The Mortal Presidency: Illness and Anguish in the White House

THE MORTAL PRESIDENCY

Copyright © 1998 by Fordham University Press

All rights reserved

LC 97-50051

ISBN 0–8232–1836–8 (hardcover)

ISBN 0–8232–1837–6 (paperback)

Second Edition

Third Printing 2005

Library of Congress Cataloging-in-Publication Data

Gilbert, Robert E.

The mortal presidency: illness and anguish in the White House / Robert E. Gilbert.—2nd ed.

p. cm.

Includes bibliographical references and index.

ISBN 0–8232–1836–8 (alk. paper).—ISBN 0–8232–1837–6 (pbk. : alk. paper)

1. Presidents—United States—Health. I. Title.

E176.1.G55 1998

973′.099—dc2I

97-50051

CIP

Designed by Barbara DuPree Knowles

Visit us online at www.fordhampress.com.

To the Memory of my Mother

Contents

Acknowledgments

Introduction: A President Falls, Another Collapses

ONE Presidential Pathology and Mortality

TWO The Trauma of Death: Calvin Coolidge

The Early Years

The Massachusetts Politician

The Vice Presidency

The White House Years

Psychological Vulnerability

THREE Functioning in Chains: Franklin D. Roosevelt

The Early Years

The First Two Terms: 1933–41

The Third Term: 1941–45

The Fourth Campaign and Inauguration: 1944–45

The Yalta Conference: February 1945

The Aftermath: March–April 1945

FOUR Pain and Duty: Dwight D. Eisenmhower

The Early Years

The First Term: 1955–57

The Second Term and After: 1957–69

The Political Effects of Eisenhower’s Illnesses

Eisenhower’s Obsession with Duty

FIVE Illness at Camelot: John F. Kennedy

The Early Years

Kennedy’s Bad Back

Addison’s Disease

The Impact of Illness on Kennedy’s Presidency

The Impact of Medication on Kennedy’s Presidency

Kennedy’s Drive to Excel

Conclusion

SIX Ambition and Torment: Lyndon B. Johnson

The Early Years

The Congressional Years

The Vice Presidency

The Presidency

The Final Years

The Political Effects of Johnson’s Illnesses

The Fear of Rejection

SEVEN Scars in the Teflon: Ronald Reagan

Early History

The First Term: 1981–85

The Second Term: 1985–89

The Political Implications of Reagan’s Medical Emergencies

The Curse of Drink: Reagan’s Psychological Vulnerability

EIGHT Prescriptions

The Twenty-fifth Amendment Revisited

The Executive Office Re-examined

The Vice Presidency Upgraded

Conclusion

Photographs

Notes

Index

Acknowledgments

In preparing both the first and second editions of this interdisciplinary study, the advice and assistance of individuals of widely varying backgrounds was essential. I take pleasure in acknowledging, therefore, the contributions made to this project at its various stages by Betty Glad (University of South Carolina), Fred I. Greenstein (Princeton University), Dennis R. Goldenson (Carnegie-Mellon University), George McKenna (City University of New York), Steven A. Peterson (Alfred University), Barbara Dowd Pearce (University of Massachusetts, Lowell), Stanley R. Renchon (City University of New York), Robert Swansbrough (University of Tennessee, Chattanooga), Kenneth W. Thompson (University of Virginia), and the late Thomas C. Wiegele (Northern Illinois University). Also, a number of colleagues at Northeastern University contributed in important ways, especially Helen Lambert (Biology), Irene A. Nichols (Education), and Robert L. Cord, Michael S. Dukakis, W. D. Kay, David A. Rochefort, and Michael C. Tolley (Political Science).

Thanks must go as well to Drs. Benjamin Aaron, Joseph Giordano, S. David Rockoff, and Samuel Spagnolo (George Washington University Medical Center), Dr. Eric Louie (Loyola University Medical Center), Drs. Kevan Hartshorn and Jerrold Levine (Boston University Medical School), and the late Dr. Tema Carter, a rehabilitation specialist in Brookline, Massachusetts.

Also, I am indebted for their help and guidance to the late Dr. Janet Travell, White House Physician to President Kennedy, Dr. James M. Young, White House Physician to Presidents Kennedy and Johnson, Dr. Daniel Ruge, White House Physician to President Reagan, Dr. Lawrence Mohr, White House Physician to Presidents Reagan and Bush, and Dr. E. Connie Mariano, White House Physician to President Clinton.

I would like to thank my research assistants at Northeastern University for their help over the years this project has been in progress, the staff of the Forbes Library (who assisted me with my Coolidge research), and the staffs of the Franklin D. Roosevelt, Dwight D. Eisenhower, John F. Kennedy, and Lyndon B. Johnson Libraries for the invaluable assistance they provided, expecially James Leyerzapf, Maura Porter, Ron Whealan, and Mary Knill. Special thanks go to John Coolidge, the late President’s son, for his unique insights and frankness. Also I acknowledge with gratitude two Research and Scholarship Development Grants from Northeastern University that allowed me to spend several weeks at both the Dwight D. Eisenhower and Lyndon B. Johnson Libraries exploring documents pertinent to the medical histories of these two presidents.

To those individuals at Basic Books who provided guidance and support in the publication of the first edition of this book, especially Phoebe Hoss, the late Martin Kessler, Akiko Takano, Randall Pink, and Michael Wilde, I express my appreciation. To Frances Ricker, Adelle Robinson, and Christine Sheris, I offer a word of thanks for their expert typing of various portions of the first edition.

In facilitating the publication of the second edition of this work, I am grateful to Mary Beatrice Schulte and Loomis Mayer of Fordham University Press and to Marion K. Pinsdorf of Fordham University.

I would like to thank, too, the Working Group on Presidential Disability, co-chaired by Dr. James F. Toole of the Bowman–Gray School of Medicine and Arthur S. Link of Wake Forest University. Interacting with Group members at three multi-day meetings over two years sharpened my awareness and deepened my understanding of issues relating to presidential disability.

Finally, I am grateful to those family members and friends who encouraged me along the way. Their support meant a great deal, especially at those low moments that are inevitable.

ROBERT E. GILBERT

Boston, Massachusetts

Introduction

A President Falls, Another Collapses

It was late winter in Florida. The President of the United States had arrived at Hobe Sound shortly after midnight on March 14, 1997, looking forward to a golfing excursion later that day. Golf pro Greg Norman, at whose estate William Jefferson Clinton was staying, gave his guest a tour of his home and then, at 1:20 A.M., the President started to depart for his guest cottage. As he walked down a flight of stairs, President Clinton’s heel caught on a step, and he stumbled badly. As he fell, his leg snapped so loudly that it was actually heard by his host. Norman caught the President in mid-fall and eased him to the ground, where he sat in great pain. The physician on duty, Dr. William Lang, immediately evaluated the President, treated his injured leg with ice and immobilization, and summoned an ambulance.

Dr. E. Connie Mariano, Senior White House Physician, received the news at her hotel that the President had been injured and she rushed to St. Mary’s Hospital in West Palm Beach, arriving there about twenty minutes before he did. At St. Mary’s, the President was examined by Dr. Joel Cohen, an orthopedic surgeon. An MRI (Magnetic Resonance Imaging) test showed that while Clinton’s bone was not damaged, 90 percent of his right thigh muscle was shredded. Interestingly, during the time when the MRI test was being conducted on the President, a military aide sat just outside the door, holding the codes for unleashing nuclear missiles as well as the presidential succession agreement that had been drawn up between the President and Vice President. In the meantime, both Vice President Gore and his Chief of Staff had been notified of the President’s accident.¹

Dr. Cohen recommended surgery and although Dr. Mariano concurred, she preferred to have the procedure performed in Washington. She had discussed with one of the President’s closest aides, Bruce Lindsay, various scenarios under which the Twenty-fifth Amendment should be invoked and Vice President Gore made Acting President of the United States. After consulting with Dr. Cohen about the type of anesthesia that leg surgery of this sort would require, she was informed that the procedure is normally performed under epidural (not general) anesthesia. Since the President would be conscious throughout the surgery, Dr. Mariano informed Lindsay that, in her view, the Twenty-fifth Amendment would not apply in this instance.

The President’s leg was put in another splint, and he was given a shot of Ketorolac (an injectible anti-inflammatory drug similar to motrin) to ease his pain. At 8 A.M., after periods of fitful sleep, President Clinton was placed in a Secret Service van and taken to the airport. He was carried up the stairs of Air Force One by Secret Service agents while Dr. Lang held his leg in place. The President reportedly had little pain at the time.

As the plane made its way back to Washington, Dr. Mariano instructed Clinton’s staff that only family members should see him in the hospital and that he should be spared phone calls and nonessential business. Upon arrival at Andrews Air Force Base, the presidential party left immediately for Bethesda Naval Hospital where the President signed a consent form for surgery. He was given an electrocardiogram and underwent blood work and at 1:40 P.M. he was given an epidural injection which made him numb from the waist down but which did not affect his reasoning abilities in any way. Around the same time, an IV was put in his arm for fluids. Surgery commenced at 2:30 P.M. and lasted for two hours and four minutes. The President was awake throughout.

A five-inch longitudinal incision was made by Dr. David Adkison in the President’s leg about four inches above the right knee. His muscle—the quadriceps tendon—which had been torn diagonally was sutured together, and the sutures were extended past his tendon into his knee cap. Three holes were drilled in his knee cap and the sutures were attached through them to his knee. When he heard the unpleasant drilling noise, Clinton asked what it was and seemed nonplussed at the answer.

The President was wheeled back to his suite at 5:10 P.M. with the epidural still in place. Dr. Mariano had told him earlier that if at any time he received any medication that would affect his central nervous system, invocation of the Twenty-fifth Amendment would have to be considered. The President responded by instructing his medical team not to give him anything that would make him feel dopey. Within two hours, Clinton was well enough to speak to the press by speaker phone. On the following day, he taped a speech to the Gridiron Dinner, although his leg pain had begun to increase and an extra dose of Ketorolac had had to be administered to him.

At 11 A.M. on March 16, with no temperature and no sign of infection in his incision, the President was discharged from the hospital. Seated in a wheelchair, he returned to the White House in a van borrowed from Jim Brady, press secretary to Ronald Reagan who was seriously wounded in the 1981 assassination attempt against that President. At the White House, rugs had been taped down in the living quarters and bars installed in the shower (which will remain in place for future Presidents). In order to reduce the swelling, the President’s knee was iced down two or three times a day. Also, he began aggressive physical therapy twenty-four hours after his release from the hospital, at first from bed to chair and then on parallel bars and crutches. Not surprisingly, he experienced some pain as he moved his leg, but the President proved to be a very good patient and faithfully followed the regimen laid out for him by his doctors.

On March 19, President Clinton left for a meeting with Russian President Boris Yeltsin in Helsinki. He used a wheelchair there at Dr. Mariano’s insistence because crutches tended to tire him out. In Helsinki, he was on blood-thinning medication so that blood clots to the leg would not develop, his leg was elevated, and he continued to get physical therapy which caused him some discomfort. During the week following his return from Finland, the President began working again in the Oval Office. Although pleased that his recovery was proceeding on schedule, he experienced some frustration at being so limited in his activities. He had, after all, been a very mobile Chief Executive and now felt somewhat dejected at his newly restricted lot in life. His travel schedule had to be modified, with trips to Mexico and the rest of Latin America postponed until later in the year. Reportedly, aides worried about the unaccustomed image of a normally robust President being lifted in and out of vehicles, and one of them remarked that we don’t want things looking too FDRish around here.²

As time passed, however, the President progressed rapidly. He bicycled for 45 minutes every day, guarded against a weight increase by eating smaller portions of food and more fruit, and swam in the White House pool two or three times a week. Finally, on his birthday in August, which he celebrated while vacationing on Martha’s Vineyard, Clinton began once again to jog. In September, Dr. Mariano indicated that the President was a full month ahead of schedule in his recovery.

It is interesting to note that although White House officials discussed conditions under which the Twenty-fifth Amendment would be invoked during President Clinton’s surgery and subsequent convalescence, it was, in fact, not invoked. Nor was it invoked during the Bush Administration immediately preceding, even though the matter was discussed at that time as well and even though those circumstances were even more ominous and unsettling.

In early May 1991, while jogging at Camp David, President Bush suddenly felt unusually fatigued and became short of breath. Accompanied by Secret Service agents, he went immediately to the presidential retreat’s infirmary, where Dr. Michael Nash, the physician on duty, found that Bush’s heartbeat was irregular. The President left almost immediately by helicopter for Bethesda Naval Hospital for further tests and treatment.

Although the story immediately dominated the news media, medical reports issued by the White House press secretary, Marlin Fitzwater, were uniformly positive. The President had not suffered a heart attack, he had not lost consciousness, he had had no chest pains, he was entirely stable, and there was no cause for alarm. The President, Fitzwater reported, had even taken his briefcase to the hospital so that he could continue to work.³

The President’s irregular heartbeat—diagnosed as atrial fibrillation—continued into the following day, but doctors indicated that the cardiac irregularity represented nothing very unusual or dangerous. One cardiologist suggested, however, that the sudden appearance of atrial fibrillation in a 66-year-old man … has to be taken seriously.⁴ The condition might be an indication of an underlying heart problem, possibly a heart attack, or, more likely, a narrowing of the heart’s arteries or a damaged heart valve.

Atrial fibrillation is a condition that is not uncommon throughout the United States. It can be caused by stress, exercise, or even excessive caffeine and results in an unusually rapid heartbeat—up to 150 beats per minute rather than the normal rate of between 60 and 100 beats. The condition in itself normally is not life-threatening; but if it continues for a long period, it can lead to the formation of blood clots which may become dislodged and strike the brain.⁵

The news of the President’s cardiac condition came as a surprise to a nation that thought of its President as active, vibrant, and robust. Although Bush was the fourth oldest man ever inaugurated as President, he seemed to radiate good health.¹ In fact, after a five-hour physical examination in late March 1991, he had received glowing reports from his doctors. His cholesterol levels were described as being within the desirable range, his blood pressure was normal, and his blood chemistry tests were said to be satisfactory.

For a man about to turn sixty-seven, the President’s medical history gave no real hint of impending heart trouble. Many years before, while he was in his early thirties, Bush had collapsed in a London hotel room, suffering from a bleeding ulcer. He was told by his doctor at the time that he tried to do too much and worried too much and that if he didn’t mend his ways, he wouldn’t be around in ten years, maybe five. Bush later wrote that his doctor’s blunt words forced him to accept the fact that he couldn’t do everything, and that his energy should be directed toward those things that could be accomplished rather than those that could not.⁷ Later, he also found that exercise was helpful in reducing stress and shortly after the age of fifty, began jogging on a regular basis.⁸

Nevertheless, a number of the President’s friends indicated that he still internalized a good deal of tension.⁹ Prior to developing atrial fibrillation, Bush appeared fatigued to some associates and upset over news stories that in 1980 he had helped stop U.S. hostages from being released by Iran in order to damage President Carter’s re-election campaign. Also, the pressures of the successful Gulf War undoubtedly had taken their toll on the commander in chief, and he was particularly stung by criticism that he had badly mishandled the plight of the Kurdish refugees in Iraq. In other words, Bush had been under greater than usual stress for several months before he was stricken, and his irregular heartbeat may well have reflected this fact.

At Bethesda Naval Hospital, the President underwent an electrocardiogram and ultrasound tests which revealed no structural problems in his heart. By Monday, his heartbeat had returned to normal after digoxin, and then procainamide, were administered to him. Had these medications failed to slow down the President’s heart, doctors were considering the use of electrical shocks to achieve this result. Bush would have had to undergo a general anesthetic for a limited period of time, and the shocks would have been used to stop his heart for a moment so that its normal rhythm would resume. According to White House Physician Lawrence Mohr, although this is considered a low-risk procedure, the Twenty-fifth Amendment would have been invoked and Vice President Dan Quayle would have become acting president for a short time.¹⁰

This thought and, in fact, the entire subject of Quayle’s standing just a heartbeat away from the presidency caused considerable distress throughout the country. At the time, Quayle’s favorablility rating stood at an abysmal 19 percent, and his competence to handle the office of the presidency was widely questioned, even by Republican party leaders. When Bush returned to the White House on 6 May, he tried to bolster his vice president’s position by saying that Quayle has my full support, always has, and he’s doing a first class job.¹¹ The President’s words did not reassure the nation, however; nor did they quiet talk that Quayle’s place on the 1992 Republican ticket might be in jeopardy.

Shortly after the President’s discharge from the hospital, doctors announced that his heart condition had been due to thyroid dysfunction, and surprisingly diagnosed him as having Graves’ disease, the same ailment from which his wife, Barbara, suffers. Since the disease is not thought to be contagious, the chances that both husband and wife would have it were estimated at 1 in 10,000.¹²

Graves’ disease is of unknown origin. Researchers suspect, however, that it may be caused by bacteria and/or stress. Whatever its cause, Graves’ disease forces the thyroid gland to become overactive, which, in turn, intensifies the body’s metabolism. If untreated, the condition can lead to fever, rapid pulse, breathing difficulties, exhaustion, and even heart failure.¹³

Bush began receiving large doses of radioactive iodine—so large, in fact, that doctors advised him to avoid close contact with family members for several days, in order to avoid exposing them to the radioactivity. The iodine rectifies the thyroid dysfunction, normally within two to six weeks, and the atrial fibrillation tends to disappear. Although the treatment occasionally results in too severe a slowdown in thyroid function, hormone tablets taken on a daily basis usually provide an effective remedy.¹⁴

Within a short period of time, Bush seemed to return to good health. Eight months later, however, the President’s physical condition suddenly and dramatically became the center of news attention once again after he was stricken in Tokyo at a state dinner being given in his honor by Prime Minister Kiishi Miyazawa.

President Bush’s visit to Japan was the culmination of a 12-day, 26,000-mile journey through the western Pacific to advance the cause of American business and improve the nation’s balance of trade. To some of the reporters who were traveling with the President, Bush had occasionally seemed fatigued and out of sorts.¹⁵ On 8 January, he played a vigorous game of tennis with the American ambassador, the Japanese emperor, and the crown prince and lost badly. By evening, the President did not feel well and summoned his personal physician, Dr. Burton Lee, who diagnosed enteritis (intestinal flu). Since Bush wanted very much to attend the prime minister’s state dinner that evening, he ignored his doctor’s advice to remain in his quarters, and traveled instead to Miyazawa’s official residence. Secret Service agents reportedly were warned, however, that the President might not make it through the meal.¹⁶ Then, while standing in a receiving line, Bush became quite ill. He excused himself, rushed to a men’s room, and vomited. He believed that that had taken care of his stomach problems, but soon learned that it was just the beginning.¹⁷

At 8:20 P.M., as he finished the first course of his meal, the President suddenly became very pale and then fainted. His head dropped to his chest, his body rolled to his left, and he vomited onto his own clothing and that of Prime Minister Miyazawa. The First Lady rushed forward with a napkin which she held to her husband’s mouth, and a Secret Service agent leaped onto and over the table to take hold of the President and ease him gently onto the floor. The Japanese prime minister held the President’s head in his arms, and aides removed his jacket as the audience stared in shock. Secretary of Commerce Robert Mosbacher, seated near the President, later described the scene as scary.¹⁸

Within a short time, Bush regained consciousness and, after an interval of several minutes during which he was examined by Dr. Lee, rose to his feet and smiled reassuringly at the relieved and applauding crowd. Immediately, however, he departed from the prime minister’s official residence, wearing an overcoat that had been provided by a Secret Service agent to cover his soiled clothing, and returned by limousine to Akasaka Palace, where he was staying during his visit. He was examined there by Dr. Lee and by Dr. Allen Roberts and given an antinausea medication (Tigan).¹⁹ Although he had a reasonably good night’s sleep, he was still somewhat shaky the next morning, and most of the next day’s engagements were canceled.

In Washington, the President’s press secretary indicated that the White House physician did not believe that any special monitoring was necessary, since all aspects of the examination indicate that it is a common case of the flu.²⁰ Nevertheless, an electrocardiogram was administered to the President in order to monitor his heartbeat. It revealed no abnormalities and no return of the irregular heartbeat that had afflicted him eight months earlier.²¹

Gastroenteritis is a common ailment whose sufferers sometimes become severely dehydrated and, after suddenly changing their position (for example, rising to their feet from a sitting position), occasionally faint. Doctors indicate, however, that it is uncommon for sufferers to faint while seated at a table. Dr. Gerald Mandell of the University of Virginia explained that the fainting at the table puts it in the unusual category because it doesn’t happen very often²²

The film footage of the President’s collapse also fell into the unusual category. Shown over and over again in the United States, the scenes of the President slumping into the arms of the Japanese prime minister struck some as being all too symbolic of the central problem the President had gone to Japan to resolve—an ailing American economy slumping into the arms of Japan.

Inevitably, the President’s collapse, coming within weeks of the New Hampshire presidential primary, sent political shock waves through the country. One of his aides understated the case when he pointed out that collapsing and falling under the table in full view is never a political plus for a president.²³ In addition to Bush’s political embarrassment, there were medical concerns as well. Dr. David Benditt, a Minnesota cardiologist, has indicated that patients who are dehydrated, fatigued, or under stress, or who have engaged in physical exercise, may be more susceptible to short-term fainting spells.²⁴ But several life-threatening medical conditions can also provoke this physical reaction. Specifically, a heart attack, a stroke, and/or gastrointestinal bleeding could have been responsible for the President’s symptoms.²⁵ This fact not only caused concern but also resurrected once again the Quayle issue.

According to the President’s chief of staff, Samuel Skinner, no thought was given at any time to a transfer of power to the vice president.²⁶ Quayle had been informed of Bush’s sudden illness at 6:20 the following morning. He later remarked that while he was confident of his ability to become President if necessary, that thought didn’t even cross my mind.²⁷ The thought of Quayle’s ascendancy certainly did cross the minds of other people, however, and provoked another flurry of uneasiness.

President Bush appeared to recover quickly from his embarrassing indisposition and tried hard to downplay the episode. He told reporters, I don’t think there is any political downside, and joked that even Democrats get the flu.²⁸ Bush’s campaign strategists had to hope, however, that no further health scare would cast a cloud over his campaign for re-election.

President Bush’s medical problems in both 1991 and 1992—and President Clinton’s in 1997—call renewed attention to the subjects of presidential health, presidential disability, and presidential mortality. The presidency is a tension-filled position, and tension, as I shall discuss in some detail, is intimately related to both illness and death.

In contrast to the many authors who have written about the constitutional and extraconstitutional duties of the American presidency, I focus here on the physical and psychological dangers of the office rather than on its powers and responsibilities. My goal is not only to uncover a sobering historical record but also to establish a framework that will explain and refine it. Furthermore, in case studies, I illustrate more specifically the subject of presidential ill health and analyze the impact of ill health on the presidencies of six twentieth-century chief executives—Calvin Coolidge, Franklin Roosevelt, Dwight Eisenhower, John Kennedy, Lyndon Johnson, and Ronald Reagan.

Coolidge died at the age of sixty, just a few years after leaving the White House, where he suffered from debilitating psychological and physical illness. Roosevelt died in office of natural causes at the age of sixty-three, after years of disability and disease. Eisenhower actually exceeded his life expectancy, but endured a life of illness and pain, accentuated during the period of his presidency. Kennedy was assassinated at the age of forty-six, after suffering painful and debilitating illnesses for much of his life. In 1961, he became the youngest man ever elected to the presidency; in 1963, he became the youngest president ever to die in office. Johnson died at the age of sixty-four, four years after leaving the White House and after an adult lifetime filled with painful and dangerous afflictions. And although Reagan, who also exceeded his life expectancy, was sometimes described as having lived a charmed life as the nation’s chief executive, his presidency brought him face to face with painful and life-threatening medical crises.

In addition to providing a medical profile for each of these presidents, I shall examine in detail the political effects of their illnesses and medical emergencies and wherever appropriate, construct a psychological profile in an effort to provide a broad context for each president’s reactions to his disabilities and pain.

Finally, in the concluding chapter, I will explore a number of general implications of presidential illness. Presidential disability comes in a variety of forms, almost all of which were unrecognized and unaddressed by the Framers of the Constitution. Even the Twenty-fifth Amendment, added to the Constitution in 1967, fails to resolve all aspects of the problem. Further work is needed in this important area of public policy. Also, in light of the historical record, new attention must be focused on the vice presidency and efforts made to upgrade both the office and the process by which individuals are chosen to fill it. Moreover, consideration should be given to reducing some presidential pressures by downsizing his/her responsibilities as chief administrator of the United States. In short, the fact that so many of our presidents have been, to some degree and in some form, disabled must be addressed in terms of both public policy and political practice. I hope that my concluding chapter will at least point out helpful directions in which to move.

1 Former President Bush has had and has now a number of medical problems. As a teenager, he suffered from hepatitis. He has hay fever, allergies, and mild arthritis of the hips and knees. He has had irritable bowel syndrome; and in 1986, a small noncancerous polyp was removed from his colon. He has a slightly enlarged prostate and had a small skin cancer removed from his face during his vice presidency. In 1989, a small, benign cyst was removed from one of his fingers; and in 1990, he was diagnosed as having a mild case of glaucoma.⁶

THE MORTAL PRESIDENCY

Chapter ONE

Presidential Pathology and Mortality

Historians and political scientists often describe the presidency of the United States as a stressful, burdensome, debilitating position. Dorothy James refers to the office as literally a killing job whose pressures continue to mount.¹ Milton Plesur argues that no responsible union would ever approve the President’s hours for a ‘hard hat.’² Richard Pious points out that always there is the burden of office which takes its toll on the health and well-being of the incumbent.³ And Thomas Cronin begins and ends his 1980 volume on the presidency by quoting John Steinbeck: We give the President more work than a man can do, more responsibility than a man should take, more pressure than a man can bear.⁴

Since 1789, forty-one men have occupied the office of President. Taken as a group, presidents of the United States have tended to die prematurely, either while in office or shortly after retirement from the White House. The position, then, surely would seem injurious to the health of those who hold it.

It is, first of all, disturbing to note that four presidents have died in office at the hands of assassins: Lincoln was assassinated at the age of fifty-six, Garfield at forty-nine, McKinley at fifty-eight, and Kennedy at forty-six. While assassinated presidents have not been included in all mortality computations of this study, since their deaths were due to wholly unnatural causes, it still remains true that murder comes rather too often to American presidents. Also, physical attacks on presidents are both common and frequent. During this century, almost half of all presidents have been physically assaulted.⁵ Unfortunately, every President stands in clear and present danger of injury and death from physical assaults by potential assassins. In 1981, President Reagan became the first incumbent President in American history to survive being shot by an assailant. All others have died, either immediately or soon thereafter.

The history of the American presidency has been filled with so much violence, in fact, that Stephen Sondheim’s musical production that opened Off-Broadway in early 1991 was entitled Assassins. The focal points of the play were the men who assassinated presidents Lincoln, Garfield, McKinley, and Kennedy and the men and women who tried unsuccessfully to kill presidents Roosevelt, Nixon, Ford, and Reagan. That a musical intended ultimately for Broadway would center on the actual and planned murders of American presidents is a sad—indeed, a shocking—commentary on American political life.

Even excluding the four assassinated presidents and excluding, of course, President Clinton and the living former presidents (Bush, Reagan, Carter, and Ford), the remaining thirty-two presidents together paint a striking picture of premature death. The factors responsible for this sobering reality are worthy of detailed scrutiny.

Table 1 presents a historical view of life expectancies for white men in the United States born between 1730 and 1956. Because the federal government did not begin computing life tables until the start of the twentieth century, the data found in table 1 are composites of life tables for the United States and for the state of Massachusetts, which did compute life tables fairly regularly in the pre-1900 period. It is worth noting that as an urbanized, densely populated state, Massachusetts almost certainly would not have boasted the most favorable mortality levels in early American history.⁶ White men born outside of that and other urbanized states, therefore, might have been expected to live even longer than the data in table 1 suggest.

While the data in table 1 pertain to the average white male, a number of subgroups of the white male population have had higher life expectancies. For example, children of wealthy parents have been less likely to succumb to infant mortality, and mortality levels for the college-educated and for lawyers have been below the average.⁷

Table 1 Life Expectancy for White Males

SOURCES: United States Department of Commerce, Historical Statistics of the United States, 1949, p. 45; U.S. Bureau of the Census, The Statistical History of the United States (New York: Horizon Press, 1965), p. 24; U.S. Bureau of the Census, Statistical Abstraction of the United States, 1941–70, Washington, D.C., Life-expectancy projections for the years 1730–80 have been computed from data for the years 1789–1850.

Since a large majority of presidents (34 out of 41) have been college graduates, and since most (26 out of 41) have been lawyers,¹ their life expectancies should be higher than the life expectancy figures cited in table 1. In addition, upon attaining the office of President, the best of medical care has been available to these men; and even after retirement from the White House, former presidents have access to medical attention that is normally beyond the reach of the average white male citizen. One would think, therefore, that presidents and former presidents would have a greater-than-ordinary prospect of a long life. Unfortunately for them, however, this is not the case.

Table 2 cites each deceased president, his age at death and his life expectancy (based on the data contained in table 1). For those presidents who died between the ages of forty and sixty, the data found in column 4 of table 1 were used to compute life-expectancy projections. For those presidents who died after the age of sixty, the data found in column 5 of table 1 were applied. The differential column of table 2 indicating the actual longevity of each president (age at death in relation to life expectancy) dramatically discloses the large number of presidents who died prematurely.

Table 2 reveals that of the thirty-six deceased presidents, twenty-five died prematurely. Excluding the four assassinated presidents, twenty-one out of thirty-two deceased chief executives failed to reach their individual life expectancy. The trend toward premature death has been even more starkly dramatized during the past 150 years (1841–1991). Of the twenty-eight deceased presidents who served during this period, twenty-three died prematurely. Excluding the four assassinated chief executives, nineteen of the remaining twenty-four presidents died premature deaths.

Table 2 Presidential Mortality

*Assassinated President.

†Non-assassinated President who died in office.

‡In tables 2 and 3 and in the footnote on page 14, both the arithmetic mean and the median averages are included to describe presidential mortality and the proclivity of presidents to premature death. While the arithmetic mean is the more commonly used statistic, it may be subject to misinterpretation due to a few extreme cases, especially when the total number of cases is small. Therefore, the more conservative medians (the value attained by half of the group in question) are also included for all comparisons.

Throughout the entire history of the presidency, the longest-lived presidents are, somewhat surprisingly, the first ten (Washington through Tyler): as a group, they lived 3.7 years beyond their life expectancy. Six of the chief executives within this comparatively hardy group lived beyond their life expectancy, and only four died prematurely.

The shortest-lived presidents are the ten men, excluding the assassinated Lincoln and Garfield, who followed the first ten. These chief executives (Polk through Cleveland) fell 6.7 years short of their collective life expectancy. Among this group of presidents, nine died premature, but natural, deaths, and only one (Buchanan) reached or exceeded his individual life expectancy.

The final group of deceased presidents (Benjamin Harrison through Richard Nixon, excluding the assassinated McKinley and Kennedy) failed to reach their collective life expectancy by 3.2 years. Individually, eight of these presidents died premature deaths, and only four reached or exceeded their life expectancy.

One might suspect that the substantial differences in mortality among these three groups of presidents could be attributed to changes that have taken place within the office itself and to the increase or decrease of pressures that result from such changes. During the twentieth century, the presidency has become increasingly institutionalized and it is tempting to conclude that the burdens of the office have been lessened by the addition of layers of assistants onto the executive branch. As already noted, the most recent group of deceased presidents, excluding the assassinated McKinley and Kennedy, enjoyed somewhat longer lives than the group of presidents who served immediately before them. They were not, however, as long-lived as either the first ten presidents or the general white male population. Also, a close analysis would indicate that the institutionalization of the presidency cannot be credited with any increase in the life span of our more recent presidents.

It must be noted immediately that the relatively favorable mortality level of the more recently deceased presidents is due essentially to Presidents Hoover and Truman, who reached the ripe old age of ninety and eighty-eight, respectively—14.6 and 14.0 years beyond their individual life expectancies. If these two chief executives are removed from consideration, the mortality level of our more recent group of deceased presidents is as poor as that of their immediate predecessors.

Also, considerable misunderstanding surrounds the concept of the institutionalization of the presidency. Undoubtedly the office has been institutionalized to some degree, particularly since the administration of Franklin D. Roosevelt. But no matter how institutionalized the presidential office has become, the occupant of that office simply cannot escape its duties or its tensions. Even during vacation periods, when most of us can leave our work far behind us, presidents find that their breaks from the Washington scene are, in the strictest sense of the term, working vacations. For example, one of President Kennedy’s aides gives us a revealing glimpse into that President’s restful visits to Hyannisport and Palm Beach.

Wherever he went, Kennedy was linked by telephone to the White House switchboard, guarded by the Secret Service, and discreetly followed by one of an alternating team of Army warrant officers carrying in a slender black case the secret codes by which the Presidential order for nuclear retaliation would be given. Wherever he went, he received the same daily CIA briefing from a military or other aide and read most of the same daily newspapers, which were down in to him if necessary. Wherever he went, he took with him the bulky black alligator briefcase he had carried since his first days in the House—the same bag he often took over to the Mansion in the evening—bulging with whatever he and his staff felt he needed to read by way of mail, magazines, briefing memos and assorted dispatches and documents. During absences of forty-eight hours or more, additional materials were down to him regularly. Wherever he went, he kept in constant touch with Washington, signed bills and executive orders, and conferred on or contemplated current crises.⁸

Not only are the burdens of the presidency inescapable, those burdens are, in some respects, even heavier today than in the past because the mental stresses of the office have grown in recent decades. This can be attributed to the advent of the nuclear age and to the complexity of international politics, both of which present new burdens for contemporary occupants of the White House. Lyndon B. Johnson has confided:

I heard Richard Nixon conclude his oath of office with the words ‘so help me God.’ To me they were welcome words. I remember two thoughts running through my mind: first, that I would not have to face the decision any more of taking any step, in the Middle East or elsewhere, that might lead to world conflagration—the nightmare of my having to be the man who pressed the button to start World War III was passing.⁹

Johnson, of course, occupied the White House during very difficult times, with a divisive war, urban riots, and other crises demanding his attention. When he spoke on television late in his term about his efforts to end the war in Vietnam, one of his former aides was struck by the deterioration in his appearance:

I had not seen LBJ on television for quite a while and I was shocked. My mind went back over the changes in his appearance and manner during his five years in the White House. There were the days immediately after the assassination, the rangy, rugged figure, every antenna alert, … looking around him with those hard, piercing eyes, always as if he were sniffing out friend and foe, always as if he were remembering that a smile or a handshake might be needed here or there.… Now in March of 1968, an old weary battered man was on the television screen. The face was deeply lined and sagging; the drawl occasionally cracked and wavered. His manner gave no intimation of FDR, and little of the LBJ of 1964. Rather, it suggested a lecturish, querulous schoolmaster.¹⁰

Johnson left the presidency as a sad and troubled figure and died prematurely just four years later. It should be noted, however, that the presidents who served after him are, with the exception of Richard Nixon, still living. In fact, despite his agony as the Watergate President, Nixon survived to the age of eighty-one. Gerald Ford, Jimmy Carter, Ronald Reagan, and George Bush have, at this writing, reached the ages of eighty-four, seventy-three, eighty-six, and seventy-three, respectively.¹¹ This means, of course, that two of these presidents (Ford and Reagan) have already well-exceeded their life expectancy and two (Carter and Bush) are close to reaching theirs. But only time will tell what the overall longevity record will be for contemporary presidents. Also, it is not clear whether the recent apparent improvement in presidential longevity is due to an unusually hardy group of