The President’s Wounds

     After the first shock caused by the inhuman crime perpetrated upon President McKinley has passed, the question of paramount interest to every citizen is, what hope have we that this valuable life will be spared to the nation? In the light of surgical knowledge and experience with similar injuries, what are the chief dangers and on what ground can we place our hopes for the President’s recovery?
     The details received at the time of writing are not quite so full as we should like. From the information received, however, it seems that the crime was committed about 4 P. M., and about three hours after the ingestion of food. The wounds were caused by two bullets from a short-barreled revolver, fired from directly in front and at a range of about one foot.
     The first shot struck the sternum at about the nipple line and was deflected, traveling just under the skin to a point immediately below the left nipple. The second bullet entered the abdomen at a point two and a half inches to the left of the median line, and at a level of about half an inch above the umbilicus. The would-be assassin and the President were standing directly in front of each other, and the weapon was held in the right hand. Arguing from the course of the first bullet, the course of the second, it seems almost certain, was from before directly backwards and from above slightly downwards. This would lead us to think that unless deflected after entering the body, which, however, is not very likely, its course would carry it through the lower anterior wall of the stomach a little to the cardiac side of the middle, through the stomach, making a wound of exit in the posterior wall a little lower than the wound of entrance. Then it would reach the posterior abdominal wall at a point near or at the left crus of the diaphragm, a little above the kidney.
     The chest wound is probably not dangerous, for it seems to be merely a non-penetrating wound of the chest of a kind which, although painful and sometimes difficult to heal, is practically without mortality. One important fact which this wound shows is that the muzzle velocity of the bullet was not very great, as evinced by the fact of its not penetrating the sternum, although fired from directly in front. This is not a favorable circumstance, for bullets of lesser velocity produce the larger and more ragged wounds.
     The immediate dangers from such an abdominal wound are hemorrhage from an injury of the great vessels situated to the left of the spinal column, wound of the pancreas, which is usually immediately fatal, and injury to the spinal cord by penetration of the spinal canal by the bullet. Time has shown that all these dangers have been mercifully escaped, and now there remain only the secondary effects to be feared.
     By far the greatest of these secondary dangers is peritonitis, yet there are two factors that give us hope that the President will escape this complication. These are an empty stomach at the time of injury and prompt operation by skillful hands.
     The first of these is most important, as the empty stomach would, of course, cause less soiling of the general peritoneal cavity. Nevertheless there are many cases in which the contents of the stomach have extremely soiled the peritoneal cavity, in which recovery has followed operation. In fact, the stomach is less apt to contain virulent micro-organisms than any other part of the intestinal canal. The statistics of early operation for perforation of the different parts of the alimentary canal are very gratifying, and even in the perforations of typhoid fever, where there are present many factors which would lead us to fear a lethal termination, which are not present in President McKinley’s case, the results have been brilliant.
     The immediate operation by the skillful surgeons by whom it was done, and the time that has already elapsed, make it almost certain that there is no danger of peritonitis from the primary soiling of the peritoneum. Peritonitis might possibly arise later from leakage at the site of the repaired wounds in the stomach, either by the wounds being opened by the peristaltic movements of the stomach or by sloughing of the sutures, but this is extremely unlikely, for the same reason that prevented the primary peritonitis.
     Perhaps next to peritonitis uremia is most to be [413][414] feared, together with the other dangers inseparable from an extensive operation upon a man of the President’s age. These dangers are, however, minimized because of the skillful hands in which the President is placed and because of his temperate habits.
     An injury to the spine can be ruled out, as it would surely have shown itself before this.
     Injury to the kidney would have been shown by blood in the urine, and a retro-peritoneal or free peritoneal hemorrhage. The greatest danger here, aside from a free hemorrhage, is a secondary retro-peritoneal abscess, which would be a serious but not necessarily fatal complication.
     Should the bullet be lodged in the muscles of the back it will probably give no trouble; should it do so, however, it can readily be located by the aid of the X-rays and removed.
     As long ago as 1822, long before the days of aseptic surgery, there was reported the famous case of Alexis St. Martin, who was shot in the abdomen with a musket ball and received far more extensive lesions than appear to have been inflicted upon President McKinley, and yet under the care of Dr. William Beaumont the patient recovered and lived for many years, although with a gastric fistula.
     There are other remote effects of the injury that may possibly interfere with the President’s subsequent health, such as contraction of the cicatrices of the wounds in the stomach or adhesions between the stomach and other organs. It is, however, too soon for the discussion of these points.
     In summary, the three chief dangers by which the President is threatened are peritonitis, retro-peritoneal abscess, and uremia. The first seems most important, but prompt aseptic surgery has done very much to minimize this. The second, retro-peritoneal abscess, depends on an infection of the final resting place of the bullet and, although very serious, is not necessarily fatal. The third, uremia, depends largely upon the previous state of the patient’s kidneys, which is unknown to us.
     So, though we cannot deny that the crime of Czolgosz has greatly imperiled the life of the Chief Executive, yet we have strong grounds for the hope that this valued life will be spared to us for many long years to come.