Source: Medical Record
Source type: journal
Document type: editorial
Document title: “The Revelations of the Autopsy”
Date of publication: 21 September 1901
Volume number: 60
Issue number: 12
|“The Revelations of the Autopsy.” Medical Record 21 Sept. 1901 v60n12: pp. 457-58.|
|William McKinley (autopsy); William McKinley (medical care: criticism); William McKinley (medical condition); William McKinley (surgery).|
Click here to see a Cleveland Journal of Medicine editorial written in response to the editorial below.
Click here to see a Philadelphia Medical Journal editorial written partly in response to the editorial below.
The Revelations of the Autopsy
Taken in connection with the clinical history of the case, and the extremely optimistic views of some of the consultants, the discovery of certain of the lesions named is both a surprise and a disappointment. It is a pity indeed that such an evident failure in diagnosis should have been so conspicuously demonstrated to the general public. It has proved, in fact, the lost opportunity for an entirely contrary exhibition of judgment, skill, and tact.
In reconciling the findings after death with the symptoms during life, there are many relations between causes and effects, which, although hidden before, are now very painfully apparent. We may comfort ourselves by saying that, under the circumstances, events were uncontrollable and results unavoidable, but the public, alas! view the real situation in a very matter-of-fact way.
The operation of suturing the stomach wounds was timely, proper, and, so far as it went, brilliant. Medical men the world over were proud to hear that it had been done so promptly and so well upon a person of such importance.
But now, in the light of the autopsy, we know that the operation, carefully conducted as it was, was necessarily an incomplete one. This is speaking of the procedure from a strictly surgical standpoint, irrespective of the ultimate doom of the patient in any event. Time was precious, and prolonged search for the ball was impossible, consequently the condition and course of the wound beyond the stomach could not be positively ascertained at the time. The surgeons satisfied themselves, therefore, that it was safe to leave this terminal wound to itself and close up the abdomen. They used their best judgment under trying conditions; but, unfortunately, that judgment was in error.
Then came the bulletins and interviews so eagerly read by an anxious nation. It was stated at first that the stomach wounds were the only causes for anxiety, that the ball having lodged in the muscles of the back would become safely encysted, and that septic peritonitis from possible leakage of the stomach contents was the only thing to be feared. When the latter danger was over, there came the surprising intelligence that the patient would certainly recover. This in face of a continued high temperature and rapid pulse! Then it was announced that all the wounds had healed perfectly, and the only real danger was centered in a weak heart. Hardly had this bulletin been issued when it was announced that the external wound was found to be infected, necessitating the removal of some stitches. Still it was said that the distinguished patient was doing excellently well—in fact, even better than before. Next was the report of an attack of indigestion, claimed to be due to food given too soon, and last of all and without warning came the appalling accounts of his rapid collapse and surprisingly quick death.
Worst of all, however, were the actual facts of the autopsy which seemed to prove to the public that the doctors had been wrong in their conception of the case from the beginning to the end.
Sadly enough, not one of the principal lesions gave any evidence of its existence during life. The good condition of the wound behind the stomach, of which all the surgeons were so pronouncedly confident, was an illusion and a snare. What was considered to be a most insignificant factor became the most important of all. Instead of the terminal track of the bullet being healed and the ball encysted, it was found, at the autopsy, to be gangrenous throughout. Thus a most startling error of diagnosis was flauntingly accentuated by an indignant and astonished press.
The practical surgeon very properly asks himself why the condition and the direction of the track behind the stomach was not discovered at the time the parts were exposed during the operation? That the problem was not solved then and there was certainly not due to any want of forethought on the part of the operator, whose skill in his line no one can question. The only answer must be that such a thorough examination of the parts was impossible at the time. Still it seems hard to explain why all the gentlemen on the case were so satisfied with the real nature of a wound that they, obviously, knew nothing about.
The M R was exceedingly anxious on this point and earnestly called attention to the possibility of there being a wound of the pancreas or kidney or both. Unfortunately, as the sequel too well shows, we were right in at least one particular.
Another matter is that which referred to the desirability of an x-ray examination to locate the ball. The R urged this as of the greatest importance, and yet, with the apparatus at hand, it was repeatedly and publicly stated that such an examination was not at all necessary. In fact, it seemed safer to guess than to be sure. What comment suggests itself in this connection when even at the autopsy, so far as can be ascertained at present, it was not considered worth the trouble to search for the ball beyond a certain point! What excuse must be offered to the public for the utter inability to find the bullet even in the dead body! All these matters may, however, be properly explained when the fuller account of the post mortem is given to the medical and lay public.
Many different theories have been offered by the medical attendants concerning the cause of gangrene of the bullet track. By some the condition is charged to a poisoned bullet, by others to the leakage of pancreatic juice into the bullet sinus, and  by still others to mere lack of recuperative energy in the tissues involved.
On these points, however, the profession is willing to suspend judgment, pending the completion and publication of the official reports of the post-mortem examiners.
Viewing the strictly surgical aspects of the case in the light of the autopsical demonstrations, certain points of treatment might naturally suggest themselves. Everyone knows that such an injury as existed in the President’s case is uniformly fatal. The most favorable result that could have been expected was the healing of the wound and the possible establishment of a fistula. This would certainly be infinitely better even as a tentative measure than accidentally leaving a leaking kidney or pancreas in a closed cavity to work such mischief as was manifested in the gangrenous condition of the surrounding tissues of the case in question.
Allowing that the bullet had actually lodged in the muscles of the back, also that the missile was within easy reach, it would be following a good surgical rule to establish drainage by the most direct route posteriorly. This course, however, could not be followed, as the bullet, on account of the unfortunate conditions already noted, was not accurately located. Under the circumstances, therefore, and taking everything into consideration, it is comforting to note that all was done for the distinguished patient that was possible. In fact, as was repeatedly stated by the operator, “the case was a fatal one from the start.”
In thus remarking upon the public aspects of the case it is only for the purpose of getting at the truth and learning perhaps a useful lesson. In the same spirit we can afford to view the strictly professional side. To err is human, but wisdom comes from experience. It is safe to say that under like circumstances in future the gentlemen concerned would act somewhat differently. We sincerely trust that they at least would not then be asked to explain why they allowed a lost ball to be buried with the victim’s body.