Spring 2004
The author (ΑΩΑ, University of Rochester, 1955) is professor and vice chairman of the Department of Medicine at the UMDNJ-Robert Wood Johnson Medical School. He is a previous contributor to The Pharos. Theodore Roosevelt (TR), the assistant secretary of the Navy, paced restlessly about his office. It was February 25, 1898, and there were many things to do. The shattered hulk of the U.S.S. Maine lay submerged in Havana Harbor. An investigation into the cause of the explosion was underway. TR had no doubt that the Spanish were responsible and that the war that he had worked so diligently to bring about was imminent.(1,2) This morning he was elated to learn that his superior, Secretary John D. Long, would be taking the day off to visit his osteopath for more electrical treatments and massage for his various aches and pains. As always, the secretary had advised his assistant secretary not to do anything before his return, but TR routinely ignored these admonitions. Springing into action, TR scribbled orders and gave them to the clerks for coding and dispatch around the world. One cable was to Commodore George Washington Dewey, the commander of the Pacific fleet, ordering him to sail immediately for Hong Kong and to keep the ships full of coal and ready to engage the Spanish Navy in Manila Bay at the outbreak of war. He also sent a message to Congress requesting special wartime legislation. Upon the secretary’s return to the office, Long wrote in a memo to President McKinley, “I find that Roosevelt, in his precipitate way, has come very near to causing more of an explosion than happened to the Maine. . . . The very devil seemed to possess him.”(1p603) TR had no intention of spending his time behind a desk in Washington when war broke out. He had always dreamed of proving his manhood in combat, and he now sensed that this opportunity was finally approaching. But how could he leave when his wife, Edith, was at death’s door?(1–3) She had “collapsed” on January 4, 1898, with sudden onset of fever, weakness, and malaise, just two months after the uneventful birth of her fourth child. This acute illness was called “the grippe,” but her physician suspected typhoid fever during the next week as her temperature increased and remained constantly elevated. After the first week, fever and malaise gradually diminished until January 17, when she had a sudden recurrence of high fever accompanied by severe lumbar pain and sciatica so intense that she could not sleep. This back pain was initially attributed to prolonged bed rest, but it had progressed every day, along with rising fever. Her temperature was never below 101° and it rose much higher in the evening. Then on February 23, two days before, she had developed unilateral tenderness and swelling in the lower abdomen and groin. Her physician remained puzzled, and just this morning TR had sent for the most respected diagnostician in the area, Dr. William Osler, from the new Johns Hopkins Hospital. Osler agreed to visit her the following day. Of course, TR had continued to work during Edith’s prolonged illness and had hired a trained nurse to stay with her. Edith had learned to be selfsufficient, since TR’s work took him away from home for long periods of time, and he frequently traveled alone on hunting trips and visits to his North Dakota ranch, leaving her alone and often pregnant to care for the family homes and the children. Now he realized that all semblance of normal family life had vanished. The younger children had been sent to stay with friends. His oldest child by his first marriage, 14-year-old Alice, was “uncontrollable” and a constant source of concern. Theodore Jr., age 10, was complaining of severe headaches and several physicians had been unable to identify the cause. Soon, both would be sent to stay with TR’s sister Anna (“Bamie”) in New York. The household was in shambles because he had depended on Edith to do virtually everything, including managing the family finances; every morning she put $20 in his pocket, and at the end of the day he seldom remembered where the money had gone. Now he was sometimes embarrassed to find himself without pocket money. Dr. Osler’s consultation only increased TR’s anxiety. It was the doctor’s opinion that the swelling around Edith’s groin and lower abdomen was due to an abscess in the psoas requiring urgent incision and drainage. TR was appalled at the drastic recommendation and he feared for Edith’s life. He had never spoken to anyone of the death of his first wife after childbirth, but that painful memory could not have been far from his mind at this hour. To compound that loss, his mother had died of typhoid on the same day. Normally a decisive person, TR was reluctant to proceed, and he solicited opinions from other physicians, friends, and acquaintances. The day after the consultation, Edith seemed a bit better, but during the next week her condition worsened. A gynecologist was finally called to see her on March 5. He confirmed Osler’s diagnosis and made arrangements for surgery at home on the following day. Under anesthesia with ether, the abscess was incised successfully, leaving an open draining wound, and during the next few days Edith’s pain and fever improved. However, she was still bedridden and very weak, and her recovery was in doubt. TR worried about her constantly, but was also depressed about the effect her illness had on his own plans with his friend Leonard Wood4 to raise a volunteer cavalry regiment for service in Cuba. On March 15 TR wrote to a friend “I shall chafe my heart out if I am kept here instead of being at the front.”(5p795) In a letter to his oldest son on March 27 he wrote, “Today I took a hard walk with Doctor Wood and we both discussed how we could get into the army that would go to Cuba.”(3p171) Edith continued to look weak and “terribly wasted,” but she was certainly aware of her husband’s distress. On April 4, Edith rose from her bed in the morning and, after her husband had left for work, was able to dress and go downstairs for breakfast. Later she impulsively called for her carriage and asked to be driven to the Metropolitan Club, where TR was accustomed to go for lunch. Women were not permitted in the club, but fortunately she saw Leonard Wood leaving and asked him to inform TR that a lady wanted to speak to him outside. Unsuspecting, TR emerged from the club and, recognizing his wife, came running to embrace her. Edith later wrote her son “I wish you could have seen his face of surprise and delight.”(3p172) Yes, Edith was back, and by this miraculous appearance she was telling him that, at long last, he had permission to leave! Years later TR said, “I know now that I would have turned from my wife’s deathbed to have answered that call,”(3p173) but he was spared that difficult decision. Despite her fears for his safety, and her desolation at his departure, Edith recognized that it was hopeless to oppose his irresistible will. After a month of feverish preparation, TR left to join his Rough Riders on May 6. Edith was well enough by June 1 for a railroad journey to Tampa to see her husband briefly before the departure of the Cuban expedition, the first American force to fight in a war overseas. The Rough Riders had trained in San Antonio in record time and would be among the first wave of troops to hit the beach at Daiquiri. On arrival at the Tampa Bay Hotel, Edith was pleased to learn that the regimental commander, Leonard Wood, had given her husband permission to join her at night if he would return to camp for reveille at 4:00 a.m. Before departing three days later, she reviewed the cavalry unit at mass drill, met the officers, and bade farewell to TR, who was now firmly on the road to glory. The stage was set for the Rough Riders’ famous charge up San Juan hill. In just three years TR would progress from a minor public official to President of the United States. Edith’s acute febrile illness was initially described as “the grippe” but her physician suspected typhoid fever. This diagnosis in outpatient practice would undoubtedly be based upon clinical findings, although both blood cultures and a serologic test were available in 1898.(6) In Osler’s textbook, the first chapter (48 pages) was devoted to typhoid, which at that time was the most important acute febrile illness in the United States, resulting in 35,000 to 40,000 deaths annually.(7) During the Spanish-American War, one of five soldiers had typhoid, a far more common cause of death than military action. We have no information on the clinical clues in Edith’s case but they may have included rose spots, gastrointestinal symptoms, or a pulse rate that did not increase in proportion with the temperature elevation. The fever in typhoid usually declines gradually after the second week, but secondary complications become more evident and lead to considerable morbidity and mortality. With other notable physicians of his era, Osler was well versed in identifying these complications, the subject of many of his 70 publications on typhoid. Edith had recrudescent fever with lumbar pain and sciatica at the end of the second week of illness. These persisted for more than a month, after which she developed an abscess in the groin, suggesting spinal osteomyelitis with extension of infection along the course of the psoas muscle. A walled-off abscess from an intestinal or appendiceal perforation cannot be ruled out, but this would be less likely in the absence of abdominal pain and the presence of lumbar pain and sciatica. Typhoid osteomyelitis is rarely seen today, but several large series were reported before antibiotics were available. Osler saw six cases in a single year.(7) Staphylococcus aureus is now known to be the most common cause. Osteomyelitis in adults, regardless of the etiology, is most common in the spine, involving two adjacent vertebral bodies and the disc space between them. Spontaneous vertebral fusion is a frequent outcome and the patient may often be free of residual symptoms. This was true in Edith Roosevelt’s case; she lived to be 87, surviving her husband by almost 30 years. All physicians are aware of the impact of a serious illness on family relationships, job performance, and psychosocial status. Illness and loss bring out the best and worst in those affected. When a prominent person is involved either as a patient or family member, the illness may have broader implications and may occasionally influence the course of history. Edith Roosevelt’s illness occurred at a critical moment, just prior to a brief and wildly successful war, one that would change the United States from an isolationist nation into an imperial power. Leading the charge into the new century, as he had led his Rough Riders into the hail of Spanish Mauser bullets at San Juan hill, was a young and dynamic president. Edith’s illness left TR stunned and frustrated, but after her miraculous recovery he was reinvigorated and seemingly irresistible in his dash to the political summit. Edith had been close to death, and TR’s own indecision might have contributed to this outcome. He had been unable to deal emotionally with his first wife’s death and had abandoned human contact to be alone in the western wilderness. TR was never able to speak of her again, even to his daughter Alice, the only child of that marriage. Had TR not gone to Cuba in 1898 the outcome of the war would have been the same, but his leadership and his vision of America’s role in the new century might have been lost. It may be instructive to examine the illness from the perspective of the main participants and to evaluate the behavior of each. Edith Kermit Roosevelt had been a childhood playmate of TR and a close friend of his younger sister. Many family members and friends had expected them to marry some day but, while he was a student at Harvard, TR met and married Alice Lee, the beautiful daughter of a prominent Bostonian. Edith concealed her disappointment and attended the wedding. After Alice’s tragic death and TR’s western flight, a chance encounter led to a renewal of their relationship and to their marriage in 1886.(1–3) By most standards, the marriage had been a success during the 12 years preceding Edith’s illness. Edith understood TR better than he understood himself and was his intellectual and emotional equal, despite their differing personalities. She was well-read, witty, and articulate, but she cherished her privacy and preferred to avoid the limelight. She was always composed, selfassured, and never overly extravagant, all useful qualities in a future first lady. Clearly superior to her husband in judging character and in business sense, she often served as his closest advisor. Edith made attempts to restrain TR’s impulsive behavior, but recognized and accepted her limitations. TR noted that every time he had gone against his wife’s advice he had paid for it. Henry Adams, the eminent historian and philosopher who had known the Roosevelts during TR’s previous Washington appointment as Civil Service Commissioner, admired Edith’s quiet but effective control of TR: “He stands in such abject terror of Edith. . . . What is man that he should have tusks and grin!”(3p126) During her illness, Edith demonstrated her selfless devotion to her family. Just before surgery TR noted: “She behaved heroically; quiet, and even laughing, while I held her hand until the ghastly preparations had been made.”(5p790) Perhaps Edith’s finest moment was her surprise appearance at the Metropolitan Club on her first day out of bed, an inspiring gesture that proved to be the turning point in TR’s life. In contrast to his wife, Edith’s illness appeared to bring out the worst in TR. As always, he was preoccupied with his work and annoyed by the distractions of his disintegrating home life. However, as he watched Edith’s progressive course, wracked with pain and fever, TR’s own defenses weakened, and he succumbed to anxiety and indecision. The surgery essential to her survival was delayed for more than a week. Nevertheless, he seems to have learned from the experience how completely he depended on Edith and how he might improve as a father. His son’s headaches had resolved after he left home to stay with his aunt Bamie in New York, where he was seen in consultation by TR’s friend, Dr. Alexander Lambert. Lambert later wrote to TR that the headaches had an emotional cause and resulted from too much pressure from his father. The consultant In 1898, William Osler was in peak form as a consultant and academician. Although the details of his examination on Edith Roosevelt are unavailable, we know that his performance was competent and professional, and his diagnosis and recommendations were on the mark. Because he hoped for a nonsurgical solution, TR failed to appreciate Osler. In a letter several days after the examination, he wrote, “The Baltimore expert did no good.”(5p787) All’s well that ends well This story recaptures a moment in history when one person’s illness collided with the march of momentous world events, and the lives of two great figures at the turn of the twentieth century intersected. The patient emerged unscathed from a life-threatening illness, and one can only wonder how a less salubrious outcome might have modified the American century that was about to begin. References 1. Morris E. The Rise of Theodore Roosevelt. New York: Coward, McCann & Geoghegan; 1979. 2. Dalton K. Theodore Roosevelt: A Strenuous Life. New York: Alfred A. Knopf; 2002. 3. Morris SJ. Edith Kermit Roosevelt: Portrait of a First Lady. New York: Coward, McCann & Geoghegan; 1980. 4. Pinals RS. The physician who ran for president: The life of Leonard Wood—A study in professionalism. Pharos Summer 2003; 64: 12–18. 5. Morison EE, editor. The Letters of Theodore Roosevelt. Volume I: The Years of Preparation, 1868–1898. Cambridge (MA): Harvard University Press; 1951. 6. Howell JD. Technology in the Hospital: Transforming Patient Care in the Early Twentieth Century. Baltimore (MD): Johns Hopkins University Press; 1995. 7. Osler W. The Principles and Practice of Medicine: Designed for the Use of Practitioners and Students of Medicine. New York: D. Appleton; 1900. The author’s address is: Department of Medicine |