Wednesday, June 10, 2009

JFK and Addison’s Disease

By Robert E. Gilbert

Gravely ill, Kennedy was admitted to a London hospital in 1947. His doctor's verdict: "He hasn't got a year to live."

Throughout his early life, John Fitzgerald Kennedy seemed an unlikely prospect for national and international leadership. He was a "rather frail little boy" and almost died of scarlet fever at the age of three. Moreover, his mother has told us that this was "only the beginning": "almost all his life, it seemed, he had to battle against misfortunes of health." The family used to joke that if a mosquito bit Jack, the mosquito would surely die. In addition to the usual childhood illnesses, John Kennedy suffered from diphtheria, allergies, frequent colds and flu, hives, an irritable colon, a weak stomach which required a bland diet most of his life, and asthma- which caused him considerable difficulty as a teenager.

In 1930 [at the age of 13], he wrote his mother from boarding school complaining of blurriness and color blindness in his right eye – years later he would become hard of hearing in his left ear as well - and told his father that he had gotten dizzy and fainted at Mass. He underwent an appendicitis operation in 1931, had his tonsils and adenoids removed and came down with an enervating case of jaundice two years later, and in the mid-1930s developed a severe case of pneumonia.

Approximately one year later, he had to end his studies at the London School of Economics after coming down with another case of jaundice so severe that it required hospitalization. After returning to the United States and beginning studies at Princeton, where he would be close to the New York doctors who were treating him, the jaundice recurred and forced Kennedy to spend two months in Boston's Peter Bent Brigham Hospital and then move to Arizona to recuperate. In the fall of 1936, he entered Harvard University, where he was closer to his family, but illness followed him. A bad case of the flu prevented him from making the swimming team which was to compete against Yale, and in 1940, he developed a case of urethritis which recurred with some frequency throughout the remainder of his life. His bladder and prostate difficulties were so persistent, in fact, that shortly before his marriage he questioned one of his physicians about his ability to have children. During these early years, he was described as “a slight, very slight, young man.”

In addition to back problems so grave that his brother Robert said of him that “at least one half of the days that he spent on this earth were days of intense physical pain,” John F. Kennedy suffered from a debilitating, potentially life-threatening disease for at least the last 16 years of his life. Had Kennedy contracted it even a few years earlier than he did, he almost certainly would have died.

While on a visit to London in the fall of 1947, Congressman Kennedy became so seriously ill with weakness, nausea, vomiting, and low blood pressure that he was given the last rites of the Roman Catholic Church. The physician who examined him diagnosed his condition as Addison’s disease and told one of Kennedy’s friends that “he hasn’t got a year to live.” Journalist Arthur Krock, however, remembered being told by Joseph Kennedy, even before his son first ran for Congress in 1946, that Jack had Addison’s disease and was probably dying. Krock related that Joseph Kennedy “wept sitting in the chair opposite me in the office.” If Krock’s memory was accurate, it would appear that John Kennedy contracted Addison’s disease somewhat earlier than previously thought. Indeed, this might well explain Kennedy’s illness during his first campaign for the House of Representatives, when he collapsed during the final campaign event, a parade in Charlestown, sweating heavily and his skin discolored.

One of the common symptoms of Addison’s disease is a discoloration or bronzing of the skin. Although several of Kennedy’s biographers indicate that he did not have skin discoloration and/or that he insisted he did not, other observers found that he had a surprisingly deep tan, or yellowish skin, or skin of a greenish tinge. One who saw him during the 1960 campaign reported that his face was “lined and tanned to the extreme – and rough-looking, like the surface of a steak.” Theodore Sorenson, special counsel to the President, related that Kennedy once responded to a suspicious reporter’s question about his year-round tan “by exposing a part of his anatomy that had not been burned by the sun.” This, however, was no proof that his tan was natural, since Addisonian bronzing is “usually more marked on the exposed portions of the skin.”

Earlier, when a journalist had asked him about the unusual tinge of his skin, Kennedy replied with uncharacteristic candor, “The doctors say I’ve got a sort of slow motion leukemia, but they tell me I’ll probably last until I’m 45. So I seldom think about it except when I have the shots.”

When Addison’s disease was first discovered in the mid-1800s, it was regarded as fatal. Before 1930, 90 percent of persons with the disease died within five years; but in the late 1930s, researchers developed a synthetic substance, desoxycorticosterone acetate (DOCA), which greatly reduced the mortality rate. However, it remained important for those with the disease to avoid great stress, since stress increases the body’s need for steroids, which the Addisonian’s adrenal glands cannot provide.

Classic Addison’s disease has been caused by tuberculosis. Since John Kennedy never suffered from tuberculosis of any kind, he and his spokespersons maintained that he did not have Addison’s disease in the classic sense. Rather, they attributed his adrenal insufficiency to the physical strain of having to spend many hours in the water after his PT boast was sunk and to the case of malaria he contracted soon afterward.

Nevertheless, Kennedy was wholly dependent on the cortisone therapy that Addisonians rely upon for survival. Initially, he took 25 milligrams of cortisone by mouth; he then took it through injection. Also, he had implanted in his thighs DOCA tablets of 150 milligrams, which were replaced several times a year. There are even reports that the Kennedy family kept a reservoir of DOCA and cortisone in safety deposit boxes around the country so that Jack would have ready access to these medications wherever he traveled. One of his closest aides recounts that John Kennedy “used (and carried with him around the country) more pills, potions, poultices and other paraphernalia than would be found in a small dispensary.”

Addison’s disease often produces severe muscular cramping and thus may well have compounded Kennedy’s back problems. Clearly, the disease played an important role in heightening the dangers associated with his back operations in 1954. In the case of Addisonians at the time, even such a simple procedure as a tooth extraction might have been followed by death. The disease was so serious that occasionally patients who did not appear to be in any immediate danger would die suddenly. Surgery, therefore, was extraordinarily dangerous in Kennedy’s case.

An article that appeared in a 1955 issue of the AMA Archives of Surgery and examined the case of a 37-year-old male Addisonian who underwent spinal sugery at the New York Hospital for Special Surgery on October 21, 1954, is widely believed to have John Kennedy as its subject. Kennedy, after all, was a 37-year-old male Addisonian who had undergone surgery on the date and at the hospital specified. This article pointed out that the surgical procedures performed on JFK, a lumbosacral fusion and sacroiliac fusion, were considered dangerous because of his adrenocortical insufficiency due to Addison’s disease. Throughout the more than three-hour operation, the patient received hydrocortisone intravenously. In the postoperative period, this treatment was supplemented by added dosages of desoxycorticosterone, salt, and cortisone given intramuscularly. Except for a urinary tract infection which arose three days after the operation, a mild reaction to a transfusion, and a wound infection, the patient did not develop a full-scale “Addisonian crisis,” even though he suffered from “marked adrenocortical insufficiency.”

It was precisely the danger of an “Addisonian crisis” that led doctors at the Lahey Clinic in Boston to refuse to perform the operation in the first place, since they feared that Kennedy might not tolerate surgery well and die. Although their worst fears were not realized, Kennedy’s convalescence following his back surgery was protracted and painful. [White House physician Janet] Travell estimated that he suffered from a chronic infection in the soft tissues of his back for three and a half years after the back operations were performed. Addison’s disease, with its proclivity to render patients more susceptible to infection, almost certainly played a role in making Kennedy’s recovery so slow and agonizing.

By the time John Kennedy launched his presidential campaign in the late 1950s, new treatments for Addison’s disease (Meticorten and the fluorohydrocortisone derivatives or the glucocorticosteroid compounds) had been developed, the adrenal problems associated with the ailment had become entirely manageable, and a normal life span had become possible for the first time. Nevertheless, Kennedy’s physical condition was made an issue in the campaign, despite a statement by one of his physicians that he was “fully rehabilitated from the depletion of adrenal function which he had suffered as a result of his wartime injuries.”

As he battled Lyndon B. Johnson for the Democratic presidential nomination, some of Johnson’s allies made reference to Kennedy’s Addison’s disease and used it as an argument against his nomination. India Edwards, a southern Democratic party leader, told a group of reporters that “Kennedy was so sick from Addison’s disease that he looked like a spavined hunchback.” She also asserted that doctors had told her that were it not for cortisone, Kennedy would be dead. Another prominent Johnson ally, campaign manager John Connolly [not to be confused with Texas politician John Connally], charged that, if nominated and elected, Kennedy “couldn’t serve out the term” since “he was going to die.”

The Kennedy forces responded to these attacks by asserting that “John F. Kennedy does not now nor has he ever had an ailment described classically as Addison’s disease, which is a tubercular destruction of the adrenal gland. Any statement to the contrary is malicious and false.” In addition, Dr. Travell spent three or four hours with Dr. Eugene Cohen hammering out a statement on Kennedy’s health; it was dated June 11, 1960, and sent in letter form to Kennedy for release to the press. The two doctors found the statement difficult to write. In fact, Travell later admitted that they “fought over every word of it.” The statement read in part:

"We wish to point out that the fact that your adrenal glands do function has been confirmed by a leading endocrinologist outside of New York City.

With respect to the old problem of adrenal insufficiency, as late as December, 1958 when you had a general check-up with a specific test of adrenal function, the result showed that your adrenal glands do function."

After Kennedy won the presidential nomination of his party on the first ballot, there was considerable interest in the choice of his vice-presidential running mate. Highly revealing is a generally overlooked comment made by Philip Graham, late publisher of the Washington Post, in a memorandum concerning Lyndon Johnson’s selection for second place on the 1960 ticket:

"I told LBJ Jack would be phoning him and then…I returned to the vacant bedroom to call Adlai [Stevenson, the Democrats’ 1952 and 1956 presidential nominee]. In our prior talk he had argued for [Missouri Senator Stuart] Symington on pure expediency grounds and I had been a bit testy in pointing out that any VP was likely to be President." [Emphasis added]

During the general election campaign, an attempt was made to steal Kennedy’s health record; and the office of Dr. Cohen, the coauthor of the statement on his adrenal insufficiency, was actually vandalized. Also, prominent Republicans raised new questions about Kennedy’s health. Congressman Walter Judd of Minnesota, a former medical missionary and the 1960 Republican keynote speaker, stated unequivocally:

"For one thing I would like a flat answer to rumors in medical circles that Case Number Three in the American Medical Association’s Archives of Surgery, Vol. 71, relates to Senator Kennedy. If so, this represents information which Senator Kennedy is duty bound to make fully available to the consideration of every voter."

Republican questions about Kennedy’s health were diffused largely by the vigorous campaign he waged and by the image of vitality he projected. Except for the flu, acute sinusitis, and a case of laryngitis that “completely unnerved” him, he was well throughout the campaign period, and Dr. Travell saw him only once or twice. One of his closest aides expressed relief that the nominee’s “history of bed-confining fevers did not recur.” At one of his first press conferences after his election, Kennedy made an extraordinarily rare reference to the rumors of his ill health: he insisted to reporters, “I have never had Addison’s disease. I have been through a long campaign and my health is very good today.”

We know now that Kennedy’s Addison’s disclaimer was untrue, even though he may not have fully realized it at the time. Kennedy maintained that his adrenal insufficiency was a side effect of the malaria he contracted after the war. This is a possibility, since “malaria has been known to cause lesions in the adrenal cortex.” Since Kennedy did not suffer at any time from tuberculosis, he adrenal insufficiency seems likely to have resulted from atrophy of the adrenal glands. One medical specialist has reported that about half of all Addisonians he treated suffered from adrenal gland atrophy rather than from tuberculosis. Nine years after Kennedy’s death, his autopsy photographs were viewed by Dr. John Latimer who found that “no abnormal calcification could be seen…to suggest tuberculosis or hemorrhage of the adrenals. It is [my] firm belief that the President suffered from bilateral adrenal atrophy."

Dr. Travell later stated for the record that John Kennedy did indeed suffer from Addison’s disease. Asked in 1966 whether it would be fair to say “for a secret historical record” that Kennedy had had Addison’s disease, Travell responded:

"The term Addison’s disease has been extended at the present time to include all degrees of adrenal insufficiency and all causes of adrenal insufficiency. So that I would say yes to your question. At the present time, the broader meaning of this diagnosis would now cover his condition, although even 15 years ago it would not have."

As early as 1953, however, a physician associated with the Lahey Clinic had indicated that Kennedy had been suffering from and treated for Addison’s disease since the late 1940s. While that physician pointed out that Kennedy had been a patient of the Lahey Clinic since 1936 and had had “quite a variety of conditions,” he described his Addison’s disease as the most serious of Kennedy’s many ailments. Apparently, Travell did not speak for all of Kennedy’s doctors.

Kennedy insisted to aides that he did not have Addison’s disease, and he went so far as to tell one of them in 1959 that “no one who has the real Addison’s disease should run for the Presidency, but I do not have it.” When, around the same time, Dr. Travell tried to discuss his Addison’s disease with him, Kennedy retorted, “But I don’t have it, Doctor.” Travell explained to him, without evident success, that he didn’t have classic Addison’s disease, but that “doctors disagree maybe because they aren’t talking about the same thing.” In 1960, when one of his aides expressed unhappiness over the selection of Lyndon Johnson as his vice-presidential running mate, Kennedy replied, “Get one thing clear…I’m 43 years old, and I’m the healthiest candidate for President in the country, and I’m not going to die in office.”

There is no evidence that John Kennedy’s physical ailments had any negative impact on his conduct of the presidency. Indeed, Dr. George Burkley [head of the military medical unit at the White House] emphatically stated that “his back pain affected his normal conduction of the office of President in no way. He tended his office and went back and forth occasionally – at one point he was on crutches – but that did not deter him from his full duty as President.”

Burkley also asserted that adrenal insufficiency “was never a problem with the President when under my care.” Dr. Janet Travell agreed with this assessment, saying, “We had much smoother control of the problem of adrenal insufficiency while he was in the White House when he was in one place and not travelling around.” She added, “I thought…that his health would be more than adequate for him to carry the duties and responsibilities of the presidency, and indeed it was.” In the 34 months of his tenure, Kennedy missed only one day of work because of illness.

Indeed, rather than adversely affecting him politically, Kennedy’s physical ailments vitally contributed to the development of his character and to the formation of his political personality. Even more significant perhaps, John F. Kennedy’s ailment may have led to his meteoric political career – so far as his drive toward the glory of the presidency was an attempt, however subconscious, to prove his worth and demonstrate his strength by rising above all others.

Robert E. Gilbert is professor of political science at Northeastern University. This article is excerpted from his book The Mortal Presidency: Illness and Anguish in the White House. Copyright 1992 by Basic Books. Published by arrangement with Basic Books, a division of Harper Collins Publishers, Inc.