The President’s Case

Life is Short, the Art is Long, the Time is Urgent; Experience Fallacious, and Judgment difficult.
                                                                                                                   — Hippocrates.          

     The triumphant life, the tragic death of William McKinley, the twenty-fifth President of the United States has passed into history.
     During the fateful days which followed the cruel blow of an assassin, all the world stood still and centered their vision upon that hospital couch where science struggled mightily with death.
     In spite of every resource death won.
     But though nations come and go, republics flourish or wither, rulers pass away, the healing art moves on, and the surgeon will turn from the keen disappointment as to the outcome of this illustrious case to a study of its scientific aspects.
     It is therefore not out of place to devote several pages of this issue to the correct official records of the case of President McKinley, in a form which many readers will undoubtedly find worthy of preservation for future reference.
     From a technical standpoint it is admitted that the case is beyond adverse criticism. All that human skill, knowledge, promptness, daring and an overmastering sense of duty could accomplish were devoted to the President’s case. The most brave and skillful of modern surgeons gave their best knowledge to the saving of that valuable life. From the autopsy it is evident that the best directed medical skill was doomed from the beginning to be frustrated—the unexpected happened.
     To ascertain the cause of the results in this case, and if possible to provide against its recurring, many able men will bend their energy. The future treatment of wounds of the abdomen will be placed upon a firmer basis and a better footing than ever before. Because this life was lost many lives will be saved.
     Grand and noble in his life, in dying William McKinley will have advanced the cause of surgery, and in so doing he has not suffered and died in vain.

THE OPERATION.

     President McKinley was wounded at about 4:30 p. m. Sept. 6th. In less than a half hour he was removed to the Emergency Hospital on the Exhibition Grounds. He was received by the son of Dr. Mann, the acting house surgeon, hypodermic injections were at once administered and preparations made for the operation. In less than an hour after the bullet was fired the operation was begun.
     It was found that two bullets of 32-calibre had struck the President from the front, at close range. One ball struck the sternum on the left side, between the second and third ribs, but did not penetrate. The second bullet penetrated the abdomen at a point two and one-half inches to the left of the median line, and at a level of about one and one-half inches above the umbilicus.
     An incision five inches in length was carried into the abdomen following the trajectory of the bullet. The anterior wall of the stomach was found to be perforated. This was satured [sic] with fine black silk. The intestines were inspected but no injury found. A perforation over one inch in diameter was found in the posterior wall of the stomach. This was lacerated irregularly, and with contused edges. This wound was also suured [sic] with fine silk.
     The course of the bullet after passing through the stomach could not be traced. But little peritoneal contamination was present. The abdominal cavity was thoroughly irrigated with normal surgical salt solution and closed without drainage. In this latter procedure through and through-sutures of silk worm gut were used, and the facia brought together with catgut. The wound was finally covered with aseptic gauze held in place by “Z O” Adhesive plaster and bandages.
     While yet under the influence of the anesthetic, the patient was conveyed to the residence of Mr. Milburn, the President of the Exposition. Dr. Rixey re- [191][192] mained at the house continuously. Consultations of all the physicians were held three times each day. No profound shock followed the operation. From the time of the operation to the end, the pulse was rapid and erratic, and gave great concern to the attendants. The temperature, however, fell. There was no abdominal tenderness, no meteorism, no muscular contraction. Examination of the blood showed no leucocytosis, and the fear of peritoneal sepsis gradually disappeared.
     Nutritive enemata were given, but were not retained. Broths given by the mouth were retained. The only solid food given was a bit of toast well soaked in broth, administered the fifth day. Indican was present in the urine, but this disappeared after evacuation of the bowels was secured. On the sixth and seventh day heart stimulants, digitalis, adrenalin [sic], oxygen inhalation, etc., were resorted to, but there was no reaction from the stimulation. The urine examinations were negative. The President suffered no pain, and in the absence of positive indications, hope was not abandoned until the seventh day.
     The following is the official report of the autopsy:
     “The bullet which struck over the breastbone did not pass through the skin and did little harm. The other bullet passed through both walls of the stomach near its lower border. Both holes were found to be closed by the stitches, but the tissue around each hole had become gangrenous. After passing through the stomach the bullet passed into the back walls of the abdomen, hitting and tearing the upper end of the kidney. This portion of the bullet track was also gangrenous, the gangrene involving the pancreas. The bullet has not yet been found. There s [sic] no sign of peritonitis or disease of other organs. The heart walls were very thin. There was no evidence of any attempt at repair on the part of nature, and death resulted from the gangrene which affected the stomach around the bullet wounds as well as the tissues around the further course of the bullet. Death was unavoidable by any surgical or medical treatment, and was the direct result of the bullet wound.”

ABSTRACT OF OFFICIAL BULLETINS.

     Friday, Sept. 6.—7 p.m.—The operation successfully performed. The President stood the operation well. Condition in general gratifying; justifies hope of recovery.
     10:50 p.m.—Is rallying satisfactorily and resting comfortably.

     Saturday, Sept. 7.—1 a.m.—Free from pain and resting well.
     3 a.m.—Continues to rest well.
     5 a.m.—Has passed a good night.
     9 a.m.—No serious symptoms have developed.
     3:30 p.m.—Continues to rest quietly; no change for the worse.
     9:30 p.m.—Condition much the same. Responds well to medicine.

     Sunday, Sept. 8.—3:20 a.m.—Has passed a fairly good night.
     9 a.m.—Has passed a good night and condition is quite encouraging. Mind is clear and he is resting well; wound dressed at 8:30 and found in a very satisfactory condition. There is no indication of peritonitis.
     12 m.—The improvement in the President’s condition has continued since last bulletin.
     4 p.m.—Since the last bulletin has slept quietly, four hours together since 9 o’clock. Condition satisfactory to all physicians present.
     9 p.m.—Is resting comfortably and there is no special change since last bulletin.

     Monday, Sept. 9.—6 a.m.—The President passed a somewhat restless night, sleeping fairly well. General condition unchanged.
     9:20 a.m.—Condition becoming more and more satisfactory. Untoward incidents are less likely to occur.
     3 p.m.—The President’s condition steadily improves and he is comfortable, without pain or unfavorable symptoms. Bowel and kidney functions normally performed.
     9:30 p.m.—Condition continues favorable.

     Tuesday, Sept. 10.—7 a.m.—The President has passed the most comfortable night since the attempt on his life.
     9 a.m.—Condition this morning is eminently satisfactory to physicians. If no complications arise, a rapid convalescence may be expected.
     3:20 p.m.—There is no change since this morning’s favorable bulletin.
     10:30 p.m.—The condition of the President is unchanged in all important particulars. When the operation was done on Friday last it was noted that the bullet had carried with it a short distance beneath the skin a fragment of the President’s coat. This foreign material was, of course, removed, but a slight irritation of the tissues was produced, the evidence of which appeared only to-night. It has been necessary on account of this slight disturbance to remove a few stitches and partially open the skin wound. This incident cannot give rise to other complications. In consequence of this separation of the edges of the surface wound the healing of the same will be somewhat delayed. The President is now well enough to begin to take nourishment by the mouth in the form of pure beef juice.

     Wednesday, Sept. 11.—6 a.m.—Passed a very comfortable night.
     9 a.m.—Rested comfortably during the night. Decided benefit has followed the dressing of the wound made last night. Stomach tolerates beef juice well, and it is taken with great satisfaction. Condition this morning is excellent. [192][193]
     3:30 p.m.—Continues to gain and the wound is becoming more healthy. The nourishment taken into the stomach is being gradually increased.
     10 p.m.—Condition continues favorable. Blood count corroborates clinical evidence of absence of any blood poisoning. Is able to take more nourishment and relish it.

     Thursday, Sept. 12.—6:20 a.m.—Has had a comfortable night.
     9:30 a.m.—The President has spent a quiet and restful night, and has taken much nourishment. He feels better this morning than at any time. He has taken a little solid food this morning and relished it.
     3 p.m.—Condition very much the same as this morning. His only complaint is of fatigue. He continues to take a sufficient amount of food.
     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.
     12 m.—All unfavorable symptoms have improved since last bulletin.

     Friday, Sept. 13.—1:50 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 and easily compressible.
     9 a.m.—Condition has somewhat improved during the past few hours. There is a better response to stimulation. He is conscious and free from pain.
     2:30 p.m.—Has more than held his own since morning, and his condition justifies the expectation of further improvement. Is better than yesterday at this time.
     4 p.m.—Only slightly improved since last bulletin.
     5:35 p.m.—The President’s condition is grave at this hour. He is suffering from extreme prostration. Oxygen is being given. He responds to stimulants but poorly.
     6:30 p.m.—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.
     9:30 p.m.—The President is dying.

     Saturday, Sept. 14.—2:15 a.m.—The President is dead.

ROLL OF HONOR.

     The medical and surgical attendants of President McKinley who so well performed a grave public duty under most trying circumstances, will ever be honored by an appreciative public. Conscious of the fierce glare of public opinion, the distinguished patient’s surgeons accepted their tremendous task.
     The operation was not a difficult one, but it was the fact that the censure of the nation and the criticism of the surgical world would fall with tremendous force upon the slightest mistake in judgment or technique, that required the fortitude. To their credit let it be recorded that there was no hesitancy, no delay, no shrinking from responsibility, no red tape. Their consistent and dignified action, the celerity and skill with which they performed their duties will ever be regarded with pride by their professional brethren.
     In less than an hour after the illustrious patient was wounded, he was operated upon in the Emergency Hospital in the Exposition Grounds. Dr. Matthew D. Mann, Professor of Obstetrics and Gynecology, University of Buffalo, performed the operation. He was assisted by Dr. Herman Mynter, Professor of Operative Surgery, University of Buffalo, Dr. John Parmenter, Professor of Anatomy and Clinical Surgery, University of Buffalo, and Dr. E. Wallace Lee of St. Louis. Dr. Eugene Wasdin of the Marine Hospital Service administered the anesthetic (ether). Dr. Presley M. Rixey, the President’s physician, and Dr. Roswell Park, Professor of [S]urgery, University of Buffalo, arrived before the operation was complete. Dr. Charles McBurney of New York was sent for as consultant and arrived the following day. On the sixth day Dr. Charles G. Stockton of Buffalo, Dr. Edward G. Janeway of New York and Dr. W. W. Johnson of Washington were summoned as medical experts.
     The male nurses in attendance were Palmer A. Elliott, Ernest Vollmeyer and John Hodgins of the Army Medical Service.
     The female nurses were Miss Helen Mohan, Miss Conley, Miss Hunter and Miss Grace McCullogh.

THE HOSPITAL AND THE DRESSINGS.

     No small amount of credit is due to the medical management of the Pan-American Exposition, in that through their foresight they had established a completely equipped Emergency Hospital on the Exposition Grounds. Thus it was possible to give to the nation’s illustrious patient without delay, the advantages of all the appliances known in the technique of modern surgery. The equipment of this hospital was faultless for emergency service, and without ostentation, delay or confusion its staff responded to this most unexpected draft upon its resources. [193][194]
     The surgical dressings used in this Hospital are those of Johnson & Johnson’s manufacture exclusively. These dressings were used in the first instance of the operation upon the President, and afterward during the entire course of the case.
     The makers of these dressings and the surgeons in attendance, while realizing the great responsibility with the eyes of the world focused upon that wound, never for one moment doubted the reliability of the dressings used. So far as the dressings were concerned all was perfect. There was no inflammation, no pus, no irritation. Probably no greater compliment could be paid to the integrity of the dressings used in this remarkable case, than the final report of the surgeons at the autopsy: “Death was unavoidable by any medical or surgical treatment.”

AUTOPSY NOTES.

     On opening the abdomen, the wall of which was two and one-half or three inches in thickness, the omentum was found adherent all around the wound of operation. This wound was five inches long, extended down to the muscle and was healthy in appearance, no gangrene being present. The omentum was healthy and no signs of peritonitis were evident. The intestines were smooth and shiny without adhesions or exudate. The mesentery of the transverse colon was adherent to the stomach wound. On loosening these adhesions, the sutures of the wounds of the anterior and posterior walls of the stomach were found tight and in place, allowing no leakage.
     Around the sutures, however, there was a zone of total gangrene of the wall of the stomach about two inches in diameter and ready to slough.
     From the wound in the posterior wall of the stomach it was found that the bullet passed through the transverse mesocolon near its attachment, thence through the posterior layer of peritoneum cutting a groove into the upper end of the left kidney, and entering into the retro-renal fatty tissue. The whole track of the bullet presented the appearance of a gangrenous hole, the gangrene in the retro-renal tissue being of the size of a fist. From this point the bullet passed into the posterior muscular tissue and could not be found, although careful search was made for four hours.