Some of the Surgical Aspects of the Assassination of President McKinley

     Within the past thirty-five years, three presidents of the United States have been stricken down by the murderous weapon of an assassin.
     In each instance there were several features of striking surgical interest. In all three, the resources of science and art were impotent; we may say, that their wounds were from the beginning mortal.
     In the case of the illustrious Lincoln, the missile entered the skull just posterior to the right ear, about an inch from the torcular, tore widely open the lateral sinus and lodged in the brain substance. The commotion transmitted through the emcephalon was so great that the anterior fossa of the base of the skull was widely fissured and the supra orbital plates shivered into fragments.
     Consciousness was lost and mortal symptoms immediately supervened, death following in six hours.
     In President Garfield’s case, the missile entered from behind, tearing through the thick lumbar muscles and the body of the ninth dorsal vertebra, in transit wounding the spinal cord. During life the position of the bullet could not be located. [260][261]
     Immediately on being shot, the President fell to the ground, was soon in deep shock with signs of paralysis of both lower extremities. The President lingered nearly four months before the end came.
     In this case, for several weeks after the murderous assault, there were some very good reasons for expecting an ultimate recovery. He survived the immediate danger of mortal hemorrhage, the paralysis improved, there was no evidence of perforation of the hollow viscera, he had fair digestive power, besides, he was a person of good habits, with a robust constitution. But, as time sped on, it was obvious that the unfortunate man was doomed, the effects of shock lingered, infection set in, metastatic suppuration followed, with a steady rise of temperature; increasing exhaustion and final loss of digestive power; added to this continued pain and loss of rest. The patient had made a brave fight for his life, but the odds were against him.
     It was thought at that time—20 years ago—that could the missile be only located and extracted, the patient’s life might have been saved.
     Laparotomy at that time for penetrating wounds of the abdomen, was yet untried, and of the floroscope or the Roentgent Rays nothing was known. Lister was then working out his system of antiseptics, and many had adopted it, but it was only in its trial stages, and was by no means generally employed. On autopsy, after the viscera of the abdomen were removed, the bullet was found, well encysted in the pancreas. At that time, all that the resources of the healing-art could accomplish was to aid the processes of nature and alleviate symptoms.
     Since that epoch, very considerable advances have been made in operative medicine, but let no one delude himself with an impression that they are of as widespread a character as some would have us believe. We have no means yet which will enable us to overcome the effects of age, nor to prevent the death of tissues, after what Cowan well describes as “the local shock to parts after a traumatism.” We cannot well mend a shattered spine, nor restore tissues which have been destroyed.

The Third Assassination.

     The medical aspects of the late President McKinley’s case in many respects are the most extraordinary and unique on record. No doubt, but for years to come, they will occupy an important place in the annals of surgery, and serve as an object to the rising generation of practitioners.
     Too much haste and too much optimism seemed to be the conspicuous features here. About four hours after eating a mid-day lunch, while standing in an erect position, the President was shot twice, at very short range, not more than one or two feet—the cartridge being 32 calibre. One ball struck the sternum and glanced, the other pierced the abdomen one inch above and to the left of the umbilicus—immediately over the hypogastrium—a highly vital area. For the moment, the President was dazed rather than shocked; he gazed for a moment on the assassin and sat down. It does not appear from the bulletins, that immediately after the assault the President showed any signs of grave constitutional disturbance, of large hemorrhage or great shock. Almost immediately he was removed in an ambulance to the Emergency Hospital, and within one hour after the shooting he [261][262] was on the operating table.
     The active participators in the laparotomy consisted in one gynaecologist, a member of the medical staff of the Navy, a professor of surgery, and a visiting surgeon on the grounds. The chief surgeon of the hospital, Dr. Roswell Park, was not present when the operation began but was there soon after.
     Now, why this haste till Park arrived, or until a larger number of experienced general surgeons could be called, that deliberate council could be had?
     But why, may be enquired, a moment’s delay when there are good grounds of suspecting the penetration of a hollow viscus?
     To such we must answer that the lessons of Stimpson’s statistics on “Results after interference, and non-interference in penetrating gun-shot wounds of the abdomen,” the writings of Reclus, the records of the Cuban war, and those up to date in the Transvaal, have been lost, as all of these clearly demonstrate that few escape a mortal end, after laparotomy for gun-shot wounds, while a large number recover under expectant treatment.
     Rarely, or perhaps, it may be said, never do we find a double perforation of the gastric walls without co-incident damage to other important organs, the liver, spleen, the pancreas, kidney or lungs; in one such case in the writer’s hands, mortal hemorrhage came from the left kidney, in another the internal iliac artery was opened and a fatal secondary hemorrhage into the left pleural cavity occurred.
     In the case of Mr. McKinley, it is said that one and one-half hours were consumed in the operative procedure. This seems a long time, but to one who has ever encountered the difficulties of suturing a posterior perforation in the mobile, living stomach, it certainly implies no lack of skill, but to employ what prophylactic we may, the immediate or ultimate shock succeeding is invariably very great. This following immediately on the shock of the assault, tries the vital powers to their utmost, and certainly enfeebles the reparative processes of the system. There is no case of recovery yet recorded after laparotomy for gun-shot wound of the stomach in one over 50 years old.
     The optimistic bulletins, the sanguine expectations, the “absence of sepsis and of peritonitis,” “the normal blood count,” the certainty of recovery while tissue asphyxia, decomposition and sphacelus were slowly but steadily undermining life, seem indeed quite incomprehensible. In a case of this character of world-wide notoriety, the effect of the laity must certainly tend to discredit the prognosis, the opinion of physicians and the boast of the profession that medicine is approaching an exact science.
     Far better for the prestige and honor of the profession had it been if the medical staff had taken a determined stand and firmly resisted the importunities of friends and the press, and stubbornly refused to commit themselves until all chances of error in prognosis were impossible.