The written history of bowel-associated problems can be traced as far back as the Book of Judges in the Bible showing that the pre-Christian Israelites were well aware of abdominal injuries and problems (Black, 2000). But, even before the Bible recordings, the Egyptians in 2000 bc recognized disorders of the bowel, although writings often recorded on papyrus were not specific as to what these may have been. The Greeks and Romans were not to be left out in their writings on bowel problems; however, it was the Greeks with Hippocrates and Herodotus who made specific mention of bowel disease. Although Hippocrates is known as the 'father' of medicine (the Hippocratic oath) and is the most celebrated physician in history, little is known about him, other than that he lived on the island of Kos and taught medicine for money. He tried to dispel the idea of alternative medicine to lay the early foundations of biomedicine. Herodotus, although not a medical man, was a historian, who on his travels collected historical, geographical, ethnological, mythological and archaeological information recording wars and their causes.
After the Romans the period of time until ad 1100 was to be known as the 'Dark Ages' because it has been judged as a time in the western world of un-enlightenment and obscurity with political fragmentation and a lack of centres of learning. Yet, although the history of stomas can be traced as far back as Celsus in 55 bc to ad 7, quoted by Dinnick in 1934, diverticular disease was first described by Littre (1732) when he dissected a neonate and described what he saw in the bowel as a diverticular hernia.
In 1783, Matthew Baillie a Scottish physician who studied with William Hunter, succeeded to Hunter's famous anatomy school in London and in 1793 wrote the first treatise in English on morbid anatomy. It was within this treatise that Baillie mentioned diverticular disease (Oschner and Bargen, 1935). In the twentieth century Painter and Burkitt (1975) suggest that the history of diverticular disease can be divided into five phases:
1. The disease as a curiosity
2. The recognition of diverticular disease as a clinical problem
3. The recognition of diverticular disease as a growing medical problem
4. The surgical approach to diverticular disease
5. The role of the colonic muscle in the pathogenesis of the disease.
In 1927, Spriggs and Marxer suggested that the term 'diverticulum' originated from the word 'divertikel' which was said to have been used by Fleischman in 1815 in describing this anomaly in the colon. Between 1815 and 1869 many writers of medical articles were stating that they all believed that these 'divertikel' were not nascent but acquired later in life - thought to be caused by constipation. Even at this early stage in medical history, it was recognized that a fistula could be one of the associated complications of diverticular disease (Jones, 1859).
Although rarely seen in the nineteenth century, the recognition of diverticular disease as a clinical problem was emerging at the beginning of the twentieth century and was described as having complications such as fistulas, adhesions, peritonitis and stenosis (Beer, 1904). In the UK it was not until 1917 that the first 'classic' description of diverticular disease was published by Telling and Grunner (1917) before any medical textbooks.
The recognition of the size of the problem of diverticular disease in medicine was revealed once radiology advanced and could show that diverticula were not unusual; postmortem and barium studies were undertaken to demonstrate this. On the other side of the Atlantic, Mayo (1930) estimated that 5% of patients over the age of 40 years would demonstrate diverticula in their colons. This figure concurs with current postmortem studies undertaken in both Europe and America. Up until World War II, resection of the colon carried a high mortality rate of up to 10%. As a result of this high mortality rate, doctors felt that there should be preventive ways to stop diverticula of the bowel along with their complications and surgery. Believing that roughage could irritate the colon, Spriggs and Marxer (1925) believed that the bowel should be cleansed and there should be plenty of vegetables and fruit in the diet, but that any irritants from fruit and vegetables such as pips, stalks, pith and tough skins should be left out of the diet. As a result of the removal of these irritants in the diet and no other roughage, the low residue diet was born and recommended for diverticular disease with no proof that it would be of any value.
In the 1940s, when antibiotics were on the horizon, Smithwick (1942) advocated that resection of the offending colon with minimal mortality could be carried out, provided that the patient was fully assessed and prepared. Resection of the diseased colon then became a standard surgical procedure. In 1923 Hartmann (Black, 2000) had perfected the end-colostomy and this procedure was used and is still often used in many hospitals as a two-stage procedure for the resection of diverticular disease. However, in the twenty-first century a new consensus of opinion is evolving towards a single-stage procedure, although selection for a single or staged resection remains the most controversial issue.
The physiology of the colon related to the pathology of diverticular disease, which covers the fifth phase of Painter and Burkitt's (1975) discussion when they and Arfwidsson (1964) investigated colonic pressure in relation to the pathogenesis of the disease, and in 1964 Painter had suggested that the pain, often termed colic, that patients experience in diverticular disease may be caused by 'excessive segmentation leading to an intermittent functional colonic obstruction'.
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