Case of the Late President M’Kinley

     We have refrained from occupying space in preceding issues of this journal with anything in connection with the lamentable tragedy that not only shocked but was a most serious blow to the entire nation. The secular press with its daily telegraphic service, the weekly medical and other publications have with succeeding issues supplied such facts as were obtainable and much useless conjecture and opinions, some of which needed very material revision; and our monthly confreres, some premature, others with more matured facilities have not been sparing in the use of printers’ ink so that anyone might be advised as to the saddening and grievous theme. Personally we have had opportunities through other channels of placing our opinion on record as to our sincere sorrow that the citizens of this great republic for the third time in a brief generation have been destined to mourn and lament under so grievous a calamity. On being called upon at a meeting of the Nashville Academy of Medicine, at its regular meeting on the Tuesday following the closing of so sad a page in the nation’s history for an expression of opinion on the cause of death, we find that the opinion then expressed with the limited opportunities afforded at that time have been sustained by the final report in full of the surgeons and medical advisors in charge of the case.
     The leading weekly medical publications, headed by the Journal of the American Medical Association have given in full this report, which is doubtless in the hands of many of our readers. We regret that our limited space necessitates restricting ourselves to the following abstract, which is hereby submitted for the benefit of those of our many reader [sic] who may not have seen the report in full:
     The report lays emphasis on the complete harmony that existed among the physicians. It says of the operation that the utmost care was used to prevent infection of the abdominal cavity and of the wound. The wounds in the stomach were sutured with silk, using double rows of stitching so arranged that the greatest possible security was given to the sutured spots. The application of these stitches was accompanied by great difficulties, especially the sutured opening of the superior wall of [517][518] the stomach. The chief trouble was the depth of the abdominal cavity, the lack of instruments to draw the edges of the wound apart during the sewing and the lack of good light.
     Speaking of the search for the bullet during the operation, the report says:
     The operation on the stomach now being finished, Dr. Mann introduced his arm so as to palpate carefully all the deep sutures 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.”
     It was decided not to introduce any gauze or tubes into the abdomen for drainage, as this was not necessary, but the wound was not sewed up so tightly that no drainage could take place naturally.
     On the fifth day, September 10, took place the much discussed removal of stitches from the wound in the abdominal wall. The report says:
     “In the evening the dressings were examined, and as there was considerable staining from the discharges, it was thought best to remove four stitches and to 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 suppuration seemed to extend down to the muscle.
     “The remainder of the wound looked healthy, and it was thought that the infection was due to the bullet or to a piece of clothing which had been carried into the wound at the time of the shooting. The wound was then dressed and on the following day the patient’s condition was very much improved.
     “The findings at the autopsy, as well as the developments of the case during the last days, exclude all possibility of absolute injury to the stomach by premature giving of solid food, as was alleged at the time when unfavorable symptoms came on after change to solid food.
     “On the fifth day the President sipped hot water, on the sixth he had beef juice, the first food taken by mouth since the operation.
     “In the meantime nutritive enemas were given, but were not well retained. At 8:30 o’clock on the morning of the seventh day he was allowed 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 had in the meanwhile been doing very well and had been dressed daily after the removal of the stitches and the sloughing tissue.
     “The President seemed at his best and a favorable result was now confidently predicted. There was no sign of blood poisoning or of inflammation of the peritoneum. The only alarming symptom was his rapid pulse, but as the President had naturally a rather rapid pulse and as it had been of a fairly good quality right along, the surgeon did not attribute very great importance to this sign. On the seventh day, towards noon, [518][519] the pulse began to grow weaker and grew rapidly wore [sic]. Stimulants were given and the food was discontinned [sic], while castor oil and an enema of ox gall were given to move the bowels. At midnight there was some improvement in the pulse after an injection of salt solution into the subcutaneous tissue. On the eighth day the condition of the President was described as very serious, as he did not respond to stimulation. Stimulants and injections of salt solution, coffee and broth were given, but without much effect.
     At 5 o’clock oxygen was given and continued for some hours.
     At 6:30 o’clock the President was restless, at 10 P. M. he lost consciousness and continued to sink until he died at 2:15 A. M. on September 14.”
     In speaking of the criticism that Roentgen rays should have been used to locate the bullet, Dr. Mann says in his report:
     “We were often asked why, after the operation, we did not use the X-ray to find the bullet. 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 X-ray could and would have been used.”
     The report of Dr. Harvey R. Gaylord, pathologist to the New York State Pathological Laboratory, on the autopsy, is lengthy and detailed. The abdominal wound shows no evidences of necrosis or sloughing. No inflammation of the peritoneum was found. The wound in the front wall of the stomach was found “held intact by silk sutures,” but the area of stomach wall around it was discolored, grayish green and easily torn. The area around the wound on the posterior wall of the stomach was also of a dull gray color, but the sutures held the wound intact.
     Behind the latter wound there was a spot of discoloration which showed that the sloughing process had gone backwards in the track of the bullet. The gangrenous cavity found behind the stomach involved the pancreas and the surrounding loose tissues, the bottom of the blind pocket being formed by the upper end of the left kidney, which was found to be lacerated at that point to the extent of about 2 centimeters.
     The track of the bullet was then traced through gangrenous tissues in the fat behind the kidney to the muscles of the back wall of the abdomen; the direction of the bullet, however, could not be traced any further. The search for the bullet was most thorough and painstaking, but in spite of all efforts it could not be found, and the autopsy had to be discontinued because the time allotted to it by the family of the late President had already been exceeded.
     Examination of the heart muscle showed that it was affected with well marked fatty degeneration and in some places the muscle fibres showed groups of dark brown granules, demonstrating a diseased condition of the cardiac muscle.
     Dr. Gaylord believes that the repair to the stomach wounds had been [519][520] effective and that the gangrene around these wounds does not seem to have been the result of any well-defined causes. He attributes the gangrenous condition of the tissues solely to lowered vitality in the parts. The appearance of the gangrenous tissues showed that the gangrene took place shortly before death.
     In speaking of the causation of the cavity behind the stomach he says that it must largely be attributed to the action of the missile. It may have resulted from the rotation of a nearly spent ball or from the simple concussion of the bullet as it passed into the soft tissues.
     The injury to the pancreas, producing a cavity within it, occurred during the passage of the bullet, because the cavity was found walled off by fibrin in an advanced organization. There was no leakage of pancreatic fluid into the surrounding tissue. The extensive gangrene of the pancreas seems to have been an important factor in the case, though it had never been shown how much of this organ must be destroyed to cause death. The wound in the kidney is of no importance except as showing the track of the bullet.
     The diseased condition of the heart muscles shows why the pulse was so frequent and and [sic] why it did not respond to stimulation at the critical time.
     The report of the bacteriologist, Dr. Herman G. Matzinger, is largely what we may call “negative,” i. e., it concerns rather the absence of germs than their presence. As the result of an examination of various tissues and fluids removed, Dr. Matzinger concludes that “the absence of known pathogenic bacteria, particularly in the gangrenous cavity, warrants the conclusion that bacterial infection was not a factor in the production of the condition found in the autopsy.
     A chemical analysis by Dr. Hill of the remaining bullets and of the contents of the cartridge chambers in the murderer’s pistol showed that there was no poisonous material, thus disposing of the theory of a poisoned bullet.
     We can but congratulate those in charge of the case as having discharged their duties faithfully, courageously, and with a careful attention to every detail from beginning to end; and if all succeeding cases of gunshot wounds in this locality and of approximate character, receive similar treatment, we fully believe that it will but add additional lustre to the surgical achievements of the day. In this case there were special conditions of a constitutional character over which the highest degree of surgical art and skill could have no control. That day may come, but it has not yet.
     Some premature discussion has already been indulged in coming from various sources, in regard to the compensation of those in charge of the case. It may be presumptious [sic] in making such a suggestion, but we cannot but think if the matter is entirely ignored by those directly interested, and is left entirely to the people, their representatives who will assemble in Washington in December next, will surely appreciate the situation sufficiently to appoint a suitable committee who will look carefully into [520][521] the matter and recommend a proper appropriation for a liberal remuneration to each and every one of those who devoted the best of their abilities untiringly and zealously in the discharge of such responsible duties as fell to their lot.