Franklin D. Roosevelt's paralytic illness
Encyclopedia
Franklin D. Roosevelt's paralytic illness began in 1921 at age 39, when Roosevelt
Franklin D. Roosevelt
Franklin Delano Roosevelt , also known by his initials, FDR, was the 32nd President of the United States and a central figure in world events during the mid-20th century, leading the United States during a time of worldwide economic crisis and world war...

 got a fever after exercising heavily at a vacation in Canada. While his bout with illness was well known during his terms as President of the United States
President of the United States
The President of the United States of America is the head of state and head of government of the United States. The president leads the executive branch of the federal government and is the commander-in-chief of the United States Armed Forces....

, the extent of his paralysis was kept from public view. After his death, his illness and paralysis became a major part of his image. He was diagnosed with poliomyelitis
Poliomyelitis
Poliomyelitis, often called polio or infantile paralysis, is an acute viral infectious disease spread from person to person, primarily via the fecal-oral route...

 two weeks after he fell ill. However, a 2003 retrospective
Retrospective diagnosis
A retrospective diagnosis is the practice of identifying an illness in a historical figure using modern knowledge, methods and disease classifications...

 study favored a diagnosis of Guillain-Barré syndrome
Guillain-Barré syndrome
Guillain–Barré syndrome , sometimes called Landry's paralysis, is an acute inflammatory demyelinating polyneuropathy , a disorder affecting the peripheral nervous system. Ascending paralysis, weakness beginning in the feet and hands and migrating towards the trunk, is the most typical symptom...

.

Timeline and history of illness

In August 1921, at the age of 39, while vacationing at Campobello Island in Canada
Canada
Canada is a North American country consisting of ten provinces and three territories. Located in the northern part of the continent, it extends from the Atlantic Ocean in the east to the Pacific Ocean in the west, and northward into the Arctic Ocean...

, Roosevelt contracted an illness characterized by fever
Fever
Fever is a common medical sign characterized by an elevation of temperature above the normal range of due to an increase in the body temperature regulatory set-point. This increase in set-point triggers increased muscle tone and shivering.As a person's temperature increases, there is, in...

; protracted symmetric, ascending paralysis
Ascending paralysis
Ascending paralysis refers to a form of paralysis where the presentation appears in the lower limbs before the upper limbs.It can be associated with:* Guillain–Barré syndrome *Tick paralysis...

 of the upper and lower extremities; facial paralysis; bladder
Urinary bladder
The urinary bladder is the organ that collects urine excreted by the kidneys before disposal by urination. A hollow muscular, and distensible organ, the bladder sits on the pelvic floor...

 and bowel dysfunction; numbness; and dysesthesia
Dysesthesia
Dysesthesia comes from the Greek word "dys", meaning "not-normal" and "aesthesis", which means "sensation" . It is defined as an unpleasant, abnormal sense of touch, and it may be, or not be, considered as a kind of pain...

. The symptoms gradually resolved except for paralysis of the lower extremities.

August 9
  • Roosevelt fell into the cold waters of the Bay of Fundy
    Bay of Fundy
    The Bay of Fundy is a bay on the Atlantic coast of North America, on the northeast end of the Gulf of Maine between the Canadian provinces of New Brunswick and Nova Scotia, with a small portion touching the U.S. state of Maine...

     while boating.


August 10
  • Roosevelt went sailing on the Bay of Fundy with his three oldest children, put out a fire, jogged across Campobello Island, and swam in Lake Glen Severn and the Bay. Afterward, he felt tired, complained of a "slight case of lumbago
    Low back pain
    Low back pain or lumbago is a common musculoskeletal disorder affecting 80% of people at some point in their lives. In the United States it is the most common cause of job-related disability, a leading contributor to missed work, and the second most common neurological ailment — only headache is...

    ", and had chills. He retired early. Chills lasted through the night.


August 11
  • One leg was weak. By afternoon, it was paralyzed. That evening, the other leg began to weaken. E.H. Bennet, the local family physician, was called that evening and diagnosed a cold.


August 12
  • Roosevelt could not stand. He had bilateral paralysis
    Paralysis
    Paralysis is loss of muscle function for one or more muscles. Paralysis can be accompanied by a loss of feeling in the affected area if there is sensory damage as well as motor. A study conducted by the Christopher & Dana Reeve Foundation, suggests that about 1 in 50 people have been diagnosed...

    . His legs were numb. He also had painful sensitivity to touch, general aches, and fever of 102°F. He could not pass urine. Bennet reevaluated Roosevelt and suggested a consultation with William W. Keen
    William Williams Keen
    William Williams Keen was the first brain surgeon in the United States. He also saw Franklin Delano Roosevelt when his paralytic illness struck, and worked closely with six American presidents.-Biography:...

    , an eminent physician vacationing nearby.


August 13
  • He was paralyzed from the chest down. On that day and following, his hands, arms, and shoulders were weak. He had difficulty moving his bowels and required enema
    Enema
    An enema is the procedure of introducing liquids into the rectum and colon via the anus. The increasing volume of the liquid causes rapid expansion of the lower intestinal tract, often resulting in very uncomfortable bloating, cramping, powerful peristalsis, a feeling of extreme urgency and...

    s.


August 14
  • Keen diagnosed a clot of blood to the lower spinal cord, prescribed massage of the leg muscles, and predicted a gradual improvement over a period of months. Roosevelt continued to be unable to pass urine for two weeks, and required catheter
    Catheter
    In medicine, a catheter is a tube that can be inserted into a body cavity, duct, or vessel. Catheters thereby allow drainage, administration of fluids or gases, or access by surgical instruments. The process of inserting a catheter is catheterization...

    ization. His fever continued for six to seven days.


August 18
  • Roosevelt was briefly delirious. Keen reconsidered his diagnosis and now believed that the cause was possibly a lesion
    Lesion
    A lesion is any abnormality in the tissue of an organism , usually caused by disease or trauma. Lesion is derived from the Latin word laesio which means injury.- Types :...

     in the spinal cord.


August 25
  • On examination by physician Robert Lovett, Roosevelt's temperature was 100°F. Both legs were paralyzed. His back muscles were weak. There was also weakness of the face and left hand. Pain in the legs and inability to urinate continued. Lovett and Bennet concluded that the diagnosis was poliomyelitis.


Mid-September
  • In mid-September, at New York City Presbyterian Hospital, there was pain in the legs, paralysis of the legs, muscle wasting in the lower lumbar
    Lumbar
    In tetrapod anatomy, lumbar is an adjective that means of or pertaining to the abdominal segment of the torso, between the diaphragm and the sacrum ...

     area and the buttocks, weakness of the right triceps, and gross twitching of muscles of both forearms.


Later
  • There was gradual recovery from facial paralysis, weakness in upper extremities and trunk, inability to urinate, inability to defecate, dysesthesia
    Dysesthesia
    Dysesthesia comes from the Greek word "dys", meaning "not-normal" and "aesthesis", which means "sensation" . It is defined as an unpleasant, abnormal sense of touch, and it may be, or not be, considered as a kind of pain...

     in legs, and weakness in lower back and abdomen. But he mostly remained paralyzed from the waist down, and the buttocks were weak.

Possible causes

The unquestioned diagnosis at the time and thereafter in countless references was paralytic poliomyelitis, which was understandable because polio was epidemic
Epidemic
In epidemiology, an epidemic , occurs when new cases of a certain disease, in a given human population, and during a given period, substantially exceed what is expected based on recent experience...

 in the adjoining northeastern United States during the late nineteenth and early twentieth centuries, and because one of the foremost polio experts in the world, Dr. Lovett, made the diagnosis based on personal observations of the patient. Also, the disease struck in mid-summer, when poliomyelitis was more common. Furthermore, it has been reported that motor neurons innervating muscles vigorously exercised at the start of polio are those more likely to be paralyzed. Finally, fever usually occurs in polio.

However, Roosevelt's age (39 years) and many features of the illness are more consistent with a diagnosis of Guillain-Barré syndrome (an autoimmune peripheral neuropathy
Peripheral neuropathy
Peripheral neuropathy is the term for damage to nerves of the peripheral nervous system, which may be caused either by diseases of or trauma to the nerve or the side-effects of systemic illness....

). During the early twentieth century, almost all cases of paralytic polio were in children, and few adults over 30 years contracted the disease, having acquired immunity during childhood. Paralytic polio is rarely symmetric or ascending. The paralysis in polio usually progresses for only three to five days. In paralytic polio, the fever usually precedes the paralysis. Meningismus is common in paralytic polio. The studies suggesting a link between exercise and paralytic polio are subject to recall bias
Recall bias
In psychology, recall bias is a type of systematic bias which occurs when the way a survey respondent answers a question is affected not just by the correct answer, but also by the respondent's memory. This can affect the results of the survey. As a hypothetical example, suppose that a survey in...

. In contrast, every neurological feature of Roosevelt's illness was consistent with Guillain-Barré syndrome. Fever is found in some cases, and about 15% of severe cases have permanent neurological sequelae.

Roosevelt's principal physicians during his illness, Robert Lovett and George Draper, were experts in polio. It is possible that the diagnosis of Guillain-Barré syndrome was not on their minds, since the disease was not as well known at the time. In 1916, Georges Guillain
Georges Guillain
Georges Charles Guillain was a French neurologist born in Rouen.He studied medicine in Rouen and Paris, where he learned clinical education at several hospitals. He developed an interest in neurology, and his first important scientific work involved lesions of the plexus brachialis...

 and Jean Alexandre Barré
Jean Alexandre Barré
Jean Alexandre Barré , French neurologist, worked in 1916 on the identification of the Guillain-Barré syndrome....

 described the cerebrospinal fluid
Cerebrospinal fluid
Cerebrospinal fluid , Liquor cerebrospinalis, is a clear, colorless, bodily fluid, that occupies the subarachnoid space and the ventricular system around and inside the brain and spinal cord...

 finding in two soldiers with ascending paralysis, loss of deep tendon reflexes, paraesthesia, and pain on deep palpation of large muscles.

A peer-reviewed study published in 2003, using Bayesian analysis, found that six of eight posterior probabilities favored a diagnosis of Guillain-Barré syndrome over poliomyelitis. For the purposes of the Bayesian analysis in the 2003 study, a best estimate of the annual incidence
Incidence (epidemiology)
Incidence is a measure of the risk of developing some new condition within a specified period of time. Although sometimes loosely expressed simply as the number of new cases during some time period, it is better expressed as a proportion or a rate with a denominator.Incidence proportion is the...

 of Guillain-Barré syndrome was 1.3 per 100,000. For paralytic poliomyelitis in Roosevelt's age group, the best estimate of the annual incidence
Incidence (epidemiology)
Incidence is a measure of the risk of developing some new condition within a specified period of time. Although sometimes loosely expressed simply as the number of new cases during some time period, it is better expressed as a proportion or a rate with a denominator.Incidence proportion is the...

 was 2.3 per 100,000.

Based on the incidence
Incidence (epidemiology)
Incidence is a measure of the risk of developing some new condition within a specified period of time. Although sometimes loosely expressed simply as the number of new cases during some time period, it is better expressed as a proportion or a rate with a denominator.Incidence proportion is the...

 rates for Guillain-Barré syndrome and paralytic polio, and the symptom probabilities for eight key symptoms in Roosevelt's paralytic illness, six of the eight key symptoms favored Guillain-Barré syndrome:
  1. Ascending paralysis for 10–13 days
  2. Facial paralysis
  3. Bladder / bowel dysfunction for 14 days
  4. Numbness / dysesthesia
    Dysesthesia
    Dysesthesia comes from the Greek word "dys", meaning "not-normal" and "aesthesis", which means "sensation" . It is defined as an unpleasant, abnormal sense of touch, and it may be, or not be, considered as a kind of pain...

  5. Lack of meningismus
  6. Descending recovery from paralysis


Two of the eight key symptoms favored polio:
  1. Fever
  2. Permanent paralysis


Exact disease incidences and symptom probabilities are not known. When disease incidences were artificially changed in favor of polio to values that were still somewhat realistic, six of eight key symptoms still favored Guillain-Barré syndrome. The only symptom that was somewhat sensitive to changes in symptom probabilities was fever. However, the reasonable change in the symptom probabilities caused the presence of fever to favor Guillain-Barré syndrome. Indeed, two thirds of GBS cases are triggered by an infection. Therefore it is not unresonable to expect that a fever would be present with the onset of GBS. With respect to permanent paralysis, most GBS patients, up to 75%, reach a full recovery. But as many as 15% incur long term disability, such as permanent paralysis. Thus both fever and permanent paralysis do not rule out GBS as FDR's diagnosis. Indeed they are compatible with a disgnosis of GBS.
Furthermore, in polio, the virus attacks only motor nerves but sensory nerves are not injured. In contrast, pain and other sensory changes (dysesthesias) are common in GBS, reflecting sensory nerve damage. Given that FDR experienced pain and other sensation issues, such as numbness, those symptoms are not compatible with polio. They do support a diagnosis of GBS.

A key finding in GBS is elevated spine fluid protein without a concommitent increase in cells. Unfortunately, Roosevelt's cerebrospinal fluid
Cerebrospinal fluid
Cerebrospinal fluid , Liquor cerebrospinalis, is a clear, colorless, bodily fluid, that occupies the subarachnoid space and the ventricular system around and inside the brain and spinal cord...

 was never examined. The number of leukocytes is increased and concentration of protein is usually normal in the cerebrospinal fluid of patients with polio. The converse occurs in Guillain-Barré syndrome.. Information on FDR's spinal fluid is not available. Nevertheless, other aspects of his illness (the ascending pattern of paralysis, facial weakness, etc.) support GBS as his diagnosis.

Furthermore, it remained unclear where exactly F.D. Roosevelt could have contracted the polio virus. According to J.D. Wilson in his 1963 monograph on polio vaccination, Margin of Safety, there had been a small epidemic in New York that year with several hundred cases, but no case occurring on or near Campobello Island.

Personal impact

Regardless of the cause, the result was that Roosevelt was totally and permanently paralyzed from the waist down. Fitting his hips and legs with iron braces, he laboriously taught himself to walk a short distance by swiveling his torso while supporting himself with a cane. Despite the lack of a cure for paralysis, for the rest of his life Roosevelt refused to accept that he was permanently paralyzed. He tried a wide range of therapies, but none had any effect. Nevertheless, he became convinced of the benefits of hydrotherapy
Hydrotherapy
Hydrotherapy, formerly called hydropathy, involves the use of water for pain-relief and treating illness. The term hydrotherapy itself is synonymous with the term water cure as it was originally marketed by practitioners and promoters in the 19th century...

, and in 1926 he bought a resort at Warm Springs, Georgia
Warm Springs, Georgia
Warm Springs is a city in Meriwether County, Georgia, United States. The population was 478 at the 2010 census.-History:Warm Springs first came to prominence in the 19th century as a spa town, due to its mineral springs which flow constantly at nearly 32 °C...

, where he founded a hydrotherapy center for the treatment of polio patients which still operates as the Roosevelt Warm Springs Institute for Rehabilitation, with an expanded mission.

Charitable legacy

After he became President, he helped to found the National Foundation for Infantile Paralysis, now known as the March of Dimes
March of Dimes
The March of Dimes Foundation is a United States nonprofit organization that works to improve the health of mothers and babies.-Organization:...

. The March of Dimes initially focused on the rehabilitation of victims of paralytic polio, and supported the work of Jonas Salk
Jonas Salk
Jonas Edward Salk was an American medical researcher and virologist, best known for his discovery and development of the first safe and effective polio vaccine. He was born in New York City to parents from Ashkenazi Jewish Russian immigrant families...

 and others that led to the development of polio vaccines. Today, the Foundation focuses on preventing premature birth, birth defects and infant mortality.

Roosevelt's association with the March of Dimes led to his image being placed on the face of the American dime
Dime (United States coin)
The dime is a coin 10 cents, one tenth of a United States dollar, labeled formally as "one dime". The denomination was first authorized by the Coinage Act of 1792. The dime is the smallest in diameter and is the thinnest of all U.S...

.

Public awareness of FDR's disability

Roosevelt was able to convince many people that he was in fact getting better, which he believed was essential if he was to run for public office again. In private he used a wheelchair. But he was careful never to be seen in it in public, although he sometimes appeared on crutches. He usually appeared in public standing upright, while being supported on one side by an aide or one of his sons. For major speaking occasions an especially solid lectern was placed on the stage so that he could support himself from it; as a result, in films of his speeches Roosevelt can be observed using his head to make gestures, because his hands were usually gripping the lectern. He would occasionally raise one hand to gesture, but his other hand held the lectern.

Roosevelt was very rarely photographed while sitting in his wheelchair, and his public appearances were choreographed in such a way as to avoid having the press cover his arrival and departure at public events which would have involved his having to get in or out of a car. When possible, his limousine was driven into a building’s parking garage for his arrivals and departures. On other occasions, his limo would be driven onto a ramp to avoid steps, which Roosevelt was unable to ascend. When that was not practical, the steps would be covered with a ramp with railings, with Roosevelt using his arms to pull himself upward. Likewise, when traveling by train as he often did, Roosevelt often appeared on the rear platform of the presidential railroad car the Ferdinand Magellan
Ferdinand Magellan Railcar
Named after the Portuguese explorer, the Ferdinand Magellan is a former Pullman Company observation car which served as Presidential Rail Car, U.S. Number 1 from 1943 until 1958. The Gold Coast Railroad Museum in Miami-Dade County, Florida acquired it in 1959...

. When he boarded or disembarked, the private car was sometimes shunted to an area of the railroad yard away from the public for reasons of security and privacy. A private rail siding underneath the Waldorf Astoria
Waldorf-Astoria Hotel
The Waldorf-Astoria is a luxury hotel in New York. It has been housed in two historic landmark buildings in New York City. The first, designed by architect Henry J. Hardenbergh, was on the Fifth Avenue site of the Empire State Building. The present building at 301 Park Avenue in Manhattan is a...

 was also used.

In keeping with social customs of the time, the media generally treated Roosevelt's disability as taboo. News stories did not mention it, and editorial cartoonists, favorable and unfavorable, often showed the president with normal mobility. According to famed broadcaster David Brinkley
David Brinkley
David McClure Brinkley was an American newscaster for NBC and ABC in a career lasting from 1943 to 1997....

, who was a young White House reporter in World War II, the Secret Service actively interfered with photographers who tried to take pictures of Roosevelt in a wheelchair or being moved about by others. However, there were occasional exceptions.

See also

  • Polio Hall of Fame
    Polio Hall of Fame
    The Polio Hall of Fame consists of a linear grouping of sculptured busts of fifteen scientists and two laymen who made important contributions to the knowledge and treatment of poliomyelitis...

  • Sunrise at Campobello
    Sunrise at Campobello
    Sunrise at Campobello is a 1960 American biographical film made by Dore Schary Productions and Warner Bros. It tells the story of the initial struggle by future President of the United States Franklin Delano Roosevelt and his family when he was stricken with paralysis at the age of 39 in August...

  • Warm Springs
    Warm Springs (film)
    Warm Springs is a 2005 television film about American President Franklin D. Roosevelt's struggle with polio, his discovery of the Warm Springs, Georgia spa resort and his work to turn it into a center for the aid of polio victims, and his resumption of his political career...

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