History of Wound Care: Case File - Theodore Roosevelt

It was early 1880, and Theodore “Teddy” Roosevelt Jr. was attending Harvard University, nearing the completion of his senior year. His impending graduation would soon give way to a lengthy political career that would culminate in his serving as the 26th president of the United States. But he was also a “brokenhearted”¹ student who had recently ended a lengthy engagement to longtime sweetheart Edith Kermit Carow and had buried his father, who died after a brief and ravaging bout with stomach cancer, the previous year. Having vowed to finish his schooling in honor of his dad, Roosevelt was primed to do great things while being fueled by a fierce determination — a trait that would continue to identify him as a man and help him to mend his spirts when he met and became engaged to Alice Hathaway Lee, a socialite whom he passionately courted for many months before receiving her acceptance to marry. He would soon become a member of the New York State Assembly and would go on to hold such posts as president of New York City’s Board of Police Commissioners, assistant secretary of the U.S. Navy, and governor of New York before being voted into the White House as vice president under William McKinley. Of course, Roosevelt’s political career tells only part of the story of this “Trust Busting,” “Rough Riding” “Teddy Bear” who eventually garnered a celebrity-type status that still holds him as one of the more popular presidents to run this country. That reputation would start to be realized while still at Harvard, where he’d win a silver medal as a boxer, be elected to the oldest existing social club in the U.S. (the Hasty Pudding Club; yes, members make their own pudding for meetings), preside over the university’s finance and natural history clubs, and begin to write a book about the naval history of the War of 1812¹ — one of nearly 20 books that he’d author.² An avid tennis player, he was also wont to hike, row, play polo, and ride horses as part of his pursuit to living what he called the “strenuous life.” It was a life that would lead him to frequent traveling, including expeditions in South America and Africa, tours of Europe, and time out West, where he’d emulate some of his passions, such as establishing ranches in North Dakota. At age 39, he’d lead the Battle of San Juan Hill, and as a 53-year-old he’d survive an assassination attempt outside of a Milwaukee, WI, hotel. Yes, Roosevelt had a relatively long life still ahead of him as he pursued that Harvard degree. And he’d live that life in a fashion that strictly went against doctor’s orders, as shortly before earning his bachelor’s magna cum laude a Harvard physician by the name of Dudley Allen Sargent informed the self-proclaimed “Bull Moose” of an irregular heartbeat that was concerning enough to advise a sedentary lifestyle and to avoid all physical exercise, including the climbing of stairs.¹

“Roosevelt obviously ignored him,” said Susan Sarna, chief of cultural resources at Sagamore Hill National Historic Site, Oyster Bay, NY, the longtime residence of Roosevelt that today serves as a popular tourist attraction and houses some of the most intimate collections available on Roosevelt. “He obsessed with rowing boats, hiking, hunting, boxing, and jujitsu – and all of these activities were the types of things he obsessed about because his father always told him, ‘If you’re strong, you won’t have these [health] problems.’”

“These problems” include a myriad of conditions that afflicted Roosevelt, literally for his entire life, and in many ways negatively impacted his last few years and played a role in his death at age 60, which, on paper, according to multiple sources, was due to a suspected pulmonary embolism. Although he’d reportedly not only ignore the physician’s recommendation to “avoid undo excitement, which was probably the treatment for that [heart] condition in those times,” according to Sarna, he’d tell the physician, “If I must live the sort of life you’ve described, I don’t care how short it is.”¹ And so the story of Roosevelt’s healthcare history hardly ends here. In fact, it most likely runs much deeper than he or any physician at the time could have predicted and includes a years-long struggle with chronic wounds and infections stemming not from his being shot in the chest by John Flammang Schrank that fateful evening in 1912 (see sidebar), but mainly due to the adventurous lifestyle he promised to live (and an infamous trolley car accident). And for all the irregularity of his beating heart, it would indeed prove to be Bull-Moose strong enough to endure multiple tragedies, including the death of his dear Alice, whom would die soon after the birth of their first child (on the same day as his mother, no less) due to kidney complications that were masked by the pregnancy, and the death of his youngest son, Quentin. That’s not to say that these events did not negatively impact his health, however. As part of our ongoing series on the History of Wound Care, Today’s Wound Clinic examines Roosevelt’s complicated clinical narrative and poses some questions about what his healthcare diagnoses and treatments might resemble if he were alive today.

Asthma & Other Afflictions
The second of four children born into a wealthy New York family in 1858, Roosevelt is generally believed to have been born with congenital asthma,¹ although he was not actually diagnosed with the condition until about age 2, Sarna said. Roosevelt once wrote, “I was a sickly, delicate boy who suffered much from asthma, and frequently had to be taken away on trips to find a place where I could breathe.”³ According to Sarna, these “trips” included long carriage rides with his father into the Adirondack Mountains and Oyster Bay in an attempt to get air into his lungs, a recommended remedy at the time. “They thought that the faster the carriage rode the better air would enter his lungs and free up his breathing,” she said. “His father also used to force him to smoke cigars, and they used to give him a ton of coffee. He didn’t smoke as an adult, but he was a heavy coffee drinker his whole life.”
The asthma stayed with him too, and there is at least some speculation that he embellished the severity of disease and his attacks due to the attention that he got from his father when he displayed symptoms.

“Some authors do say that he had more attacks [than the clinical evidence suggests] to get attention from his father — that he longed for attention from his parents,” Sarna continued. “He tended to have asthma attacks quite a bit on weekends, it seemed, particularly on Sundays. And some people claim he purposely had asthma attacks so that he didn’t have to go to Sunday school or so that he could spend the day with his father, because whenever he would have an attack, his father would drop everything to be with him.” During his teen years, Roosevelt wrote about asthma attacks that were “among his worst” while living with a host family in Germany during an extended visit to the country, one of many travels he experienced beginning at an early time in his life (usually with his family), which could count as further evidence of his symptoms correlating with separation from his parents (or perhaps the stress of that circumstance). Additionally, when his first wife Alice died on Valentine’s Day in 1884 of Bright’s disease (today known as nephritis), he was said to have suffered attacks. His mother, Martha Bulloch Roosevelt, died that very day, also in Roosevelt’s home, due to complications of typhoid fever. Despite his daughter being just two days old, Roosevelt would soon travel to the West for an extended time to grieve and to “harden” himself. (Alice would remain in the care of Roosevelt’s sister until the age of three, when Roosevelt reassumed her custody.⁴)

“This all sends him onto a retreat of sorts,” said Sarna. “He ran from the issues that were [at home] and to grieve — or to figure out how to grieve because he didn’t know what to do when his mother and his wife died. He had bought a ranch previously with his brother, the Maltese Cross Ranch, in the Dakotas. So, he went out there and has said that the experience ‘hardened him and made him the man that he was.’ He loved Alice dearly, but he had a habit of running away from handling situations. For instance, when he was at Harvard and courting Alice, and she wasn’t exactly agreeing to his courtship in the beginning, in his diary he writes that he went ‘for a ride.’ And out West, he was riding in the saddle 12-18 hours per day. And when he returned home, the attacks had lessoned. But he never got rid of them.”

He probably never reached any point in his life in which he’d be likened to having a “clean bill of health” either.

“His entire life, if it wasn’t an asthma attack, it was something else,” Sarna said. Most notably would be his recurring struggle with malaria, which he first contracted while in Cuba with the Rough Riders in 1898 during the Spanish-American War. “A lot of the troops down there died of malaria and yellow fever,” she explained. “After the war was over, they were quarantined in Montauk.” It’s been reported that although Roosevelt did not require isolation, he did stay with his men.⁵ Likewise, the malaria remained with him. “He didn’t have any real symptoms until he came back [home], and they were supposedly not bad at all, but unfortunately, the malaria supposedly did kick up more often [from then on],” Sarna said. At the time, malaria was treated by ingestion of a Peruvian bark containing quinine, which did not cure the disease but helped to alleviate symptoms.⁶ Today, while quinine is still used for treatment, it is not the only option, and preventive measures can be taken for those who travel or would otherwise be at risk.⁷

As a child, Roosevelt also developed a severe astigmatism that was not properly diagnosed until about age 13 when he had difficulty hitting a target while firing his first gun with his father in Central Park. Because he was homeschooled and never sat in a public classroom, his poor eyesight lingered. (Coincidentally, unfortunately, he would eventually lose all sight in his left eye by 1908 after a boxing injury in 1904 that resulted in a detached retina.) “He had problems with his throat — laryngitis,” Sarna added. “We don’t know why he constantly lost his voice, but he did have a high-pitched voice and spoke a lot. He always had a problem with his vocal chords. He also got [frequent] stomach aches, irritable bowel almost, but he stops writing about them as he gets older,” she continued. “He wrote about them quite a bit, and how he wasn’t ‘feeling well,’ until he met Alice. Once he meets Alice, he doesn’t write about being ill. Then, Alice dies and it’s almost like he develops this euphoric type of attitude. People would say things like he went up the stairs three at a time or he was always working. And that was because he never stopped. He literally couldn’t stop. It was as if had he stopped moving, then everything would catch up to him — that he’d realize he wasn’t happy.”

Although he never developed a substance abuse problem like his brother Elliott, whose reported alcoholism is said to have led to a suicide attempt that ultimately caused his death in 1894, “he managed to keep the demons at bay, so to speak, by not drinking or smoking, but he never stopped — he couldn’t sit still,” Sarna said.

An article written in 2015 by Carlos Arturo Camargo Jr., MD, DrPH, and Tweed Roosevelt, great grandson of Roosevelt, claims that at the very least Roosevelt’s asthma was not psychosomatic and that the historical record provides strong evidence for poorly controlled, persistent asthma.⁸  Sarna also said that there is no reason to believe that hypochondria could have been a factor. “I wouldn’t say he was a hypochondriac because he fought his ailments and I think he really was sick,” she said. “Some people think he had sleep apnea, he might have had gout, and he definitely had, in 1916, an attack of pleurisy, which of course is what he ended up dying from. The rest of his life, however, his injuries were bad and they weren’t from being a hypochondriac.”

On Accidents & Ambitions
To that end, there is more than anecdotal evidence to suggest that Roosevelt’s personality traits and hobbies played more than a casual role in his health.

“Something that seems to travel with him at all times is his thrill-seeking, his constantly putting himself in the face of danger,” Sarna said. “He rides up San Juan Hill on horseback when he’s the center of the target. Soon before his presidency he sustained concussions after falling off his horse playing polo, and he broke an arm and ribs while riding at Sagamore Hill. He boxes as the president against a professional. Everything he did was sort of like he wasn’t worried if he lived or died.”

These sentiments somewhat reflect the findings of the Camargo/Tweed Roosevelt research: “We believe that [Roosevelt’s] childhood struggles with asthma, and the misconception that he vanquished his illness through exercise [another example of the somewhat remedy suggested to him by his parents and/or physicians], were experiences that profoundly affected his worldview,” the authors write. “[Roosevelt] is known for his appreciation of life's struggles and for a bedrock belief that people can create major change with sufficient motivation and hard work. In different ways, misunderstandings about asthma contributed to the early development of these personal characteristics.”⁵
Similarly, Joshua Reyes, chief of interpretation, visitor services, and natural resources at Sagamore Hill, sees a certain sense of machismo playing its part in not just Roosevelt’s actions but in his overall health.
“I think he never accepted the fact that he was getting old,” Reyes said. “It’s similar to what you see in athletes, especially among football players, where ‘Father Time always catches up with them.’ Sometimes people are ready and accepting of it, but most are not. They just think they can keep going, and that was certainly Theodore Roosevelt for his whole adult life — all the way up until his death.”

A case in point that alludes to a potential mind/body connection to Roosevelt from a behavioral aspect: “He remarked when he went down to South America, the trip that almost killed him, that it was his ‘last chance to be a boy,’” Reyes said. “So, he was always ‘young at heart,’ and that wasn’t just with physical activity that he would participate in, but also his eating. I think most young men go through that phase where they are just ‘eating machines,’ and Teddy just never really grew out of that.”

In a book titled All In The Family by Theodore Roosevelt III, he reveals that Roosevelt would “eat a dozen hard-boiled eggs for breakfast — in one sitting. He was a big eater, and that was one of the reasons his wife [Edith] had him enrolled in a physical training camp in 1917 in Connecticut – to lose some weight.”
His weight also became an issue after the scary trolley accident in 1902, when a horse-drawn carriage carrying a party that included Roosevelt and Secret Service agent William Craig was struck by a speeding trolley. Craig was killed and Roosevelt was thrown 15 feet. While he reportedly suffered no broken bones, Roosevelt had contusions⁶ to his face and a serious injury to his left leg that confined him to a wheelchair for at least one month, during which time he gained an excessive amount of weight that he never really lost. “His weight was a factor in his overall health the rest of his life,” said Sarna — though neither she nor Reyes believe his weight issues reached the point of a diabetic or obese condition. “I think the food was just more related to his overall behavior,” Reyes said. “Edith spoke about how he ‘continued to play hard with his grandchildren.’ It’s just a reflection of him feeling like he was younger than he really was.”

The Not-Able-To-Be Walking Wounded

What is not debatable is that the leg injury plagued Roosevelt for the remainder of his life. Although at the time the consensus appears to be that the injury was not serious enough to be life-threatening or altering, records show that an abscess developed about one week after the accident, osteomyelitis set in,⁶ and surgery was required. Without the benefit of antibiotics (not to mention the sophistication of today’s surgical procedures), there would be no true remedy for Roosevelt. “The [initial] surgery didn’t completely drain [the wound], and it never really healed completely from that day on,” Sarna said. While the occasional flare-up and recurring pain do not dramatically alter Roosevelt's life during the ensuing years, which included his participation in a yearlong African expedition outfitted by the Smithsonian Institution, Roosevelt’s condition would become exacerbated during another infamous voyage into the Brazilian jungle and down the Rio da Dúvida (“River of Doubt”; today named the Roosevelt River in his honor) in late 1913 and early 1914. On the latter trip, he was older, didn't have as much stamina, and became malnourished when his group, which included his son Kermit, ran out of provisions and food. The hot weather and disease-carrying insects made for a tenuous environment, and when Roosevelt sliced his leg on a rock while on the waters infection quickly set in again — this time to the point of chronic osteomyelitis and the inability to ambulate.⁶ “It is a deep wound, blunt trauma to the same leg, and the leg becomes reinfected since it had never really healed,” Sarna said. “They find evidence of erysipelas, and he has a very difficult time even standing because the leg was in such bad shape. He is weak because he has malaria and malnutrition. It was not a great trip [and] that poor leg never did well after that. He would develop abscesses that would have to be drained the rest of his life. He’s walking around with an intermittent open chronic wound to the leg. By February of 1918, one year before he dies, the infection has spread to his middle ears, to the mastoid bone. He is in very bad shape.”

Roosevelt’s Final Days

By the time his presidency is over, Roosevelt had already been experiencing chronic rheumatoid arthritis among his many chronicled maladies. “His joints are constantly swollen, and he’s experiencing a lot of pain,” Sarna said. “By 1918 he was having operations on his ear, and that failed, so now he’s blind in one eye, deaf in one ear, has a bullet near his heart, and had infections in his leg and could barely walk.”
According to an article by the New York Times that was filed the morning of his death in 1919, “he tore his leg badly when he was thrown from a boat while descending the River of Doubt, and the wound became badly infected. While ill from this, he suffered an attack of fever. His health was never sound for any long period since his return from South America early in 1914. … The wound in his leg was directly responsible for the complication of diseases which [sic] sent him to the hospital in February of last year, where for a time his life was despaired of. He suffered from a fistula and from an abscess in the ear, which stopped just before it reached the mastoid process. … The cause of death was an embolus.”⁹

By that October, about three months after Quentin was killed while with the U.S. Army in an aerial combat over France on July 14 (Bastille Day), “all of his joints were severely swollen,” Sarna said. “He also had an attack of lumbago, and so by the time he dies with the pulmonary embolism he is in horrible shape with infections all over and swelling. He had been in and out of the hospital for a full year.” At the end of 1918, he was hospitalized for about one month due to the various infections before being discharged to return home Christmas Eve.⁶ According to the Times report, “Roosevelt was working hard as late as Saturday [he died on a Monday], dictating articles and letters. He spent Sunday quietly, but looked and felt well, until shortly before 11 o’clock [at night], when he had difficulty in breathing. After treatment, he felt better and returned to bed.” The breathing issues were not connected to his asthma, and he was found unresponsive at approximately 4 a.m. By all accounts, his final moments were rather peaceful, but the many circumstances of his health continue to raise questions among researchers and scholars about how much physical and emotional pain he actually did live with for many years. Had he been alive today, his medical treatment plan would likely have included long-term antibiotics and pain medication, debridement, skin grafting, and perhaps a prosthetic, as well as lifestyle changes.⁶ Sarna also said there are reasons to believe that mental healthcare would be recommended.

“He definitely had some underlying issues,” she said. “He could run the country, but he couldn’t discipline his children properly. He was never around for the births of any of his children [due to Alice’s death]. He could face a Spaniard shooting at him charging up a hill, he could face snakes and malaria and death by going down the Brazilian, and he could face a rhino charging at him. But he couldn’t handle the emotional issue of [possibly] losing another person. He actually was very sensitive.”

Joe Darrah is managing editor of Today’s Wound Clinic.

SIDEBAR
Roosevelt Lives to Speak About Assassination Attempt

Beyond serving as vice president and president of the United States, Theodore Roosevelt Jr. was known to be many things. Philanthropist. Author. Boxer. Hunter. Assemblyman. Governor. Rancher. Police commissioner. Conservationist. Naturalist. Explorer. And the list goes on. Throughout it all, he was also known to be very long-winded and today there exists records of the hundreds of speeches that he delivered.¹⁰ “He spoke a lot,” said Susan Sarna, chief of cultural resources at Sagamore Hill National Historic Site, Oyster Bay, NY, the longtime residence of Roosevelt that today serves as a popular tourist attraction and houses some of the most intimate collections available on Roosevelt — this despite having to overcome a speech impediment.¹¹ Although Roosevelt was not necessarily regarded for the quality of his oratory skills,¹¹ his style certainly can be credited with saving his life. Were it not for a 50-page set of notes that he carried in his jacket on the evening of Oct. 14, 1912, the very speech that he had planned to deliver at the then Milwaukee Auditorium while campaigning for the soon-to-be-held presidential election (he lost), Roosevelt would not have survived an assassination attempt that occurred en route to the engagement.
“Friends, I shall ask you to be as quiet as possible. I don’t know whether you fully understand that I have just been shot,”¹² Roosevelt reportedly told the assembly when he disregarded the orders of a physician who was among the party traveling with him from the Gilpatrick Hotel in an open-air car to the speech. The doctor wanted to take the then 53-year-old immediately to the hospital. Instead, after actually taking the time to confront shooter John Flammang Schrank, an unemployed New York City saloonkeeper who reportedly planned the assassination attempt and followed Roosevelt across the country for weeks,¹² during the frantic minutes following the single gunshot, Roosevelt demanded that the driver get him to the event, where he reportedly spoke for 90 minutes. A bit of a showman to say the least, Roosevelt is said to have revealed to the crowd his bloodstained shirt, which, with the additional “protection” of a vest and a steel eyeglasses case that accompanied the folded speech papers in the coat pocket, slowed the bullet enough to not reach any vital organs and instead remain lodged against his right rib.¹² X-rays taken at Chicago’s Mercy Hospital in the early-morning hours following the attempted assassination confirmed to the onsite physicians that leaving the bullet in the president’s chest would indeed be safer than attempting surgery (as well as due to risks related to anesthesia and infection),⁶ though it is said that the injury exacerbated his chronic rheumatoid arthritis for the remainder of his life.¹²

1. Grant G. The Courage and Character of Theodore Roosevelt: A Hero Among Leaders. Nashville, TN: Cumberland House;1996.

2. Roosevelt, T (2006). An Autobiography. New York, NY: Charles Scribner's Sons;1913.

3. Wagenknecht E. The Seven Worlds of Theodore Roosevelt. Oyster Bar, NY. Theodore Roosevelt Association;1958.

4. Miller N. Theodore Roosevelt, A Life. New York, NY. William Morrow & Company;1992.

5. Draffen D. Roosevelt's rough ride led to Montauk. New York Times. 1998. Accessed online: www.nytimes.com/1998/05/17/nyregion/roosevelt-s-rough-ride-led-to-montauk.html

6. Blank Reid C. Historic trauma cases: Theodore Roosevelt. ADVANCE for Nurses. 2010. Accessed online: http://nursing.advanceweb.com/historic-trauma-cases-theodore-roosevelt-26572

7. Malaria. Mayo Clinic. 2018. Accessed online: www.mayoclinic.org/diseases-conditions/malaria/symptoms-causes/syc-20351184