President McKinley’s Case

     The attention of the medical and surgical world of two continents is centered just now upon the post mortem developments in President McKinley’s case. The question which has arisen, concerning the probable cause of gangrene found along the track of the wound, is one of intense interest and importance to the profession, not only because it is an incident of great public prominence, but from a strictly scientific standpoint. Suggestions have been made, (1) that the bullet may have been poisoned; (2) that the pancreas was wounded permitting an escape and oozing of its secretion into contiguous tissues; (3) that the patient was diabetic. It is, of course, possible that any one of the above mentioned conditions may have existed; yet it seems to us that the first and third suggestions are highly improbable, while the facts themselves in the second are disputed, it being claimed that the pancreas was secondarily involved as the result of the necrotic process and not as a cause.
     The gangrene or death of a given tissue or cell is the result of nutritive failure: i. e., either no nutriment is brought to the cell (capillary circulation here being stopped), or else the toxic waste products of cell irritation are allowed to accumulate and choke absorption,—and the cell languishes in the midst of its own excreta. In other words, the normal inter- [339][340] change between blood and tissue being interrupted, the latter dies for lack of nutriment. In the President’s case there has been no evidence of the existence of an embolus which checked arterial flow to the affected parts; but, rather, the symptoms have pointed to a vitiated blood, together with a partial capillary stasis. There seems to have been an entire loss of reparative energy owing to the presence of some disturbing factor, and the question arises whether such agent was introduced from without or generated within. Did the irritation caused by the passage of a non-poisoned bullet, or even by the incision of the surgeon’s knife, result in the establishment of a local toxemia similar to that observed in the diabetic patient when injured or operated upon?
     The frequent association of gout and diabetes has caused much speculation of late as to the probable similarity of origin of these two complaints, and much food for reflection is afforded us in this case of the President. Was he suffering from a gouty diathesis, and were retrograde tissue products present in excess which served as a disturbing factor. We are informed by his physicians that excretion was illy performed by the patient throughout his illness. In considering the infective materials generated in the act of inflammation, Dr. Jonathan Hutchinson writes as follows: “Whilst there can be little doubt that the introduction at the time of the injury of some living germ matter (bacillus), developed in connection with the process of inflammation in the contributor, very greatly adds to the risk and gives character to the inflammation induced, there are good reasons for doubting whether any such material is essential. It is highly probable that in some instances a chemical product of decomposition may take its place, and further, that in some cases no poison of any kind has been introduced. In the latter group we have to suppose that the tissues of the person wounded are capable of generating as the result of merely mechanical irritation a poison which shall prove infective. We have to accept the proposition—in all probability the truth—that the inflammatory process, however initiated, is always attended by the production of a virus (living, or chemical, or both). Inflammation in its early stages always leads to multiplication of modified cell organisms which may be infective; in its later stages it leads to death of cells and may favor the access to the blood of the chemical elements, the result of decomposition which may prove very injurious.” (Charlotte Medical Journal, September, 1898, p. 320). [340][341]
     “The importance of careful preparation of the patient when operations within the abdominal cavity are about to be done,” says Prof. Augustin Goelet, of New York, “is universally admitted, yet it often falls short of the actual requirement, because insufficient time is allowed. Something more is necessary than the clearing out of the intestinal tract and examination of the urine to exclude albumen and sugar. When practicable, where immediate operation is not demanded, from one to three weeks at least should be consumed in getting the patient in condition. Careful preparation will lessen the shock of exposure of the peritoneal cavity, minimize the unpleasant effect of the anæsthetic and render the convalescence smoother. It will also facilitate the work of the surgeon by overcoming intestinal distention, enabling him to do better work in a shorter time and will materially lessen the mortality following abdominal operations. It is particularly important to establish a normal functionating [sic] activity of the excretory organs—especially the liver. For thoroughly cleaning out the intestinal tract and establishing a proper functional activity of the liver preparatory for operation, a heaping teaspoonful of thialion is given in a glassful of hot water an hour before breakfast. Every intervening night and morning a similar dose of thialion is given to maintain an active condition of the bowel which it does by exciting the flow of bile. There is no other drug the continuous administration of which acts so reliably and satisfactorily without deleterious effect. It may be continued for days producing two or three free evacuations each day without the least depression. It arrests fermentation not alone by discharging bile into the intestines, but also by re-establishing a normal alkalinity of their contents, and at the same time it increases the secretion of urine and renders it alkaline.” [Cf. Charlotte Med. Jour., Dec., 1898.]
     In other words, it is the belief of the above author, that to obtain best results in an operation of this character, we should strive to secure the elimination of the peccant materials by keeping the excretory organs in good working order and by strengthening the cells and tissues in their fight against their destroyers. All this was, of course, impossible in the President’s case. Immediate operation was demanded, and without it death was certain. But is there not here a lesson to be derived? Does not the case of this illustrious patient—whose sedentary mode of life led to the impairment of the metabolic functions and gradual accumulation of toxic waste products within the system and which paralyzed reparative energy when the occa- [341][342] sion demanded—indicate to us the importance of maintaining a proper functional activity of the excretory organs? “When,” (as one writer states), “the truth is once thoroughly understood and appreciated that anything which interferes with the functional activity of the excretory organs and prevents the free elimination of poisons, not only causes the blood to become loaded with toxic materials, and thus renders it less able to take up the retrograde products of cell activity than when it contains a comparatively small amount of these materials, but that the poisoned blood less readily conveys the nutrient material which is absolutely necessary for the life and health of the cells, and that the accumulating poisons inhibit their activity and lessen their power to recognize and combat maleficent agents,—when, I say, we once fully appreciate the importance of these truths and realize to how great an extent the welfare of the body depends on the consentaneous activity of the cells, the blood and the excretory organs, we will be able to appreciate the importance of auto-intoxication as an active factor in the production of disease.”