The early days of diverticula of the colon.
|Article Type:||Case study|
(Care and treatment)
Diverticulitis (Case studies)
Colon (Anatomy) (Surgery)
Colon (Anatomy) (Health aspects)
|Publication:||Name: Journal of Perioperative Practice Publisher: Association for Perioperative Practice Audience: Academic Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2012 Association for Perioperative Practice ISSN: 1750-4589|
|Issue:||Date: Jan, 2012 Source Volume: 22 Source Issue: 1|
|Geographic:||Geographic Scope: United Kingdom Geographic Code: 4EUUK United Kingdom|
As a 17 year old first-year medical student at Oxford University in
1943, busily dissecting a cadaver in the Anatomy Department, I could not
help noticing a series of peculiar pea-sized swellings along the course
of the sigmoid colon. I showed these to our Professor of Anatomy, the
much respected Sir Wilfred Le Gros Clarke FRS, who said 'Those are
diverticula, my boy. As an Oxford student you should know, (which, in
fact, I did not!), that the word 'diverticulum' is Latin for a
'wayside house of ill fame or ill repute', and well do they
deserve that descriptive term'. I carefully excised the affected
piece of colon, put it in a bottle of formalin and, at the end of term,
put it onto the mantelpiece of my bedroom at home. A few years later, my
mother, in a clearing-up mode, threw the dusty bottle away. What a pity
that I am unable to produce a photograph of my specimen to illustrate
Later, now a senior surgical registrar, I was reviewing cases of acute perforated diverticulitis of the colon admitted to the old Radcliffe Infirmary, (now, like all 15 of the hospitals that I have worked in, closed down or pulled down). I thought that it would be interesting to introduce my article with a historical review of the subject. I reasoned that surely if a first year medical student, with no knowledge whatsoever of pathology, could observe diverticula with such ease, there would be brilliant descriptions of colonic diverticula and their complications in the writings of the great 17th, 18th and early 19th century clinicians and pathologists of the past. However, I drew a blank. Nothing in Mathew Baillie's 'Morbid Anatomy of the Human Body', nothing in Addison and Bright's great textbook, (by the authors who themselves had described pernicious anaemia, Addison's disease of the suprarenal glands and Bright's disease of the kidney). Nothing even in the 'Descriptive Catalogue of the Pathological Specimens' in the Hunterian Museum at the Royal College of Surgeons - so the great John Hunter had never seen an example in all the vast numbers of autopsies he had performed. In fact, the first undoubted description of diverticula of the colon that I could discover was in 1849. This was by Jean Cruveilier, Professor of Descriptive Pathology in Paris, who wrote, (and I translate from his French), 'We not infrequently find between the bands of longitudinal muscle in the sigmoid a series of small, dark, pear-shaped tumours, which are formed by herniation of the mucosa through openings in the muscle coat'.
The first account in English appeared just a few years later, in 1857. This was by Dr. S. Habershon, physician at Guy's Hospital, who wrote in his textbook 'Pathological and Practical Observations on Diseases of the Alimentary Canal'; 'Pouches of the colon sometimes become of considerable size the orifices of these small sacs are bounded by hypertrophied longitudinal and circular fibres and their contents remain almost shut off. These pouches are the results of constipation; muscular fibres become hypertrophied, but their efforts to propel onwards their contents lead to these minute hernial protrusions'.
The first operation for this condition was reported by Rutherford Morison, a pioneer abdominal surgeon of Newcastle - upon - Tyne, in 1903, for what he thought to be a malignant obstructing tumour of the sigmoid colon. However, examination of the resected specimen showed this to be what he called 'sacculitis. Sadly, the patient died postoperatively.
By the early 20th century, diverticula of the colon were well recognised but still considered something of a rarity. For example, in his paper on diverticula of the alimentary canal, published in 1910, Sir Arthur Keith could only find seven examples of colonic diverticula in the pathological museums of all the London teaching hospitals and the Hunterian Museum, of which he was curator. In sharp contrast to this, he found 149 examples of diverticula higher up the canal, from the pharynx down to Meckel's diverticulum in the ileum.
A breakthrough came in 1917, when Maxwell Telling, physician to the General Infirmary at Leeds, chose the British Journal of Surgery in which to describe, in great detail, the pathological changes, clinical features and complications of this condition. Indeed, since the First World War, diverticula of the colon have become increasingly common in Europe and North America, although the condition remains rare in rural Africa and much of Asia and South America. Since uncomplicated divericulosis is symptomless, its exact incidence is not known. It is detected in about a quarter of all barium enema examinations in the over 40's in this country and in increasing incidence with each increasing decade - but asymptomatic people do not have this procedure performed on them! Autopsy studies reveal colonic diverticula, usually confined to the sigmoid colon, in about 40% of subjects, but again these are nearly all in elderly people. In contrast, an autopsy study in Hong Kong in 1985 gave an incidence of 5% of cases.
There is considerable evidence that relates dietary fibre intake to the prevalence of diverticula. When more refined methods of milling of grain was introduced into this country a century ago, the fibre content of flour fell to about one tenth of its former level. Our 'modern' diet is in contrast to the diet rich in natural fibre in populations where this condition is uncommon. The 'Western' diet is associated with thickening of the muscle coats of the colon, especially in the sigmoid, and the high intra-colonic pressures thus engendered result in prolapse of the mucosa at the sites of penetration of blood vessels through the bowel wall. Fortunately, in the great majority of people, the diverticula remain symptomless (diverticulosis). However, like any 'wayside houses of ill-fame', they may become inflamed (diverticulitis), and may result in perforation, abscess formation, fistulation into adjacent structures or haemorrhage from erosion of adjacent blood vessels.
As my professor said, diverticula well deserve their name!
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by Professor Harold Ellis
Correspondence address: Department of Anatomy, University of London, Guy's Campus, London, SE1 1UL.
About the author
Professor Harold Ellis
Emeritus Professor of Surgery, University of London, Department of Anatomy, Guy's Hospital, London
No competing interests declared
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