The Case of the President, Continued

     ON Thursday evening of last week, after the MEDICAL NEWS for the issue of the 14th inst. had gone to press, rumors began to be rife of a change in the President’s condition. The symptoms of failing circulation grew urgent and persisted in spite of vigorous stimulation. It soon became evident that a fatal termination of the case, which had seemed so hopeful up to that date, was only a question of time and that the end was not far off. Science could do little more than delay for a few hours the inevitable.
     Cause of Death.—The question that interested all citizens and especially the medical profession of this country and, it may well be said, of the world was, What was the cause of the fatal issue? The autopsy was expected to give a clear answer and remove the dark mystery which had baffled the diagnostic skill of the remarkable assembly of medical and surgical experts whose assistance had been sought. The official abstract from the autopsy findings showed very clearly that death was inevitable from the beginning. The wounded internal tissues, instead of reacting so as to produce union, became gangrenous. The declaration in the matter was most explicit. The signed report reads 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 on the part of 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.”
     This indicated that death was due to the gangrenous process, but gave very little clue to the cause of the gangrene. Internal tissues injured by bullet wounds do not become gangrenous unless there is some circumstance in addition to the mere passage of a bullet. What this accessory factor could have been has occupied general attention during the week.
     Was the Bullet Poisoned?—It was suggested at the autopsy by a well-known medical authority that the bullet was poisoned. Chemical and bacteriological examinations of the cartridges left in the revolver will have to be made to determine definitely this point. In the meantime certain considerations seem to render such an hypothesis unlikely. The poison could scarcely be a chemical irritant, since a 32-caliber bullet could not carry on its outer surface enough of any chemical that is ordinarily known even to medical men to produce such a fulminant death of tissues. As will be remembered scarcely more than one-half the surface of the bullet in a cartridge is exposed for coating with foreign material and any such material would be removed in a great degree during the course of the bullet through the revolver barrel, the clothing and external tissues of the victim. There are popular traditions of virulent poisons that act in minutest quantities, but medicine knows of none that would act as this one is said to have done.
     Was the Poison Used a Bacterial Agent and not a Chemical Compound?—This is more possible, but there is no known culture of bacteria that will produce gangrene locally without giving signs of a general septic condition. It has been suggested that if the bullet were dipped previous to insertion in the revolver in putrid meat, gangrene would result wherever it came in contact with the tissues. This would not produce local death of tissue without provoking a reaction. Such a procedure might cause sepsis, but not gangrene, unless the vitality of the parts wounded had been very much reduced. Gangrene is not putrefaction, which is an active biological process due to the presence of living germs, but is death of the tissues involved.
     Wound of the Pancreas.—It has been suggested that the President’s death was directly due to a wound of the pancreas. The secretion of the pancreas is supposed to have escaped and followed the track of the bullet causing by its presence the gangrene or local death of the tissues wherever it flowed over the wounded part. Against this theory there are a good many objections. The first and most important one is that the track of the bullet seems to have been such that the pancreas was not wounded. The bullet passed through the walls of the stomach near its lower border and so its course would carry it several inches below a normally situated pancreas. Besides this, supposing there was a wound of that organ, pancreatic secretion might [441][442] easily have reached the wound in the posterior wall of the stomach, but it is hard to understand how it could have found its way to the anterior gastric wall, since the surgeons declare that the President’s stomach was found nearly half-full of food at the time of the operation. A wound of the pancreas, supposing a prolapse of that organ to account for such an accident, would have taken place near its tail where the pancreatic ducts are small and there would be very limited discharge of its secretion.
     With regard to the effect of the pancreatic juice, while it produces necrosis of fatty tissue, it does not produce gangrene. The characteristic appearance of the peritoneum where a discharge of pancreatic juice has taken place is well known to those who have seen many autopsies and would have been recognized at once by the experienced pathologists who made the autopsy.
     It is true that we are in the dark to a great extent with regard to all the effects of injuries to the pancreas. It is now nearly twenty-five years since Senn, of Chicago, published his work on the surgery of the pancreas of animals, which formed the basis of all medical knowledge on the subject throughout the world, and very little progress has been made in the matter since that time. The surgery of the pancreas was one of the questions for special discussion at the last International Medical Congress and the conclusions reached at that time show how lacking we are in definite knowledge notwithstanding the recent great advances in abdominal surgery.
     This much is certain, however, that wounds of the pancreas are by no means necessarily fatal. The escape of pancreatic fluid produces characteristic foci of fat necrosis, but does not produce the lowering of vital resistance which would lead to local death of all tissues with which it happened to come in contact. A number of recoveries from wounds and operations on the pancreas are reported and gangrene is not one of the complications or sequelæ usually anticipated.
     Possible Factors in the Result.—There remain certain other organic injuries that may have had their effect in producing the lowered vitality of tissue which led to localized gangrene and consequently to the fatal termination. An extremely important organ, well known in recent years by reason of certain fatalities that have been attributed to it after blows in the region of the stomach, is the solar plexus. The disturbance of the President’s pulse during the first few days after the operation was attributed by one of the most prominent surgeons in charge of the case to irritation of this extremely sensitive organ, the abdominal brain as it has been not inaptly called. Unfortunately our knowledge of the functions of the various parts of the nervous system and especially of the abdominal sympathetic nervous system is not sufficient to enable us to say with any degree of assurance what would be the effect of direct injury or serious irritation of this organ. The manipulations necessary for the suturing of the wounds in the stomach had to be carried out in the immediate neighborhood of this delicate organ. This is true, however, in all wounds of the stomach and usually there are no serious consequences. It is not impossible that the irritation produced by the passage of the bullet itself and the subsequent operative procedures should have produced serious sympathetic nervous disturbance. The smaller blood-vessels are especially under the control of the sympathetic. This nervous irritation might have produced the interference with the circulation that led to the local death of tissue. But the direction of the bullet in its course from front to back was away from rather than toward the median lines where it would have involved the solar plexus.
     Another consideration that seems worth while discussing is the possible effect of a wound of the suprarenal capsule. The bullet, after its passage through the stomach, tore the upper part of the left kidney and injured the left suprarenal body. A few years ago this would have been considered of no special significance. Now we know that the secretion of the suprarenal capsule is an active agent in producing localized contraction of blood-vessels and consequent diminution of the circulation in tissues. Whether this could have had any effect in lowering the vitality of the wounded tissues and so inducing gangrene is doubtful, but must not be left entirely out of consideration.
     There remains the question of the President’s individual resistive vitality. There are persons whose reactive power is extremely limited. Diabetics, for instance, are prone to suffer from gangrene after very slight injuries. The late President did not suffer from diabetes, but for some time an abnormal condition of his kidneys has at least been suspected. His age was a factor against his prompt recovery, but should not have made it impossible. Constitutional lack of reactive vitality seems the most important element in the unfortunate and unexpected fatal issue.
     It is clear that no human skill could have saved the President’s life and that everything that modern scientific medicine could possibly suggest was done for him. The surgeons have been all too freely blamed for their optimistic bulletins. Their wishes may have obscured their better judgments. It is always easy to be wise after the event. At noon on Tuesday, September 9th, the President’s pulse was 104 and his temperature below 100º F. This certainly presented a most encouraging condition of affairs after the shock to which the patient had been subjected. There was every reason to think that danger from infection was past. The fatal issue emphasizes the necessity that always exists for most careful prognosis whenever patients are much advanced beyond middle life. The present case, however, contained elements so entirely unusual that no human foresight or even the greatest possible caution could have prevented the sad disappointment that ensued.