Cover of FDR’s Deadly Secret by Steven Lomazow and Eric Fettmann. New York: PublicAffairsTM, 2009; 276 pages, $25.95, ISBN 978-1-58648-744-7.
Review by Joan M. Mones, D.O.
FDR’s Deadly Secret is written by Steven Lomazow, M.D. and Eric Fettmann. It is 276 pages long including the notes to chapters, bibliography and index. It can be found in the United States history section of major bookstores. Dr. Lomazow is a board-certified neurologist and an Assistant Professor of Neurology at the Mount Sinai School of Medicine in New York City with a practice history in neurology that spans over 25 years. Mr. Fettmann is a journalist with 35 years of experience currently working as an associate editorial page editor for the New York Post newspaper. FDR’s Deadly Secret represents “a medical biography of Franklin D. Roosevelt,” according to the authors. It is based on their extensive research and includes information taken from the diary of Roosevelt’s cousin, Margaret “Daisy” Suckley, not published until 1995.
In the preface, and in Chapter 1, titled, “An Orator Stumbles,” they proffer their basic premise that Franklin D. Roosevelt (FDR) had “cancer, melanoma to be exact, originating in the pigmented lesion above his eye – that eventually spread to his brain and abdomen.” One of the major factors contributing to the authors’ conclusion is their examination of FDR’s address to Congress and the American people following Roosevelt’s meeting in 1945 with Winston Churchill and Joseph Stalin in Yalta, Crimea. This speech, given six weeks before Roosevelt’s death, was considered by many at the time to be “rambling,” “sometimes marked by hesitancy,” and “Time magazine calculated that he’d departed from his text forty-nine times, adding a total of seven hundred words.” After comparing the actual audio of the speech and the available video clips with the actual written text of the speech, Lomazow and Fettmann, too, were surprised by Roosevelt’s poor performance as he was considered at the time to be “the greatest political orator of the twentieth century.” They noted “time after time [FDR] stumbled over the text, making mistakes that sometimes were simple and at other times were substantial” and they concluded that FDR “could not fully see all of the words on the page” and that he was unable “to find the left margin of each page or to see the left side of the individual words – forcing him to reconstruct sentences on the fly.” It became apparent to them that FDR was “suffering from a neurological condition called left hemianopia” which, in their opinion, was caused by a metastasis to the brain from the “large pigmented lesion over his left eyebrow, which had grown and darkened over a period of nearly two decades, was not a harmless sunspot, but rather a deadly melanoma, or skin cancer.” The authors further contend that FDR died, not from a cerebral hemorrhage due to uncontrollable hypertension and severe cardiovascular disease as widely believed, but from hemorrhage into a cerebral metastasis of melanoma. Lomazow and Fettmann acknowledged the possibility that FDR had severe cardiovascular disease and may have had prostatic carcinoma, as well, and offer the following caveat regarding their diagnosis of metastatic melanoma:
“It is unlikely we will ever know with absolute certainty what killed the thirty-second president of the United States. No autopsy was performed (though none of those present could ever agree why), and, save for a few lab slips that turned up in 1957, the whereabouts of Roosevelt’s medical file, maintained by Ross McIntire, has been unknown since his death.”
Nevertheless, the authors are convinced they have a strong, “albeit circumstantial case” that FDR died of cancer. They believe that their assumptions, if correct, represent “a profound historical revelation” for the following reasons:
“Conventional wisdom has it that Roosevelt took ill in early 1944, ran for a fourth term not knowing he was ill, and then suffered a rapid physical breakdown only in the last few weeks before his death, retaining his mental powers to the end. But if the melanoma scenario is correct, it means that Roosevelt, while still in his second term, knew he was almost certainly doomed to die of cancer within five years.”
The physicians who cared for FDR are also a major part of FDR’s Deadly Secret, and Lomazow and Fetttmann write that their book “explodes another long-standing myth,” namely, that FDR’s doctors were incompetent and “botched” his care, especially Dr. Ross McIntire, Roosevelt’s primary physician. The authors provide extensive arguments to the contrary. Another major assertion of the authors is that FDR was very much aware of his physical ailments, was in complete control of his health care decisions, and that the true reality of Roosevelt’s health was kept from the American people not only by Roosevelt’s physicians but also by Roosevelt himself, who was complicit in the cover up. The final paragraph in Chapter 1 conveys Lomazow and Fettmann’s opinion in that regard:
“Franklin Roosevelt, with the help of his doctors, chose to roll the dice with history, believing that he was the best man for the times. He might have been right when he made the decision to run for a third term, even perhaps when he decided to campaign for a fourth. But he could not beat the medical odds for long. That his risky gamble succeeded for as long as it did hardly excuses the overwhelming danger of the choice he made – raising profoundly disturbing implications for future presidents.”
Roosevelt’s campaigns, his election to an unprecedented four terms as president, his various positions within the Democratic Party, and the offices he held including the governorship of New York are woven throughout the book. Concerning the incorporation of politics into FDR’s Deadly Secret, Lomazow and Fettmann offered this explanation: “We did not intend this to be a political book, although it is impossible to avoid politics entirely when considering the effect that cancer had on Roosevelt’s performance as president.”
Having established the objectives and basic premise of their book, Lomazow and Fettmann begin their chronicle of FDR’s medical history in Chapter 2 noting that Roosevelt’s first major illness, typhoid fever, occurred in 1889 when he was 7 years old. Chapter 3, titled, “Triumph Over Mortal Matter“ is devoted to Roosevelt’s affliction with polio and begins with the riveting sentence: “August 10, 1921 – the last day that Franklin Delano Roosevelt would ever walk unassisted – was much like any other summer day at Campobello.” In this chapter, the authors’ detail how the media initially reported that FDR had pneumonia; however, when the New York Times finally wrote that FDR indeed had polio they emphasized that he “would definitely not be crippled.” Lomazow and Fettmann also emphasize how Roosevelt, himself, propagated that false belief providing this direct quote of Roosevelt’s from a letter he wrote five years after he had contracted polio: “the legs are greatly improved. I get around now with no brace on [my] right knee & hope to get rid of the other this summer.” Unfortunately, FDR was never able to walk without braces on both his legs and he was fitted with steel braces that “ran from his heels to above his hips.”
It is important to mention that throughout FDR’s Deadly Secret, there are extensive footnotes that add additional information to the topics under consideration. One such footnote, pertinent to the discussion of polio, can be found on page 33 which informs that, “During his second term, FDR launched the March of Dimes campaign to fund polio research, which led to Dr. Jonas Salk’s successful vaccine, news of which was announced in 1955, on the tenth anniversary of Roosevelt’s death.”
Of particular interest to the readers of this journal, Dermatopatholgy: Practical and Conceptual, is Chapter 6, titled, “The Brown Blob” which is devoted to an analysis of the pigmented lesion over FDR’s left eyebrow. In it, Lomazow and Fettmann detail the late Dr. A. Bernard Ackerman’s opinion of the lesion based on his examination of “hundreds of photos of the lesion together with the authors of this book over a period of several weeks.” The earliest photograph of the lesion, according to Lomazow and Fettmann, was in 1923, which is not depicted in their book, but reportedly “showed a barely visible dark spot.” Sequential photographs of the appearance of the lesion beginning in 1928 through 1942 are depicted in the glossy photographic section of the book and an incision in Roosevelt’s left eyebrow can be seen in the photograph on the cover of the book. The image of Roosevelt on page 193, probably taken toward the end of his life, shows that the lesion had disappeared and there is the suggestion of a well healed scar in the middle of his eyebrow. Following their examination of these photographs the authors concluded that “Ross McIntire was regularly reducing the lesion at the margins for cosmetic reasons, most likely using cauterization with electricity and curettage (scraping).”
In 1941, at the beginning of Roosevelt’s third term in office as president, he developed gastrointestinal symptoms and an episode of severe iron deficiency anemia in which his hemoglobin was 4.5 mg/dl; however, Dr. McIntire, reported to the press that FDR had only slight “gastrointestinal upset.” The details of this episode are reported on in chapter 7 titled, “The Beginning of the End.” It was also during this time that there was speculation that Roosevelt had been diagnosed with prostate cancer. Not long thereafter, FDR developed “swelling in the ankles” due to decreased cardiac function. Subsequent chapters chronicle FDR’s progressive physical decline including the development of cardiac failure with orthopnea in 1944, constant headaches, hypertension at “frighteningly high levels” and recurring bouts of abdominal pain with nausea. On November 7, 1944, Roosevelt was elected to a fourth term in office but by then he was having seizures. These seizures, in the opinion of Lomazow and Fettmann, are “best characterized in present-day neurological parlance as ‘partial complex’ highly suggestive of an abnormality of the temporal lobe of the brain” which they posit were due to an “asymptomatic stroke, attributable to his severe cardiovascular disease.”
An interesting development concerning the management of FDR’s deteriorating health vis-à-vis the media is detailed in Chapter 10 wherein Breckinridge Long, an assistant secretary of State and Steve Early, the White House press secretary contacted J. Edgar Hoover, head of the Federal Bureau of Investigation, to investigate so-called “rumors” of FDR’s declining health. Hoover sent his agents to Rochester, Minnesota, to interview doctors at the Mayo clinic and his agents found the “rumors” to be true and that the consensus in the medical community was that FDR had “a serious heart ailment.” In this chapter, the authors reinforce their hypothesis that FDR’s “recurring bouts of excruciating pain [were] caused by the cancer that had metastasized to his bowel.”
Chapters 11 and 12 detail the last few months of FDR’s life including a more in depth portrayal of the events surrounding the Yalta Conference, FDR’s address to Congress and the nation regarding the conference, and his continued physical deterioration with pronounced weight loss. The day Roosevelt died is described in great detail in Chapter 13, incorporating information from the journal of his cousin, Daisy, who was with him during the final hours of his life. Lomazow and Fettmann write: “As she [Daisy Suckley] later recorded, ‘He looked at me with his forehead furrowed in pain and tried to smile. He put his left hand up to the back of his head & said: “I have a terrific pain in the back of my head.'” This occurred at approximately 1:10 PM and Roosevelt was pronounced dead at 3:35 PM, the same day. Also included in this chapter and published for the first time ever, is a narrative of the preparation of Roosevelt’s body for burial written by his embalmer, F. Haden Snoderly. In this account, he noted that FDR’s abdomen was distended and the arteries so sclerotic that he was unable to inject them with the embalming solution. An interesting historical footnote can be found on page 189 informing that “In the three weeks following Roosevelt’s death, Benito Mussolini was executed, Adolf Hitler committed suicide, Berlin fell to the Red Army, and Germany surrendered.”
After FDR died, numerous inquiries were made by the press into his health which the authors discuss in Chapter 14. The authors note, “For the first time the American people were told in stark terms, of the precarious condition of their president’s health during the last year and a half of his life.” Demands were made “not only [for] an interview [by Dr. Ross McIntire and Dr. Frank Lahey] about their examinations of FDR but also their complete medical records and files.” Sensational and tabloid articles speculating about FDR’s health also began to appear with such titles as “The Strange Death of President Roosevelt,” “Suppressed Medical Facts and Uncalled-For Secrecy Give Rise to Sinister Rumors” and “They’re Lying about FDR’s Health!,” to name a few. In Chapter 15, Lomazow and Fettmann review and discuss some of the articles written in medical journals about Roosevelt’s health. The authors also describe how Dr. Harry Goldsmith was inspired to embark on a “three-decade investigation of Roosevelt’s health” when listening to a lecture by the famed surgeon, Dr. George T. Pack of Memorial Sloan-Kettering Hospital. In that lecture, Dr. Pack disclosed that “an old friend and colleague, Frank Lahey, had seen FDR in consultation in 1944, determined that the president had a metastatic tumor and advised him not to run for a fourth term.” Dr. Goldsmith eventually wrote an article titled, “Unanswered mysteries in the death of Franklin D. Roosevelt” published in the journal, Surgery, Gynecology & Obstetrics, which “garnered national attention” and served as an important reference for Lomazow and Fettmann. In the article, Goldsmith “raised the possibility that a pigmented lesion over the thirty-second president’s left eye – quite visible, but rarely commented on n his lifetime – may have been malignant.”
In the final chapter of FDR’s Deadly Secret, titled “The Next Deadly Secret,” Lomazow and Fettmann review the history regarding the laws of presidential succession and the eventual passage, in 1966, of the Twenty-fifth Amendment to the United States Constitution. According to them, “This provided for the first time that in the case of a vacancy in the office, the president would name a new vice-president” and that “a president can declare himself unable to ‘discharge the powers and duties of his office’ by so notifying congressional leaders.” Lomazow and Fettman further discuss some of the problems inherent in the amendment and they point out that Aron Seth Kesselheim of Harvard University has written that it contains a “fatal flaw. No where does it require a medical evaluation of the president.” In the final pages of their book, Lomazow and Fettmann offer the pro and cons of some of the suggestions that have been proposed to address this concern.
Dr. Mones is a dermatopathologist at the Ackerman Academy of Dermatopathology in New York, NY. Contact her at JMones@dermpathdiagnostics.com .
Review by Claudia I. Vidal, M.D., Ph.D.
I have to admit I was very apprehensive when I first received the invitation to review the book FDR’s Deadly Secret. I am by no means an avid historian and was worried that the book would be . . . .well, boring and just another addition to the genre of diseases-of-famous-persons. To my surprise, the book is a well told narrative that is approached as a medical mystery that attempts to clarify the nature of the pigmented lesion above Franklin Delano Roosevelt’s left eyebrow. I found the book very readable, not only for those in the medical profession, but also for the general public. And, I could see how it could have a wide following among those interested in American history and medical mysteries. Is the book likely to interest the readership of Dermatopathology: Practical and Conceptual? The answer is yes. Even prior to the book, much has been written about Roosevelt’s pigmented lesion. As early as 1940, Dr. Ruben Peterson wrote a letter to the President about the lesion urging his doctors to take a closer look for he was worried that it was malignant. Later Hugh L’Etang, a historian, re-examined the possibility that Roosevelt had melanoma. (1) This was confuted by none other than Howard G. Bruenn, MD, a cardiologist and member of Roosevelt’s inner circle of physicians. (2) More recently, in 2008, the inquest into the nature of the pigmented lesion has remained a debated topic. The late A. Bernard Ackerman and Steven Lomazow, one of the authors of this book, wrote an article in the Archives of Dermatology about the lesion. (3) This article was then commented by Dr. Harry S. Goldsmith. (4)
Before I continue, What are the aims of the book? In the book, neurologist Steven Lomazow and journalist Eric Fettmann state that they’ve discovered the true cause of Franklin Delano Roosevelt’s 1945 death. They build their “strong circumstantial case” that contends that Roosevelt suffered from cancer by building on the 1979 medical paper by Dr. Harry S. Goldsmith, (5) revelations in the 1995 publication of the diary of FDR’s cousin Daisy Suckley, (6) and photographic analysis.
Archives show that in the spring of 1923, a photograph on the cover of Time magazine showed a tiny pigmented lesion above Roosevelt’s left eyebrow. The lesion grew through the 1930s, stretching from the lower part of FDR’s forehead to the base of his eyebrow, and then disappeared in the 1940s, apparently removed through multiple procedures. The book states that “Ross McIntire [Roosevelt’s personal physician] was regularly reducing the lesion at the margins for cosmetic reasons, most likely using cauterization with electricity and curettage (scraping).” The “brown blob” as the book refers to the pigmented lesion, “would prompt a physician to suspect a highly malignant skin cancer called melanoma.” This is based on the current “ABCDE” criteria for diagnosis of a malignant melanoma, where the proponents of the mnemonic are: Asymmetry, Border irregularity, Color variability, Diameter greater than 6 mm, and Elevation, Enlarging or Evolving. (7)
Although most historians blame hypertensive cardiovascular disease for Franklin Delano Roosevelt’s massive cerebral hemorrhage that caused his death, the authors assert that Roosevelt’s fatal stroke at the age of 63 was a result of metastatic malignant melanoma rather than his other various comorbidities – that FDR’s deadly secret was melanoma.
As the book chronicles FDR’s life from a vigorous young patrician, to his battle with polio at age 39, to his eventual presidency and terms in office until his fatal stroke in April of 1945, it highlights a man whose health is shrouded in secrecy. In fact, the secrecy surrounding the President’s health seems to take on a greater role in the book than the apparition that he had melanoma. The book states that Press Secretary Stephen T. Early told a reporter from the Washington Post, (8)“There is every disposition at the White House to keep secrets. People working here are not given to loose talk – or else they wouldn’t be here.” In fact, it is well documented in the book as well as other publications that Ross T. McIntire, a career navy man and eye, ear, nose and throat specialist, was appointed Roosevelt’s personal physician not only because the President was prone to sinus infections, but also because of his reputation of “keeping a tight lip” and unwavering loyalty. Ross T. McIntire, who had a “look-see” approach to the President, relentlessly assured the public of the President’s “excellent condition for a man his age” (9) and possibly destroyed FDR’s medical records after his death. The book also highlights how the American public was shielded from Roosevelt’s health by the press’s willingness to play down his infirmity. Every aspect to disguise FDR’s health was taken from submitting press publications for approval before publication to only taking choreographed photos of the President.
DOES THE BOOK ACCOMPLISH ITS AIMS? Although the authors make a plausible case that FDR’s pigmented lesion above his left eyebrow was melanoma, I feel that Dr. Lomazow and Mr. Fettmann may be more convinced of their case than the knowable facts will support.
The authors acknowledge that FDR suffered from many maladies, and in the words of his biographer, Geoffrey C. Ward, FDR “seems to have been susceptible to every Groton germ.” They also record FDR’s hypertensive cardiovascular disease throughout the book and briefly highlight that he was a life time smoker and drank alcohol regularly. Even after reading the book, it is undeniable that Roosevelt’s severe cardiovascular problems were sufficient to kill him. It is unrefuted by the authors that the numerous small strokes experienced by the President prior to the stroke that killed him were likely the result of his hypertensive cardiovascular disease and arthrosclerosis. Still, the authors attest that it was metastatic cancer, not heart disease, that produced the increasing frailty, weight loss, and confusion that alarmed so many during his final year as President and “Coupled with the knowledge that melanoma is notorious for its rate of brain metastases, and that hemorrhages from them are the second most common cause of death among melanoma victims, the implications are obvious.”
The “brown blob” that the authors base their case on has only a single chapter devoted to it (Chapter 6), with only a brief mentioned in subsequent chapters of the book. I feel this is likely because such little hard evidence exists. Roosevelt’s medical records have disappeared, no autopsy was performed and none of his doctors have ever said that he had cancer. Still, it would have been nice to have more of the photographs of the lesion appear in the book as it is clear that they exist. Ackerman and Lomazow, in their article on the subject, (3) mention that they “examined thousands of photographs that recorded the pigmented lesions, many of them close up (and enhanced even further by us).” Of course, it should go without saying that caution should be made when making medical diagnosis from photographs, as various factors including lighting and camera angles, not the mention retouching, can alter the appearance.
Furthermore, as Dr. Lomazow and Mr. Fettmann use the aforementioned article (3) from the Archives of Dermatology that examines Roosevelt’s pigmented lesion as part of their case, they fail to highlight that Dr. Lomazow, one of the authors of this book, was also one of the authors with Ackerman in the paper. It is only if one reads the references that this is clear. It is likely that they only mention Ackerman’s name because just as the authors state he is “widely considered one of the world’s leading experts in the diagnosis of melanoma.” Likewise, there seems to be a bias with the use of quotations from the paper. A diagnosis of melanoma is not as clear cut in the Ackerman article as the authors portray it to be in the book. In the refutation by Ackerman to Harry S. Goldsmith’s article “Roosevelt’s Pigmented Lesion: Probably Not a Melanoma,” the article (10) states that they ” . . . set forth clinical criteria in favor and against melanoma . . . .On clinical grounds it is impossible to exclude melanoma . . . the answer to the question of the authentic character of it must now be couched in supposition.” Hence, although a diagnosis of melanoma can be entertained, necessary histologic evidence for the diagnosis is lacking; and thus, other pigmented skin lesions including solar lentigo, seborrheic keratosis, and pigmented basal cell carcinoma remain in the differential diagnosis. Worth mentioning, the only reference of histologic evidence in the book appears merely as footnote. The footnote reads “in 1991 Dr. William Ober wrote Dr. Hugh L’Etang and informed him that in 1949 . . . he saw a tissue slide of Roosevelt’s lesion and that it showed a benign seborrheic keratosis…”
Even by acceding to all of the author’s evidence and accepting that Roosevelt indeed had a melanoma located above his left eye, many questions remain and obfuscate their case. Questions like: What subtype of melanoma would Roosevelt’s melanoma be classified as? And even if FDR had melanoma, did he have metastatic melanoma? The former question is important as the clinical course including the rate of metastasis varies by subtype. To expand on this, I would like to propose that the lesion would most resemble lentigo maligna melanoma, based on the gross morphologic findings, site of the pigmented lesion and that FDR was no stranger to the sun. The natural course of lentigo maligna melanoma is to slowly expand in a centrifugal fashion prior to invading vertically into the dermis where it may gain access to the vasculature resulting in metastasis. It has been estimated that only 5% of lentigo maligna melanoma progress to invasive melanoma. (11) This brings up the latter question. The authors offer very little to demonstrate that if the President did have melanoma, did the cancer actually metastasize to his brain? They put forth FDR’s profound weight loss in the years between 1944 and 1945 and his visual defects in 1945 as their only evidence. Recalling that McIntire used cauterization with electricity and curettage on the lesion, would the treatment, although partial and unarguably not sufficient, affect the course of the lesion? Additionally, the author’s maintain that a cerebral hemorrhage caused by metastasis to the brain was the cause of Roosevelt’s death. Yet, metastasis to other skin sites, lungs and liver are organs melanoma most likely travels to once it spreads. And although brain metastases are common in melanoma, they are not as common as the above mentioned organs. (12)
In sum, it is undeniable that the authors have written about a “conspiracy of silence” and an intriguing medical mystery. But in the end, the author’s deduction in melanoma, although corroborated by some evidence, lacks the necessary histologic evidence and they are faced with the same problem that has plagued not only historians, but others who have written about the subject – there is no histologic proof. We are left with only what Ross McIntire replied to Dr. Ruben Peterson, (13) who first brought the lesion to attention “that the pigmented area above the President’s eye is very superficial and has never shown any sign of an inflammatory nature. You can rest assured that it is under observation at all times.” Nonetheless, R. D. Cumming once wrote “A good book has no ending” and likewise, even after reading the entire book, the “secret” the authors allude to will remain a secret – making the book an engrossing “medical biography” at the very least.
- L’Etang H. The Pathology of Leadership. New York, NY: Hawthorne Books; 1946: 86-102.
- Bruenn HG. Clinical notes on the illness and death of President Franklin D. Roosevelt. Ann Intern Med. 1970;149(6):899-908.
- Ackerman AB, Lomazow S. An inquiry into the nature of the pigmented lesion above Franklin Delano Roosevelt’s Left Eyebrow. Arch Dermatol. 2008; 144(4):529-532.
- Goldsmith HS. Roosevelt’s Pigmented Lesion: Probably Not a Melanoma. Arch Dermatol. 2009;145(3):339.
- Goldsmith H. A Conspiracy of Silence: The Health and Death of Franklin D. Roosevelt: Impact on History. New York, NY: iUniverse Inc.; 2007.
- Ward GC. Closest Companion: The Unknown Story of the Intimate Friendship Between Franklin Roosevelt and Margaret Suckley. New York, NY: Simon & Schuster Paperbacks; 1995.
- Abbasi NR, Shaw HM, Rigel DS, et al. Early diagnosis of cutaneous melanoma: revisiting the ABCD criteria. JAMA. 2004;292(22):2771-2776.
- Washington Post, August 21, 1942.
- McIntire RT, Creel G. White house physician. New York, NY: GP Putman’s Sons; 1946.
- Ackerman AB. In reply to “Roosevelt’s Pigmented Lesion: Probably Not a Melanoma.” Arch Dermatol. 2009;145(3):340.
- Nestle FO, Halpern AC. “Melanoma” in “Dermatology.” 2nd ed. Bolognia JL, Jorrizo JL, Rapini RP. (Eds): Spain: Elsevier; 2008:1751.
- Meyers ML, Balch CM. Diagnosis and Treatment of Metastatic Melanoma. In: Cutaneous Melanoma. Balch CM, Houghton AN, Sober AJ, Soong S-J (Eds), St. Louis: Quality Medical Publishing, Inc. 1998:329.
- McIntire TR. To Ruben Peterson, January 25, 1940, Ross McIntire papers, FDRL-HP.
Dr. Vidal is a dermatopathologist in the Department of Dermatopathology, Saint Louis University School of Medicine, St. Louis, MO. Contact her at email@example.com.
Response from Steven Lomazow, M.D., and Eric Fettmann
We appreciate the kind reviews of FDR’s Deadly Secret by both Dr. Mones and Dr. Vidal, in particular the latter’s description of our book as a “very readable … well-told narrative” that is likely to attract a wide following among both the general public and members of the medical profession. Nevertheless, there are a few points to which we’d like to respond.
Like Dr. Vidal, we very clearly made the point in our book that one cannot make a definitive diagnosis based solely on photographs, for precisely the reasons she enumerates, particularly the likelihood of pre-publication retouching. Photographic evidence, however, cannot be discounted completely, particularly when those similarities appear in literally hundreds of pictures. But we also obtained a photograph that was undeniably free of any outside alteration: a proof of a close-up color portrait of Roosevelt that showed unmistakable evidence that the lesion over his eye had been subjected to surgical procedures.
We would like to have been able to present more photos of the lesion in our book, but the format, as well as the need to include other pictures precluded that. This is why we set up a web site, fdrsdeadlysecret.com, as a companion to the book, which includes photos and video that we could not include in the book itself.
We have to disagree with Dr. Vidal’s contention that the only evidence we show to suggest that FDR’s melanoma metastasized to his brain was the dramatic weight loss in his final year. On the contrary, the opening chapter of our book presents what we believe is a strong case that Roosevelt showed definite signs of hemianopia while delivering his last major address, the report on Yalta, just six weeks before his death. Our analysis of FDR’s actual reading text, and the clear signs of a left-side deficit, show strongly that Roosevelt had developed a brain tumor – and it was bleeding from this tumor, we believe that produced his fatal hemorrhage.
And, contrary to Dr. Vidal’s assertion, we do present considerable evidence to suggest that Roosevelt’s melanoma metastasized not only to his brain but also to his abdomen.
Dr. Vidal is in error when she writes that we stated that FDR suffered “numerous small strokes … prior to the stroke that killed him.” We do not contend that he suffered many previous strokes; this was an allegation that was made in 1949 which we document – but which we also show was refuted by the available evidence. We do write that in the last year of his life Roosevelt manifested frequent partial-complex seizures that most probably were attributable to a stroke and were that probably misinterpreted by some observers as individual strokes or what we would today call TIA’s.
She is correct, however, to fault us for failing to sufficiently note that a paper by the late Dr. A. Bernard Ackerman, which we cite extensively, was co-written by one of the book’s co-authors. This is an error that will be corrected in future editions.
We must further disagree with Dr. Vidal’s conclusions in that she did not “see the forest through the trees.” Viewing the entire case in the perspective of a 58 year old man having a pigmented lesion with the characteristics of melanoma removed, followed by the onset of severe paroxysmal abdominal pain nearly four years later and a subsequent forty pound weight loss with death from a cerebral hemorrhage, the ultimate picture is far more clear.
As Dr. Vidal indicated, ours is by necessity a circumstantial case. No autopsy was performed and the bulk of Roosevelt’s medical records have been missing since his death. Nonetheless, we are convinced that our case is exceedingly strong and indeed the most probable scenario. We invite readers to evaluate it and judge for themselves.
Steven Lomazow, MD, and Eric Fettmann. Website: http://fdrsdeadlysecret.blogspot.com/
Final thoughts by Mark A. Hurt, M.D., Book Review Editor
I offer my thanks to Drs. Mones and Vidal for their reviews as well as Dr. Lomazow and Mr. Fettmann for their response to the reviews.
Tantalize. The word means “to tease or torment by or as if by presenting something desirable to the view but continually keeping it out of reach.” (1) The term traces from Greco-Roman mythology to King Tantalus, the king of Phrygia, who, because he offended the Gods, his punishment was submersion into water and temptation by fruit and drink. Yet, the nature of his hydraulic submersion afforded him the ability to attain neither fruit nor drink.
Such is my emotion after reading FDR’s Deadly Secret. I suffer from an uneasy torment. Did President Franklin D. Roosevelt have melanoma or did he not? He certainly did have a dark macule over and into his left eyebrow. It also became less evident from 1939-1942, as the authors documented in the 3 photographs between pages 134-135 of the book.
It is also true that FDR was cachectic, a clinical emaciation that occurs often in cancer patients, toward the end of his life.
Yet, is this enough to assert with certainty that FDR had melanoma, much less metastatic melanoma? Even the authors admit the case is compelling but circumstantial. Indeed.
What is the differential diagnosis for the macule? Ackerman & Lomazow, in their 2008 article (2) from the Archives of Dermatology, assert only three possibilities: melanoma in situ, solar lentigo, and reticulated seborrheic keratosis, the latter being a more fully expressed manifestation of solar lentigo. A similar point of view was expressed in Chapter 6 of the book, titled “The Brown Blob.” I can think to two more possibilities: large cell acanthoma and reticulated melanotic macule. Admittedly, large cell acanthomas are often included within the spectrum of solar lentigo, as was Ackerman’s position (3) from at least 1992 until his death, to my knowledge. Finally, a pigmented macule that occurs on the skin or the mucous membranes has been termed “reticulated melanotic macule” or “ink spot lentigo” (4, 5) when it occurs on the skin and “mucosal melanotic macule” when it occurs on the mucous membranes. It is also a hyperpigmentation of keratocytes that differs from a solar lentigo.
That clinicians, including dermatologists, confuse melanomas in situ with solar lentigines is common, in my experience. In the last ten years of my practice, I have seen two such dramatic cases. The first was a large, geographic patch on the cheek of an older woman; it was thought by all dermatologists present to be melanoma in situ — only to be proven a solar lentigo by multiple biopsies and over-staining with Melan-A on every biopsy, confirming the hyperpigmentation of the keratocytes and the uniformity and periodic spacing of the melanocytes. The second example occurred on the forehead of a priest; the patient claimed it had been present for 20 years, and it was thought to be melanoma in situ; the histopathological examination proved it to be a solar lentigo/large cell acanthoma with a periodic population of melanocytes with Melan-A over-staining.
The point is, simply, that histopathological examination is required to differentiate these lesions, whether for FDR or anyone else.
Nonetheless, this is a very well written and interesting historical narrative. I found it, for instance, fascinating that, when FDR was stricken with poliomyelitis, how difficult and expensive it was to establish the diagnosis, even with the experts of the day, for which FDR paid $600 in 1921 to Philadelphia Surgeon William W. Keen. For those readers who are not aware of how to relate this price to 2010 prices, consider the value in terms of gold. In 1921, the United States of America was on a gold standard of $20.67 per Troy ounce of gold. At this writing the market value of gold is $1,178.00 per Troy ounce of gold. In terms of gold per Troy ounce, FDR was charged 29.03 Troy ounces of gold (902.93 grams). Thus, in 2010 dollars, Roosevelt’s consultation with Dr. Keen was $34,194.48! Unfortunately, Dr. Keen did not make the correct diagnosis, even at that price; the correct diagnosis was made by Samuel Levine, an internist at the Peter Bent Brigham Hospital.
Although Dr. Lomazow and Mr. Fettmann have not had the opportunity to read my comments, I welcome any follow-up comments from them, which I am happy to publish in a future edition of the Journal.
- “tantalize.” Webster’s Third New International Dictionary, Unabridged. Merriam-Webster, 2002. http://unabridged.merriam-webster.com (23 May 2010).
- Ackerman AB, Lomazow S. An inquiry in the nature of the pigmented lesion above Franklin Delano Roosevelt’s left eyebrow. Arch Dermatol 2008; 529-532.
- Roewert HJ, Ackerman AB. Large-cell acanthoma is a solar lentigo. Am J Dermatopathol 1992; 14:122-32.
- Kaddu S, Soyer HP, Wolf IH, Rieger E, Kerl H. [Reticular lentigo]. Hautarzt 1997; 48:181-5.
- Sánchez JL. New concept: a unifying concept of melanotic macule. Dermatopathol Pract Concept 1998; 4(2):article 3, on the web at www.derm101.com
Dr. Hurt is an Associate Editor and the Book Review Editor of Dermatopathology: Practical and Conceptual. He practices dermatopathology in Maryland Heights, MO, USA. Contact him at firstname.lastname@example.org or his website at www.markahurt.com.