Extract
Following World War II, the number of orthopaedic surgeons rapidly increased and the specialty expanded to include the treatment of fresh fractures. Many factors contributed to this development. This article discusses the contributions of Franklin D. Roosevelt to the growth of orthopaedic surgery.
Following World War II, the number of orthopaedic surgeons rapidly increased and the specialty expanded to include the treatment of fresh fractures. Many factors contributed to this development. This article discusses the contributions of Franklin D. Roosevelt to the growth of orthopaedic surgery.
From the earliest time in recorded history, surgeons followed armies to treat their battle injuries. The orthopaedic surgeons of the nineteenth century treated musculoskeletal deformities; infections, particularly tuberculosis of bones and joints; and the complications of trauma, especially in children, but they did not engage in the treatment of acute trauma. Their knowledge of the anatomy and physiology of bones and joints provided them with the opportunity to use their skills to treat those needing rehabilitation during World War I. As they became proficient in this role, they also became involved in the acute treatment of fractures.
In his presidential address at the Seventy-fourth Annual Meeting of the American Orthopaedic Association (AOA) in 1961, Edward F. Cave stated, "Orthopaedic surgery was reborn and expanded during and after World War I, largely because trauma to the extremities became a part of orthopaedic surgery for the first time."1 Later in the address, Cave stated, "World War II changed all of this. The sections of orthopaedic surgery in military hospitals often represented the largest divisions on the surgical services. Surgical teams sent to the forward areas were staffed by orthopaedic surgeons…. If the development of orthopaedic surgery was enhanced by World War I, it was expanded tenfold by the experience gained in the War of 1939—45, thanks in no small measure to one of our members, the late Major General Norman T. Kirk, who was at that time the Surgeon General of the Army."
In 1940, prior to the American entry into the war, the American Academy of Orthopaedic Surgeons (AAOS) had 863 members. In 1960, following the war, membership had increased to 2651 members (numbers supplied by the AAOS). There are doubtless many reasons for this growth, but the one explored in this article concerns the impact of a president who was paralyzed by poliomyelitis and led the nation during the most cataclysmic event of the twentieth century—a president who was under the care of the leading orthopaedists and broke with tradition by appointing an orthopaedic surgeon, not a general surgeon, as the Surgeon General of the Army and under whose watch the specialty assumed dominant responsibility for the treatment of acute trauma to the musculoskeletal system.
Roosevelt had been Secretary of the Navy under Woodrow Wilson and was an unsuccessful candidate for the vice presidency in 1920. When he returned to Washington on July 20, 1921, he rendered a report refuting charges by the then-Republican administration that homosexuality had pervaded the navy during his tenure. Working in the heat of Washington that summer, he submitted a creditable response and the charges were dropped. This was his last official act, and he looked forward to a long vacation and a return to civilian life at his summer home on Campobello Island in New Brunswick, Canada2.
Before leaving for Campobello, he stopped in New York City to attend to business at the Fidelity and Deposit Company of Maryland, of which he was vice president3. He was also president of the Greater New York Boy Scouts Council, and he used this opportunity to visit a Boy Scout camp at Bear Mountain on July 273.
He left New York City in early August, sailing on board the yacht Sabala, owned by the chairman of his company. On August 10, the day after his arrival at Campobello, Roosevelt went sailing with his children on board the Vireo, his new yacht. En route, they landed on a deserted island to extinguish a brush fire and jogged several miles to a lake where they went swimming. On returning home, he complained of fatigue and a backache, which had been present for several days and had become more intense. He skipped dinner and went directly to bed. Later in the evening, he had chills and an elevation of temperature.
On awakening on the morning of August 11, he noted that his left leg was weak. Within a few hours, both legs were weak, the back pain had become worse, a severe headache had developed, and his temperature had climbed to 102°F. The family physician, Dr. E.E. Bennet of Lubec, Maine, was called on August 12, and he made a diagnosis of a cold; however, on reflection, Bennet became uneasy with the diagnosis as his patient was having difficulty with urination, severe headaches, malaise, and increasing weakness of his legs. He suggested that Dr. W.W. Keen of Philadelphia, who was vacationing at Bar Harbor, Maine, be called for a consultation4.
William Keen, professor of surgery at Jefferson Medical School, had served as a surgeon in both the Civil War and World War I, was widely known and respected, and was a contemporary of Harvey Cushing and William Halstead. He was also one of the surgeons who performed the secret operation on President Grover Cleveland in 1893, after he was wounded in an attempted assassination.
Dr. Keen examined Roosevelt on August 14 and diagnosed a blood clot in the spinal artery in the lower spine. He was optimistic and predicted a full recovery, but the next day the paralysis had spread to the trunk muscles.
On August 14, Eleanor Roosevelt wrote to James Roosevelt, Franklin's half-brother:Aug 14/21Dear Rosy,We have had a very anxious few days as on Wed. evening Franklin was taken ill. It seemed a chill but Thursday he had soreness and pain in his back and legs that I sent for the doctor,—by Friday evening he lost the ability to walk or move his legs but thought they felt numb…. Yesterday a.m. Dr. Bennett and I decided we wanted the best opinion we could get quickly so Louis Howe (who, thank heavens, is here, for he has been the greatest help) went with Dr. Bennett to Lubec and they canvassed the nearby resorts and decided that the best available diagnostician was the famous old Dr. W. W. Keen of Philadelphia and he agreed to motor up … He arrived about 7:30 and made a most careful, thorough examination … He thinks a clot of blood, from a sudden congestion has settled in the lower spinal cord … I do not want particulars to get in the papers so I am writing the family that he is ill from the effects of a chill …Affectionately always,Eleanor5
Aug 14/21
Dear Rosy,
We have had a very anxious few days as on Wed. evening Franklin was taken ill. It seemed a chill but Thursday he had soreness and pain in his back and legs that I sent for the doctor,—by Friday evening he lost the ability to walk or move his legs but thought they felt numb…. Yesterday a.m. Dr. Bennett and I decided we wanted the best opinion we could get quickly so Louis Howe (who, thank heavens, is here, for he has been the greatest help) went with Dr. Bennett to Lubec and they canvassed the nearby resorts and decided that the best available diagnostician was the famous old Dr. W. W. Keen of Philadelphia and he agreed to motor up … He arrived about 7:30 and made a most careful, thorough examination … He thinks a clot of blood, from a sudden congestion has settled in the lower spinal cord … I do not want particulars to get in the papers so I am writing the family that he is ill from the effects of a chill …
Affectionately always,
Frederick Delano, Eleanor's uncle, learned of the illness when he was in Washington and spoke to a Dr. Parker, who suggested it might be poliomyelitis. Delano then took urgent action:Aug 30, 1921Dear EleanorI am so sorry that I did not get your Sunday letter till Thursday and Mr. Howe's till yesterday, but as soon as I did I acted promptly. In order to be nearer the scene of action and perhaps consult a doctor who could go to Campobello, I came over on the Federal last night [from Washington] …. I thought I ought to consult the best man in Boston. The great Dr. Lovett (Robert W. Lovett) was away but … I called up the Peter Bent Brigham Hospital and they recommended Dr. Levine (Samuel A. Levine of 21 Bay State Road) as their best man on Infantile Paralysis. I saw Levine at 2:15 and read him your letter and Howe's letter and your last telegram. He said at once, as did Dr. Parker in Washington, that it was unquestionably Inf Paralysis. Secondly, he said you should stop the manipulations and massage as unwise so early in the game…. This Dr. Levine has had a great deal of practice in this disease and as you probably know "Boston" has rather specialized in it….Dr. Keen, all doctors seem to know. He is a fine old chap, but he is a surgeon and not a connoisseur on this malady. I think it would be very unwise to trust to his diagnosis, when the Inf. Paralysis can be determined by test of the spinal fluid….Your devoted UncleFrederick A DelanoP.S. Levine is a man of 30 or 32 and I don't think he will be unreasonable in his charges…. Don't let this be treated lightly, the disease is too serious to trifle with.Your affect. Uncle, F. A. D.6
Aug 30, 1921
Dear Eleanor
I am so sorry that I did not get your Sunday letter till Thursday and Mr. Howe's till yesterday, but as soon as I did I acted promptly. In order to be nearer the scene of action and perhaps consult a doctor who could go to Campobello, I came over on the Federal last night [from Washington] …. I thought I ought to consult the best man in Boston. The great Dr. Lovett (Robert W. Lovett) was away but … I called up the Peter Bent Brigham Hospital and they recommended Dr. Levine (Samuel A. Levine of 21 Bay State Road) as their best man on Infantile Paralysis. I saw Levine at 2:15 and read him your letter and Howe's letter and your last telegram. He said at once, as did Dr. Parker in Washington, that it was unquestionably Inf Paralysis. Secondly, he said you should stop the manipulations and massage as unwise so early in the game…. This Dr. Levine has had a great deal of practice in this disease and as you probably know "Boston" has rather specialized in it….
Dr. Keen, all doctors seem to know. He is a fine old chap, but he is a surgeon and not a connoisseur on this malady. I think it would be very unwise to trust to his diagnosis, when the Inf. Paralysis can be determined by test of the spinal fluid….
Your devoted Uncle
Frederick A Delano
P.S. Levine is a man of 30 or 32 and I don't think he will be unreasonable in his charges…. Don't let this be treated lightly, the disease is too serious to trifle with.
Your affect. Uncle, F. A. D.6
In another letter to James Roosevelt, Eleanor wrote:Aug 23, 1921Dear Rosy… On Uncle Fred's urgent advise [sic] which I feel I must follow, I have asked Dr. Keen to get Dr. Lovett here to determine if it is I.P. or not, Dr. Keen thinks not.7
Aug 23, 1921
Dear Rosy
… On Uncle Fred's urgent advise [sic] which I feel I must follow, I have asked Dr. Keen to get Dr. Lovett here to determine if it is I.P. or not, Dr. Keen thinks not.7
Dr. Lovett traveled to Eastport, Maine, on August 25, 1921, and examined Roosevelt. Later, he wrote to Dr. George Draper, a practitioner known to Lovett who was particularly interested in poliomyelitis and was working with the poliovirus at the Rockefeller Institute for Medical Research in New York with Dr. Simon Flexner. Dr. Draper was also the author of a book published by the Institute in 1912 entitled A Clinical Study of Acute Poliomyelitis with coauthors Frances W. Peabody and A.R. Dochez. On September 12, 1921, Lovett wrote Draper:Dear Dr. Draper,With regard to Mr. R., I was called to see him in Campobello and I saw him with W. W. Keen…. There was some uncertainty in their minds about the diagnosis, but I thought it perfectly clear so far as the physical findings were concerned and I never feel that the history is of much value anyway…. There had been some hyperaesthesia of the legs preceding the bath for a day or two.He had, I thought, some facial involvement, apparently no respiratory, but a weakness in the arms, not very severe and not grouped at all. There was some atrophy of the left thenar eminence… His bladder was paralyzed … There was scattered weakness in the legs.8
Dear Dr. Draper,
With regard to Mr. R., I was called to see him in Campobello and I saw him with W. W. Keen…. There was some uncertainty in their minds about the diagnosis, but I thought it perfectly clear so far as the physical findings were concerned and I never feel that the history is of much value anyway…. There had been some hyperaesthesia of the legs preceding the bath for a day or two.
He had, I thought, some facial involvement, apparently no respiratory, but a weakness in the arms, not very severe and not grouped at all. There was some atrophy of the left thenar eminence… His bladder was paralyzed … There was scattered weakness in the legs.8
The paralysis first developed in the legs and within a few days ascended to the trunk muscles. Some muscles in the upper extremities were also involved. The upper extremity muscles returned to normal in the course of a few months. Later, in 1922, Lovett reexamined Roosevelt and noted residual paralysis, with a muscle rating of less than 4, of the following muscles: abdominals, quadratus lumborum, gluteus maximus, iliopsoas, tensor fasciae latae, sartorius, hip abductors and adductors, and hamstrings. The anterior tibial muscles on both the right and left sides were rated 0. (A rating of 4 indicates a muscle can resist gravity and some resistance, but is not of normal strength. A rating of 0 indicates complete paralysis.) For some unexplained reason, a spinal tap was never done.
The distribution of the paralysis would indicate that bilateral long leg braces were a necessity, and the weakened pelvic and femoral muscles might also call for a pelvic band attached to the long leg braces.
At a repeat examination by Lovett in May 1923, all muscles of the upper extremities were normal. The trunk and abdominal muscles were rated 2 to 3; the pelvic and femoral muscles were 1 to 3; the anterior and posterior tibial muscles were 0; and the right and left gastrocnemius, peroneals, toe flexors, and extensors were 2 to 3. (A rating of 2 indicates the muscle cannot resist gravity, and a rating of 3 means a muscle can resist gravity.) This muscle rating remained unchanged throughout the rest of Roosevelt's life. In February 1922, flexion contractures of his hips and knees developed. He was treated by Arthur Krida, an orthopaedic surgeon in New York City, who applied corrective casts and had him maintained in the prone position9.
Roosevelt rose to the challenge. He firmly believed that, with perseverance, effort, and knowledge of the disease, his will was strong enough to overcome such a physical disability. He set himself a goal to walk without braces or crutches. In the years after 1922, he devoted much of his time to communicating with orthopaedists and became familiar with the exercises and treatment recommended by them. In letters to his doctors and friends, he remained a confirmed optimist, describing how he could move a toe better today than yesterday. At his family home at Hyde Park, he was determined to walk the length of his driveway, which was a quarter of a mile. Each day, wearing his braces and supported with crutches, he lurched along until exhausted, but he never could accomplish this goal. He became an expert on the rehabilitative treatment of the disease, advising others how to exercise. In a letter to Katherine Lake, his therapist, he wrote:March 5, 1923I think the legs are really coming along in fine shape. I have tried all sorts of interesting experiments, such as cutting off one of the old braces just above and just below the knee, using this and the left leg on the parallel bars seems to give good results to the knee muscles …10
March 5, 1923
I think the legs are really coming along in fine shape. I have tried all sorts of interesting experiments, such as cutting off one of the old braces just above and just below the knee, using this and the left leg on the parallel bars seems to give good results to the knee muscles …10
He also dabbled into alternative therapies. A Dr. Cunningham from the University of Kansas recommended a high-pressure atmospheric chamber to increase his oxygen intake. On another occasion, Roosevelt tried high-intensity lights. Other victims of poliomyelitis throughout the country wrote him letters to consult with him and learn his methods of therapy. He replied at length with his opinions about therapy.
One correspondent offered him a motorized wheel chair, to which Roosevelt responded:Dec 21, 1923The motor chair sounds most interesting. My chief difficulty in regard to it is that where I am in the country, I like to spend a lot of my time in the woods and our wood roads are extremely rough…. This autumn I have been able to sit on a horse and be led around the place. Of course, I would fall off if the horse trotted, and what I need is a horse constitutionally unable to trot and which is also guaranteed against any sidewise motion.11
Dec 21, 1923
The motor chair sounds most interesting. My chief difficulty in regard to it is that where I am in the country, I like to spend a lot of my time in the woods and our wood roads are extremely rough…. This autumn I have been able to sit on a horse and be led around the place. Of course, I would fall off if the horse trotted, and what I need is a horse constitutionally unable to trot and which is also guaranteed against any sidewise motion.11
In 1950, when a retrospective analysis of his paralysis was published, doubt was cast on the diagnosis of poliomyelitis. It was suggested that he had contracted Guillain-Barré syndrome, a condition not fully described in 1921. The evidence that mitigated against poliomyelitis was the slow development of the paralysis, the symmetry of the involved muscles, the absence of meningismus, the presence of dysesthesias, and the fact that he had contracted the disease as an adult, which was a rare occurrence as the condition was prevalent among children. Roosevelt had a fever, which is common in poliomyelitis, but is not present in Guillain-Barré syndrome. Yet, Lovett, Chairman of the Harvard Infantile Paralysis Program, and Draper in New York had no doubt about the diagnosis. Unfortunately, a spinal tap, which could have clarified the diagnosis, was never suggested, perhaps because the doctors felt so secure in their diagnosis; both Lovett and Draper in their practice frequently depended on spinal taps12.
Poliomyelitis was first described by Heine in 184613. It was known as infectious, to occur in epidemics in late summer, and its victims usually were children below the age of five years. Contrary to expectation, the demographics of the infection showed a prevalence that was highest in the middle and upper social classes who practiced high sanitary standards13.
In 1907, a severe epidemic occurred in New York City, and it subsequently spread throughout the United States and Canada13. In 1916, another epidemic left 27,000 individuals with paralysis throughout the country, but the disease also occurred sporadically. The virus was shown to gain a portal of entry through the nasopharynx and the gastrointestinal tract, causing intestinal symptoms that cleared up in most individuals; however, some instances were followed by paralysis three or four days after the onset. Many young infants and children gained immunity to the poliomyelitis virus after a bout of gastrointestinal sickness; those who acquired the virus at a later age were more prone to become paralyzed.
A developing poliomyelitis epidemic sent a message of fear and panic to the families with children13. The random selection of victims and the absence of any effective treatment added to the terror of the disease. Summer schools were closed, as were swimming pools; meetings were cancelled, and parents and their children left the cities in such numbers that they were turned back at railway stations and highway checkpoints. The newspapers raised the pitch of tension by publishing a daily score card of the new cases.
When Lovett decided that Roosevelt was sufficiently recovered from the acute phase of the disease, he allowed him to be moved. In a private railway car, he traveled from Eastport, Maine, to Grand Central Station in New York City. He was admitted to the Presbyterian Hospital, where he received physical therapy and supportive treatment and remained until October 1921. Unfortunately, his hospital records were destroyed14.
In a letter to Dr. Draper in 1925, Roosevelt revealed that he had given some of his serum to a child with poliomyelitis and he described his experiences with the leading orthopaedists in the country:First of all let me tell you how perfectly delighted I was to get the note from Perry Osborne in regard to the use of my serum on his child. It gave me a real thrill and at the same time made me feel like a hero who is being decorated for valor in a battle in which he did not take part….Of course, I have seen the methods of practically all the other doctors in the country—the Lovett method, Goldthwaite method, Hibbs method, St. Louis method, Chicago method, etc. etc. They are all good in their way, but McDonald [of Marion, Massachusetts] uses what they use and goes one step further. The principle of the others is the exercise of individual muscles, primarily in the line of straight pull. McDonald's exercises give all this, but in addition exercises the muscles in coordination with each other…. McDonald exercises the quadriceps with and against gravity, direct motion singly, in pairs, alternately, reciprocally and also with a rotary motion, singly, in pairs, alternately and reciprocally. He also uses parallel bars and swimming.15
First of all let me tell you how perfectly delighted I was to get the note from Perry Osborne in regard to the use of my serum on his child. It gave me a real thrill and at the same time made me feel like a hero who is being decorated for valor in a battle in which he did not take part….
Of course, I have seen the methods of practically all the other doctors in the country—the Lovett method, Goldthwaite method, Hibbs method, St. Louis method, Chicago method, etc. etc. They are all good in their way, but McDonald [of Marion, Massachusetts] uses what they use and goes one step further. The principle of the others is the exercise of individual muscles, primarily in the line of straight pull. McDonald's exercises give all this, but in addition exercises the muscles in coordination with each other…. McDonald exercises the quadriceps with and against gravity, direct motion singly, in pairs, alternately, reciprocally and also with a rotary motion, singly, in pairs, alternately and reciprocally. He also uses parallel bars and swimming.15
A business associate, George Foster Peabody, co-owner of Georgia Warm Springs, wrote to Roosevelt about Lewis Joseph, a patient with poliomyelitis who had spent time in the pool at Warm Springs and had recovered sufficiently to walk. Willing to explore any avenue that could lead to a so-called cure, Roosevelt traveled to Warm Springs to see Joseph and discuss his routine of exercises and swimming. Roosevelt was impressed and was even more convinced after using the pool, in which the water remained at a constant temperature of 88°F and was highly charged with limestone and other salts that provided buoyancy. His days were spent exercising in the water, then exercising out of the water, followed by periods of sun bathing. After such a regimen, he tested his muscles and was sure they had gained strength.
Ultimately, he used part of his personal wealth to purchase the spa as a nonprofit organization; his primary motive was the desire to allow those less fortunate to recover function after paralysis. It became known as the Georgia Warm Springs Foundation, and Roosevelt was known as Doctor as he taught his patients exercises and examined them for improved muscle function. In a letter to Jeremiah Milbank, a philanthropist, he requested funds and revealed his concerns for those unable to afford therapy.April 25, 1928My Dear Mr. Milbank,My figures show that there were over 15,000 diagnosed cases of poliomyelitis in the United States alone last year….Over a period of two years we have built up the facilities here and now have over 150 people pass through our hands. There seems to be no question that we are obtaining very reasonable results in the restoration of function….There are about one hundred and fifty thousand victims of infantile paralysis who have been to a greater or lesser extent crippled; and the great majority of these patients could be helped as a comparatively very small percentage receive adequate treatment…. Our own experience is that even helpless cases dating back for many years can be, in most cases, restored to some form of useful activity. Our use of natural warm water as the medium for the giving of carefully directed exercises seems to enable the average patient to take much more exercise without fatigue than in the older method of giving these exercises in the air…. I want to hear about your plans, for while our work does not overlap, they are both for the same purpose and have a common meeting point.Very sincerely yours,Franklin D. Roosevelt16
April 25, 1928
My Dear Mr. Milbank,
My figures show that there were over 15,000 diagnosed cases of poliomyelitis in the United States alone last year….
Over a period of two years we have built up the facilities here and now have over 150 people pass through our hands. There seems to be no question that we are obtaining very reasonable results in the restoration of function….
There are about one hundred and fifty thousand victims of infantile paralysis who have been to a greater or lesser extent crippled; and the great majority of these patients could be helped as a comparatively very small percentage receive adequate treatment…. Our own experience is that even helpless cases dating back for many years can be, in most cases, restored to some form of useful activity. Our use of natural warm water as the medium for the giving of carefully directed exercises seems to enable the average patient to take much more exercise without fatigue than in the older method of giving these exercises in the air…. I want to hear about your plans, for while our work does not overlap, they are both for the same purpose and have a common meeting point.
Very sincerely yours,
Patients at Warm Springs were charged $42 a week, if they could afford this amount, and, if not, many were accepted, paying less. This amount included board, food, use of the pools, the service of a therapist, as well as consultations with a resident orthopaedist. If a larger number of patients were to be treated, additional funds needed to be sought. Roosevelt could appeal to many of the wealthy families known to him, but first he needed a scientific stamp of approval on the value of the project.
At the Annual Meeting of the American Orthopaedic Association (AOA) in Atlanta, Georgia, in April 1926, Roosevelt had requested permission from the president of the Association, Michael Hoke, to be in the program and address the membership17. When this was refused, he then requested that the Association form a committee to investigate the work of the Warm Springs Foundation and its rehabilitative successes. Hoke and most members of the executive committee were suspicious, believing that Roosevelt would use the name of the Association to advertise the virtues of the Foundation and profit from it. Several members disagreed and offered to form such a committee, ex officio, recognizing that their conclusions would in no way be regarded as a sanction by the AOA. Some of the members supporting Roosevelt were Albert Freiberg of Cincinnati, Ohio; Fred Dickson of Kansas City, Missouri; George Bennett of Baltimore, Maryland; Robert Osgood of Boston, Massachusetts; and LeRoy Abbott of St. Louis, Missouri.
Freiberg chaired the committee, which included Dickson and Bennett, and the agreed-on protocol demanded that an experiment that was to last six months be conducted. Patients with poliomyelitis were to be sent to Warm Springs, where they would be supervised by the committee, and a report on any improvement would be made. A resident orthopaedist who was to be assigned at Warm Springs would be in charge of the experiment. Dr. Leroy Hubbard, an orthopaedic surgeon and rehabilitation specialist from New York, accepted the post of resident. In May 1926, the committee sent letters to orthopaedic surgeons throughout the country requesting that they submit the names of patients with poliomyelitis who would be willing to enter the protocol. The patients were not to have an acute case of the disease that would show expected improvement or to have a chronic case beyond the time when rehabilitative improvement could no longer be anticipated. The letter ended with the statement, "Finally the committee wishes to say that it has absolute confidence in Mr. Roosevelt's sincerity and altruism in making this experiment, believing that he is absolutely free from any spirit of gain or desire for publicity."18
In the summer of 1926, Roosevelt wrote Freiberg:Aug 3, 1926Dear Dr. Freiberg,As you know, my hope is that your Committee will find this experimental period to have been worth while and upon your report, will of course, depend my plans for the future of Warm Springs. If you gentlemen are thoroughly and 100% convinced that it is worth while, I want, immediately after November 1st, to seek to raise the money necessary (my estimate would be $300,000) to build a fireproof sanitarium … capable of taking care of 100 or more patients at a time…. Dr. Osgood and Dr. Abbott have already seen the place.Very sincerely,Franklin D. Roosevelt19
Aug 3, 1926
Dear Dr. Freiberg,
As you know, my hope is that your Committee will find this experimental period to have been worth while and upon your report, will of course, depend my plans for the future of Warm Springs. If you gentlemen are thoroughly and 100% convinced that it is worth while, I want, immediately after November 1st, to seek to raise the money necessary (my estimate would be $300,000) to build a fireproof sanitarium … capable of taking care of 100 or more patients at a time…. Dr. Osgood and Dr. Abbott have already seen the place.
Very sincerely,
The newspapers learned of the experiment and pressured Roosevelt to divulge the details, but he kept the promise he had made. He was sincerely convinced of the value of such an establishment and believed it would be a forerunner of other such centers to give postoperative care for other conditions. Later that summer, Hubbard wrote a preliminary report to the committee:While the number of patients treated at Warm Springs was not large and the period covered was too short to expect extrardinary [sic] results in this class of patients, yet they all gained sufficiently, both in muscle power and functional activity…Respectfully submitted,Leroy W. Hubbard, M.D.Orthopaedic Surgeon in Charge20
While the number of patients treated at Warm Springs was not large and the period covered was too short to expect extrardinary [sic] results in this class of patients, yet they all gained sufficiently, both in muscle power and functional activity…
Respectfully submitted,
Leroy W. Hubbard, M.D.
Orthopaedic Surgeon in Charge20
In October 1926, Freiberg wrote Roosevelt a discouraging letter indicating that the committee felt that the results shown at that time could have been achieved to the same degree at any well-equipped facility elsewhere. They softened their criticism by recommending that, as a charitable enterprise conducted on a highly ethical plane, both the medical profession and philanthropy should continue to support it. In order to avoid disappointment, it should be made clear to the participants that there is nothing miraculous to be expected and that the treatment given can be carried out elsewhere.
In November, Fred Dickson wrote Freiberg that he had visited Warm Springs and was convinced of the sincerity of Roosevelt21. As to the place, Dickson found it ideal. "I, myself, was in the pool for one and a half hours and came out feeling like a fighting cock." As to the increase in function of the patients, he observed a definite, but not a startling improvement.
Bennett also advised caution. "It is my opinion that we have no right to offer Roosevelt an opinion of the Association until we are authorized, not if it takes ten years and I think this should be told Roosevelt."22
In reply, Roosevelt stated he was aware that the committee was ex officio. He simply wanted approval by a group of nationally known orthopaedists so that he could make his appeal to John D. Rockefeller Jr. and others for support23.
Hubbard made his final report in December 192620. Twenty-three patients (twelve male and eleven female) were evaluated. The average age was seventeen years, and the average stay at Warm Springs was eleven weeks. The parameters measuring improvement were the increases in the ratings of individual muscles and, secondarily, the functional improvement, including gait, use of braces, and grasp. No miracles occurred, but the majority of patients made more progress than they would if they had stayed at home.
Dr. Hoke remained intransigent. He wrote:I don't know who appointed Doctors Freiberg, Dickson and Bennett. The names probably came up in the discussion of the matter, but they were not officially appointed by me or by an official committee of the American Orthopaedic Association. May I, therefore, request that in the future neither my name nor the name of the American Orthopaedic Association be used in any letter or circular matter of this kind. What use you may feel you can make of the names of Doctors Freiberg, Dickson and Bennett you will have to take up with them.24
I don't know who appointed Doctors Freiberg, Dickson and Bennett. The names probably came up in the discussion of the matter, but they were not officially appointed by me or by an official committee of the American Orthopaedic Association. May I, therefore, request that in the future neither my name nor the name of the American Orthopaedic Association be used in any letter or circular matter of this kind. What use you may feel you can make of the names of Doctors Freiberg, Dickson and Bennett you will have to take up with them.24
In another angry letter to Freiberg, Hoke wrote:Last year when the Association met here Bob Osgood was very insistent that Mr. Franklin Roosevelt, proprietor of Warm Springs, be given an opportunity to address the Association about Warm Springs in its relation to the treatment of infantile paralysis. Bob thought I was rather hard-boiled because I refused to invite him to address the Association. Bob then decided a committee be appointed, the committee to supervise the experiments that Mr. Roosevelt was to carry out. I was just as insistent, and did all that I could to keep the Executive Committee from making such an appointment because I felt it was pretty clear that Mr. Roosevelt was more interested in the advertisement of his property … than he was in idealism and philanthropy…17
Last year when the Association met here Bob Osgood was very insistent that Mr. Franklin Roosevelt, proprietor of Warm Springs, be given an opportunity to address the Association about Warm Springs in its relation to the treatment of infantile paralysis. Bob thought I was rather hard-boiled because I refused to invite him to address the Association. Bob then decided a committee be appointed, the committee to supervise the experiments that Mr. Roosevelt was to carry out. I was just as insistent, and did all that I could to keep the Executive Committee from making such an appointment because I felt it was pretty clear that Mr. Roosevelt was more interested in the advertisement of his property … than he was in idealism and philanthropy…17
With the establishment of the Foundation, Roosevelt asked the leading orthopaedic surgeons of the country to serve on a consulting board. These included Drs. Robert Osgood, Frank Ober, and Legg of Boston, Massachusetts; Drs. Bailey and LeRoy Abbott of St. Louis, Missouri; Dr. Fred Dickson of Kansas City, Missouri; Drs. Moore and Hektoen of Chicago, Illinois; Dr. George Bennett of Baltimore, Maryland; Dr. Kidner of Detroit, Michigan; Dr. Porter of Evanston, Illinois; Dr. George Draper of New York City; Dr. Albert Freiberg of Cincinnati, Ohio; and Dr. Michael Hoke of Atlanta, Georgia. Drs. Bruce Gill and DeForest Willard of Philadelphia were also requested.
Roosevelt wrote, "The New York situation is difficult for, as you know, many of the orthopedic surgeons belong to the Dr. Russell Hibbs School and they do not think along the same lines as we do. I am inclined to think, however, that Dr. Whitman is coming around to our point of viewpoint …"25
With persistent and eloquent diplomacy, Roosevelt assuaged Hoke and convinced him to become chief surgeon at Warm Springs and an avid supporter of the Foundation. Later, Edward Irwin of Atlanta succeeded Hoke at Warm Springs.
It is fair to conclude that Franklin D. Roosevelt, as a result of his poliomyelitis, was well known to the orthopaedic community, was familiar with their viewpoints, and felt comfortable talking their language. Moreover, he had close friends and was in communication with the leading orthopaedic surgeons of the country. The national publicity surrounding Roosevelt and his every undertaking was reflected on orthopaedic surgeons throughout the country.
When Roosevelt took the oath of office for the presidency of the United States of America in 1932, the country was prostrate and in its greatest crisis since the Civil War. The Great Depression had paralyzed the country's financial system. Banks were closing as an onslaught of depositors sought to withdraw their money. Factories ground to a halt and were closing their doors. The number of unemployed was thirteen million and soaring. Roosevelt's long and persistent struggle against poliomyelitis had taught him to deal with adversity, to maintain his optimism, and to find new answers to old problems. The disease he had contracted at Campobello had wrought within him a spiritual rebirth that he was able to transmit to the country. Within 100 days after taking office, he had insured bank deposits and the banks reopened; he regulated the stock market, subsidized mortgages on homes and farms that were to be foreclosed, changed the tax system to increase the taxes on the wealthy, and later instituted Social Security for each individual.
When war was declared in December 1941, his extensive orthopaedic background became a factor in his medical appointments. The term of Major General John C. Magee, who was appointed Surgeon General of the Army in 1939, was to expire in 1943. The American Medical Society; the National Medical Association; the Red Cross; and the president's personal doctor, Vice Admiral Ross McIntire, hoped that Roosevelt would reappoint Magee. However, some in the military, including Secretary of War Henry Stimson, felt Magee was inadequate, and a list of eligible candidates was prepared by General Marshall's headquarters and was submitted to Stimson, who then recommended Brigadier General Albert C. Kenner, a general surgeon who was the chief medical officer in North Africa and was highly recommended by Generals Dwight D. Eisenhower and George S. Patton. Roosevelt originally concurred in the appointment, but suggested to Stimson that it not be presented to the Senate immediately. However, he did recommend that Kenner be relieved of his post in North Africa and flown to Washington to be briefed on the problems of the Surgeon General26.
Roosevelt demurred, changed his mind about the Kenner appointment, and wrote to Stimson on April 8, 1943, suggesting that any appointee should be well received by the medical profession. He wrote: "As you know I am in much closer touch with the medical profession in all its ramifications than most people are and I believe that some other selection could be made who would do more credit to all of us."26
Stimson wrote in his diary under the date of April 9, 1943: "Then late in the morning a letter came from the President asking me if I would not reconsider my nomination of General Kenner for Surgeon General. This was quite a body blow…. I came to the conclusion that it would be rather foolish to ask the President to reconsider—I have seen too much in my life time of the failure of efforts made to make a man who has made up his mind to reconsider his decision."27
On April 10, Stimson replied to the president, who had asked him to look further for a candidate28. He noted that Roosevelt emphasized that he wanted a surgeon general who would be regarded as an outstanding choice by the medical profession. Stimson then proposed Brigadier General Norman T. Kirk and pointedly drew Roosevelt's attention to the fact that he not only had a proven record in the army but was internationally known as an expert orthopaedic surgeon. He referred to a report from Walter Reed Hospital that this officer was a high-class orthopaedist and his work on amputations and bone grafts was equal to the best turned out by the most efficient clinics in the United States. Another recommendation from the commanding officer of Letterman Hospital characterized Kirk as "an outstanding general, an orthopaedic surgeon suitable for civilian contacts."28
Kirk had been elected a member of the AOA in 1929, and was a diplomate in both orthopaedic and general surgery, a fellow of the American College of Surgeons, a member of the American Academy of Orthopaedic Surgeons and the Southern Surgical Association, and a member of the National Research Council29.
With the war in full swing, the surgeon general commanded 90,000 medical officers and 450,000 corpsmen30. Orthopaedic surgery was then a recognized entity, separate from general surgery, with its own consultants. The medical officers in the military were preponderantly young and just out of internship. They were exposed to the trauma of war wounds and were supervised by qualified orthopaedic consultants who were either in their surgical unit or traveled from unit to unit organizing training programs, teaching, and supervising treatment to make sure that the regimens of therapy from the Surgeon General's office were meticulously followed30.
From his own experience, Roosevelt was both concerned and knowledgeable about rehabilitation. In December 1944, he wrote Stimson that, before discharge, all casualties should receive from the army the benefit of physical and psychological rehabilitation, which prompted Kirk to remark, "The idea gets around that the Army is making the boys crazy. The truth is that the Army is finding it out."31
The rapid increase in the number of orthopaedists following World War II is unquestionably multifactorial. In the latter half of the twentieth century, the practice of medicine was evolving in the direction of specialization, and long-established fields of medicine and surgery were fragmenting as a result of the explosion of knowledge. Orthopaedic surgery was accepted by the medical profession and the public as separate from general surgery. As knowledge of the musculoskeletal system increased, new avenues opened, leading to a wider array of surgical procedures and therapeutic modalities, which in itself expanded the numbers of orthopaedists and the dimensions of the specialty. A similar expansion in general surgery allowed an influx of orthopaedic surgeons into the field of trauma. General surgeons had lost interest in trauma and were occupied with cancer and body cavity surgery, which allowed orthopaedic surgeons to take over trauma to the extremities.
The role played by Franklin D. Roosevelt in furthering the specialty of orthopaedic surgery is circumstantial. I was not able to uncover any evidence that Roosevelt knew Kirk before his appointment or that Roosevelt had issued any specific directive to the Surgeon General of the Army or to the chiefs of other medical departments in all of the services to give preference to orthopaedists in the treatment of traumatic injury of the extremity or spine.
On the other hand, for eleven years, a highly popular national political figure whose newsworthy activities were constantly in the public scrutiny was unable to walk without aids. His struggle against his paralysis, which he fought with the help of leading orthopaedists from around the country, was known to all as was his interest in Warm Springs. The Warm Springs Foundation, the President's Birthday Ball that was held throughout the country, and the March of Dimes all revolved about treatment in orthopaedics and strengthened the specialty. Funds provided by the Foundation eventually led to the ultimate conquest of poliomyelitis by Jonas Salk and Albert Sabin.
Roosevelt had personal knowledge of the problems of paralysis and contributed to its treatment and rehabilitation. When the name of a well-known orthopaedic surgeon was suggested as a candidate for Surgeon General of the Army, he dismissed other candidates for this job. General Kirk, in his turn, emphasized the specialty by appointing qualified orthopaedic surgeons as consultants to circulate through military hospitals to teach and influence thousands of young surgeons in the principles of the specialty.
Fired in the crucible of world conflict, under the direction of a leader paralyzed and unable to walk unaided, orthopaedics in the United States was defined and matured.
Cave EF. Trauma and the orthopaedic surgeon. J Bone Joint Surg Am.1961;43:582-9.43582
1961
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Walker T. Roosevelt and the fight against polio. London: Rider; 1954.
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Ditunno JF Jr, Herbison GJ. Franklin D. Roosevelt: diagnosis, clinical course, and rehabilitation for poliomyelitis. Am J Phys Med Rehabil.2002;81:557-66.81557
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Letter, Eleanor Roosevelt to Rosy Roosevelt, August 20, 1921. Folder: Infantile Paralysis. Papers of Eleanor Roosevelt. Franklin D. Roosevelt Library, Hyde Park, New York.
1921
Letter, Frederick A. Delano to Eleanor Roosevelt, August 30, 1921. Folder: Infantile Paralysis. Papers of Eleanor Roosevelt. Franklin D. Roosevelt Library, Hyde Park, New York.
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Letter, Eleanor Roosevelt to Rosy Roosevelt, August 21, 1921. Folder: Infantile Paralysis. Papers of Eleanor Roosevelt. Franklin D. Roosevelt Library, Hyde Park, New York.
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Letter, R.W. Lovett to G. Draper, September 12, 1921. BMS c39. Countway Library of Medicine, Boston, Massachusetts.
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Chart note made by R. W. Lovett on Franklin D. Roosevelt's medical record, January 28, 1922. BMS c39. Countway Library of Medicine, Boston, Massachusetts.
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Letter, Franklin D. Roosevelt to Mrs. K. Lake, November 5, 1923. Folder: Infantile Paralysis. Franklin D. Roosevelt Library, Hyde Park, New York.
1923
Letter, Franklin D. Roosevelt to Mr. Van Rensselaer, December 12, 1923. Folder: Infantile Paralysis. Franklin D. Roosevelt Library, Hyde Park, New York.
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Goldman AS, Schmalstieg EJ, Freeman DH Jr, Goldman DA, Schmalstieg FC Jr. What was the cause of Franklin Delano Roosevelt's paralytic illness? J Med Biogr.2003;11:232-40.11232
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Letter, Franklin D. Roosevelt to J. Milbank, April 25, 1928. Folder: Infantile Paralysis. Franklin D. Roosevelt Library, Hyde Park, New York.
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Letter of M. Hoke to A. Freiberg (date not known). Freiberg Papers, MS716. Box 1, Folder 3-6. Jacob Rader Marcus Center of American Jewish Archives, Cincinnati, Ohio.
Letter of A. Freiberg to Orthopaedic Surgeons. Freiberg Papers. MS716, Box 1, Folder 3-6. American Jewish Archives, Cincinnati, Ohio.
Letter of Franklin D. Roosevelt to A. Freiberg, 1926 August 8. Freiberg Papers. MS716, Box 1, Folder 3-6. American Jewish Archives, Cincinnati, Ohio.
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Letter of L. Hubbard to A. Freiberg (date not known). Freiberg Papers. MS716, Box 1, Folder 3-6. American Jewish Archives, Cincinnati, Ohio.
Letter of Fred Dickson to A. Freiberg, 1926 November. Freiberg Papers. MS716, Box 1, Folder 3-6. American Jewish Archives, Cincinnati, Ohio.
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Letter of George H. Bennett to A. Freiberg, 1926 November. Freiberg Papers. MS716, Box 1, Folder 3-6. American Jewish Archives, Cincinnati, Ohio.
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Letter of Franklin D. Roosevelt to A. Freiberg, 1926 November. Freiberg Papers. MS716, Box 1, Folder 3-6. American Jewish Archives, Cincinnati, Ohio.
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Letter of Dr. M. Hoke to A. Freiberg (date not known). Freiberg Papers. MS716, Box 1, Folder 3-6. American Jewish Archives, Cincinnati, Ohio.
Letter of Franklin D. Roosevelt to A. Freiberg, 1928 January 26. Freiberg Papers. MS716, Box 1, Folder 3-6. American Jewish Archives, Cincinnati, Ohio.
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Henry Stimson Diaries, April 8, 1943. Document 5, V42, p. 157. Franklin D. Roosevelt Library, Hyde Park, New York.
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Henry Stimson Diaries, April 9, 1943. Document 5, V42, p. 157. Franklin D. Roosevelt Library, Hyde Park, New York.
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Who's who in America 1944-45. Wilmette, IL: Marquis. p 353.