Ike's Prognosis

Who shall decide, when Doctors disagree . . .?

--Pope

Did President Eisenhower get the right operation for his ileitis? What are his chances of regaining sufficiently good health to serve in the presidency for four more years? Politics aside, these questions have been the basis of bee-buzz conversations over cigarettes and coffee in many hospitals or medical-centers' common room since the President's operation (TIME, June 18). Neither can be answered with the kind finality that marked the first bulletins after Ike's operation.

On the operation actually performed, fellow surgeons refuse to criticize Major General Leonard Heaton who operated on the President. On Ike's medical future, professionals vary in their prognostications, but think that the President is in danger of more trouble. The trouble, if it comes at all, could range from occasional minor intestinal distress, through recurrent disabling attacks of diarrhea, low fever and malaise, to a need for more surgery. The course of ileitis is so variable that doctors cannot dogmatize about the outcome of an individual case. Explains Dr. Everett Duane Kiefer of Boston's famed Lahey Clinic: "There are few diseases which should leave the physician with a greater sense of humility."

Cut Off the lleum? For Ike's kind of regional ileitis the fashion in operations has gone through three main phases. At first it was taken for granted that the only thing to do was to cut the diseased section of ileum out of the body and attach the cut end of the ileum to the colon. But this was a relatively long and bloody procedure. It gave no better results than two types of bypass operations, which came into fashion next (see diagram). In one, the type performed on Ike, a healthy loop of ileum is drawn up and spliced into the colon, but the diseased section is left in place. This is "bypass without exclusion." In the other, the diseased ileum is cut off, and its open end is stitched shut; it is left dangling. This is "bypass with exclusion."

Some bright young surgeons leaped to the conclusion that Ike's type of operation, which has been abandoned in some medical centers, must have been wrong. They cited impressive authorities. Dr. Burrill B. Crohn, who first described and named the disease, says in his basic text, Regional Ileitis, that cutting off the diseased ileum "is a sine qua non to the success of any operation." Less than two years ago, at a doctors' round table, New York Hospital Surgeon William F. Nickel Jr. said to Crohn: "One should never [join] small bowel to large bowel . . . without dividing the small bowel, because those patients invariably get into trouble in our experience. Is that yours?" Replied Dr. Crohn: "That is correct."

But the more experienced an up-to-date surgeon is, the less willing he seems to be to criticize the operation performed on Ike. Many last week echoed the words of a Boston surgeon: "Only the surgeons who did the operation know exactly what they were dealing with, and they alone were qualified to decide what to do." A noted internist, safely out of the surgeons' crossfire, added: "I have seen patients get well after all three types of operation--and some who have failed to get well after all three."

Relapse Rates. One of the most bandied arguments against bypass without exclusion is that patients have a high rate of relapse. But this is true of all ileitis victims. Dr. Crohn has put the rate at no higher than 35%; Mayo Clinic figures make it 60%. Says Dr. Crohn: "With the increasing length of follow-up studies, it has become evident . . . that the rate of recurrence of ileitis is increasing."

The explanation is simple: the disease was recognized only 24 years ago, and the counting of relapses has always been limited to the years since 1932. Now, relapses have been noted as long as 24 years after the first acute attack. Says Tulane University's Dr. Frederick Boyce: "No matter how expert the therapy and how gratifying the immediate results, there is no assurance whatever that the patient has been cured. A low rate of recurrence [in medical reports] usually means that the follow-up has not been long enough for recurrences to appear."

Boston's Dr. Jacob Fine objects strongly to use of the word "recurrence," which implies that the disease has once been cured and has returned. Not so, he says: the operation does not cure; the disease is still there. It will be there for a long time in the best of cases, even if the inactivated section of ileum atrophies from disuse. There is always the possibility of its breaking out in another healthy stretch of ileum and again becoming acute.

Says another Bostonian, Dr. Louis Zetzel: "It is this high recurrence rate, even in the hands of the most enthusiastic sponsors of any one form of operation, that has relegated surgery to the role of a palliative rather than curative measure. This disappointing aspect is usually found within a year of operation . When the operation is limited to a sidetracking without [exclusion], there may be persistence rather than recurrence of activity--an eventuality found in almost half the patients so treated." Many patients who relapse after surgery require a second operation; several have had a third, some even a fourth.

At the age of 65, U.S. white males have a life expectancy of 13 more years, according to the actuarial tables. A coronary occlusion such as Ike's reduces life expectancy by at least 30%. How much the ileitis further reduces the Presidents outlook for long life or jeopardizes his working capacity is not known. But in 50% of cases like his there are relapses within five years.

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