Medicine: Emergency at Walter Reed

The human digestive tract can become inflamed anywhere along its 25-to-35-ft. length from gullet to anus. Inflammation of the stomach (gastritis) or large bowel (colitis) is common. For reasons that medical researchers have not yet fathomed, inflammation of the ileum, the lower third of the small bowel, is far less common. It escaped description as a recognized disease until 1932, when Dr. Burrill Crohn, of Manhattan’s Mount Sinai Hospital, listed its symptoms and put a name to it: regional ileitis. Usually it is limited to the last couple of loops in the small intestine before the junction with the ascending colon, part of the large intestine (see chart). Europeans often call it Crohn’s disease.

The cause of ileitis is unknown (even the tubercle bacillus was once indicted, now dysentery bacteria are suspected), and the disease is probably commoner than was believed until recently, because it is difficult to diagnose. Emotional disturbances are often prominent features: anxiety, tension and irritability. One authority recommends lowering emotional tension by “leaves of absence from college or business, or by the solution of marital problems.”

The effects of ileitis are fairly well-known. Inflammation in the end loops causes the walls of the ileum to become engorged with blood, while the inner surface develops scar tissue. The inflamed area becomes swollen with water. These conditions narrow the passage through which the remnants of food, now mostly digested, pass into the colon. When the closure is extreme, waste matter cannot be discharged.

When such a closure struck President Eisenhower early Friday morning, he felt pains in the lower quarter of his abdomen. At the first call from Mamie Eisen hower, Presidential Physician Howard McCrum Snyder, knowing his longtime patient’s susceptibility to indigestion, prescribed milk of magnesia ; he figured hope fully that it could do no harm and might bring the upset to a quick end. But as Ike’s discomfort became gradually worse, Snyder went to the White House to sit up the rest of the night with him. The President vomited repeatedly, and Dr. Snyder now knew that something worse than a stomach upset had hit the President. Calling in Walter Reed’s Dr. Francis Pruitt to help, Dr. Snyder deduced by noontime that the President had acute ileitis.. This diagnosis, one of more than a dozen possibilities suggested by the symptoms, could not have been confirmed in the White House bedroom without X rays if Snyder had not been familiar with Ike’s previous attacks and his medical history. This goes back to a “voluntary” appendectomy in 1923—after a series of unexplained upsets—and severe dysentery in the 1930s. On either of these occasions the disease could have planted itself. It usually strikes between the ages of 20 and 40.

It was obviously necessary to get Ike to the hospital to confirm the diagnosis and determine what to do about it.

But what if it were decided to operate? Ike was full of an anti-clotting drug that he had been taking regularly since his heart attack to reduce the danger of other blood clots forming in his coronary arteries. By reducing the blood’s clotting tendencies, such a drug creates a danger of excessive bleeding during surgery. Furthermore, would Ike’s heart stand the strain of a prolonged major operation under deep general anesthesia? These were among the grave matters to be decided by the more than a dozen doctors who eventually sat in on the case in the living room of the presidential suite at Walter Reed hospital.

Failure: Suction. First, of course, everything possible was done to avert the need for surgery. An uncomplaining patient, Ike submitted to the discomfort of having a thin Levin tube worked up his nose, down his gullet and into his stomach. This was hooked up with a Wangensteen suction apparatus in the hope that the backed-up, partly digested food could be drawn off. But it did not help. X rays showed that the intestine was in fact closing more tightly. Soon the doctors could hear no bowel sounds through their stethoscopes. These were clear danger signs: such a severe blockage might quickly lead to shock or to gangrene in the bowels; either of these could mean quick death.

Fortunately, Ike’s heartbeat, blood pressure and breathing were normal as he lay abed, sustained only by intravenous feedings with glucose. The anti-clotting drug was being counteracted. Heart Specialists Paul D. White and Thomas Mattingly were confident that their patient could take the strain of operation, agreed to stand by in the operating theater in case of emergency. At 2 a.m., seeing no sign of a break in the intestinal roadblock, the doctors decided unanimously: operate.

Anesthesiologists Harvey Slocum and Howard Kortis went to Ike’s room and gave him a shot of Pentothal sodium, augmenting it with a small injection of curare (Indian arrow poison) to relax his muscles. After time for these to take effect, attendants carried Ike on his bed to the operating theater 100 yards down the hall on the same floor. There a team of 15 doctors and nurses awaited him.

Tall, bespectacled Major General Leonard Dudley Heaton, commandant at Walter Reed and one of the nation’s top surgeons, was head man. He had performed, many times, the operation he was about to perform on the President of the U.S. Facing him across the operating table stood Philadelphia Surgeon Isidor Schwaner Ravdin. Two sterile nurses*flanked them. At the head of the table, Anesthesiologists Slocum and Kortis hovered over their cylinders, valves and gauges. They slipped a tube into Ike’s windpipe and put him under with nitrous oxide mixed with oxygen, followed by ether. Two circulating nurses and two additional nurses kept the surgeons’ trays filled with gauze and assorted gadgets.

Exposed: Small Bowel. Only the President’s lower-right belly peeped from beneath his green surgical sheets. Surgeon Heaton swabbed the area with an antiseptic, then raised his scalpel and made a six-inch incision to the right of the midline (between the navel and Ike’s old appendectomy scar), extending upward to the rib margin. A trickle of blood was swabbed. Then Heaton cut through the relatively bloodless muscle wall and the peritoneum into the abdominal cavity. Retractors held the gaping wound open as Heaton and Ravdin explored deeper. Under the brilliant lights, the surgeons worked without seeming hurry but with a tremendous sense of urgency. Every two or three minutes the anesthesiologists reported: “Your patient is doing well.”

Eventually the surgeons laid bare the end of the small bowel. It was grossly inflamed and so swollen that they estimated the inside passage to be no wider than the lead in a pencil. Tracing it back, they found that the disease spread along a ten-inch stretch. A quick consultation with Dr. Brian Blades and Dr. John H. Lyons (who, like White, were standing by, but were unscrubbed) confirmed the operating-surgeons’view. The diseased area need not be cut out, but should be bypassed.

This decision demanded another: How? There was no undiseased ileum next to the ascending colon, and it would have been difficult to make a connection there. It seemed best to cut a new channel into the transverse colon, bypassing the ascending colon, which removes water from the bowel contents. In time, nature would transfer the bypassed colon’s water-absorbing quality to a portion still in use. The doctors were so confident, on the basis of hand and naked-eye examination (“gross pathology”), that the diseased area showed no sign of malignancy that they did not bother to take a biopsy specimen (a tiny tissue sample) for microscopic examination. They decided to leave the ten-inch diseased area in place, assuming that in a man of Ike’s age it will atrophy from disuse, cause no trouble or discomfort. Making a 1½-inch hole in the ileum and another like it in the colon, the surgeons put the two pieces of gut side-by-side and stitched around the holes, completing what they call an “ileo-transverse colostomy.” Then they closed up the President’s abdomen. The entire operation had taken an hour and 53 minutes.

Within six hours Ike was awake, feeling some smarting and pain, but able to make restrained wisecracks with the hospital staff. He was spared the discomfort of having drains in the wound because there were no accumulations of pus at the site of surgery, and with their patient on precautionary antibiotics, the doctors had no reason to fear that any would develop. Ike needed little sedation (meperidine) to help him sleep (he dozed most of the time next day, spent “a reasonably comfortable” first night). The doctors fed glucose into his veins. Intravenous feeding was to go on for four days. The suction tube was left in to draw off gas lest he become distended and disrupt his wound. This week, with all going well, the President will get his first liquids by mouth. Thirty-one hours after the operation, he took his first steps with the help of two orderlies.

Facing the press after his hard night’s work, Surgeon Heaton was confident about the President’s chance for a full recovery. That chance is indeed good. Perhaps 15%, not more than 35%, of ileitis patients who undergo surgery later have recurrences, sometimes requiring further operations. Ike’s prospects are indicated by the remarkable vitality that enabled him to snap back so successfully after his heart attack.

* So-called because only they handle sterile instruments. Non-sterile nurses put aside used instruments and waste materials. Some surgeons call the two classes simply “clean nurses” and “dirty nurses.”