James L. Franklin
Chicago, IL

First published in the Illinois Carol Fisher Chapter Newsletter of September 11, 2005.
Published by the Crohn’s and Colitis Foundation of America. 

It is still well within the public consciousness that Dwight David Eisenhower suffered a myocardial infarction three years into his first term of office as President of the United States and that he overcame this illness and went on to win a second term in office. It is, perhaps, less well remembered that nine months after suffering a heart attack he underwent an operation to relieve a small bowel obstruction secondary to regional enteritis and again was able to overcome this setback and campaign for re-election. If in 1956 the nature of coronary artery disease and prognosis were poorly understood by the general public, regional enteritis was virtually unknown. The illnesses of our Presidents have both fascinated the nation and offered instruction. Heightened public consciousness has led in some cases to greater funding for medical research or improved awareness of the need for preventative health measures.

On June 9, 1956 Eisenhower was operated on for a worsening bowel obstruction that had begun 24 hours earlier. This was the culmination of a long history of intermittent gastrointestinal symptoms that had plagued his career. In 1922, during his first assignment after graduating from West Point in the Panama Canal Zone, he suffered several bouts of abdominal pain and weight loss. Based on his self-diagnosis that the culprit was his appendix, he persuaded doctors in Denver to perform an appendectomy in 1923. He had on a number of occasions undergone thorough diagnostic evaluations, but it was not until a month before his 1956 surgery that small bowel X-rays had revealed a picture typical of regional enteritis involving the terminal ileum. The report of X-ray studies that were performed in 1949 as part of an evaluation of severe intestinal symptoms revealed some “irregularity of caliber of the small bowel.” In view of the subsequent diagnosis of Crohn’s disease, these findings suggest that this disease had been present for some years prior to his surgery in 1956. At a meeting of the Southern Surgical Association in December 1963, a presentation, subsequently published in the Annals of Surgery in May 1964, Lt. General Leonard D. Heaton described the two-hour operation performed in the early hours of June 9, 1956 at Walter Reed General Hospital. In this article Heaton defended, against considerable public criticism, his decision to bypass the 30–40 cm diseased segment of terminal ileum rather than perform a primary resection of the abnormal small intestine. In the operation that was performed above the diseased segment was anastomosed to the transverse colon. The president made a steady recovery from this surgical procedure with the exception of a wound infection and left the hospital on the twenty-first postoperative day.

The decision to bypass rather than remove the diseased small intestine was defended by the surgeon on the grounds that while he recognized that resection would have been preferable, the need to expeditiously relieve the small bowel obstruction and minimize risk for the 65-year-old president who had recently suffered a major heart attack was the primary goal of the operation. In his discussion he refers to the inflammatory process as being of the “dry” type rather than the “wet” type, meaning chronic rather than acutely inflamed, as contributing to his justification for the bypass procedure. In his discussion, he bristled at his critics whose comments he felt multiplied in direct ratio to their distance from the operating room and the patient.

Equally remarkable was an article again presented at the Southern Surgical Association in December 1970 and subsequently published in the Annals of Surgery in May 1971 titled “A Review of the Late General Eisenhower’s Operations: Epilog to a Footnote to History.” The article summarized the now deceased president’s medical history and included a description of the autopsy finding relevant to his Crohn’s disease. Follow up on the operation performed in 1956 included mention of the fact that biennial radiological studies of the small intestine all revealed that the anastomosis of the small intestine to the transverse colon remained widely patent and free of any sign of Crohn’s disease. The bypassed segment of terminal ileum remained unchanged. In December of 1966 the former President underwent a successful cholecystectomy for lower chest discomfort and abdominal distress following meals. Gallstones had been demonstrated on X-rays obtained earlier in the year. What was to prove his final illness began in April 1968 when he again suffered a myocardial infarction at his home in Palm Desert, California. He was transferred to Walter Reed Hospital to convalesce but the course of his recovery was complicated by multiple episodes (14) of ventricular fibrillation requiring electrical defibrillation. Against this background of cardiac difficulties he developed recurrent episodes of small bowel obstruction which had begun in May 1967 and recurred in August 1967 and again in December 1968. A final obstruction in February 1969 failed to resolve with conservative treatment and on February 23rd, surgery was performed to relieve the obstruction. The recurrent small bowel obstructions had been caused by a loop of small intestine (18 cm) above the patent anastomosis that was adherent to the abdominal wall. The bypassed segment of terminal ileum which was affected by Crohn’s disease remained unchanged from the original operation of 1956. The former President again made a steady recovery and by the fourteenth postoperative day was returned to the care of the cardiologists. In March of that year his cardiac status deteriorated and he died on March 28, 1969 just short of his 79th birthday. An autopsy confirmed the findings of his final operation and microscopic examination of the diseased terminal ileum was “characteristic of relatively quiescent Crohn’s disease.”

Eisenhower wrote in his 1967 book, At Ease: Stories I Tell to Friends of his long history of gastrointestinal distress that “Three decades would pass before I would learn the cause of my repeated distress, when doctors described it as ‘a young man’s disease’ ileitis.” Both the diagnosis and the duration that Eisenhower suffered with this illness have been disputed. Writing for the Journal of Medical Biography in 2002 in an article titled “Did President Eisenhower have Crohn’s disease?” Adrian Marston, a distinguished British vascular surgeon credited with the clinical description of ischemic colitis, has questioned the diagnosis and put forth the hypothesis that the changes in the terminal ileum resulted from ischemia (lack of blood flow) to the terminal ileum that followed the President’s 1955 myocardial infarction. He also cites Eisenhower’s age at the time of the operation, 65 years, as being against the diagnosis. Marston reports that he tried to locate autopsy material for review of the pathologic diagnosis of Crohn’s disease but was unsuccessful. He dismisses the long history of gastrointestinal distress as being the result of Crohn’s disease. In a book review of Robert H. Ferrell’s 1992 Ill-Advised Presidential Health and Public Trust, published in the Journal of the American Medical Association, Dr. Ogelsby Paul, an American cardiologist and biographer of the famous cardiologist Paul Dudley White who had been called into consultation during Eisenhower’s heart attack in 1955, expressed doubt that the history of Crohn’s disease extended as far back as 1922. Reviewing the articles published in the Annals of Surgery, and a review of Clarence G. Lasby’s fascinating book Eisenhower’s Heart Attack: How Ike Beat Heart Disease and Held on to the Presidency, I think that Eisenhower was correct in his feelings that he had suffered from this illness for many years and the above mentioned abnormal small bowel X-ray of 1949 supports this clinical impression.

Just as Eisenhower’s success in his battle with coronary artery disease served as an inspiration to patients afflicted with heart disease, his battle with gastrointestinal difficulties and Crohn’s disease, which did not prevent him from becoming the nation’s most beloved hero of World War II and President of the United States is a source of encouragement to victims of Inflammatory Bowel Disease. Clarence Lasby’s book on Eisenhower’s heart attack is a very interesting study of the politics of illness and the relationship of our President to the public and press as it relates to health care issues. Eisenhower recognized as President that the public had a right to be accurately informed about the health of their elected officials.

References

1. Heaton, L.D., Ravidin, I.S., Blades, B. and Whealan, T.J., President Eisenhower’s Operation for Regional Enteritis: A Footnote to History. Ann. Surg., May 1964, 159: 661-666.
2. Hughes, C.W., Baugh, J.H., Mologne, L.A., Heaton, L.D., A Review of the Late General Eisenhower’s Operations: Epilog to a Footnote to History. Ann. Surg. May 1971,173: 793-799.
3. Marston, A. Marston, Did President Eisenhower have Crohn’s Disease? Journal of Medical Biography 2002; 10: 237-239.
4. Paul, Oglesby, Presidential Health: Ill-Advised: Presidential Health and Public Trust (Book Review), JAMA Nov. 24, 1993 270: 2497-2498.
5. Oglesby Paul, Take Heart; the life and prescription for the world’s premier cardiologist. The Francis A. Countway Library of Medicine, Distributed by The Harvard University Press, Boston, 1986