Paralytic illness of Franklin D. Roosevelt

Rare photograph of FDR in a wheelchair, with Ruthie Bie and Fala, taken by his cousin Margaret Suckley (February 1941)

Franklin D. Roosevelt's paralytic illness began in 1921, when the future President of the United States was 39 years of age. Roosevelt (FDR) was diagnosed with poliomyelitis at the time, but a peer-reviewed 2003 analysis found that Guillain–Barré syndrome - nearly unknown in the US in 1921 - was the most likely cause of his illness. FDR was left with permanent paralysis from the waist down, and was unable to stand or walk without support. In 1926, his belief in the benefits of hydrotherapy led him to found a rehabilitation center at Warm Springs, Georgia. FDR laboriously taught himself to walk short distances while wearing leg braces by swiveling his torso, supporting himself with a cane and gripping the arm of another person. The extent of his paralysis was kept from public view, as he avoided being seen using his wheelchair in public. However, his disability was well known before and during his Presidency and became a major part of his image. In 1938, he founded the National Foundation for Infantile Paralysis, leading to the development of polio vaccines.

History

The Roosevelt family at Campobello (1920)

Roosevelt supporting himself on crutches at Springwood in Hyde Park, New York, with visitors including Al Smith (August 7, 1924)

FDR and Eleanor Roosevelt at Hyde Park (September 16, 1927)

FDR at Warm Springs (1928)

FDR in his wheelchair aboard Vincent Astor's yacht, the Nourmahal (April 1935)

FDR in his wheelchair with a group assembling on the terrace of Springwood, before a Hudson River cruise on the USS Potomac (September 12, 1937)

In August 1921, 39-year-old Franklin D. Roosevelt, at the time a practicing lawyer in New York, joined his family at their vacation home at Campobello, a Canadian island off the coast of Maine. Several weeks before, his wife Eleanor had moved the household—including five children aged 5–15, a governess and her mother, and 40 to 50 trunks—to the remote island for the summer-long vacation. As he usually did, Roosevelt stayed behind until things got settled. As former Assistant Secretary of the Navy, he spent two weeks in Washington, D.C., giving testimony to a Senate committee investigating a Navy scandal in mid-July. On July 28 he fulfilled a commitment associated with his recently being elected president of the Greater New York Council of the Boy Scouts. On August 5, FDR sailed up the New England coast with his friend and new employer, Van Lear Black, on Black's ocean-going yacht. Among those at Campobello when Roosevelt arrived were his political aide Louis Howe, his wife and their young son.

Roosevelt spent a day talking business with Howe. Then, on August 10, he spent a day of strenuous activity with his family. Roosevelt soon exhibited an illness characterized by fever, ascending paralysis of the upper and lower extremities, facial paralysis, bowel and bladder dysfunction, and numbness and hypersensitivity of the skin. Most of the symptoms eventually resolved themselves, but he was left permanently paralyzed from the waist down.

Timeline

July 28

• FDR visited the Boy Scout Jamboree at Bear Mountain State Park.

July 29

• Roosevelt went to the family home at Hyde Park, New York, where he reviewed papers related to a Navy scandal. In the first days of August he returned to Manhattan. He prepared to join his family at their summer home—a large red cottage with 18 bedrooms and no electricity or telephone—at Campobello Island.

August 5–8

• Roosevelt traveled to Campobello on board the yacht Sabolo.

August 9

• Roosevelt fell into the cold waters of the Bay of Fundy. Later, arrives at Campobello.

August 10

• FDR, his wife Eleanor, their daughter Anna and sons James and Elliott spent the day on the family sailboat, the Vireo. On Cobscook Bay they went ashore on one of the islands and beat out a fire with pine boughs, then sailed back home. Roosevelt took his five children swimming at their favorite pond, then raced his sons the two miles back to their cottage. Afterward, Roosevelt complained of chills, nausea, and pain in his lower back. He skipped dinner and went to bed. Chills lasted through the night.

August 11

• In the morning, as Roosevelt got out of bed, his right knee felt weak and he was unable to walk it off. He later told Eleanor he could not go on a camping trip they had planned, and complained of stabbing pain in the back of his legs. His temperature was 102 °F. Eleanor stayed behind with the other adults and the two younger children, Franklin Jr. and John, and sent the older children on their camping trip. As their boat was being packed Eleanor asked the fisherman helping them to speak to the doctor in the nearby village of Lubec and ask him to visit Campobello.
• Dr. Eben H. Bennet, a general practitioner the Roosevelts had known for years, visited FDR and diagnosed a bad summer cold.
• By afternoon, Roosevelt's right knee would not support him when he tried to stand. By the evening his left knee was weakening.

August 12

• Both of Roosevelt's legs felt rubbery upon his waking in the morning. His skin had sensation, but his legs were sluggish. Pain shot through his legs, feet and back. He became desperately anxious.
• Bennet returned and according to Eleanor was "mystified" at FDR's symptoms. He suggested a consultation with Dr. William W. Keen, an eminent physician vacationing nearby. Fifteen years retired and 84 years of age, Keen was a revered surgeon who was on the faculty while Bennet was studying medicine. He was also known for his discretion in cases involving prominent people in public life. Telephoning from Bennet's office, Howe located Keen at Bar Harbor.
• 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. He was unable to tighten the muscles of his buttocks or abdomen. By evening he could not hold a pencil and his thumbs were affected.

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.
• Keen traveled by car to Lubec, where he was met by Howe and a boat that ferried them to Campobello around 7:30 p.m. In Roosevelt's second-floor bedroom, Keen made what Eleanor described as "a most careful, thorough examination", and the household went to bed.

August 14

• Roosevelt continued to be unable to pass urine for two weeks, and required catheterization. His fever continued for six to seven days.
• Keen repeated his examination, a bending and prodding that Elliott later termed "excruciating" for his father.
• Keen diagnosed a clot of blood to the lower spinal cord, and prescribed massage of the leg muscles. He attributed FDR's condition to the "chill and exposure" of August 9–10. In Roosevelt's presence he said the condition would be temporary, and that his ability to move the toes of one foot was a "very encouraging" sign that the clot was already being absorbed.
• Outside of Roosevelt's hearing, Keen told Eleanor that FDR may be paralyzed for months, that the clot might take a long time to be absorbed. Roosevelt would need to stay at Campobello for several weeks.
• Eleanor and Howe considered how much to tell those who must be informed of Roosevelt's illness. Letters she wrote to most family members repeated Bennet's vague diagnosis that FDR was "ill from the effects of a chill". She wrote a letter to James Roosevelt Roosevelt, FDR's older half-brother Rosy, and asked him to meet Sara Delano Roosevelt, FDR's mother, when she returned from Europe on August 31. If he were unable to meet her ship, Eleanor would ask Sara's brother, Frederic Adrian Delano, Roosevelt's favorite uncle. Eleanor would write a brief letter that could be given to Sara.
• Howe started answering Roosevelt's mail, choosing the same careful phrases that Eleanor used, and writing that FDR was under doctor's orders "not to so much as look at the postage stamp on a letter for some time."
• Eleanor and Howe began massaging Roosevelt's legs as instructed by Keen, bringing on agonizing pain.

August 15

• Howe wrote a long letter to Fred Delano. Although Howe's letter was subsequently lost, Delano's response clearly indicates that Howe provided a detailed recounting of events and expressed doubts about Keen's diagnosis. Some of the Roosevelt children showed symptoms similar to FDR's—chills and fever—that could not be due to blood clots, and Howe wanted another opinion. Howe himself was needed at Campobello and could not search for another doctor, so he asked for Delano's help. He also shared his suspicions about infantile paralysis, which he had not mentioned to Eleanor.
• Prostrate and mildly sedated, Roosevelt was occasionally delirious.

August 17

• Eleanor received a lengthy letter from Keen in which he reconsidered his diagnosis. He now concluded that Roosevelt's condition was probably not due to a blood clot, and instead believed it could be the result of an inflammation of the spinal cord. He projected that the recovery "might be a longer business", and enclosed a bill for the startling amount of $600.

August 19

• Delano received Howe's letter at his home in Washington, D.C. He called his son-in-law, a physician, who recommended he speak to another physician, a Dr. Parker. Parker told Delano that the case sounded like infantile paralysis, and that the leading authorities on the disease were at the Harvard Infantile Paralysis Commission, at Peter Bent Brigham Hospital in Boston. Delano caught a train and arrived the next morning.

August 20

• Dr. Samuel A. Levine was at his office when Delano telephoned Brigham Hospital on Saturday morning. Levine said the senior members of the Harvard Infantile Paralysis Commission were out of town, but he would try to answer Delano's questions. After reviewing the messages Delano had received from Campobello, Levine said Keen's diagnosis could be dismissed. In an unpublished manuscript, Levine later wrote that "it seemed to me that Mr. Roosevelt was suffering from acute poliomyelitis". He urged that a lumbar puncture be done that same day, with the goal of making a diagnosis, but mainly because Levine believed there could be acute benefit from the procedure.
• Eleanor was called to the village to take a telephone call from Delano, who told her about his meeting with Levine. It was then that Eleanor first learned that poliomyelitis was suspected. Delano wrote Eleanor a follow-up letter the same day, advising her to stop massaging Roosevelt's legs, and to disregard Keen's advice: "I think it would be very unwise to trust his diagnosis where the Inf. Paralysis can be determined by test of the spinal fluid."
• Eleanor communicated with Keen, who "very strenuously" resisted the idea of poliomyelitis. Keen contacted Dr. Robert Lovett, one of the directors of the Harvard Infantile Paralysis Commission, and asked him to visit Campobello.

August 22

• Lovett called Levine, a 30-year-old doctor who was one of his former students, and invited him to dinner at the Harvard Club. He tested him on how to distinguish whether paralysis was caused by poliomyelitis or by a clot or lesion of the spinal cord.

August 23

• Lovett left for Campobello.

August 24

• Lovett met Keen in Eastport, Maine, and interviewed him about the case. A boat took them to Campobello Island.
• Lovett saw Roosevelt and performed a "more or less superficial" examination since FDR was highly sensitive to touch. Nerves that regulated his breathing were unaffected. The arms were weak; the muscles of the abdomen were "pretty normal"; the bladder was paralyzed; the left thumb indicated atrophy but the limbs were not deformed. Roosevelt could not stand or walk, and Lovett documented "scattered weakness, most marked in the hips". Some muscles appeared to be recovering, with "a pretty fair degree of power after two weeks".

August 25

• 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.
• After a brief conference with Keen, Lovett saw Roosevelt. With Eleanor, Howe, Bennet and Keen present, Lovett informed him that the "physical findings" presented a "perfectly clear" diagnosis of poliomyelitis.
• Lovett ordered an end to massage, which had no benefit and caused pain, and recommended a trained nurse to care for FDR. He privately told Howe that any improvement in Roosevelt's condition "would be very slight unless he had the most extraordinary will and patience".
• Lovett assured Eleanor that if her children and Howe's son had been infected with the virus they had fought it off.
• Lovett recommended that Roosevelt rest at Campobello until mid-September, and enter a New York hospital for convalescence under the care of Dr. George Draper, an expert on poliomyelitis who was coincidentally FDR's own personal physician. Lovett would consult from Boston.

September 1

• FDR still unable to urinate. His leg pain continues.

September 14

• FDR was strapped into a makeshift stretcher and carried downstairs by six men, beginning a long and painful journey to New York. A launch took him over choppy waters to the railroad station at Eastport. A private railway car took him the 600 miles to Grand Central Station and a waiting ambulance.

September 15

• Roosevelt was admitted to Presbyterian Hospital, at Madison Avenue and 70th Street in New York City.
• 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.

October 28

• Roosevelt was transferred from Presbyterian Hospital to his house on East 65th Street. His chart still read "not improving".

Later

• Roosevelt's fever returned and his vision blurred, causing him to fear going blind. He exercised daily, probably to excess; his hamstrings tightened, and his legs were encased in plaster to straighten them by degrees.
• 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.

Diagnosis

The first symptoms of FDR's 1921 paralytic illness were on August 10, 1921. Franklin initially complained of "lumbago", intense fatigue, and chills.

After falling ill, he was seen by four doctors. The first, Eben Homer Bennet, the Roosevelt family doctor, diagnosed a heavy cold. The second, William Keen of Philadelphia, thought Roosevelt had a blood clot. A third doctor, Robert Lovett, believed that Roosevelt could make a full recovery. The last one, George Draper, FDR's personal physician, disagreed, and ultimately proved to be correct: FDR's legs remained paralyzed for the rest of his life.

FDR's physicians never mentioned GBS in their communications concerning FDR's case, indicating that they were not aware of it as a diagnostic possibility. In 1921, an American physician would assume that if an individual developed a sudden, non-traumatic flaccid paralysis, it was due to paralytic polio. All reports before 1921 of what we now call GBS, including Guillain's 1916 report, were by European physicians, in European journals. the result was that very few American physicians knew that GBS was a separate disease. For example, Lovett mistakenly believed that Landry’s ascending paralysis, now termed GBS, was one of the clinical presentations of paralytic polio. The concept of GBS as a separate disease was not widely accepted in the United States until after the Second World War.

Warm Springs

October 3, 1924 was the first time Roosevelt traveled to Warm Springs, Georgia and it soon became his home away from home. For many years to come Warm Springs would be where Franklin would retreat in comfort and do hydrotherapy for his legs. On April 29, 1926 he bought the center with the intention of making it into a rehabilitation center for polio patients. One of FDR's major goals was to get the American Orthopedic Association to endorse the resort, but he was rejected because there was no real progress in physical health. It is now the Roosevelt Warm Springs Institute for Rehabilitation, a comprehensive rehabilitation facility operated by the state of Georgia.

Governor and President

In 1929 Roosevelt was elected Governor of New York and moved into the Governor's Mansion in Albany. Before he could move in, the mansion underwent renovations due to Roosevelt's health. The mansion was made wheelchair friendly with ramps and an elevator.

Roosevelt won the Presidential election in 1932 in a landslide victory and become the first, and so far only, disabled person to be President of the United States. Before he moved into the White House, ramps were set everywhere in order to make it wheelchair friendly. To avoid the public, FDR addressed the country through radio, and when shown on newsreels he was standing on his own. Any pictures of the President were taken at certain angles and at a distance.

Personal impact

FDR at Warm Springs (1929)

Roosevelt was totally and permanently paralyzed from the waist down, and unable to stand or walk without support. For the next few months, he was confined to indoor pursuits, including resuming his lifelong hobby of stamp collecting. In December 1921, after he had recuperated for several months, a physiotherapist began working with him to determine the extent of the damage. In time he was able to perform small exercises on his own, moving one muscle and then another. He was fitted with heavy steel braces that locked at the knee and provided enough stability that he could stand with crutches. In 1922, at Springwood, he worked diligently to make his way across the room. He set himself the goal of getting down the long driveway, managing to do it once but never trying again.

In October 1922 Roosevelt visited his law office at the Equitable Building, where a welcome-back luncheon had been arranged, but the chauffeur assisting him failed to brace the tip of his left crutch and Roosevelt fell onto the highly polished lobby floor. Laughing, he asked two young men in the crowd of onlookers to help get him back on his feet. After the luncheon he told friends it was a "grand and glorious occasion", but he did not go back to his office for two months.

FDR believed that warmth and exercise would help rebuild his legs. He bought a run-down 71-foot houseboat, and in February 1923 he sailed to Florida with friends and a skeleton crew. Eleanor found it dull and left, but Roosevelt sailed for weeks, fishing and spending time with a succession of friends who came to visit. He designed a pulley system that lowered him into the water to swim. In May 1923 Lovett documented no overall improvement over the preceding year, but FDR would not accept his doctors' determination that further progress was unlikely. He tried a range of therapies, and made two more voyages on his houseboat, but his efforts had no effect.

"Between 1925 and 1928, Franklin would spend more than half his time—116 of 208 weeks—away from home, struggling to find a way to regain his feet," wrote biographer Geoffrey Ward. "Eleanor was with him just 4 of those 116 weeks, and his mother was with him for only 2. His children hardly saw him."

Roosevelt lost the use of his legs and two inches of height, but the subsequent development of the rest of his body gave him a robust physique and he enjoyed many years of excellent health. Jack Dempsey praised his upper-body musculature, and FDR once landed a 237-pound shark after fighting it on his line for two hours.

Social impact

FDR was the United States' first disabled president, so there has been discussion concerning how he handled his health. In Hugh Gallagher's book, FDR's Splendid Deception, he posits that FDR was desperate to appear normal. When discussing his limited use of a wheelchair in the public, Gallagher states, "This was not by accident. It was a strategy served to minimize the extent of his handicap, to make it unnoticed when possible and palatable when it was noticed.". Historian James Tobin also argues that FDR used his disability to his advantage. In his book, The Man He Became, Tobin states, "But he could, instead, show himself to be something he had never been seen as before: a fighter and, and better yet, an underdog; not a man to pity, not a man to envy, but a man to cheer." Despite any controversy, he has become an inspirational figure for disabled people around the world.

Public awareness

FDR used crutches when nominating Al Smith at the 1924 Democratic National Convention, the speech that marked his return to public life (June 26, 1924)

"No movies of me getting out of the machine, boys": FDR exiting a car during a campaign trip to Hollywood, California (September 24, 1932)

Photograph by Margaret Suckley showing FDR walking with assistance toward the dedication ceremony for the home of Woodrow Wilson (May 4, 1941)

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 only to go from one place to another. 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 on 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.

With his physiotherapist at Warm Springs, Roosevelt laboriously taught himself to walk short distances while wearing iron braces on his hips and legs, by swiveling his torso. For this "two-point walk", seen in a few rare films and photographs, he would grip the arm of a strong person with his left hand, and brace himself with a cane in his right. He would heave one stiff leg forward, from the hip, and then the other. He exhibited the walk for the first time when he addressed the 1928 Democratic National Convention—with such success that he was pressed to run for governor of New York. FDR's walk was slow and seemingly natural, but the endeavor was always risky since he could easily fall.

Roosevelt was very rarely photographed while sitting in his wheelchair, and his public appearances were choreographed to avoid the press covering his arrival and departure at public events, which would have shown him getting into 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. 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. Track 61, a private rail siding underneath the Waldorf Astoria, was also used. When Roosevelt's trains used a ramp and the president was on a publicly known trip, he insisted on walking on the ramp no matter how difficult. In 1940 an elevator was installed.

When Roosevelt addressed the Congress in person on March 1, 1945, about a month before his death, he made public reference to his disability for almost the first time in 20 years. "I hope that you will pardon me for this unusual posture of sitting down," FDR began, "but I know you will realize that it makes it a lot easier for me not to have to carry about ten pounds of steel around on the bottom of my legs."

Journalist John Gunther reported that in the 1930s he often met people in Europe, including world leaders, who were unaware of FDR's paralysis. However, Winston Churchill wrote in his memoirs that he "wheeled him in his chair from the drawing-room to the lift as a mark of respect, thinking also of Sir Walter Raleigh spreading his cloak before Queen Elizabeth."

David Brinkley, who was a young White House reporter in World War II, stated that the Secret Service actively interfered with photographers who tried to take pictures of Roosevelt in a wheelchair or being moved about by others. The Secret Service commonly destroyed photographs they caught being taken in this manner; however, there were occasional exceptions.

The Roosevelt Memorial in Washington D.C includes a statue of FDR in a wheel chair, although many believed that FDR should not have been displayed as a disabled person because it would ruin the image the country had of him.

Legacy

FDR accepts a $1 million check, the proceeds of the first national President's Birthday Ball to benefit the work of the Georgia Warm Springs Foundation (1934)

FDR with Basil O'Connor (1944)

March of Dimes

Main article: March of Dimes

On January 3, 1938, Roosevelt founded the National Foundation for Infantile Paralysis, now known as the March of Dimes. Reconstituted from the Georgia Warm Springs Foundation he founded in 1927, it was an alliance between scientists and volunteers, with volunteers raising money to support research and education efforts. Basil O'Connor, an attorney and close associate of Roosevelt, helped establish the foundation and was its president for more than three decades. The organization 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 March of Dimes focuses on preventing premature birth, birth defects and infant mortality.

The organization's annual fundraising campaign coincided with FDR's birthday on January 30. Because he founded the March of Dimes, a dime was chosen to honor Roosevelt after his death. The Roosevelt dime was issued in 1946, on what would have been the president's 64th birthday.

Roosevelt Warm Springs Institute for Rehabilitation

Main article: Warm Springs Historic District

Roosevelt's center at Warm Springs operates today as the Roosevelt Warm Springs Institute for Rehabilitation, a comprehensive rehabilitation facility operated by the state of Georgia. A center for post-polio treatment, it provides vocational rehabilitation, long-term acute care, and inpatient rehabilitation for amputees and people recovering from spinal cord injuries, brain damage and stroke.

Retrospective diagnosis

A 2003 peer-reviewed study of Roosevelt's paralytic illness, using pattern matching, reconstructing the pathogenesis, and Bayesian analysis, found that six of eight posterior probabilities favored a diagnosis of Guillain–Barré syndrome (GBS) over poliomyelitis. For the purposes of the analysis, a best estimate of the annual incidence of GBS was 1.3 per 100,000. For paralytic polio in Roosevelt's age group, an annual incidence of 1.0 per 100,000 was used. The paralytic polio rate was derived from the exceptionally severe polio epidemic that struck New York City in 1916, to give paralytic polio "the best chance to succeed". The prior probability of paralytic polio in FDR’s age group in the United States in 1921 was likely much lower, because paralytic polio was at one of its lowest ebbs in the Northeastern region of the country at that time. In July 1921, three cases were reported in New Jersey. By late August some 100 cases were reported in the state of New York. Based on the incidence rates for GBS and paralytic polio, and symptom probabilities from the medical literature, FDR's symptoms were analyzed by Bayesian analysis.

Six of eight symptoms favored GBS, with posterior probability of GBS shown for each:

1. 98% - FDR’s paralysis was symmetric and ascending, and progressed more than four days, whereas the paralysis in poliomyelitis is typically asymmetric, variable in its ascent or descent, and usually progresses for only two to four days. A review of the medical research literature revealed only one report of paralytic polio with a symmetric, ascending paralysis.
2. 97% - Facial paralysis, as FDR had, in the absence of other cranial nerve abnormalities, is not consistent with a polio diagnosis, but is common in GBS.
3. 93% - Prolonged bladder/bowel dysfunction: FDR had prolonged decreased motility of the smooth muscles of the bladder and of the lower intestinal tract. Such protracted autonomic nervous system abnormalities are rare in paralytic polio, since polioviruses do not attack autonomic nerves.
4. 98% - Numbness / hyperesthesia: FDR experienced a brief loss of pain and touch (partial anesthesia) in his lower extremities. Immediately after, he endured severe, protracted pain to the slightest touch (hyperesthesia) in his lower extremities. Sensory abnormalities rarely if ever occur in paralytic polio (solely affects motor neurons), but are common in GBS (sensory neurons also affected).
5. 93% - Meningismus (neck stiffness), a characteristic feature of paralytic polio, was absent in FDR’s case.
6. 98% - A consistent descending pattern of recovery from paralysis is absent in paralytic polio, but common in GBS.

Two of eight symptoms were in favor of polio, with posterior probability of polio shown for each:

1. 99% - FDR had fever up to 102 °F, which is rare in GBS, although the pattern of the fever that FDR experienced was atypical of paralytic polio.
2. 72% - FDR had permanent paralysis which occurs in about 50% of polio survivors, and only about 15% of cases of GBS.

Using all eight symptoms in a Bayesian analysis, based on disease incidence rates and symptom probabilities from the medical literature, the overall probability that FDR had GBS is over 99%.

It is possible FDR was exposed to an infectious agent at the Boy Scout Jamboree in late July. However, the two-week interval before the onset of his neurological illness was in keeping with both the incubation period of poliomyelitis, and with exposure to an infectious agent leading to GBS. There are no reports that any scouts or personnel at the camp were ill around the time of FDR’s visit. However, in 1912 and 1915, FDR had illnesses compatible with Campylobacter jejuni, a major causative agent of GBS.

Several authors have stated that FDR was especially vulnerable to polio since he was raised on an isolated family estate and had little contact with other children until he entered Groton at age 14. However, FDR was not a "boy in a bubble". He had many possible exposures to polioviruses before 1921. Most polio cases are asymptomatic or a mild illness. Yet those asymptomatic individuals are able to transmit the viral infection. When the prior probability of polio was artificially adjusted 100-fold (to 99.4%) to favor polio, overall Bayesian analysis of FDR's symptoms still greatly favored GBS (99.97% posterior probability). FDR’s symptoms are typical of GBS, not of paralytic polio, so they overwhelm the initial prior probability.

In 2014, historian James Tobin argued that a lumbar puncture was done, based on excerpts from an "unpublished note" by Dr. Samuel A. Levine of the Harvard Infantile Paralysis Commission. Tobin was not able to print or release the note. Tobin wrote that "Levine's private note indicates that Dr. Lovett did examine the cerebrospinal fluid and knew very well that a high level of white blood cells was consistent with poliomyelitis. . . . If Lovett had discovered a low white blood cell count, he would have doubted that poliomyelitis was the cause of FDR's illness. Yet Lovett wrote George Draper that "I thought [the diagnosis] was perfectly clear as far as the physical findings were concerned.""

In 2017, the full "unpublished note" was published. Based on the full text, the note was not found to support the idea that a spinal tap was performed, because: 1) The note, written many years after 1921, had many errors. 2) Levine never saw FDR. 3) Levine did not mention who did the procedure, or the results. 5) Lovett had made it clear he would not do the procedure. 6) None of FDR's physicians at Campobello were equipped to do the procedure. 7) "Physical findings" means information gained from a physical examination of the patient. Lovett described many "physical findings": hyperesthesia, facial paralysis, etc. But neither he, any of FDR's other physicians at Campobello, FDR, Eleanor, nor any of FDR's associates ever said that a spinal tap was done.

The book went on to say: "Given the invasive nature of a spinal tap, and the difficulty that would have occurred doing the procedure on a patient in FDR’s condition, it seems highly unlikely that a direct observer would have failed to mention anything about it. . . . Even if a spinal tap had been performed, it would have been done at the earliest about 15 days after the onset of the neurological illness, around when Lovett first saw FDR. . . . One should keep in mind that the classical distinction between paralytic polio and GBS, the concentrations of leukocytes and total protein in CSF, blurs after the first several days of the onset of paralysis in both diseases."

"In any event, there was no cure for either disease in 1921," wrote biographer Jonathan Alter. However, Dr. Samuel Levine, who first made a polio diagnosis in FDR's case, mistakenly thought that the main benefit of a spinal tap, if done, would be to improve the outcome by lowering elevated CSF pressure. And even today, some authors mistakenly believe that FDR's paralysis, assuming a polio diagnosis, could have been prevented with early intervention. However, there is no objective evidence that a spinal tap lessens the possibility of paralysis in polio. And it unlikely FDR's physicians would have tried human serum injections into the CSF, or that it would have helped. Lovett did not think the injections were useful, and there were alarming meningeal symptoms associated with the injections, probably secondary to the formation of antigen-antibody complexes. Concerning GBS, virtually all of the effective measures that are currently standard practice for the medical management of GBS were not developed until many decades after FDR's 1921 illness, so FDR's prognosis would not have improved even if GBS had been diagnosed.

See also

• Polio Hall of Fame
• Sunrise at Campobello (1958 play)
• Sunrise at Campobello (1960)
• Eleanor and Franklin (1976)
• Eleanor and Franklin: The White House Years (1977)
• Warm Springs (2005)