The President’s Case

     PRESIDENT MCKINLEY died at two o’clock on the morning of Saturday, September 14th, seven and a half days after his injury was received. Up to and including most of Thursday, the sixth day after the injury, he had apparently been advancing steadily toward recovery; his temperature had fallen below 100º F., his abdomen was soft and painless and he had taken liquid food by the mouth with relish, but his pulse remained at a little above 120, and on Tuesday some of the stitches had been removed from the incision for the relief, as stated, of a slight infection thought to have been caused by a piece of the shirt carried into the wound by the bullet. His recovery was predicted by those in attendance and by many other physicians interviewed by the papers in various parts of the country, and the prediction seemed amply justified because he had passed the period during which the habitual causes of death after such an injury and operation manifest themselves.
     But on Thursday a notable weakness of the heart appeared; it was thought to be due to indigestion, and a laxative was given. Early in the morning of Friday the weakness recurred in an alarming way and persisted, with some intervals of slight improvement under stimulation, until his death twenty-four hours later. Death came quietly after six hours of unconsciousness.
     A brief official note of the autopsy, made nine hours after death, was promptly published, and has been followed by informal but apparently authorized statements giving additional details by some of the attending surgeons.
     The official account of the autopsy is as follows:

     “The bullet which struck over the breastbone did not pass through the skin and did little harm. The other bullet passed through both walls of the stomach near its lower border. Both holes were found to be perfectly closed by the stitches, but the tissue around each hole had become gangrenous. After passing through the stomach, the bullet passed into the back wall of the abdomen, hitting and tearing the upper end of the kidney. This portion of the bullet track was also gangrenous, the gangrene involving the pancreas. The bullet has not yet been found. There was no sign of peritonitis or disease of other organs. The heart walls were very thin. There was no evidence of any attempt at repair by Nature, and death resulted from the gangrene, which affected the stomach around the bullet wounds, as well as the tissues around the further course of the bullet. Death was unavoidable by any surgical or medical treatment and was the direct result of the bullet wound.”

     The unofficial statements are somewhat conflicting as to matters of fact and opinion. Dr. Wasdin is reported as saying:

     “I have seen many gangrenous cases, but none in which the parts lacerated by the bullet were so completely and uniformly affected. The entire tract of the wound from the outer surface of the abdomen, through the tissue, fat, stomach, and abdominal cavity back of the stomach was thoroughly and completely gangrened.
     “The wound in the posterior wall of the stomach was particularly affected, the gangrene extending for a radius of almost two inches around the sutures.
     “I have never seen such a condition. When the stomach was removed the tissue bore no resemblance to human tissue, and, in fact, was as bloodless as, and much resembled, a piece of clay.
     “On Tuesday it was decided to open the external wound in the abdomen. There had been some irritation there, and we decided to find out the cause. At first we took out a few of the stitches and, later, laid open the entire incision, leaving an opening in this wound five inches long and three inches deep. It required no effort to open the incision. We immediately found in the track of the bullet through the flesh and fatty tissue that gangrene had developed. None of the parts other than those around the immediate [465][466] bullet wound were affected. We removed this affected tissue, cleansed the wound and closed it.”
     Dr. Wasdin attributed the gangrene to “some powerfully corrosive poison” introduced upon the bullet, and added: “My belief that the bullets were poisoned is strengthened by the fact that the wound in the breast, although very slight, had gangrened when the autopsy was performed.”
     Dr. Park, in an interview said to have been written out in his presence, says:

     “There is no reason to believe that poison was introduced into the wounds. The gangrene was caused by the secretion of the pancreas escaping from the wound and producing the trouble. The pancreas was perforated by the bullet. There was no way in which we could determine from outward evidences that gangrene had set in. There are no indicative symptoms.”
     “Is it not a fact, Doctor, that when the surface wounds were opened Tuesday it was found to be affected by gangrene, and that the affected portions were then removed?”
     “No, Sir; it is not. There was merely an irritation, and we found nothing that indicated the presence of gangrene. Even at the autopsy it was discovered that gangrene existed only along the track of the bullet from the posterior wall of the stomach to the kidneys. The wound in the anterior wall of the stomach was but very slightly affected.”

     Dr. Mann says:

     “No. The only parts in the abdominal cavity penetrated or touched by the bullet were the stomach walls and the top of the kidney. The pancreas was not touched, although it was involved in the gangrenous process. I was surprised, in fact astounded, at the condition of the internal organs revealed by the autopsy. In all my experience I have never found organs in such a state; to use a vulgar phrase, they were rotten.”

     Dr. Mynter says that the pancreas was not wounded and that no gangrene was observed along the course of the bullet through the anterior abdominal wall when the incision was opened on Tuesday. Both he and Dr. Mann declare themselves unable to account for the extensive gangrene.
     Of these differences as to matters of fact, the one concerning the presence of gangrene in the parietal incision may be dismissed as simply due to a difference of definition. Something must have been wrong there, or the sutures would not have been removed. Whether that was an “irritation,” as Dr. Park calls it, or a superficial necrosis along the track of the bullet, it could not have affected the result, and its sole significance is in its possible bearing upon the cause of the extensive gangrene observed elsewhere.
     Much the same can be said of the asserted and denied wounding of the pancreas. It is asserted by one, denied by three, and not mentioned in the formal report. Probably, therefore, it did not exist or was slight.
     There remains the extensive gangrene, which is affirmed by all and which was undoubtedly the cause of death, and the question of its origin. Two theories have been advanced, (1) that it was due to a poison conveyed by the bullet, and (2) that it was due to the action of pancreatic juice that had escaped from the wounded gland. The second theory seems untenable because similar action is not described as occurring after other wounds involving an escape of the pancreatic juice, because the gangrene involved parts (the anterior wall of the stomach), which the escaping juice could not have reached except after having passed by other parts which were not similarly affected and because it appears to have been a necrosis, a death in bulk, rather than a progressive digestion. And this view is reinforced by the fact that as the patient had been fed for the first four days exclusively by the rectum, the pancreas had not been stimulated to functional activity.
     The other theory, that of a poisoned bullet, is warmly urged by Dr. Wasdin. In the absence of specific proof, such as may yet be furnished by bacteriological or chemical tests of the tissues and of the other bullets, it seems as unlikely to be correct as the other. The author of the theory admits his inability to name a poison that would produce such an effect, and the two poisons recommended in the Anarchist manual of assassination, curari and verdigris, are incompetent to produce it. We must therefore await the results of the investigation said to be now in progress. If sloughing existed, as asserted by Dr. Wasdin, beneath the unbroken skin of the breast, where it was struck by the other bullet, it cannot be explained by either theory.
     The gangrene, extensive as it was, seems to us not so different from others observed under analogous circumstances as to require the assumption of exceptional causes for its explanation. Necrosis of tissue in a thinner or thicker cylinder along the track of a bullet is thought to be the rule, and ordinarily it is easily taken care of by liquefaction and ab- [466][467] sorption. And necrosis, even of considerable extent, in feeble patients, about a sutured wound is certainly not unknown even if rare, and is explained by interference with the local circulation either by tension or by the spread of coagulation within the blood-vessels. It has not been made known to us whether this was a septic or an aseptic necrosis, but it was presumably septic, since the parietal wound presented symptoms, due apparently to the same process at that point, which necessitated the removal of the sutures.
     In either case, and especially in the former, the spread of the process in a patient of low reparative power would not be so very exceptional or surprising. Was the President such a patient? Apparently he was. According to Dr. Wasdin, when the incision was reopened toward the end of the fifth day “no effort” was required to open it throughout its entire length, although only the track of the bullet was affected. That expression would hardly have been used unless he had intended to indicate that the amount of repair usual after that lapse of time had not taken place. Then, the President was fifty-eight years of age, had led a sedentary, laborious, and anxious life, and had a complexion and appearance which for some years had been commented upon as indicative of impaired vitality.
     It is evident that the surgeons, notably Drs. Mann and Mynter, with whom the first decision lay, acted with commendable promptitude and courage in undertaking the operation, and showed excellent judgment in its course and skill in its execution. They did all that could properly have been done and nothing that should have been left undone. The usual causes of death after such injury and operation were escaped or removed or prevented, and their patient succumbed to a complication which is so rare that it could not reasonably have been anticipated and could not have been averted. The President died because he could not carry on the processes of repair, and because the effort to do so was more than the vitality if the tissues involved could support. This, of course, excludes the possible presence of poison brought by the bullet or of destructive action by the pancreatic juices. If either of those was a factor, it needs only to substitute it in the statement for the assumed defective vitality of the patient. Whatever cause acted, it was unrecognizable at the operation and uncontrollable then or subsequently.
     There has been some criticism of the confident assurances of recovery made by those in attendance after the fifth day. To us the progress of the case up to that time appears fully to have justified those assurances and the public anxiety to have required them. The habitual causes of death had been escaped, and recovery could be prevented only by some rare complication which there was no reason to anticipate. The only irregular symptom was the frequency of the pulse, and that could be reasonably accounted for without invoking conditions that endangered life. There was not the slightest nausea, no complaint of discomfort, not the least abdominal pain; a soft abdomen in which percussion and firm pressure disclosed no sensitiveness; the bowels acting; the tongue clearing; the temperature falling; and a cheerful mind. Who can think that with such conditions on the sixth day the surgeons were not fully justified in believing that recovery was assured and, believing, in saying so? That a rare and at that time wholly unindicated complication should have then intervened was their and our misfortune. They did their work skilfully and judiciously, their behavior was dignified, restrained, and worthy of the best traditions of the profession, and they had the misfortune, when success seemed to have been secured, of seeing it overthrown by a complication which could not have been foreseen or avoided. They deserve our admiration and sympathy, not our criticism.