McKinley was shot twice at close range on Sept. 6, 1901. One bullet bounced harmless off his sternum and did not enter his body 1a. The other entered the left upper quadrant of his abdomen, piercing the front and back walls of the stomach 1b. He underwent surgery within hours. He survived the operation, but died on the ninth post-operative day. Both his post-operative course MORE 2a and his autopsy SEE BELOW 2b have been meticulously documented 3 4. There was intense controversy about McKinley's medical care MORE. Some thought that McKinley could have been saved had renowned surgeon Roswell Park performed the operation MORE. More recent commentators believe, however, that McKinley died from pancreatic necrosis, a condition which is still difficult to treat today, and which the surgeons of McKinley's time could not have treated or prevented 1.
Ordinary signs of death; ecchymosis in dependent portions of the body. Rigor mortis well marked. Upon the surface of the chest to the right of the midsternal line a spot 1 cm. in diameter, dark red in color, with a slight scab formation covering it; measuring from the supersternal notch the distance is 5 1/2 cm.; from the right nipple, 10 cm.; from the line of the right nipple, 8 1/4 cm. Surrounding this spot, at which point there is an evident dissolution of the continuity of the skin, is a discolored area of oval shape extending upward and to the right. In its greatest length it is 11 cm., and in its greatest width, 6 cm. It extends upward in the direction of the right shoulder. The skin within this area is discolored; greenish yellow and mottled. The surface of the abdomen is covered with a surgical dressing which extends down to the umbilicus and upward to just below the nipples. The innermost layer of cotton is covered or stained with balsam of Peru and blood. On removing this dressing a wound is exposed. Inserted in the wound are two layers of gauze, likewise impregnated with balsam of Peru. The wound has been packed with gauze saturated with the same substance. The wound is 14 1/2 cm. in length and is open down to the abdominal muscles. The layer of abdominal fat is 3 3/4 cm. in thickness. The appearance of the fat is good, a bright yellow in color. No evidence of necrosis or sloughing. In the left margin of the surgical wound, lying 1 cm. to the right of a line drawn from the umbilicus to the left nipple, 15 1/2 cm. from the nipple and 16 1/2 cm. from the umbilicus, is a partly healed indentation of the skin, and an excavation of the fat immediately beneath it. This extends down to the peritoneal surface. The base of the surgical wound is formed by folds of omentum. On making the median incision, starting from the supersternal notch and extending to a point just below the symphysis, the subcutaneous fat is exposed, which is of bright yellow color and normal appearance, except in an area which corresponds superficially to the area of discoloration described as surrounding the wound upon the chest wall. In this area the fat is of a red color, the connective tissue structure is infiltrated with dark red pigment. The subcutaneous fat is firm and measures 4 3/4 cm. in thickness. On opening the sheath of the right rectus muscle it is seen to be of dark red color. (Culture taken from ecchymotic tissue under the upper bullet hole and from between the folds of the small intestine.) (Three tubes from each locality on agar and gelatine.)
On opening the abdominal cavity the parietal surface of the peritoneum is exposed and is found to be covered with a slight amount of bloody fluid; is perfectly smooth and not injected. The great omentum extends downward to a point midway between the umbilicus and the symphysis. It is thick, firm; its inferior border is discolored by coming in contact with the intestines. Below the umbilicus a few folds of intestines are exposed. These are likewise covered with discolored blood, after the removal of which the peritoneal surface is found to be shiny. On the inner aspect of the abdominal wound the omentum is found to be slightly adherent to the parietal peritoneum, and can be readily separated with the hand from the edge of the wound. (Culture taken at this point, the surface of the wound.) At this point the omentum is somewhat injected. This adhesion to the omentum is found to extend entirely around the abdominal wound. The peritoneum immediately adjacent to the inner aspect of the abdominal wound is ecchymotic. In the omentum immediately beneath the abdominal wound is an incision, 5 cm. from the medial line and extending downward from the margin of the ribs 8 cm. On removing the subcutaneous fat and muscles from the thoracic wall, the point which marks the dissolution continuity of the skin upon the surface is found to lie directly over the margin of the sternum and to the right side between the second and third ribs. There is no evidence of ecchymosis or injury to the tissues or muscles beneath the subcutaneous fat. On making an incision through the subcutaneous fat directly through the wound upon the surface a small cavity is exposed about the size of a pea just beneath the skin, which is filled with fluid blood. (A section of tissue, including the lower half of the wound and extending through the subcutaneous fat, is taken for examination. The upper portion of the wound is removed for chemical examination.) The subcutaneous tissue underlying the area of discoloration on the surface of the chest wall shows hemorrhagic infiltration.
On removing the sternum the lungs do not extend far forward. A large amount of pericardial fat is exposed. Pleural surface on both sides is smooth. There are no adhesions on either side within the pleural cavities. The diaphragm on the right side extends upward to a point opposite the third rib in the mammary line. No perceptible amount of fluid in either pleural cavity. On opening the pericardial cavity the surface of the pericardium is found to be smooth and pale. The pericardium contains approximately 6 c.c. of straw-colored, slightly turbid fluid (some taken for examination).
On exposing the heart it is found covered with a well-developed paniculus. The heart measures from the base to the apex on the superficial aspect 10 1/2 cm. The right ventricle is apparently empty. The heart feels soft and flaccid. On opening the left ventricle a small amount of dark red blood is found. The muscle of the left ventricular wall is 1 1/2 cm. in thickness; dark reddish brown in color; presents a shiny surface. The average thickness of the pericardial fat is 3 1/2 mm. (Blood taken from the auricle for examination.) The left auricle contains but a small amount of dark, currant-colored blood. The mitral valve admits three fingers. The right ventricle, when incised in the anterior line, is found to be extremely soft; the muscular structure is 2 mm. in thickness. The paniculus measures 7 mm. The muscle is dark red in color; very shiny.
On opening the right auricle it is found to be filled and distended by a large currant-colored clot which extends into the vessels. The tricuspid orifice admits readily three fingers. The coronary arteries were patulous and soft; no evidence of thickening.
On unfolding the folds of intestine there is no evidence of adhesion until a point just beneath the mesocolon is reached, when, on removing a fold of small intestine a few spoonfuls of greenish gray thick fluid flows into the peritoneal cavity. On the anterior gastric wall is an area to which a fold of the omentum is lightly adherent. On breaking the adhesion there is found a wound about midway between the gastric orifices, 3 1/2 cm. in length, parallel with the greater curvature of the stomach, 1 1/2 cm. from the line of omental attachment. This wound is held intact by silk sutures. The cardiac end of the stomach is free. There is no evidence of adhesion at any other point on the anterior wall. The gastric wall surrounding the wound just mentioned, for a distance of 2 or 3 cm., is discolored, dark, greenish gray in appearance, and easily torn. On exposing the posterior wall of the stomach from above along the greater curvature of the stomach the omentum is found to be slightly adherent, a line of silk ligatures along the greater curvature of the stomach marking the site where the omentum had been removed. On throwing the omentum downward the posterior gastric wall is exposed. On the posterior wall of the stomach, a distance of 2 cm. from the line of omental attachment, is a wound approximately 2 cm. in length, held intact by silk sutures. The gastric wall surrounding this wound is discolored. On the surface of the mesocolon, which is posterior to the gastric wall at this point, is a corresponding area of discoloration, the portion coming directly in contact with the wound in the gastric wall being of dull gray color. The remainder of the surface of the posterior wall of the stomach is smooth and shiny. Beyond the surgical wound in the posterior wall of the stomach is found an opening in the retro-peritoneal fat large enough to admit two fingers. This opening communicates with a tract which extends downward and backward as far as the finger can reach. The tissues surrounding this tract are necrotic. On removing the descending portion of the colon a large irregular cavity is exposed, the walls of which are covered with gray, slimy material, and in which are found fragments of necrotic tissues. Just at the superior margin of the kidney is located a definite opening which forms the bottom of the tract traced from the stomach. On stripping the left kidney from its capsule, it is found that the superior portion of the capsule is continuous with the cavity. The weight of the left kidney is 5 oz., 1 gr. The kidney is readily stripped from its capsule; is dark red; the stellate veins are prominent; and along its greater curvature are numerous dark red depressions. On the superior aspect of the kidney is a protrusion of the cortex, dark-red in color, and in this protrusion is a laceration 2 cm. in length, extending across the superior border approximately at right angles to the periphery of the kidney and from before backward. On incising the kidney, the cortex and medulla are not easily distinguishable from one another; both are of rose-red color, the cortex measuring approximately 6 mm. in thickness. The vessels in the pyramids of farriem are very prominent. Beneath the protruding portion of the surface the cortex is dark red in color. This discoloration extends downward in pyramidal form into the medulla. The laceration of the surface marks the apex of the protrusion of the kidney substance. Between the spleen and the superior aspect of the kidney is a necrotic tract which extends down and backward and ends in a blind pocket. The tract, which includes the superior aspect of the kidney, can be traced into the perinephritic fat to a point just above the surface of the muscles of the back. The necrotic cavity, which connects the wound on the posterior wall of the stomach and the opening adjacent to the kidney capsule, is walled off by the mesocolon and is found to involve a considerable area of the pancreas. A careful examination of the tract leading down toward the dorsal muscles fails to reveal the presence of any foreign body. After passing into the fat the direct character of the tract ceases and its direction can be traced no farther. The adjoining fat and the muscles of the back were carefully palpated and incised without disclosing a wound or the presence of a foreign body. The diaphragm was carefully dissected away and the posterior portion of the thoracic wall likewise carefully examined. All fat and organs which were removed, including the intestines, were likewise examined and palpated without result.
The great amount of fat in the abdominal cavity and surrounding the kidney rendered the search extremely difficult.
The liver is dark red in appearance, the gall bladder distended. The organ was not removed.
The right kidney is embedded in a dense mass of fat; capsule strips freely; it weighs 5 ounces; measures 11 1/2 cm. substance is soft; cortex is 6 mm. in thickness. There are a few depressions of the surface, and the stellate veins are prominent.
The pancreas at its center forms part of the necrotic cavity. Through its body are found numerous minute hemorrhages and areas of gray softening, the size of a pea and smaller. These are less frequent in the head portion of the pancreas.
The cause of death having been established and the autopsy having lasted nearly four hours, it was discontinued, as a further search for the bullet could serve no useful purpose.
There is no evidence of organic disease in any organ examined.
In regard to the chemical and bacteriological report, I have just received, under date of September 24, from Dr. Matzinger, the following:
There was no bacterial or chemical source of poison found on either cartridge or weapon.In Dr. Matzinger's report submitted later he says the clinical examination of the empty shells and cartridges were negative, and closes his report with the following paragraph:
The absence of known pathogenic bacteria, particularly in the necrotic cavity, warrants the conclusion that bacterial infection was not a factor in the production of the conditions found at the autopsy.A copy of Dr. Gaylord's report, received by me on October 16, gives the following anatomical diagnosis:
"Gunshot wound of both walls of the stomach and the superior aspect of the left kidney; extensive necrosis of the substance of the pancreas; necrosis of the gastric wall in the neighborhood of both wounds; fatty degeneration, infiltration, and brown atrophy of the heart muscle; slight cloudy swelling of the epithelium of the kidneys.The cause of death of the President has been made plain by the autopsy. It was due primarily to a gunshot wound by a .32 caliber bullet fired at close range, devitalizing the tissues immediately surrounding its tract, so that gangrene of those parts injured, involving the stomach, pancreas, kidney, and other tissues were absorbed, and with the degenerated condition of the muscular tissue of the heart caused death, the final symptoms being those of exhaustion.
Name of deceased: McKinley, William.
Office: President of the United States.
Date of death: September 14, 1901.
Time of death: 2:15 a.m.
Place of death: 1168 Delaware avenue, Buffalo, N. Y.
Date of burial: September 19, 1901.
Place of burial: Canton, Ohio.
Cause of death: Gangrene of both walls of stomach and pancreas following gunshot wound.
I hereby certify that McKinley, William, President of the United States, died while at Buffalo, N. Y., as set forth in the record of his case, as follows:
The President was holding a public reception at the Academy of Music, Pan-American Exposition, Buffalo, N. Y., on September 6, 1901, and whilst shaking hands with the people was shot at 4:07 p.m. through the stomach by Leon F. Czolgosz.
There is good evidence that the disease (or injury) causing death was in line of duty, the facts being as follows: The President was shot by an assassin whilst receiving the people.
I must mention here the giving up by Mr. John G. Milburn of his entire home in Buffalo and the devoting of his whole time and energy to the care of the President.
In concluding this report I must also refer to the untiring and devoted services of Mr. George B. Cortelyou, secretary to the President, who, with Mr. Nelson P. Webster, Mr. M. C. Latta, members of the Executive staff, and Mr. C. A. Conrad, of the Post Office Department, were on duty night and day. Executive Mansion Steward William Sinclair and Messengers Charles Tharin, Thomas Lightfoot, and Harry Mickie were also on duty at the Milburn house during the President's illness.
In obedience to the Department's orders, I was with the President's party at Buffalo, N. Y., on September 6. Upon arrival at the railroad station on its return from Niagara Falls, about 3:30 p.m., the President directed me to escort Mrs. McKinley to the Milburn house.
As soon as I learned of the attempt on the President's life, I hastened to his side at the Emergency Hospital on the Exposition grounds and was in the operating room with him at about 5:30 p.m. The President was under the influence of the anesthetic administered by Dr. Eugene Wasden of the United States Marine Hospital service. Dr. M. D. Mann, with a full corps of assistants, was ready to begin a laparotomy, which all deemed imperative.
Being satisfied with the completeness of the preparation and the ability of the operating surgeon, I made ready to assist and watched every step of the operation. The wounds having been closed, and the President's condition being good, I requested Dr. Roswell Park, the Medical director of the Pan-American Exposition, to send nurses and a surgical bed to the Milburn house and to take personal charge of the removal of the President, as I had to inform Mrs. McKinley of her husband's condition and make ready a room for his reception.
On his arrival I assumed charge of the case, having as consultants Dr. M. D. Mann, of Buffalo, N. Y.; Dr. Roswell Park, of Buffalo, N. Y.; Dr. Herman Mynter of Buffalo, N. Y.; Dr. Eugene Wasden, of the U. S. Marine Hospital Service. Dr. Charles McBirney, of New York, joined the consultations at 3 p.m. September 8, and left for home after the 9:30 a.m. bulletin of September 12. Dr. Charles G. Stockton, of Buffalo, N. Y., joined the consultations at 5 p.m. September 12. Dr. Edward G. Janeway, of New York, and Dr. W. W. Johnson, of Washington, D. C., arrived and Dr. McBirney returned after all hope had departed. All were present at the autopsy. Dr. H. G. Matzinger of Buffalo, N. Y., made all the urinalyses and also had charge of the chemical and bacteriological work. The histological examination of the tissues were made by Dr. H. R. Gaylord, who, with Dr. Matzinger, performed the autopsy.
In addition to the nurses mentioned, Miss Grace McKenzie, of Baltimore, Md., was employed after her arrival, and Miss Evelyn Hunt, of San Francisco, Cal., Mrs. McKinley's nurse, assisted as required.
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a p. xii b p.77
a pp.51-70 b pp.71-82Comment: Dr. Rixey was the White House physician for both William McKinley and Theodore Roosevelt.