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An Inquiry Into the Nature of the Pigmented Lesion

Above Franklin Delano Roosevelt’s Left Eyebrow
A. Bernard Ackerman, MD; Steven Lomazow, MD

Background: Little note was taken when Franklin Conclusions: The failure of observers of Roosevelt,
Delano Roosevelt was alive and since his death of the especially his physicians, to comment on his riveting fa-
pigmented lesion above his left eyebrow that fulfilled cial lesion and to identify it as a probable melanoma
clinical criteria for melanoma. speaks volumes about how flawed were clinical criteria
for diagnosis of flat and slightly raised lesions of mela-
Observations: On morphologic grounds alone, it is noma in the 1930s and 1940s.
impossible to exclude the possibility that Roosevelt had
a melanoma. Arch Dermatol. 2008;144(4):529-532

technical considerations, LENTIGO/SEBORRHEIC KERATOSIS
such as the angle of the
head, the lighting of the A solar lentigo is a benign neoplasm con-
face, and the brightness stituted of pigmented keratocytes. When
and contrast of the print, the pigmented it becomes elevated and, in the process, as-
lesion above Franklin Delano Roosevelt’s sumes an appearance more advanced his-
left eyebrow shows considerable varia- topathologically, the same condition then
tion in intensity in many of the photo- is referred to as a seborrheic keratosis of
graphs (Figures 1, 2, 3, 4, and 5) of the reticulate type. On occasion, a solar
the person most photographed in the lentigo/seborrheic keratosis may acquire
20th century. In the photographs in characteristics that conform to the
which Roosevelt’s face is captured in ABCDEs. Roosevelt was an inveterate sailor
profile, the pigmented lesion appears to and had many solar lentigines, particu-
extend from the lower part of the fore- larly on the dorsum of his hands, these
head to the base of the eyebrow. contrasting strikingly with the pig-
mented lesion above his left eyebrow. De-
OBSERVATIONS spite that reality, not all solar lentigines
are tiny; some may achieve a size like that
The criteria currently touted for diagno- of the lesion above Roosevelt’s left eye-
sis of a slightly raised lesion of mela- brow—and even larger.
noma, a malignant neoplasm composed On gross morphologic grounds alone,
of abnormal melanocytes, are the the pigmented lesion above Roosevelt’s left
“ABCDEs”: Asymmetry, Border irregu- eyebrow could be either a melanoma or a
larity, Color variability, Diameter greater solar lentigo/seborrheic keratosis. Only a
than 6 mm, and Elevation (or, for some study of sections of tissue obtained by bi-
proponents of the mnemonic, Enlarging opsy would enable the conundrum to be
or Evolving). The fully developed pig- resolved conclusively. No evidence ex-
Author Affiliations: Ackerman mented lesion above Roosevelt’s left eye- ists that the lesion ever was biopsied or
Academy of Dermatopathology brow admirably fulfills those criteria. But treated in any way. Sad to say, most of
(Dr Ackerman) and the ABCDEs also are encountered from Roosevelt’s medical records are missing;
Departments of Medicine and
time to time in a disparate variety of none at all pertinent to the pigmented le-
Neurology, Mount Sinai School
of Medicine (Dr Lomazow) other pigmented lesions of the skin, sion above the left eyebrow have been
New York, New York. among them being solar lentigo/ found.
Dr Lomazow is also in private seborrheic keratosis, melanocytic nevi of The fact that the pigmented lesion was
practice in Belleville, different kinds, and pigmented basal cell variegate in shades of brown and very dark
New Jersey. carcinoma. brown in the arciform portion of it is more

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Figure 3. Franklin Delano Roosevelt in August 1938 (age 56 years) with an
asymmetric, brown, seemingly barely raised plaque, darker in shape arciform
at the top and on the right side of it, but lighter in a central zone macular.
The plaque is larger in size than it was in 1933 (Figure 5).7

consonant with melanoma than with solar lentigo/

seborrheic keratosis. Moreover, whereas a large solar len-
tigo/seborrheic keratosis on a face usually is accompa-
nied there by other large solar lentigines/seborrheic
keratoses, melanoma presents itself conventionally as an
isolated lesion, as was the case for Roosevelt’s pig-
mented lesion. That finding, too, favors a diagnosis of
Figure 1. Franklin Delano Roosevelt in 1900 (age 18 years) with no melanoma. However, melanoma, being the malignant neo-
pigmented lesion above his left eyebrow.7
plasm irrepressible in growth that it is, would be ex-
pected in the course of the 20 years from 1923 to 1943
to have attained a diameter greater than that of the le-
sion seen above Roosevelt’s left eyebrow (at the apogee
it was only about 2.5 cm ⫻ 2.0 cm in diameter). Fur-
thermore, for several years prior to 1943, the lesion
showed no sign of centrifugal extension or of progres-
sive elevation above the surface of the skin. That behav-
ior also militates somewhat against melanoma.
Episodically, a melanoma may undergo involution in
the form of ever-expanding hypopigmentation over the
course of several years, the process often causing the pig-
mented portion yet remaining to assume an archlike con-
figuration. Only uncommonly does a melanoma regress
entirely, leaving as residuum but a macule of hypopig-
mentation. Although the arciform character of the dark-
est pigmentation of Roosevelt’s lesion surely is in keep-
ing with the clinical appearance of partial regression of
melanoma, it would be unusual for the lesion above the
left eyebrow to have undergone complete regression in
the rather short space of 4 years (ie, in the period from
early 1940 to 1943). Biologically, such a phenomenon
is unlikely. For regression in toto of a melanoma that size
to have occurred should have taken considerably longer.
Solar lentigo/seborrheic keratosis also is known to re-
gress completely, but when that happens, almost always
Figure 2. Franklin Delano Roosevelt in 1923 (age 41 years) with a subtle, the lesion is small, situated on the chest, and accompa-
uniformly tan, poorly marginated macule above his left eyebrow.7 nied often by signs of inflammation so noticeably viola-

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Figure 5. Comparison of the appearance of the skin above Franklin Delano

Roosevelt’s left eyebrow in the 10 years from 1933 to 1943. A, Roosevelt in
1933 (age 51 years) and B, in January 1943 (age 61 years), showing a very
faint residual outline of what was a pigmented lesion. Note the marked
contrast in the appearance of the skin above the left eyebrow.7

tographs and films, fewer than a handful show him com-

promised physically, despite the fact he was wheelchair
bound. Every aspect of his appearance and public per-
sona was painstakingly orchestrated.
Ross T. McIntire, MD, a career navy man who even-
Figure 4. Franklin Delano Roosevelt in August 1940 (age 58 years) with an tually attained the rank of Vice Admiral and Surgeon Gen-
asymmetric, apparently slightly raised lesion, brown in an arc at the superior
pole and hypopigmented in the lower two-thirds. No additional growth since eral of the Navy, was Roosevelt’s personal physician from
1938 is apparent.7 1933 until the President’s death in 1945. A specialist in
head, eye, ear, nose, and throat disease, McIntire was cho-
ceous that at this stage of involution it is known univer- sen to be Roosevelt’s personal physician not only
sally as “lichen planus–like keratosis,” lichen planus being because the President was prone to sinus disease, but be-
an eruption typified by purple papules. cause McIntire had a reputation for unwavering loyalty
If Roosevelt’s lesion did not undergo involution en- and for “keeping a tight lip.” He was recommended for
tirely, then it must have been removed surgically or have that post by Roosevelt’s close friend, Cary T. Grayson,
been camouflaged by makeup. However, there is no evi- MD, who had been physician to Woodrow Wilson and
dence for either. No sign of a scar from a surgical exci- was a central figure in the cover-up of Wilson’s devas-
sion is apparent. In short, how his pigmented lesion came tatingly disabling stroke in 1919.
to disappear from 1940 to 1943 remains an enigma. In- After Roosevelt’s death in April 1945, persistent ru-
dependent of that, on the basis of all that is known pres- mors surfaced about his health. McIntire, in a book
ently about the morphologic aspects and biologic behav- (largely ghostwritten) published in 1946,2 denied that
ior of his lesion, it is impossible, despite the imponderables, Roosevelt had experienced any chronic malady of sig-
to exclude melanoma. nificance. Until McIntire’s death in 1959, any informa-
tion germane to Roosevelt’s health was guarded closely
IN THE CONTEXT OF HIS HEALTH IN GENERAL In a volume that appeared in 1970, historian Hugh
L’Etang3 was the first to raise publicly the specter that
All details of Roosevelt’s health, especially during his 12 Roosevelt had a melanoma. His assertion was deflected
years as the 32nd President of the United States, were in an apparently coincidental but, more likely, a pur-
shrouded in secrecy while he was alive. The most fla- posefully timed article by Howard G. Bruenn, MD,4 a car-
grant example of duplicity was that although Roosevelt diologist who was the last surviving member of the in-
never was able to support his own weight without the use ner circle of Roosevelt’s physicians and who saw Roosevelt
of metal braces on his legs as a consequence of his having on a daily basis from March 1944 to April 1945. Bruenn
contracted poliomyelitis in 1921, the American public was set forth many previously undisclosed details that came
shielded from knowledge of his extraordinary physical dis- from Roosevelt’s medical records, emphasizing those of
ability. Most Americans were unaware that he was un- a cardiologic and vascular character that the President
able to walk without assistance. Complicit in this “splen- had experienced during the last year of his life.4 No ref-
did deception” (the title of a biography of Roosevelt by erence whatsoever was made by Bruenn to the pig-
historian Hugh G. Gallagher,1 who also had contracted po- mented skin lesion above the left eyebrow, despite it being
liomyelitis) were Roosevelt’s physicians, as was the press. decidedly unsightly. That omission, the wording of an
Of the tens of thousands of images of Roosevelt in pho- editorial that accompanied Bruenn’s article,9 and corre-

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tologists throughout the United States and the world who
regularly observed it in photographs and in films? As-
toundingly, to our knowledge, the only reference dur-
ing Roosevelt’s lifetime to that lesion was by McIntire7
in a letter written in January 1940 in response to a col-
league, Reuben Peterson, MD, in which the physician/
admiral assured that the lesion was “under observation
at all times.”
In the 1920s, 1930s, and 1940s, a lesion such as
Roosevelt’s was not diagnosed as melanoma, even by der-
matologists, but was considered to be benign—that is, a
senile pigmented patch (Figure 6)—or, at worst, a pre-
malignant neoplasm designated as a Hutchinson mela-
notic freckle or precancerous circumscribed melanosis.
Even in the late 1950s, such a lesion was deemed to be a
precursor of melanoma, not a melanoma per se.
The editorial that appeared in 1970 in the Annals
of Internal Medicine complementary to the article by
Bruenn affirmed that “there was no clinical evidence for
such a lesion [melanoma] and no autopsy was per-
formed.”9(p530) But that statement certainly is not in syn-
chrony with the attributes of Roosevelt’s lesion. On clini-
cal grounds alone—that is, gross inspection—it is
impossible to exclude melanoma. Because it seems that
the lesion described herein never was biopsied, the an-
swer to the question of the authentic character of it must
for now be couched as supposition.
Figure 6. In his textbook of dermatology published in 1917, William A.
Pusey, MD,8 diagnosed this extensive lesion as a “pigmented senile patch”
but had a biopsy sample been taken and read by a competent
dermatopathologist, the findings surely would have been those of melanoma,
Accepted for Publication: August 30, 2007.
presumably in situ. Correspondence: A. Bernard Ackerman, MD, Acker-
man Academy of Dermatopathology, 145 E 32nd St, 10th
spondence between Bruenn and Roosevelt’s children sug- Floor, New York, NY 10016 (jdelarose@ameripath
gest a deliberate attempt to minimize the impact of .com).
L’Etang’s assertion of melanoma. Author Contributions: Study concept and design: Acker-
In 1979, Harry S. Goldsmith, MD,5 a well-respected man and Lomazow. Acquisition of data: Ackerman and
surgeon, raised, for the first time in a peer-reviewed medi- Lomazow. Analysis and interpretation of data: Acker-
cal journal, the possibility that Roosevelt’s pigmented le- man. Drafting of the manuscript: Ackerman. Critical re-
sion was a melanoma. Goldsmith5 cited reports and ob- vision of the manuscript for important intellectual content:
servations of creditable and competent physicians and, Ackerman and Lomazow. Study supervision: Lomazow.
in addition, presented what he deemed to be photo- Financial Disclosure: None reported.
graphic evidence of the existence and then the disap- Additional Contributions: We thank the staff of the
pearance of the lesion in question. Goldsmith’s article Franklin Roosevelt Library at Hyde Park, New York, for
gained considerable attention at the time it was pub- its assistance.
lished, but the emphatic public denial by Bruenn served
to quash the hypothesis of melanoma and preserve the REFERENCES
prevailing idea that the cause of Roosevelt’s medical con-
ditions and ultimately his death was primarily of a car- 1. Gallagher HG. FDR’s Splendid Deception. New York, NY: Dodd Mead & Co; 1985.
diovascular nature. When contacted by Time magazine, 2. McIntire RT, Creel G. White House Physician. New York, NY: G.P Putnam’s Sons;
Bruenn baldly stated: “Roosevelt did not have a cancer.
3. L’Etang H. The Pathology of Leadership. New York, NY: Hawthorne Books; 1946:
This can be stated with certainty.6(p58)” Goldsmith’s propo- 86-102.
sition was reduced to mere footnote. 4. Bruenn HG. Clinical notes on the illness and death of President Franklin D. Roosevelt.
Ann Intern Med. 1970;72(4):579-591.
5. Goldsmith HS. Unanswered mysteries in the death of Franklin D. Roosevelt. Surg
COMMENT Gynecol Obstet. 1979;149(6):899-908.
6. Did Roosevelt have cancer? Time. December 17, 1979;114(25):58.
Given the fact that melanoma, solely on the basis of clini- 7. Franklin Delano Roosevelt Library. Ross McIntire Collection, Box 4. Hyde Park,
NY: Franklin Delano Roosevelt Library.
cal inspection, should have been the most likely suspect 8. Pusey WA. The Principles and Practice of Dermatology: Designed for Students
for Roosevelt’s lesion, why was that possibility never and Practitioners. New York, NY: Appleton; 1917.
raised? How could it have gone undiagnosed by derma- 9. Medicine and history. Ann Intern Med. 1970;72(4):530.

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