The Greatest Misdiagnosis in History
Roosevelt went on vacation with his family to Campobello in New Brunswick, Canada eleven years before he would be elected to the presidency in 1932. After falling into the Bay of Fundy on August 9th and experiencing a day filled with strenuous activity, 39-year-old Roosevelt awoke on August 11th with a rapidly branching paralysis. Although he eventually regained the function of his upper extremities, his legs, limp and unresponsive, were never able to regain their previous mobility.
Diagnosis
Roosevelt was officially diagnosed with poliomyelitis on the fifteenth day of his illness, by one of his two principal physicians, Dr. Robert W. Lovett. Lovett's diagnosis was never questioned at the time. It certainly made sense, as polio was an epidemic in the northeastern region of the country, where Hyde Park is located, and Roosevelt experienced the fever, headache, muscle soreness, and flaccid paralysis that characterized the second phase of paralytic polio. During Roosevelt's time, polio was perhaps the most well-known cause of flaccid paralysis--a paralysis characterized by limp, unresponsive muscles--but it was not the only one.
In 1916, French neurologists Georges Guillain and Jean Alexander Barre described the cerebrospinal fluid findings in the bodies of two soldiers in the French Army. The two men experienced ascending paralysis, paralysis that presents itself in the lower limbs, then works its way to the upper limbs; loss of deep tendon reflexes; paraesthesia--a numb, tingling, sensation; and pain during palpation of the larger muscles. Electromyography--a diagnostic procedure used to assess the health of muscles and motor neurons--was performed on the soldiers and minor disturbances in nerve-muscle stimulation were found. More importantly, the men's cerebrospinal fluid was found to contain few white blood cells along with a high concentration of protein, precisely the opposite of what constitutes the cerebrospinal fluid found in polio victims. These symptoms and findings were strung together in the naming of another paralytic illness, one that Roosevelt might really have had: Guillain-Barré syndrome (GBS).
In 1916, French neurologists Georges Guillain and Jean Alexander Barre described the cerebrospinal fluid findings in the bodies of two soldiers in the French Army. The two men experienced ascending paralysis, paralysis that presents itself in the lower limbs, then works its way to the upper limbs; loss of deep tendon reflexes; paraesthesia--a numb, tingling, sensation; and pain during palpation of the larger muscles. Electromyography--a diagnostic procedure used to assess the health of muscles and motor neurons--was performed on the soldiers and minor disturbances in nerve-muscle stimulation were found. More importantly, the men's cerebrospinal fluid was found to contain few white blood cells along with a high concentration of protein, precisely the opposite of what constitutes the cerebrospinal fluid found in polio victims. These symptoms and findings were strung together in the naming of another paralytic illness, one that Roosevelt might really have had: Guillain-Barré syndrome (GBS).
Case Study
In 2003, scientists at the University of Texas Medical branch in Galveston, Texas conducted a case study to shed light on the true nature of Roosevelt's illness. They began with the morning of August 11th, when the green sprouts of a personal crisis and a national concern first showed its tips. That morning, Roosevelt began to feel one leg weaken, followed by the other, and by the following day, he could no longer stand. His temperature was 102°F, he felt an ache all over his body, and he had a heavy cold. He did not, however, feel any particular pain in his spine or neck. The first diagnosis he received was from his family physician, Dr. E.E. Bennett, who declared that he had a "heavy cold." On August 13th, paralyzed from the chest down, Roosevelt was examined by another doctor, Dr. W. W. Keen, who proclaimed he had "a clot of blood from a sudden congestion--settled in the lower spinal cord." As Eleanor wrote in a letter to Roosevelt's half-brother James Roosevelt "Rosy" Roosevelt,
"The doctors now agree that there is no doubt but that F. is suffering from the after effects of a congestion of the lower part of the spinal cord which was of unusually high duration so far as the acute symptoms show. It is too early yet to say finally if this came from his chill and exposure which brought to a focus an irritation that had existed some time or from an attack of I.P.--The symptoms so far would be the same in either event and the treatment identical."
Thus, long before his official diagnosis, infantile paralysis was, unsurprisingly, suspected to be the cause of his paralysis. During the next few days, Roosevelt's already weak arms, shoulders, and hands continued to lose their strength, he had difficulty in defecation and urination, and his fever continued for nearly a week. On the day of his official diagnosis, his temperature was 100°F and his paralysis had subsided to affect his body only from the waist down. His back muscles were weak, he felt pain and discomfort in some regions of his face and in his thumbs, and he continued to experience pain at the slightest touch of his legs. Over the following six weeks, Roosevelt regained control of and strength in his upper extremities, as well as his ability to sit, urinate, and defecate. His lower abdominal and back muscles began to strengthen, but the state of his legs did not improve, and in January of 1922, the lower portion of his legs suddenly hyper-flexed and "locked," no longer limp but rigid. After wearing casts and then leg braces and an abdominal sling, and only while using crutches, Roosevelt could finally stand once more, though his lower paralysis did not subside in the least. The permanence of his condition was determined after a re-examination by Roosevelt's other principal physician, Dr. George Draper, on March 25th. Draper maintained contact with Dr. Lovett throughout the process, but not once was the cause of Roosevelt's paralysis ever mentioned in Draper's letters to the other doctor. Perhaps he, too, had his doubts about the true nature of Roosevelt's illness.
Guillain-Barré syndrome was never suspected to cause Roosevelt's disability because it was not yet known as a cause of flaccid paralysis. In the present study, however, it is known that, considering the signs and symptoms Roosevelt expressed after he became ill, the most probable disease he could have had was either polio or GBS. The probability of Roosevelt having each of these diseases was determined through Bayesian analysis tactics, in which the posterior probabilities--retrospective estimates of the diagnostic probabilities of flaccid paralysis at the time of Roosevelt's illness--were calculated by multiplying the probability of disease incidence in Roosevelt's age group by the likelihood of certain symptoms occurring in the disease. Through this technique, it was determined that six out of eight posterior probabilities strongly favored GBS over polio. The symptoms analyzed from Roosevelt's case were:
Guillain-Barré syndrome was never suspected to cause Roosevelt's disability because it was not yet known as a cause of flaccid paralysis. In the present study, however, it is known that, considering the signs and symptoms Roosevelt expressed after he became ill, the most probable disease he could have had was either polio or GBS. The probability of Roosevelt having each of these diseases was determined through Bayesian analysis tactics, in which the posterior probabilities--retrospective estimates of the diagnostic probabilities of flaccid paralysis at the time of Roosevelt's illness--were calculated by multiplying the probability of disease incidence in Roosevelt's age group by the likelihood of certain symptoms occurring in the disease. Through this technique, it was determined that six out of eight posterior probabilities strongly favored GBS over polio. The symptoms analyzed from Roosevelt's case were:
1. ascending, nearly symmetric flaccid paralysis that progressed for 10-13 days;
2. facial paralysis;
3. prolonged bladder and bowel dysfunction;
4. numbness and dysaesthesia, the distortion and abnormality of senses;
5. absence of meningismus, a state of meningeal irritation;
6. fever;
7. descending pattern of recovery from paralysis; and
8. permanent paralysis.
These symptoms match those typical of GBS on a far greater scale than those seen in polio victims (See Table 1). Though fever is rare in GBS, it can appear at the onset of the disease, and minor degrees of asymmetrical paralysis, as found in Roosevelt's case, are also common in victims of the illness. On top of the Bayesian analysis, it is known that few adults who contracted paralytic polio in the first half of the twentieth century were older than 30 years of age.
Though Roosevelt's cerebrospinal fluid, the key difference between polio and GBS, was not examined, it is highly probable that Roosevelt had been wrongly diagnosed all those years ago. Infantile paralysis, a symbol of the hardship that plagued many Americans during the 1930s-- a cause for which he and the rest of America fought so diligently and passionately for-- might not have been at fault for Roosevelt's affliction. Regardless, Roosevelt's establishment of the National Foundation for Infantile Paralysis and his work at the Warm Springs Foundation inspired many to take a stand against the epidemic, for the betterment of the nation. There may be no confirmation as to exactly which paralytic illness the great president had contracted, and no one may yet be 100% certain of its nature, but one thing is for sure: the potential greatest misdiagnosis in American history was a blessing in disguise for the future of polio victims and the entire country.
Though Roosevelt's cerebrospinal fluid, the key difference between polio and GBS, was not examined, it is highly probable that Roosevelt had been wrongly diagnosed all those years ago. Infantile paralysis, a symbol of the hardship that plagued many Americans during the 1930s-- a cause for which he and the rest of America fought so diligently and passionately for-- might not have been at fault for Roosevelt's affliction. Regardless, Roosevelt's establishment of the National Foundation for Infantile Paralysis and his work at the Warm Springs Foundation inspired many to take a stand against the epidemic, for the betterment of the nation. There may be no confirmation as to exactly which paralytic illness the great president had contracted, and no one may yet be 100% certain of its nature, but one thing is for sure: the potential greatest misdiagnosis in American history was a blessing in disguise for the future of polio victims and the entire country.
Table 1
Clinical features Age of onset Flaccid paralysis Progress of paralysis Facial paralysis Bladder/bowel dysfunction Numbness Dysaesthesia Meningismus Fever Recovery form paralysis Permanent paralysis |
Roosevelt’s case 39 years symmetric, ascending 10-13 days present 14 days present protracted absent present symmetric, descending symmetric |
GBS mainly adults symmetric, ascending 10-14 days common, bilateral 7-14 days common protracted absent rare symmetric, descending in about 15% of cases |
Poliomyelitis mainly young children asymmetric 3-5 days rare, save in bulbar type 1-3 days absent absent common common asymmetric in about 50% of cases |