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The Untold Neurological Disease of Franklin Delano

The Untold Neurological Disease of Franklin Delano

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Published by Steven Lomazow M.D.

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Published by: Steven Lomazow M.D. on Jan 07, 2010
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The untold neurological disease ofFranklin Delano Roosevelt (18821945)
Steven Lomazow
Conventional wisdom suggests that Franklin Delano Roosevelt died on 12 April1945 aged 63 from a massive cerebral haemorrhage attributable to uncontrolled hypertensionand atherosclerosis. Evidence from numerous reliable sources is presented, based largely on aconstellation of previously unrecognized neurological symptoms including seizures,encephalopathy and hemianopia, supporting a scenario that, while indeed he suffered fromsevere cardiovascular disease, Roosevelt died from melanoma with the terminal eventattributable to a metastatic lesion in the brain.
The final event
In the last two years of his life, Franklin DelanoRoosevelt manifested a constellation of neurologicalsymptoms that had a major influence on his ability tofunction as President which are, in large part, the keyto diagnosing a previously unappreciated malignantprocess that was responsible for his death on 12 April1945. The evidence is scattered in thousands of first-hand accounts, letters, newsreels, photographs anddocuments. As early as 1923, a macular lesion aboveRoosevelt’s left eye
can be seen that darkened andexpanded over the next decade and, in the mid-to-late30s, exhibited morphology compatible with melanoma,
a highly malignant and vascular tumour notorious forits propensity to metastasise and bleed in the brain.At 13:10 on 12 April 1945 at Warm Springs, Georgia,the 63-year-old President Roosevelt was stricken by acatastrophic intracerebral haemorrhage that originatedin the right posterior cerebral hemisphere and rapidlyprogressed in a classic transtentorial herniation fashion.Eyewitnesses at the scene have described these eventsin detail, namely the cardiologist and primary physi-cian Howard G Bruenn
and Roosevelt’s cousin,Margaret ‘Daisy’ Suckley.
In 1946 the presidential physician Admiral Ross TMcIntire wrote that Roosevelt’s fatal haemorrhage wasunsuspected
and vigorously defended this contentionuntil his death in 1959. The present accepted view of this event was laid out in detail by Bruenn, thePresident’s primary physician from April 1944, in his1970 paper
published with the consent and partici-pation of the family, alleging that Franklin DelanoRoosevelt (FDR) showed little concern for his healthand that his death was solely a consequence of severeand longstanding hypertension and atherosclerosis.
Bruenn’s account of events
Only recently has the veracity of Bruenn’s assertions been challenged.
Each of the dozens of major biogra-phical works published since 1970, beginning with thatof James MacGregor Burns
who collaborated directlywith Bruenn and the family, is based on Bruenn’saccount. Why should anyone doubt the first-handaccount of the man who essentially lived with thePresident and treated him daily for the last year of his life?The principal reason is the diary of ‘Daisy’ Suckleywho, unbeknown to the President and his physicians,preserved her correspondence with Roosevelt and kepta detailed diary of her relationship with him. First pub-lished in Geoffrey Ward’s 1995 book,
Closest Companion
,no other document is more revealing of the true stateof Roosevelt’s health and psyche. The diary reveals astory of progressive loss of vitality and the deep con-cerns Roosevelt had about his health, directly and cred-ibly controverting the scenario described by Bruenn.More doubt is cast upon Bruenn’s account by under-standing how Roosevelt dealt with his previous healthproblems. After the fateful summer of 1921, Rooseveltwas never again able to stand without the use of  braces. While the nature of the illness that struck him isstill a matter of debate,
his intense rehabilitative effortsand contributions toward the understanding and cureof polio, his unchallenged diagnosis during his life-time, are well appreciated.
Doctor Roosevelt
FDR took an active role in his rehabilitation, devisingtreatments and novel ways of objectively measuringimprovement.
He sought out the most learned auth-orities in the field and gave advice to other victims,gaining him the title of ‘Doctor Roosevelt’ aroundWarm Springs. He personally financed and developedthe medical centre there and founded a charity to raiseawareness of the disease. The ‘March of Dimes’ wasdirectly responsible for funding the scientific researchthat eventually produced a successful vaccine for
Steven Lomazow
MD, is a neurologist practising in New Jersey. He isa 1976 graduate of the University of Health Sciences
ChicagoMedical School and did his neurological training at the University of Minnesota. He was the president of the Neurological Association of New Jersey and currently is a member of the New Jersey State Boardof Medical Examiners. Correspondence: Steven Lomazow, 8 McGuirkLane, West Orange, NJ 07052, USA (email: Lomazow@comcast.net)
 Journal of Medical Biography
: 235–240. DOI: 10.1258
poliomyelitis. In 1946 Roosevelt’s image was placed onthe dime to commemorate his immense contributiontowards conquering polio.Roosevelt made extraordinary efforts to conceal thedegree of his own disability from the public, bothpersonally and through surrogates including hispolitical operative, Louis Howe
and, later, presidentialphysician McIntire who was recommended for his posi-tion largely because of his ability to ‘keep a closemouth’ by Admiral Cary T Grayson, a long-time friendof Roosevelt and the mastermind of the cover-up of Woodrow Wilson’s severe disability following a largenon-dominant hemisphere stroke in October 1919.Roosevelt exercised strict personal control over everydecision that affected his health. Despite the fact thathe was wheelchair bound, none of the tens of thou-sands of photos seen publicly during his lifetimeshows him in a physically compromised state. Evenafter his death, McIntire and, later, Bruenn, intention-ally and deceptively protected the privacy of hismedical history. Roosevelt’s penchant for secrecy andintrigue is well recognized. His existing medicalrecords carry the names of at least 30 different aliases.FDR was very prone to infectious disease. While hewas a governor and president, he was frequently laidup for days or weeks with illnesses that the public wasinformed were influenza, sinus trouble, grippe andswamp fever.
The dread disease
A 2008 paper in
Archives of Dermatology
co-authoredwith dermatopathologist A Bernard Ackerman
describes the pigmented lesion above Roosevelt’s lefteye and presents a differential diagnosis of melanomaand solar lentigo. The primary lesion underwentmarked changes throughout 1940 with essentially totaldisappearance by the end of 1941. The natural historyof the two possible pathologies is incompatible withthe well-documented rapid change in morphology. Theoverwhelming probability is that the lesion wasremoved surgically. The highest degree of secrecyneeded to be enforced since any hint that the Presidentwas being treated for a highly malignant condition, asmelanoma was known to be at the time,
wouldhave been disastrous to his future aspirations. Otherthan a letter from a Massachusetts gynaecologistexpressing concern about it,
the lesion quietlydisappeared.Roosevelt had mild, intermittent hypertension notedas early as 1933 that accelerated rapidly in 1944 withone transient episode of inability to write his name cor-rectly in 1937
and a well-documented syncopalepisode in March 1940.
In 1943 many new and per-sistent problems began to show.
Beginning in late 1943 a progressive intention tremorwas noted that ultimately had a profound effect uponhis handwriting (Figure 1). As early as June 1943 FDRasked his secretary to get him a larger coffee cup so asnot to spill the contents when he drank from it. Severalreliable observers reported an intention tremor of vari-able intensity. While it worsened generally with time, itwaxed and waned from day to day. Some samples of FDR’s handwriting early in 1945 are virtually unintelli-gible yet some in March are much clearer. There werenever any overt signs of extrapyramidal disease or lab-oratory evidence of significant hepatic disease. Therewas moderate hypoxemia and an unknown degree of renal disease. Severe congestive heart failure wastreated with digitalis from early April 1944. FDR’smother, two of his sons and a daughter had a tremor.His alcohol use was moderate, he smoked two packetsof cigarettes a day and, beginning in May 1944, wasusing phenobarbital, 30–60 mg three times daily.Observers described the tremor. Harry Truman (18August 1944)
noted ‘In pouring cream in his tea,he got more cream in the saucer than he did in the cup.His hands are shaking and he talks with considerabledifficulty’. Ambassador Joseph P Kennedy (October1944)
noted ‘his hands shake violently when he triesto take a drink of water. About 10 percent of the timehe is talking, his words are not clearly enunciated’. TheDirector of Public Relations at the White House, DavidNoyes (20 March 1945)
noted ‘the president wastrying to light a cigarette and put the cigarette in his
Figure 1 FDR’s handwriting to show the changes in his tremor (author’scollection): (a) on 1 June 1944, (b) on 7 September 1944, (c) on his lastcheque dated 9 April 1945
236 Journal of Medical Biography Volume 17 November 2009
holder to light it in the usual way. Unable to connectthe match, his hand shaking badly, he opened the deskdrawer, placed his bent elbow inside, partly closed thedrawer and got a firm hold on his hand’. The Secretaryto the Treasury, Henry Morgenthau (11 April 1945)
wrote ‘he was mixing cocktails. His hands shook sothat he started to knock the glasses over and I had tohold each as he poured the cocktail ... I noticed that hetook the two cocktails and then seemed to feel a little better’.Obviously an intention tremor; the family historyand apparent response to alcohol are highly suggestiveof benign essential tremor. With progression mirroringthe worsening of Roosevelt’s associated medicalproblems, enhancement by metabolic encephalopathyand possibly neuropathy must also be consideredseriously.
The beginning of the end
The Teheran Conference, held from late November toearly December 1943, marked the turning point inRoosevelt’s health after which there was an inexorabledownhill course. At this conference the first report of severe paroxysmal abdominal pain is reported,
likelythe first recorded episode of symptomatic metastaticdisease, a consequence of intussusception well knownto be associated with small bowel metastases frommelanoma. Two other well-documented major abdomi-nal attacks occurred in May
and August of 1944.
Although cholelithiasis was advanced as the sourceof FDR’s abdominal pain, his diet was more in keepingwith a patient with partial bowel obstruction, the likelycause of a 40-pound weight loss in his last year. Thetime frame for the appearance of metastatic disease inlate 1943 after removal of the primary lesion in 1940 isconsistent with the natural history of melanoma.
Lethargy and seizures
From late 1943 there are many reports of a persistentand progressive lethargy and somnolence. From earlyin 1944 Roosevelt’s level of alertness varied. He wor-sened generally as the days progressed. As April 1945neared, the periods of exhaustion and stupor worsenedand he had many more bad days than good.On 27 March 1944 FDR was diagnosed with severecongestive heart failure which likely was a major con-tributor to his tiredness. Shortly afterwards he wasstarted on digitalis which brought about rapid remark-able clinical improvement. Despite another month of seclusion, an enforced four-hour workday and mid-daynaps, the lethargy progressed. Secretary Grace Tully(1944)
‘worried when Mr Roosevelt suddenly dozedover his mail. She had witnessed it several times. Inchats with political friends he frequently ‘drew a blank’as they listened: abashed, he had to ask what he had been talking about’. Assistant Secretary of StateBreckinridge Long (1 November 1944)
noted ‘I amnot sure nowadays that things are properly and fullypresented to the President and in such a manner thathe can pass on these matters with a full understandingof the consequences of decisions’. Long-time friendand Secretary of Labor Francis Perkins (January 1945)
noted ‘I had a sense of his enormous fatigue. He hadthe pallor, the deep gray color of a man who had beenlong ill. He supported his head with his hand asthough it were too much to hold up. His lips were blue. His hands shook’.Speechwriter John Gunther (February 1945)
noted‘His fatigue was crushing, and he had intermittentperiods of being virtually comatose. In fact his exhaus-tion was so complete that, on occasion, he could notanswer simple questions and talked what was close tononsense’. Winston S Churchill (February 1945)
noted‘His captivating smile, his gay and charming mannerhad not deserted him, but his face had a transparency,an air of purification, and often there was a far-awaylook in his eyes’. Churchill’s physician, Lord Moran (13February 1945)
wrote ‘he sat looking straight aheadwith his mouth open, as if he were not taking thingsin ... He has all the symptoms of hardening of thearteries of the brain in an advanced stageand ‘ThePresident vacillated between intellectual acumen and avacuous attitude which was impossible to penetratewith ideas and conversation. These extremes presentedthemselves within hours of each other’. Judge Marvin Jones (17 March 1945)
‘remembered that MrsRoosevelt carried most of the conversation and thePresident would sometimes brighten up for a momentand then ... his head would drop down’.At FDR’s last public appearance, at the White Housecorrespondents’ dinner on 21 March 1945, Allen Drury,correspondent for the United Press, noted how old andthin and scrawny-necked FDR looked when he waswheeled in, how he stared out at the crowded tables asthough he did not see the people, how he failed torespond to the blare of trumpets and to the applause.Everyone watched the greatest performer of all howhe steadily drank wine and smoked his uplifted ciga-rette, how he leaned forward with his hand cupped behind his ear to hear a joke repeated as laughterwelled up in the room, how his booming laughter rangout. Then a few moments later observers noticed howhe simply sat at the table with an intent, vagueexpression on his face, while his jaw dropped and hismouth fell open.
The Canadian Prime Minister McKenzie King (26March 1945)
wrote ‘Roosevelt repeated two longstories ... that he had told King the night before, Kingnoticed that Mrs Roosevelt and Anna ‘seemed a littleembarrassed’. Speechwriter Robert Sherwood (March1945)
noted the president was ‘in much worse shapethan I have ever seen him ... he had seemed unnatu-rally quiet, even querulous, never before had Sherwoodfound himself in the position of having to carry onmost of the conversation without reply’. In March 1945‘Roosevelt was an animated human being from nine inthe morning until an hour after midday. Each day atlunchtime he appeared to shatter into helpless frag-ments. The good nature seemed intact but the bodyand the mind faded in function toward a smilinghelplessness’.
S Lomazow Untold neurological disease of Franklin Delano Roosevelt (1882–1945) 237

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