Harry Truman’s Complicated Cholecystectomy

Abstract

Mini-Abstract: Harry S. Truman, the 33rd President of the United States, developed right-sided abdominal pain the year after he left office. Misdiagnosed with appendicitis, Truman underwent an appendectomy before a cholecystectomy treated the underlying cholecystitis. This error was concealed at the time from the American people. His postoperative course was closely followed by Americans through newspapers and was complicated by a bout of Clostridium difficile colitis. Truman survived this episode to die of heart failure decades later.

INTRODUCTION

Harry S. Truman was the 33rd president of the United States from 1945 to 1953 (Figure 1). He served as Vice President until April 12, 1945, when he assumed the presidency upon the death of Franklin D. Roosevelt. Truman managed a very eventful post-World War II presidency and enjoyed relatively good health until 1954, when he presented to his physician, Dr. Wallace Graham, with right-sided abdominal pain. Misdiagnosed as acute appendicitis, his acute cholecystitis subsequently required two incisions to treat: one to remove his appendix and the other for a diseased gallbladder. A nearly fatal, presumed Clostridium difficile infection stymied his postoperative course. This article relies on original medical records, housed in the Harry S. Truman Presidential Library, as well as contemporary newspaper articles to review Truman’s medical history before, during, and after his presidency and to discuss his clinical course after his complicated cholecystectomy.

FIGURE 1.

Portrait of Harry S. Truman. Image in the public domain under Wikimedia commons.

SOCIAL AND POLITICAL HISTORY

Harry S. Truman was born on May 8, 1884, in Lamar, Missouri.¹ His middle initial “S” was to acknowledge his grandfathers: Anderson Shipp Truman and Solomon Young. His family eventually moved to Independence, where Truman graduated from high school in 1901. He attended Spalding’s Commercial College in Kansas but left after 1 year to work a variety of odd jobs. He tried to join the National Guard but was initially rejected due to his poor eyesight; only memorizing the eye chart and a second chance enabled his commission. With America’s entry into World War I, he joined the active-duty army and served overseas until his discharge in 1919 as Captain. Other than his eyesight, Truman had no health problems during this period.

After the Great War, Truman married Bess Wallace, and they had one child. A brief business venture as a haberdasher financially failed, encouraging Truman to turn to politics as a vocation. He was elected as a County Judge in 1922 and developed a lifetime alliance with Tom Pendergast, the Democratic political boss of Kansas City, Missouri. He served in a variety of political roles until Pendergast supported Truman’s successful run for the US Senate from Missouri in 1934. In September of 1937, Truman was hospitalized at the Army-Navy Hospital in Arkansas for exhaustion. He stayed in the hospital for more than a week with only the diagnosis of “overwork.”² Truman was reelected to the Senate in 1940 where he served until he was tapped as Vice President for Franklin Roosevelt’s 4th presidential election campaign in 1944.

PAST MEDICAL HISTORY

Truman became president upon the death of Roosevelt on April 12, 1945. As reported by his physician, Wallace Graham, Truman had episodes of biliary colic during his presidency, occasionally requiring evaluation at Walter Reed Hospital.³ Otherwise, he continued to experience excellent health until July 1952, near the end of his second term. Truman’s first significant illness started on Friday, July 11, 1952, with the prodrome of fatigue, malaise, sore throat, and abdominal pain. He got much worse on Sunday, July 13, when he experienced a rigor associated with a fever of 103.6°F. His physician General Graham sent Truman to Walter Reed where the President was flushed, shaky, and continued to complain of a sore throat. Truman had tachycardia (heart rate up to 120 beats per minute) with a temperature of 103°F and a respiratory rate of 36 breaths per minute. His chest examination was revealing for “heavy moist rales.”² Although at Walter Reed, Truman was febrile for 5 days and was seen by a variety of specialists for this illness. Bacterial cultures of the President’s throat grew Alpha Streptococcus, Hemophilis influenza, and Neisseria catarrhalis. Based on his presentation and culture results, Truman was treated with antibiotics for “strep throat.” He eventually improved enough to return to the White House on July 19. He resumed work in the Oval Office on July 21, 9 days after his illness began.²

CHOLECYSTECTOMY

Truman finished his second term as president in January of 1953, returned to Independence, Missouri, and enjoyed excellent health until the summer of 1954. On Friday, June 18, 1954, Truman developed abdominal pain while attending a performance of “Call Me Madam” at the Starlight outdoor theater in Swope Park, Kansas City. The President had expected to be called upon to make a cameo on stage during the play, performing as himself. His abdominal pain began shortly after the start of the play, and he returned home without ever appearing on stage.^1,4,5

The following day Truman initially felt better, but his pain worsened in the afternoon of the 19. Dr. Graham was called to the Truman home in Independence, where his first impression was that the former President had indigestion. Through the evening, as Truman’s pain persisted, Dr. Graham decided that Truman needed to be admitted to the hospital. Dr. Graham drove the former President to the Kansas City Research Hospital in his personal car after Truman refused the ambulance that had been called. Truman arrived at the Research Hospital at 10 pm where Dr. Graham’s history and physical examination suggested that the diagnosis was appendicitis, recommending an appendectomy.^3,6

The Surgeon

Wallace Harry Graham was born on October 9, 1910, and grew up in Kansas City where his father, a physician, was friendly with Harry and Bess Truman (Figure 2).^7–9 Graham graduated from Missouri State Teacher’s College in 1934 before matriculating to Creighton University School of Medicine. He served several internships, including at Massachusetts General Hospital. In an era before surgical residencies were common, he traveled to Europe for postgraduate education, spending time in Vienna, Budapest, and Edinburgh, the latter through the Royal College of Surgeons.^10,11 Already in the Army reserves, Graham was called to duty during World War II, landing on Omaha Beach four days after D-Day and treating combat casualties throughout the ensuing campaign; he himself was wounded in action during Operation Market-Garden. He was ordered to attend to President Truman at the Potsdam Conference in 1945, interestingly also treating Joseph Stalin at the same meeting for a diarrheal illness. After the war, Graham stayed with Trumans as the official White House physician, rising the rank of Major General. He moved back to Missouri and private practice following the inauguration of President Dwight D. Eisenhower.

FIGURE 2.

Colonel Wallace H. Graham, at the White House. Image in the public domain from the Truman Library.

The Operation—June 20, 1954

At 12:55 am on June 20, 1954, Truman was taken to an operating room on the sixth floor and anesthetized with sodium pentothal and ether.³ Dr. Graham thought the former President had appendicitis but prepped both the upper and lower abdomen. Graham started with a right rectus infraumbilical incision, a standard approach for an appendectomy. As he opened the abdomen he found fluid in the right lower quadrant, but through the appendectomy incision, he could see that the gallbladder was inflamed. He then removed the appendix (the operative report did not describe the technique). The appendectomy incision was closed by running the peritoneal layer with no. 1 chromic and closing the fascia with 2-0 silk, while the subcutaneous layer was closed with 3-0 chromic. The skin was closed with interrupted vertical mattress sutures, and no drain was left in the right lower quadrant incision. Dr. Graham then made a right subcostal incision to perform a cholecystectomy, the primary source of infection. There was fluid around the very edematous gallbladder, tracking into the right lower quadrant. The cholecystectomy began with exposure of the infundibulum, as he initially dissected out the porta hepatis. Graham described sequential “clamp, cut and tie” of both the cystic artery and cystic duct. As was routine in that era, the gallbladder “bed” was closed with a “GI suture.” The common duct was exposed and did not appear enlarged; therefore, the common duct was not opened or explored. A Penrose drain was placed near the gallbladder bed and brought out through a separate stab wound. The peritoneum of the right subcostal incision was closed with a running suture while the transversalis fascia was closed with interrupted 2-0 silk. The subcutaneous tissues were closed with 3-0 chromic and the skin was approximated with 2-0 silk vertical mattresses. Truman tolerated the procedure well and returned to the recovery room around 3 am. Dr. Graham planned a postoperative length of stay of 9 to 10 days, which was appropriate for the 1950s postsurgical care after gallbladder surgery.^3,12

Surgical pathology confirmed a diagnosis of acute cholecystitis: the report detailed the gallbladder as 9 × 8.5 cm in diameter. Upon dissecting it, the pathologist noted “wealth of multi-faceted, tiny, black stones,” which were soft and friable. There were also several small stones within the cystic duct. Grossly, the wall of the gallbladder was noted as being trabeculated and having fibrinous exudate scattered all over the mucosal surface. Microscopically, the wall seemed to be of normal thickness, “but edematous and congested with blood…with ulceration of mucosal epithelium.”¹³ The appendix was measured at 8.5 cm in length by 0.5 cm in diameter with a smooth glistening surface and some meso-appendiceal fat attached. On sectioning, the appendiceal wall was noted as “translucent and practically obliterated.” Microscopically, the appendix had a wall of normal thickness with its lumen obliterated by connective tissue. There was no description of acute infection of the appendix.¹³

POSTOPERATIVE CARE

Truman’s postoperative course was detailed by daily articles in the national press, with the wire services and major newspapers stationing reporters in Kansas City for the duration of the hospitalization. Largely confined to relaying what Truman’s medical team deigned to tell them, the ongoing coverage reflected Americans’ fascination with the health of celebrities and particularly presidents.^14,15 It also represents an era when reporters were more willing to trust official sources of information, with little evidence of journalists pushing back against the given narrative. On postoperative day 1, Truman was able to sit in a chair but did not walk.¹⁶ The next day Truman’s temperature was 99.2°F; he was able to walk to a chair and shave himself.¹⁷ He was still nil per os on postoperative day 2, but Dr. Graham stated that the former president’s diet would be advanced to a “fluid diet” the following day. Truman stayed on a “surgical liquid diet” until June 25, when Dr. Graham announced in a press release that Truman had taken a turn for the worse due to atelectasis.¹⁸ On the evening of the 25th, Graham examined the ex-president and reported to the press that Truman had “a little plug low in the lung.”¹⁹

Pseudomembranous Colitis

Despite the public statement about atelectasis, Truman developed a low-grade temperature, nausea, abdominal pain, and diarrhea on the 24th. Originally, it was described as “inflammation of the intestine,” and cultures were taken of the stool. Dr. Graham thought the gastrointestinal distress was a “hypersensitivity reaction” to the oxytetracycline (Terramycin), he prescribed to treat the gallbladder infection.^20,21 Dr. Graham stopped the oxytetracycline and instead added erythromycin to finish an antibiotic course for the original gallbladder infection.²² By the 25th, these “hypersensitivity” symptoms had worsened, and on Saturday morning Truman was dramatically ill with intestinal symptoms.²³ Truman’s condition was described as “serious” by the Research Hospital Bulletin when he spiked his temperature to 102°F.⁴

In the 1950s, the Research Hospital did not have air-conditioning in all the rooms, and during the week of Truman’s illness the temperatures in Kansas City exceeded 100°F. Mrs. Truman insisted that something be done about the extraordinary heat in the hospital room, so Truman was moved on Saturday the 26th to a room on the fifth floor of the hospital where an air-conditioner had been installed.²³

By the afternoon of June 27, Truman had stabilized and was tolerating liquids by mouth again. He had spiked a temperature in the morning of the 27th to 102°F, but by the evening, his temperature was down to 99.2°F. Blood cultures taken on the 27th showed no growth.²⁴ Dr. Graham had called Dr. Martin Mueller, an internist, for consultation on Truman’s persistent severe diarrhea.²⁵ Graham also called Dr. W. Alan Wright and Dr. Frederick C. Fink, both of the Pfizer Pharmaceutical Company. In 1950, Pfizer had released Terramycin in the US market. Dr. Graham was looking to the medical experts at Pfizer to determine if Truman’s condition was a rare side effect of their drug.^26,27

On June 28, as Truman’s severe diarrhea persisted, he began to pass “membranous” material from his rectum. A stool sample was sent to the Research Hospital pathology laboratory who reported the presence of considerable membranous material covered in mucous with a large number of bacterial colonies and leukocytes. There was no intestinal mucosa found during the microscopic evaluation of the specimen.²⁸ The passage of “membranous” material certainly alarmed the physicians, as they continued to discuss the possibility of “hemorrhage” as a possible complication of the ex-President’s persistent diarrhea. The physicians would have presumed that Truman was sloughing his colonic mucosa, a situation that would prompt concern about bleeding.²⁶

By the eighth postoperative day, Truman’s clinical status had not changed. He continued to run a low-grade temperature (100°F) and endured high-volume watery diarrhea. He had been sedated earlier in the week to manage his extreme abdominal discomfort, but on the 28th, the sedation had been stopped, and the former President appeared more alert.²⁶

By June 29, Truman had started to improve and the research hospital upgraded his condition from “serious” to “fair.” He continued to have some nausea and hiccups but was able to take a small amount of food by mouth. His abdominal pain was now gone, and his white blood count had normalized without a left shift, but his exhaustion persisted.^29,30 Truman continued to improve all of his symptoms except his loose stools, which were still present in the hospital on July 3. By this time, his drain and sutures were out, but he continued to struggle to maintain his fluid balance due to his large-volume green liquid stool.²²

Truman went on to endure a protracted course. He had persistent loose stools for several weeks after his discharge from the hospital on July 8, 1954. He returned to his home on a regular diet without abdominal pain but had intermittent fevers and diarrhea well into the fall of 1954. On September 22, Dr. Wallace continued to be concerned about Truman’s slow progress when he warned the former President that his “blood tests and…complete physical condition” did not warrant travel.³¹ At the end of September, Dr. Graham was still monitoring Truman’s progress; he checked his complete blood count on September 29, which was again normal.³⁰ Eventually, Truman’s diarrheal illness resolved, and he went on to live another 18 years in relatively good health. He had a hernia repair in 1963, but otherwise was medically well until 1972 when he died at the age of 88 of heart failure.^32,33

ANALYSIS OF TRUMAN’S MEDICAL AND SURGICAL CARE

The original presumed diagnosis for Truman’s abdominal pain was appendicitis, but intraoperative findings and surgical pathology confirmed that the actual etiology causing right-sided abdominal pain was acute cholecystitis. This was clinically discovered when his surgeon peered into the small right lower quadrant incision for the source of purulent fluid tracking down the paracolic gutter. After Dr. Graham removed the appendix and closed the appendectomy incision, a second incision was required extirpate the diseased gallbladder. In an era antedating ultrasound or CT imaging, right-sided abdominal pain was always a diagnostic dilemma. In elective patients, an oral cholecystogram could provide supportive evidence of gallbladder disease, but Truman had an urgent presentation that prompted an operation at 1 am.³⁴ There were no imaging studies in the 1950s that would facilitate making a diagnosis. Therefore, Dr. Graham explored Truman through a right lower quadrant incision because he thought appendicitis was at the top of the differential. For most of the 20th century, surgeons typically removed an appendix during planned appendectomies, even if it appeared healthy, to reduce future diagnostic confusion. In the 1950s, up to a 20% negative appendectomy rate was acceptable. Graham followed that tradition: having made an appendectomy incision, he removed the appendix.^35,36

Diagnostic dilemma between appendicitis and cholecystitis was unusual even in the 1950s. The chance of finding cholecystitis at the time of exploration for appendicitis was <1% in a 15-year review of several community hospitals published in 1955.³⁷ In misdiagnosing Truman, Graham made a rare but excusable error in judgment. More importantly, once Graham realized that the gallbladder was diseased, he made the correct decision to close the right lower quadrant incision and make a separate subcostal incision to remove the gallbladder.³⁸ Attempting to extend a right lower quadrant incision to take out the gallbladder can lead to an incision that is difficult to close while failing to provide adequate exposure to the gallbladder. Only a right lower quadrant paramedian incision should be extended to take out the appendix and the gallbladder through one opening, but a paramedian incision was rarely used for the presumptive diagnosis of appendicitis.³⁸

More troubling was the discordance between what actually happened and interview answers Graham provided to the press. Even though the initial conduct and description of the operation focused on appendicitis, Graham told reporters that “we expected to find trouble with the gall bladder…what we found additionally was…a secondary infection of the appendix.”³ That “expectation” conflicts with the original choice of incision in the right lower quadrant. He also informed the press that the gallbladder infection had “seeped downward and caused a secondary infection of the appendix,” despite the pathology report noting no evidence of acute appendicitis.³ While such an explanation may be excused in the immediate aftermath of the operation, with elevated emotions and before any confirmatory pathology, Graham doubled down on this claim in later interviews, recounting Truman’s “appendix was close to his gallbladder and both were infected,” when he knew that this was not true.⁷ It is interesting to ponder why he provided a more accurate account in the medical records, which only described cholecystitis. Perhaps the ethics of the medical profession inspired greater honesty; the risk of being “caught” by other members of Truman’s health care team may also have prompted a more reliable rendering of events. Notably, no members of the medical team publicly contradicted Graham’s press statements.

Truman developed debilitating diarrhea after surgery. Given his symptoms and use of two antibiotics postoperatively, scholars now believe that President Truman suffered from antibiotic-associated pseudomembranous colitis. This presumption is supported by the fact that Truman shed pseudomembranous material from his rectum, and its presence was dramatic enough that his doctors sent it for pathologic evaluation. Truman’s diarrhea persisted for weeks but did resolve with supportive measures. There has never been any mention of a specific diagnosis concerning this episode in President Truman’s life except from one oral history gathered in 2001 from Dr. Phillip D. Reister, who was interviewed about his time as one of President Truman’s personal physicians. During the interview, he remarked that, “… he [President Truman] ended up with pseudo membranous colitis… he almost died.”³⁹ Dr. Reister’s comment concerning the clinical scenario benefited from a broad understanding of Clostridium difficile as the cause of pseudomembranous colitis, which was not known until the 1970s.⁴⁰ Pseudomembranous colitis was originally described in the 1880s,⁴¹ and by the early 1950s, it was noted to be associated with antibiotic use.⁴² Dr. Graham and his consultants were worried about the impact of the antibiotics on Truman’s complication and contacted scientists at the Pfizer pharmaceutical corporation assuming this might be a toxic reaction to Terramycin. At the time of his illness, there is no evidence that Truman’s doctors understood that the diarrheal illness might be antibiotic-associated pseudomembranous colitis.

MIRACLE CURES

Once news of President Truman’s “enteritis” reached the nation through newspaper reports and wires, Dr. Graham received myriad letters from random but interested parties across the country, all proposing peculiar remedies. These suggestions accord with a long tradition of distrusting orthodox medical practice in America, substituting homegrown or seemingly natural remedies. In one letter, the author surmised that the President was receiving injections of “chemical” solutions, such as saline, that would hasten the “inevitable consequences of interfering with Mother Nature’s healing processes rather than helpfully assist the same.”⁴³ Another missive recommended using “black metallic magnetic sand” to help with wound healing and pus and germ extraction.⁴⁴ Correspondence from “The Angel Joseph” highlights the inflammatory property of “chemicals” and how sugar is the best medicine. “Sugar is cooling and soothing,” and should be mixed with unchlorinated mountain valley water, tea, and consumed every hour. Within 24 hours, The Angel Joseph predicted, a vast improvement in symptoms.⁴⁵ Neither Wallace nor the rest of Truman’s medical team took these suggestions seriously, but they nonetheless reflect how closely citizens followed the former President’s medical travails and their genuine interest in abetting his healing.

CONCLUSIONS

In 1954, Harry S. Truman developed right-sided abdominal pain prompting an operation for presumed appendicitis through a right lower quadrant incision. He had a normal appendix but significant cholecystitis and underwent an open cholecystectomy through a second incision in the right upper quadrant. His postoperative course was complicated by a life-threatening diarrheal illness that may have been caused by Clostridium difficile overgrowth after being treated with a new antibiotic, Terramycin, causing pseudomembranous colitis. He responded to several weeks of supportive care and lived another 18 years in relatively good health.