CHAPTER XXI.

TWO OF OUR PRESIDENTIAL TRAGEDIES.

The Mortal Wounds of Garfield and McKinley Scientifically Compared-The Case Professionally Considered and a Most Interesting Study Made of the Medical Mysteries Attending the Death of the Two Latest Presidents Elected from Ohio.

The names of Garfield and McKinley have been coupled together in the speech of millions all over the world during the sad first September of the century. The widow of President Garfield has lived over again the sorrows of the summer that was so fearful for her. It is horribly strange that two men of Ohio, distinguished on the battlefield and in the House of Representatives, and elected President on their merits, both men combining immense capacity with incessant industry, should receive mortal wounds from two depraved egotists, each of the murderers equipped with a pistol, one shooting his victim selected as the head of the nation for slaughter. The assassin of Garfield shot him in the back, and was hidden in the recess between a door and a window, and unnoticed until the President of the United States walked in, accompanied by the Secretary of State, James G. Blaine, when there was a sound of a fire cracker and Garfield fell; McKinley, extending his hand as an act of courtesy to a citizen, who managed to force himself almost into contact with the President, and shot him through a handkerchief. There never were more venomous reptile scoundrels born than the murderers of the two Presidents who were representative of the high civilization of a great industrial community. It happened that the funeral of McKinley was on the anniversary of the death of Garfield.

There were two shots fired by the murderer in each case. Garfield was hit first slightly in the left arm, a mere flesh-wound, as was the first received by McKinley. The Journal of the American Medical Association says:

The second and fatal wound of President Garfield was caused by a 44-caliber bullet from a British bulldog revolver, fired from the rear. The result of the autopsy showed how completely the distinguished surgeons in attendance had been deceived as to the real nature of the injury; for instead of passing through the liver, transversing the

abdominal cavity, and lodging in the anterior wall, as was thought, the wound was entirely extra-peritoneal. The records of the autopsy leave no room for doubt, for the post-mortem was made by the President's eight surgeons themselves and the report was signed by all. The official announcement of its results said:

"It was found that the ball, after fracturing the right eleventh rib, had passed through the spinal column in front of the spinal canal, fracturing the body of the first lumbar vertebra, driving a number of small fragments of bone into the adjacent soft parts and lodging below the pancreas, about two inches and a half to the left of the spine and behind the peritoneum, where it had become completely encysted.

"The immediate cause of death was secondary hemorrhage from one of the mesenteric arteries adjoining the track of the ball, the blood rupturing the peritoneum and nearly a pint escaping into the abdominal cavity. An abscess cavity, 6x4 inches in dimensions, was found in the vicinity of the gall-bladder, between the liver and the transverse colon, which were strongly adherent. It did not involve the substance of the liver, and no communication was found between it and the wound. A long suppurating channel extended from the external wound between the loin muscles and the right kidney almost to the groin. This channel, now known to be due to the burrowing of pus from the wound, was supposed during life to be the track of the ball.”

While the immediate cause of President Garfield's death is said to have been secondary hemorrhage, such a result was due to a sloughing blood vessel, one of the usual terminations of septic cases. President Garfield had pyemia. His symptoms indicated it; the autopsy proved it. The question has been asked a thousand times during the last few days on account of the favorable bulletins reporting President McKinley's condition, if his distinguished predecessor in office could have been saved by modern surgery. Possibly he could, though it is optimistic and presuming too much to say that such a result would have been, as has so often been said in the recent past, reasonably certain.

A 44-caliber revolver bullet fracturing the rib, then crashing through the body of a lumbar vertebra and driving a number of fragments into the soft parts, thence lodging behind the pancreas, makes a wound and condition not to be despised by even the boldest and deftest of modern operators. Moreover, President Garfield was a stout man, which would have increased the difficulties. Were such a bullet promptly located

to-day by the X-Rays, any experienced and conscientious surgeon would hesitate as to his course. If he elected to remove the bullet, again he would be embarrassed to know whether it were best to choose the anterior or posterior route. A laminectomy is a comparatively simple operation in a thin subject, but to reach the body of a vertebra, much less go anterior to it, as would have been necessary to have recovered the ball and removed the spiculæ of bone driven forward by it, in a patient of President Garfield's build, would have taxed both the anatomical knowledge and surgical daring of the greatest of his surgeons, the gifted Agnew. If the anterior route were chosen, one has only to think of the important vessels and nerves superimposed on the bullet, and almost in contact with it. By either, anterior or posterior route, the danger from hemorrhage would of necessity have been great.

Again, can we say that pyemia has been banished from surgery? Certainly not; rare it is, to be sure, at present; but President Garfield had just the kind of a wound that is to-day, with all our much-vaunted aseptic and antiseptic surgery, difficult to treat and uncertain in its results. Compound fractures, especially of soft bones such as vertebra and ribs in inaccessible situations, constitute the most fertile cause of pyemia to-day. Moreover, pyemia following bone injuries is admittedly more fatal than pyemia following injury to soft parts. Therefore, there should not have been at the time so much criticism of those brave and skillful men who labored incessantly for nearly three months to save their distinguished patient. Now that the matter is up again for discussion, it should be the duty of medical men, particularly, to set matters and history right, and not encourage the belief, so general, that President Garfield's wound, fatal in 1881, would be trivial to-day. It was fatal in 1881 and would probably be fatal in 1901. Mistakes may have been made, but even if they had not been, there is little likelihood that the nation would have been spared the poignant grief at the bril liant Garfield's untimely taking-off and the disgrace of a second murdered President.

President McKinley was shot from the front with a 32-caliber ball entering five inches below the left nipple and one and one-half inches to the left of the median line. It transversed the abdominal cavity, perforating both anterior and posterior walls of the stomach, the opening in the former being small, the one in the latter large and ragged—just the character of wound usually made by a pistol ball at close range.

After thorough closure of the gastric wounds, from which there had been some extravasation, a careful search was made for other possible injuries. None was discovered, and the surgeons were reasonably certain that the bullet had found lodgment in the muscles of the back. The abdominal cavity was freely irrigated with normal salt solution and closed without drainage by through-and-through sutures of silkworm gut. A small piece of clothing-presumably from the undershirt-had been carried in by the bullet, but was, we understand from the statements given out, found in the abdominal portion of the wound.

In exploring the abdomen, Dr. Mann acted wisely in enlarging the original wound, rather than performing median section. Irrigation of the cavity is to be distinctly commended; likewise the use of interrupted sutures, saving as they do the loss of time, and facilitating to no inconsiderable degree, when rightly placed, drainage two important elements in the President's condition.

Whether or not provision should have been made for further drainage depends entirely upon the existing conditions, and they were best judged by the distinguished surgeons charged with the responsibility of saving, if possible, the most precious life in the world. The profession has had the utmost confidence in each of them; the nation has shown its gratitude for the promptness with which their awful responsibility was assumed, and the thoroughness and ability with which it was carried out.

If the operation had been hurried there might be some reason to feel that possibly each step of it could not have been considered as judiciously as the occasion demanded. Such was not the case; the President was under ether an hour and a half, and was in such good condition all the time that there was no demand made upon the operator for haste. The autopsy shows that good judgment was shown in not prolonging search for the ball.

In declining to use the X-rays subsequently, notwithstanding the general anxiety as to the ball's exact location, the surgeons were judiciously passive and followed the teachings of the greatest of military surgeons. A second anesthesia and operation for the extraction of a 32caliber bullet in the muscles of the back would, under the circumstances, have been not only injudicious, but censurable. One cannot forbear to say at this time that the Roentgen rays are not an unmixed blessing, as death has followed operations for encysted bullets that were

doing no harm at the time of their removal. One of a yielding nature may be induced to act against his better judgment, on account of the anxiety and importunings of patient and friends, always greater than they should be, but due to an exaggerated importance given by laymen to the "ball" and its recovery. Those who knew the President's surgeons personally have felt assured from the first that no precipitate action would be taken to meet a danger largely chimerical in its nature, whilst urgent, portentous, awful problems were pressing forward for solution. What were the probabilities when it was known that President McKinley, a man fifty-eight years old, with a weak heart, had sustained a penetrating wound of the abdomen? Death, undoubtedly, was the likelier issue. When, however, the details of the operation were given on Saturday morning, and it was recalled that the President was shot at 4:30 in the afternoon, when his stomach was presumably empty, or nearly so, more than a modicum of comfort and hope was felt by a stricken nation. The operation had been promptly done; it had been thoroughly well done; it had been done by the best exponents of modern surgery. The incidents of the first, second, and third days-the period of greatest danger-were distinctly favorable to the President's recovery, though his abnormally high pulse rate caused uneasiness. It had all along been out of proportion to the temperature and respirations, but it was explained as being usual with him. The fourth and fifth days served only to fortify his surgeons in the opinion already expressed that he would recover. It seemed that he would and that he should get well; yet there were still dangers ahead to which a too hopeful and impulsive people were oblivious. They came on the sixth day, and had practically ended this magnificent life in another twenty-four hours!

Of the exact causes leading to the change which resulted in death, we shall know more when the full report of the autopsy is published. This will be after cultures have been made and a histological examination has been completed. When this full scientific report is officially given out it will be time to discuss the cause which led to the necrotic condition found at the autopsy, but not before. Until then at least there should be no criticism of the management of the case, and full credence should be given to the official bulletins signed by the attending surgeons, and to these only. The absence from Buffalo of the nearest relatives of President McKinley at the time of the unfavorable change