Four United States' presidents have been assassinated during their terms of office:  Lincoln, Garfield, McKinley and Kennedy. The surgical care provided to these assassinated presidents was excellent in the case of Lincoln and Kennedy. However, Garfield and McKinley received marginal care, and a strong argument can be made that their surgery actually contributed to their demise.

Lincoln was shot on April 14, 1865 by John Wilkes Booth, an actor from Maryland, who was very anti-union. This was a conspiracy that also involved attempts on the life of the Vice-President and Secretary of State Seward. The first person to reach Lincoln after he'd been shot was a 24-year-old Army surgeon, Dr. Charles Augustus Leale. His care was truly remarkable and was very similar to current ATLS guidelines.

The wound was obviously a fatal wound, and the President lived for an additional 9 hours and 52 minutes. His assassin was also killed by Boston Corbett two weeks later. Eight of the conspirators went to military trials, and four were sentenced to death, which was carried out on the 7^th of July 1865.

Unfortunately, Lincoln and the remaining three presidents who were assassinated had poor autopsies that were either incomplete or failed in getting all of the information necessary to dispute conspiracy theories.

Garfield was shot on the 2^nd of July 1881 in a railroad station waiting to start the July 4^th holidays. One of the wounds grazed his right arm; the other entered the right side of his back near the first lumbar vertebra. The wound was continuously probed by many ungloved surgeons' fingers, and the President gradually developed malnutrition, sepsis, and died on the 19^th of September 1881. The autopsy showed that he had a fatal hemorrhage from the splenic artery, probably caused by the bullet, but possibly also by either a finger or one of the multiple probes that was inserted into his wound.

The period of time between Garfield and McKinley was marked by multiple assassinations in Europe. Anarchists killed the President of France, the Empress of Austria and the King of Italy. During the investigation of the king's death, a list of six individuals was found, and William McKinley was number five.

McKinley was shot on September 6, 1901 at the Pan American Exposition in the Temple of Music by an anarchist – Leon Csolgosz. He was operated on by an obstetrician, who was not familiar with management of either gunshot wounds nor surgery in the upper abdomen. McKinley lingered for almost a week, but died of peritonitis on the 14^th of September at 2:00 am. At autopsy, the bullet was never found, and the autopsy was halted by President McKinley's wife.

Kennedy was assassinated on the 22^nd of November 1963 by Lee Harvey Oswald. Kennedy was immediately taken to Parkland Hospital, but died 30 minutes after arrival. He was agonal when he arrived at the emergency room. Trauma surgeons were present, and his care was excellent. The fatal wound involved the entire right hemisphere of his brain.

Like President Lincoln, Kennedy's assassin was killed one day later. There are some remarkable similarities and coincidences associated with the Lincoln/Kennedy assassinations. Both were shot in the back of the head on a Friday, seated with their wives. Their associates were injured. Both had partial autopsies, and both presidents were rocking chair enthusiasts. Both presidents' assassins were shot, and both were succeeded by vice-presidents named Johnson. There are almost 200 similarities between Kennedy and Lincoln. I believe they were simply coincidences.

The lessons learned from these four assassinations include:

1. Single surgeon/captain of the ship

2. Appropriate use of consultants

3. Non committee medicine

4. Appropriate nursing care

5. Expert forensic pathology

6. Complete autopsy