Fatal spinal cord injury of the 20th president of the United States: day-by-day review of his clinical course, with comments.

Background: This article presents the medical history of the 20th president of the United States, James A. Garfield, with an emphasis on his spinal cord injury (SCI). Numerous references debate the care he received from the medical and surgical perspectives, but little has been written about the essential aspect of his gunshot wound-namely, the damage to his spinal cord. President Garfield was shot in the lumbar spine and was bedridden until he died 80 days following his injury. This article contrasts state-of-the-art care in 1881 to today's standards of care for SCI.

Method: Literature review. A record of daily reports of the president's condition was analyzed. Comparisons were made between the president's care and what is now available.

Findings: Although the president had access to the best physicians, the chronicle of his course underscores the deficiencies in basic medical care, the controversies concerning surgical intervention, and the problems inherent in the care of a prominent patient. Press releases did not overtly address spinal cord trauma and its complications so as to avoid conveying the president's degree of incapacity. Garfield's SCI was documented on autopsy. The bullet entered the 10th intercostal space, 3 1/2 inches to the right of the spinous processes, fracturing the 11th and 12th vertebrae and nicking the T1 2-L1 disc. The bullet then passed through the right side of the body of L1 and exited the vertebra anteriorly and to the left and lodged behind the pancreas, where it was found encased by a firm cyst.

Conclusion: Deficiencies in general medical care and surgical technique at the time contributed to the president's demise. This case was marked by controversies that still are debated today-for example, whether the bullet should have been removed surgically. Examination of available evidence suggests that with today's advances in medical, surgical, and SCI medicine, a person with this type of injury would likely survive and be a candidate for rehabilitation.