Franklin D. Roosevelt's paralytic illness

.cite journal
author=Ditunno JF, Herbison GJ
title=Franklin D. Roosevelt: diagnosis, clinical course, and rehabilitation from poliomyelitis
journal=Am J Phys Med Rehabil
volume=81
issue=8
pages=557–66
year=2002
pmid=12172063
doi=] However, one retrospective study concludes that he more likely had Guillain-Barré syndrome.

Timeline and history of illness

In August 1921, 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" [Gallagher, HS, "FDR's Splendid Deception", New York, Dodd, Mead (1985)] , and had chills. He retired early. Chills lasted through the night.

;August 11

* One leg was weak. By the afternoon, it was paralyzed. That evening, the other leg began to weaken.

;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.

;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 enemas. He continued unable to pass urine for two weeks, and required catheterization. His fever continued for six to seven days. On August 18th, he was briefly delirious.

;Late August

* 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.

;Mid-September

* In mid-September, at New York City Presbyterian Hospital, there was pain in the legs, paralysis of the legs, muscle wasting in 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 nineteenth and early twentieth centuries. 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.cite journal
author=Horstmann DM
title=Acute poliomyelitis relation of physical activity at the time of onset to the course of the disease
journal=J Am Med Assoc
volume=142
issue=4
pages=236–41
year=1950
pmid=15400610
doi=
accessdate=2008-03-02]

Yet his 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 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. In contrast, every neurologic 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.cite journal
author=Goldman AS, Schmalstieg EJ, Freeman DH, Goldman DA, Schmalstieg FC
title=What was the cause of Franklin Delano Roosevelt's paralytic illness?
journal=J Med Biogr
volume=11
issue=4
pages=232–40
year=2003
pmid=14562158
url=http://www.rsmpress.co.uk/jmb_2003_v11_p232-240.pdf
doi=
accessdate=2008-03-02]

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:
# Ascending paralysis for 10–13 days
# Facial paralysis
# Bladder / bowel dysfunction for 14 days
# Numbness / dysesthesia
# Lack of meningismus
# Descending recovery from paralysis

Two of the eight key symptoms favored polio:
# Fever
# 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. 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.

The cause of Roosevelt's paralysis may never be determined with certainty. However, this one study supports a diagnosis of Guillain-Barré syndrome. Other experts are skeptical of the study's conclusion.cite journal
author=Lerner BH
title=Crafting medical history: revisiting the "definitive" account of Franklin D. Roosevelt's terminal illness
journal=Bull Hist Med
volume=81
issue=2
pages=386–406
year=2007
pmid=17844721
doi=
url=
accessdate=2008-03-02]

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. Although the paralysis had no cure at the time, 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 Dr. Jonas Salk and others that led to the development 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. [cite web|url=http://www.usmint.gov/mint_programs/circulatingcoins/index.cfm?flash=yes&action=CircDime|title=Circulating Coins - Dime|publisher=United States Mint|accessdate=2008-10-11] [cite web|url=http://www.pcgs.com/articles/article984.chtml|title=Franklin D. Roosevelt: The Man on the Marching Dime|last=Reiter|first=Ed|date=June 28, 1999|publisher=PCGS|accessdate=2008-10-11]

Public awareness of the 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 gripping the lectern.

ee also

*Polio Hall of Fame
*Sunrise at Campobello
*Warm Springs (film)

References