Doctor Zebra > Presidential Health > Other notables > Candidates > John McCain > Problems

Health of John McCain (2008)

Introduction Laws Sources Problems Invasive Melanoma Discussion A Plan Bibliography

Medical Problem List

Introduction

All good medical records contain the patient's "problem list." All good physicians base their thoughts about the patient on the problem list. Non-physicians should, however, understand two things about it.

First, "problem" is too strong a word. The medical problem list simply includes everything that is out of the ordinary about the patient, even when it is not a "problem" in the true sense of the word (1).

Second, nothing is too trivial to find its way onto the problem list.

Contents of This Page

Senator McCain's Medical Problem List

Editorial: The length of this page should not be viewed as evidence that the McCain campaign has been open about the Senator's recent health. For example, and by contrast, the problem list for Abraham Lincoln contains 81 items (2), and a discussion of a subset of those problems spans 312 pages (3).
 

Tumors & Growths
Malignant melanoma, introduction
Melanomas are dangerous skin cancers. Senator McCain has had four melanomas (at least), as follows:

YearSiteStageInvasive?References
1993Left shoulder0No (4) (5)
2000Left arm0No (4) (5)
2000Left lower temple?Yes (4) (5)
2002Left nasal sidewall0No (4) (5)

Each melanoma was a new primary melanoma and did not represent a recurrence of any previous melanoma (4).

The three non-invasive melanomas are technically called "melanoma in situ, stage zero." These developed on sun-exposed skin. Two were removed at Mayo Scottsdale; one was removed elsewhere in 1993 (5). (Another source says the 1993 tumor was removed at the Mayo Clinic (6).) There is no evidence of any recurrence of melanoma at any of these three sites (5).

The invasive melanoma of 2000 is discussed at length on on a separate page. As of May 2008, there was no evidence of recurrence or spread ("metastasis") of the invasive melanoma, this being nearly eight years after surgery (4).

In the words of Sen. McCain's dermatologist (5), as of May 2008:

  • The senator has no evidence of melanoma.
  • He continues to monitor his skin carefully.
  • He comes in for a skin examination every 3-4 months.
  • He not only practices good habits of sun safety but also advocates them publicly.

One source reports that Sen. McCain has had three or four dermatologic checkups each year since 2000 (7). The Senator's wife performs dermatological checks on him at home (8).

Senator McCain's most recent dermatological evaluation at the Mayo Clinic was July 28, 2008 (9). A biopsy of a lesion on his right temple showed no evidence of skin cancer (10).

Each of the four melanomas is discussed individually, below.

Malignant melanoma, 1993: shoulder
In 1993, a Navy doctor recommended that Senator McCain consult a dermatologist for a lesion on his shoulder. McCain waited more than six months before seeking care (7). The lesion turned out to be his first melanoma. It was on the left shoulder (4), an area described as "sun exposed" (5).

Editorial: Dear Reader, do not follow this example. McCain got away with waiting six months, but he was lucky. One wonders what he was thinking. Most people, told that they might have a serious cancer, would eagerly have it removed, especially if it is as easy to remove as an early melanoma.

The melanoma was in situ, meaning it was limited to the top layers of the skin and was not invasive (4). It was excised and there is no evidence it has recurred (5).

Question: It is unclear what institution removed this melanoma from Senator McCain. One source says the Mayo Clinic (6). Another source says it was not Mayo Scottsdale (5).

Doctors declared McCain cured of this melanoma in 1999, since his cancer had not recurred in more than five years (6).

Malignant melanoma, 2000: left arm
The attending physician at the United States Capitol discovered this melanoma "after it had escaped the eye of Mr. McCain's personal physician at Mayo Clinic Scottsdale" (7).

Simultaneously (one presumes), the Capitol physician also spotted the much more serious invasive melanoma on McCain's left temple (7).

Editorial: See the invasive melanoma page for comments and questions about the August 2000 melanomas.

The section on the invasive melanoma discussed the (small) impact of these tumors on the 2000 Presidential campaign.

The melanoma was in situ, meaning it was limited to the top layers of the skin and was not invasive (4). It was excised and there is no evidence it has recurred (5). It occurred in an area described as "sun exposed" (5).

Malignant melanoma, 2000: left temple, with possible spread
Because it was invasive, this was the most serious of the four melanomas. Its discussion is extensive, and is presented on a separate page.
Malignant melanoma, 2002: left side of nose
This tumor was on the left nasal sidewall (4), an area described as "sun exposed" (5). It was discovered during a routine dermatological examination on Jan. 17 (11). It was "less than one centimeter" (11) [presumably this means less than one centimeter in diameter].

Editorial: Presumably "less than one centimeter" means less than one centimeter in its largest horizontal extent.

Senator McCain was scheduled to undergo surgery at the Mayo Clinic Hospital in Phoenix to remove the melanoma on Monday, February 4. A 90 minute procedure to cover the scar from the removal of the tumor was scheduled for the Tuesday or Wednesday afterwards (11).

Editorial: The cited source was written before the operations occurred. Further research would probably unearth reports written afterwards. The need for a cosmetic operation after the removal of the tumor is probably more a function of the location of the tumor than of the tumor's extent. That is, even if the tumor had been pinpoint, providing a one-centimeter margin around the tumor would result in a patch of missing skin almost an inch in diameter. This type of scar, on so visible a feature as the nose, would certainly demand plastic surgery.

The melanoma was in situ, meaning it was limited to the top layers of the skin and was not invasive (4). It was excised and there is no evidence it has recurred (5).

Reference (12) includes a photograph of McCain shortly after the operation that removed this melanoma.

Non-melanoma skin cancer
Since his first melanoma in 1993, Senator McCain's doctors have "periodically removed suspicious moles or lesions from his skin. Most of these lesions consisted of basal cell carcinoma, the least worrisome and most common type of skin cancer" (6). Squamous cell cancers have also been removed (4), including one in February 2008 (8).

Senator McCain has had more than a dozen patches of abnormal skin cut out or chemically destroyed this decade (13).

Skin cancer risk factors
Medical science has identified several factors that increase a person's chance of developing skin cancer.

Senator McCain's risk factors include light skin, light eyes and a history of excessive sun exposure. He has no known family history of melanoma. He has few moles and he has no known history of atypical moles (5).

Senator McCain is said to have had prolonged sun exposure at a young age -- long before the wide use of sunscreen (7). "`I spent too much time in the sun, and every few months I have to go and have some basal cells removed from my old craggy features,' Mr. McCain told CNN recently, before one of his periodic checkups" (6).

Editorial: Total sun exposure is not as powerful a predictor of melanomas as is the number of sun-burns during youth. The higher the number of sun-burns, the higher the risk of later developing melanoma.

"Now, on the campaign trail, Mr. McCain appears to take care to shield himself from the sun, slathering on powerful sunscreen before outdoor events, finding spots of shade from which to speak and sometimes wearing baseball caps while outside" (7).

Colonic polyps
McCain first had an adenomatous colon polyp removed in the 1990s. The next two tests -- performed years apart -- proved negative (14).

Senator McCain has had four colonoscopies from 2000-2008 (13). During his most recent colonoscopy in April, six benign polyps were removed (15). These six were apparently all the polyps that were seen (14).

Editorial: Four colonoscopies were performed in nine years. This seems remarkably frequent, given that, in persons with normal colons, the usual interval between examinations is 10 years. However, colonoscopy every three years is recommended for some persons with polyps.

It is not clear that the pathology reports have been supplied for all the polyps the Senator ever had removed. Perhaps they were, but the hurried reporters did not have time to systematically record them. These reports should be released.

The medical documents inspected by reporters in May 2008 contained pictures of the interior of the Senator's colon, as seen through the colonoscope (8).

The plan is to continue the Senator with periodic colonoscopies in the future (14).

Benign prostatic hypertrophy
At the same time as the laser treatment of bladder stones (August 2001), some benign enlarged prostate tissue was surgically removed. Since then, he has normal urination (4).

It has been reported that the Senator has had "a prostate biopsy that showed no sign of cancer" (8). Presumably this is the same incident as in the paragraph above.

The Senator has had at least one measurement of prostate specific antigen (PSA). It measured 1.1 -- a reassuring value (8)

Editorial: PSA testing can detect prostate cancer at an early stage. Such testing is routine for all men over 50 (and some past 40) because prostate cancer is a significant risk to their lives.
Kidney cysts
Senator McCain has "a number of small benign cysts in both kidneys." These do not impact his kidney function (4).

Question: How are the cysts known to be benign? Scans of the kidneys can tilt the odds toward benign or cancerous, but they cannot say for sure. Were the cysts biopsied? Or are the Senator's physicians playing the odds?
Thyroid nodules
The CNN medical reporter who saw Senator McCain's medical records in 2008 said the Senator had nodules in his thyroid gland, and it "looks like they're not a problem for him" (8).

Editorial: It would be of interest to know the data that led the reporter to his conclusion. The reason: In medicine, the word "nodule" is ambiguous. It is sometimes a purely descriptive term that means the same thing as "lump." It can also mean "a lump that is not cancer."
 

Cardiovascular System & Risk Factors
Exercise tolerance
During two stress tests for his heart (one in 2000, one in 2008 (8)), he was able to exercise on a treadmill for 10 minutes (13). "His current stress echocardiogram is normal at a high level of exercise. There is no evidence of decreased blood supply to any part of his heart muscle" (4). The "numbers" on stress echoes did not change between 2000 and 2008, and his "heart function appears to be good" (8).

Assumption: These tests were done purely for preventive purposes, as part of an "executive physical," and not because the Senator was having chest discomfort or other symptoms or signs of cardiac disease.

Question: It would have been helpful to know which treadmill protocol was used in these tests. Exercise testing provides useful information about future risk of heart disease, but specific predictions cannot be made without knowing the treadmill's speed and up-angle during the ten minutes of exercise.

Editorial: In the statement that his "current stress echocardiogram is normal at a high level of exercise," one wonders if there is an implicit "for his age" that should be appended. The demands of the Presidency, which occasionally do accelerate the heart to a significant degree, are not adjusted downwards for age.

He walked the Grand Canyon rim to rim in 3 days in August 2006 without problems (13) (4) and continues to hike whenever his schedule permits (4).

Editorial: This is an impressive feat for a 70-year-old man. The trail is about 24 miles long and includes a final climb of about 4000 feet in elevation. It can be concluded that the Senator's cardiorespiratory fitness was good (for his age) in 2006.
High LDL cholesterol, low HDL cholesterol
"According to a pool report based on the review of the records, Mr. McCain's cholesterol level was recorded as high in 2003, with a total cholesterol of 226 and an LDL, or harmful cholesterol, of 139, and an HDL, or good cholesterol, of 35. Mr. McCain was put on Vytorin, which worked in reducing his cholesterol in subsequent checks, but he was taken off this year after reports that the drug may not work. Mr. McCain was instead put on simvastatin, which the records said did not reduce his cholesterol by as much but was deemed `acceptable'" (15).

Editorial: Vytorin is a combination of two different cholesterol-lowering medications. It is unusual to begin treating a mildly elevated cholesterol with two medications. Normally, one medication is used, and a second added only if the first proves inadequate. It is possible that enthusiasm for Vytorin is the explanation for using it first: in treating cholesterol, "lower is better" and so the prospect of a greater cholesterol drop with one Vytorin pill daily was more attractive than the prospect of a smaller reduction with a different once-daily pill. It is puzzling why the reporters of this story, who supplied several numbers for the Senator's cholesterol profile before treatment started, did not supply numbers for his current cholesterol profile. Instead, they quoted a qualitative term, "acceptable," suggesting that the numbers were not available. This raises questions about the completeness of the information that was disclosed in May 2008.

Editorial: The elevated LDL cholesterol is not the only cholesterol abnormality deserving treatment. The Senator's level of HDL cholesterol, 35 mg/dl, is below the desired level. Unfortunately, raising the HDL level is more difficult than lowering the LDL. Sometimes a "statin" drug, such as simvastatin, will raise HDL, but there is no indication that is happening here.
Episode of high-ish blood sugar
One note among those released in 2008 described Senator McCain's fasting blood sugar value as "impaired" (14).

"Asked to elaborate, [Dr.] Eckstein said he thought that the note referred to a 111 mg/dl blood sugar, with normals `in most labs' being between 70 mg/dl and 100 mg/dl. Eckstein said he followed that test result with another that he did not identify, `which was completely normal'" (14).

Editorial: Blood sugar is discussed in the cardiovascular section because high blood sugar levels, as in diabetes mellitus, significantly increase the risk of cardiovascular disease.

Editorial: The Senator is taking a medication (hydrocholorothiazide (HCTZ) 25mg, presumably daily) that can raise blood sugar levels. Presumably his physicians believe the benefit of the medication outweighs its sugar-raising risk and other risks.

Diabetes mellitus is diagnosed when the level of sugar (glucose) in the plasma of venous blood is 140 mg/dl or higher on more than one occasion.

Editorial: It is reassuring that the reporters noticed the reference to impaired blood sugar among the hundreds of pages of documents. It bespeaks a review of reasonable depth.

Editorial: The follow-up test was most likely a hemoglobin A1C measurement, or an oral glucose tolerance test.
Isolated systolic hypertension
Senator McCain's systolic blood pressure (the top number in a blood pressure reading) "had sometimes been slightly high" (14). The Senator's internist added that he has encouraged McCain to reduce his salt intake.

McCain has, for an unknown period of time, been taking two blood pressure-lowering medications: hydrochlorothiazide (HCTZ) and amiloride.

Although he is said to be taking the HCTZ to prevent kidney stones from forming, his dose (25 mg, presumably daily) is high enough to treat high blood pressure. The Senator's physician has said, however, that "the drug was being prescribed solely for kidney stone prevention" (14).

Editorial: For all practical purposes, reducing salt intake is prescribed only to lower blood pressure. Combined with the statement that the Senator's top blood pressure was "sometimes slightly high," this would appear to make the diagnosis of "isolated systolic hypertension."

Isolated systolic hypertension (i.e. elevation of the top blood pressure number) is very common in older Americans. It is an indication of stiffening arteries, which occurs universally with aging in the civilized world. Small doses of diuretics ("fluid pills"), such as HCTZ and amiloride, are very effective treatments (for blood pressure, not for civilization).

It is hard to believe that Senator McCain's physician has never said to his patient: "You're getting two for one with the HCTZ: it is helping keep your blood pressure down and keeping kidney stones away. It may even be three-for-one, because HCTZ makes the amiloride necessary, which further lowers your blood pressure."

Editorial: Sleep apnea is now listed first among the identifiable causes of high blood pressure. Given that Senator McCain has high blood pressure, and a thick neck, it would be worthwhile to test him for sleep apnea, especially if he snores.
Overweight?
It is difficult to tell from television images whether Senator McCain is overweight. He has the appearance of being "thick" around the middle. I have not encountered a weight for him. He is 5 feet 9 inches tall (8) (16).
Orthostatic symptoms?
The descriptions of Senator McCain's "vertigo" vary (see below). Some descriptions clearly implicate head movements as precipitating the symptoms. Others say that standing too quickly precipitates the symptoms.

Question: The distinction is significant. Symptoms that occur upon standing ("orthostatic symptoms") are more often cardiovascular in origin than vestibular in origin. If the Senator were often dehydrated (caused by his two diuretic medications, for example), that would explain his orthostatic symptoms. Cardiovascular reflexes, which most people take for granted, can become blunted with age, and represent another possible cause of orthostatic symptoms.

It would be helpful to see the full reports on these symptoms, and the cardiovascular evaluation (if any) they prompted.

Smoking history
The Senator smoked two packs of cigarettes per day, for 25 years, until 1980.
Cardiovascular summary
"He has no evidence of heart or other cardiovascular disease" (4).

Editorial: Heart disease, and its close cousin, stroke, are together the #1 killer of adults in the United States. The risk of heart disease and stroke increases sharply with age. Although the broad, general statement above is reassuring in its simplicity, it is probably untrue.

First, there is the possibility that at least some of the Senator's dizzy spells are cardiovascular in origin (see above).

Second, the reports of the Senator's top-blood-pressure-number sometimes being high, while on two anti-hypertensive medications, would seem to indicate that he has some form of high blood pressure. High blood pressure is a cardiovascular disease.

One also wonders if the Senator's usual blood pressure readings are in the range of "pre-hypertension."

Question: If the Senator's blood pressure has "sometimes been slightly high," despite taking two anti-hypertensive medications, one must consider the possibility that high blood pressure mayhave caused some end-organ damage over the years. It would, therefore, be reasonable to inquire: (1) does he have left ventricular hypertrophy? (2) what is his kidney function? (3) what do his retinal vessels look like?

(Abnormal thickening of the heart muscle ("left ventricular hypertrophy") is another major cause of heart attack and stroke. It would be reassuring, however, to hear more detailed statements that the Senator's resting echocardiogram and electrocardiogram are normal.)

Senator McCain takes baby aspirin (7) (daily, one presumes) "for blood clot prevention" (4).

Editorial: Aspirin is a reasonable measure to prevent heart attacks and the major type of stroke, especially given his many cardiovascular risk factors.
 

Urology
Kidney stones, prevented with medication
"Since August 2001, he has normal urination and has not passed a kidney stone" (4).

Assumption: Presumably he passed one or more kidney stones before August 2001.

However, a CNN reporter has said that the Senator started to have bleeding in his urine in Jan. 2006, due to kidney stones (8).

Question: Knowing the year in which blood was in his urine would help tidy up the record. It's probably 2001, as a third report (14) says.

As of May 2008, he had small kidney stones in his right kidney (4) (four stones (13)). They do not affect his kidney function (4).

"He takes medication to help prevent future kidney stones" (4).

Editorial: As mundane as kidney stones may appear to be, they present an interesting problem for a President. The pain of a kidney stone can be so severe that it is difficult or impossible to think straight. Sometimes narcotics are required to control the pain. The question arises, therefore, under what circumstances should a President with excruciating pain from kidney stones cede power to the Vice President? The 25th Amendment to the Constitution provides a mechanism whereby the Vice President and the Cabinet can wrest power from an incapacitated President, but the amendment does not clearly define the threshold for such an action. A few Presidents and their Vice Presidents have had an understanding about power transfer (12). Most have not.
Bladder stones, treated with laser
Senator McCain had 4 bladder stones fragmented by a laser in August 2001, at the same time some benign enlarged prostate tissue was surgically removed. Since then, he has had normal urination (4).
 

Neuro-Psychiatry
Dizziness and/or vertigo
Senator McCain reported dizziness in 2000, described by a physician as "mild positional rolling sensation with rapid turning of his head when he gets out of bed in the morning" (13). Another report characterized the symptoms as "occasional momentary episodes of dizziness when he stands up too quickly" (15). And a third reporter described the episodes as dizziness, "specifically when he sort of tips his head back, for example, to put in eye drops" (8).

The Senator's internist said: "When he and many other people arise from sitting or lying down, they get a sudden whirling sensation which may last two to five seconds and then disappears. It does not indicate any vascular problem to the brain, and it is not a precursor to stroke." (14)

Editorial: The multiple descriptions suggest that the problem was mentioned during multiple physician visits.

After testing (15), the symptoms were diagnosed as "benign positional vertigo." It was treated by teaching McCain to move his head so as to relieve the sensation (13).

Editorial: The New York Times took pains to mention that benign positional vertigo is not a precursor to a stroke. It seems prudent to repeat that here. But that presumes the diagnosis is correct...
Drooping left eyelid
In the first half of 2008, during one of the Senator's appearances on television, I happened to notice that his left upper eyelid momentarily drooped as he was speaking. Freeze frame confirmed this impression. Many commentators in the blogosphere noticed this phenomenon later in the year. There has apparently been no information forthcoming from medical or campaign sources.

Question: Is this a true droop or a transient lid lag? What is the cause?

The main causative possibilities would seem to be: (1) an undesired effect of the operation on his left temple, (2) a lesion in the central nervous system, e.g. a metastasis from a melanoma, (3) an undesired effect of the lens-replacement operation on that eye, (4) some other trauma to the head, (5) an abnormality of the right lid, which has the effect of making the left lid look abnormal.

Now that several months have passed, without worsening, a lesion in the central nervous system would be unlikely.

Personality
In records released in 1999, doctors said Senator McCain's mental status and psychological tests were normal. A psychiatric evaluation in 1974, apparently performed as part of a Navy program to track the health of former prisoners of war, described him as ambitious, competitive and energetic (15).

The documents released in 2008 made no mention of McCain's psychological or emotional state, beyond numerous references to him being "pleasant and energetic" (13). Another reporter similarly noted that there were "hardly any" mentions of the Senator's mental health in the documents (8).

Editorial: There are frequent references in the news media to Senator McCain's temper. I have not seen that analyzed medically.
Mental effects of wartime captivity
As a prisoner of war, McCain was repeatedly beaten, bound and placed in prolonged solitary confinement (17). He later told doctors that he had tried to commit suicide twice. But by 1977, he said he had "all but forgotten the traumas of captivity" (15).

Despite this, McCain has never received a diagnosis of post-traumatic stress disorder (PTSD) (17).

Editorial: Research suggests that PTSD has been rare in American aviators who were POWs in Viet Nam (17).

For an unspecified period of time after his return from Viet Nam, Mr. McCain participated in a United States Navy project to gauge the health of former prisoners of war (7). However, he "has not for many years participated in any POW follow-up" (17).

Editorial: Perhaps as a public figure, Senator McCain felt that continuing his participation in the Navy's study was too risky.

The records exposed in May 2008 contain "no psychological material because McCain has not been treated for anything related to that in the time frame of records we are releasing," according to a McCain campaign spokesperson (17).

Intermittent sleeplessness, treated with medication
No details of this symptom are known. He has taken Ambien CR "as necessary for sleep when traveling" (4). He has also taken melatonin in the past (8).

Editorial: Sleeplessness is sometimes a sign of sleep apnea, though it is not a classic sign.
Assessment of risk for cognitive impairment
In May 2008, Senator McCain's internist stated that there was no evidence of short-term memory loss in the Senator, either in his history or his examination. The internist did not say if he had performed tests of Mr. McCain's "mental status" (15).

Editorial: Short term memory and "mental status" are two different things. (Mental status includes factors such as mood, hallucinations, and so on.) I get the sense that a reporter asked the internist if he had performed formal testing of Senator McCain's short term memory, and the response somehow came out talking about mental status. Or, it is possible someone asked about the "mini-mental-status" examination, which is used to identify persons with dementia.
Alcohol consumption history
Senator McCain has made allusions to self-indulgence as a youth, including alcohol. Quantitative reports of his consumption have not appeared. His father has been characterized as an "alcoholic."
Short, thick neck
This finding is apparent in photographs and video recordings of Senator McCain.

Editorial: A short thick neck increases the risk of sleep apnea. Untreated sleep apnea can alter mood, memory, judgment, and patience. Sleep apnea helped wreck the Presidency of William Howard Taft.

Sleep apnea can also raise blood pressure, and the Senator appears to have some abnormalities of blood pressure. It would be worthwhile to test the Senator for sleep apnea, especially if he snores.

 

Trauma
Plane crash #1
While in military flight training, McCain's airplane crashed into Corpus Christi Bay during landing. He "was knocked cold on impact. When he came to, the plane was underwater, and he had to swim to the surface to be rescued. ... McCain took some painkillers and a nap, and then went out" for the evening (16).
Shrapnel wounds
In 1967 McCain's airplane, with him in the cockpit, was struck by an accidentally-fired missile while still on the deck of the aircraft carrier USS Forrestal. To escape his burning aircraft, McCain jumped about 9 feet from the cockpit to the deck. Moments later, a bomb exploded, peppering him with "tiny bits of shrapnel in his legs and chest, but the wounds weren't serious; his father would later report to friends that Johnny `came through without a scratch'" (16).
Plane crash #2 (ejected) and captivity
Senator McCain broke both arms and a leg/knee (18) after ejecting from his combat aircraft during the Viet Nam War in 1967. During his capture by the North Vietnamese, he was "bayoneted in the ankle and the groin, and had his shoulder smashed by a rifle butt" (16).

Inadequate treatment of the injuries, plus torture by his captors in Hanoi, added to these orthopedic problems (17).

After he was released in 1973, he returned home on crutches and began a painful physical rehabilitation (18). Initially, his knee was frozen at 180 degrees, but nine months of therapy ultimately allowed him to flex it to 90 degrees. Ninety degrees was required for flying status in the Navy (12).

Ultimately, he was left with a decreased range of motion in his arms, evident in the shrugging appearance of his shoulders (17). In his autobiographies, McCain said that his knee still bothered him in cold weather and that he was unable to raise his hands above his shoulders (18).

Nevertheless, McCain later regained flight status and commanded a Navy squadron before retiring from the military in 1981. (18)

His current orthopedic status has been reported inconsistently:

  • News report: "He continues to be mildly bothered by degenerative arthritis in his shoulders, hands and knees" (13).
  • Statement of his physician, Dr, Eckstein: "He does not complain of bone or joint pain and does not take pain medication" (4).
  • News report: "Dr. Eckstein has said Mr. McCain might need a joint replacement in the future" (15).
  • News report: The Senator may need both shoulders replaced "at some point in the future" (8).
Senator McCain is receiving a $58,000 annual disability pension "because of his limited body movements due to injuries as a POW," according to one of his staff members (18). The pension is 100% exempt from taxes, which is said to indicate the seriousness of the disability (18).

Editorial: There is a contradiction here. Senator McCain was returned to flight status after the war. This should not have been done (or would not have been done) had the range of motion in his arms or legs been severely compromised. For example, it is important that aviators be able to egress their aircraft rapidly and safely during ground emergencies. It is especially important that naval aviators be able to swim if they end up in the ocean. Both of these activities would be difficult or impossible with restricted range of motion in the arms. Thus, it is inconsistent that the Navy awarded the Senator a disability pension for range-of-motion issues, while at the same time saying his range of motion was acceptable for flying duties.
Plane crash #3
After returning from captivity, McCain was piloting a single-engine ultralight that crashed. He has never spoken of this crash publicly. A friend recalled, in a 1999 interview, that the crash left McCain with bandages on his face and one arm in a sling (16).
 

Other
Prominent left cheek; Left facial scar
Senator McCain sometimes tells audiences that he has "more scars than Frankenstein" (7).

The prominence of the Senator's left cheek is a result of the big operation in August 2000 to remove the invasive melanoma. His surgeon wrote that the cheek's appearance "is a result of an absence of soft tissue on the face in front of his ear that makes the masseter (the chewing muscle) over the jaw appear more prominent. To be clear, the swelling is not due to any evidence of cancer" (19).

Senator McCain expressed concern about his appearance to his physicians, "complaining several times the scar was `thick' and visible and that his face appeared swollen. He underwent a minor operation to minimize the scar and later wore a face mask designed to put pressure on the scar to help it heal. `Patient is to wear the garment at night since he will not be able to do that during the day due to the nature of his work,' a doctor wrote. The records show that McCain rarely wore the mask because he was unable to sleep with it on" (13).

As part of efforts to maintain the Senator's appearance, physicians have recommended wearing loose-fitting shirts (8).

Editorial: Presumably a tight collar would impeded drainage of fluid from the Senator's face, and thereby contribute to a puffy appearance.
Portion of parotid gland missing
A portion of the Senator's left parotid gland was removed as part of the big August 2000 operation to remove the melanoma on his temple (13).

Editorial: The parotid gland is one of the salivary glands. Saliva is important in preserving dental health. When the salivary glands malfunction, the teeth often begin to suffer.
Prematurely white hair
Editorial: This striking feature of Senator McCain's appearance has not attracted medical commentary. To be sure, it is a difficult area, in which relatively little is known. First, a distinction is often made between graying of the hair and whitening of the hair (20), but it is not clear how rigid that distinction is. Second, it has been difficult to convincingly associate medical conditions with premature graying. Pernicious anemia is one of the most frequently mentioned associations. Conflicting evidence associates coronary heart disease.

Premature graying runs in some families. The very few photographs I have seen of the Senator's father show him, alas, wearing a hat.

There is a long tradition that great emotional shock can whiten the hair. I have not reviewed the literature on this subject. In this context, it is natural to ask if the Senator's experiences as a prisoner of war may have factored into his hair's change.

Most recently, it has become apparent that loss of stem cells in the hair is involved in graying and whitening. Whether this reflects on stem cell function in the rest of the body is unknown to me, but the lack of an obviously shortened life span in persons with prematurely white hair is reassuring.

A video of Senator McCain during the 2008 campaign shows that the hair on his forearms is still dark.

Nasal allergies
For allergies, he is reported to take Zyrtec (4), and occasionally Claritin or Flonase (7).

Editorial: The Senator's hay fever must not be easy to control, given that he has tried three different medications for it.
Former smoker
McCain smoked two packs of cigarettes each day for 25 years, quitting in 1980 (8).

Editorial: It would be unlikely that McCain had access to cigarettes during the 5 1/2 years he was a prisoner of war. Thus, at the time of his release from captivity, he had certainly beaten (through no action of his own) any tobacco addiction he might once have had. Apparently, however, he returned to smoking after his release.
Abnormal chest X-ray
Senator McCain has a granuloma in the "right upper part of his lung" and fibrosis in the "right lower part of his lung." These are followed with chest x-rays. (8)

Contrariwise, it has been reported that "he recently had a CT scan of his chest performed, and it proved normal"" (14).

Question: It would be helpful to reconcile the abnormal chest x-rays with the abnormal chest CTs in this ex-smoker. It would be very unusual to have these abnormalities on chest x-ray be invisible on CT scan.
Lens implants
Because of cataracts, artificial lenses were implanted in both eyes (8).

Editorial: Cataracts could be another sign of heavy past exposure to sunlight.
Family history
His father died of a heart attack at age 70 (8). His mother is still living and "spry" at age 96 (12).
General
In May 2008, Senator McCain's internist stated (4): "At the present time, Senator McCain enjoys excellent health and displays extraordinary energy. While it is impossible to predict any person's future health, today I can find no medical reason or problems that would preclude Senator McCain from fulfilling all the duties and obligations of President of the United States."

Editorial: There is a good deal less to this statement than it appears. The Constitution enumerates an astonishingly small number of required duties for the President. Surprisingly, the major duty is presenting an annual message to Congress. We recognize this as the State of the Union address, but in earlier times, the President merely sent a written message to the Congress. Thus, even a significantly ill person would be able to fulfill the Constitutionally required duties. (Examples: Abraham Lincoln wrote his 1863 message while he was recovering from smallpox (2) and Woodrow Wilson finished his term in office despite a stroke that shattered him 17 months earlier.)
 

Medication List
Prescription
This list was provided by reference (4). In no case was the dose of the medication quantified.
  • HCTZ (hydrochlorothiazide) ("for kidney stone prevention")
  • Amiloride ("to preserve potassium in the blood stream")
  • Zyrtec ("an anti-histamine as necessary for nasal allergies")
  • Ambien CR ("as necessary for sleep when traveling")
He is reported to occasionally take Claritin or Flonase for allergies (7).
Over the Counter

Footnotes

1. For example, pregnancy should appear on the problem list, even thought it is not a health threat to most healthy women.
2. Sotos, John G. The Physical Lincoln Sourcebook. Mt. Vernon, VA: Mt. Vernon Book Systems, 2008, printing 1.1.
3. Sotos, John G. The Physical Lincoln. Mt. Vernon, VA: Mt. Vernon Book Systems, 2008, printing 1.1.
4. Eckstein, John D. Statement in Trastek.
5. Connolly, Susan M. Statement in Trastek.
6. Alvarez, Lizette. "McCain Discloses New Case Of Malignant Melanoma." NYTimes.com. 2000 August 17.
7. Altman, Lawrence K. "On the Campaign Trail, Few Mentions of McCain's Bout With Melanoma." New York Times. 2008 March 9.
8. Gupta, Sanjay. "McCain in 'excellent health,' doctor says." (Video report.) CNN.com. 2008 May 23. [Note: to see the video, click on the VIDEO tab, located next to the READ tab.]
9. Aigner-Treworgy, Adam; Murray, Mark. "McCain's mole removed." MSNBC.com. 2008 July 28.
10. Irving, Frank. "McCain's skin cancer history." Advanceweb.com. 2008 July 30.
11. Reuters. Sen. McCain to Undergo Surgery for Skin Cancer. 2002 Feb. 4.
12. Gupta, Sanjay. "Fit to Lead." CNN. Special Investigations Unit. Broadcast 2008 October 11. Note: I have some questions about bias in this source. They claimed that Senator McCain's temple melanoma was the size of a dime and the thickness of a nickel. It was actually larger then a penny (which is larger than a dime) and thicker than a nickel. In addition, they devoted much air time to Senator Obama's smoking history, without once mentioning that Senator McCain smoked two packs of cigarettes per day for about 25 years.
13. Shear, Michael D.; Brown, David. "McCain's Medical Records Indicate He Is Cancer-Free, Generally Healthy." Washington Post. 2008 May 24, page A03.
14. CNN.com. "McCain in 'excellent health,' doctor says." 2008 May 23.
15. Altman, Lawrence K.; Bumiller E. "McCain's Health Is Called Robust by His Doctors." New York Times. 2008 May 24.
16. Dickinson, Tim. "Make-Believe Maverick: A closer look at the life and career of John McCain reveals a disturbing record of recklessness and dishonesty." Rolling Stone issue #1063. Posted online 2008 October 11 (or earlier).
17. Brown, David. "POW Aftereffects in McCain Unlikely: Research Shows Past Trauma Probably Won't Affect Candidate's Life Span." Washington Post. 2008 May 23, page A06.
18. Vartabedian, Ralph. McCain's disability pension may renew questions about his fitness." Los Angeles Times. 2008 April 22, page A12. (First on-line version had title "John McCain gets tax-free disability pension.")
19. Hinni, Michael L. Statement in Trastek.
20. Nordlund, James J. "Premature canities." Page 659 in: Nordlund JJ, et al (eds). The Pigmentary System. 2nd ed. Malden, MA: Blackwell Pub., 2006. (ISBN 9781405120340 @ Amazom.com)