Franklin D. Roosevelt's paralytic illness

One of only a few known photographs of Roosevelt in a wheelchair

Franklin D. Roosevelt's paralytic illness began in 1921 at age 39, when Roosevelt got a fever after exercising heavily during a vacation in Canada. While his bout with illness was well known during his terms as President of the United States, 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 two weeks after he fell ill. However, a 2003 retrospective study favored a diagnosis of Guillain-Barré syndrome.

Timeline and history of illness

In August 1921, at the age of 39, while vacationing at Campobello Island in Canada, Roosevelt contracted an illness characterized by fever; protracted symmetric, ascending paralysis of the upper and lower extremities; facial paralysis; bladder and bowel dysfunction; numbness; and dysesthesia. The symptoms gradually resolved except for paralysis of the lower extremities.

August 9

• Roosevelt fell into the cold waters of the Bay of Fundy 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", 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. 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, an eminent physician vacationing nearby.

August 13

• Roosevelt 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 enemas.

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 catheterization. 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 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 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 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 in the adjoining northeastern United States during the late 19th and early 20th 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). During the early 20th 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. 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 and Jean Alexandre Barré described the cerebrospinal fluid 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 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 was 2.3 per 100,000.

Based on the incidence 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
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 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 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 cases were reported on or near Campobello Island.

Personal impact

Roosevelt's stateroom aboard USS Iowa replaced the shower with a bathtub in consideration of his condition.

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, and in 1926 he bought a resort at Warm Springs, Georgia, 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. The March of Dimes initially focused on the rehabilitation of victims of paralytic polio, and supported the work of Jonas Salk 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.

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. 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 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, 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
• Sunrise at Campobello
• Warm Springs