The Health Of The President: Theodore Roosevelt

Theodore Roosevelt (1858 — 1919)

Theodore Roosevelt was the most forceful and aggressive President since Andrew Jackson and equally colorful and popular. Both men were born fighters and leaders of men, who underwent the trial of chronic disease before they matured. Though T. R. resembled Jackson in aggressiveness and temperament, he vied with Jefferson in versatility and variety of interests. Roosevelt himself felt a kinship with the stormy Hickory, the man of the people, but disliked the Sage of Monticello, a man with a background similar to his own. Theodore Roosevelt had no understanding of the agrarian philosophy and the Olympian world view of Jefferson, the exponent of the humanistic renaissance of the eighteenth century. Teddy was the typical representative of industrialized America at the turn of the nineteenth century, which suddenly had grown into a young giant among the world powers, bursting with vitality and self-assurance.

Roosevelt was born in New York City on October 27, 1858, the second of four children of Theodore and Martha Bulloch Roosevelt. Six generations of the Dutch Roosevelts before him were identified with Manhattan, and the most recent of them were well-to-do. Teddy’s mother was born in Georgia of Scotch-Huguenot and English extraction. The chance mixture of different racial strains accounted for the multicolored personality of Teddy Roosevelt. Among his inherited characteristics he also displayed certain traits of degeneration such as a congenital form of nearsightedness and a severe bronchial allergy, from which his younger sister also suffered.

He was only an infant when he developed violent attacks of bronchial asthma. This condition is caused by a swelling of the mucous lining of the small bronchial branches with secretion of mucus. Concurrently the air tubes become spastically contracted, impeding the breathing, particularly expiration. The spells are brought on by certain irritating substances, called allergens, inhaled or else carried by the blood stream, such as derivatives from some foods. Nervous and emotional stimuli can also trigger attacks of asthma.

Such episodes occurred during Teddy’s childhood at frequent intervals. He would be suddenly aroused from a sound sleep by a feeling of suffocation, gasping for breath, his face a bluish white. He had not even enough breath left for a loud cry. Only a low moan would accompany his wheezing, rattling expiration. His parents fed the frightened child all kinds of soothing syrups which he could hardly swallow; they let him inhale the suffocating fumes of stramonium (Jimson weed) leaves or steam from a kettle scented with aromatics. These medications only resulted in a croupy cough. The exhausted and sleepy little patient could not catch his breath when lying down, and for many nights could only find comfort and sleep in his father’s arms.

Roosevelt’s asthma continued throughout his childhood and adolescence. The attacks were not limited to the pollen seasons in summer and fall but occurred also in winter and spring. Often they were accompanied by diarrheas, indicating that the intestinal canal was also sensitive to some allergens.

Over the years all kinds of nostrums were tried on the patient. Quacks recommended the smoking of cigars, which made the panting little fellow only more miserable by nauseating him. More effective was the coffee treatment, the caffeine from a strong cup of coffee at times arresting an attack at the cost of a sleepless night.

In 1869 the Roosevelts took a trip abroad, hoping that a change of climate would benefit their two asthmatic children. They visited Paris, the Riviera, Italy, Austria and Germany. For little Ted the journey meant a succession of asthma attacks and diarrheas, relieved by a few breathing spells in mountain resorts, where the air had a lower atmospheric pressure and contained less dust and pollen. A second trip to the dry climate of Egypt and the Holy Land during 1872 and 1873 was better tolerated by Teddy. During the summer of 1873 the four children were left for a while with a German family in Dresden. In the damp old city the boy got another asthma spell and had to be taken to a spa in the hills to recuperate.

Even if these travels in foreign countries did not help Roosevelt’s asthma, they certainly left a lasting impression on him, lifting his horizon beyond American provincialism and giving him an awareness of the characteristics of different nations and a foundation for his knowledge of global politics as President.

Compared with Roosevelt’s severe allergy, the childhood diseases of chicken pox, measles and mumps were almost pleasant experiences and left no aftereffects. The recurrent attacks of bronchial asthma during his formative years set up a lasting pattern of responses in Roosevelt’s personality. The terrifying experience of feeling the invisible constriction in his chest, and the desperate struggle for breath in the dark sickroom, instilled in him a yearning for the outdoors, where he could fill his thirsty lungs with clean drafts of fresh air. It was possibly in reaction to these frightening childhood impressions that Roosevelt as an adult courted danger—as if to prove to himself that he had conquered his deep-seated fearfulness.

Teddy’s respiratory and digestive allergies retarded his physical development. He was a pale, thin boy, small for his age, with skinny legs, eager blue eyes and sandy hair. Also, one of the family traits was his protruding teeth; orthodontics was still unknown. In his later life, Roosevelt hid them under his walrus mustache.

His father was a leonine man who encouraged his asthenic son to build up his body by systematic exercise. He installed a private gymnasium on the open-air porch of his brownstone house in New York. There, under the direction of instructors, Teddy applied himself patiently day by day, year by year, lifting the weights, doing pull-ups on the rings, and working out on the parallel bars. In time the narrow-chested youth who looked like a scarecrow transformed himself into a big, muscular, broad-shouldered man.

Another weakness that molded Roosevelt’s character was his extreme nearsightedness. Because he was taught by private tutors and did not sit on public school benches, his myopia was not discovered until he was thirteen years old. Before this, his vision served for writing and reading, which he did voraciously. At a distance he could only discern vague outlines of objects, and was a clumsy playmate whom the other children teased. His defective vision was first recognized when he was being taught by his father to shoot a rifle. He could not focus the sights.

Fitted with thick-lensed glasses, Teddy practiced target shooting with double determination until he became a crack shot. To compensate for the humiliation caused by his weakness and awkwardness as a child, he developed a compulsion to excel in games and sports that called for strength, endurance and skill, such as boxing, wrestling, obstacle riding and mountain climbing. Despite the thick lenses and unorthodox style, he even became an acceptable tennis player.

At Harvard, Roosevelt made Phi Beta Kappa, and graduated in 1880 without having decided on a career. History and politics interested him. In 1882 he published his first book, on the naval war of 1812, starting a prolific rather than artistic literary career.

In 1878, his father died from a condition diagnosed as intestinal obstruction by a fast-growing malignant tumor, on which the doctors of the time did not dare to operate.

Following his graduation, Theodore married Alice Lee, who died four years later from unknown puerperal complications following the birth of their daughter Alice. His mother died of typhoid fever only twelve hours after his wife’s death. The twenty-six-year-old Roosevelt was left alone with his baby. During the years of his marriage his asthma had much improved and his attacks occurred at lengthening intervals. His profound grief brought on a severe relapse combined with a persistent hacking cough, causing suspicion that he might be developing tuberculosis of the lungs. On the doctors’ advice he went west and bought a ranch in North Dakota.

It was with some reluctance that he left, because he had to give up a promising political career as assemblyman of the 21st. District at Albany, where he had taken up the good fight against the evils of corruption in government. Soon his love of nature and the wide-open spaces made young Roosevelt feel at home at the ranch. He threw himself enthusiastically into the unaccustomed role of cowboy and in time became an expert at branding the calves and breaking in the horses.

During this period his long history of accidents and broken bones began. He fractured an arm when he was thrown from a bucking broncho, and a few months later a shoulder blade when a rearing horse fell on top of him. Always a Spartan, Roosevelt was undaunted by such trifles and forever retained a glowing memory of his life in the West. With restless energy he wrote thousands of pages about the West and its history.

But he was not satisfied with roughing it on the ranch. Roosevelt occasionally took a vacation and participated in the bone-breaking sport of fox hunting on Long Island. On one occasion the run crossed unusually rough country, with the result that before the contest was over, half the gay party were ready for the hospital. The host had dislocated his knee; a guest had broken several ribs; Teddy’s brother-in-law had torn half the skin off his face and been knocked unconscious. As for Roosevelt, his mount struck the top rail of a five-foot fence, fell heavily and rolled over his rider on a heap of stones. The indestructible horseman got up, his face covered with blood from cuts and bruises, his left hand hanging limp from a fractured wrist. He remounted and continued for another five miles, taking twenty more fences and catching up with the survivors of the slaughter. That night he went out to dinner, proudly exhibiting his bandaged head and arm in a plaster cast. The next day he walked for three hours in the woods.

His bones mended, his mind and body refreshed, Roosevelt returned in 1886 to New York and his political career. In the same year he married Edith Kermit Carow. They had four sons and a daughter, whom the father taught from early youth the Spartan principles in which he believed.

In 1889 Roosevelt was appointed Civil Service Commissioner by President Benjamin Harrison. In this position he continued his life-long fight for good government. With his honest efforts he combined a native genius for personal publicity which made him good copy. In 1895 he accepted the position of Police Commissioner in New York and with his usual vigor tackled the unholy alliance of politics, graft and crime, exposing them to the light of day regardless of friend or foe.

President McKinley appointed him Assistant Secretary of the Navy in 1897. Anticipating the Spanish-American War, Roosevelt ordered a crash program of naval target practice. In February 1898, as acting Secretary, he cabled Admiral Dewey exact instructions for offensive operations in the Philippines. After war was declared in May, Roosevelt could not endure sitting behind a desk in Washington letting others get the excitement and glory. He promptly resigned from his office to participate in the combat. Together with Colonel Leonard Wood he organized the first United States Voluntary Cavalry, called the “Rough Riders,” and led the famous charge up Cattle Hill at San Juan. As he led the spectacular attack, he was armed not only with a revolver, but also with a dozen pair of spectacles in their metal cases distributed all over his pockets.

The casualties of the Cuban campaign were comparatively small; however, the losses from sickness were staggering. The trouble started at the point of mobilization at Tampa, Florida, where the expeditionary force was severely stricken with food poisoning from spoiled canned rations and with typhoid fever from poor sanitation. In Cuba, sporadic cases of yellow fever and numerous ones of dysentery swelled the sick list. But the most devastating plague was a tropical form of malaria which almost forced the withdrawal of the attacking army from Santiago de Cuba.

After the city was captured, the commanding general begged the War Department in Washington to permit the removal of the army from the pest-ridden area. This request was denied and the forces seemed doomed to be wiped out by the epidemics.

Because General Shaffer could not make the officials in Washington understand the gravity of the situation, Roosevelt, who had no army career to risk, went over the heads of his superiors directly to the press, and by public pressure forced the hand of the War Department, thus saving the expeditionary force from possible destruction.

Like Julius Caesar, Roosevelt was his own press agent and did not understate his own exploits. He returned to the United States like a conquering hero who, singlehanded, had defeated the enemy. Even the kindly McKinley remarked that nobody got so much out of the war as Theodore Roosevelt.

As a public hero he was elected governor of New York in January, 1899. He immediately went to work fighting against the spoils system and for taxation of corporation franchises. Unable to stop the aggressive reformer, who had the public on his side, the special interests and political bosses looked for a way of making him innocuous. They figured that it would be best to kick him upstairs into the silent obscurity of the Vice-Presidency, where the obstreperous hero would have four years of oblivion.

In a political deal, the Republican leaders of New York and Chicago forced him on President McKinley as running mate. The Colonel, as he liked to be called, saw through the scheme, which was meant to be his political grave, and hesitated several weeks accepting the nomination. Finally, popular pressure and party loyalty induced him to bow to what appeared to be the end of his career. But even as Vice-President he succeeded in keeping his name alive by publishing a book of verbose essays and addresses.

The assassination of McKinley hastened the fulfillment of Roosevelt’s destiny as President, hurdling him over the entrenched interests. In his inauguration speech he promised to continue the cautious policy of his predecessor. But being the man he was, he could not follow in anybody’s footsteps; he had to plot his own course and set his own pace.

His achievements in this direction are history: the enforcement of the Sherman Anti-Trust Law; the regulation of railroad rates; the reclamation and preservation of national resources; and the Pure Food and Drug Act, so important for the public health. In international politics he paved the way for building the Panama Canal; mediated the peace between Russia and Japan; was instrumental in the Conference of Algeciras, postponing World War I for eight years; and truly deserved the Nobel Peace Prize he received in 1906.

In spite of all his hard work as President he still found time to spend two hours every day on strenuous physical exercise. One day as he was boxing with a young captain, his opponent forgot to pull his punches, and hit Roosevelt’s left eye. The blow caused a hemorrhage, followed by a detachment of the retina and almost total blindness. Thereafter, the President stopped boxing and took up ju jitsu. A chain of other accidents followed. Once he was almost killed when his hose somersaulted and he landed on his head. Three times during 1904 he injured a leg, once tearing a muscle of his thigh and causing a considerable hemorrhage.

Not all of Roosevelt’s accidents came about in the pursuit of sport. Some of them were due to the haste with which he always moved. In 1902 the carriage in which he was riding collided with a trolley car, killing a secret service man beside him and throwing the President forty feet. The severe impact injured one of his thigh bones; an infection followed and necessitated surgical treatment. The leg injury gave him trouble for the rest of his life, flaring up on several occasions.

After leaving the White House in 1909 the Colonel went on an African safari and shot innumerable animals. He described his adventures in voluminous letters and articles in magazines and newspapers. Returned from his trip, he learned of the growing split between the conservative wing of the Republican party toward which President Taft was leaning, and the progressive elements favoring him. Thus it came to a break between the two friends. When the Republican convention in 1912 steamrollered Taft’s nomination for a second term, Roosevelt bolted the party and became candidate of a third, “Progressive,” party. From the remark of the former President that he felt “as fit as a bull moose,” this ungainly ruminant became the symbol of the new party and gave it its popular name.

In his campaign against Taft, Roosevelt showed the hostility of a bad conscience and stooped to personal invective against his old friend. At times he seemed to be intoxicated by his own oratory and ranted almost incoherently, as if drunk. His enemies made capital of this impression, calling him a drunkard. Actually, Roosevelt hardly ever touched liquor and drank only light wines in moderation. The former President’s raving got on the nerves of cultured Henry Adams, in whose veins the acid of his ancestors flowed, and he quipped: “Roosevelt is never sober, only he is drunk with himself, and not with rum.”

During the campaign Roosevelt was shadowed by a paranoiac, John Schrank, whose sick brain created a drama in which he was to be the hero. The spectacular T. R. was the most publicized figure at the time, and stalking him gave the shy little man a feeling of self-importance. To shoot him down would give him for one moment the sense of ecstatic power and make the world take notice of him at last. In John Schrank’s dream-world delusions, the ghost of McKinley appeared to him, pointing to Roosevelt as his, McKinley’s, murderer and asking him to avenge his death. To rationalize his crime, he convinced himself that it was his sacred duty to uphold tradition against a third term, which his villain was flouting. His mental regression was also evident in the banal poems he wrote, which were almost as incoherent as those of Guiteau, Garfield’s assassin.

His opportunity came on the evening of October 14, 1912, in Milwaukee, when he could approach his target at a distance of six feet, in front of a hotel. He had a .38 Colt, which could not fail to hit Roosevelt as he stood there waving at the crowd. The Colonel felt something hot strike his chest, without being aware of much pain. The impact made him stagger back but he braced himself and did not fall. Before Schrank could fire a second shot he was bowled over by Roosevelt’s secretary, a former college football tackle.

The bullet had struck Roosevelt in the right breast close to the nipple and passed upward and medially about four inches, fracturing the fourth rib but not entering the pleural cavity. As the madman was being dragged away, the Colonel put his hand to his lips and coughed. Not finding blood on his fingers, he knew that his lungs were not injured and the wound was not critical.

A Colt fired at such short range has great penetrating power and the bullet would certainly have torn the lungs and probably the large vessels of the heart if it had not been impeded by the contents of Roosevelt’s bulging breast pocket. The bullet pierced one of his numerous metal spectacle cases, then passed through the manuscript of his prepared speech that was loosely folded to fit the pocket, serving as a bulletproof vest. Unquestionably it was the most effective speech of Roosevelt’s career.

Always an actor, Roosevelt rose to the occasion. He insisted upon being driven to the auditorium instead of the hospital and to deliver his scheduled speech. As he opened his coat to take out the bullet-pierced manuscript, his blood-soaked shirt became visible, arousing a wild frenzy among the large audience. In his excitement Roosevelt hardly looked at his script, but extemporaneously delivered a rambling address lasting fifty minutes, directing his blasts at random against the trusts, the Standard Oil Company, and the Republican bosses.

During the harangue the speaker’s friends formed a circle around the podium ready to catch the bleeding Colonel in case he collapsed. Exhausted, but still on his feet, he was finally prevailed upon to end his speech and be taken to the hospital. There, several doctors examined him, among them Dr. Joseph C. Bloodgood of the Johns Hopkins Hospital, who happened to be in the audience. Roosevelt knew the doctor, greeted him warmly and asked him to look after him. “I do not want to fall into the hands of too many doctors and have the same experience that McKinley and Garfield had.” Dr. Bloodgood expressed his regret at not being able to treat the Colonel, since he was not on home grounds. He advised him to take the short trip to Chicago and entrust himself to the famous surgeon John B. Murphy.

Roosevelt agreed. Dr. Bloodgood personally called John B. Murphy’s home and arranged for the examination. In the meantime, three other well-meaning friends of Roosevelt had called their own favorite surgeons—Drs. Bevan, McArthur, and Ochsner, all of whom were waiting at the railroad station to receive the illustrious patient at the scheduled time.

By some curious mix-up Roosevelt arrived on a special train three hours earlier and was met by Dr. Murphy, who took him to his own hospital without notifying his colleagues. This questionable behavior of Dr. J. B. Murphy, who was not noted for consideration toward his confreres, led to serious charges against aim before the American Medical Association. He was accused (but afterward exonerated) of “stealing” the patient and deliberately seeking notoriety.

Contrary to the surgical practice used with disastrous consequences on President Garfield, Dr. Murphy did not probe Roosevelt’s wound, thus avoiding the risk of carrying bacteria from the outside into the wound. He took X-ray pictures which revealed the location of the bullet outside the pleura, imbedded in the fractured fourth rib. He decided not to attempt removing the bullet by surgery unless an infection set in making it necessary.

The patient received a prophylactic injection of tetanus antitoxin, in general use since the end of the nineteenth century, introduced by Emil von Bering, who also had discovered the diphtheria antitoxin. The fractured rib caused pain in breathing, which was relieved by strapping the chest, bed rest and mild sedatives. No complications occurred. The external wound healed promptly. After a week, the patient felt so well that he could leave for his home in Oyster Bay, Long Island.

Just two weeks after his injury, Roosevelt made two major campaign speeches before capacity crowds in Madison Square Garden. The American people admired Teddy’s pluck, but at the polls they elected Woodrow Wilson, the Democratic candidate, over the split opposition. Roosevelt carried the lead bullet in his chest for the rest of his life. It became well encapsulated and never troubled him.

Roosevelt took his defeat in good grace and looked for other outlets for the overflowing energy that could not be contained in a life of leisure. This in spite of a chronic rheumatoid arthritis from which he had been suffering for years. Now, at the age of fifty-four, it crippled him a good deal, and often prevented him from doing his daily stint of exercises. As a consequence, he became too fat around his waistline but was not Spartan enough to control his gargantuan appetite.

According to a friend he ate like a trencherman. It was not unusual for him to consume a whole chicken with trimmings all by himself, and wash it down with four big glasses of milk. He also drank great quantities of coffee and tea. He had his special coffee cup, described as being more like a bathtub. Its contents required five to seven lumps of sugar for sweetening. Eventually, Roosevelt made the usual show of reducing by substituting saccharine.

Though overweight and rheumatic, he retained great endurance in all physical activities. In 1913 he was invited on a lecture tour to South America and wanted to use the occasion for undertaking a spectacular geographical exploration, to satisfy his spirit of adventure and his craving for the limelight. Aside from these motivations, he was all his life genuinely interested in natural science, geography, zoology and botany. He selected as his goal the River of Doubt, one of the tributaries of the Amazon River, whose origin and course had never been mapped. With the support of the Brazilian government he rashly organized an expedition which was supposed to last some six weeks, but took almost eight months.

Different versions of the adventure have been given, the most credible one by his son and faithful companion, Kermit. From the start the party was beset by bad luck and illness. One man was drowned; a second went berserk and killed a member of the party. The journey took much longer than expected. A third of the food supply was used up with only one-sixth of the distance covered. For forty-seven days they did not meet another human being. They lost part of their baggage and were left without clothes except what they wore, daily drenched by the tropical rains then steamed dry on their backs. Occasionally the rains kept up and they had to lie all night in their soaking-wet clothes.

Roosevelt developed a tropical fever resembling the malaria he had contracted fifteen years before in Cuba, resistant to quinine. One day, in his weakened condition, he jumped into the rapids to save two canoes from being smashed against the rocks. He was banged against a sharp stone and received a deep gash, on the same thigh he had injured eleven years before. The wound became infected, the leg started to swell and drain pus, either from a new or a reactivated infection of the thigh bone. A veritable plague of deep abscesses developed, probably from a spread of the infection through the blood stream, and was followed by symptoms of dysentery.

For days he lay in his boat, floating down river half dead in. the blazing sun. Fortunately, the toxins from the severe infection eased his torture by numbing his brain with the fog of delirium. To the surprise of his companions he survived and was carried on a stretcher out of the jungle, after the expedition had almost been given up as lost.

The damaged leg never healed. The suppuration of the bone recurred at intervals, with the separation of little sequesters of lead bone and the formation of draining fistulas which often had to be reopened when they closed up. In addition to his infected leg, the penetrating dampness of the jungle had aggravated Roosevelt’s chronic rheumatism. His only reward was the honor of having the River of Doubt named for him—the Rio Roosevelt.

In February 1918 the crippled Colonel contracted a severe throat infection that spread to both middle ears. He was taken to the Roosevelt Hospital (also named for him) in New York. The admitting diagnosis was “bilateral acute otitis media, inflammatory rheumatism, and abscess of the thigh.” The pain in. both ears was getting worse, the fever climbing, and it was necessary to pierce both ear drums to release the pus which had formed behind them. After ten days, the right ear was drying up, but the left ear continued discharging pus. X-ray pictures showed that the suppurative process had infiltrated the cavities of the mastoid bone behind the ear.

At that time, as today, the accepted treatment for mastoiditis with pus formation was surgical opening of the bone for better drainage. In Roosevelt’s case the physicians in charge did not perform this operation, with the consequence that the left ear continued running, without completely draining the pus, which was what gradually destroyed the middle ear. Thus at the age of sixty, Roosevelt was deaf in the left ear, in addition to being blind in the left eye.

There must have been some reason why the undoubtedly competent doctors did not advise simple mastoidectomy, the opening and direct drainage of the bone. They must have suspected that the rheumatic ailment of the patient was not rheumatoid arthritis, but recurrent rheumatic fever with silent involvement of the heart. Any major surgery under such conditions might have stirred up a progressive inflammation and destruction of the valves of the heart. The physicians preferred not to take such a risk and treated the running ear conservatively with gentle irrigations and instillations of weak antiseptic solutions.

As Roosevelt’s health improved, his old wanderlust awakened once more. He returned to his beloved Middle West. The unavoidable motion and friction of his chronically infected thigh during the journey brought on a severe infection of erysipelas, a type of streptococcus that spread through the subcutaneous tissue, producing a rose-colored swelling and blistering of the skin. Before the discovery of the sulfa drugs and antibiotics, it used to carry a considerable mortality by causing blood poisoning. Roosevelt recovered, however, to receive a few weeks later the crushing news that his youngest son, Quentin, serving in the Air Corps in France, had been shot down and killed shortly before Armistice.

Roosevelt’s grief aggravated the pain in his muscles and joints, which became so severe that he had to be readmitted to the hospital with the diagnosis of inflammatory rheumatism.

The current attack caused him more pain than ever before, particularly in his lower back and his legs. After a while his condition improved and he was discharged in time to celebrate Christmas with his family in his beloved refuge at Oyster Bay. For ten days he felt better and his old cheerfulness returned.

On January 5, 1919, he wrote an editorial for a newspaper, spent a comfortable day, went to bed at eleven o’clock. At four o’clock in the morning, an attendant who occupied an adjoining room noted that the Colonel was breathing strangely. He called the day nurse, but by the time she reached his bedside Roosevelt was dead. No postmortem was performed. The clinical impression of three doctors who had treated him was that death had come from a coronary occlusion by a blood clot. They believed that the patient’s recent attack of inflammatory rheumatism had not directly contributed to his death.

Chronologically, Roosevelt’s life lasted only some sixty years. By the tempo of his life it compressed within its span the experiences, activities and accomplishments of a score of lives of ordinary mortals.

Total
0
Shares
Comments 3
  1. Wow! That was a very descripted and well written article! It was full of useful information that lots of people my age (13) could find very helpful. However, I would like to ask of you, just two things. Could you specify the truth regarding the Theodore Roosevelt Polio rumor? Also, I would like for you to make it easier to get permission to print out this fabulous and informative collection of research. Thanks!

    And May The Force Be With You,

    Darlena McCullovich

    Admin: You don't need a permission to print the article, go ahead! =)

Leave a Reply

Your email address will not be published. Required fields are marked *