The Health of the First Ladies: Medical Histories from Martha Washington to Michelle Obama (38 page)

Mrs. Reagan preoperatively directed her physicians to perform a modified radical mastectomy under general anesthesia with no interval wake-up between biopsy and definitive therapy. Dr. McIlrath from the Mayo Clinic was the lead surgeon. The cancer measured 7 millimeters and was defined as “non-invasive,” that is, it was confined to the breast ducts and had not invaded into the breast tissue itself. John Hutton reported that the lymph nodes were free of cancer as expected. He further announced that no further treatment was necessary beyond regular follow-up. The cure rate for this type of breast malignancy is close to, if not at, 100 percent.
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The publicity surrounding this news event initiated a rush by women towards doctors’ offices and mammography clinics for breast exams, as did news of Betty Ford’s cancer thirteen years previously. Immediately after the news reports, there was a 30–50 percent increase in mammography screening. A retrospective analysis published two years later noted a lower twelve percent increase. This surely cheered the first lady, who, while still in the hospital, released he following statement through a spokesperson: “I can only hope and pray that women everywhere are calling their doctors for appointments.”
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The first lady returned to the White House after six days in the hospital. Advances in medical care had significantly reduced hospital stays; Mrs. Ford’s hospitalization for breast cancer surgery lasted two weeks. A one-year follow-up examination on Mrs. Reagan was negative for tumor, and there has been no recurrence twenty-six years later.
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The thirteen-year interval between the surgeries of these two first ladies saw dramatic changes in the surgical approach towards this cancer. The destructive and excessive radical mastectomy had been replaced by the modified radical mastectomy for most tumors. In this procedure only a small amount of chest muscle is removed. A further advance was the substitution of a lumpectomy for small cancers similar to Mrs. Reagan’s. A lumpectomy excises the tumor with an adequate margin of uninvolved breast tissue; this surgery is usually supplemented with radiation or chemotherapy.

The first lady’s treatment option was widely criticized by the press and medical “experts” on two counts: First, her choice of a more extensive operation than was necessary, and second, her avoidance of an interval between biopsy and definitive surgery to allow an opportunity for the patient to carefully review treatment options. The headline in the
New York Times
the day after the surgery shouted, “Mastectomy Seen as Extreme for Small Tumor.” A lay expert was quoted that Nancy Reagan’s decision “set us back years.” Contemporary articles in both the
Washington Post
and the
Chicago Tribune
also second-guessed Nancy Reagan. The furor came close to negating the beneficial publicity that her surgery had evoked.
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This controversy deeply troubled and frustrated the patient involved. Five months later in a television interview Nancy Reagan responded that a lumpectomy probably would have required radiation or chemotherapy, and both would have interfered with her schedule as first lady. She elaborated: “I couldn’t possibly lead the kind of life I lead and keep the schedule I do.” She added that doctors who were not involved in her case had no business criticizing the treatment choices she made. She stressed “it was she, and not her husband or her doctors, who had made the decisions about which treatment to follow. It was my choice to make, so don’t criticize me for making what I thought was the right choice for me.”
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The carping may have had a small element of merit. In the six months after Mrs. Reagan’s surgery there was a documented 25 percent reduction in the use of breast conserving surgery (lumpectomy) as opposed to mastectomy among women with local or regional breast cancer. The effect was greatest among women who were demographically related to her. But this reduction was transient and disappeared after about six months.
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Nancy Reagan has been healthy but increasingly frail in the quarter-century after leaving the White House. A basal cell carcinoma was removed from beneath her left nostril during a 1990 physical examination at the Mayo Clinic. Her sense of balance has deteriorated; she experiences frequent falls, and she has been hospitalized for a fractured pelvis and fractured ribs. A recent visit to a favorite Beverly Hills restaurant shocked customers with her frailty and noticeable leg bruises due to her falls.
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Rosalynn Carter, first lady to President Jimmy Carter (1977–1981), was the second of three successive first ladies to undergo a biopsy for a breast lesion. A lump was detected in her breast during a routine six-month physical examination at Bethesda Naval Hospital in April 1977. Navy captain Dr. William Fouty removed the lesion. Pathological examination confirmed its benign nature. Mrs. Carter remains free of breast tumors thirty-seven years later.
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The first lady again had minor surgery at Bethesda Naval Hospital in August 1977. Navy captain Dr. Douglas Knab performed a dilatation and curettage (D&C) of the uterus. Mrs. Carter’s press secretary gave a succinct and unrevealing report to the press: “It is a routine procedure and a private matter.”
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Barbara Bush, Hillary Clinton, Laura Bush and Michelle Obama

Introduction

This quartet of first ladies served in the White House from 1989 to the present. All four were relatively healthy; their illnesses were either underemphasized in the press or concealed from the public: Their diseases were neither nettlesome to their presidential husbands nor disruptive of the presidential routine. All were under the constant medical care of a modernized and upgraded White House Medical Unit (WHMU), the military organization responsible for the wellness and medical treatment of the first family.

“George is very healthy, and I always questioned the press’ right to know things about his body that had nothing to do with his ability to govern.”
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Barbara Pierce Bush remains an outspoken and universally admired mother and grandmother. She is the wife to a two-term vice president (1981–1989) and one-term president (1989–1993). Barbara Pierce married navy pilot George H. W. Bush on January 6, 1945.
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Their marriage has lasted for 68 years and counting. Barbara Bush had six successful pregnancies between 1946 and 1959, giving birth to four sons and two daughters.
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However, the Bush’s oldest daughter, Robin, died from leukemia seven months after the diagnosis. The child was one month shy of her fourth birthday.
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Mrs. Bush’s health had always been robust. In the 18 months leading up to her husband’s presidential inauguration in 1989, she never had felt better and was very pleased that she was losing weight, a reduction of eighteen pounds. However, during the week before George Bush’s January 1989 inauguration, her eyes began to bother her.
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The new first lady described her symptoms in a March 20 diary entry: “They started acting up the week before the inauguration. I thought it was a makeup problem, allergy to makeup, etc. But it didn’t stop. They are red, sort of tearing all the time, itch, are puffy and I see double…. Frankly, it is a little scary.”
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The innately voluble Barbara Bush was the first to inform the public about her illness. She broke the news at an informal March 29 news conference in the White House: “I wouldn’t have told you this, but I’m so bored reading about my weight; people keep saying: ‘She’s dieting.’“ She revealed that Dr. Burton Lee III, the Bush family’s personal physician in the White House, insisted on diagnostic tests after he was informed of her symptoms. She added that her eyes looked like “horrible-big puffy, horrible eyes.” “Pop eyes,” she described their appearance.
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The tests were performed at Walter Reed Army Medical Center, where the diagnosis of Graves’ disease (hyperthyroidism) was established. Mrs. Bush colorfully described her problem as “an overactive thyroid—it just went wacko.” Her diary entry, dated March 20, 1989, reads colloquially: “they think I have a thyroid gone berserk.”
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The first lady determined that the public should be informed immediately since Graves’ disease was not a life-threatening condition if treated. Later in the day of her news conference, her press office belatedly caught up with the story. It formally announced that Barbara Bush had Graves’ disease. In addition, its official statement disclosed that treatment with methimazole had commenced and that marked improvement of her eye symptoms had occurred. Methimazole is a drug that inhibits the synthesis of the thyroid gland’s hormones.
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The following month Mrs. Bush was again an outpatient at Walter Reed. She sipped a solution of a radioactive form of iodine to further suppress the hyperactivity of her thyroid gland.
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Graves’ disease is the most common cause of hyperthyroidism, i.e., increased activity of the thyroid gland. For reasons still unknown, antibodies to the patient’s own thyroid are produced which lead to an uncontrolled production of thyroid hormone. The hormone controls the body’s metabolism and is critical for regulating mood, weight, and mental and physical energy levels. Surprisingly, thyroid hormone receptors are also present elsewhere in the body other than the thyroid. The adipose (fat) and muscle cells of the eye orbit contain such receptors. In Graves’ disease, these orbital constituents expand and crowd out the eyeball; protrusion of the eyes is a result. Eye protrusion, also known as exophthalmos, is a diagnostic sign of Graves’ disease and in Mrs. Bush’s case it produced weight loss and eye problems. At sixty-two years of age, she was older than the usual patient—a woman closer to the age of twenty.
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Graves’ disease was named for an astute nineteenth-century Irish physician, Robert Graves, who at age thirty-nine described four young women with the condition. Three presented symptoms of an enlarged thyroid gland and tachycardia (an abnormally increased heart rate). The fourth exhibited severe exophthalmos. Graves’ insight was to connect the symptoms of the four women into a single clinical entity. However, as frequently is the case with eponyms, the namesake was mistaken regarding its essential features. Graves erroneously concluded that the diseased organ was the heart, not the thyroid gland.
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Mrs. Bush’s ocular symptoms continued. Despite initial optimism, the double vision, tearing, and irritation did not improve. An August return visit to Walter Reed concluded that although her thyroid function was under control the uncomfortable eye complaints persisted. Consequently, another treatment was instituted: Oral steroids in the form of prednisone.
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Despite prednisone therapy, the symptoms still persisted three months later. Therefore, the first lady sought a second opinion apart from Doctor Lee and the specialists attached to the military hospitals in the Washington, D.C., area. She flew to the Mayo Clinic in Rochester, Minnesota, for a series of tests and recommendations for alternative treatment. Perhaps her choice of an external consultant was influenced by the Reagans’ past successful treatments by physicians from this esteemed institution. The Mayo Clinic reduced the daily prednisone dosage and recommended a course of radiation to her eye orbits.
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Prednisone is not without side effects, which Mrs. Bush acknowledged: “I was weaning myself off the prednisone … and it was very painful. I was taking therapy to strengthen my muscles…. [P]rednisone … killed something in my right hip and caused muscles to weaken, especially around my knee and hips. I confess that I was in a lot of pain that would last through the fall.”
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A ten-day course of low-level X-rays at Walter Reed Army Medical Center followed in January 1990. The objective of the irradiation was shrinkage of the muscles and fat of the eye orbits in order to reduce swelling and inflammation. The hope was to provide more room for the eye muscles to adjust, limit double vision, and reduce the exophthalmos.
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There is no indication that the first lady’s disease affected the functioning of the president. Mrs. Bush’s account of the first hundred days of the Bush administration showed no let-up in the 41st president’s hectic executive, travel, and social schedule.
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Two decades later, in March 2010, the eighty-four-year-old Mrs. Bush was briefly hospitalized in Houston with undisclosed, but baffling, symptoms. After several days of testing the diagnostic conclusion was a mild relapse of Graves’ disease. The Bush family spokesman “described her symptoms as not life-threatening but would not go into further detail at the time.” A slight adjustment was made to her medications that she had been taking for twenty years. Since 1990, there has been no reference to exophthalmos.
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