DIVERTICULOSIS and DIVERTICULITIS of the INTESTINE by HAROLD C

20 Postgrad Med J: first published as 10.1136/pgmj.29.327.20 on 1 January 1953. Downloaded from

DIVERTICULOSIS AND DIVERTICULITIS OF THE INTESTINE By HAROLD C. EDWARDS, C.B.E., M.S., F.R.C.S. Surgeon, King's College Hospital, London

Introductory trophy of the muscularis mucosae in the wall of Primary diverticula of the small and large in- the pouch. testine are acquired by a process of herniation of The vessel whose channel through the muscular the mucosa through the muscle coat of the bowel coat determined the site of herniation can usually and are an affection of middle age and later. The be demonstrated. In the small intestine the blood mechanism, as with herniation through the ab- vessels pass through the muscle coat almost im- dominal parieties, is exceedingly complex and little mediately they leave the mesentery, hence the understood. It is generally agreed that two basic diverticula are closely related to the latter; in the factors are concerned-pressure within the cavity colon the blood vessels, after leaving the mesentery, under the serous coat to the of the of the bowel, which forces the mucosa against the pass edge Protected by copyright. muscularis; and an outlet, or locus minoris longitudinal muscle band before piercing the cir- resistentiae, such as that provided by the gap in cular coat to reach the submucosa. Hence di- the muscle coat occasioned by the passage of blood verticula of the colon appear in two rows on either vessels or, in the case of the duodenum, by the side of the mesentery and at some distance from it. common bile duct. The unknown factor lies in As the blood vessel passes under the longitudinal the behaviour of the plain muscle itself, upon muscle of the colon a small branch is given off to which layer the integrity ofthe bowel wall depends. the corresponding taenia epiploica; thus in obese It has been demonstrated that atonicity or atrophy subjects the pouches are often obscured by fat. of the muscle is not a constant, or even a common, At first the diverticulum is conical in shape, but causal factor. Not only does the microscopic eventually, when fully formed, is globular, its anatomy bear evidence against such a supposition, mouth being narrower than its maximum diameter. but it is well known that passive pressure alone, as In the duodenum and jejunum the pouch may in acute obstruction, does not produce pouching. become very large-of golf ball size and over- It has been suggested that local spasticity of the but in the colon the size rarely exceeds that of a http://pmj.bmj.com/ muscle wall is a more probable antecedent' to small grape. herniation, and there the matter rests., All those contributory factors which arrive coincidentally Si uation with middle age, and which predispose to external /Th mos mmon sites for diverticula are the abdominal herniae, are doubtless concerned and oidcol the duodenum and the upper the tendency to diverticulosis increases pro- JjIunum, m that order. It is not uncommon to gressively with find diverticula in all three sites in the same age. individual. Radiological evidence of the coexist- on September 27, 2021 by guest. Anatomy ence of diverticula of the colon was present in 17 The muscle coat of the intestine usually ends of a consecutive series of 8o cases of diverticula abruptly at the orifice through which the mucosa of the second part of the duodenum (2I per cent.), is extruded, though it may be everted to accompany against an anticipated incidence of approximately the hernia for a short distance. The muscularis Iz per cent. in normal people of the same age mucosae accompanies the mucous membrane, so group. that a few fibres may be present throughout the diverticulum, although in the fully-formed diver- Clihical Aspect ticulum the fundus usually consists of mucous The underlying cause for clinical symptoms due membrane covered only by the serosa. Occasion- to diverticula is retention of intestinal contents, ally, more especially in jejunal diverticula, there to which they are predisposed by their deficient may be some evidence of compensatory hyper- musculature and their bottle-neck communication. Postgrad Med J: first published as 10.1136/pgmj.29.327.20 on 1 January 1953. Downloaded from Yanuary 1953 HAROLD C. EDWARDS: Diverticulosis and Diverticulitis of the Intestine DIVERTICULOSIS

Diverticulitis of Mild Degree CHRONIC DIVERTICULITIS l Pericolitis ACUTE DIVERTICULITIS I l CHRONIC Adhesions to OBSTRUCTION neighbouring PERFORATION and organs PERITONITIS LOCALIZED ABSCESS Rupture into Anaerobic Cellulitis peritoneal cavity FISTULA FORMATION I (a) SIGMOIDO-CUTANEOUS SIGMOIDO-VESICAL (b) Protected by copyright. (c) Into hollow organs other than bladder with the parent intestine. The nature of both Perivaterian diverticula. These pouches, which symptoms and complications will thus depend are usually single, nearly always arise in posterior largely upon the nature of the contents and the relationship to the common bile duct and pass to anatomy of the area of bowel from which the the left behind the head of the pancreas, being diverticula arise. separated from the latter by a layer of areolar tissue. Many of the patients are visceroptic. The The Duodenum diverticula do not give rise to recognizable symp- Hernial diverticula of the duodenum are to be toms until they have enlarged sufficiently to retain

found in about 2 per cent. of all radiological ex- duodenal contents for a significant period. The http://pmj.bmj.com/ aminations of the gastrointestinal tract, and about symptoms are then those of a flatulent dyspepsia, 80 per cent. of these appear at the site of entry of with a sense of oppression in the epigastrium after the common bile duct into the duodenum, and are meals, and borborygmi. Pain is not a common hence called perivaterian. Except when situated symptom. The mimicry of chronic cholecystitis at the duodeno-jejunal flexure, duodenal diver- is particularly close and acquired diaphragmatic' ticula other than perivaterian very rarely give rise hernia may also produce similar symptoms. It to symptoms. must be stressed always that, unless there is The first part of the duodenum is never the seat unequivocal evidence of delay in the diverticulum, on September 27, 2021 by guest. of hernial diverticula and pouching in this situation the latter should not be regarded as the cause of is the result of chronic duodenal ulceration. The the symptoms. affected part of the duodenum is shortened by Perforation of a perivaterian diverticulum is contraction of scar tissue due to ulceration and almost unknown, but other complications are the unaffected unscarred portion of the duodenum recorded, e.g. chronic pancreatitis, obstructive balloons outwards. Though evidence of attenua- jaundice. Seldom, however, can diverticula be tion of the muscular wall may be found at the held responsible for either and any association fundus of such pouches when they are large and of between the two is likely to be coincidental. long standing, in the early stages their wall is Management. It is probably advisable to ignore normal. They never give rise to symptoms per se the presence of a small duodenal diverticulum dis- and their significance lies in furnishing absolute covered by barium meal. Knowledge of its exist- evidence of past or present chronic duodenal ence is of no material value to the patient and there ulceration. is no -known treatment which can influence it in- 22 POSTGRADUATE MEDICAL JOURNAL Yanuary '953 Postgrad Med J: first published as 10.1136/pgmj.29.327.20 on 1 January 1953. Downloaded from i.i..I;!·:...;,'i.c.3.-' ~~~~~~~~~...... :.: . . ,, i'"......

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6i FIG. Ib.-The diverticulum after removal.

FIG. ia.-Perivaterian diverticulum showing retention 24 hours after ingestion of barium. to ensure that it is not violated and the pouch cut away after sealing its mouth with a clamp. Repair by two layers of catgut is recommended. The any way. Operation should be considered only removal of a pouch from the neighbourhood of the when the diverticulum retains barium after the duodeno-jejunal region is facilitated by division stomach has been empty for several hours and is of of the ligament of Treitz, after identifying and large size. In only three of a series of 8o patients safeguarding the inferior mesenteric vein. in whom a perivaterian diverticulum was revealed http://pmj.bmj.com/ by radiography could the author regard them as a The Jejunum probable cause of the symptoms. In all three Diverticula are less common in the jejunum barium was retained from I8 to 36 hours after the than the duodenum, probably because of the part stomach had emptied. (Figs. Ia and b). played in the formation ofthe latter by the common Diverticula at the duodeno-jejunal flexure. Di- bile duct. The condition is one of progressive verticula here tend to increase in size quickly, diverticulosis, with multiple pouches, which down the the probably because their mouth is at the acute turn spreads bowel, rarely reaching ileum; on September 27, 2021 by guest. of the bowel, and they are thus placed at a great it resembles diverticulosis of the colon in this mechanical disadvantage. Theby tend to burrow to tendency to progression. In old people many the ripht underneath the peritoneum and when of hundreds of pouches may be found. large size may cause intermittent duodenal obstruc- The symptoms caused are similar to those caused tion. For this reason operation for their removal by perivaterian diverticula, but may be even more should usually be undertaken. pronounced, especially as far as borborygmi are Operation. To remove a perivaterian diverticu- concerned. In addition, however, when large- lum it is necessary to mobilize the duodenum and and they may grow to the size of a tangerine-they roll it over to the left, when the pouch comes into tend to cause intermittent jejunal obstruction, with view. A finger placed into the pouch through a hypertrophy of the jejunal wall. The diverticula. small opening in the anterior wall of the duodenum may occasionally become acutely inflamed and will assist if difficulty is met in separation from the may, rarely, perforate. Spontaneous haemorrhage pancreas. The common bile duct must be exposed has also been recorded. Jafnuary 1953 HAROLD C: EDWARDS E Diverticulosis and Diverticulitis of the Intestine 23 Postgrad Med J: first published as 10.1136/pgmj.29.327.20 on 1 January 1953. Downloaded from

...::·::..·· ·.·· :··:····. :··:·. ...:. :':i.:l::i·:. :i:i·::··i· ·:·:·:' i.;"ll:il ilil'iiiii!iib ··· :·: ·'··:··i· i··.·.:::i·: i'· ··· ·:I: :.·:· .· The Colon .i .·: is the commonest ii I.S.iiiiiii.iiiS ::::a Diverticulosis of the colon ·;···:.F·. "'II radiological abnormality of the large bowel in ...-· .··..·;·;.·:····ZI·::·::·:··:;::..:·:':;': :::.i Isiii over The condition was found in ·i'·:i·: ·.··: ·' .7:':::::li:I.ilH il(lli; subjects 45. 254 ·'::.·.:·: '::·':.:.':" !lii$i'liiliL5iiiili8i)iiiiiiiiilil:: j.jr:ji·iiiiiiiij!ij.i'iiii..!!iii:ls··I::·:::··:;:·:·:··:: 'liiii::r: of consecutive barium enema examinations ·::·:·i··:·:: :.;·.;·.: .·..:..·:·. -:i·ilzl8:iii::;i·i:·:i: i'ili.i:iilliliii.iiii i;iii 2,139 is:i. SI: ::I ifii; ·:···;:·;···;·:;·:i·:r:;;·;;1iiiL during a I3 -year period at King's College Hos- ·z'i' i:·i:li·li·i·:i::ii.:·::I::::i··ii·l:.:'i 'i·i:iiliiiiilisiBiilii!iEiliiil:HLi an incidence of I2 cent. If examinations ·. : ,..::r·:··..:·. pital, per ·.· .:::.::··::i.::s·l.ia on patients of under years are excluded, the ··;:···::::.·:I·:··I: ·:, ..: ·:::::;·:·i:::::r·:..::-i-:%.-7,..., :...... :._.;··· ·::·::..:::l....i.i:i8i.. 35 .i··:I·i:uiiili!iiiiii;fdiii.aiFiitil;li :::::::;:::i:':' i:i ItiiiFii5lliiiTli. figures are 25 in 1,623 examinations, an incidence i::ll'ili:iiii'l$iiii:ii::i'lil;:ii:'iidii;ii::jj:l;;llij;j;iiijiliil:ij·:·::::ili.':;!ii;:ii.ii!tilH!i:iiliiiii.i;ii;t;i!iililiiii8::iiiiiisliiii;iisii.ii.i:ii gj8iZll8i8i8ii .i.i8iiiiiii L. of i6 per cent. Although occasionally a few ::r:i.i;.i::i::i:ii:1,1:1::es:1·:1::1 :i::.·i: i: iEiniii.i.ili.i.iili8ii!ililil i.ji.i.jiijiiiiFIiCCI..li.i..il.j.i.i. gi.iCiliaifii!iZiii ..:. :.:·: ····.·:··:;:::·::;::··:··:·;:·.::'::"::·:·::·i:::.::;·::;::i::::::.:: .i.lii.i. isolated pouches irregularly spaced throughout the ····"·.·:"': ·":;.·' ·:I' bowel may be revealed by X-ray, diverticulosis of Il.i.j.. ··:·...'...... :.i:'iii4.i:iiiiii':IK':j':i..j':: .diLS. :::::::i:al:nl.:s::i:i .ili;.l...".;.!! the colon in its common and characteristic form is ·:··i:ii:::::-::'·:;.·:::.i.:iiiiil:l;diili:l.lii;;'i 'i:'::ii. ::··i:fi'jj:Il:B:;:li::;:!iii;ii!i!5!i::':::·:·.: -:(:r·:-::;::.::.::i::.;. ;i8iifiiriliii.iiiiiilili:i::;i:i:l;ii.i9:llllliil..%iliii:li:v:ailii. LSfliliiiii& ZiliEllJiPPi.l..li iiiii8ii.iiiii5i';iicii.ii.liiiiil:i::illilii$:igiiliiiiiiiii:l:ili'll::l:ii:::::: :iiii:iijliPi::::iii "i.:"::":"::'::.i.":'::i!ii9iiiiilii8ill a progressive disorder, which commences in the iiiiiiiilililiilliiiiiiiiaiiaillilii"""..laes.zi.iiiiioi.iitx;irii.iiiiiiiIIiai:i:.:liiii:;iiiiiiaii;i.ii;ii:i.iitiiHiti i8iii2i$il iii i.i..:"":"::":": sigmoid and spreads throughout the colon, in- i4iPiiii4.J1$!6iiIi.iigi;Bi::i;:iilJi3iliiiii;ili.isidiiiiiiii!.liiiijiiiiHi.aiiiiisi..ii.ieglijilil:-,,,,i ,izlii.illilil8il2il&:E'. j;Zi.wj.i.c.isi..iliiiiiii:::·::i:: rd·:,i: Piilli·iCi"ZliLLli.i..na:eia cluding, in the most advanced cases, both the LdlBiliiP vermiform appendix at one extreme and the I:i·.li:l:.;i.lC;lliiliPi..fiiiii:iliP '''' iil!l.i.ll.l TiliiiLBilllii. ii.iaii..ii:iiiii.si.as ill5llllillllLP rectum at the other. Cidil .iiliiHiliiiiri Radiology may reveal diverticula at an early B:li.ii.i liiiiil! I1IEI.Z. .i.llliiiii stage in their development, a ' saw-edge ' appear- Irriil IFiLLi. ance being noted on the contour of the barium- Ii: slii;i:------· iUi.iililii41 i:·-·- an which and rzl!ea.Clibii''ll"i plill.....is :iB:l:bLZ.iLI.:..::.:·: filled colon, appearance Spriggs ifiliti :::::g:::::e:?ii:···-·;·:r:::;:·r Marxer call the ' state.' At a later iJilii :Ii: ii:isii·iiiiia:..·.:iai:n:si..

pre-diverticular Protected by copyright. $iii:i$l.i8i8 ail.i Bi :.::i*ai:a:a:amti:n:ir·: -:-:.·-::gWii.iii!ii.iiili.i":ii:'iPi iiiiii:iiiitiii·iii$ii:ii;iilii8:iliiilidiiiili:liiil5iislii the are funnel shaped, until finally c.·:4iil31:iiiijia·:·;:·:::·-..isiiiil .i.i.ifFi!.iZ.i.ifT stage pouches ai·il:iPF the mucosa is blown out to a globular swelling .· :·-·. about of a The ·..;r·.s .··-c: :·f forming seven-eighths sphere. ::il.r:::.:::::.ii.ii·it .·ia--.pi%::.i::,:: :::7*:i.:.ii:·::::?i. :ee:e.iiili%4iiPBill8Ji.ii.Q1Siiiii.lii and narrow communication sometimes to be i::.l:: i.illili.ll long il'i'cigiiiiiqiiiiij seen on and the of a :ili·:::::i::(:i:I::':'':Piil.·. :.:. :.'..·.: :·::·:i.::I:::k.:l·:::..i:;:i,,,,:::l: :::l:i:::::l:::i·ii:iiiiiii8i:liiiY:. :.:·i: :..il ·.:·:·,·.-: X-ray, giving appearance ·::·:· ''i ".nrigiWliCilB4,·iBi::i:ii:i.i ie::"L::8:".i!ii.i;li.i.ilhliili. ..'tB grape on its stem, is due either to spasm of the itLfiiiiil f:;··'::I '· i. '.' ...;..".:... ···I·r-. I:w:s:a·r muscularis at the orifice of the diverticulum or to IB::::-.:**:a .-:B:s .· ··· ·:·. Pi.l:8·d:.·p' i.,: ·······: ····;' 'i::'.. .·;: thickening of the bowel wall at this site from I:KC:I: :I·:·.'.:··:. ':j:I·:··iiji:: :.:i.i:;:i·i::::::'' :· :I·;:·:::i·i···:··::l:i·.:''·:: .·.):.:.::I:::::I:i::.:l.:l::::·':i...i·.: '::· .zi:·i:.:lzliell:iii:i:iiiiiiii-·': :'·: :'· L:: li:ii·'::,:iriiiiiQ:I:iili chronic inflammation. Occasionally, even when I'·"::··l···:·':i··i·i·i::·..i·-::·::l.iie .:·:i.·i··:jidll there is no clinical evidence of re- ;:: ·:··:·'·''·': ::· :'':''I'·I:iiiiiil.:'::.' :q·.:·.·li:i;i.·...... in! ::·: diverticulitis, ·--;····I:i·.··i·.··li.iii; tention of faecal material in the is revealed :· ·.·..I iii: pouches ····i:·· ;:· .9 by X-ray (Fig. .:i: :li: 3). .i.I ::I.. .:ll:::i:;·····i i';iLif Diverticulitis. Excepting the caecum di- ·.;;. ;. ...;:·: :;·;:::::I::::· ··· .: ·:EiiiiB:· (q.v.), :i··.i :i:::: I:i:::iqi:jil$:q g·i::·: .·: ·i·.' .·il:::·l·:Pli':i··::i:·.?·il::iiiii:ii verticulitis -diverticulosis is http://pmj.bmj.com/ iiiiii!liilili.li;Ci3;l;iiiii':I::ii'ii leii4ii· complicating very ;::i.::.::-::::::l::I::i::"·:.·:·:::I:·:.i· I:"::;:::·" Ili.l'.:i::il.i:::::::j::i:'i··l:ii:l::: ::..l'.·i 'i' :I..'.:. i·::ili.li;liliielilii8i:·..:·;:·::·:;·:··:·.:·.:..·:::l.:l·.:i.·II:l:l.iiii:··i:·.·.:::':.::i·j.:i.i:::::1I::ldii:;:iiiBi.:itii::i :I'::':: ·II':i:·:':: ii:ISiiii rarely seen elsewhere than in the sigmoid. This is i;: '·I·:··I Si·i41I Wi:: eiirii IL" because: the is the starting place of ·.5Pil;siLt:; '.:'.:,:·:;·'i -...,:-:?:P:B·:· (a) sigmoid r;::::.·.·;: i::: i.sli.;.i diverticulosis ofthe colon; (b) the faeces here reach i:.iig:..l:li.:ll:li:I:liI: :·······:· :·:: i:w.i.· l:ij;;gii;i.j.i.iii.iii:i:15iiil'igi!iii:.i'lif ::; maximum of and thus reten- ·· their :'·':::'· :'::'' ''" degree solidity Bld6i.·iilii:Xii;.·i:ili:::.iil;i:;l:·:.I:...... :::":::., :·.·.; ::... :..: :...... ,.._.._.. Ciifii.!ditiii·wliilii:il3Ciiiiiiii!i Ilisil!ir:l··l:i:i'i:iiiiii::ii :i·I: :·Ei:j!)i;ii:lii:ii::li:il..ilil:i::":'::'i''i.·. ·-·-: d·iil:iiiii;ii;;ii;il$iiiigBi..i.i.ij.d.:i::;::;::r:r;:sr:::::::: tion in the pouches is favoured; (c) the length of FIG. 2.-Operation specimen. Attacks of pain suggesting stay of the faeces in the sigmoid is normally longer intermittent obstruction had been caused. Note than elsewhere in the bowel; and (d) the sigmoid the hypertrophy of the jejunal wall. From a man is the narrowest part of the colon. on September 27, 2021 by guest. aged 70. It is very difficult to ascertain the incidence of diverticulitis, for the border line between what The attitude to treatment should be at least as may be called a mild degree of diverticulitis and conservative as with perivaterian diverticula, par- diverticulosis is often ill defined. Established ticularly in view of the tendency to progressive recurrent diverticulitis (q.v.) is, however, com- involvement of the bowel, operation being enter- paratively rare. One unexplained fact in this tained only when radiology demonstrates pro- connection is that, whereas diverticulosis shows longed retention. little discrimination between the sexes, established At operation the best policy is probably to resect chronic diverticulitis is at least two and a half the segment of jejunum which bears the largest times as common in men as it is in women. pouches and perform end-to-end anastomosis Management of diverticulosis and diverticulitis o] (Fig. 2). mild degree. The majority of patients with diver- 24 POSTGRADUATE MEDICAL JOURNAL January I953 Postgrad Med J: first published as 10.1136/pgmj.29.327.20 on 1 January 1953. Downloaded from ticulosis go through life without suffering any untoward symptoms from that source. It is thus probably wisest if diverticulosis is revealed ' by accident,' and if there are no signs that any inflammation is present, not to make the patient B9 aware of his condition. The most that should be A done is to advise, from a general standpoint, avoidance of constipation. Regimentation in diet, which is a life sentence, should be reserved for those in whom there is already some evidence of diverticulitis, e.g. occasional pain or discomfort in the left iliac fossa, increasing irregularity of bowel action, radiological evidence of bowel spasm or rigidity and of faecal retention in the pouches. Treatment for such patients is based upon three factors: avoidance of constipation, elimination of i d i ind'gestible foods from the diet, and bowel lavage. The complications. The surgeon is chiefly concerned with the complications of diverticulosis. These may be conveniently summarized as follows, though the scheme suffers from failure to indicate the infinite shades in degree of chronic diverticulitis:

Chronic diverticulitis with recurrent exacerbations. Protected by copyright. The process is a continuous one, marked by periods of exacerbation in which are presented all the signs and symptoms and constitutional disturb- ances attendant upon the presence of an inflammatory mass in the left iliac fossa, sometimes including the passage of blood. This clinical state is the usual prelude to perforation, to abscess formation, to fistula formation, and to obstruction. It is generally held that the role of the surgeon only begins when one or other of these serious complications has developed. Accumulated experience of the fate of those who come to surgery late, or for whom palliative colostomy has been (!t!! 0p d t performed, has given rise to misgivings as to (I http://pmj.bmj.com/ whether this conservatism is With FIG. 3.-A series of diagrams compiled from radiographs always justified. illustrating the stages of diverticulosis. (a and b) the perfection of those new methods which have so Spasticity of the colon with irregular indentations greatly increased the safety of intestinal surgery it between the haustra, which are themselves irregular. is necessary to take fresh stock of the situation. (c and d) The piediverticular state (sau -edge colon). Resection of the mass a (e) Club-shaped diverticular. (f) Fully-formed, inflammatory during flask-shaped diverticula. (g) Various appearances quiescent period, and when the process is yet given by retention of faeces in the diverticula. young, is an attractive and effective alternative to some palliative procedure deferred until the disease on September 27, 2021 by guest. is long established and the dangers of radical operation increased by the grosser nature of the The ideal procedure is segmental resection of the lesion and the added years of the patient. affected area and restoration of continuity by There is called for, not so much a categorical immediate end-to-end anastomosis, with Paul's formula for treatment, but a change of attitude operation as an alternative possibility. A tem- from ' let us await complications before surgery' porary proximal colostomy should normally pre- into ' let us circumvent complications by surgery.' cede resection by some months. The fate of many patients who have been subjected Diverticulitis during an acute exacerbation. It is to colostomy as the sole treatment of diverticulitis, important to. envisage the probability of the pre- including its complications, bear evidence that its sence of an abscess in the peri-colic tissue during use should rarely, if ever, be entertained, except as an acute exacerbation and by treatment to en- a preliminary to a radical operation, deavour to prevent its spread, There may be January 1953 HAROLD C. EDWARDS: Diverticulosis and Diverticulitis of the Intestine 25 Postgrad Med J: first published as 10.1136/pgmj.29.327.20 on 1 January 1953. Downloaded from occasions when the surgeon is tempted to consider ostomy should be performed at the same time. In operation and exteriorization should he feel that either event the peritoneal cavity should be drained perforation is imminent, but, on the whole, he will and antibiotics given. be best advised to delay interference and treat the Abscess. Abscess formation is a very common patient by rest in bed, a fluid diet, and antibiotics, accompaniment of recurrent diverticulitis. The of which streptomycin is probably the most effec- abscess may be small and may not give clinical tive. At this stage aperients and lavage must be evidence of its presence, but remain buried in a avoided. thick mass of pericolic fibrous tissue. It may, Perforation and peritonitis. Perforation may be however, develop quickly and form a large col- the first indication of the presence of diverticula lection of pus under tension seeking an exit. It in the bowel in the younger age group. A violent may burst into the peritoneal cavity, into a neigh- seizure of acute pain is followed by evidence of bouring hollow organ, or into the abdominal spreading peritonitis, which should lead to im- parieties on the left side. The bursting of an mediate laparotomy. The greatest danger is in abscess into the peritoneal cavity usually causes delay. Perforation is, however, more commonly a acute spreading peritonitis, demanding immediate complication of the established condition and may operation, the method ofoperative procedure being be the climax of a severe exacerbation of diverticu- as for perforated diverticulum. The outlook for litis. At operation a thickened and greatly inflamed such cases is grave. Occasionally, however, evi- colon is then found and, though pus and faecal dence of rupture of an abscess may be slight and material and foul-smelling gas are discovered on may cause little peritoneal reaction. Rupture of opening the abdomen, it may be impossible to find an abscess into neighbouring bowel may result in the actual perforation. In some such cases the spontaneous relief from symptoms. Rupture into peritonitis is doubtless due to rupture into the one of the female pelvic organs, and even into the peritoneum of a pericolic abscess and the com- ureter, has been described, but the commonest Protected by copyright. munication of the latter with the lumen of the organ to be affected is the bladder, with later bowel may have become sealed off. development of sigmoido-vesical fistula. Occasionally perforation into the peritoneal The appearance of an abscess underneath the cavity, particularly in long-standing cases of abdominal parieties is self-evident and the treat- diverticulitis, may cause very mild symptoms, there ment should be immediate drainage without any being little inflammatory reaction by the peri- direct attack upon the bowel. Drainage of such toneum. The explanation for this is not known. an abscess usually results in relief from the acute The prospect of recovery after early operation diverticulitis, but a fistula will probably persist for perforation will vary with the length of history through the drainage wound (sigmoido-cutaneous of diverticulitis which precedes the catastrophe fistula). Occasionally an abscess may develop in and with the degree of pericolitis revealed at the parieties insidiously without any preceding operation. The prognosis after early operation in history of a severe attack of diverticulitis and patients with no previous history, or a history of closely resembling a cold abscess due to tubercu- short duration, is excellent, for the bowel wall is lous disease. http://pmj.bmj.com/ still flexible and the perforation can readily be Sigmoido-cutaneous fistula. Fistulae on to the found and easily closed. The closure is reinforced skin, which may sometimes be multiple, are rarely by omentum and the pelvis drained. In some, spontaneous, but usually develop after opening an recovery may be complete and the patient experi- acute abscess, after operation for perforation, or as ence no further trouble; in others a sigmoido- a complication of radical operation upon sigmoido- cutaneous fistula may develop (q.v.). vesical fistulae. Those following drainage of an The real problem is in the surgical management abscess tend to heal spontaneously and the question on September 27, 2021 by guest. of those cases in which there has been a long of operation should, therefore, in any case, be history of recurrent attacks of diverticulitis and in deferred for several months. A decision will which at exploration the bowel is found to be finally be needed as to whether the fistula should immensely thickened and congested, and particu- be allowed to remain or an attempt at cure be larly in those in whom the actual point of perfora- made. The latter must be of a radical nature, with tion cannot be identified. In such an event the excision of the affected bowel, for no compromise safest procedure is to exteriorize the bowel, if this is permissible between doing nothing and the is practicable. An alternative is to attempt to seal radical operation. off the inflamed area with pericolic fat and omen- The decision to operate will rest mainly upon tum; in the old and the very ill patient the opera- the age and general condition of the patient. The tion may need to be restricted to this procedure. fistula may cause little inconvenience and may be In others, in whom there is a prospect of sub- well tolerated by the patient, especially if old. Its sequent resection, a transverse diversional col- presence acts, in fact, as an insurance of some POSTGRADUATE MEDICAL JOURNAL January I953 Postgrad Med J: first published as 10.1136/pgmj.29.327.20 on 1 January 1953. Downloaded from degree against the development of further inflam- haps a little more emphasis upon conservatism. matory masses. In the younger age group, and There should be no compromise between non- in those who find the presence of a fistula em- interference and radical cure. Colostomy alone is barrassing and irksome, radical operation should an infliction and not a cure and should be rigidly usually be attempted. At the present day the pro- avoided, for it adds to the patient's discomfort cedure is a safe one and the only serious risk is a without necessarily affecting the fistula. recurrence of the fistula as a result of leakage from Older people, and especially in those whose the suture line. Though it is possible sometimes fistulae developed after a long history of recurrent to do the operation in one stage, it is usually diverticulitis, are best advised against radical oper- expedient to precede the excision by a transverse ation, though selection of cases for operation is a colostomy, allowing some two to three months matter of clinical judgment and cannot be the between the two operations. subject of any ex cathedra statements. Radical Sigmoido-vesical fistula. Diverticulitis is the cure should certainly be entertained in the younger commonest cause of sigmoido-vesical fistula. age group of patients, and especially in those in Usually it is a complication of recurrent diverticu- whom there has been no great length of history of litis which has been a cause of ill health for some diverticulitis before the fistula developed. The years, though it sometimes occurs in the younger principle of a preliminary transverse colostomy age group following a short history of diverticulitis. preceding the radical operation by two to three In 15 cases the average duration of symptoms of months should usually be followed. Temporary diverticulitis preceding the development of a fistula supra-pubic drainage of the bladder after repair in the bladder was three years and nine months. of the fistula and resection of the involved bowel is The history varies considerably, but usually the desirable. formation of a fistula is preceded by an acute Obstruction. The mass of fibrosis which de- attack of diverticulitis, with pyrexia, the appear- velops around the inflamed sigmoid may be re-Protected by copyright. ance of a tender mass low down on the left iliac sponsible for producing acute small intestine fossa and frequency of micturition. The tender obstruction as a result of adhesions. This is a rare mass is due to an abscess, which eventually rup- consequence, however, and the more likely result tures into the bladder, with immediate relief of the is a narrowing of the sigmoid from contraction of acute abdominal symptoms, but exacerbation of the scar tissue. The state of chronic obstruction urinary symptoms. There is severe vesical pain, which results may closely simulate carcinoma of the with intense frequency, and the urine is heavily bowel. Diagnosis between the two is, in fact, not laden with faecal-smelling pus. There may also always possible, though the history and the radio- be haematuria. Gas, followed by faeces, may not logical appearance, particularly if a double contrast appear for some days, though a week or more may enema is used, will usually enable the differential pass. In one case pneumaturia was not established diagnosis to be made. It is necessary to em- as a regular feature until after many months. The phasize that the presence of diverticula in the interval between the rupture of the abscess and colon, as revealed by the radiograph, does not the presence of faeces will depend upon the length preclude the possibility of new growth, for,http://pmj.bmj.com/ of time it has taken to establish a fistulous track. although there is no evidence of direct causal The acute bladder symptoms tend to subside association between diverticulosis and cancer, both quite quickly and may eventually disappear. After are common. In a series of I62 patients with some weeks the bladder mucosa, except at the site diverticulosis, nine had radiological evidence of of the fistula, will return to a normal cystoscopic cancer ofthe bowel. In other words, the diverticu- appearance. After the initial outpouring of faeces losis patient is neither more nor less liable to fistula is liable to close to cancer of the bowel than is the normal subject.

the sufficiently prevent on September 27, 2021 by guest. any further escape of semi-solid material, except It goes without saying that chronic obstruction as an occasional incident, and the main symptom due to diverticulitis will demand surgical relief. will therefore be the passage of gas per urethram. In older people, who are poor operative risks, a Ascending infection of the kidney is rare and short-circuit operation around the area of the this should be taken into account when considering obstruction is an excellent alternative to any treatment. Once a fistula has declared itself it is attempt at resection. Permanent colostomy wise to defer any question of operative treatment should be avoided. for some months, in order to allow the pericolic inflammation to subside and to allow the bladder Diverticulosis and Diverticulitis of the to establish immunity. Furthermore, the fistula Caecum may, rarely, heal spontaneously. Diverticulitis of the caecum occupies a some- The criteria for operation are similar to. those what special place, for it differs from diverticulitis governing sigmoido-cutaneous fistulae, with per- of the sigmoid colon in three particulars: January 1953 C. S. NICOL: The Treatment of Neurosyphilis 27 Postgrad Med J: first published as 10.1136/pgmj.29.327.20 on 1 January 1953. Downloaded from i. The age incidence is lower. subsequent excision and, finally, closure. This is 2. The pouches'are often solitary. a protracted and irksome experience for the 3. The pouches are peculiarly liable to cause patient, but there appears to be no alternative. acute symptoms. Acute diverticulitis of the caecum, which closely resembles acute appendi- Diverticula of the Appendix citis in its clinical features, may, in fact, be the Diverticula of the appendix may be demon- first indication of the presence of a pouch. Rarely, strated in about t per cent. of appendices removed chronic inflammation of a diverticulum causes a at operation. They may be associated with mass in the right iliac fossa which is liable to be generalized diverticulosis of the colon or may mistaken for cancer and the true nature of which result from disorganization of the appendix mus- only comes to light after excision. culature as a result of chronic fibrosis. They are not The management of a case of acute diverticulitis in themselves of any notable clinical significance. revealed at operation undertaken on a diagnosis of acute appendicitis will vary according to the find- BIBLIOGRAPHY EDWARDS, H. C. (I939), Diverticula of the Small and Large ings. There have been cases recorded in which Intestine, John Wright & Sons, Bristol. the inflamed diverticulum was readily seen and KRON, S. D., and SPECTER, J. (I95o), Gastroenterology, is, 62. MAYFIELD, L. H., and WAUGH, J. M. (I949), Ann. Surg., was excised. In others there is found a mass of x29, I98. inflammatory tissue and the wall of the caecum MAYFIELD, L. H., and WAUGH, J. M. (I949), Ibid., 130, i86. itself is inflamed. The best for ORR, I. M., and RUSSELL, J. Y. W. (i95x), Brit. 7. Surg., 39, acutely procedure I39. the latter condition is to exteriorize the bowel, with WALKER, R. M. (I945), Brit. J. Surg., 32, 457. Protected by copyright. THE TREATMENT OF NEUROSYPHILIS By C. S. NICOL, M.D., M.R.C.P. Medical Officer in Charge, Special Treatment Centre, St. Bartholomew's Hospital: Assistant Physician. Whitechapel Clinic, London Hospital

In a paper dealing with the treatment of neuro- A classification of neurosyphilis is always syphilis, it is first necessary to discuss briefly the difficult as the involvement of meninges, vessels incidence, clinical classification and natural history and parenchyma never occurs alone, but one or http://pmj.bmj.com/ of the condition. other type usually predominates. It is almost certain that 'invasion' of the I. Early syphilis (within first four years of nervous system by the treponema pallidum occurs infection): during the primary stage of the disease in all cases, (a) Asymptomatic neurosyphilis. but in the majority these organisms do not survive (b) Acute syphilitic meningitis (may occur in to produce an inflammatory process, thus 'in- secondary stage or later). volvement ' may occur in to per cent. of cases. 2. Late syphilis (after fourth year of 25 35 infection): on September 27, 2021 by guest. This involvement is first manifested by a pleo- (a) Asymptomatic neurosyphilis. cytosis and increased protein content of the spinal (b) Meningeal syphilis of brain or spinal cord fluid in the secondary stage of the disease as (often termed meningo-vascular as there is also demonstrated by the pioneer work of Ravaut involvement of smaller vessels). (I903). Even after involvement of the nervous (c) Vascular syphilis of brain or spinal cord system at this stage spontaneous regression occurs (involvement of medium-sized vessels). in a number of cases so that Bruusgaard's (1929) (d) Parenchymatous: analysis of patients with untreated syphilis seen (i) General paresis.. many years later, gave a figure of 9.5 per cent. for (ii) Tabes dorsalis. those with neurosyphilis, while Rosahn's (1946) (iii) Optic atrophy. analysis of autopsy findings in 77 patients with (e) Gumma of brain or spinal cord. untreated syphilis showed pathological evidence It is important to know something of the natural of neurosyphilis in 7.6 per cent. history of neurosyphilis and realize that reversal