The Atlantic | December 2002 | The Medical Ordeals of JFK

Contents | December 2002

More on politics and society from The Atlantic Monthly.

From Atlantic Unbound:

Flashbacks: "The Cultural Meaning of the Kennedys" (December 4, 2002)
Articles by John F. Kennedy, Caitlin Flanagan, Thomas Mallon, and others offer insight into the Kennedy mystique.

Interviews: "Pulling Back the Curtain" (November 14, 2002)
Presidential historian Robert Dallek, the author of "The Medical Ordeals of JFK" (December Atlantic), discusses new revelations about President Kennedy's serious health problems and his efforts to keep them hidden.

Interviews: "Darker Than We Want to Know" (January 8, 1998)
Seymour Hersh discusses his controversial best seller The Dark Side of Camelot—why he wrote it, why it's right, and why historians of John F. Kennedy's presidency have been wrong.

The Atlantic Monthly | December 2002

The Medical Ordeals of JFK

Recent assessments of Kennedy's presidency have tended to raise "questions of character"—to view his Administration in the context of his sometimes wayward personal behavior. Such assessments are incomplete. Newly uncovered medical records reveal that the scope and intensity of his physical suffering were beyond what we had previously imagined. What Kennedy endured—and what he hid from the public—both complicates and enlarges our understanding of his character

by Robert Dallek

.....

oncealing one's true medical condition from the voting public is a time-honored tradition of the American presidency. William Henry Harrison, who died of pneumonia in April of 1841, after only one month in office, was the first Chief Executive to hide his physical frailties. Nine years later Zachary Taylor's handlers refused to acknowledge that cholera had put the President's life in jeopardy; they denied rumors of illness until he was near death, in July of 1850, sixteen months into his presidency. During Grover Cleveland's second term, in the 1890s, the White House deceived the public by dismissing allegations that surgeons had removed a cancerous growth from the President's mouth; a vulcanized-rubber prosthesis disguised the absence of much of Cleveland's upper left jaw and part of his palate. The public knew nothing about the implant until one of the President's physicians revealed it in 1917, nine years after Cleveland's death.

In the twentieth century Woodrow Wilson, Calvin Coolidge, Franklin Delano Roosevelt, and Dwight D. Eisenhower all, to one degree or another, held back the full truth about medical difficulties that could have jeopardized their hold on the Oval Office. Wilson suffered a paralyzing stroke in 1919 that made him merely a figurehead during the last year and a half of his term. After Coolidge's sixteen-year-old son died of blood poisoning, in the summer of 1924, Coolidge himself struggled with a clinical depression that made inactivity and passivity the principal features of his Administration. It has been well known for some time that Roosevelt went to great lengths to conceal how physically incapacitated he had been rendered by polio. If voters had known the truth about his generally deteriorating health in 1944, it is unlikely that they would have re-elected him a third time—but they did not know, and FDR died just three months into his fourth term, in April of 1945. Though Eisenhower was much more open about his health than any of his predecessors, the full disclosure of his maladies (including heart disease) in 1956, when he was sixty-six, might have discouraged the country from electing him President again; he had a heart attack during his first term and suffered a number of other medical problems, including a minor stroke, during his second.

The lifelong health problems of John F. Kennedy constitute one of the best-kept secrets of recent U.S. history—no surprise, because if the extent of those problems had been revealed while he was alive, his presidential ambitions would likely have been dashed. Kennedy, like so many of his predecessors, was more intent on winning the presidency than on revealing himself to the public. On one level this secrecy can be taken as another stain on his oft-criticized character, a deception maintained at the potential expense of the citizens he was elected to lead. Yet there is another way of viewing the silence regarding his health—as the quiet stoicism of a man struggling to endure extraordinary pain and distress and performing his presidential (and pre-presidential) duties largely undeterred by his physical suffering. Does this not also speak to his character, but in a more complex way?

Not only the extent of Kennedy's medical problems but the lengths to which he and his family went to conceal them were significant. According to Bill Walton, a Kennedy family friend, JFK was followed everywhere during the 1960 presidential campaign by an aide with a special bag containing the "medical support" that was needed all the time. When the bag was misplaced during a trip to Connecticut, Kennedy telephoned Governor Abe Ribicoff and said, "There's a medical bag floating around and it can't get in anybody's hands ... You have to find that bag." If the wrong people got hold of it, he said, "it would be murder." (The bag was recovered.)

In 1983 the Kennedy biographer Herbert Parmet observed that "dealing with the Kennedy medical history is in some ways like trying to uncover aspects of vital national-security operations." In 1995, when executors of Joseph P. Kennedy's estate made additional family papers available in the JFK Library, reports to Joe about Jack's medical condition remained closed. Before, during, and since his presidency, the Kennedys have guarded JFK's medical records from public view, apparently worrying that even posthumous revelations about his health would hurt his reputation for honest dealings with the public.

Of course, evidence of Kennedy's medical problems has been trickling out for years. In 1960, during the fight for the Democratic nomination, John Connally and India Edwards, aides to Lyndon B. Johnson, told the press—correctly—that Kennedy suffered from Addison's disease, a condition of the adrenal glands characterized by a deficiency of the hormones needed to regulate blood sugar, sodium and potassium, and the response to stress. They described the problem as life-threatening and requiring regular doses of cortisone. The Kennedys publicly denied the allegation. They released a letter from two of JFK's doctors describing his health as "excellent" and Kennedy as fully capable of serving as President. During his Administration, according to Admiral George Burkley, a physician on the White House staff, Kennedy was so determined not to give the impression that he was "physically impaired ... and require[d] the constant supervision of a physician" that he shunned having "a medical man in the near proximity to him" in public.

It appears that Richard Nixon may have tried at one point to gain access to Kennedy's medical history. In the fall of 1960, as he and JFK battled in what turned out to be one of the closest presidential elections ever, thieves ransacked the office of Eugene J. Cohen, a New York endocrinologist who had been treating Kennedy for Addison's disease. When they failed to find Kennedy's records, which were filed under a code name, they tried unsuccessfully to break into the office of Janet Travell, an internist and pharmacologist who had been relieving Kennedy's back pain with injections of procaine (an agent similar to lidocaine). Although the thieves remain unidentified, it is reasonable to speculate that they were Nixon operatives; the failed robberies have the aura of Watergate and of the break-in at the Beverly Hills office of Daniel Ellsberg's psychiatrist.

Using personal letters, Navy records, and oral histories, biographers and historians over the past twenty years have begun to fill in a picture of Jack Kennedy as ill and ailment-ridden for his entire life—a far cry from the paragon of vigor (or "vigah," in the family's distinctive Massachusetts accent) that the Kennedys presented. After a sickly childhood he spent significant periods during his prep school and college years in the hospital for severe intestinal ailments, infections, and what doctors thought for a time was leukemia. He suffered from ulcers and colitis as well as Addison's disease, which necessitated the administration of regular steroid treatments. And it has been known for some time that Kennedy endured terrible back trouble. He wrote his book Profiles in Courage while recovering from back surgery in 1954 that almost killed him.

But the full extent of Kennedy's medical ordeals has not been known until now. Earlier this year a small committee of Kennedy Administration friends and associates agreed to open a collection of his papers for the years 1955-1963. I was given access to these newly released materials, which included x-rays and prescription records from Janet Travell's files. Together with recent research and a growing understanding of medical science, the newly available records allow us to construct an authoritative account of JFK's medical tribulations. And they add telling detail to a story of lifelong suffering, revealing that many of the various treatments doctors gave Kennedy, starting when he was a boy, did far more harm than good. In particular, steroid treatments that he may have received as a young man for his intestinal ailments could have compounded—and perhaps even caused—both the Addison's disease and the degenerative back trouble that plagued him later in life. Travell's prescription records also confirm that during his presidency—and in particular during times of stress, such as the Bay of Pigs fiasco, in April of 1961, and the Cuban Missile Crisis, in October of 1962—Kennedy was taking an extraordinary variety of medications: steroids for his Addison's disease; painkillers for his back; anti-spasmodics for his colitis; antibiotics for urinary-tract infections; antihistamines for allergies; and, on at least one occasion, an anti-psychotic (though only for two days) for a severe mood change that Jackie Kennedy believed had been brought on by the antihistamines.

Kennedy's charismatic appeal rested heavily on the image of youthful energy and good health he projected. This image was a myth. The real story, disconcerting though it would have been to contemplate at the time, is actually more heroic. It is a story of iron-willed fortitude in mastering the diffi-culties of chronic illness.

"God What a Beating I'm Taking"

ennedy suffered severe health problems almost from the time of his birth. Three months before he turned three, in 1920, he came down with a bad case of scarlet fever, a highly contagious illness, and life-threatening for so small a child. He spent more than two months in the hospital and recuperating in a Maine sanatorium.

During the 1920s he suffered from a variety of other childhood maladies, including bronchitis, chicken pox, ear infections, German measles, measles, mumps, and whooping cough. His illnesses filled the family with anxiety about his survival.

In 1930, at age thirteen, Jack was afflicted with an undiagnosed illness that restricted his activities. From October to December he lost four to six pounds, felt "pretty tired," and did not grow. One doctor attributed it to a lack of milk in his diet, but that failed to explain why during a chapel service at the Canterbury School, his boarding school in New Milford, Connecticut, he felt "sick dizzy and weak." He wrote to his father, "I just about fainted, and everything began to get black so I went out and then I fell and Mr. Hume [the headmaster] caught me. I am O.K. now." In April of 1931 Jack collapsed with abdominal pains, and the surgeon who examined him concluded that it was appendicitis and that an operation was necessary at a nearby hospital in Danbury, Connecticut.

The operation did not solve the problem. In the fall of 1932, while boarding at the Choate School, in Wallingford, Connecticut, Jack complained of abdominal discomfort and fatigue. His weight was only 117 pounds—less than robust for a fifteen-year-old boy. In January and February of 1933 "flu-like symptoms" plagued him, along with almost constant pain in his knees. "Jack's winter term sounded like a hospital report," an official fiftieth-anniversary remembrance of his attendance at Choate recounted, "with correspondence flying back and forth between Rose Kennedy and [the headmaster's wife]. Again, eyes, ears, teeth, knees, arches, from the top of his head to the tip of his toes, Jack needed attention."

Over the summer of 1933, after he had turned sixteen, he gained no weight. And matters got worse the following year. In the winter of 1934 he became very sick and had to be rushed by ambulance to New Haven Hospital for observation. His symptoms included weight loss and a bad case of hives. Doctors feared that he had leukemia and began regularly checking his blood counts. "It seems that I was much sicker than I thought I was," Jack wrote to his classmate LeMoyne Billings after he got out of the hospital, "and am supposed to be dead, so I am developing a limp and a hollow cough." His rectum was "plenty red after the hospital," he complained. "Yours would be red too if you had shoved every thing from rubber tubes to iron pipes up it." By March, Jack's symptoms had largely disappeared, but his doctors remained uncertain about the cause of his difficulties.

In June of 1934, as his junior year at Choate ended, he began feeling ill again, and his parents sent him to the famous Mayo Clinic, in Rochester, Minnesota. He spent a miserable month there, "the God-damnest hole I've ever seen," he wrote to Billings. By himself at the Mayo and then at nearby St. Mary's Hospital, where he was transferred after two weeks, he maintained his sanity and kept up his hopes for a return to friends and family through a series of such letters. Jack handled what he feared was a life-threatening disease with a biting wit and a refusal to complain openly to anyone but his friend. Judging from the medical tests described in the correspondence and in later medical records, Jack had colitis, which was initially thought to be peptic-ulcer disease. The doctors began by prescribing a diet of bland food preparatory to tests that Jack had hoped would be over in a few days. But the exams lasted much longer. "I am suffering terribly out here," he wrote to Billings. "I now have a gut ache all the time. I'm still eating peas and corn for my food." He expected to be there for at least another twelve days. Two days later he told Billings, "God what a beating I'm taking. I've lost 8 lbs. And still going down ... I'm showing them a thing or two. Nobody able to figure what's wrong with me. All they do is talk about what an interesting case."

"It would be funny," he declared wishfully, "if there was nothing wrong with me. I'm commencing to stay awake nights on that. Still don't know when I'll get home. My last eight meals have been peas, corn, prunes."

Six days later he gave Billings another graphic description of his ordeal. "I've got something wrong with my intestines. In other words I shit blood." He feared he might be dying. The doctors were still trying to determine the cause of his illness. "Yesterday I went through the most harassing experience of my life," Jack wrote. "[A doctor] stuck an iron tube 12 inches long and 1 inch in diameter up my ass ... My poor bedraggled rectum is looking at me very reproachfully these days ... The reason I'm here is that they may have to cut out my stomach!!!!—the latest news."

All the gastrointestinal and colon tests indicated that Jack had colitis and digestive problems, which made it difficult for him to gain weight and threatened deadly consequences if the colon became ulcerated or bled.

Judging from accounts published in the January 1934 and December 1936 issues of the Mayo Clinic journal, Proceedings, the clinic's usual therapy for colitis involved a combination of restricted diet; relief of emotional stress, which was assumed to be a major contributor to both colitis and ulcers; and injection of a serum obtained from horses. Although the clinic claimed a measure of success with this treatment, it was clearly no panacea. Corticosteroids, which research centers were then testing, seemed more promising in the treatment of a whole variety of illnesses.

What Steroids Did to Him

n the late 1930s the first clinical use of corticosteroids—which are compounds derived from adrenal extracts, and which have come to be used to reduce tissue inflammation—was made possible when doctors learned how to administer DOCA (desoxycorticosterone acetate) in the form of pellets implanted under the skin. It is now well established that Kennedy was treated with DOCA after his Addison's disease was diagnosed, in 1947. But it is possible that Jack was taking DOCA as early as 1937. Early that year, in a handwritten note to his father after a family vacation, Jack worried about getting a prescription filled in Cambridge, Massachusetts, where he was a freshman at Harvard College. "Ordering stuff here very [illegible word]," he wrote to his father. "I would be sure you get the prescription. Some of that stuff as it is very potent and he [Jack's doctor] seems to be keeping it pretty quiet." Given that corticosteroids had just become clinically viable and were being touted as a therapeutic cure-all, it is reasonable to hypothesize that the prescription Jack asked for was DOCA. Moreover, nine years later, in 1946, Paul Fay, one of Jack's friends, watched him implant a pellet in his leg. The way in which the medication was administered indicates it was DOCA. Fay remembers Jack's using "a little knife ... [to] just barely cut the surface of the skin, try not to get blood, and then get underneath and put this tablet underneath the skin, and then put a bandage over it." Then, he said, "hopefully this tablet would dissolve by the heat of the body and be absorbed by the bloodstream." In short, it appears that Jack was on steroids—still an experimental treatment, with great uncertainty as to dosage—for his colitis well before the Addison's disease diagnosis.

If so, he may have paid a high price. Physicians in the 1930s and 1940s did not realize what is common medical knowledge today—namely, that corticosteroids are effective in treating acute colitis but have deleterious long-term effects, including osteoporosis of lower-back bones and increased incidence of serious infection (owing to suppression of the body's immune system). Kennedy would suffer from all these problems, including outright degeneration of his lumbar spine. In addition, the long-term use of cortico-steroids suppresses normal adrenal function; it may have been the cause of Kennedy's Addison's disease. (Jack's sister Eunice also had Addison's, however, indicating that his disease may have had an inherited component.)

From September of 1934 to June of 1935, Jack's senior year of prep school, the school infirmary had kept a close watch on his blood count; Joe Kennedy passed these records on to the Mayo doctors. At that time there was still concern that Jack might be suffering from leukemia. In retrospect, any changes in his blood count may have been a reaction to the drugs he was taking. When he fell ill the following autumn, a doctor advised that Jack had agranulocytosis, a decrease in granular white blood cells, which made him more susceptible to infections.

Shortly after leaving Choate, Jack had to spend two months at the Peter Bent Brigham Hospital, in Boston. Uncertain whether they were dealing strictly with colitis or with a combination of colitis and ulcers, and worried that his medicines were playing havoc with his white-blood-cell count, his doctors performed additional tests. According to a letter Jack wrote to Billings, his white-blood-cell count was 6,000 when he entered the hospital and down to 3,500 three weeks later. "At 1500 you die," Jack joked. "They call me '2000 to go Kennedy.'"

By the end of January 1936 he was more worried than ever about his health, though he continued to use humor to defend himself against thoughts of dying. "Took a peak [sic] at my chart yesterday and could see that they were mentally measuring me for a coffin. Eat drink & make Olive [his current girlfriend], as tomorrow or next week we attend my funeral. I think the Rockefeller Institute may take my case ... Flash—they are going to stick that tube up my ass again as they did at Mayo."

From 1938 to the end of 1940, while Kennedy attended Harvard, intestinal problems plagued him relentlessly. In February of 1938 he had gone back to the Mayo Clinic for more studies, but with no good results. In June he spent two weeks in New England Baptist Hospital for the same complaints, but again with no improvement. In October he was still "in rotten shape," but he refused to re-enter the hospital for more of what now seemed like pointless tests. In February of 1939, however, he gave in and went back to the Mayo Clinic. It was the same old routine: a diet of bland foods three times a day and another inspection of his colon and digestive system. By November, under the care of William Murphy, of Harvard, the physician and Nobel laureate who co-discovered the treatment for pernicious anemia and had an uncommon faith in the healing power of liver extracts, Jack recorded that he was going to "take my first liver injection today and I hope they work." They did not. A year later he was still wrestling with abdominal pain, spastic colon, and low weight. If he was taking DOCA and it was limiting the effects of his colitis (and it is not clear that it was), it was certainly worsening his stomach problems. The steroids may also have contributed to the onset of duodenal ulcers, which weren't diagnosed until November of 1943. But there would be no public acknowledgment of any of these ailments, or any outwardly evident self-pity. Refusing to let health concerns stop him became a pattern that allowed Kennedy to pursue a political career.

"Yellow as Saffron"

erious back problems added to Kennedy's miseries from 1940 on. In 1938 he had begun having "an occasional pain in his right sacro-iliac joint," according to a Navy medical history recorded in December of 1944.

It apparently grew worse but at times he was completely free from symptoms. In the latter part of 1940 while playing tennis he experienced a sudden pain in his lower right back—it seemed to him that "something had slipped." He was hospitalized at the Lahey Clinic ... for ten days. A low back support was applied and he was comfortable. Since that time he has had periodic attacks of a similar nature.

Kennedy's service in the southwest Pacific on PT boats —which he managed to arrange by calling on his father's connections to hide his various illnesses from military physicians—added to his pain, especially after a Japanese destroyer sank his boat, leading to a week-long physical ordeal. (For all the accuracy of the popular accounts praising Kennedy's valor on PT-109, the larger story of his endurance has not been told. Lennie Thom, his executive officer, wrote letters home discussing JFK's back problem and his refusal to report to sick bay: "Jack feigned being well." Kennedy acknowledged to his parents that life on the boats was "not exactly what the Dr ... ordered." But he did not let on to his crew or his commanding officer that he was ill or in pain. And except for his chronic back ailment, which he simply could not hide, and which he seemed to take care of by wearing a "corset-type thing" and sleeping with a plywood board under his mattress, the men on PT-109 saw no poor health. Before the war was over, however, Kennedy found himself once again in the hospital for both back and stomach problems.)

Although college football injuries and his Navy mishaps may have contributed to the back pain, the steroids he was most likely taking to control his colitis may have caused the underlying problem. Navy medical records indicate that back surgery Kennedy underwent in 1944 had revealed clear evidence of osteoporosis. The surgeons removed "some abnormally soft disc interspace material" and anticipated additional problems if he continued to suffer bone loss. It was, as it had long been with Kennedy, one thing after another.

At the beginning of 1945 Kennedy went to Castle Hot Springs, Arizona, in an attempt to recover his health. It was an elusive quest. Although he refused to complain to his father about his continuing maladies, his doctor reported to Joe that Jack was "not getting along well at all." He remained in almost constant back pain, and he had trouble digesting his food. A companion in Arizona remembered that "he looked jaundiced—yellow as saffron and as thin as a rake." He returned to the Mayo Clinic for a while, but the doctors had nothing new to recommend, so he didn't stay; he traveled to San Francisco and Europe as a correspondent for the Hearst newspapers. Friends in San Francisco told him he looked "sickly"; in Europe he became terribly ill with a high fever, nausea, and vomiting. Back in Boston, in June of 1946, he collapsed at a parade, where a witness remembered his turning "very yellow and blue" and looking like he was having a heart attack.

Despite his medical difficulties, Kennedy ran successfully for a House seat in 1946. A returning war veteran who knew him then says, "I was as thin as I could be at that time, but Jack was even thinner. He was actually like a skeleton, thin and drawn." Despite the medications he was taking for the colitis, he continued to have abdominal pain and problems gaining weight. Because hot baths gave him temporary relief, he spent some time every day soaking in a tub. He also had experienced a burning sensation when urinating, the result of a "non-specific urethritis" dating from 1940 (possibly an infection contracted from a sexual encounter in college), which later became chronic prostatitis, or inflammation of the prostate, which sulfa drugs temporarily suppressed.

A strenuous daily routine during the campaign intensified Kennedy's fatigue, nausea, and vomiting—symptoms of the as yet undiagnosed Addison's disease. People around him noticed his bulging eyes and jaundiced complexion, and the limp caused by unremitting pain. They marveled at his stamina and refusal to complain; it was "a tremendous effort of will," one of them says.

The following year, while in England, Kennedy became ill again. He ended up in a hospital in London, where a doctor for the first time diagnosed the Addison's disease. (Because Kennedy had served in the South Pacific and malaria has similar symptoms, and because Kennedy's long history of stomach and colon problems suggested that his difficulties were related to an ulcer or colitis, his previous doctors had not diagnosed the Addison's.) The doctor told Pamela Churchill, Winston Churchill's daughter-in-law and a friend of Kennedy's, "That young American friend of yours, he hasn't got a year to live." On his way home to the United States, on the Queen Mary, Kennedy became so sick that upon arrival a priest was brought aboard to give him last rites before he was carried off the ship on a stretcher. In 1948, when bad weather made a plane trip "iffy," he told his friend Ted Reardon, "It's okay for someone with my life expectancy," but suggested that his sister Kathleen and Reardon take the train.

By 1950 Kennedy was suffering almost constant lower-back aches and spasms. X-rays in the Travell records, which I examined with the help of a physician, show that the fourth lumbar vertebra had narrowed from 1.5 cm to 1.1 cm, indicating collapse in the bones supporting his spinal column. By March of 1951 there were clear compression fractures in his lower spine. He needed crutches to get up a flight of stairs. Later that year, during a trip to Japan, he had a severe crisis related to Addison's when he apparently neglected to take his steroid medications. He ran a temperature of 106�, and his doctors feared for his life. The episode convinced him to be more rigorous about taking his medicine, and over the next two years back problems became his principal complaint.

In 1952, during a successful campaign to replace Henry Cabot Lodge as senator from Massachusetts, Kennedy suffered headaches, upper respiratory infections, stomachaches, urinary-tract discomfort, and nearly unceasing back pain. He consulted an ear, nose, and throat specialist about his headaches; took anti-spasmodics and applied heat fifteen minutes a day to ease his stomach troubles; consulted urologists about his bladder and prostate discomfort; had DOCA pellets implanted and took daily oral doses of cortisone to control his Addison's disease; and struggled unsuccessfully to find relief from his back miseries.

Dave Powers, one of Kennedy's principal aides, remembers that at the end of each day on the road during the campaign, Kennedy would climb into the back seat of the car, where "he would lean back ... and close his eyes in pain." At the hotel he would use crutches to get himself up stairs and then soak in a hot bath for an hour before going to bed. "The pain," Powers adds, "often made him tense and irritable with his fellow travelers." (Much later, in February of 1960, during the presidential campaign, as Kennedy stood for hours in the freezing cold shaking hands with workers arriving at a meatpacking plant in Wisconsin, Powers whispered to Kenneth O'Donnell, another Kennedy aide, "God, if I had his money, I'd be down there on the patio at Palm Beach.")

By the spring of 1954 Kennedy's back pain had become almost unbearable. X-rays show that the fifth lumbar vertebra had collapsed. Kennedy could not bend to pull a sock onto his left foot, and he had to ascend and descend stairs moving sideways. Beginning in May he had to rely on crutches more than ever, and walks from his office to the Senate for quorum and roll calls, on hard marble floors, became a daily ordeal. In August a team of physicians from the Lahey Clinic, in Boston, visited him on Cape Cod, where they described yet another surgery, a complicated procedure to achieve spinal and sacroiliac fusions that, they hoped, would strengthen his lower spine. They explained that without the operation he might lose his ability to walk, but that so difficult a surgery on someone with Addison's disease posed risks of a fatal infection, because the steroids were suppressing his immune system.

Rose Kennedy said later, "Jack was determined to have the operation. He told his father that even if the risks were fifty-fifty, he would rather be dead than spend the rest of his life hobbling on crutches and paralyzed by pain." Joe tried to dissuade his son from the surgery, reminding him of FDR's extraordinary achievements despite confinement to a wheelchair. After he entered the New York Hospital for Special Surgery, on October 10, the team of endocrinologists and surgeons postponed the operation three times in order to assure an "extended metabolic work-up prior to, during, and after surgery."

The operation, which finally took place on October 21 and lasted more than three hours, was at best a limited success. A metal plate was inserted to stabilize Kennedy's lower spine. Afterward a urinary-tract infection put his life in jeopardy. He went into a coma, and once again a priest was called to administer last rites. By December Kennedy had shaken the infection and was sufficiently recovered to be moved to the family's Palm Beach home. Nevertheless, he remained far from well; his doctors could not promise that he would ever walk again. Moreover, there was reason to believe that the site of the plate was infected. Consequently, in February another operation was performed at New York Hospital, to remove the plate. The Travell records show that extracting it meant removing three screws that had been drilled into bone and replacing damaged cartilage with a bone graft. After another three months recuperating in Florida, Kennedy returned to Washington in May.

The Cover-Up

ecause his absence from Washington over so long a period could not be hidden, the Kennedys had no choice but to acknowledge JFK's condition. Public awareness of his surgery and slow recovery, however, benefited rather than undermined his image. Kennedy came through this medical ordeal looking courageous—not weak and possibly unfit for higher office, as his family had feared. Nevertheless, the Kennedys did not trust that coming clean about his health problems in the future would generate a similar result. Consequently, the true state of his health now became a carefully guarded secret. His closest aides did not know the full extent of his problems. Although Evelyn Lincoln, Kennedy's secretary, made sure that he took his daily medications (as many as eight different kinds), she apparently had limited knowledge of why he needed them. The evidence I've seen suggests that only Jackie, Joe, Bobby, and Jack's doctors were fully informed.

One thing in particular remained unknown until the Travell records were opened this year: from May of 1955 until October of 1957, as he tried to get the 1956 vice-presidential nomination and then began organizing his presidential campaign, Kennedy was hospitalized nine times, for a total of forty-five days, including one nineteen-day stretch and two week-long stays. The record of these two and a half years reads like the ordeal of an old man, not one in his late thirties, in the prime of life.

All Kennedy's confinements at this time were at New York Hospital, except for one in July of 1955, at New England Baptist. Terrible back pain triggered an eight-day hospitalization beginning on May 26, 1955. General work-ups from this period noted continuing back miseries, with a chronic abscess at the site of his 1954-1955 surgeries; repeated bouts of colitis with abdominal pain, diarrhea, and dehydration; and prostatitis marked by pain on urination and ejaculation, along with urinary-tract infections. On July 3 he spent one day at New England Baptist being treated for severe diarrhea. Eleven days later he entered New York Hospital for a week to relieve his back pain and treat another attack of diarrhea.

On January 11, 1956, he spent three days in the hospital, where he received large doses of antibiotics to counter respiratory and urinary-tract infections. When nausea, vomiting, dehydration, and continuing urinary discomfort occurred at the end of January 1957, he spent two more days in the hospital. In July abdominal cramps put him in the hospital again for forty-eight hours. Fevers of unknown origin, severe abdominal discomfort, weight loss, throat and urinary-tract infections, a recurrence of his back abscess (which was surgically drained), and his all too familiar acute back pain and spasms resulted in three hospitalizations for a total of twenty-two miserable days in September and October.

During this time Kennedy had zero flexion and extension of his back, meaning that he could not bend forward or backward at all; only with great difficulty could he turn over in bed, sit in a low chair, or reach across a table to pull papers toward him. He also had problems bending his right knee and from a sitting position could raise his left leg to only 25 percent of what was considered normal height. There was "exquisite tenderness" in his back, and he was suffering from arthritis. Yet he managed to hide all this from everyone but his doctors and intimates.

In 1955 Kennedy had consulted Janet Travell about muscle spasms in his left lower back, which radiated to his left leg and made him unable to "put weight on it without intense pain." He asked her repeatedly about the origin of his back troubles, but she found it impossible "to reconstruct by hindsight what might have happened to him over the years." It was clear to her, however, that Kennedy "resented" the back surgeries, which had brought him no relief and "seemed to only make him worse." He might have done better, of course, to blame the steroids that weakened his bones.

According to the Travell records, the treatments for his various ailments included ingested and implanted DOCA for the Addison's, and large doses of penicillin and other antibiotics to combat the prostatitis and the abscess. He also received injections of procaine at "trigger points" to relieve back pain; anti-spasmodics—principally Lomotil and trasentine—to control the colitis; testosterone to keep up his weight (which fell with each bout of colitis and diarrhea); and Nembutal to help him sleep. He had terribly elevated cholesterol, 410 in one testing, apparently aggravated by the testosterone, which may have added to his stomach and prostate troubles.

Kennedy's collective health problems were not enough to deter him from running for President. Though they were a considerable burden, no one of them impressed him as life-threatening. Nor did he believe that the many medications he took would reduce his ability to work effectively; on the contrary, he saw them as ensuring his competence to deal with the demands of the office. And apparently none of his many doctors told him that were he elevated to the presidency, his health problems (or the treatments for them) could pose a danger to the country.

After reaching the White House, Kennedy believed it was more essential than ever to hide his afflictions. The day after his election, in response to a reporter's question, he declared himself in "excellent" shape and dismissed the rumors of Addison's disease as false. An article based largely on information supplied by Bobby Kennedy echoed JFK's assertions. Published in Today's Health, an American Medical Association journal, and summarized in The New York Times, the article described JFK as being in "superb physical condition." Though it reported some adrenal insufficiency, it said that a daily oral medication neutralized the problem, and it assured readers that Kennedy would have no problem handling the pressures of the presidency.

A Thousand Days of Suffering

uring his time in the White House, despite public indications of continuing back difficulties, Kennedy enjoyed an image of robust good health. But according to the Travell records, medical attention was a fixed part of his routine. He was under the care of an allergist, an endocrinologist, a gastroenterologist, an orthopedist, and a urologist, along with that of Janet Travell, Admiral George Burkley, and Max Jacobson, an émigré doctor from Germany who now lived in New York and had made a reputation by treating celebrities with "pep pills," or amphetamines, that helped to combat depression and fatigue. Jacobson, whom patients called "Dr. Feelgood," administered amphetamines and back injections of painkillers that JFK believed made him less dependent on crutches.

When Kennedy went to France, in June of 1961, to meet Charles de Gaulle, Travell and Burkley accompanied him on Air Force One. Unknown to Travell and Burkley, Jacobson flew on a chartered jet to Paris, where he continued giving the President back injections. In addition Travell was injecting him with procaine two or three times a day to relieve his suffering, which in the spring and summer of 1961 had become unbearable. On August 27 she noted in her records that Kennedy's cry of pain in response to the injections brought Jackie in from another room to see what was wrong. In June of 1961, after Senator George McGovern had expressed sympathy to Bobby about JFK's suffering, Bobby acknowledged its seriousness. If it were not for Travell's care during the previous several years, Bobby wrote in response, his brother "would not presently be President of the United States."

The Travell records reveal that during the first six months of his term, Kennedy suffered stomach, colon, and prostate problems, high fevers, occasional dehydration, abscesses, sleeplessness, and high cholesterol, in addition to his ongoing back and adrenal ailments. His physicians administered large doses of so many drugs that Travell kept a "Medicine Administration Record," cataloguing injected and ingested corticosteroids for his adrenal insufficiency; procaine shots and ultrasound treatments and hot packs for his back; Lomotil, Metamucil, paregoric, phenobarbital, testosterone, and trasentine to control his diarrhea, abdominal discomfort, and weight loss; penicillin and other antibiotics for his urinary-tract infections and an abscess; and Tuinal to help him sleep. Before press conferences and nationally televised speeches his doctors increased his cortisone dose to deal with tensions harmful to someone unable to produce his own corticosteroids in response to stress. Though the medications occasionally made Kennedy groggy and tired, he did not see them as a problem. He dismissed questions about Jacobson's injections, saying, "I don't care if it's horse piss. It works."

In 1961 Burkley concluded that the injections, along with back braces and positioning devices that immobilized Kennedy, were doing him more harm than good. Burkley and some Secret Service men, who observed the President's difficulties getting up from a sitting position and his reliance on crutches, feared that he would soon be unable to walk and might end up in a wheelchair. Out of sight of the press, Kennedy went up and down helicopter stairs one at a time. After a meeting with JFK, in Bermuda in December of 1961, British Prime Minister Harold Macmillan recorded, "In health, I thought the President not in good shape. His back is hurting. He cannot sit long without pain."

In the fall of 1961 Burkley insisted to Travell that Kennedy consult Hans Kraus, an orthopedic surgeon who, like Jacobson, was a European émigré. When Travell resisted the idea, Burkley threatened to go to the President. Kraus, a brusque Austrian, confirmed Burkley's worst suspicions: he told Kennedy that if he continued the injections and did not begin regular exercise therapy to strengthen his back and abdominal muscles, he would become a cripple. Fearful that frequent visits by Kraus to supervise such therapy might trigger press inquiries and unwanted speculation, Kennedy was initially reluctant to accept the recommendation. The lost medical kit and the apparent attempts to steal his medical records during the 1960 campaign had put Kennedy on edge about the potential political damage from opponents armed with information about his health problems.

But mindful that ignoring Kraus's advice might eventually result in his being confined to a wheelchair, Kennedy accepted that something had to be done. He and Kraus agreed to describe the therapy sessions as exercises to upgrade the President's condition from very good to excellent. Kennedy then began a regimen of three exercise sessions a week in a small White House gymnasium next to the swimming pool. Limiting Travell's access to the President, Burkley and Kraus used exercises, massage, and heat therapy to ease Kennedy's back spasms and increase his mobility. Performed with his favorite country and western and show tunes playing in the background, the exercise therapy became a respite from the demands that crowded Kennedy's schedule. In the event of an emergency, he had immediate access to Kraus by means of a phone installed in Kraus's car. (Travell, meanwhile, was kept on at the White House so that she wouldn't reveal Kennedy's secrets to the public; if she had been forced out, she might have been tempted to talk.) By January of 1962 Burkley and Kraus saw JFK having a better month than at any time in the previous year. At the end of February they described the past four weeks, "medically speaking," as the "most uneventful month since the inauguration; since the 1960 campaign, for that matter." And in April they pronounced his general condition "excellent."

Nevertheless, Kennedy continued to need extensive medication. His condition at the time of the Cuban Missile Crisis is a case in point. The Travell records show that during the thirteen days in October of 1962 when Moscow and Washington brought the world to the brink of a nuclear war, Kennedy took his usual doses of anti-spasmodics to control his colitis, antibiotics for a flare-up of his urinary-tract problem and a bout of sinusitis, and increased amounts of hydrocortisone and testosterone, along with salt tablets, to control his Addison's disease and boost his energy. Judging from the tape recordings made of conversations during this time, the medications were no impediment to lucid thought during these long days; on the contrary, Kennedy would have been significantly less effective without them, and might even have been unable to function. But these medications were only one element in helping Kennedy to focus on the crisis; his extraordinary strength of will cannot be underestimated.

This is not to suggest that Kennedy was superhuman, or to exaggerate his ability to endure physical and emotional ills. On November 2, 1962, he took ten additional milligrams of hydrocortisone and ten grains of salt to boost himself before giving a brief report to the American people on the dismantling of the Soviet missile bases in Cuba. In December, Jackie complained to the President's gastroenterologist, Russell Boles, that the antihistamines for food allergies had a "depressing action" on the President. She asked Boles to prescribe something that would assure "mood elevation without irritation to the gastrointestinal tract." The Travell records reveal that Boles prescribed one milligram twice a day of Stelazine, an anti-psychotic that was also used as a treatment for anxiety. In two days, Kennedy showed marked improvement, and he apparently never needed the drug again.

From the start of his presidency John F. Kennedy had the example of FDR, who had functioned brilliantly despite his paralysis. Roosevelt, however, never needed the combination of medicines on which Kennedy relied to get through the day. When Kennedy ran for and won the presidency, he was in fact gambling that his health problems would not prevent him from handling the job. By hiding the extent of his ailments he denied voters the chance to decide whether they wanted to share this gamble. It is hard to believe that he could have been nominated, much less elected, if the public had known what we now know about his health. Then again, given the way Richard Nixon performed in the White House, how many people would retrospectively offer him their votes for 1960, even knowing of Kennedy's health problems?

There is no evidence that JFK's physical torments played any significant part in shaping the successes or shortcomings of his public actions, either before or during his presidency. Prescribed medicines and the program of exercises begun in the fall of 1961, combined with his intelligence, knowledge of history, and determination to manage presidential challenges, allowed him to address potentially disastrous problems sensibly. His presidency was not without failings (the invasion of Cuba at the Bay of Pigs and his slowness to act on civil rights were glaring lapses of judgment), but they were not the result of any physical or emotional impairment.

Lee Harvey Oswald killed Kennedy before the President's medical ailments could. But the evidence suggests that Kennedy's physical condition contributed to his demise. On November 22, 1963, Kennedy was, as always, wearing a corsetlike back brace as he rode through Dallas. Oswald's first bullet struck him in the back of the neck. Were it not for the back brace, which held him erect, the second, fatal shot to the head might not have found its mark.

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Robert Dallek is a professor of history at Boston University. His book An Unfinished Life: John F. Kennedy, 1917-1963, from which this article is drawn, will be published next fall by Little, Brown. Jeffrey Kelman, M.S., M.D., contributed his medical expertise to the article.