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Taft and Pickwick*: Sleep Apnea in the White House FREE TO VIEW

John G. Sotos
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*From Apneos Corporation, Palo Alto, CA.

Correspondence to: John G. Sotos, MD, Derom Apneos Corporation, 2033 Ralston Ave, #41, Belmont, CA 94002-1737; e-mail: taft@apneos.com



Chest. 2003;124(3):1133-1142. doi:10.1378/chest.124.3.1133
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As President of the United States from 1909 to 1913, William Howard Taft’s minimum body mass index was 42 kg/m2. This article presents evidence that he suffered from obstructive sleep apnea, manifested by excessive daytime somnolence, snoring, systemic hypertension and, perhaps, cognitive and psychosocial impairment. As president, Taft’s hypersomnolence was severe and obvious, but never prompted official discussion of his fitness to govern. Within 12 months of leaving office, Taft permanently lost over 60 pounds. His somnolence resolved. As Chief Justice of the United States from 1921 to 1930, he was not somnolent. President Taft’s case illuminates historical puzzles of his performance as President, raises public awareness of sleep apnea, and informs discussions of presidential disability and the 25th Amendment to the Constitution of the United States.

Figures in this Article

I have lost that tendency to sleepiness which made me think of the fat boy in Pickwick. My color is very much better and my ability to work is greater.

William Howard Taft

President of the United States

June 28, 190912

William Howard Taft was President of the United States from 1909 to 1913, and Chief Justice of the United States from 1921 to 1930. Despite this unequalled record of achievement, “Taft is remembered, if at all, for being the fattest president. His obesity has become a staple of quiz shows and trivia games, a humorous sweetener that generations of historians have sprinkled through bland lectures.”3

Taft’s obesity was not a humorous sprinkle. I will present evidence that Taft suffered from a serious complication of obesity, severe obstructive sleep apnea (OSA),4 before and throughout his Presidency. Because OSA can cause hypersomnolence, psychosocial difficulties, and neurocognitive defects,5 it is appropriate to ask whether Taft was disabled by his illness. I will, therefore, also describe how his inner circle and his physicians reacted to his manifestations of OSA. Taft’s relationship to Sir William Osler is particularly instructive, since Osler was one of the few physicians of the era attuned to the medical implications of sleepiness in obese patients.

I examined multiple published works about Taft and his times, plus items from the 700,000 documents in the William Howard Taft papers held by the Library of Congress.1 As all Taft scholars have found, the candid, contemporaneous observations of Taft’s closest White House aide, Major Archibald Butt,6 proved especially valuable. I could not locate Taft’s medical records.

Taft was born in 1857. Before becoming president in 1909, he had been an attorney, a judge, Solicitor General of the United States, civil governor of the Philippine Islands and, under President Theodore Roosevelt, Secretary of War. Taft won the 1908 Presidential election easily, but had a stormy administration and was soundly defeated for re-election in 1912. On leaving office, he became Professor of Law at Yale. In 1921, President Warren Harding fulfilled Taft’s lifelong dream and appointed him to the Supreme Court as Chief Justice. Taft spent 9 happy and productive years on the bench, resigning his position just 5 weeks before dying in 1930.

Taft was 5 feet 11.5 inches tall,78 although he seemed taller in person.910(p245)Figure 1 shows his adult weights.

In college, Taft’s sleep tendencies were, to his occasional dismay, normal. He wrote home about sitting in church where “the Fickle Goddess sleep wouldn’t come worth a cent and so I was doomed to listen to one of the dryest [sic] sermons I ever heard.”11(p40)

Evidence of excessive somnolence appeared as early as 1900.12 Taft was 43 years old and living in the Philippines when a typhoon struck in the night, shaking his house, uprooting trees, and sounding like “the bombardment of heavy artillery.”13(p106–107) Taft’s terrified wife awakened him only with great difficulty. He got to a chair, but was quickly asleep again, and snoring. When re-awakened, he fell asleep yet again. Years later, his wife was still upset over the episode.14

Seven months earlier, Taft had weighed 275 pounds.8 His weight increased rapidly in the Philippines15 and soon exceeded 300 pounds.13(p161) Four months after the typhoon, Taft wrote about the tropics: “one’s appetite is very strong at meals, and one’s desire to sleep is also great.”16 He spent adequate time in bed,17(p132) drank little alcohol, and did not smoke.11(p375,1072),,18(p 50),19

After suffering a near-fatal rectal abscess, Taft returned to the United States in early 1904 to become Secretary of War. Though removed from the tropics, he was still somnolent, sometimes snoring in meetings with President Roosevelt.20

Taft had insight into his problem. In October 1905, he promised his wife: “I will make a conscientious effort to lose flesh. I am convinced that this undue drowsiness is due to the accumulation of flesh … were I appointed to the bench I fear I could not keep awake in my present condition.”11(p286),,21 He claimed to sleep “very well” at night.22

Two months later, Taft began a diet prescribed by Dr. Nathaniel E. Yorke-Davies of London,22 plus a program of “physical culture.”18,23 Over 5 months, Taft’s weight dropped from 320 to 255 pounds.24

Taft maintained his reduced weight into September 1906, but by July 1907 he weighed 284 pounds and was becoming noncompliant with Yorke-Davies’ diet.25 As the 1908 Presidential election neared, Taft’s weight reached 297 pounds.26 During the campaign, he fell asleep on speaking platforms, while driving on the street, and while dining out.17(p195)

Taft was 51 years old and weighed between 300 and 332 pounds on his inauguration day.2728 Despite his continuing physical culture program,2930 Taft weighed > 300 pounds his entire presidency. Pressured to diet by his wife and doctor,29 he freely indulged his appetite during his frequent travels outside the White House.31

As President, Taft could fall asleep anywhere, anytime (Fig 2 ).32 He fell asleep during conversations with the Speaker of the House,6(p18) the Chief Justice of the Supreme Court,6(p613) and the wife of the French ambassador.6(p540) He napped before11(p463) and after33 a mid-morning meeting with the President of Mexico. Senator James Watson observed: “Most of the time [Taft] simply did not and could not function in alert fashion … Often when I was talking to him after a meal his head would fall over on his breast and he would go sound asleep for ten or fifteen minutes. He would waken and resume the conversation, only to repeat the performance in the course of half an hour or so.”34 The White House butler would leave the last few courses of dinner in front of the sleeping Taft rather than awaken him. The doorman, who was the last servant to leave, would eventually collect the dishes.14

Taft frequently fell asleep “in the middle of the day’s business—at his desk, at a public affair, or while signing commissions.”31 Publicly, he slept at the opera,6(p617) at funerals,6(p85) and, “invariably,”6(p769) in church. He fell asleep while playing cards6(p548),,35 and while sitting upright in his car,6(p504,638,659),,36 even an open car on Fifth Avenue in New York City.37 On a cross-country drive “his great bulk would lunge from side to side as the car turned or jolted over street-car tracks and crossings, yet he would never wake.”6(p504) He could sleep while standing.6(p76) Two photographs of Taft at a Naval review in November 1911 show him standing with face relaxed and eyes apparently closed (Fig 3 ).,11(p610),,38

Taft’s somnolence was more trying to his guests14 and intimates than to himself. When his wife scolded him over his “bad habit,” Taft would only reply “Now, Nellie, you know it is just my way.”14 Possibly for this reason, Nellie called him “sleeping beauty.”11(p74),,13(p8),,39(p31) She also prodded him awake when necessary17(p175) and covered for him in conversations.14,39(p162) The ever-present Archie Butt would stay near Taft in public, inconspicuously awakening him with a hard nudge,6(p769) by dropping an object,6(p535) or with his “old trick,” a coughing spell.6(p770) Butt took this seriously, feeling it as much his duty “to protect him from such situations as to guard his person from anarchists.”6(p85)

Early in his term, Taft’s somnolence improved,6(p179) as noted in the introductory quotation.2 Taft ascribed the improvement to his exercise program, which made him “harder” without weight loss. Within months, however, the somnolence returned.6(p267) To stay awake, Taft would “balance his eyeglasses on his finger end; when sleep overtook him, the finger became limp, the glasses would topple and wake him up.”32

Taft continued to snore as President.6(p769),,31 Butt describes an evening in which the President “wanted some music from the Victor [but] greatly marred its effect by snoring noisily through it.”6(p535) On at least one public occasion, Butt had concerns that the sleeping Taft “would fall into heavy snores.”6(p85) Because partial sleep deprivation worsens snoring,40 it is noteworthy that Taft would sleep in a separate room from his wife when “particularly tired.”29

Taft could work for long stretches,41 but generally “spent but a few hours a day” in his office.32 He awakened at 7 am.17(p224),,27,29 Retiring after midnight provoked comment from Butt.6(p206,309,651,796) Remarkably, given the pressures of the presidency, Taft was sleepless only twice.6(p169),,42 Taft himself described sleeplessness as “an exception.”43 Aside from a vague single episode of sleep talking,6(p34),,44 and profuse nocturnal sweating during hot Washington summers,42,4546 I found no descriptions of Taft’s sleep.

Taft’s obesity produced other complications. In October 1910, he developed gout at the summer White House in Massachusetts.6(p543–544,788) A Boston physician, Dr. James Marsh Jackson,4748 evaluated Taft and found the President’s systolic blood pressure was 210 mm Hg.49 Jackson thought Taft’s heart was “weakened” and “in a very bad state.”6(p547–548) Butt spoke with Jackson:

I told [Jackson] how the President had a way of dropping to sleep as he was writing or playing cards, and he shook his head in such a way as to cause chills to run up and down my spinal column…. I then urged on [Jackson] the utmost secrecy in turn in regard to this matter, and I tried to bring to his mind the result of the condition of the country should such a state of affairs become known—to say nothing of the fatal results to the President’s political future if any hint of invalidism should even be whispered. He said he would not mention it to anyone.6(p547–548)

Jackson advised weight loss,6(p543) but Taft did not lose weight. A year later Butt wrote, “he pants for breath at every step.”6(p775) In January 1912, the writer Henry Adams had a chance street encounter with the President and wrote the following:

[Taft] gave me a shock. He looks bigger and more tumble-to-pieces than ever, and his manner has become more slovenly than his figure; but what struck me most was the deterioration of his mind and expression. [He] is ripe for a stroke. He shows mental enfeeblement all over, and I wanted to offer him a bet that he wouldn’t get through his term.50

Rumors about the President’s health began circulating.6(p808) Butt knew Taft needed help, but was powerless:

He looks terribly. His flesh looks like wax, and his lips are thin, and he is getting those unhealthy bags under his eyes. I begged him to see a specialist, for I felt sure that all his drowsiness was due to some toxin in his system … His response was a slap on the back, followed by: “Archie, you go to hell! I will not be hauled around by specialists! [Secretary of the Navy] Meyer has been talking to you, I know.”6(p839)

Butt’s chronicles end in April 1912, with his death aboard SS Titanic.

In March 1913, Taft, then 55 years old, left the White House at his peak lifetime weight: 335 to 340 pounds.51 He later recalled: “I was nervous and fretful, and for a month I found it hard to sleep.”19 He then began a weight loss program directed by Dr. George Blumer, Dean of the Yale Medical School. A year later, Taft weighed 264 pounds.52 He retained that weight, approximately, until the end of his life.

Taft’s hypersomnolence resolved. As President, he had been a “poor reader [who] soon gets tired and goes to sleep.”6(p657) As a Yale professor, however, Taft prepared his many addresses and articles himself, without a research assistant.7 He stayed awake in church.7 As Chief Justice (from 1921 to 1930), “some of his colleagues often dozed in court, [but] Taft was now always alert to everything going on.”39(p262)

His systolic blood pressure improved by 40 to 50 mm Hg,5354 but he experienced intermittent atrial fibrillation, treated with digitalis.5558 Gout continued to trouble him17(p291,359); more than 30 uric acid calculi were removed from his bladder in 1922.11(p1073),,53 As early as 1925, Taft noticed that he was mentally declining.11(p1074) By 1928, he considered himself an invalid.11(p1077)

Taft’s final illness began with bladder problems in January 1930. A medical bulletin was issued when he resigned from the Supreme Court on February 3, 1930: “For some years Chief Justice Taft has had a very high blood pressure, associated with general arteriosclerosis and myocarditis. Together with these conditions he had a chronic cystitis. He has no fever and suffers no pain. His present serious condition is the result of general arteriosclerotic changes.”59 There are indications, however, he had cancer.17(p466) Taft died on March 8, aged 72 years.11(p1074–1078)

Taft had three major risk factors for OSA60 : he was male, severely obese, and had a “short… generous” neck.39(p28) His size-54 pajamas had a neck size of 19 inches.61 His body habitus exhibited central obesity (Fig 4 ).

Taft had two signs of OSA: excessive daytime somnolence and snoring. He may also have been polycythemic: his face was described as “ruddy”13(p161) and “florid.”6(p159),,9 ,39(p28) Systemic hypertension is a known complication of OSA,62 albeit common in the general population. Most importantly, Taft’s somnolence correlated with his weight. Taft’s remarkable weight loss after the presidency produced an equally remarkable improvement in his somnolence, blood pressure and, likely, survival.

In October 1910, President Taft was 53 years old, weighed 330 pounds, and snored. With these data, the model of Viner et al63 predicts a 97% chance that Taft had sleep apnea, defined as an apnea-hypopnea index > 10/h.

The nature of Taft’s sleeping difficulty in 1913 is unclear. Although OSA may masquerade as insomnia,64 heart failure is another possibility, given Taft’s “weak heart” and “panting for breath at every step.” Sleep disturbances such as orthopnea, paroxysmal nocturnal dyspnea, Cheyne-Stokes respiration,65 and central sleep apnea66 are associated with heart failure. Any combination of hypertension, obesity, and OSA could have caused heart failure. The reasons for his transiently decreased somnolence in June 1909 are unclear; there are reports of exercise without weight loss improving sleep apnea.67

Taft lacked the cardinal manifestations of two other syndromes causing excessive daytime somnolence: periodic leg movements of sleep and narcolepsy. A third cause, the obesity hypoventilation syndrome (OHS), cannot be excluded without blood gas measurements. Most patients with OHS have sleep apneas, but the defining feature is hypoventilation while awake and asleep. Taft lacked other signs of OHS, such as cyanosis6(p839) and pedal edema.6(p789)

OHS has been known as the “Pickwickian syndrome” since 1956.68 Before (and after) the nosologic separation of OSA from OHS in 1965,6970 it was common to call any sleepy obese patient “Pickwickian.” Biographers have entertained whether Taft had Pickwickian syndrome,39(p126),,71 but more strongly hold that a psychological need to escape anxiety and strife caused his sleepiness.39(p126),,44 This seems unlikely because Taft’s somnolence was initially distressing,21 was involuntary,32 correlated better with his weight than his happiness, and was so profound that other psychopathology would likely have been manifest.

Thus, I conclude that OSA is the most probable explanation for Taft’s hypersomnolence. Except for periods associated with successful dieting (1906 to mid-1908, and perhaps briefly in 1909), he was likely afflicted from approximately 1900, when he started gaining weight in the Philippines, into 1913, when he started his post-presidency weight loss. He appears to have become symptomatic at approximately 300 lb. Based on Taft’s history of falling asleep during tasks requiring active attention, such as card playing and signing documents, he would be classified as having severe OSA syndrome.4

Disability is traditionally judged according to the requirements of an occupation.72 Taft recognized that judges should not be somnolent or sleep on the bench,11(p529),,21 but as President dismissed his own hypersomnolence as “just my way.”14

No formal definition of Presidential disability existed during Taft’s era. Only in 1967 did the 25th Amendment to the US Constitution define a disabled president as one “unable to discharge the powers and duties of his office.” The Amendment charges the Vice President and Cabinet to judge disability. Thus, in applying the modern standard to Taft, the reactions of persons around him must be examined.

Among Taft’s inner circle, Archie Butt and Senator Watson expressed concern over Taft’s sleepiness, as perhaps did Secretary of the Navy George Meyer.6(p839) Watson explicitly links Taft’s sleepiness and lack of executive ability with overeating, and seems to suggest a related memory dysfunction.34

Yet, Taft’s biographers do not record accusations of disability from either politicians or the public. Instead, amusement was a common reaction to Taft’s sleeping spells, even from persons familiar with the demands of the presidency. When Taft slept through music that would “wake anyone but a dead man,” his Attorney General joked: “He must be dead.”6(p535) Watson himself told a just-awakened Taft: “Mr. President, you are the largest audience that I ever put entirely to sleep in all my political experience.”34 In earlier years, even Theodore Roosevelt, seeing his hand-picked successor asleep and snoring, “would only beam the more, like a mother pleased to see a child at peace.”20 A present-day politician describes Taft’s “public naps [as] the stuff of legend,” without questioning his fitness for office.73 Despite Archie Butt’s efforts, the public knew of Taft’s hypersomnolence,11(p763) as intimated by doggerel in Life magazine encouraging Roosevelt to re-enter politics:,74

poem Teddy, come home and blow your horn, The sheep’s in the meadow, the cow’s in the corn. The boy you left to tend the sheep Is under the haystack fast asleep.

Butt initially believed Taft’s sleeping ability was an asset, enabling the President to “catch these little cat naps on trains and between interviews.”6(p17–18) He continued to believe this, even after speaking with Dr. Jackson.6(p613) Finally, 3 years into the administration, Butt realized Taft’s sleepiness was pathologic and vainly begged him to see a specialist.6(p839) Butt, however, never expressed [written] concerns that somnolence undermined the President’s effectiveness.

Thus, despite Taft’s extraordinary hypersomnolence, there is no evidence that anyone in his inner circle, or in politics, questioned his ability to discharge presidential powers and duties. By modern Constitutional standards, Taft was, therefore, not disabled.

Sleep apnea was not a recognized clinical entity in Taft’s era. Although case reports of sleepy obese patients existed,7576 the significance of hypersomnolence was generally unknown. However, William Osler, the leading physician in the English-speaking world in the early 20th century, was an exception. Osler knew the case reports, and his textbook77 popularized Dr. Christopher Heath’s observation78 that patients in these reports resembled a severely obese, hypersomnolent boy named Joe in Charles Dickens’ 1836 novel The Posthumous Papers of the Pickwick Club. By 1905, Osler had seen a case himself,,77 and earlier had described obstructive apneas in sleeping children,79 including their behavioral sequelae.80

Osler and Taft maintained a warm, but mostly long-distance friendship from 190281 until Osler’s death in 1919.82 Osler had multiple opportunities to observe Taft from 1904 to 1905 (Fig 5 ),84 years when Taft would have been somnolent as Secretary of War. Although Osler gave medical advice regarding Taft’s daughter,17(p160),,85 their correspondence does not mention Taft’s health or sleepiness. Osler resided in England during Taft’s presidency; thus, one of the few physicians able to appreciate the President’s symptoms did not have access to the President.

Taft had a doctor-patient relationship with some 30 physicians during his life, including White House physicians Matthew DeLaney8687 and Cary Grayson.6(p445,449) Whether they learned of the Butt-Jackson conversation is unknown. Dozens more physicians were socially acquainted with Taft, including W. W. Keen,88 who had operated on President Grover Cleveland’s maxillary cancer in 1893; Harvey Cushing89 ; and S. Weir Mitchell,90 the dean of American medicine, who himself had a long interest in sleep medicine.76

Apart from James Marsh Jackson, no physician mentioned Taft’s somnolence, although most of Taft’s health-related correspondence occurred during his nonsomnolent post-presidential years. Nevertheless, it appears that physicians close to Taft did not regard him as disabled.

If not disabling, to what extent did sleep apnea impair Taft’s performance as president? Sleep apnea is associated with several cognitive impairments, including difficulties in attention and psychomotor function, memory and learning, and executive and frontal lobe function.91 In severe sleep apnea, these decrements “appear substantial and of a size that might be expected to produce deleterious consequences for everyday function.”91 Moderate sleep apnea imparts 50% of the psychomotor decrement associated with hypnosedative use.92

Historians note a perplexing contrast between Taft’s presidential buffetings and his exceptional government service before and after the presidency.39(p14) Taft’s “clear, strong mind” in college93 and the Philippines,94 and his “exceptional intellectual productivity” after the Presidency93 contrast with presidential characterizations of “thinking with only half of his normal clarity”11(p812,822) and of “mental enfeeblement.”50

Beyond intellect, politics requires an exacting assembly of careful speech, thinking on one’s feet, memory, and understanding of human nature. Specific defects of verbal fluency,95 mental flexibility,96 and working memory97 may occur in sleep apnea.

The politics of the presidency left Taft “baffled,” “foggy,” and “bewildered.”10(p232),11(p856),,98 Even his brother called him a “very poor politician.”15 With a “naive inability to judge the sound of words in private conversation, as well as in public utterances,”10(p230) President Taft made politically self-damaging remarks so often41 that he was called “Mr. Malaprop” and “Taft the Blunderer.”10(p213–227,232) By contrast, Taft “demonstrated no little artistry” subduing a political foe in the Philippines.94 In college, Taft had “a decided aptitude for undergraduate politics”41 ; and “what is more remarkable, Taft out of office was a man of good political judgment.”10(p234) One senator wrote of the ex-President, “If Mr. Taft could have done as well when in office as he talks while out of office he would never have been defeated for re-election.”99

These striking contrasts suggest OSA interfered with Taft’s conduct of the presidency. Assessing the precise effect will require a more detailed medicohistorical analysis, however, because Taft disliked interpersonal conflict and the contentious politics of the Presidency tormented him. Nevertheless, given Taft’s profound hypersomnolence, it seems doubtful he fully commanded as president the extraordinary executive skills he demonstrated as chief executive of the Philippines and of the Supreme Court.

Because of his severe OSA, Taft likely experienced unrelenting mental and physical fatigue each day of his presidency. Fortunately for the nation, these burdens did not unbalance him. He adhered to his bedrock principle of reverence for the law93 and made significant accomplishments during his administration. Unfortunately for Taft, however, his unrecognized sleep apnea probably impaired mental faculties critical for political success and contributed to his political reputation as an inept bungler.

When Taft died in 1930, there was an enormous outpouring of grief and tribute. The public had long forgotten his presidential bumblings, replacing them with admiration and fondness for a man who gave 35 unswervingly honest years to public service. Now, an additional facet of William Howard Taft emerges: his perseverance and ultimate triumph against appetite, obesity, and sleep apnea.

Abbreviations: OHS = obesity hypoventilation syndrome; OSA = obstructive sleep apnea

Figure Jump LinkFigure 1. Adult weights of William Howard Taft. Born in 1857, Taft’s adult height was 71.5 inches. A body mass index of 40 kg/m2 is considered severe obesity. Circles are known weights. Arrow indicates June 28, 1909, the day Taft wrote of his Pickwick-like tendency to sleep. Secondary sources report weights from 297 to 332 pounds the year preceding.Grahic Jump Location
Figure Jump LinkFigure 2. Undated photograph of Taft. The distinct floor shadows suggest it is daytime. Reprinted with permission from Pringle.11Grahic Jump Location
Figure Jump LinkFigure 3. Taft asleep on his feet? The relaxation of Taft’s facial muscles is apparent when compared to those of the other men in the picture. A second photograph taken at the same event also shows Taft standing with his eyes apparently closed.11(p610) At far right is Secretary of the Navy George Meyer, and to his right, Major Archibald Butt. Reprinted with permission from Howe.38Grahic Jump Location
Figure Jump LinkFigure 4. Taft in 1908. Courtesy of the Library of Congress.Grahic Jump Location
Figure Jump LinkFigure 5. Program from the Taft-Osler dinner of March 11, 1905. Reprinted with permission from the Alan Mason Chesney Medical Archives of The Johns Hopkins Medical Institutions.84Grahic Jump Location

I thank Drs. David Burton, Philip Smith, and Alan Schwartz, as well as Cynthia Du Puy, Jacqueline Parker, Jack Wahlquist, and the staffs of the Stanford University Libraries, the Alan M. Chesney Archives of the Johns Hopkins Medical Institutions, the Countway Library of Medicine, the William Howard Taft National Historical Site, and the Library of Congress.

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Papers. William Howard Taft to James M. Jackson, November 15, 1911.
 
Papers. William Howard Taft to George Blumer, January 18, 1914.
 
Levenson, JC, Samuels, E, Vandersee, C, et al The letters of Henry Adams. Volume VI: 1906–1918.1988,490 Belknap Press. Cambridge, MA:
 
Papers. William Howard Taft to George Blumer, May 18, 1913.
 
Papers. William Howard Taft to W. Yorke-Davies, February 9, 1914.
 
Papers. William Howard Taft to George Blumer, January 2, 1923.
 
Papers. William Howard Taft to Thomas A. Claytor, August 1, 1926.
 
Papers. William Howard Taft to George Blumer, July 11, 1913.
 
Papers. William Howard Taft to Annie S. Taft, July 8, 1926.
 
Foster, JF Harvey Cushing: a biography.1946,468-469 Charles C. Thomas. Springfield, IL:
 
Papers. William Howard Taft to Harvey Cushing, December 14, 1926.
 
Marx, R The health of the Presidents.1960,306 G. P. Putnam’s Sons. New York, NY:
 
Fogel, RB, White, DP Obstructive sleep apnea.Adv Intern Med2000;45,351-389. [PubMed]
 
Arnebeck B. White House workout: William Howard Taft and the good fight against the 54-inch waist. Washington Post Magazine. September 15, 1985.
 
Peppard, PE, Young, T, Palta, M, et al Prospective study of the association between sleep-disordered breathing and hypertension.N Engl J Med2000;342,1378-1384. [PubMed]
 
Viner, S, Szalai, JP, Hoffstein, V Are history and physical examination a good screening test for sleep apnea?Ann Intern Med1991;115,356-359. [PubMed]
 
Krakow, B, Melendrez, D, Ferreira, E, et al Prevalence of insomnia symptoms in patients with sleep-disordered breathing.Chest2001;120,1923-1929. [PubMed]
 
Hanly, P, Zuberi-Khokhar, N Daytime sleepiness in patients with congestive heart failure and Cheyne-Stokes respiration.Chest1995;107,952-958. [PubMed]
 
Javaheri, S, Parker, TJ, Liming, JD, et al Sleep apnea in 81 ambulatory male patients with stable heart failure: types and their prevalences, consequences, and presentations.Circulation1998;97,2154-2159. [PubMed]
 
Giebelhaus, V, Strohl, KP, Lormes, W, et al Physical exercise as an adjunct therapy in sleep apnea: an open trial.Sleep Breath2000;4,173-176. [PubMed]
 
Burwell, CS, Robin, ED, Whaley, RD, et al Extreme obesity associated with alveolar hypoventilation: a Pickwickian syndrome.Am J Med1956;21,811-818. [PubMed]
 
Gastaut, H, Tassinari, CA, Duron, B Etude polygraphique des manifestations episodiques (hypniques et respiratoires) du syndrome de Pickwick.Rev Neurol (Paris)1965;112,568-579. [PubMed]
 
Jung, R, Kuhlo, W Neurophysiological studies of abnormal night sleep and the pickwickian syndrome.Prog Brain Res1965;18,140-159. [PubMed]
 
Bumgarner, JR The health of the Presidents: the 41 United States Presidents through 1993 from a physician’s point of view.1994,171 MacFarland & Company. Jefferson, NC:
 
Cocchiarella, L, Anderson, GBJ Guides to the evaluation of permanent impairment 5th ed.2000,8 AMA Press. Chicago, IL:
 
Dole, B Great Presidential wit.2001,72 Scribner. New York, NY:
 
Sullivan, M Our times, volume 4: the war begins.1940,441 Charles Scribner’s Sons. New York, NY:
 
Kryger, MH Sleep apnea: from the needles of Dionysius to continuous positive airway pressure.Arch Intern Med1983;143,2301-2303. [PubMed]
 
Lavie, P Nothing new under the moon: historical accounts of sleep apnea syndrome.Arch Intern Med1984;144,2025-2028. [PubMed]
 
Osler, W The Principles and practice of medicine 6th ed.1905,431 Sidney Appleton. London, England:
 
Clinical Society of London: Friday, February 8th, 1889.BMJ1889;i,358-359
 
Osler, W The principles and practice of medicine 1st ed.1892,335-339 D. Appleton and Company. New York, NY:
 
Blunden, S, Lushington, K, Kennedy, D Cognitive and behavioural performance in children with sleep-related obstructive breathing disorders.Sleep Med Rev2001;5,447-461. [PubMed]
 
Bliss, M. William Osler: A life in medicine. 1999; Oxford University Press. Oxford, UK:.
 
Papers. William Howard Taft to Lady Osler, March 13, 1920.
 
Papers. Fred Carpenter to Mrs. William Osler, October 15, 1904.
 
Dinner to Secretary of War William H. Taft and Dr. William Osler given by Mr. William A. Marburg, Saturday the eleventh of March, One thousand nine hundred and five, Maryland Club, Baltimore. In the papers of William Howard Kelly MD, in the Alan M. Chesney Medical Archives of the Johns Hopkins Medical Institutions, Baltimore MD, 1905.
 
Papers. William Osler to William Howard Taft, June 13, 1904.
 
Papers. William Howard Taft to Matthew DeLaney, March 3, 1913.
 
Papers. William Howard Taft to Robert A. Taft, May 18, 1909.
 
Papers. William Howard Taft to Horace D. Taft, October 28, 1909.
 
Papers. William Howard Taft to Delia Torrey, November 13, 1909.
 
Earnest, ES S. Weir Mitchell: novelist and physician.1950,206-207 University of Pennsylvania Press. Philadelphia, PA:
 
Engleman, HM, Kingshott, RN, Martin, SE, et al Cognitive function in the sleep apnea/hypopnea syndrome (SAHS).Sleep2000;23(Suppl 4),S102-S108. [PubMed]
 
Kim, HC, Young, T, Matthews, CG, et al Sleep-disordered breathing and neuropsychological deficits: a population-based study.Am J Respir Crit Care Med1997;156,1813-1819. [PubMed]
 
Burton, DH The learned presidency: Theodore Roosevelt, William Howard Taft, Woodrow Wilson.1988,119 Farleigh Dickinson University Press. Rutherford, NJ:
 
Minger, RE William Howard Taft and United States foreign policy: the apprenticeship years 1900–1908.1975,189 Univerisity of Illinois Press. Urbana, IL: 195
 
Barnes, M, Houston, D, Worsnop, CJ, et al A randomized controlled trial of continuous positive airway pressure in mild obstructive sleep apnea.Am J Respir Crit Care Med2002;165,773-780. [PubMed]
 
Engleman, HM, Martin, SE, Deary, IJ, et al Effect of continuous positive airway pressure treatment on daytime function in sleep apnoea/hypopnoea syndrome.Lancet1994;343,572-575. [PubMed]
 
Adams, N, Strauss, M, Schluchter, M, et al Relation of measures of sleep-disordered breathing to neuropsychological functioning.Am J Respir Crit Care Med2001;163,1626-1631. [PubMed]
 
Davis, OK. Released for publication: some inside political history of Theodore Roosevelt and his times, 1898–1918. 1925; Houghton Mifflin Company. Boston, MA:.
 
Foraker, JB Notes of a busy life.1916;Volume 2,459 Stewart & Kidd Company. Cincinnati, OH:
 

Figures

Figure Jump LinkFigure 1. Adult weights of William Howard Taft. Born in 1857, Taft’s adult height was 71.5 inches. A body mass index of 40 kg/m2 is considered severe obesity. Circles are known weights. Arrow indicates June 28, 1909, the day Taft wrote of his Pickwick-like tendency to sleep. Secondary sources report weights from 297 to 332 pounds the year preceding.Grahic Jump Location
Figure Jump LinkFigure 2. Undated photograph of Taft. The distinct floor shadows suggest it is daytime. Reprinted with permission from Pringle.11Grahic Jump Location
Figure Jump LinkFigure 3. Taft asleep on his feet? The relaxation of Taft’s facial muscles is apparent when compared to those of the other men in the picture. A second photograph taken at the same event also shows Taft standing with his eyes apparently closed.11(p610) At far right is Secretary of the Navy George Meyer, and to his right, Major Archibald Butt. Reprinted with permission from Howe.38Grahic Jump Location
Figure Jump LinkFigure 4. Taft in 1908. Courtesy of the Library of Congress.Grahic Jump Location
Figure Jump LinkFigure 5. Program from the Taft-Osler dinner of March 11, 1905. Reprinted with permission from the Alan Mason Chesney Medical Archives of The Johns Hopkins Medical Institutions.84Grahic Jump Location

Tables

References

Taft, WH (1969)William H. Taft papers Library of Congress. Washington, DC: [henceforth cited as “Papers”]
 
Papers. William Howard Taft to Charles P. Taft, June 28, 1909.
 
Carnes, MC William Howard Taft. McPherson, JM eds.To the best of my ability: the American Presidents2000,188-194 Dorling Kindersley. New York, NY:
 
Sleep-related breathing disorders in adults: recommendations for syndrome definition and measurement techniques in clinical research; The Report of an American Academy of Sleep Medicine Task Force.Sleep1999;22,667-689. [PubMed]
 
Day, R, Gerhardstein, R, Lumley, A, et al The behavioral morbidity of obstructive sleep apnea.Prog Cardiovasc Dis1999;41,341-354. [PubMed] [CrossRef]
 
Butt, AW. Taft and Roosevelt: the intimate letters of Archie Butt, military aide. 1930; Doubleday, Doran. Garden City, NY:.
 
Hicks, FC William Howard Taft, Yale Professor of Law & New Haven citizen: an academic interlude in the life of the twenty-seventh President of the United States and the Tenth Chief Justice of the Supreme Court.1945,80 Yale University Press. New Haven, CT: 99, 117
 
Taft WH. Application to the Provident Savings Life Assurance Society of New York, February 1, 1900. [Available at William Howard Taft National Historic Site, Cincinnati, OH].
 
White, WA The autobiography of William Allen White.1946,403 Macmillan. New York, NY: 426
 
Thompson, CW. Presidents I’ve known and two near Presidents. 1929; Bobbs-Merrill. Indianapolis, IN:.
 
Pringle, HF. The life and times of William Howard Taft. 1939; Farrar & Rinehart. New York, NY:.
 
Papers. William Howard Taft to Charles P. Taft, September 12, 1900.
 
Taft, HH. Recollections of full years. 1914; Dodd, Mead & Company. New York, NY:.
 
Parks, LR, Leighton, FS My thirty years backstairs at the White House.1961,114 Fleet Publishing Corporation. New York, NY: 120–121
 
Taft, HD Memories and opinions.1942,108 Macmillan. New York, NY: 114, 116
 
Papers. William Howard Taft to Harriet C. Herron, January 19, 1901.
 
Ross, I. An American family: the Tafts; 1678 to 1964. 1964; World Publishing. Cleveland, OH:.
 
Barker, CE. With President Taft in the White House. 1947; A. Kroch and Son. Chicago, IL:.
 
Mr. Taft on diet loses 70 pounds. New York Times. December 12, 1913; page A1.
 
Sullivan, M Our times: Volume 3; Pre-War America.1940,17-18 Charles Scribner’s Sons. New York, NY:
 
Papers. William Howard Taft to Helen Herron Taft, October 9, 1905.
 
Papers. William Howard Taft to N. E. Yorke-Davies, December 9, 1905.
 
Papers. William Howard Taft to N. E. Yorke-Davies, December 31, 1905.
 
Papers. William Howard Taft to N. E. Yorke-Davies, April 16, 1906.
 
Papers. William Howard Taft to N. E. Yorke-Davies, July 18, 1907.
 
Anderson, JI A mountain of misery: an intimate history of William Howard Taft [dissertation].1973,208 Department of History, University of California Los Angeles. Los Angeles, CA:
 
Coletta, PE The Presidency of William Howard Taft.1973,1 University of Kansas Press. Lawrence, KS: 53
 
Taft reaches city. Washington Post. February 28, 1909; 1.
 
Jaffray, E Secrets of the White House.1927,23-25 Cosmopolitan Book Corporation. New York, NY: 31–32
 
Hoover IH, Irwin H. Hoover papers: diary entry for March 4, 1913. Washington, DC: Library of Congress Manuscript Division.
 
Smith, IRT, Morris, JA “Dear Mr. President”: the story of fifty years in the White House mail room.1949,7 Julian Messner. New York, NY: 66–67, 89
 
Hoover, IH 42 years in the White House.1934,268-269 Houghton Mifflin Company. Boston, MA:
 
Papers. William Howard Taft to Helen Herron Taft, October 17, 1909.
 
Watson, JE As I knew them: memoirs of James E. Watson.1936,134-135 Bobbs-Merrill. Indianapolis, IN:
 
Papers. William Howard Taft to Helen Herron Taft, July 19, 1912.
 
Papers. William Howard Taft to Helen Herron Taft, July 14, 1912.
 
Longworth, AR Crowded hours: reminiscences of Alice Roosevelt Longworth.1933,221 Charles Scribner’s Sons. New York, NY:
 
Howe, MAD George von Lengerke Meyer: his life and public services.1920,450 Dodd, Mead and Company. New York, NY:
 
Anderson, JI. William Howard Taft: An intimate history. 1981; W.W. Norton. New York, NY:.
 
Stoohs, RA, Dement, WC Snoring and sleep-related breathing abnormality during partial sleep deprivation. N Engl J Med. 1993;;328 ,.:1279
 
Hammond, JH The autobiography of John Hays Hammond.1935,531 Farrar & Rinehart. Murray Hill, NY: 561, 581–582
 
Papers. William Howard Taft to Helen Herron Taft, July 11, 1911.
 
Papers. William Howard Taft to Helen Herron Taft, October 24, 1909.
 
Manners, W. TR & Will: a friendship that split the Republican party. 1969; Harcourt, Brace & World. New York, NY:.
 
Papers. William Howard Taft to Helen Herron Taft, July 13, 1909.
 
Papers. William Howard Taft to Helen Herron Taft, July 13, 1912.
 
James Marsh Jackson MD [obituary]. Boston Med Surg J 1919; 180:87.
 
Papers. William Howard Taft to James M. Jackson, November 15, 1911.
 
Papers. William Howard Taft to George Blumer, January 18, 1914.
 
Levenson, JC, Samuels, E, Vandersee, C, et al The letters of Henry Adams. Volume VI: 1906–1918.1988,490 Belknap Press. Cambridge, MA:
 
Papers. William Howard Taft to George Blumer, May 18, 1913.
 
Papers. William Howard Taft to W. Yorke-Davies, February 9, 1914.
 
Papers. William Howard Taft to George Blumer, January 2, 1923.
 
Papers. William Howard Taft to Thomas A. Claytor, August 1, 1926.
 
Papers. William Howard Taft to George Blumer, July 11, 1913.
 
Papers. William Howard Taft to Annie S. Taft, July 8, 1926.
 
Foster, JF Harvey Cushing: a biography.1946,468-469 Charles C. Thomas. Springfield, IL:
 
Papers. William Howard Taft to Harvey Cushing, December 14, 1926.
 
Marx, R The health of the Presidents.1960,306 G. P. Putnam’s Sons. New York, NY:
 
Fogel, RB, White, DP Obstructive sleep apnea.Adv Intern Med2000;45,351-389. [PubMed]
 
Arnebeck B. White House workout: William Howard Taft and the good fight against the 54-inch waist. Washington Post Magazine. September 15, 1985.
 
Peppard, PE, Young, T, Palta, M, et al Prospective study of the association between sleep-disordered breathing and hypertension.N Engl J Med2000;342,1378-1384. [PubMed]
 
Viner, S, Szalai, JP, Hoffstein, V Are history and physical examination a good screening test for sleep apnea?Ann Intern Med1991;115,356-359. [PubMed]
 
Krakow, B, Melendrez, D, Ferreira, E, et al Prevalence of insomnia symptoms in patients with sleep-disordered breathing.Chest2001;120,1923-1929. [PubMed]
 
Hanly, P, Zuberi-Khokhar, N Daytime sleepiness in patients with congestive heart failure and Cheyne-Stokes respiration.Chest1995;107,952-958. [PubMed]
 
Javaheri, S, Parker, TJ, Liming, JD, et al Sleep apnea in 81 ambulatory male patients with stable heart failure: types and their prevalences, consequences, and presentations.Circulation1998;97,2154-2159. [PubMed]
 
Giebelhaus, V, Strohl, KP, Lormes, W, et al Physical exercise as an adjunct therapy in sleep apnea: an open trial.Sleep Breath2000;4,173-176. [PubMed]
 
Burwell, CS, Robin, ED, Whaley, RD, et al Extreme obesity associated with alveolar hypoventilation: a Pickwickian syndrome.Am J Med1956;21,811-818. [PubMed]
 
Gastaut, H, Tassinari, CA, Duron, B Etude polygraphique des manifestations episodiques (hypniques et respiratoires) du syndrome de Pickwick.Rev Neurol (Paris)1965;112,568-579. [PubMed]
 
Jung, R, Kuhlo, W Neurophysiological studies of abnormal night sleep and the pickwickian syndrome.Prog Brain Res1965;18,140-159. [PubMed]
 
Bumgarner, JR The health of the Presidents: the 41 United States Presidents through 1993 from a physician’s point of view.1994,171 MacFarland & Company. Jefferson, NC:
 
Cocchiarella, L, Anderson, GBJ Guides to the evaluation of permanent impairment 5th ed.2000,8 AMA Press. Chicago, IL:
 
Dole, B Great Presidential wit.2001,72 Scribner. New York, NY:
 
Sullivan, M Our times, volume 4: the war begins.1940,441 Charles Scribner’s Sons. New York, NY:
 
Kryger, MH Sleep apnea: from the needles of Dionysius to continuous positive airway pressure.Arch Intern Med1983;143,2301-2303. [PubMed]
 
Lavie, P Nothing new under the moon: historical accounts of sleep apnea syndrome.Arch Intern Med1984;144,2025-2028. [PubMed]
 
Osler, W The Principles and practice of medicine 6th ed.1905,431 Sidney Appleton. London, England:
 
Clinical Society of London: Friday, February 8th, 1889.BMJ1889;i,358-359
 
Osler, W The principles and practice of medicine 1st ed.1892,335-339 D. Appleton and Company. New York, NY:
 
Blunden, S, Lushington, K, Kennedy, D Cognitive and behavioural performance in children with sleep-related obstructive breathing disorders.Sleep Med Rev2001;5,447-461. [PubMed]
 
Bliss, M. William Osler: A life in medicine. 1999; Oxford University Press. Oxford, UK:.
 
Papers. William Howard Taft to Lady Osler, March 13, 1920.
 
Papers. Fred Carpenter to Mrs. William Osler, October 15, 1904.
 
Dinner to Secretary of War William H. Taft and Dr. William Osler given by Mr. William A. Marburg, Saturday the eleventh of March, One thousand nine hundred and five, Maryland Club, Baltimore. In the papers of William Howard Kelly MD, in the Alan M. Chesney Medical Archives of the Johns Hopkins Medical Institutions, Baltimore MD, 1905.
 
Papers. William Osler to William Howard Taft, June 13, 1904.
 
Papers. William Howard Taft to Matthew DeLaney, March 3, 1913.
 
Papers. William Howard Taft to Robert A. Taft, May 18, 1909.
 
Papers. William Howard Taft to Horace D. Taft, October 28, 1909.
 
Papers. William Howard Taft to Delia Torrey, November 13, 1909.
 
Earnest, ES S. Weir Mitchell: novelist and physician.1950,206-207 University of Pennsylvania Press. Philadelphia, PA:
 
Engleman, HM, Kingshott, RN, Martin, SE, et al Cognitive function in the sleep apnea/hypopnea syndrome (SAHS).Sleep2000;23(Suppl 4),S102-S108. [PubMed]
 
Kim, HC, Young, T, Matthews, CG, et al Sleep-disordered breathing and neuropsychological deficits: a population-based study.Am J Respir Crit Care Med1997;156,1813-1819. [PubMed]
 
Burton, DH The learned presidency: Theodore Roosevelt, William Howard Taft, Woodrow Wilson.1988,119 Farleigh Dickinson University Press. Rutherford, NJ:
 
Minger, RE William Howard Taft and United States foreign policy: the apprenticeship years 1900–1908.1975,189 Univerisity of Illinois Press. Urbana, IL: 195
 
Barnes, M, Houston, D, Worsnop, CJ, et al A randomized controlled trial of continuous positive airway pressure in mild obstructive sleep apnea.Am J Respir Crit Care Med2002;165,773-780. [PubMed]
 
Engleman, HM, Martin, SE, Deary, IJ, et al Effect of continuous positive airway pressure treatment on daytime function in sleep apnoea/hypopnoea syndrome.Lancet1994;343,572-575. [PubMed]
 
Adams, N, Strauss, M, Schluchter, M, et al Relation of measures of sleep-disordered breathing to neuropsychological functioning.Am J Respir Crit Care Med2001;163,1626-1631. [PubMed]
 
Davis, OK. Released for publication: some inside political history of Theodore Roosevelt and his times, 1898–1918. 1925; Houghton Mifflin Company. Boston, MA:.
 
Foraker, JB Notes of a busy life.1916;Volume 2,459 Stewart & Kidd Company. Cincinnati, OH:
 
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