When Presidential Brains Go Awry: Neuro Disorders In The Oval Office

By Richard Knox

Thomas Jefferson probably suffered from migraines. Woodrow Wilson had a devastating stroke while in office. FDR was known to have seizure-like blank-outs. And Ronald Reagan’s own family is still arguing about whether he had signs of Alzheimer’s during his time in the Oval Office.

The health of presidents is a perennially intriguing subject. But this Presidents Day weekend, a New York neurologist is focusing new attention on the presidential disorders that arguably matter most: those of the brain and central nervous system.

“Do we really know about the health status of our leaders and should we?” asks Dr. Nicholas Silvestri. “I think in the case of neurologic illness, we should.”

Dr. Nicholas J. Silvestri
Dr. Nicholas J. Silvestri (Sandra Kicman, University at Buffalo)

Silvestri, a history buff on the faculty of the University at Buffalo School of Medicine and Biomedical Sciences, thinks commanders-in-chief ought to undergo neuropsychological testing just as regular recruits do.

And he wonders if the 48-year-old 25th Amendment, which provides for presidential succession if a president becomes unfit to govern, is really suited to determine cognitive or mental fitness. That’s a touchy matter the Constitution currently leaves entirely in political hands.

Now, of course, too rigorous a screen could deprive the nation of a truly great (if mentally flawed) president. Abraham Lincoln, for example, famously suffered from depression.

We’ll come back to the issue of how presidential brain unfitness should be determined. But first, let's take a journey through the surprising twists and turns of the neurological history of U.S. presidents, guided by Silvestri. He pulled that history together for a Lincoln’s Birthday seminar in Buffalo, and described its high points in an interview.

Migraine, Seizures, Strokes

First stop: migraine headache. It’s a common ailment that doesn’t disqualify anyone from a highly responsible job. But still, migraines are “an extremely debilitating collection of neurological symptoms,” as the Migraine Research Foundation puts it — possibly a matter of concern in a president who needs to function at the top of his game during a crisis.

Silvestri says there’s evidence that John Adams, Jefferson, Lincoln, Dwight Eisenhower and John F. Kennedy suffered from migraines.

James Madison and FDR probably had seizure disorders, Silvestri says. From his college years, Madison was known to have spells that temporarily paralyzed him. “He would stare off, become immobile, and not react to his surroundings,” Silvestri says. It may be a reason Madison didn’t fight in the Revolution.

Silvestri thinks Madison’s spells were probably psychogenic seizures — a reaction to stress. “It’s what Freud describes as hysteria,” he says.

Whatever it was, Madison evidently grew out of it. The disorder didn't prevent him from coauthoring the Constitution or the Federalist Papers, nor hinder him as president. “He was the last president to lead a field army in battle, during the War of 1812,” Silvestri notes.

FDR Didn't Have Polio? 

FDR probably didn’t suffer from polio -- the disease he has long been associated with. Instead, many researchers think the evidence points to a different cause of FDR’s paralysis -- a rarer disease called Guillain-Barre syndrome. Here he is in 1943. (George R. Skadding/AP)
FDR probably didn’t suffer from polio -- the disease he has long been associated with. Instead, many researchers think the evidence points to a different cause of FDR’s paralysis -- a rarer disease called Guillain-Barre syndrome. Here he is in 1943. (George R. Skadding/AP)

FDR’s health problems are well known. They include the polio he supposedly suffered at the age of 39, his subsequent lifelong leg paralysis, and the soaring blood pressure that led to a fatal brain bleed two months after the Yalta Conference that carved up post-war Europe.

Less known are the seizures he had throughout his presidency.

“FDR was witnessed by several people, including Turner Catledge of the New York Times, when he would stop in his tracks and stare into space,” Silvestri says.

One of these occurred when Roosevelt was meeting with New York Sen. Frank Mahoney and Edwin Watson, the president’s appointments secretary. “Watson said, ‘Don’t worry, he’ll come out of it, he always does,’” Silvestri says.

The neurologist says Roosevelt’s sky-high blood pressure — a systolic reading over 200 was frequent — could have caused blood vessel damage that led to seizures.

But the most surprising revision in FDR’s neurologic history is the likelihood that he probably didn’t suffer from polio — the disease he has long been associated with. Roosevelt founded the National Foundation for Infantile Paralysis (as polio was then known), which became the March of Dimes.

Roosevelt’s polio diagnosis was understandable. In 1921, when he was stricken with fever and sudden paralysis during a summer vacation on Campobello Island, polio outbreaks were common in North America.

But Silvestri and other researchers think the evidence points to a different cause of FDR’s paralysis — a rarer disease called Guillain-Barre syndrome that was first described by two French physicians just five years earlier.

Guillain-Barre happens when a person’s immune system confuses certain molecules on nerve cells with similar chemical markers on microbes. That results in a misdirected immune attack that causes temporary or, in some cases, permanent damage to the nerve cells — and thus, paralysis.

Recent research highlights a number of reasons why FDR probably suffered from Guillain-Barre rather than polio. Among them:

• Polio predominantly strikes children and rarely adults over 30. FDR was 39 when he fell ill.
• There were no reported outbreaks of polio near Campobello Island at the time.
• Some of FDR’s symptoms don’t jibe with polio. For instance, he couldn’t stand the slightest touch on his legs, even the slight pressure of bedsheets. “That doesn’t occur with polio,” Silvestri says.
•  Taken altogether, Roosevelt’s symptoms are more consistent with Guillain-Barre.

But it probably wouldn’t have made any difference if the correct diagnosis had been made at the time. Nowadays, Guillain-Barre can often be arrested before permanent damage occurs with infusions of antibodies and plasma exchange to filter out the marauding antibodies. But those treatments weren’t invented until the late 20th century.

Similarly, Roosevelt would undoubtedly have benefited from modern blood pressure treatments, so he might have avoided heart failure and cerebral hemorrhage.

Wilson: Stroke? What Stroke? 

The most devastating neurologic disorder to affect a sitting U.S. president was the massive stroke that Woodrow Wilson suffered in October of 1919 as he was on a whistle-stop train campaign to persuade Americans to support the League of Nations — unsuccessfully, as it turned out.

Wilson suffered several “little strokes” accompanied by headaches and left-sided weakness during the tour. Then one morning his wife Edith found him on the floor of the bathroom, moaning and unable to move.

Wilson was rushed back to Washington, but Edith and close advisers covered up what had really happened. Wilson’s Cabinet and others were told that the president had suffered a nervous breakdown and couldn’t be disturbed. Meanwhile, Edith was effectively in charge of the government.

Wilson’s stroke was revealed only in February 1920, five months after the fact.

Silvestri says all signs point to Wilson’s stroke damaging the right front parietal area of his brain, causing weakness and stiffness on the left side of his body and droopiness on the left side of his face.

Wilson also suffered striking personality changes, becoming irritable and depressed — another characteristic of a right frontal stroke. And he seemed not to appreciate how incapacitated he had become, ignoring his left-sided deficits. That can also be a mark of a stroke in that region. Wilson was so oblivious of his disability that he had to be talked out of running for another term.

What If

Today, of course, there’s no question a president in Wilson’s situation would be declared incapacitated and his vice-president put in charge.

The 25th Amendment, adopted in 1967, requires either the president to declare his disability in writing or the vice president and a majority of the Cabinet to notify the speaker of the House and president pro tempore of the Senate that the president is unfit to discharge his duties.

But the 25th Amendment is silent on how the officials are to determine a president’s unfitness in medical situations that are less dramatic than Wilson’s massive stroke.

For instance, it’s possible that a president may one day show signs of early dementia — either from Alzheimer’s or other forms of cognitive impairment.

Many worried about that very thing when Ronald Reagan was running for his second term, at the age of 73. A fumbling performance during a debate against his opponent, Walter Mondale, raised the question. In a subsequent debate, Reagan batted away a question about his age by declaring he would “not make age an issue of this campaign,” adding that “I am not going to exploit, for political purposes, my opponent’s youth and inexperience.”

In 2011, Reagan’s son Ron wrote in a book that his father began to show signs of Alzheimer’s while he was in the White House, a claim supported by others. But the possibility has been fiercely denied by Reagan’s son Michael and his widow, Nancy.

Reagan was diagnosed with Alzheimer’s in 1994, five years after leaving office, and died 10 years later at the age of 93.

Silvestri says it’s possible that Reagan had “mild cognitive impairment” while he was president, but was not seriously impaired mentally.

“From everything I’ve read and seen, I’m not confident he suffered from Alzheimer’s during his presidency,” the neurologist says. One reason is that Reagan lived a decade after his formal diagnosis — much longer than average, and 15 years after he left office.

At the same time, Silvestri thinks it's likely a sitting president may someday show signs of serious cognitive decline — it is a common condition, after all, and presidents are often in their 70s. And, he thinks, it would be a good idea to devise an objective, nonpolitical process to diagnose that condition before it happens.

Readers, thoughts? Do you support Silvestri's idea? 

Richard Knox Senior Correspondent, CommonHealth
Richard Knox is a senior correspondent for WBUR's CommonHealth.



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