President Eisenhower's Operation for Regional Enteritis: *

A Footnote to History

LT. GEN. LEONARD D. HEATON, f MC, U.S.A, ISIDOR S. RAVDIN,4 M.D.,BRIAN BLADES,§ M.D., LT. COL. THOMAS J. WHELAN,f MIC, U.S.A.

From the Walter Reedl General Hospital, Washington, D. C.

THE RIGHT of any President of the UnitedStates to a certain amount of privacy can-not be gainsaid. On the other hand, theillness of any President is a matter of greatconcern to the nation, as it has always been,and it now has become a matter of greatconcern to the whole world. It is the rightof the people of the country to have thefacts while the illness is in progress. Whenit is over, it becomes history. It is with fullrealization of the historical implicationsthat we make this report, for which wehave General Eisenhower's gracious andunconditional permission, on his operationfor small bowel obstruction secondary toregional enteritis in June 1956.

It is noteworthy that of the 35 Presidentsof the United States-the present incum-bent is not included in this list-four diedin office, President Harrison, in 1841,7 Presi-dent Taylor, in 1850,1 President Harding,in 1923,11 and President Franklin D. Roose-velt, in 1945,6 and that four were assassi-nated, President Lincoln, in 1865,4 Presi-

* Presented before the Southern Surgical Asso-ciation, Hot Springs, Virginia, December 10-12,1963.

f The Surgeon General, United States Army.t Professor of Surgery, University of Pennsyl-

vania School of Medicine, Professor, GraduateSchool of the University of Pennsylvania, Phila-delphia, Pennsylvania.

§ Professor and Chairman, Department of Sur-gery, George Washington University School ofMledicine, Washington, D. C.

1T Chief, General and Peripheral Vascular Sur-gery, Walter Reed General Hospital.

dent Garfield, in 1881,8 President McKinley,in 1901,' 10 and President Kennedy, in 1963.Of the remainder, President Jackson 2 waschronically ill during both terms of office.President Wilson3 had a disabling illnessthat made him a practical invalid for thelast two years of his second term. PresidentCleveland5 had a resection of his maxillafor a sarcoma in the first year of his secondterm in 1893, from which he recovered ap-parently completely. Except for PresidentKennedy's death, all of these illnesses anddeaths are now on record in the medicalliterature. It is, therefore, appropriate thatthe details of President Eisenhower's opera-tion be added to these accounts.

Case HistoryPresent Illness: President Eisenhower, then 65

years of age and the thirty-fourth President of theUnited States, was taken ill with vague ill-defineddiscomfort in the lower abdomen about 12:30 a.m.on Friday, June 8, 1956, nine months after amyocardial infarction from which he had madea satisfactory recovery. His personal physician,GEN. Howard McC. Snyder, was called and ar-rived at the White House 30 minutes later.

The first examination of the abdomen revealedno particular point of tenderness, but moderatedistention and tympany were evident. The pulseat this time ranged from 94 to 100/min., withoccasional extrasystoles, and the blood pressurewas 140/100 mm. Hg.

For the next few hours, the President sleptfitfully. At 6:00 a.m., a tap water enema, by whichfeces and flatus were expelled, gave no relief; nordid a second enema which returned clear. Mean-time, the pain had gradually assumed a colickycharacter and centered around the umbilicus and

661

662 HEATON, RAVDIN, BLAIDES AND WHELAN

FIG. 1. Small bowel series showing localizedregional enteritis in the terminal ileum performedon May 11, 1956. No skip areas are seen.

in the right lower quadrant. No flatus was passed,and distention became more prominent. At 10:30a.m. the patient vomited 1,500 cc. of bile-stainedfluid, without solid material or undigested food.The pulse was then regular at 92/ min., but theblood pressure had fallen to 100/76 mm. Hg.

The first consultant summoned by GeneralSnyder to see the President was COL. Francis W.Pruitt, MC, Chief of Medicine, Walter Reed Gen-eral Hospital. He found the President listless,apathetic, perspiring freely, with his skin some-

what cool and clammy and with his normal ruddycolor absent. The pulse was then 120/min. andnot of good volume, and the blood pressure was

105/70 mm. Hg. The abdomen was moderatelydistended and there was some generalized resist-ance but no rigidity.

COL. Pruitt's initial impressions were: 1) Intra-abdominal bleeding related to anticoagulant ther-apy; or 2) Small bowel obstruction secondary to

regional ileitis; or 3) Intestinal perforation withperitonitis.

A hemoglobin concentration performed at theWhite House gave a value of 21 Gm.% (as com-

pared to 16.5 Gm.% a month earlier), whicheffectively ruled out the first possibility as thecause of the President's shock-like picture.

After 600 cc. of 5 per cent glucose in waterhad been administered, the systolic blood pressure

Annals of SurgeryMay 1964

rose to 115 mm. Hg and the puilsc dropped to100 per miniiiute. It was now tlhouiglht that thePresident could safely be moved, and he was,therefore, transported by ambulance to WalterReed General Hospital, where he arrived at1:30 p.m.

At this time his shock-like state had abated.Physical examination immediately after admissionrevealed the temperature to be 37.50 C., the pulse94/min. and the blood pressure 120/80 mm. Hg.The President's face was rather flushed, but hewas mentally alert and seemed in no great dis-tress. The remainder of the examination was nega-tive except for the abdomen, which was somewhatdistended and tympanitic. There was rather diffusetenderness but no evidence of rebound tenderness.There was an area of dullness to flatness over theright lower quadrant. Bowel sounds were hypo-active, with occasional high-pitched sounds. Noabnormal mass was felt.

Meantime, the four surgical consultants sum-moned by General Snyder, MAJ. GEN. Leonard D.Heaton, and Drs. Isidor S. Ravdin, Brian Bladesand John H. Lyons, were asssembled at the hos-pital by 6:00 p.m. Two of them (L. D. H. andI. S. R.) were out of the city and arrived, respec-tively, from Gloucester Point, Virginia, and Chi-cago, Illinois. COL. Thomas Mattingly, Mc, whohad treated the President during his cardiac ill-ness, was also summoned.

Previous History: The President's previousmedical history of significance revealed that in1923 his appendix had been removed at Fitz-simons General Hospital after several episodes ofright lower quadrant pain beginning about a yearearlier. Histopathologic study revealed "chroniccatarrhal appendicitis." Over the subsequent 33-year period he had had episodic lower abdominalpain, and in November, 1947, a diagnosis of par-tial small bowel obstruction had been entertained.Spontaneous resolution of the clinical picture oc-curred.

The President had had no other abdominalsurgery, but because of recurrent abdominal pain,numerous gastro-intestinal roentgenograms hadbeen obtained over the years. It was not until amonth before this hospital admission, however,that a small bowel series, performed by COL.Elmer Lodmell, MC, Chief of Radiology, WalterReed General Hospital, revealed a picture typicalof regional enteritis involving the distal ileum(Fig. 1).

Laboratory Data: Blood study gave the follow-ing values: Hemoglobin, 15.8 Gm.%o; hematocrit,49; white blood cell count 10,600/mm.a, with 74per cent polymorphonuclear leukocytes. Bloodchemistry revealed serum sodium 137.5 mEq./

OPERATION FOR REGIONAL ENTERITIS

L.; potassium 4.9 mEq./L.; chlorides 104 mEq./L.; and C02 17.7 mEq./L. These values revealed,in addition to dehydration, a metabolic acidosis.

Two electrocardiograms showed no evidenceoI recent myocardial damage. Evidence of the oldmyocardial infarct was the only abnormal finding.Serial films revealed increasing dilatation of smallbowel, probably the jejunum.

Preoperative Course: With the present x-ray

findings and the knowledge of the findings in theexamination a month earlier, the diagnosis ofsmall bowel obstruction secondary to regionalenteritis seemed the most tenable explanation ofthe presenting clinical picture.

At 1:00 a.m. on June 9, 1956, still more

marked distention of the involved loops of smallbowel (Fig. 2) prompted the unanimous opinionof all those responsible for the care of the Presi-dent that surgery was indicated. The opinion was

succinctly stated in a note written on the chartby Dr. Ravdin:

"There can be no doubt that the Presidenthas intestinal obstruction of an acute nature.The films made of his large and small bowelon May 11, 1956, disclose areas of the termi-nal ileum which are identical with those seen

in an area of regional enteritis with "skipareas.

"He has drained moderately from his gas-

tric tube, but in spite of this the number ofloops which are distended has increased as

recorded in the last x-ray over that taken at

1830 hours."The abdomen is softer. Peristalsis is pres-

ent at times. The pulse has shown a tendencyto become more rapid.

"He has passed no gas by rectum. Urinaryoutput of 490 cc. shows that his kidneys are

functioning."The dilemma facing us is whether to

delay operation further or to go ahead andside-track the area of obstruction. Because thedistended gut area has increased, because thecondition has existed for 24 hours, becauseoperation with the patient in good conditionis safer than waiting until the necessity ofoperation is forced upon us, I favor interven-tion.

"The only alternative to this would belong tube (Miller-Abbott) intubation, which,if it gives evidence of emptying the small gutis defensible. If it does not give such evidencepromptly, I would again favor laparotomy."

Confronted with a 65-year-old patient, whose

obstruction was apparently increasing in spite ofthe correct application of nonsuirgical measures,

-

...

FIG. 2. Roentgenogram of the abdomen re-

vealing dilated jejunal loops performed at 1:00a.m., June 9, 1956. The diagnosis of small bowelobstruction of a high degree is obvious.

whose blood chemistries revealed signs of per-

version, and who had a recent history of cardiacinfarction, there seemed little justification for thehighly dubious course of further delay in the hopethat the blocked bowel would release itself. In-stead, as time passed, there seemed every justifica-tion for the course which was adopted, surgicalintervention without further delay, while all thecircumstances were still favorable.

Preoperative preparation consisted of naso-

gastric decompression; parenteral fluids (2,000 cc.

of 5%o glucose in physiologic salt solution and1,000 cc. of 5% glucose in water); penicillin300,000 units every six hours; and streptomycin,0.5 Gm. every 12 hours. Potassium chloride 20mEq. was added to the fluids.

Operation: At 2:20 a.m., June 9, 1956, anes-

thesia was induced by COL. Harvey C. Slocum,,ic, Chief of Anesthesiology, Walter Reed GeneralHospital, with pentothal sodium (Thiopental so-

dium) and nitrous oxide-oxygen. Cyclopropaneand ether were used to maintain the plane ofsurgical anesthesia, with curare for muscle relaxa-tion. The endotracheal technic was used. Electro-cardiographic observations were made during theone hour and 54 minutes of surgery, from 2:57a.m. to 4:51 a.m. The President's condition at no

time gave rise to any anxiety.

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HEATON, RAVDIN, BLADES AND WHELAN

When the abdomen was opened through a

right paramedian incision, there was a moderateamount of straw-colored fluid in the peritonealcavity. Dense adhesions presenting between thegreater omentum and the appendectomy scar inthe right lower abdomen were divided. Theirlysis brought into view the ileum, whose terminal30 to 40 cm. presented the typical appearance

of chronic so-called dry regional enteritis. That is,the involved area was grayish-red, thickened, in-durated, and contracted, with claw-like projectionsof mesenteric fat to the antimesenteric border.The contiguous mesentery was thickened, short-ened, and opaque, but there were no large, suc-

culent lymph nodes within it. The pathologic proc-ess just described was sharply demarcated, andno skip areas were noted.

The small bowel immediately proximal to theinvolved area was greatly dilated and moderatelyedematous, but the color was pink, and the at-tached mesentery was normal in length, consist-ency, and translucency.

No other abnormalities were found on furtherexploration.

Ileotransverse colostomy was performed in con-

tinuity by the standard two-layer technic, usinginterrupted silk sutures in the outer layer andcontintuous chromic catgut sutures in the innerlayer.

One hundred cc. of neomycin (1%) was in-jected into the colon at the site of the intendedanastomosis before the bowel was opened. Spillagewas kept to a minimum by careful packing andaspiration. Palpation of the stoma revealed thatthe anastomosis was adequate. Five hundred cc.

of blood were given during the operation.The procedure described was carried out with-

out incident of any kind. At its end, the bloodpressure was 130/80 mm. Hg, the pulse 84, andthe respirations 20.

Postoperative Course: The usual postoperativemeasures were employed, including nasogastricsuction, intravenous fluids, analgesics, and penicil-lin and streptomycin. Postoperative ileus occa-

sioned some concern, btut it was well controlledwith gastric suction. When flatus was passed ingood quantities on the fifth postoperative day, thetube was removed and oral feedings were cau-

tiously begun. They were so well tolerated thatsolid food was taken and retained by the seventhpostoperative day.

Vital signs were never a cause for anxiety. Atno time did the puilse exceed 100 or the respira-tion 24, and both were uisuially below theselevels. The hiighest immiie(ediate postoperative terni-

peratuire was 37.90 C. by rectumii, and the only

time the reading exceeded this level-it was

usually well below it-was on the eleventh post-operative day when it reached 38.2° C. on one

occasion, as the result of a minor wound infection.This infection was the only real complication inthe postoperative course. There were no cardio-vascular difficulties at any time. Anticoagulanttherapy, which had been discontinued beforeoperation, was reinstituted on June 27, 1956.

The President was ambulated on the first post-operative day, June 10, and daily thereafter forincreasingly long periods. He received official visi-tors (Secretary of State Dulles and ChancellorKonrad Adenauer of West Germany) and trans-acted official business on the fifth postoperativeday, June 14, and daily thereafter.

On the sixth day, one of the surgical residentson round-the-clock duty with him wrote in theprogress notes, "This patient feels and acts likea well man." This was the President's status when

he left the hospital on the twenty-first postopera-tive day.

Discussion

There is, of course, no necessity for fur-ther justification of our decision to operate

promptly on a patient with regional en-

teritis in which the complication, obstruc-tion of the small bowel, was the primaryand dominant problem. From the strictlysurgical point-of-view there exists the ne-

cessity of explaining our use of a procedure,that is, the in continuity bypass which isconsidered by most authorities and by our-

selves as an inferior procedure in the surgi-cal management of the majority of cases

of regional enteritis. Resectional therapy

or bypass in discontinuity are our preferredprocedures for treating florid or so-calledwet types of regional enteritis, and therewas considerable criticism of our use of theoperation that was chosen.

The reasons for our use of ileotransversecolostomy in continuity were as follows:

1. Surgical operation was primarily designed torelieve ileal obstruction and had to be performedexpeditiously.

2. President Eisenhower's regional enteritis was

not of the wet type. Instead, it was typical of thelife history of the (lisease as it progresse(l throughthe florid stage, withouit the (levelopmenet of coirn-

plications requiirinig operation in his youinger years,

664 Annals of SurgeryMay 1964

OPERATION FOR REGIONAL ENTERITIS

to reach the cicatrized, dry or burned-out stagethat is unlikely to progress or recur.

3. The operation was performed as an emer-

gency procedure, which made it impossible toprepare the bowel for major resectional therapy.In addition, it was thought that resection wouldbe too much surgery in a patient who had hada relatively recent myocardial infarct.

4. It was thought unwise to perform ileotrans-verse colostomy in discontinuity for two reasons:

1) if the distal ileum, after transection, were

closed proximal to an obstruction and droppedback into the abdomen, there was a risk of a

blowout, a risk believed to be too great; and 2)if this procedure had been elected, then it wouldhave been necessary to create an ileal fistula forsafety, which would have lengthened the dura-tion of the operation and would have necessitateda second procedure later.

Comments on the selection of operationarrived by letter and wire from numerous

known and unknown colleagues, many ofthem surgeons but many of them from de-cidedly remote specialties. A professor ofpreventive medicine, for instance, did notthink that the bypass we had created couldpossibly prove competent. We came towelcome the opinion of the physicians who

limited their public statements to the effectthat only surgeons with a close-up view ofthe Eisenhower peritoneal cavity had any

right to comment on what had been donewithin it. One reporter stated it quite wellwhen he wrote that criticism multiplied indirect ratio to the distance of the criticsfrom the operating room and from thepatient.We wish to emphasize again that re-

gional enteritis was not our immediateproblem. Instead, our overwhelming prob-lem was how best to handle a patient withobstruction of the small bowel; a patientwho had not responded to conservativemeasures; a patient whose blood chemicaltests had been affected unfavorably by theduration of the obstruction; a patient who

was 65 years old and who had a back-ground of recent cardiac disease; and,finallv, a patient wlho required emergency

operation and who, therefore, could not

FIG. 3. Small bowel series in May, 1963, show-ing a well-functioning ileocolostomy stoma. Theregional enteritis lesion in the terminal ileum isunchanged except for further cicatrization. Theproximal small bowel is normal and skip areas arenot seen.

undergo the regimen considered desirable,if not imperative, in intestinal resection.

Conclusion

Seven and a half years have passed sincethat memorable night in June, 1956, andduring this time General Eisenhower has

remained without symptoms from the dis-eased terminal ileum which was then by-passed. The lesion, as observed on roent-genograms of the small bowel, appears thesame in May, 1963 (Fig. 3) as it did inMay, 1956 (Fig. 1). There has been no

development of skip areas. The disease,therefore, has remained static, and obstruc-tive symptoms, for which the operation was

performed, have been completely relievedby ileotransverse colostomy in continuity.We have never wavered in our belief thattime would justify the decision made dur-ing those fateful hours.

V'olume 159Number 5 665

666 HEATON, RAVDIN, BLADES AND WHELAN Annals of Surgery

Acknowledgment

We acknowledge with appreciation the in-valuable editorial assistance given to us in thepreparation of this manuscript by Miss ElizabethNI. McFetridge.

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