Report on the Autopsy

     Ordinary signs of death: ecchymosis in dependent portions of the body. Rigor mortis well marked. Upon the surface of the chest, to the right of the midsternal line, a spot 1 cm. in diameter, dark-red in color, with a slight crust formation covering it, 5.5 cm. from the suprasternal notch; from the right nipple, 10 cm.; from the line of the right nipple, 8.25 cm. Surrounding this spot, at which point there is an evident dissolution of the continuity of the skin, is a discolored area of oval shape extending upward and to the right. In its greatest length it is 11 cm.; and in its greatest width, 6 cm. It extends upward in the direction of the right shoulder. The skin within this area is discolored, greenish-yellow and mottled.
     The surface of the abdomen is covered with a surgical dressing, which extends down to the umbilicus and upward to just below the nipples. The innermost layer of cotton is covered or stained with balsam of Peru and blood. On removing this dressing, a wound, parallel to, and somewhat to the left of, the median line, is exposed, inserted in which are two layers of gauze, likewise impregnated with balsam of Peru. The wound is 14.5 cm. in length, and is open down to the abdominal muscles. The layer of abdominal fat is 3.75 cm. in thickness. The appearance of the fat is good, a bright yellow in color. No evidence of necrosis or sloughing. In the left margin of the surgical wound, lying 1 cm. to the right of a line drawn from the umbilicus to the left nipple, 15.5 cm. from the nipple and 16.5 cm. from the umbilicus, is a partly healed indentation of the skin, and an excavation of the fat immediately beneath it (this is the site of the entry of the bullet), extending down to the peritoneal surface. On making the median incision, starting from the suprasternal notch and extending to a point just below the [606][607] symphysis, the subcutaneous fat is exposed, which is of bright yellow color and normal appearance except in an area which corresponds superficially to the area of discoloration described as surrounding the wound upon the chest wall. This area marks the site of a hemorrhage into the subcutaneous fat. The remainder of the subcutaneous fat is firm and measures 4.75 cm. in thickness on the abdominal wall. On opening the sheath of the right rectus muscle, it is seen to be of dark-red color. (Culture taken from ecchymotic tissue under the upper bullet hole and from between the folds of the small intestine. Three tubes from each locality on agar and gelatin.)
     On opening the abdominal cavity, the parietal surface of the peritoneum is exposed, and is found to be covered with a slight amount of bloody fluid; is perfectly smooth and not injected. The great omentum extends downward to a point midway between the umbilicus and the symphysis. It is thick, firm; its inferior border is colored by coming in contact with the intestines. Below the umbilicus a few folds of intestines are exposed. These are likewise covered with discolored blood, after the removal of which the peritoneal surface is found to be shiny. On the inner aspect of the abdominal wound the omentum is found to be slightly adherent to the parietal peritoneum, and can be readily separated with the hand from the edge of the wound. At this point the omentum is somewhat injected. This adhesion to the omentum is found to extend entirely around the abdominal wound. The parietal peritoneum immediately adjacent to the inner aspect of the abdominal wound is ecchymotic.
     On removing the subcutaneous fat and muscles from the thoracic wall, the point which marks the dissolution of continuity of the skin upon the surface is found to lie directly over the margin of the sternum and to the right side between the second and third ribs. There is no evidence of ecchymosis or injury to the tissues or muscles beneath the subcutaneous fat. On making an incision through the subcutaneous fat, directly through the wound upon the chest, a small cavity is exposed about the size of a pea, just beneath the skin, which is filled with fluid blood. The subcutaneous tissue underlying the area of discoloration on the surface of the chest wall shows hemorrhagic infiltration.
     On removing the sternum, the lungs are exposed, and do not extend far forward. A large amount of pericardial fat is exposed. Pleural surface on both sides is smooth. There are no adhesions on either side within the pleural cavities. The diaphragm on the right side extends upward to a point opposite the third rib in the mammary line. No perceptible amount of fluid in either pleural cavity. On opening the pericardial cavity, the surface of the pericardium is found to be smooth and pale. The pericardium contains approximately 6 cc. of straw-colored, slightly turbid fluid. (Some taken for examination.)
     On exposing the heart, it is found covered with a well-developed panniculus. The heart measures, from the base to the apex, on the superficial aspect, 10.5 cm. The right ventricle is apparently empty. The heart feels soft and flaccid. On opening the left ventricle, a small amount of dark-red blood is found. The muscle of the left ventriclear wall is 1.5 cm. in thickness; dark reddish-brown in color; presents a shiny surface. The average thickness of the pericardial fat is 3.5 mm. (Cultures made from the auricle.) The left auricle contains but a small amount of dark currant-colored blood. The mitral valve admits three fingers. The right ventricle, when incised in the anterior line, is found to be extremely soft; the muscular structure is 2 mm. in thickness. The panniculus measures 7 mm. The muscle is dark red in color; very shiny, and the pericardial fat invades the muscular wall at many points.
     On opening the right auricle, it is found to be filled and distended by a large currant-colored clot, which extends into the vessels. The tricuspid orifice admits readily three fingers. The coronary arteries are patulous and soft; no evidence of thickening.
     Lungs are gray color, and contain a moderate amount of coal-dust pigment. Slight amount of frothy fluid escapes from the bronchi; but the pulmonary tissue is crepitant and free from exudate.
     On unfolding the folds of intestine, there is no evidence of adhesion until a point just beneath the mesocolon is reached, when, on removing a fold of small intestine, a few spoonfuls of greenish-gray thick fluid flows into the peritoneal cavity.
     On the anterior gastric wall is an area to which a fold of the gastrocolic omentum is lightly adherent. On breaking the adhesion there is found a wound about midway between the gastric orifices, 3.5 cm. in length, parallel with the greater curvature of the stomach, 1.5 cm. from the line of omental attachment. This wound is held intact by silk sutures. There is no evidence of adhesion at any other point on the anterior wall. The gastric wall surrounding the wound just mentioned for a distance of 2 cm. to 3 cm. is discolored, dark greenish gray in appearance, and easily torn. On exposing the posterior wall of the stomach from above, along its greater curvature, the omentum is found to be slightly adherent, a line of silk 1 gatures along the greater curvature of the stomach marking the site where the omentum had been removed. On throwing the omentum downward, the posterior gastric wall is exposed. On the posterior wall, a distance of 2 cm. from the line of omental attachment, is a wound approximately 2 cm. long, held intact by silk sutures. The gastric wall surrounding this wound is discolored. On the surface of the mesocolon, which is posterior to the gastric wall at this point, is a corresponding area of discoloration, the portion coming directly in contact with the wound in the gastric wall being of dull gray color. The remainder of the surface of the posterior wall of the stomach is smooth and shiny. Beyond the surgical wound in the posterior wall of the stomach is found an opening in the retroperitoneal fat, large enough to admit two fingers. This opening communicates with a track which extends downward and backward as far as the finger can reach. The tissues surrounding this track are necrotic. On removing the descending portion of the colon, a large irregular cavity is exposed, the walls of which are covered with gray, slimy material, and in which are found fragments of necrotic tissue. Just at the superior margin of the kidney is located a definite opening, which forms the bottom of the track traced from the stomach. On stripping the left kidney from its capsule, it is found that the superior portion of the capsule is continuous with the cavity. The weight of the left kidney is 5 oz. 1 gm. The kidney is readily stripped from its capsule; is dark red; the stellate veins are prominent, and along its greater curvature are numerous dark red depressions. On the superior aspect of the kidney is a protrusion of the cortex, dark red in color, and in this protrusion is a laceration 2 cm. long, extending across the superior border, approximately at right angles to the periphery of the kidney and from before backward. On incising the kidney, the cortex and medulla are not easily distinguishable from one another; both are of rose-red color, the cortex measuring approximately 6 mm. in thickness. The vessels in the pyramids of Ferrein are very prominent. Beneath the protruding portion of the surface the cortex is dark red in color. This discoloration extends downward in pyramidal form into the medulla. The laceration of the surface marks the apex of the protrusion of the kidney substance. Between the spleen and the superior aspect of the kidney is a necrotic tract which extends down and backward, and ends in a blind pocket. The tract which included the superior aspect of the kidney can be traced into the perinephritic fat to a point just above the surface of the muscles of the back.
     The necrotic cavity which connects the wound on the posterior wall of the stomach and the opening adjacent to the kidney capsule is walled off by the mesocolon, and is found to involve an area of the pancreas, approximately 45 mm. in diameter and extending about half-through the organ. This organ at its center forms part of the necrotic cavity. Through its body are found numerous minute hemorrhages and areas of gray softening, the size of a pea or smaller. These are less frequent in the head portion of the pancreas.
     A careful examination of the track leading down toward the dorsal muscles fails to reveal the presence of any foreign body. After passing into the fat, the direct character of the track ceases; and its direction can be traced no further. The adjoining fat and the muscles of the back were carefully palpated and incised, without disclosing a wound or the presence of a foreign body. The diaphragm was carefully dissected away, and the posterior portion of the thoracic wall likewise carefully examined. All fat and organs which were removed, including the intestine, were likewise examined and palpated, without result.
     The great amount of fat in the abdominal cavity and surrounding the kidney rendered the search extremely difficult.
     The right kidney is imbedded in a dense mass of fat; capsule strips freely; it weighs 5 oz.; measures 11.5 cm.; substance is soft; cortex is 6 mm. in thickness; rose-red in color; cut surface slightly dulled. There are a few depressions of the surface, and the stellate veins are prominent.
     The liver is dark-red in color; the gall-bladder distended. The organ was not removed.

     The autopsy continued for a longer period than was anticipated by those who had charge of the President’s body, and we were requested to desist seeking for the bullet and terminate the autopsy. As we were satisfied that nothing could be gained [607][608] by locating the bullet, which had apparently set up no reaction, search for it was discontinued.

     Anatomic Diagnosis.—Gunshot wound of both walls of the stomach and the superior aspect of the left kidney; extensive necrosis of the substance of the pancreas; necrosis of the gastric wall in the neighborhood of both wounds; fatty degeneration, infiltration, and brown atrophy of the heart muscle; slight cloudy swelling of the epithelium of the kidneys.
     A matter of no inconsiderable embarrassment to us arose in the objection to our removing sufficient portions of the tissues for examination. We were able to secure only two small fragments of the stomach wall; tissue from around the wound upon the chest wall; a portion of fat from the wall of the necrotic cavity; a small piece of each kidney, that of the left kidney including the portion involved by the original wound; and pieces of heart-muscle from the right and left ventricles. The microscopic examination of these tissues follows:
     The piece of retroperitoneal fat, where it forms part of the necrotic cavity, is seen on section to be covered with a thick gray deposit, which has an average thickness of from 4 mm. to 6 mm. Beneath this, and separating it from the fat, is a well-defined area of hemorrhage from 1 mm. to 2 mm. in thickness. The appearance of this piece of tissue is characteristic of the fat tissue surrounding the entire cavity. A section made perpendicular to the surface and stained with hematoxylin-eosin shows the following characteristics: Under low power there is no evidence of round-celled infiltration between the fat cell or of fat necroses. The surface of the tissue which, in the microscopic specimen, was covered by a layer of grayish material, proves, under low power, to consist of a partly organized fibrinous deposit. At the base of this deposit is evidence of an extensive hemorrhage, marked by deposits of pigment. The surface of the membrane is of rough and irregular appearance, and contains a large number of round cells with deeply stained nuclei. Under high power the organization of the membrane may be traced from the base toward the surface. The portion immediately adjacent to the fat tissue consists of a network of fibrin inclosing large numbers of partly preserved red blood corpuscles. In many areas the red blood corpuscles are broken down and extensive deposits of pigment are found. Extending into the fibrin structure of the membrane are numerous typical fibroblasts and round cells. In some regions, pigment is evidently deposited in the bodies of large branching and spindle cells. Here and there, included in the membrane, are the remains of fat cells, and toward the surface of the membrane a large number of round cells scattered through the interstices of the membrane. There are but few polymorphonuclear leukocytes. Here and there in the membrane are fragments of isolated fibrous connective tissue with irregular contours and an appearance suggesting that they are fragments of tissue which have been displaced by violence and included in the fibrin deposit. The fibrin in the superficial layers of the membrane is formed in hyaline clumps. The organization along the base of the deposit is comparatively uniform.
     Sections stained with methylene-blue, carbol-thionin, and Gram’s method were carefully examined for the presence of bacteria, with negative results. Even upon the surface of the membrane there are no evidences of bacteria.
     The section of the left kidney, including the triangular area of hemorrhage described in the macroscopic specimen, reveals the following appearances: (Section hardened in formalin, stained with hæmatoxylin-eosin.) Examined macroscopically, section represents a portion of a kidney cortex made perpendicular to the surface of the cortex, and including an area of hemorrhage into the substance of the cortex 1 cm. in length, measured from the capsular surface downward, and presenting a width of from 5 mm. to 6 mm. The capsular surface has apparently been torn.
     Under low power the margins of the preparation are found to consist of well-preserved kidney structure. There is a slight amount of thickening of the interstitial tissue, and occasional groups of tubules are affected by beginning cloudy swelling. The glomeruli are large, and present a perfectly normal appearance. As we approach toward the center of the preparation, occasional glomeruli are met with in which the capillary loops are engorged and the adjacent tubules contain red blood-corpuscles. A short distance further, the kidney structure becomes entirely necrotic. Here and there the remains of tubules may be made out, and these are infiltrated with cells. The necrotic area presents a rough, net-like structure. As we approach toward the surface of the kidney, we find that the necrosis becomes more marked. There is the merest suggestion of kidney structure, its place being taken by disintegrated red blood-cells and leukocytes, embedded in a well-defined fibrinous network. There is great distortion of the kidney structure about the periphery of the necrotic area. In this region a considerable amount of pigment is also found in the necrotic tissues.
     Under high power, the characteristics of the necrotic tissues may be better observed. The kidney structure is broken up and torn into irregular fragments, infiltrated by red blood corpuscles and leukocytes. In the portion of the necrotic mass beneath the capsule, the kidney structure is practically obliterated, and is replaced by a network of fibrin, which includes large numbers of red blood-cells and leukocytes. Scattered through the entire necrotic area are frequent deposits of pigment.
     In the deeper portions of the necrotic area, the margins of the fibrin deposit are invaded by fibroblasts from the connective-tissue structure of the kidney. The organization in these areas is, however, slight.
     Sections stained with methylene-blue and Gram’s method and carefully examined under oil immersion, fail to reveal the presence of any organisms. In preparations stained with methylene-blue, the deposits of pigment may be readily observed. Section of the same tissue hardened in Hermann’s solution and examined for fat, shows the presence of numerous fat droplets within the epithelium of the tubules which are adjacent to the area of necrosis. In the portions of the preparation more widely distant from the area of necrosis, no fat is present.
     Section of the right kidney hardened in formalin and stained with hematoxylin-eosin reveals the presence of areas in which slight parenchymatous degeneration of the epithelium in the uriniferous tubules may be noted. These areas are not extensive, and are confined to single groups of tubules. The interstitial connective tissue of the organ seems to be slightly increased in amount, but there is no well-defined round-celled infiltration. An occasional hyaline glomerulus is to be met with in these cases surrounded by increased connective tissue. The epithelium of the kidney tubules, aside from these in which the parenchymatous degeneration is present, is well preserved. The nuclei are well stained; protoplasm, finely granular.
     A fragment of the stomach wall taken from the immediate neighborhood of the anterior wound is in a condition of complete necrosis. The nuclei of the cells are scarcely demonstrable. The epithelial surface is recognized with difficulty. At its base are apparently a few round cells. Examination of the blood-vessels reveals nothing characteristic. There is apparently no evidence of thrombosis. A section made through the gastric wall at some distance from the wound reveals the well-preserved muscular structure of the gastric wall, which presents no characteristic alterations. Superficial portions of the epithelium have apparently been affected by post-mortem digestion. However, in one portion of the preparation, the epithelium is intact, and shows distinct evidence of marked round-celled infiltration between the glandular structures. The blood-vessels contained blood corpuscles with the usual number of leukocytes.
     The fragments of heart-muscle which were removed from the right and left ventricular walls were examined in the fresh state, and exhibited a well-defined fatty degeneration of the muscle fibers, and in the case of the right ventricular wall an extensive infiltration between the muscle fibers, of fat, was apparent. Sections from these fragments of muscle hardened in Hermann’s solution are taken for examination. A fragment of muscle from the right ventricular wall was removed at a point where the fat penetrated deeply into the muscular structure, the ventricular wall at this point showing an average thickness of 2.5 mm. Under low power, the muscle fibers are separated into bundles by masses and rows of deeply stained fat cells. The muscle fibers are seen to contain groups of dark brown granules lying in the long axes of the cells. Under high power, these are resolved into extensive groups of dark brown pigment arranged around the nuclei. The muscle fibers are slender, the cross and longitudinal striation is well defined. Examined near the margin of the preparation, where the osmic-acid fixation has been successful, all of the muscle fibers are found to contain minute black spherical bodies, extending diffusely through all the muscle fibers about the entire margin of the preparation. These fine fat droplets are present in sufficient amount to speak of an extensive diffuse fatty degeneration of the muscle fibers. Where the large fat cells have separated the muscle fibers, these are found to be more a trophic [sic] than those in the central portions of the larger bundles.
     The examination of the section through the healed bullet wound on the chest walls reveals nothing of importance. The dissolution of continuity is filled in by granulation tissue, and there is evidence of beginning restoration of the epithelium from the margins. Stains for bacteria give negative results. [608][609]

     In summing up the macroscopic and microscopic findings of the autopsy, the following may be stated: The original injuries to the stomach-wall had been repaired by suture, and this repair seems to have been effective. The stitches were in place, and the openings in the stomach-wall effectually closed. Firm adhesions were formed upon the anterior and posterior walls of the stomach, which reinforced these sutures. The necroses surrounding the wounds in the stomach do not seem to be the result of any well-defined cause. It is highly probable that they were practically terminal in their nature, and that the condition developed as a result of lowered vitality. In this connection there is no evidence to indicate that the removal of the omentum from the greater curvature and the close proximity of both of these wounds to this point had any effect in bringing about the necrosis of the gastric wall, although circulatory disturbances may have been a factor. The fact that the necrotic tissue had not been affected by digestion strongly indicates that the necrosis was developed but shortly before death. The excavation in the fat behind the stomach must be largely attributed to the action of the missile. This may have been the result of unusual rotation of a nearly spent ball, or the result of simple concussion from the ball passing into a mass of soft tissues. Such effects are not unknown. The fact that the ball grazed the superior aspect of the left kidney shown by the microscopic investigation of that organ, indicates the direction of the missile, which passed in a line from the inferior border of the stomach to the tract in the fat immediately superior to the kidney. There was evidence that the left adrenal gland was injured.
     The injury to the pancreas must be attributed to indirect, rather than direct, action of the missile. The fact that the wall of the cavity is lined by fibrin, well advanced in organization, indicates that the injury to the tissues was produced at the time of the shooting. The absence of bacteria from the tissues indicates that the wound was not infected at the time of the shooting, and that the closure of the posterior gastric wound was effectual. The necrosis of the pancreas seems to us of great importance. The fact that there were no fat necroses in the neighborhood of this organ indicates that there was no leakage of pancreatic fluid into the surrounding tissues. It is possible that there was a leakage of pancreatic fluid into the cavity behind the stomach, as the contents of this cavity consisted of a thick, grayish fluid, containing fragments of connective tissue. In this case the wall of fibrin would have been sufficient to prevent the pancreatic fluid from coming in contact with the adjacent fat. The extensive necrosis of the pancreas would seem to be an important factor in the cause of death, although it has never been definitely shown how much destruction of this organ is necessary to produce death. There are experiments upon animals on record, in which the animals seem to have died as a result of not very extensive lesions of this organ. One experiment of this nature reported by Flexner (Journal of Experimental Medicine, Vol. II) is of interest. The fact that concussion and slight injuries of the pancreas may be a factor in the development of necrosis is indicated by the researches of Chiari (Zeitschrift für Heilkunde, Vol. XVII, 1896, and Prager med. Wochenschr., 1900, No. 14), who has observed (although a comparatively rare condition) extensive areas of softening and necrosis of the pancreas, especially of the posterior central portion which lies directly over the bodies of the vertebra, where the organ is most exposed to pressure or the effects of concussion. The wound in the kidney is of slight importance, except as indicating the direction taken by the missile. The changes in the heart, as shown by the macroscopic inspection and the microscropic [sic] examination, indicate that the condition of this organ was an important factor. The extensive brown atrophy and diffuse fatty degeneration of the muscle, but especially the extent to which the pericardial fat had invaded the atrophic muscle fibers of the right ventricular wall, sufficiently explain the rapid pulse and lack of response of this organ to stimulation during life.