Editor's note: In this presidential election year, Allan B. Schwartz, M.D., a professor of medicine in the Division of Nephrology & Hypertension at Drexel University College of Medicine, offers a different kind of Medical Mystery, looking at the health of U.S. presidents. This is the second in the series; you can find his article on John F. Kennedy here.

In early 1944, President Franklin Delano Roosevelt and the leaders of the Democratic party made plans for his campaign to seek an unprecedented fourth term. On March 29, 1944, Roosevelt became severely short of breath, coughing, with evidence of fluid in his lungs, predominantly in the right lower lobe.

When he was lying flat, breathing became even harder, and his skin turned bluish. FDR was not recovering from what was described as an upper respiratory infection. He continued to smoke his four packs of Camels a day.

FDR's senior physician in charge was Admiral Ross T. McIntire, an ear, nose, and throat specialist who had been treating the president for chronic sinusitis. For congestion, McIntire gave him a nasal solution that included cocaine.

Howard Bruenn, the new chief of cardiology at Bethesda Naval Hospital, was assigned to the case and found FDR's blood pressure startlingly high - ranging up to 210/110. He noted that the president was always short of breath.

Electrocardiograms showed evidence of cardiac enlargement, left ventricular hypertrophy and ischemia. Protein was detected in the president's urine, another concerning finding. After Bruenn consulted with McIntire, the president was treated with digitalis, a low-salt diet, and urged him to lose weight. FDR began to improve.

At a news conference, FDR was asked about his condition. He answered, "I got bronchitis."

With war still raging and the election nearing, the president refused to rest. On Nov. 7, 1944, Roosevelt won his fourth consecutive term.

In January 1945, the president traveled to Yalta to plan the postwar division of Europe with Joseph Stalin and Winston Churchill. FDR appeared gaunt, having recently lost almost 40 pounds. His blood pressure was recorded at 230/140. Roosevelt's daughter, Anna, noted that her father "looked dreadful, his brow was furrowed . . . jaw was hanging open, left sentences unfinished."

What exactly was wrong with the president?


President Franklin Delano Roosevelt's diagnosis was malignant hypertension, high blood pressure so severe and uncontrolled that it caused his heart failure and damage to other organs, bringing him perilously close to a stroke.

Today, his extreme hypertension, as high as 240/140 over the winter of 1944-1945, would be treated with emergency intravenous therapy plus a combination of drugs, including arterial vasodilators, diuretics, renin angiotensin aldosterone system antagonists (ACEI or ARB), beta blockers, and a low-sodium diet.

But in the mid-1940s, medical options were limited to drugs such as the antihypertensives reserpine and rauwolfia, and the sedative phenobarbitol.

When preparing for Yalta, FDR asked about the potential side effects of these medicines. Howard Bruenn, the new chief of cardiology at Bethesda Naval Hospital, said they could lead to depression and sleepiness, so Roosevelt refused to take them as he discussed the future of the world with Churchill and Stalin.

Today, a patient like FDR would be sent to a hospital emergency department for intravenous drug therapy. Once stabilized, he would likely be put on a three- or four-drug regimen to keep his blood pressure under control. A statin for high cholesterol and a blood thinner might also be considered.

But in the 1940s, there was no such thing as cardiac ultrasound, special radiology MRI, CT scan, or nuclear isotope imaging studies, no stress tests, no diagnostic coronary artery imaging. There were no cardiac enzyme blood tests.

Roosevelt made it through the Yalta talks and returned to the United States, speaking to a joint session of Congress on March 1, 1945. The exhausted president then traveled to Warm Springs, Ga., to recuperate. While a visiting artist painted his portrait, FDR complained of a terrible headache. Bruenn was summoned, but FDR died suddenly of a hypertensive cerebral hemorrhage on April 12, 1945.

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