Ischaemic colitis

Ischemic colitis: an useful clinical diagnosis, but is it ischemic?

Vascular insufficiency of the intestines.

The production of mucosal ulceration in the rabbit gut by intra‐arterial injection of microspheres

The small intestinal mucosa is particularly sensitive to ischaemia, but it also possesses a tremendous regenerative potential. The mucosa of the colon is less easily destroyed by a reduction in the blood supply, but, once damaged, it recovers imore slowly. In these pages we shall review the various structural and functional studies, performed in experimental animals, that have contributed to our understanding of the response of these epithelia to dfifferent degrees of ischaemia.

https://gut.bmj.com/content/gutjnl/22/6/512.full.pdf

Response of the intestinal mucosa to ischaemia.

Recent clinical experience (Boley, Schwartz, Lash, and Sternhill, 1963; McGovern and Goulston, 1965; Marston, Pheils, Thomas, and Morson, 1966; Miller and Knox, 1966; Sturdy, 1968) has suggested that many cases of hitherto obscure colonic disease may in fact originate from vascular insufficiency. Some of these cases are directly attributable to blockage of a major vessel by thrombosis or embolism (Marston et al, 1966; Miller and Knox, 1966) whilst in others the ischaemia originates from occlusion or spasm of the smaller intramural vessels (Boley, Krieger, Schultz, Robinson, Siew, Allen, and Schwartz, 1965). The diagnosis of colonic infarction is not always easy and the clinical features, x-ray appearances, and pathology are still not completely defined. The purpose of the present work has been to produce a number of standardized controlled vascular occlusions in the experimental animal and to study their general and local effects in the hope of increasing our knowledge of what may be expected in the clinical situation. Dogs were selected for the investigation for reasons of availability and ease of handling, and also because there is considerable laboratory experience in the behaviour of the ischaemic intestine in this species (Marston, 1962). The pattern of arterial supply to the dog's colon is shown in Figure 1. Blood arrives through the common colic artery, a branch of the superior mesenteric trunk, and the caudal (inferior) mesenteric artery. The common colic artery divides into the middle colic artery, which is distributed much as in the human colon, and the ileo-caeco-colic artery, which runs down the ascending colon and divides into two vessels which finally inosculate with the termination of the superior mesenteric. The caudal mesenteric artery runs straight to the colon and forms a 'T-junction', which above connects with the left branch of the middle colic, and below continues to form the superior rectal artery. In this way a continuous vessel, running along the inner side of the colonic loop, is formed: the marginal artery of the colon. FIG. 1. Anatomy of the blood supply to the dog's colon, showing points of ligature.

https://gut.bmj.com/content/gutjnl/10/2/121.full.pdf

Experimental study of devascularization of the colon.

Laparotomy and splenectomy in the diagnosis and management of Hodgkin's disease.

Clinical Management of Gastrointestinal Cancer.

As doctors grow older and shed clinical responsibility, they become uneasily aware that the craft that they once practised is no longer relevant to the health problems of today. Perhaps the most satisfying way of demonstrating that the volcano is not extinct is to attempt an expertise in medical history. This tends to provoke a confrontation with the historians, who are skilled in analysing data but know little about medicine. Each side regards the other as a bunch of amateurs. The dual credentials of Sir Christopher Booth, however, are impeccable. As a physician, he has fulfilled numerous impressive chairmanships and presidencies, and his professional interest in medical history goes back nearly fifty years to when he was a young medical registrar.

A Physician Reflects offers a collection of lectures and essays given over many years. The central theme is the transformation of British medicine from an art to a science, as illustrated by the superbly scholarly essay on Boerhaave, which is the best thing in the book—although Chapter 8, ‘From Art to Science’ is perhaps the one of which the author is most proud. Likewise, the pieces on the Fothergills (1980) and Samuel Gee (1993) are illuminating additions to medical history. On more recent events, Booth is on less sure ground. The chapter on ‘Gastroenterology in Britain, a Study of a Specialty’, which is largely a description of forgotten heroes of the 1970s, is of little general interest and would be best left undisturbed in the archives of some learned society. ‘The Royal College of Physicians Enters the Modern World Or “The Gold-Headed Cane”’ represents a valiant attempt to credit the denizens of Regent’s Park with the discovery of the cause of lung cancer, and will cause much innocent merriment among surgeons and others. Readers may also be troubled by his lapses into banality—for instance, ‘Medical journalism has been of vital importance for the international diffusion of knowledge and new ideas’ (p. 69), ‘Throughout the centuries, physicians have carefully studied the illnesses that they encountered’ (p. 100), ‘Computers have entered the clinic providing a useful adjunct to diagnosis’ (p. 143). But, there is much to enjoy here, not least the account of a professorship to tour Australia and New Zealand, described with elegance and vigour.

Booth concludes: ‘Whatever the Jeremiads may say, there is little doubt that the pace of advance in medical science and technology will continue to accelerate’. Well, maybe. But first-world research has focused more and more on the expensive illnesses of affluent people, and isn’t it possible that, in the face of the huge political changes that threaten our ‘western civilization’, the poorer but more populous parts of the world will refuse to continue bankrolling these inequalities, and, using simple communication techniques that they have learned from us, will overturn the entire system? It’s worth a thought.

A Physician Reflects—Herman Boerhaave and other Essays.

It is a pity that one phrase, perhaps a rather inept pleasantry in what was on the whole a friendly and sympathetic review, should have provoked sadness. Of course it's true that the College of Physicians never discovered anything— in contrast to the College of Surgeons which through the Institute of Basic Medical Sciences discovered quite a lot, and accumulated some Nobel Prizewinners.

Adrian Marston

Papers

Experimental study of devascularization of the colon.

Laparotomy and splenectomy in the diagnosis and management of Hodgkin's disease.

Clinical Management of Gastrointestinal Cancer.

A Physician Reflects—Herman Boerhaave and other Essays.

A surgeon replies