The Case of the Late President

     The death of President McKinley plunged the whole people into grief, but upon no portion did that grief fall more poignantly than upon our profession, for upon it rested the responsibility of the attempt to save his life. The attempt failed; and because it failed the profession has the right, we believe, to examine and review the case as managed by its representatives.
     Briefly the facts, as reported to the New York Medical Journal by its own special reporter, are these: The President was shot on the afternoon of September 6, at 4.07 P.M. At 6.50 P.M., two hours and forty-three minutes after the deed was committed, the President had been removed to a hospital, operated upon, and the wound closed. The operation consisted in tracing the course of the bullet through the abdominal wall, both walls of the stomach, whence its apparent course was into the deep muscles of the back. The lacerations of the stomach were repaired, the external wound closed and the bullet left to look out for itself. At the close of the operation the pulse was 122, respiration 32. After the operation the patient was removed to the house of his host, Mr. Milburn, and the outcome was waited in breathless suspense.
     From this time until the 10th inst. the case apparently progressed favorably, the temperature ranging from 104.4 to 99.8 (most of the time temperature about 101), the respiration from 24 to 34 and the pulse from 104 to 146, most of the time about 120. During this time encouraging bulletins were given to the public, and to anxious inquirers about the bullet assurance was given that it was imbedded in thick muscular tissue where it would do no harm. [507][508]
     On the 11th, at 10 P.M., we were assured “the President’s condition continues favorable,” notwithstanding the pulse had risen in the past thirty-six hours from 104 to 120 and temperature from 99.8 to 100.4. In the same bulletin we are told, “He is able to take more nourishment and relish it,” from which we infer that he was being fed by the mouth. During the 12th, the bulletins continued favorable, the temperature remaining at 100.2 and the pulse at 116 to 120. After 3.30 P.M. of the 13th the President’s condition grew gradually worse, the temperature becoming lower with a gradually accelerated pulse, until the good man passed away at 2.15 A.M., September 14.
     The autopsy showed that the course of the bullet had become gangrenous throughout but as no mention is made of any gangrene about the external wound, we believe the inference is just that it extended from within out, from the location of the bullet. The bullet has never been located. While it would be unjust in the extreme to pass judgment on the management of the case until all available data are at hand, and while no one can doubt for an instant that those in attendance put their best effort and skill into the management of the case, there are certain questions that continually arise in the medical mind which for the honor of the profession we hope in the near future will be satisfactorily answered. Some of these questions which have suggested themselves are: Taking into account the extreme mortality in gun-shot wounds of this character, varying from one recovery in three thousand cases before the days of modern surgery to a mortality of from 52 to 90 per cent. in modern times (see Phil. Med. Journal, Sept. 14, 1901) were the optimistic reports during the first week justified, especially considering the marked inequality between the pulse and temperature rates? If so, on what grounds is such extreme optimism based?
     Ought not the discrepancy above mentioned, between the pulse and the temperature, have given a hint at least that the [508][509] bullet was not behaving as innocuously as was claimed and led to the employment of the X-ray, whereby the bullet might be located and possibly removed and proper drainage established? Why, on the sixth day after a laparotomy, was food put into the stomach with two gun-shot wounds in it? Why was the bullet not located at the autopsy?
     That “in a multitude of counsellors [sic] there is strength,” there is no doult [sic] but it is equally true sometimes that “too many cooks spoil the broth,” and it has occurred to us on some previous occasions that distinguished patients have had their chances of recovery imperiled by too much advice.