The assassination of President McKinley: death from traumatic gunshot pancreatitis?

Portrait of William McKinley
Portrait of William McKinley. by Albert C. Fauley, 1896. Via the Ohio State House.

On September 6, 1901, the 25th president of the United States, William McKinley, was shot twice with a concealed weapon by the anarchist Leon Czolgosz at the Temple of Music on the grounds of the Pan-American exposition in Buffalo, New York. A popular president, he was serving a second term, having led the country to victory in the Spanish-American War and taken it out of an economic recession. He had left Washington in the middle of August for a brief rest in his native Canton, Ohio. There he spent much time walking outdoors, visiting farms, and driving about the country.1

On Wednesday, September 4, he left for Buffalo to attend the Pan-American Exposition, a world’s fair exhibiting many new technological advances such as electric lighting and the x-ray machine.3 He visited Niagara Falls on Friday morning and in the evening attended a public reception at the Temple of Music.1-4 His secretary had been concerned about his safety, but he confidently said that no one would want to harm him. There was a long reception line of people waiting to shake the President’s hand. A little girl had been brought by her father to do so. She was followed in line by an Italian with a black mustache whom the president’s guards viewed with suspicion. Then came a blond man with his right arm bandaged as though it was covering a rash or a wound. As the President shook his left hand, the man fired two shots at close range through the gauze of the bandage.2-4

The President fell to the ground. “Am I shot?” he asked.

“I fear you are,” replied one of his attendants. One bullet hit the sternum or perhaps a button, and ricocheted to the right breast, remaining superficial and later easily removed. The second bullet penetrated the abdomen. An ambulance was immediately called and took the President to the exposition hospital in a prototype “electric” ambulance driven by a third-year medical student.3 Six doctors arrived within thirty minutes. Unfortunately, the surgeon with the most experience with trauma and gunshot wounds, Dr. Roswell Park (after whom the cancer institute was later named), was at Niagara Falls performing a delicate radical neck dissection for lymphoma.3 As soon as an experienced surgeon arrived from Buffalo, it was decided to operate. The President was anesthetized with ether and the abdomen explored through a five-inch-long incision. There were two wounds in the stomach, a small entrance wound and a larger ragged one where the bullet had exited. Both were safely sewed up. The operation lasted about one hour.1-3

The surgical care rendered needs to be evaluated in terms of the facilities and knowledge of a time when intravenous fluids, blood transfusions, antibiotics, and modern anesthesia were not available. There would have been no point in moving the President to the more distant Buffalo General Hospital because the treatment would not have been different.3 Abdominal wounds were almost always fatal,3 it was by no means clear that surgical intervention would be effective, and it was risky to continue an operation much beyond one hour. Modern surgical instruments were not available and even the light in the operating room was such that a hand mirror had to be used to increase visibility.2,3 The surgeons explored the bullet manually but were not able to evaluate properly what damage had been done to retroperitoneal organs.2-4

Diagram of the pancreas
Labeled illustration of the pancreas by training.seer.cancer.gov. Via Wikimedia. Public Domain.

The President was moved to a large bedroom on the second floor of a private house. By Saturday morning, his condition had improved. An x-ray apparatus was brought from the Thomas A. Edison Laboratory to search for the bullet but was not used. On Monday it was optimistically expected that within one month the President would be able to resume his duties. Tuesday he enjoyed a meal of beef extract and asked for newspapers, which were denied. Wednesday he had a full meal and asked for a cigar but was not allowed to smoke and was given a bath. But on Thursday he suddenly collapsed. His pulse became weak and irregular, and there was no response to digitalis. By Friday morning he “sank towards a collapse.” At 5 PM it was announced that the president was receiving oxygen and suffering from “extreme prostration.” He died at 2:15 am on Saturday, eight days after the initial injury.1-4

On September 17, in response to rumors indicating dissensions and recriminations about his care, the attending doctors issued a statement emphasizing that there had never been a serious disagreement and that a very unusual harmony of opinion and action prevailed all through the case. An autopsy was done. The sutures in the stomach wall had remained intact, but there was extensive and widespread necrosis, especially of the pancreas and its surrounding structures.2 Bacteriological cultures all proved negative.

For the next one hundred years, President McKinley was thought to have had died of gangrene of the abdominal organs, often described as “creeping gangrene,” perhaps due to failure to retrieve the bullet.4 More recently the focus has shifted to the pancreas, though not necessarily to an initial injury to the organ as a whole. In this new scenario the damage would have been caused by the slow leakage of pancreatic contents from an injury to the pancreatic duct, particularly difficult to recognize at a time when even serum amylase determinations were still not available.4 Symptoms would have taken several days to develop, but the ensuing tissue destruction would have been as lethal as that of an initial acute pancreatitis. Viewed in these terms, President McKinley’s assassination would be the first reported case of traumatic gunshot pancreatitis.4 It also brought forth a new era in American history in the more aggressive pro-middle-class policies of his successor, Teddy Roosevelt.

 

References

  1. Murat Halstead. Life and Distinguished Services of William McKinley, Our Martyr President. Memorial Edition by AJ Munson, 1901.
  2. Nguyen, C., Hufford, T. Presidential Assassinations: Historical Review with Current Technology. The American Surgeon 2020; 86: 2-71, (Jan).
  3. Pappas,T. and Swanson S. Anarchy and the Surgical Care of President William McKinley. Journal of Trauma and Acute Care Surgery 2012:72:1106, (April).
  4. Ashrafian H. President William McKinley (1843-1901). The First Reported Case of Traumatic Gunshot Pancreatitis. Pancreas 2012; 41:980, (6 August).

 


 

GEORGE DUNEA, MD, Editor-in-Chief

 

 

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