Famous Patients, Famous Operations, 2002 - Part 5: The Case of the Politician with a Gunshot Wound

Albert B. Lowenfels, MD

Disclosures

October 10, 2002

Introduction

The patient was a 58-year-old politician who was shot twice in the abdomen at close range with a 32-caliber pistol while attending a political rally. Except for obesity, he had always enjoyed excellent health. Initial examination immediately after the shooting revealed that one of the bullets had struck the sternum without penetrating either the chest or the abdomen. There was a single wound in the left upper quadrant of the abdomen, marking the site of entry of the second bullet.

His condition was stable, with a heart rate of 84 bpm; he complained of only minimal pain. Within a few minutes, several surgeons gathered and all agreed about the necessity for an urgent operation. He was taken by ambulance to a nearby hospital, where, after receiving a cardiac stimulant, an exploratory operation was performed under general anesthesia less than 2 hours after the injury.

The surgeon entered the abdomen via a vertical upper abdominal incision and immediately detected a bullet wound in the anterior wall of the stomach. Upon further exploration, he found a ragged exit wound in the posterior wall of the stomach. No further injuries were detected, so after closure of the 2 gastric wounds, the incision was closed without drainage. Duration of the procedure was less than 2 hours.

The postoperative course was as follows:

Day 1 - Patient was febrile, tachycardic, and urinary output was only 270 mL

Day 3 - Urinary output had increased to 540 mL

Day 4 - A few sutures were removed from the wound, oral feedings initiated

Day 5 - Evidence of wound infection, heart rate 116-120 bpm, urine output 750 mL

Day 6 - Passed flatus and stool, but heart rate was 130 bpm and weak; given a saline enema

Day 7 - Loss of appetite, became unconscious

Day 8 - Died without regaining consciousness

An autopsy performed soon after death listed gangrene of stomach and pancreas as the causes of death.

Who is this mystery patient?

This month's special patient is William McKinley, the 25th president of the United States (Figure). On Friday, September 6, 1901, while attending the Buffalo Pan American Exposition, he was shot by Leon Czolgosz, a 28-year-old anarchist. Despite what seemed to be encouraging, early signs of recovery, President McKinley died on the eighth postoperative day.

William McKinley, 25th President of the United States (1897-1901).

The status of surgery for gunshot wounds (GSWs) of the abdomen in 1901

At the time of the shooting, Buffalo's leading surgeon, Roswell Park, was performing a cancer operation in a nearby town and was not immediately available. Dr. Mann, Dean of the Buffalo Medical school, a gynecologist and a respected surgeon, arrived promptly and became the leader of the team that operated on the President.

The operation took place in a small hospital designed to provide first aid and to care for accidents or illnesses occurring at the Exposition. Although the Exposition grounds were brilliantly illuminated with electric lights, the interiors of the buildings were not. Poor illumination hindered the operating surgeons because the only illumination came from a window in the operating room. Lack of appropriate instruments was another factor that probably led to an unsuccessful outcome.

A third factor had to do with inexperience of the surgical team in the management of abdominal GSWs. In 1901, surgeons already had considerable experience treating abdominal GSWs. In 1884, Theodore Kocher, a surgeon who eventually won a Nobel Prize for his research on thyroid disease, had described treatment for GSWs of the stomach. In 1898 Roswell Park had written about surgical treatment of GSWs, but when Park arrived during McKinley's operative procedure, he thought it best for Dr. Mann to continue with the operation. Unfortunately, Dr. Mann, although a respected surgeon, had never operated on a patient after a GSW.

There are many questions that persist concerning the conduct of the operation and the subsequent outcome.

Was an urgent operation necessary or could the operation have been delayed to allow transport of the President to the much better- equipped and staffed Buffalo General Hospital?

The President's initial condition appeared to be stable, as evidenced by a pulse rate in the 80s. Major hemorrhage seems unlikely, as was confirmed at the time of laparotomy. Yet the operation was performed under less-than-ideal circumstances with a professional team that had little experience with this type of serious injury, in a small hospital that was not designed to manage such a serious injury. Unquestionably, today, if the patient's condition were stable, the patient would have been transferred to a more well-equipped facility.

Why were there no recordings of blood pressure?

It seems incredible that at the time of McKinley's assassination in 1901, equipment to measure blood pressure, now such an important part of the examination of an injured patient, was not readily available. To determine if shock was present, surgeons could only depend on evaluation of the pulse and the respiration. An early article on measuring blood pressure in surgical patients was written in 1903, a few years after McKinley's assassination, by Harvey Cushing, a famous brain surgeon.[1]

What about use of x-rays?

In 1896, 5 years before McKinley was shot, an x-ray machine had been used to demonstrate a bullet after a gunshot injury; however, functioning x-ray equipment was not available to the surgical team caring for McKinley.

Were consultants asked to give advice about treatment or prognosis?

Several famous consultants visited the President, including Charles McBurney, a New York surgeon. He arrived a day or 2 after the operation, stayed until the sixth postoperative day, and then returned to New York after announcing that the President was recovering satisfactorily. But because of the rapid deterioration in the President's condition, he hastily returned to Buffalo by train immediately after reaching New York.

What was the probable cause of death?

Although the operating surgeons identified both the entrance and exit wounds in the stomach, they failed to detect the additional damage to the tail and body of the pancreas. McKinley presumably suffered from traumatic pancreatitis, leading to significant "third space" fluid loss, peritonitis, and probably sepsis.

How would a patient with a similar injury be diagnosed and treated today?

Plain abdominal films easily would have detected the bullet lodged within the abdomen. A computed tomography scan would provide additional information. Today, a surgeon operating on a patient with a left upper quadrant GSW inflicted at close range would have no trouble finding the stomach wounds. In addition, because of the proximity of the stomach to the pancreas, there would be a careful search for pancreatic injury. If pancreatic injury was detected, and if there was massive destruction of the body or tail of the gland, the surgeon might perform a partial pancreatectomy. Certainly, the area would be debrided and drained. Omission of a drain may have been one of the key factors leading to the President's death.

Today, with the availability of intravenous fluids, blood, and antibiotics, a favorable outcome after such an injury in a healthy 58-year-old man would be much more likely than in 1901. However, even now, the mortality rate for pancreatic injury following penetrating trauma is surprisingly high, especially if additional organs are injured, as was the case with President McKinley.[2,3] In a recent series, 27% of patients sustaining penetrating injuries of the pancreas died.[4]

How frequent are pancreatic injuries?

Pancreatic injuries are uncommon. In a review of over 16,000 trauma admissions, only 72 patients (0.4%) sustained injuries to the pancreas. GSWs accounted for 32 (45%) of all reported injuries, which is surprisingly high.[2]

What happened to the assailant, Leon Czolgosz?

Czolgosz was taken to the local jail, where at first he was thought to be insane. He pleaded guilty, and on October 29, 1901, only a few weeks after McKinley's death, Czolgosz was electrocuted.

How many Presidents have been attacked by assassins?

Assassins have threatened the lives of 14 of our 43 presidents. Four presidents died as a result of gunshot injuries: Lincoln, Garfield, McKinley, and Kennedy. It is likely that both Garfield and McKinley, who sustained abdominal wounds, would have survived if modern therapy had been available.

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