If ever there was a man who took an unlikely route to the White House, it was Chester A.  Arthur.

The New York lawyer never was elected to political office, yet took a roundabout route through New York machine politics to be named the Republican vice presidential nominee in 1880.

Six months after the election, President James Garfield's assassination made Arthur the 21st president. From there, Arthur surprised even the most ardent critics of his political-patronage past by taking up the cause of political reform, making lauded changes in the civil service system and the Navy.

He seemed an unlikely crusader. President U.S. Grant gave him the lucrative and politically influential post of collector of the Port of New York in 1871. But in 1878, newly elected President Rutherford B. Hayes fired Arthur to show he was serious about reforming the federal patronage system in New York.

Add to all that this irony: Garfield was assassinated by Charles Guiteau, who was angry after being refused a patronage appointment.

Yet ill health plagued Arthur as he served out Garfield's term.

Shortly after moving into the White House, Arthur started feeling weak, easily fatigued, and irritable. He lost his appetite and started to drop weight. By 1883, the once-robust man was noticeably thinner and appeared much older. Some colleagues thought he was less mentally acute and couldn't keep up with his daily work schedule.

His worsening physical problems then included hypertension and signs of cardiac failure.

He hoped a Florida vacation would improve his health, but the heat and humidity only aggravated his condition. In late 1883, Arthur traveled to Yellowstone National Park for fresh air and fishing, accompanied by Robert Todd Lincoln and newspaper reporters. The presidential entourage published the new National Park system books with photos and President Arthur's trip itinerary. This trip did seem to help his health.

White House records indicated a special visit by the U.S. Surgeon General, who examined  Arthur and discovered his urine was unusually dark.

What was the diagnosis that linked Arthur's long list of health complaints?


White House doctors diagnosed President Arthur with Bright’s Disease, now known as nephritis or inflammation of the kidneys. The key to the diagnosis was, and would still be today, the routine urinalysis.

British physician Richard Bright recognized the association of dark urine color and  kidney disease in the late 1820s, describing the many symptoms of nephritis.

In modern medicine, testing for kidney disease includes complete urine analysis, chemistry tests, kidney ultrasound and radiologic scans, isotopic tests, and kidney biopsy, when indicated.

Nephritis is characterized by positive test for urinary albumin and blood (hence the dark color), high blood pressure, fluid retention, and evidence of heart symptoms.  Causes of chronic kidney disease (CKD) include diabetes, high blood pressure,  kidney-related birth defects, and autoimmune diseases.  CKD is measured in five stages of severity according to amount of residual kidney function. Stage 5 CKD, or end-stage renal disease, defined as a glomerular filtration rate of less than 15 milliliters a minute, requires dialysis or kidney transplantation.

Seeing that he faced strong competition even for the Republican nomination,  Arthur decided not to run for reelection in 1884. Two months before the end of his term, New York stalwarts urged him to run for U.S. Senate, but he declined. Arthur left office in March 1885 and returned to his New York City home and law practice, though, due to his health, he took on very few assignments.

In February 1886, with his chronic kidney failure progressing, Arthur retired. He developed symptoms of heart failure, including shortness of breath and edema, and died on Nov. 8, 1886. The direct cause of death was a suspected cerebral hemorrhage due to hypertension.

Though kidney disease remains a very serious diagnosis today, modern medicine, and treatments including dialysis and transplantation, are enabling patients to live longer, better lives than Arthur, who died at 57 after years of suffering. 

Allan B. Schwartz, M.D., is a professor of medicine in the Division of Nephrology & Hypertension at Drexel University College of Medicine.