it; no waiting for the occurrence of so-called symptomatic indications for further interference, or the cry of the nation to “do something” for the illustrious sufferer. It was done with that true instinct which marks the course of the modern surgeon, and done, too, with a celerity and skill that has won for the surgery of the century new laurels. For this is not merely a personal gain for the individual who happened to wield the knife, although to him should be given every praise, any more than the favorable result, which at the time of writing seems to be assured, is the gain alone of the patient himself. As the whole American nation and, in addition, the world at large, is the gainer by the life saved, so will the entire medical profession profit by the lessons taught and the victory won.
     Surgeons who are brought face to face with the conditions which confronted those who, in the first hour following the infliction of the dastardly blow, were responsible to a vast and highly intelligent, and oftentimes hypercritical people, will realize what passed through their minds. As the eye took in at a glance the small blue-edged opening in the abdominal wall, so the mind instantly grasped the many possibilities of danger involved in the missile’s fight. Visions of a bleeding vessel in the omentum or mesentery and rapid loss of blood, with great probability of collapse and death, and of perforated viscera with the only too-certain sequel of septic peritonitis, must have passed in rapid panoramic procession before them, to say nothing of the sight of the millions with pallid faces, surging hearts and bated breath, whose concentrated gaze was turned toward the little emergency operating-room in the Queen City by the lake. To wait for symptoms of internal hemorrhage and hope that they would not appear was but to lean upon a broken reed. To postpone the saving touch until assured that infection had actually taken place would be throwing away golden moments, render the effort to save futile, and, because of this futility, lay those responsible open to the well-merited charge of cowardice. Useless would it have been to attempt to justify such a course by quoting ancient statistics designed to show that the mortality of interference was almost, if not quite as large, as non-interference, for the answer would at once have been made that, of those who recovered without operation, there was no proof that vessels or viscera had been injured, and of those who died there was a failure of the realization of the importance of time as a saving factor, and the element of proper technic evidently wanting; proper criticisms involving underlying principles and supporting the contention that in former times this most important question had not been decided upon its merits. Neither could they have urged that, proof of infection being wanting, they were not justified in interfering. This would have been met by the assertion, based upon the experience of many a surgeon in abdominal work, that to wait for peritonitis to supervene would only be waiting for an excuse to put the finishing touches to a scene already tragic in the extreme. To have endeavored to escape criticism by the assertion that no vomiting of blood had occurred, and hence the stomach had not been injured would have brought to light from the literature the cases in which perforation of the stomach, as revealed by operation, had taken place and in which vomiting, and even pain had been absent. To have quoted the statistics of the late war would have availed but little, since experience shows that the rapid traversing of the tissues by a projectile from a high muzzle-velocity modern firearm is a far different matter compared with the damage inflicted by a cheap low muzzle-velocity and black powder-driven, soft lead missile which forces its way comparatively slowly into the tissues, adding the damage of structures crowded and forced against each other to that due intrinsically to the missile itself.
     All these things are matters of thought in the surgical mind of to-day. And when the public appreciate to some extent what surgery has done for a well-beloved President, let the tribute of praise for the clear head, the cool judgment, the courage, and the skilful hand that were the instruments in the victory over the assassin’s deadly purpose, mingle with the realization of what the medical profession is to the world.
     As to the features of the case from the purely scientific standpoint, there is but little to dwell upon. The triumphs of aseptic surgery are com- [422][423] mon enough, and the experience gained since the then obscure Glasgow surgeon first promulgated his teachings have been slowly but surely pointing to the hour when the greatest living representative of the greatest of the nations of the earth should receive the benefit of those teachings in the most impressive manner. And, if it shall be that success waits upon the efforts of those who are striving for the life of the President, let it not be forgotten to acknowledge the obligation for the genius of the father of modern surgery, Joseph Lister.