The Case of President McKinley

THE following report has received the approval of, and is issued by, the undersigned, the medical staff attending the late President, William McKinley.

     October 12, 1901.

     Surgical History.—President William McKinley was shot, by Leon F. Czolgosz, in the Temple of Music, at the Pan-American Exposition, Buffalo, N. Y., at about 7 minutes past 4 on the afternoon of Friday, September 6, 1901. Two shots were fired. One bullet struck near the upper part of the sternum, and the other in the left hypochondriac region. The President was immediately conveyed to the Emergency Hospital on the Exposition grounds by the motor ambulance, where he arrived at 4.18. Dr. G. McK. Hall and Mr. Edward C. Mann, medical student, of the house staff were in charge of the ambulance, Medical Student T. F. Ellis being the driver.
     On arriving at the hospital, President McKinley was at once placed upon the table in the operating room and undressed. During the removal of his clothing a bullet fell out and was picked up by Mr. Ellis. Dr. Hall placed a temporary antiseptic dressing over the wounds, and Mr. Mann ordered a nurse to administer 0.01 gm. of morphine and 0.002 gm. of strychnine hypodermically.
     Dr. Herman Mynter, who had been telephoned from police headquarters to report immediately at the Exposition Hospital, was the first surgeon to arrive, at 4.45 o’clock. At that time Drs. P. W. Van Peyma and Joseph Fowler of Buffalo and Dr. Edward Wallace Lee of St. Louis were present. Dr. Mynter brought with him Dr. Eugene Wasdin of the United States Marine Hospital Service.
     Dr. Mynter inspected the President’s wounds, and immediately saw their serious nature. He told the President that it would be necessary to operate, and at once set about making preparations, aided by the house staff and nurses and Dr. Nelson W. Wilson, Sanitary Officer of the Exposition, who at that time assumed charge of the hospital in the absence of Dr. Roswell Park, the Medical Director of the Exposition. The President’s pulse on the arrival of Dr. Mynter was 84; he had no particular pain in the abdomen, and no apparent loss of liver dulness [sic]. He was evidently slightly under the influence of the morphine.
     Dr. Matthew D. Mann arrived at the hospital at 5.10 P.M., having been telephoned for by Mr. John C. Milburn. He was followed, five minutes later, by Dr. John Parmenter.
     An examination was at once made, followed by a short consultation between Drs. Mann, Mynter, and Wasdin, which resulted in the decision to operate at once. The necessity for the operation was explained to President McKinley, and he gave his full consent. Immediate operation was decided upon because of the danger of possible continued internal hemorrhage and of the escape of gastric or intestinal contents into the peritoneal cavity, and because the President’s pulse was getting weaker. Moreover, the daylight was rapidly failing. Dr. Roswell Park, who, by virtue of his office, had he been present would have performed the operation, was at Niagara Falls, and although a special train had been sent for him, it was uncertain when he would arrive.
     Dr. Mann was selected to do the operation, with Dr. Mynter as his associate, by the common consent of the physicians present and at the request of Mr. Milburn, President of the Pan-American Exposition, who stated that he had been requested by President McKinley to select his medical attendants. Dr. Mann selected Drs. Lee and Parmenter as assistants.
     At 5.20 Dr. Mann directed the administration of ether to President McKinley, and requested Dr. Wasdin to administer it. Ether was chosen as being, on the whole, the safer anæsthetic. While the anæsthetic was being given, the surgeons who were to take part in the operation prepared their hands and arms by thoroughly scrubbing with soap and water and immersing them in a solution of bichloride of mercury.
     The operation began at 5.29. Dr. Mann stood upon the right-hand side of the patient, with Dr. Parmenter on his right-hand side. Dr. Mynter stood upon the left-hand side of the patient, and on his right was Dr. Lee. To Drs. Parmenter and Lee were assigned the duties of sponging and the care of the instruments. Dr. P. M. Rixey, U. S. N., President McKinley’s family physician, having been detailed by the President to accompany Mrs. McKinley to the Milburn home, did not arrive until 5.30, when he gave very efficient service by guiding the rays of the sun to the seat of the operation by aid of a hand mirror, and later by arranging an electric light. Dr. Roswell Park arrived just as the operation on the stomach was completed, and gave his aid as consultant. Mr. E. C. Mann had charge of the needles, sutures, and ligatures. Mr. Simpson, medical student, was at the instrument tray.
     The nurses, under the charge of Miss A. C. Walters, superintendent of the hospital, were Miss M. E. Morris and Miss A. D. Barnes, with hands sterilized; Miss Rose Baron, Miss M. A. Shannon, and Miss L. C. Dorchester, assistants, and Miss Katharine Simmons attending the anæsthetizer.
     Besides those immediately engaged in the operation, there were present Drs. P. W. Van Peyma, Joseph Fowler, D. W. Harrington, and Charles G. Stockton of Buffalo, and Dr. W. D. Storer of Chicago.
     The Operation.—President McKinley took the ether well, and was entirely under its influence in nine minutes after the beginning of the anæsthetization. The abdomen was carefully shaved and scrubbed with green soap, and then washed with alcohol and ether and the bichloride solution.
     Inspection showed two wounds made by the bul- [601][602] lets. The upper one was between the second and third ribs, a little to the right of the sternum. The use of a probe showed that the skin had not been penetrated, but that the bullet had probably struck a button or some object in the clothing which had deflected it. The lower wound made by the other bullet—a 32 caliber—was on a line drawn from the nipple to the umbilicus. It was about half way between these points, and about 5 cm. to the left of the median line. A probe showed that this wound extended deeply into the abdominal walls, and that the direction was somewhat downward and outward.
     An incision was made from the edge of the ribs downward, passing through the bullet wound and nearly parallel with the long axis of the body. A deep layer of fat was opened, and followed by incision of the fascia and muscles to the peritoneum. After cutting through the skin, a piece of cloth, undoubtedly a bit of the President’s clothing, was removed from the track of the bullet, a short distance below the skin.
     On opening the peritoneum, the finger was introduced and the anterior wall of the stomach palpated. An opening was discovered which would not quite admit the index finger. This opening was located near the greater curvature of the stomach, and about 2 cm. from the attachment of the omentum; its edges were clean cut and did not appear to be much injured.
     The stomach was drawn up into the operation wound, and the perforation very slightly enlarged. The finger was then introduced and the contents of the stomach palpated. This was done to see if the stomach contained food, and also with the hope that possibly the bullet might be in the stomach. The stomach was found to be half-full of liquid food, but no evidence of the ball was discovered. In pulling up the stomach a small amount of liquid contents escaped, together with a good deal of gas. The tissues around the wound were carefully irrigated with hot salt solution and dried with gauze pads. The perforation in the anterior stomach wall was then closed with a double row of silk suture (Czerny-Lembert). The sutures were not interrupted with each stitch, but four stitches were introduced before the ends were tied. The loop was then cut off and the suture continued. About eight stitches were used in each row. The silk used was fine black silk, the needle being a straight, round sewing needle.
     In order to examine the posterior wall of the stomach it was necessary to enlarge the incision, which now reached about 15 cm. in length. The omentum and transverse colon were pulled well out of the abdomen. The omentum was enormously thickened with fat and very rigid. In order to reach the back wall of the stomach, it was necessary to divide about 4 inches of the gastrocolic omentum, the cut ends being tied with strong black silk in two masses on each side. In this way the stomach could be drawn up into the operation wound, and the bullet wound in its posterior wall reached. This opening was somewhat larger than that in the anterior wall of the stomach, and had frayed and blood-infiltrated edges. Its exact location was impossible to determine, but it appeared to be near the larger curvature.
     This opening was closed in the same way as the anterior wound, but with great difficulty, as the opening was down at the bottom of a deep pocket. A short curved surgical needle was necessary here. Little or no gastric contents appeared around this opening, but after it had been closed the parts were carefully irrigated with hot salt solution.
     The operation on the stomach being now finished, Dr. Mann introduced his arm so as to palpate carefully all the deep structures behind the stomach. No trace of the bullet or of the further track of the bullet could be found. As the introduction of the hand in this way seemed to have a bad influence on the President’s pulse, prolonged search for further injury done by the bullet or for the bullet itself was desisted from. The folds of the intestine which had been below the stomach were inspected for injury, but none was found. The entire gut was not removed from the abdomen for inspection, as the location of the wound seemed to exclude its injury. To have made a satisfactory search for wounds in the President’s back, it would have been necessary to have entirely eviscerated him. As he was already suffering from shock, this was not considered justifiable, and might have caused his death on the operating table.
     Before closing the abdominal wound, Dr. Mann asked each of the surgeons present, whether he was entirely satisfied that everything had been done which should be done, and whether he had any further suggestions to make. Each replied that he was satisfied. The question of drainage was also discussed. Dr. Mynter was in favor of a Mikulicz drain being placed down behind the stomach-wall. Dr. Mann, with the concurrence of the other surgeons, decided against this, as being unnecessary.
     As the last step in the operation, the tissues around the bullet track in the abdominal wall were trimmed in order to remove any tissue which might be infected. The abdominal wound was then closed with seven through-and-through silkwormgut sutures drawn only moderately tight, the superior layer of the fascia of the rectus muscle being joined with buried catgut. The edges of the skin were brought together by fine catgut sutures. Where the bullet had entered there was slight gaping of the tissues, but it was not thought advisable to close this tightly, as it might allow of some drainage. The wound was then washed with hydrogen dioxid and covered with aristol powder and dressed with sterilized gauze and cotton, which were held in place with adhesive straps. Over all was put an abdominal bandage.
     The President bore the operation very well. The time from the beginning of the administration of the anæsthetic until its discontinuance was exactly an hour and thirty-one minutes; the operation was completed at 6.50 P.M., having lasted from the time of the first incision, an hour and twenty-one minutes. At the beginning of the operation, President McKinley’s pulse was 84. At 5.38, 0.002 gm. of strychnine was administered hypodermically. At 5.55 the respiration was 32 and the pulse 84—both good in character. At 6.09 the pulse was 88. At 6.20 it was 102, fair in character; respiration 39. At 6.22, 1.50 gm. of brandy was administered hypodermically. At 6.48 the pulse was 124, the tension good but quick, respiration 36. At 7.01, after the bandage was applied, the pulse was 122 and the respiration 32. At 7.17, 0.004 gm. of morphine was administered hypodermically.
     At 7.32 the patient was removed from the hospital in the ambulance. Dr. Rixey asked Drs. Park and Wasdin to go in the ambulance, as his duty called him to go at once to inform Mrs. McKinley of her husband’s condition and to prepare a room for his reception. Drs. Mann and Mynter, with friends of the President, followed in carriages immediately after. President McKinley had not then recovered from the anæsthetic. He bore the journey to Mr. Milburn’s house exceedingly well, but it was found necessary to give him a small hypodermic injection of morphine during the transit, as he was becoming very restless. On arrival at the house of Mr. Milburn, 1168 Delaware Avenue, he was removed from [602][603] the ambulance on the stretcher and carried to a room in the northwest corner of the house, where a hospital bed had been prepared for him.
     Remarks on the Operation by Matthew D. Mann, M.D.  The difficulties of the operation were very great, owing partly to the want of retractors and to the failing light. The setting sun shone directly into the room, but not into the wound. The windows were low and covered with awnings. After Dr. Rixey aided us with a hand mirror, the light was better. Toward the end of the time a movable electric light with reflector was put in use. The greatest difficulty was the great size of President McKinley’s abdomen and the amount of fat present. This necessitated working at the bottom of a deep hole, especially when suturing the posterior wall of the stomach.
     The operation was rendered possible and greatly facilitated by a good operating table and the other appliances of a hospital, and by the presence of many trained nurses and assistants. Still, the hospital was only equipped for minor emergency work, and had but a moderate supply of instruments. Unfortunately, when called I was not told what I was wanted for, and went to the Exposition grounds entirely unprepared. Dr. Mynter had his large pocket-case, the contents of which were of great use.
     As has already been noted, further search for the bullet was rendered inadvisable by the President’s condition. The autopsy shows that it could not have been found, and that the injuries inflicted by the bullet after it passed through the stomach were of such a nature as to render impossible and unnecessary any further surgical procedure. A bullet after it ceases to move does little harm. We were often asked why, after the operation, we did not use the x-ray to find the bullet. There were several reasons for this. In the first place, there were at no time any signs that the bullet was doing harm. To have used the x-ray simply to have satisfied our curiosity would not have been warrantable, as it would have greatly disturbed and annoyed the patient, and would have subjected him also to a certain risk. Had there been signs of abscess-formation, then the rays could and would have been used.
     My reason for not draining was that there was nothing to drain. There had been no bleeding nor oozing; there was nothing to make any discharge or secretion; the parts were presumably free from infection, and were carefully washed with salt solution. As there was no peritonitis and the abdomen was found post mortem to be sterile, we may safely conclude that no drainage could have been provided which would have accomplished anything. My experience teaches me never to drain unless there is a very decided indication for it, as a drain may do harm as well as good.
     In conclusion, I wish to thank all the gentlemen who so kindly and skilfully assisted me. They were all surgeons of large experience in abdominal surgery, and their aid and advice were most valuable. Especially I wish to acknowledge my great obligation to my associate, Dr. Mynter. Not only was he an assistant, but he was much more, and helped me greatly by his skill and, as a consultant, with his good judgment and extensive knowledge of abdominal work. Although called first, he waived his claim, and generously placed the case in my hands, willingly assuming his share of the responsibility.
     The anæsthetic was most carefully administered by Dr. Wasdin, and the knowledge that he had charge of this very important duty relieved me of any anxiety on that score.
     In the eventful week that followed the operation, Dr. Park and Dr. McBurney were towers of strength in helping to decide the many difficult questions which came up.
     Dr. Rixey was in constant charge of the sick-room, aided later by Dr. Wasdin, who was detailed for this special duty. Both were unremitting in their care, and faithful to the end.
     Dr. Stockton helped us in the last three days with the highest skill and best judgment.
     Never, I am sure, under like circumstances, was there a more harmonious or better-agreed band of consultants. That our best endeavors failed was, I believe, no fault of ours; but it must be an ever-living and keen regret to each one of us, that we were not allowed the privilege of saving so noble a man, so attractive a patient, and so useful a life.
     The After-Treatment.—When put to bed the President was in fair condition: Pulse, 127; temperature, 100.6°; respiration, 30. The nurses on duty were Miss K. R. Simmons and Miss A. D. Barnes from the Emergency Hospital. Soon after his arrival, at 8.25, he was given morphine, 0.016 gm., hypodermically. There was slight nausea. The pulse soon improved. During the evening the patient slept at intervals, vomiting occasionally, but rallied satisfactorily. A slight discoloration of the dressings was noted at 10.45. There was occasional and slight pain. Ninety c.c. of urine was voided, and an enema of salt solution given and retained.

Second Day, Saturday, September 7.

     After midnight the patient slept a good deal; he was free from pain and quite comfortable.
     At 6 A.M., the temperature was 102°; pulse, 110; respiration, 24.
     Gas in large quantities was expelled from the bowels. A saline enema was given as before. Miss Simmons and Miss Barnes were replaced by Miss Maud Mohan and Miss Jane Connolly. Miss E. Hunt of San Francisco, Cal., Mrs. McKinley’s nurse, also rendered assistance, and Miss Grace Mackenzie of Baltimore, Md., arrived September 9, and was detailed for regular duty. P. A. Eliot, J. Hodgins, and Ernest Vollmeyer of the U. S. A. Hospital Corps were detailed as orderlies.
     During the forenoon, 0.01 gm. of morphine was administered hypodermically.
     At 1.15 P.M., a saline enema of 500 c.c. was given. As the pulse was rising, 0.06 gm. of fluid extract of digitalis was injected hypodermically.
     The President rested quietly until 6.30 P.M., when he complained of intense pain in the pit of the stomach, and was given 0.008 gm. morphine sulphate hypodermically. He was very restless, but after being sponged, rested again.
     At 6.30 P.M., the pulse was 130; temperature, 102.5°; respiration, 29.
     During the day the digitalis, morphine, and saline enemas were kept up at regular intervals; 4 gm. of somatose was added to the water at 10.30 P.M. At 11.15 P.M. the President passed from the bowels 240 c.c. of a greenish colored fluid and some particles of fecal matter.
     The total amount of urine for 24 hours was 270 c.c.

First Uranalysis, by Dr. H. G. Matzinger.

     Microscopic Examination.—The sediment obtained by centrifuge shows a great amount of large and small epithelial cells with some leukocytes and occasional red cells. There is a comparatively large number of hyaline casts, principally small, with some finely granular ones; also an [603][604] occasional fibrinous one. The amount of sediment is large for the quantity of urine submitted. There were no crystals in the sediment.

Third Day, Sunday, September 8.

     During the early morning the President slept a good deal, but was restless, and at times confused and a little chilly. On the whole, he passed a fairly good night.
     He expelled a little gas and brown fluid from the rectum. The digitalis was continued, and at 7.45 A.M. 0.002 gm. of strychnine was given hypodermically. At 8.20 A.M. he was clear and bright, with the pulse strong and of good character.
     The wound was dressed at 8.30, and found in a very satisfactory condition. There was no indication of peritonitis. Pulse, 132; temperature, 102.8°; respiration, 24.
     The dressing on the wound was changed because there was some exudation. The bullet track was syringed out with hydrogen dioxide. There was very little foaming, and there were no signs of pus.
     At 10.40 A.M., following an enema of Epsom salts, glycerin, and water, he had a small stool with gas, and another at noon. He was less restless and slept a good deal.
     At noon Dr. Charles McBurney joined the medical staff in consultation, having been summoned by Dr. Rixey.

     Bulletin 14, 12 m.—The improvement in the President’s condition has continued since the last bulletin. Pulse, 128; temperature, 101°; respiration, 27.

     During the day he continued to improve; he slept four or five hours and his condition was satisfactory.
     At 4.45 P.M., he was given a teaspoonful of water by the mouth; also an enema of sweet oil, soap, and water. He passed slightly colored fluid with some little fecal matter and mucus. After this he had a small quantity of water by the mouth, and at 6.20 P.M. a nutritive enema of egg, whiskey, and water, which was partly retained. Digitalis and strychnine were both given during the evening.
     At 9 P.M., the President was resting comfortably. The pulse was 130; temperature, 101.6°; respiration, 30.
     Four hundred and twenty c.c. of urine was passed during the day.

Second Uranalysis.

     Microscopic Examination.—Microscopic examination of sediment obtained by centrifuge shows fewer organic elements. Some large and small epithelial cells and some leukocytes. Casts are not so abundant as yesterday and are principally of the small finely granular variety. There is a marked diminution in small renal epithelial cells.
     Quite a quantity of large crystals of uric acid and bacteria are present.

Fourth Day, Monday, September 9.

     The bulletin tells the story of the fourth day.

     Bulletin 17, 6 a.m.—The President passed a somewhat restless night, sleeping fairly well. General condition unchanged. Pulse, 120; temperature, 101°; respiration, 28.
     Bulletin 18, 9.20 a.m.—The President’s condition is becoming more and more satisfactory. Untoward incidents are less likely to occur. Pulse, 122; temperature, 100.8°; respiration, 28.
     Bulletin 19, 3 p.m.—The President’s condition steadily improves and he is comfortable, without pain or unfavorable symptoms. Bowel and kidney functions normally performed. Pulse, 113; temperature, 101°; respiration, 26.
     Bulletin 20, 9.30 p.m.—The President’s condition continues favorable. Pulse, 112; temperature, 101°; respiration, 27.

     Codeine was substituted for morphine, as the pain was less. Digitalis and strychnine were stopped. Nutritive enemas were given at 3.20 A.M., at 4.30 and 10 P.M. Hot water was taken quite freely by the mouth.
     Attempts to get a good movement of the bowels were successful at noon, when he had a large light-brown, partly formed stool. This followed a small dose of calomel and a high enema of oxgall.
     On the whole, the President’s condition improved steadily during the day. He slept a good deal and was fairly comfortable. There was no pain on pressure over the abdomen.

Third Uranalysis.

     Microscopic Examination.—Microscopic examination of sediment obtained by centrifuge shows a decrease in the amount of organic elements and an increase of amorphous urates, but fewer crystals of uric acid. Casts are fewer and only the small granular and large hyaline varieties. The proportion of casts is greater. There are very few epithelial cells, mostly of renal type. A large number of cylindroids are found.

Fifth Day, Tuesday, September 10.

     Soon after midnight the President had a high enema of soap and water, which was expelled, together with some fecal matter. He took hot water frequently, and slept a good deal.

     Bulletin 21, 5.20 a.m.—The President has passed the most comfortable night since the attempt on his life. Pulse, 118; temperature, 100.4°; respiration, 28.

     On awaking he felt very comfortable, and his mind was clear and cheerful. The nutritive enemas were kept up, and water given by the mouth. Had two small stools during the day. The only medicine given was one hypodermic of codeine phosphate, 0.015 gm.
     In the evening the dressings were examined, and as there was considerable staining from the discharge, it was thought best to remove four stitches and separate the edges of the wound. A little slough was observed near the bullet track, covering a space nearly an inch wide, the thickness of the flaps. The separation seemed to extend down to the muscle. The surfaces, except those mentioned, looked healthy, but not granulating. It was supposed that the infection of the wound occurred either from the bullet or from the piece of clothing carried into the wound at the time of the shooting. The parts were thoroughly washed with hydrogen dioxide and packed lightly with gauze, and held together with adhesive straps.

Sixth Day, Wednesday, September 11.

     Bulletin 26, 9 a.m.—The President rested comfortably during the night. Decided benefit has followed the dressing of the wound made last night. His stomach tolerates the beef juice well, and it is taken with great satisfaction. His condition this morning is excellent. Pulse, 116; temperature, 100.2°.
     Bulletin 27, 3.30 p.m.—The President continues to gain, and the wound is becoming more healthy. The nourishment taken into the stomach is being gradually increased. Pulse, 120; temperature, 100.2°.
     Bulletin 28, 10 p.m.—The President’s condition continues favorable. Blood count corroborates clinical evidence of the absence of any blood poisoning. He is able [604][605] to take more nourishment and relish it. Pulse, 120; temperature, 100.4°.

     The blood count made by Dr. Wasdin in the evening was as follows:

     A little after midnight Wednesday morning, the patient was given 4 c.c. of beef juice, the first food taken by the stomach. It seemed to be very acceptable. Nutritive enema was given at 2 A.M.; later there was a yellow stool.
     From 4 to 8 c.c. of beef juice was given every one to two hours during the day. The rectum was becoming irritable, and did not retain the nutritive enemas well.
     At 10 A.M. the remaining stitches were removed, the wound separated and dressed. It seemed to be doing well. Most of the sloughing tissue had separated.
     The patient slept much during the day, and expressed himself as feeling very comfortable. The only medicine administered was one hypodermic of strychnine.
     In the evening he was changed to a fresh bed. Nutritive enemas were continued.
     Urine was passed much more freely—750 c.c. in twenty-four hours.

Fourth Uranalysis.

     Microscopic Examination.—Microscopic examination of sediment obtained by centrifuge shows a marked diminution in amount of organic elements, but a great increase in uric-acid crystals.
     There are very few epithelial cells—mostly of renal type.
     There are fewer casts—small and large hyaline—some finely granular.
     Cylindroids are more abundant.

Seventh Day, Thursday, September 12.

     The President slept a good deal during the night, and awoke in the morning feeling better. The beef juice was continued and increased, and a little chicken broth added to the dietary. He also had a little whiskey and water.
     At 8.30 A.M. he had chicken broth, a very small piece of toast and a small cup of coffee. He did not care for the toast, and ate scarcely any of it.
     The wound was dressed and washed with a weak solution of iodine and then with hydrogen dioxide. He was given 30 c.c. of castor oil at 9.20 A.M.
     The President now seemed at his best and his condition to warrant the favorable prognosis given out. The time for peritonitis and sepsis had passed. The bowels had moved and gas passed freely, showing that there was no obstruction. The tongue was clear, and the appetite increasing; and he seemed to be able to digest food. There was no pain nor tenderness in the abdomen, and he was able to turn easily and to sleep on his side. The urine was steadily increasing. His spirits were good and his mind clear, while his pulse, though frequent, was strong and of good quality, and the temperature low.
     The analysis of the urine gave no uneasiness, as the amount of urea was fair; there was no albumin worth considering, and the casts were rapidly diminishing. There were no more of them than are found in a large percentage of cases following a long operation under ether. The excess of indican was taken to mean merely some intestinal indigestion, and to be of no serious import. The only symptom to cause any uneasiness was the frequency of the pulse. Still, anxiety on this score was relieved by knowing that the President had naturally a rapid pulse, and that it was easily excited. The open wound was not considered important. It looked healthy, and, although it would take a long time to heal, in itself it was evidently causing no harm, nor was it likely to.
     Dr. McBurney left Buffalo for his home in the morning, having arranged to return at once if his presence was desired.
     Toward noon it was noticed that the character of the pulse was not quite so good. Infusion of digitalis, 8 c.c., was ordered, and strychnine, 0.002 gm.
     It was thought probable that there was some intestinal toxæmia, as there had been no free movement from the bowel since food had been begun, the oil having failed to act. Gradually the pulse went to 130, and grew weaker.
     Dr. Charles G. Stockton was added to the medical staff in consultation. At 7 P.M. the President was given 0.20 gm. of calomel.

     Bulletin 32, 8.30 p.m.—The President’s condition this evening is not quite so good. His food has not agreed with him, and has been stopped. Excretion has not yet been properly established. The kidneys are acting well. His pulse is not satisfactory, but has improved in the last two hours. The wound is doing well. He is resting quietly. Temperature, 100.2°; pulse, 128.

     At 9.30 P.M. a second dose of 30 c.c. of castor oil was given, followed by a high enema of oxgall. This resulted in a large, dark semifluid stool, which seemed to exhaust him somewhat. Stimulants were given freely. No more beef juice or food was given. The pulse grew rapidly worse, but at midnight there seemed some improvement, as bulletin 3 [sic] shows. At 11 P.M. 420 c.c. of normal salt solution was given subcutaneously.

     Bulletin 33, 12 m.—All unfavorable symptoms in the President’s condition have improved since the last bulletin. Pulse, 120; temperature, 100.2°.

Fifth Uranalysis.

     Microscopic Examination.—Microscopic examination of sediment obtained by centrifuge shows fewer organic elements than the last examination. There is less uric acid and a large amount of amorphous phosphates. Renal casts, about as in the last examination, with very few cylindroids.

Eighth Day, Friday, September 13.

     At midnight the pulse was fairly good, 132. Strychnine and whiskey were given at intervals, and hypodermics of camphorated oil.

     Bulletin 34, 2.50 a.m.—The President’s condition is very serious, and gives rise to the gravest apprehension. His bowels have moved well, but his heart does not respond properly to stimulation. He is conscious. The skin is warm, and the pulse small, regular, easily compressible, 126; respiration, 30; temperature, 100°.

     The wound had been dressed regularly in the manner described three times a day. At 9 A.M. the dressing was changed, and a mixture of balsam of Peru and glycerin put in on gauze after the douching.
     Stimulants were continued as before, but more freely. Coffee, 45 c.c., and clam broth, 60 c.c., were given; also liquid peptonoids.
     At 8.30, 1.50 gm. of adrenalin was given hypodermically, and repeated at 9.40.
     At 10 A.M., nearly two pints of normal salt solu- [605][606] tion was given under the skin, and one pint containing adrenalin at 6 P.M. Nitroglycerin and camphor were also injected, at various times, together with brandy and strychnine.
     Stimulants as detailed above were used freely all day.
     3.30 P.M. Pulse growing weaker.
     5.00 P.M. Oxygen given and continued for some hours.
     6.30 P.M. Last bulletin, No. 39.

     Bulletin 39, 6.30 p.m.—The President’s physicians report that his condition is most serious in spite of vigorous stimulation. The depression continues and is profound. Unless it can be relieved, the end is only a question of time.

     At 6.35 P.M., and again at 7.40, morphine was given hypodermically, as he was very restless and seemed to be suffering.
     9.00 P.M. Heart sounds very feeble.

     The President continued to sink, becoming weaker and weaker.
     At 10:00 P.M., the oxygen was discontinued. The heart sounds were very feeble and consciousness lost.
     The President died at 2.15 A.M., September 14.
     Drs. E. J. Janeway and W. W. Johnston, who, at the request of Dr. Rixey, had been summoned in consultation, arrived too late, but were present at the autopsy. Dr. McBurney also returned on Friday afternoon.

Sixth Uranalysis.

     Microscopic Examination.—Microscopic examination of sediment obtained by centrifuge, before and after clearing, shows no change from yesterday’s sample. Casts, hyaline and granular, both large and small, comparatively few. Cylindroids, a few. Crystals, large amount of uric acid, some sodium urate, and in the untreated specimen a large amount of amorphous deposit, principally of phosphates. There are a few epithelial cells, small, granular. Occasional red cells and leukocytes.