DIVERTICULITIS
OF
THE
PELVIC
COLON.1
BY
Sir C.
Gordon-Watson, K.B.E., C.M.G., F.R.C.S.,
Surgeon
to
St. Bartholomew's and St. Alark's
Hospitals.
In recent years our attention has been focussed on stagnation in the colon and the evil results that ensue. In this direction Sir Arbuthnot Lane has done much to stimulate interest, hearts of not was
not
a
"
on
that these
few of
into the
The late Father Bernard
Vaughan
been
"
on
The Sins of
total
not
are
movement afoot to abolish
society
for the errant colon. can
he states in Medical the
He
be secured
adhesions of the an
"
than Lane
And who shall say
without
pelvic address
abolishing now
by
we
learn that Sir
the extreme
penalty surgical relief
believes that careful
freeing
of
acquired
colon to the iliac fossa."
recently published
that he has
Journal same advantage by
"
for the
capital punishment
at the same time
;
Arbuthnot is in favour of
of stasis
Society
good cause ? I11 punishment for a colon steeped in iniquity extirpation. There is, at the moment,
strictures
worst sins of
inspire
The Sins of the Colon."
recent years the
has
us.
scathing
more
has been
a
awe
excite admiration, and indeed to
to
this
"
on
Indeed,
in the
many occasions
simple operation
derived
that he
had
1 A Paper read at a Meeting of the Bath and Bristol Branch of t*16 British Medical Association on Wednesday, February 27th, 1924.
DIVERTICULITIS OF THE PELVIC COLON.
Previously
had from
colectomy
risk."
Lane
has drawn
Mechanical
at
a
considerably greater
remarkable clinical
a
113
of the
picture
sequelse, which in his opinion follow development newly-formed peritoneal bands that ailchor the overloaded pelvic colon to the iliac fossa, and by and toxic
*he
of
c?ntraction
cause
what he describes
"
as
the first and last
kink." The
determining
the colon
Probable
and it is
Editions if
than
probable
and flatulence
were we should more
f?rty
^aj?rity may ^
more
0f
often.
and far cases
be
expect
more
extraperitoneal
said with
much
over
fat is
rarely
fifty,
habits, fat, flabby
in most instances
past
Co?
^ a
^ ?
in
excess.
the meridian of
life,
arid flatulent, a
close
connec-
conditions of the
pathological regards a sensitive and impassioned temperament Powerful predisposing factor in diverticulitis. and
'
u
^
the emotions and
met with
the victims of
Sheffield believes that there is
between
;
and in the
present
truth that
are
story
to meet with these pressure
often
Sedentary
tio
inflammatory
not the whole
are
Diverticulitis is
erticulitis
du
that the
must be laid at the door of intestinal stasis.
Pouches far n^er
It is
which often result from faecal retention in these
Constipation
they
established.
yet satisfactorily
that increased pressure within the colon due to and flatulent distension is the most important
^?nstipation 0r. Pouches
factors in the formation of diverticula
not
are
"the
gradual increase of fat around the bowel progressive atrophy of the unstriated muscle, ?rrnally> as we know from radiograms, the colon C?ntrac^on presents alternate rings of contraction sacculation. When subject to long-continued back is
and.11^
re
an
overloaded and flatulent colon with fat-laden
atrophied V?L
\r
?-
muscle must,
I53*
during straining
at
stool, be
SIR C. GORDON-WATSON
114 prone to
in the sacculated
yield
points. perforate during
the act of
at the
portions
We know that diverticula
once
at stool
straining
weakest
formed sometimes or
from some
sudden exertion. As Hamilton Drummond has shown, these weak occur
where the circular vessels
perforate
spots
the muscular
coat to reach the mucosa.
These weak
spots
occur
either side between the
on
lateral taenia and the mesenteric border, and it is along these lines that diverticula most The diverticula
are
small herniae of the
the muscular coats, which increase in size tend necked and to act
as
the exact
Though
commonly
to
gradually enlarge, flask-shaped
traps for faecal matter. pathology of the origin
inflammatory phenomena
retention
of
matter
in
thoroughly straightforward, and to the many-sided phenomena to
justify
the
of
description
which result from the
bears
close
so
pouches, lS an analogy
appendix inflammation
of
left-sided
Faecal of
they
diverticula diverticulitis;
these hernial
"
as
of
of
pathology
through
and bottle-
become
i.e. of the
as
mucosa
and
in the colon is uncertain, the faecal
occur.
stagnation may be followed by concretions, concretions by ulceration,
appendicitis.' the formation ulceration by
general peritonitis ?r more often by a localised abscess and perhaps a faecal fistulaIn other instances inflammation inside a diverticula#1
perforation, perforation by
results not in
perforation
is chronic from the
fibrosis,
but in inflammation outside
first,
and
As Maxwell
multiple
that
gives
rise to
fibrosis to tumour formation and
to chronic obstruction and a
of
either
occurs
Telling
so
mimicry aptly says,
peridiverticulaf
stenosis, stenosis
of carcinoma. "
Given the
herniae of the mucosa, every may be logically deduced a
pathological comparison."
which
formati0*1
secondary process priori by genera^
DIVERTICULITIS OF THE PELVIC COLON.
115
Inflammation in and around these acquired thus produces three main clinical conditions :
diverticula
Manifestations
associated with
perforation
(i)
acute
which cannot
distinguished from the acute manifestations of appendicitis except as regards the left-sided symptoms ; (2) a subacute suppurative condition analogous to the appendix abscess and
distinguished by
c?lic fistula
Emulates
the
(3)
;
a
tendency to faecal hyperplastic type
carcinoma in that
a tumour
fistula
or
vesico-
which
so
closely
forms which
Causes obstruction.
frequently
While recognising the many phases of diverticular it is important to remember that diverticula frequently exist and give rise to no symptom at all, and this
lnflammation ls
More likely to be the case when the pouches are tubular and wide at the neck. In recent years, since I have been ?n
the look
diverticula on
out a
for them,
few occasions
I
have met with innocent
during an
abdominal
operation.
Indeed, they are easily missed when searched for at autopsies, b?th from
without and
within, though when they contain matter hard lumps may often be felt in the aPpendices epiploicae. These small pouches may readily
s?Hd fecal
escaPe detection,
Usually project c?ndition
has
they occur in fat-laden bowel and fatty appendices epiploicse. This termed diverticulosis as opposed to
because
into the been
diverticulitis. When there
is a considerable inflammation round the ^Vel the diverticula may only be recognised after careful
1Ssection. The
openings
nd are often
so
^ncosa is put
on
^rummond
within the bowel lie between the rugae, small as not to be recognisable until the the stretch.
examined the colon in 500
nd
found diverticula
?^e
that
in
22 cases,
in four of them there
and it is
were
post-mortems
interesting
to
also diverticula in the
Il6
SIR C. GORDON-WATSON
small intestine and in facts which
diverticulum of the bladder,
one case a
suggestive
are
of
some
of
the
congenital
defect in the
unstriated muscle. In
intestine
Spriggs only recognised diverticula in six, but there was no special investigation for diverticula. The diagnosis of diverticulitis usually depends on radiographic evidence. As in other conditions, with perfect X-rays after an radiograms
1,000
get positive evidence which makes a certainty, but the reverse by no means holds good. The appearance of clear-cut diverticula, when seen in a skiagram, is unmistakable, and the diagnosis is readily confirmed when the opaque pockets remain visible after the remainder of the bowel has been emptied. opaque meal the diagnosis
we
may
colon may be is examined when the bulk of
Evidence of diverticula in the missed unless the
patient
pelvic
region, and again examined when the pslvic colon has been emptied. If the diverticula are a numerous positive evidence may be expected ; if only few are present, and these are filled with faecal material;
the meal is in this
or
are
perhaps
so
situated
outline of the bowel
[i.e.
escape observation. Positive evidence in doubtful be obtained
by
an
cases
is
more
filling given prior to
an
enema
flatulent distension and
patency
problem.
In
When
a
present
that he is much worried
irregularity
great
middle-aged patient
with
in the action of the
may be faced with the absence of a palpable
practitioner
pockets
may by relaxing of the pockets.
in the function of the colon
Irregularities difficulty as regards diagnosis. presents himself with the story
to
defect in the main lumen.
the muscular coats increase the
bowels the
likely
enema, which may distend the
and also show up any Belladonna
by the main profile), they may
be obscured
as to
not shown in
troublesome growth in the a
DIVERTICULITIS OF THE PELVIC COLON.
rectum he does
turbance ?e?
not know whether to assume that the dis-
of function is due to the
stasis,
is
or
an
resulting from errors It is reasonable
by advances
"
first and last
kink," inflammatory condition, i.e. a colitis of diet and unhealthy habits, or whether
diverticulitis
against
up
colon.
II7
or
an
early
carcinoma of the
hope that diagnosis may be simplified radiography and chemical pathology.
in
Fortunately,
to
diverticulitis
is
of
one
the
of
rarities
Practice. The acute manifestations, if they seldom receive, SeMom demand exactitude in diagnosis ; they take their
humble place
I?r
among the acute abdomens. they run their luck.
Worse, More interest,
chronic
Propose
type
to
think,
attaches to the subacute and
simulate
malignant stricture,
a
most instances the area involved is
the reach
s^moidoscope, frequently because
adhesions
slgmoidoscope
th
often with opaque may be possible from
more
probable diagnosis clinical history.
In
and
you my personal experiences with this An exact diagnosis may sometimes be made
sigmoidoscope, though
radiograpliy ; ^
or
give
of case.
Wlth the
I
which
cases
For better
ExCeptionally
cannot be
passed
beyond owing to
to the full extent,
the m?uths of diverticula may be seen with and an absolute diagnosis established.
slgrnoidoscope, JUne
?f last year
a
stout
lady, aged 64,
was
brought
to
that for some months she had been greatly trouhl e(I with flatulent distension, and with small, frequent teasloose but often containing small rab>v I??t^ons usually *t-like hard debris. Occasionally she had passed bloodstain ^ucus. There had been no loss of weight, and her aPPe did not suggest malignant disease. On examination sigmoidoscope I observed at 20 cm. the mouths of tty0 They were visible only on inflation, i.e. they c?uld S0en t? open up with each puff of the inflator. The peitie t took fright either at the sigmoidoscope or a^ unfortunately, ne diagnosis, and I heard no more of her. a
history
"
"
Wit^ce V^erticula. j-
Il8
so
SIR C. GORDON-WATSON
It should be noticed that the passage of blood and mucus diagnostic of new growth occurred in this case. This is
exceptional, and is usually an important point in differential diagnosis. It may be that in this case the two conditions were combined, as is sometimes the case. Carcinoma may arise, or, as it were, settle down in the midst of a In other instances diverticula form above
diverticulitis. carcinomatous
stricture.
to deal with a
not
yet
large
and I have
conditions,
been
Turner
operated
cases
would
One not
on a
expect
uncommon
increased
colonic
There
are,
associated
of both these
specimens illustrating themcase in which a perforation of a
seen
diverticulum occurred above
be
my lot carcinomata, I have has
met with diverticula in this association.
however, several recorded
Grey
it
Although
number of colon
a
a
the
behind
tension
carcinoma. formation of
a
is
stricture the
main
diverticula
of
the
factor
to
colon if in
their
production. The fact that the that
are
we
still
opposite lacking in
is the
case
makes me.
full information
as
to
think their
origin. The first case of diverticulitis that I operated on was i11 1911 at St. Bartholomew's, and this was a case which was almost certainly secondary to stricture of the rectum. The patient was a young woman of 26 when I operated on her, oHe of the youngest cases on record. I described the case at the Pericolitis Sinistra with Sacculations." I was the*1 time as of the term diverticulitis. At the age of 18 she vvaS ignorant operated on (posterior proctotomy) for stricture of the rectutf1 by Mr. Harrison Cripps. Five years later she was treated W bougies for recurrent stricture. Three years after this I a tight, fibrous stricture of the lower part of the rectum an opened the abdomen to perform colostomy. I found the peKlC colon adherent to the uterus greatly inflamed with numerous appendices epiploic?, many of which contained saccules mucous membrane. Owing to the contracted mesocolon an a very friable intestine I was unable to perform colosto^ until I had divided the bowel and closed the lower end. "
foun oking and
is
case
?ols with eal of
evidence may be an
example
quite
conclusive.
II9 The
:?
aged 56 (first seen January ist, 1923), robust covered, complained of frequent offensive troublesome colicky pains and the passage of a good
mucus in the stools. For the past few years she has 6recl in a minor degree from these attacks, which have been foil owed by quiescent periods. Recently there has been more culty in getting the bowel empty in spite of increasing doses f
UI
aperients.
^ barium
g,
.Vlc colon,"
enema
showed
"
well-marked filling defect in the defect suggestive of an annular lcture due to carcinoma, but a more diffuse stenosis involving s inches of the bowel. (Fig. 1.) taken after evacuation of the contents of -j-kg bowel showed the classical multiple opaque blobs so a*acteristic of diverticulitis. Operation revealed not only multiple diverticula but e peri diverticular inflammation. There were many eSl0ns The infl arried between the pelvic colon and the iliac fossa. area was so extensive that a short circuit between t nsverse and pelvic colon was not feasible. The patient was 0 to colostomy unless considered absolutely essential. Seeniecl to be some risk that acute symptoms might rvene from perforation of a diverticulum. of diverticula has been practised when perpagination f0r 1?n has threatened, but is only practicable when the djv rticula are few and blessed with wide necks, adh ?Ventually separated the pelvic colon from its parietal and then wrapped a superabundant great omentum Xo the involved area, stitching the free edge of the omentum t0 e outer layer of the mesentery. Way ^ h?Pecl to avoid any general peritoneal infection shoi vi ?f hv, a* Perf?ration occur, and at the same time by relief 0ns to increase the mobility and to improve the funrf ability of the pelvic colon. The after treatment in ^aSe ^as consisted. in the regular use of paraffin internally an.d ai^ enerriata to prevent stagnation in the colon. Radio?ram ^a^en a year after operation show that the stenosis patient is involved in a daily toilet which takes le time but secures comfort for the remainder of the \ ay- I think the toilet would be less strenuous if she had a CQi ostomy opening above the involved area. Del
not the
filling
v^al
^iographs
,
a(3,en^Ve
-jPPosed int0re
e^l0ris?
-
rf renia^ cons-!^S" In
^ ac
many instances
fossa may
a
sausage-shaped
be felt per abdomen, and
a
tumour in the left
diagnosis assumed
120
SIR C. GORDON-WATSON
when the clinical
picture
is
strongly against malignant
disease. The
following
case
is
an
example
of
this,
and
presents
many features of interest:? A clergyman, aged 46, was seen by me in 1914 with the following history. Twenty years ago he had an attack of jaundice. For the last fifteen years he had had dyspepsia, taking the form of acid eructations and pyrosis, in the strict sense of the word, after food. About the same time he began to have difficulty with the bowels ; after an action he would still feel that there was something there, and there might be as-
four or five small actions before he was comfortablethe bowels became so capricious in their action that he used to take some astringent when he had to perform some public duty. About two to three years ago he began to pass blood and mucus with the stools. A few months ago an was examination with bismuth made, but revealed no X-ray structural change in stomach or colon ; the marked distension of the stomach on giving sodium bicarbonate confirmed the diagnosis of hyperchlorhydria, however. He was stout and not anaemic. Physical examination revealed nothing till the left iliac fossa was reached. Here, even after the bowel had been cleared out by enemata, a sausage-shaped, definitely tender swelling was felt. The abdomen was opened, and the diseased bowel, about six inches in length, was brought to the surface and fixed. Eight days later (June, 1914) I excised the affected area and established a temporary colostomyA year afterwards, in 1915, during my absence at the war, the colostomy was closed by Mr. Lockhart Mummery. Two ye^t afterwards (1917) there were recurrent symptoms of obstruction. The transverse was now anastomosed to the pelvic colon at the junction with the rectum, and a radiograph taken a year later, in 1918, shows the anastomosis in functionThe recurrent symptoms may have been due to stricture' 0 or possibly to recurrent diverticulitis above the line anastomosis. many
as
Gradually
partial-
which, except for the length of history, gave a history which strongly suggested maligna11^ disease was treated by primary resection and anastomosis The
following
case
un4^
E.T., a woman aged 62, was admitted to St. Mark's sn my care on January 4th, 1921. On and off for ten years had suffered from attacks of diarrhoea, coming on every two
DIVERTICULITIS OF THE PELVIC COLON.
121
three days, frequently commencing at night, accompanied by abdominal pain of a griping character which lasted General J about two hours. She complained of a purulent and from the rectum, which was sometimes si' 6?SlVe discharge There was no vomiting or abdominal diai erition.bloodstained. She had been losing weight for some months. On ?
a s
of the abdomen there increased ^minati?n tenderness in the left iliac fossa and was
11s.0rrie could
e.hng
a
be felt. small
The rectum
was
resistance
sausage-shaped On sig-
normal.
was seen at inches, but up evidence of tumour or stenosis. When 0rrien was opened the upper part of the pelvic colon Wa 'n
I will refer to
Method in I
of
one
other
case
because it illustrates another
treatment?appendicostomy.
A m "lan ,, e
aged 70 was admitted to hospital with a tender mass *^ac f?ssa and considerable difficulty with his bowels. 1 Piored and found well-marked diverticulitis with many The patient was a bad subject for operation, tomy, owing to adhesions, presented difficulties. I decided PPendicostomy with a view to obtaining relief by regular Unfortunately, the patient developed bronchitis the operation and succumbed.
Coigns.
?n
irri
aftgra,!?n-
^ will be clear from the history of the
descriK
fib r?sis th e
a
already
...
peridiverticular symptoms distinguish from those observers lay considerable stress on
c^n^ca^
with stenosis
are
CarC^norna- Most absence of blood, II
cases
to this
of
not easy to
but too much
weight
must not
point. In three of the cases which I blood was occasionally noted in the stools
be
have
SIR C. GORDON-WATSON
122
To my mind the most important clinical distinction is the appearance of the patient. When carcinoma of the colon has developed to a stage which brings the patient to
usually with semi-obstructive symptoms looks the part?he is losing weight, he looks ill. a
doctor
Cases of diverticulitis of
usually
come
capricious
freedom from "
patient
long history pain and
a
actions of the bowels associated with
tenderness in the left iliac fossa, with not
with
the
symptoms. They losing weight.
of
complain
periods
of
complete
well covered and do
are
There is
no
suggestion of
appearance. A tumour may often be felt in the left iliac fossa of considerable size. A carcinoma of the pelvic colon, on the other hand, of
the shadow
is
usually
malignancy"
too small to be felt
with bimanual
in
their
(except
under
an
anaesthetic
examination).
Pain and tenderness in the iliac fossa
are
the
exception
in carcinoma. When there is marked inflammation in In addition to
pyrexia
and
diverticulitis
pain and tenderness there may be irregular leucocytosis and often irritability of the
bladder.
Inflammatory strictures involving apart do
from the rectum do not often
occur
with the
the occur.
pelvic colo*1 When they
they are usually low enough to be recognised sigmoidoscope, and may be distinguished fro#1
diverticulitis
by
the loss of
mucous
membrane at the srte
of stricture. The stricture will be tunnel-like rather than as
in carcinoma.
example
of
The
non-malignant
which I excised from and
a man
ring-like
show you is aI1 stricture of the pelvic colo*1
specimen
aged 43
I
now
symptom6
in 1919. The in favour of carcinoid'
sigmoidoscopic appearances and at the operation I could not determine whether I ^aS dealing with an inflammatory or a malignant conditio11' were
DIVERTICULITIS OF THE PELVIC COLON.
ThIe
microscope
shows
evidence
no
123
of carcinoma.
The
remains well.
before rn?1ditis
diverticulitis became
and
generally recognised sig-
familiar terms, and
pericolitis many cases of inflammatory stricture Were described under these headings. were
summarising
ticulitis
no
doubt
due to diverticulitis
the treatment of chronic
cases
of diver-
associated with fibrosis and stenosis I should like
sound
a note of warning. I have referred to cases in which I have resected the involved portion of the pelvic colon
and the 111 all
have survived the
patients
be
probability,
?Pportunity
for
a
time before I
long
a
procedure,
In the
safe excision.
but it
get
will,
another
great majority
of
Cases which call for surgical treatment (apart from acute marked ?ases) inflammation, extensive adhesions, excess of ic\ f ln the mesentery, and a small amount of healthy colon *
w
the affected
a
^
area
will all render
primary procedure,
these
most
a
resection,
hazardous
at any rate
undertaking.
resections three
separate methods were employed : ^ ?ne"Stage method, i.e. (a) resection and anastomosis in stage (an exceptionally favourable case) ; a two-stage ethod, ix% (fy primary anastomosis with secondary ; a three-stage method, i.e. (c), stage i?eversion ,^e growth outside the abdomen, stage 2?excision and colostn 0lny, stage 3?anastomosis.
^Section
.
Without
C
ure 1Ce
the the
under
must,
the
mflammatory
most
more
^?rary c?l?stomy
s
0rny
favourable
in the
hope that,
as
In a
is often the case,
condition will subside, when closure of
may be considered. of the pelvic colon is
may
conditions.
often than not, be content with
^colostomy *^e mesentery
pe^.10 cni
doubt resection and anastomosis is the ideal
brought
and dealt with
as
long,
the involved
outside at the time of the
described above.
SIR C- GORDON-WATSON
124
The above methods caused
some measure
stenosis threaten to do Milder do not
justify
seem to
which have
cases
which
or
by
reason
of
so.
while
types which,
causing much inconvenience colostomy at the time of operation,
a
happens a colostomy has been refused by the patient before operation, may be dealt with by invagination of dangerous looking saccules and by omental or
in which
those
to
apply
of obstruction
sometines
as
the involved
grafts overlapping
should be borne in mind in In
It is
with
appendicostomy. interesting feature
an
often
are
symptoms
In the
are
are
short, and
more
malignancy
"
Cases
local
come
attacks
under
followed
periodic comparative immunity fro#1
sometimes met
with; by the symptoms and by curtailed
are soon
constant
or
that active
cases
similar histories
of carcinoma of the colon
early stages
intermissions
of these
intermittent.
long immunity
of
procedure perforationinvagination ?r
with acute
histories of
observation with
by periods symptoms.
dealing
it may be wise to combine
some cases
grafting
This latter
area.
but such more
the
serious "
and
shadow
which hovers round the victims.
inflammation resistance, and dne
The ebb and flow of chronic diverticular is doubtless to
dependent
on
variations in
factors other than mechanical. In the
toxic states associated with oral
varying
sepslS
parallel. We know that period10 bouts of sciatica, lumbago, tonsillitis, etc., have so oftel1 been permanently relieved by the discovery and treatmer^ of a septic focus in a tooth socket or an accessory sinuS there
as
is, perhaps,
some
to establish without doubt
a
relationship
between the
We may assume similar factors at work connection with the septic colon pockets to account two conditions.
similar
intermissions
corresponding
local
in
their
changes.
constitutional
effects
111
f?^
DIVERTICULITIS OF THE PELVIC COLON.
After
a
symptoms the surgeon e
has been
colostomy
may be
performed
tempted to
125
for obstructive
close the
colostomy
he finds that the stricture subsequently disappears.
does,
he must remember that
111
relapses or colostomy
the absence of a short circuit Tather than the exception. I
have
If and
are common,
the rule
are
not considered treatment of these cases on medical
es' but it is
to-night.
a
point
which I
on
to obtain information
hope
^ ^0 not propose to consider diverticulitis of the caecum appendix, though I have a fine specimen of caecal
th
er*1CU^s
show you, nor will time permit me to discuss acute manifestations which present many interesting Ures- One of the most of these is that in some
striking
right-sided instead of symptoms ^stances when it has been found that the colon has been the
have been
'
pelvic
^
0ver to the
right by adhesions, just
PPendix symptoms
are
as
occasionally
left-sided.
~^t used to be thought that the passage of wind and faeces the bladder meant a recto-vesical or vesico-colic fistula
^ Malignant
origin. In recent years our knowledge of the of diverticulitis has revealed that vesical fistulse
Js Q,J*0
-p.
i
?t
uncommon,
investigation
^ese fistulae hitherto described
in
reality inflammatory
^nd
and
secondary
has shown that
as
malignant
to
C^cal
inflammation
fistulae
at the umbilicus and
^ay very often be laid
.
at
following
a
the door
Verticulitis. ^aVe
Hor
a
^?ion
^P
left iliac
of
pelvic
attempted to give you an historical survey Complete clinical picture of the many manifestations n?t
are met with v 0U
th
are
colon diverticula.
absceco di
and further
Wl
S06
in association with diverticula of the which Maxwell
^
this would involve
a
Telling
series of lectures.
drew
I have
126
MR. CHARLES A.
endeavoured rather to to
dwell
disease.
on
the
MORTON
you my personal experiences and of case which simulates malignant
give
type
You will realise from what I have said that in-
past many apparent cures following colostomy for supposed inoperable carcinoma of the colon should have been grouped under this heading. the
OF
THE
PELVIC
COLON.1
BY
Sir C.
Gordon-Watson, K.B.E., C.M.G., F.R.C.S.,
Surgeon
to
St. Bartholomew's and St. Alark's
Hospitals.
In recent years our attention has been focussed on stagnation in the colon and the evil results that ensue. In this direction Sir Arbuthnot Lane has done much to stimulate interest, hearts of not was
not
a
"
on
that these
few of
into the
The late Father Bernard
Vaughan
been
"
on
The Sins of
total
not
are
movement afoot to abolish
society
for the errant colon. can
he states in Medical the
He
be secured
adhesions of the an
"
than Lane
And who shall say
without
pelvic address
abolishing now
by
we
learn that Sir
the extreme
penalty surgical relief
believes that careful
freeing
of
acquired
colon to the iliac fossa."
recently published
that he has
Journal same advantage by
"
for the
capital punishment
at the same time
;
Arbuthnot is in favour of
of stasis
Society
good cause ? I11 punishment for a colon steeped in iniquity extirpation. There is, at the moment,
strictures
worst sins of
inspire
The Sins of the Colon."
recent years the
has
us.
scathing
more
has been
a
awe
excite admiration, and indeed to
to
this
"
on
Indeed,
in the
many occasions
simple operation
derived
that he
had
1 A Paper read at a Meeting of the Bath and Bristol Branch of t*16 British Medical Association on Wednesday, February 27th, 1924.
DIVERTICULITIS OF THE PELVIC COLON.
Previously
had from
colectomy
risk."
Lane
has drawn
Mechanical
at
a
considerably greater
remarkable clinical
a
113
of the
picture
sequelse, which in his opinion follow development newly-formed peritoneal bands that ailchor the overloaded pelvic colon to the iliac fossa, and by and toxic
*he
of
c?ntraction
cause
what he describes
"
as
the first and last
kink." The
determining
the colon
Probable
and it is
Editions if
than
probable
and flatulence
were we should more
f?rty
^aj?rity may ^
more
0f
often.
and far cases
be
expect
more
extraperitoneal
said with
much
over
fat is
rarely
fifty,
habits, fat, flabby
in most instances
past
Co?
^ a
^ ?
in
excess.
the meridian of
life,
arid flatulent, a
close
connec-
conditions of the
pathological regards a sensitive and impassioned temperament Powerful predisposing factor in diverticulitis. and
'
u
^
the emotions and
met with
the victims of
Sheffield believes that there is
between
;
and in the
present
truth that
are
story
to meet with these pressure
often
Sedentary
tio
inflammatory
not the whole
are
Diverticulitis is
erticulitis
du
that the
must be laid at the door of intestinal stasis.
Pouches far n^er
It is
which often result from faecal retention in these
Constipation
they
established.
yet satisfactorily
that increased pressure within the colon due to and flatulent distension is the most important
^?nstipation 0r. Pouches
factors in the formation of diverticula
not
are
"the
gradual increase of fat around the bowel progressive atrophy of the unstriated muscle, ?rrnally> as we know from radiograms, the colon C?ntrac^on presents alternate rings of contraction sacculation. When subject to long-continued back is
and.11^
re
an
overloaded and flatulent colon with fat-laden
atrophied V?L
\r
?-
muscle must,
I53*
during straining
at
stool, be
SIR C. GORDON-WATSON
114 prone to
in the sacculated
yield
points. perforate during
the act of
at the
portions
We know that diverticula
once
at stool
straining
weakest
formed sometimes or
from some
sudden exertion. As Hamilton Drummond has shown, these weak occur
where the circular vessels
perforate
spots
the muscular
coat to reach the mucosa.
These weak
spots
occur
either side between the
on
lateral taenia and the mesenteric border, and it is along these lines that diverticula most The diverticula
are
small herniae of the
the muscular coats, which increase in size tend necked and to act
as
the exact
Though
commonly
to
gradually enlarge, flask-shaped
traps for faecal matter. pathology of the origin
inflammatory phenomena
retention
of
matter
in
thoroughly straightforward, and to the many-sided phenomena to
justify
the
of
description
which result from the
bears
close
so
pouches, lS an analogy
appendix inflammation
of
left-sided
Faecal of
they
diverticula diverticulitis;
these hernial
"
as
of
of
pathology
through
and bottle-
become
i.e. of the
as
mucosa
and
in the colon is uncertain, the faecal
occur.
stagnation may be followed by concretions, concretions by ulceration,
appendicitis.' the formation ulceration by
general peritonitis ?r more often by a localised abscess and perhaps a faecal fistulaIn other instances inflammation inside a diverticula#1
perforation, perforation by
results not in
perforation
is chronic from the
fibrosis,
but in inflammation outside
first,
and
As Maxwell
multiple
that
gives
rise to
fibrosis to tumour formation and
to chronic obstruction and a
of
either
occurs
Telling
so
mimicry aptly says,
peridiverticulaf
stenosis, stenosis
of carcinoma. "
Given the
herniae of the mucosa, every may be logically deduced a
pathological comparison."
which
formati0*1
secondary process priori by genera^
DIVERTICULITIS OF THE PELVIC COLON.
115
Inflammation in and around these acquired thus produces three main clinical conditions :
diverticula
Manifestations
associated with
perforation
(i)
acute
which cannot
distinguished from the acute manifestations of appendicitis except as regards the left-sided symptoms ; (2) a subacute suppurative condition analogous to the appendix abscess and
distinguished by
c?lic fistula
Emulates
the
(3)
;
a
tendency to faecal hyperplastic type
carcinoma in that
a tumour
fistula
or
vesico-
which
so
closely
forms which
Causes obstruction.
frequently
While recognising the many phases of diverticular it is important to remember that diverticula frequently exist and give rise to no symptom at all, and this
lnflammation ls
More likely to be the case when the pouches are tubular and wide at the neck. In recent years, since I have been ?n
the look
diverticula on
out a
for them,
few occasions
I
have met with innocent
during an
abdominal
operation.
Indeed, they are easily missed when searched for at autopsies, b?th from
without and
within, though when they contain matter hard lumps may often be felt in the aPpendices epiploicae. These small pouches may readily
s?Hd fecal
escaPe detection,
Usually project c?ndition
has
they occur in fat-laden bowel and fatty appendices epiploicse. This termed diverticulosis as opposed to
because
into the been
diverticulitis. When there
is a considerable inflammation round the ^Vel the diverticula may only be recognised after careful
1Ssection. The
openings
nd are often
so
^ncosa is put
on
^rummond
within the bowel lie between the rugae, small as not to be recognisable until the the stretch.
examined the colon in 500
nd
found diverticula
?^e
that
in
22 cases,
in four of them there
and it is
were
post-mortems
interesting
to
also diverticula in the
Il6
SIR C. GORDON-WATSON
small intestine and in facts which
diverticulum of the bladder,
one case a
suggestive
are
of
some
of
the
congenital
defect in the
unstriated muscle. In
intestine
Spriggs only recognised diverticula in six, but there was no special investigation for diverticula. The diagnosis of diverticulitis usually depends on radiographic evidence. As in other conditions, with perfect X-rays after an radiograms
1,000
get positive evidence which makes a certainty, but the reverse by no means holds good. The appearance of clear-cut diverticula, when seen in a skiagram, is unmistakable, and the diagnosis is readily confirmed when the opaque pockets remain visible after the remainder of the bowel has been emptied. opaque meal the diagnosis
we
may
colon may be is examined when the bulk of
Evidence of diverticula in the missed unless the
patient
pelvic
region, and again examined when the pslvic colon has been emptied. If the diverticula are a numerous positive evidence may be expected ; if only few are present, and these are filled with faecal material;
the meal is in this
or
are
perhaps
so
situated
outline of the bowel
[i.e.
escape observation. Positive evidence in doubtful be obtained
by
an
cases
is
more
filling given prior to
an
enema
flatulent distension and
patency
problem.
In
When
a
present
that he is much worried
irregularity
great
middle-aged patient
with
in the action of the
may be faced with the absence of a palpable
practitioner
pockets
may by relaxing of the pockets.
in the function of the colon
Irregularities difficulty as regards diagnosis. presents himself with the story
to
defect in the main lumen.
the muscular coats increase the
bowels the
likely
enema, which may distend the
and also show up any Belladonna
by the main profile), they may
be obscured
as to
not shown in
troublesome growth in the a
DIVERTICULITIS OF THE PELVIC COLON.
rectum he does
turbance ?e?
not know whether to assume that the dis-
of function is due to the
stasis,
is
or
an
resulting from errors It is reasonable
by advances
"
first and last
kink," inflammatory condition, i.e. a colitis of diet and unhealthy habits, or whether
diverticulitis
against
up
colon.
II7
or
an
early
carcinoma of the
hope that diagnosis may be simplified radiography and chemical pathology.
in
Fortunately,
to
diverticulitis
is
of
one
the
of
rarities
Practice. The acute manifestations, if they seldom receive, SeMom demand exactitude in diagnosis ; they take their
humble place
I?r
among the acute abdomens. they run their luck.
Worse, More interest,
chronic
Propose
type
to
think,
attaches to the subacute and
simulate
malignant stricture,
a
most instances the area involved is
the reach
s^moidoscope, frequently because
adhesions
slgmoidoscope
th
often with opaque may be possible from
more
probable diagnosis clinical history.
In
and
you my personal experiences with this An exact diagnosis may sometimes be made
sigmoidoscope, though
radiograpliy ; ^
or
give
of case.
Wlth the
I
which
cases
For better
ExCeptionally
cannot be
passed
beyond owing to
to the full extent,
the m?uths of diverticula may be seen with and an absolute diagnosis established.
slgrnoidoscope, JUne
?f last year
a
stout
lady, aged 64,
was
brought
to
that for some months she had been greatly trouhl e(I with flatulent distension, and with small, frequent teasloose but often containing small rab>v I??t^ons usually *t-like hard debris. Occasionally she had passed bloodstain ^ucus. There had been no loss of weight, and her aPPe did not suggest malignant disease. On examination sigmoidoscope I observed at 20 cm. the mouths of tty0 They were visible only on inflation, i.e. they c?uld S0en t? open up with each puff of the inflator. The peitie t took fright either at the sigmoidoscope or a^ unfortunately, ne diagnosis, and I heard no more of her. a
history
"
"
Wit^ce V^erticula. j-
Il8
so
SIR C. GORDON-WATSON
It should be noticed that the passage of blood and mucus diagnostic of new growth occurred in this case. This is
exceptional, and is usually an important point in differential diagnosis. It may be that in this case the two conditions were combined, as is sometimes the case. Carcinoma may arise, or, as it were, settle down in the midst of a In other instances diverticula form above
diverticulitis. carcinomatous
stricture.
to deal with a
not
yet
large
and I have
conditions,
been
Turner
operated
cases
would
One not
on a
expect
uncommon
increased
colonic
There
are,
associated
of both these
specimens illustrating themcase in which a perforation of a
seen
diverticulum occurred above
be
my lot carcinomata, I have has
met with diverticula in this association.
however, several recorded
Grey
it
Although
number of colon
a
a
the
behind
tension
carcinoma. formation of
a
is
stricture the
main
diverticula
of
the
factor
to
colon if in
their
production. The fact that the that
are
we
still
opposite lacking in
is the
case
makes me.
full information
as
to
think their
origin. The first case of diverticulitis that I operated on was i11 1911 at St. Bartholomew's, and this was a case which was almost certainly secondary to stricture of the rectum. The patient was a young woman of 26 when I operated on her, oHe of the youngest cases on record. I described the case at the Pericolitis Sinistra with Sacculations." I was the*1 time as of the term diverticulitis. At the age of 18 she vvaS ignorant operated on (posterior proctotomy) for stricture of the rectutf1 by Mr. Harrison Cripps. Five years later she was treated W bougies for recurrent stricture. Three years after this I a tight, fibrous stricture of the lower part of the rectum an opened the abdomen to perform colostomy. I found the peKlC colon adherent to the uterus greatly inflamed with numerous appendices epiploic?, many of which contained saccules mucous membrane. Owing to the contracted mesocolon an a very friable intestine I was unable to perform colosto^ until I had divided the bowel and closed the lower end. "
foun oking and
is
case
?ols with eal of
evidence may be an
example
quite
conclusive.
II9 The
:?
aged 56 (first seen January ist, 1923), robust covered, complained of frequent offensive troublesome colicky pains and the passage of a good
mucus in the stools. For the past few years she has 6recl in a minor degree from these attacks, which have been foil owed by quiescent periods. Recently there has been more culty in getting the bowel empty in spite of increasing doses f
UI
aperients.
^ barium
g,
.Vlc colon,"
enema
showed
"
well-marked filling defect in the defect suggestive of an annular lcture due to carcinoma, but a more diffuse stenosis involving s inches of the bowel. (Fig. 1.) taken after evacuation of the contents of -j-kg bowel showed the classical multiple opaque blobs so a*acteristic of diverticulitis. Operation revealed not only multiple diverticula but e peri diverticular inflammation. There were many eSl0ns The infl arried between the pelvic colon and the iliac fossa. area was so extensive that a short circuit between t nsverse and pelvic colon was not feasible. The patient was 0 to colostomy unless considered absolutely essential. Seeniecl to be some risk that acute symptoms might rvene from perforation of a diverticulum. of diverticula has been practised when perpagination f0r 1?n has threatened, but is only practicable when the djv rticula are few and blessed with wide necks, adh ?Ventually separated the pelvic colon from its parietal and then wrapped a superabundant great omentum Xo the involved area, stitching the free edge of the omentum t0 e outer layer of the mesentery. Way ^ h?Pecl to avoid any general peritoneal infection shoi vi ?f hv, a* Perf?ration occur, and at the same time by relief 0ns to increase the mobility and to improve the funrf ability of the pelvic colon. The after treatment in ^aSe ^as consisted. in the regular use of paraffin internally an.d ai^ enerriata to prevent stagnation in the colon. Radio?ram ^a^en a year after operation show that the stenosis patient is involved in a daily toilet which takes le time but secures comfort for the remainder of the \ ay- I think the toilet would be less strenuous if she had a CQi ostomy opening above the involved area. Del
not the
filling
v^al
^iographs
,
a(3,en^Ve
-jPPosed int0re
e^l0ris?
-
rf renia^ cons-!^S" In
^ ac
many instances
fossa may
a
sausage-shaped
be felt per abdomen, and
a
tumour in the left
diagnosis assumed
120
SIR C. GORDON-WATSON
when the clinical
picture
is
strongly against malignant
disease. The
following
case
is
an
example
of
this,
and
presents
many features of interest:? A clergyman, aged 46, was seen by me in 1914 with the following history. Twenty years ago he had an attack of jaundice. For the last fifteen years he had had dyspepsia, taking the form of acid eructations and pyrosis, in the strict sense of the word, after food. About the same time he began to have difficulty with the bowels ; after an action he would still feel that there was something there, and there might be as-
four or five small actions before he was comfortablethe bowels became so capricious in their action that he used to take some astringent when he had to perform some public duty. About two to three years ago he began to pass blood and mucus with the stools. A few months ago an was examination with bismuth made, but revealed no X-ray structural change in stomach or colon ; the marked distension of the stomach on giving sodium bicarbonate confirmed the diagnosis of hyperchlorhydria, however. He was stout and not anaemic. Physical examination revealed nothing till the left iliac fossa was reached. Here, even after the bowel had been cleared out by enemata, a sausage-shaped, definitely tender swelling was felt. The abdomen was opened, and the diseased bowel, about six inches in length, was brought to the surface and fixed. Eight days later (June, 1914) I excised the affected area and established a temporary colostomyA year afterwards, in 1915, during my absence at the war, the colostomy was closed by Mr. Lockhart Mummery. Two ye^t afterwards (1917) there were recurrent symptoms of obstruction. The transverse was now anastomosed to the pelvic colon at the junction with the rectum, and a radiograph taken a year later, in 1918, shows the anastomosis in functionThe recurrent symptoms may have been due to stricture' 0 or possibly to recurrent diverticulitis above the line anastomosis. many
as
Gradually
partial-
which, except for the length of history, gave a history which strongly suggested maligna11^ disease was treated by primary resection and anastomosis The
following
case
un4^
E.T., a woman aged 62, was admitted to St. Mark's sn my care on January 4th, 1921. On and off for ten years had suffered from attacks of diarrhoea, coming on every two
DIVERTICULITIS OF THE PELVIC COLON.
121
three days, frequently commencing at night, accompanied by abdominal pain of a griping character which lasted General J about two hours. She complained of a purulent and from the rectum, which was sometimes si' 6?SlVe discharge There was no vomiting or abdominal diai erition.bloodstained. She had been losing weight for some months. On ?
a s
of the abdomen there increased ^minati?n tenderness in the left iliac fossa and was
11s.0rrie could
e.hng
a
be felt. small
The rectum
was
resistance
sausage-shaped On sig-
normal.
was seen at inches, but up evidence of tumour or stenosis. When 0rrien was opened the upper part of the pelvic colon Wa 'n
I will refer to
Method in I
of
one
other
case
because it illustrates another
treatment?appendicostomy.
A m "lan ,, e
aged 70 was admitted to hospital with a tender mass *^ac f?ssa and considerable difficulty with his bowels. 1 Piored and found well-marked diverticulitis with many The patient was a bad subject for operation, tomy, owing to adhesions, presented difficulties. I decided PPendicostomy with a view to obtaining relief by regular Unfortunately, the patient developed bronchitis the operation and succumbed.
Coigns.
?n
irri
aftgra,!?n-
^ will be clear from the history of the
descriK
fib r?sis th e
a
already
...
peridiverticular symptoms distinguish from those observers lay considerable stress on
c^n^ca^
with stenosis
are
CarC^norna- Most absence of blood, II
cases
to this
of
not easy to
but too much
weight
must not
point. In three of the cases which I blood was occasionally noted in the stools
be
have
SIR C. GORDON-WATSON
122
To my mind the most important clinical distinction is the appearance of the patient. When carcinoma of the colon has developed to a stage which brings the patient to
usually with semi-obstructive symptoms looks the part?he is losing weight, he looks ill. a
doctor
Cases of diverticulitis of
usually
come
capricious
freedom from "
patient
long history pain and
a
actions of the bowels associated with
tenderness in the left iliac fossa, with not
with
the
symptoms. They losing weight.
of
complain
periods
of
complete
well covered and do
are
There is
no
suggestion of
appearance. A tumour may often be felt in the left iliac fossa of considerable size. A carcinoma of the pelvic colon, on the other hand, of
the shadow
is
usually
malignancy"
too small to be felt
with bimanual
in
their
(except
under
an
anaesthetic
examination).
Pain and tenderness in the iliac fossa
are
the
exception
in carcinoma. When there is marked inflammation in In addition to
pyrexia
and
diverticulitis
pain and tenderness there may be irregular leucocytosis and often irritability of the
bladder.
Inflammatory strictures involving apart do
from the rectum do not often
occur
with the
the occur.
pelvic colo*1 When they
they are usually low enough to be recognised sigmoidoscope, and may be distinguished fro#1
diverticulitis
by
the loss of
mucous
membrane at the srte
of stricture. The stricture will be tunnel-like rather than as
in carcinoma.
example
of
The
non-malignant
which I excised from and
a man
ring-like
show you is aI1 stricture of the pelvic colo*1
specimen
aged 43
I
now
symptom6
in 1919. The in favour of carcinoid'
sigmoidoscopic appearances and at the operation I could not determine whether I ^aS dealing with an inflammatory or a malignant conditio11' were
DIVERTICULITIS OF THE PELVIC COLON.
ThIe
microscope
shows
evidence
no
123
of carcinoma.
The
remains well.
before rn?1ditis
diverticulitis became
and
generally recognised sig-
familiar terms, and
pericolitis many cases of inflammatory stricture Were described under these headings. were
summarising
ticulitis
no
doubt
due to diverticulitis
the treatment of chronic
cases
of diver-
associated with fibrosis and stenosis I should like
sound
a note of warning. I have referred to cases in which I have resected the involved portion of the pelvic colon
and the 111 all
have survived the
patients
be
probability,
?Pportunity
for
a
time before I
long
a
procedure,
In the
safe excision.
but it
get
will,
another
great majority
of
Cases which call for surgical treatment (apart from acute marked ?ases) inflammation, extensive adhesions, excess of ic\ f ln the mesentery, and a small amount of healthy colon *
w
the affected
a
^
area
will all render
primary procedure,
these
most
a
resection,
hazardous
at any rate
undertaking.
resections three
separate methods were employed : ^ ?ne"Stage method, i.e. (a) resection and anastomosis in stage (an exceptionally favourable case) ; a two-stage ethod, ix% (fy primary anastomosis with secondary ; a three-stage method, i.e. (c), stage i?eversion ,^e growth outside the abdomen, stage 2?excision and colostn 0lny, stage 3?anastomosis.
^Section
.
Without
C
ure 1Ce
the the
under
must,
the
mflammatory
most
more
^?rary c?l?stomy
s
0rny
favourable
in the
hope that,
as
In a
is often the case,
condition will subside, when closure of
may be considered. of the pelvic colon is
may
conditions.
often than not, be content with
^colostomy *^e mesentery
pe^.10 cni
doubt resection and anastomosis is the ideal
brought
and dealt with
as
long,
the involved
outside at the time of the
described above.
SIR C- GORDON-WATSON
124
The above methods caused
some measure
stenosis threaten to do Milder do not
justify
seem to
which have
cases
which
or
by
reason
of
so.
while
types which,
causing much inconvenience colostomy at the time of operation,
a
happens a colostomy has been refused by the patient before operation, may be dealt with by invagination of dangerous looking saccules and by omental or
in which
those
to
apply
of obstruction
sometines
as
the involved
grafts overlapping
should be borne in mind in In
It is
with
appendicostomy. interesting feature
an
often
are
symptoms
In the
are
are
short, and
more
malignancy
"
Cases
local
come
attacks
under
followed
periodic comparative immunity fro#1
sometimes met
with; by the symptoms and by curtailed
are soon
constant
or
that active
cases
similar histories
of carcinoma of the colon
early stages
intermissions
of these
intermittent.
long immunity
of
procedure perforationinvagination ?r
with acute
histories of
observation with
by periods symptoms.
dealing
it may be wise to combine
some cases
grafting
This latter
area.
but such more
the
serious "
and
shadow
which hovers round the victims.
inflammation resistance, and dne
The ebb and flow of chronic diverticular is doubtless to
dependent
on
variations in
factors other than mechanical. In the
toxic states associated with oral
varying
sepslS
parallel. We know that period10 bouts of sciatica, lumbago, tonsillitis, etc., have so oftel1 been permanently relieved by the discovery and treatmer^ of a septic focus in a tooth socket or an accessory sinuS there
as
is, perhaps,
some
to establish without doubt
a
relationship
between the
We may assume similar factors at work connection with the septic colon pockets to account two conditions.
similar
intermissions
corresponding
local
in
their
changes.
constitutional
effects
111
f?^
DIVERTICULITIS OF THE PELVIC COLON.
After
a
symptoms the surgeon e
has been
colostomy
may be
performed
tempted to
125
for obstructive
close the
colostomy
he finds that the stricture subsequently disappears.
does,
he must remember that
111
relapses or colostomy
the absence of a short circuit Tather than the exception. I
have
If and
are common,
the rule
are
not considered treatment of these cases on medical
es' but it is
to-night.
a
point
which I
on
to obtain information
hope
^ ^0 not propose to consider diverticulitis of the caecum appendix, though I have a fine specimen of caecal
th
er*1CU^s
show you, nor will time permit me to discuss acute manifestations which present many interesting Ures- One of the most of these is that in some
striking
right-sided instead of symptoms ^stances when it has been found that the colon has been the
have been
'
pelvic
^
0ver to the
right by adhesions, just
PPendix symptoms
are
as
occasionally
left-sided.
~^t used to be thought that the passage of wind and faeces the bladder meant a recto-vesical or vesico-colic fistula
^ Malignant
origin. In recent years our knowledge of the of diverticulitis has revealed that vesical fistulse
Js Q,J*0
-p.
i
?t
uncommon,
investigation
^ese fistulae hitherto described
in
reality inflammatory
^nd
and
secondary
has shown that
as
malignant
to
C^cal
inflammation
fistulae
at the umbilicus and
^ay very often be laid
.
at
following
a
the door
Verticulitis. ^aVe
Hor
a
^?ion
^P
left iliac
of
pelvic
attempted to give you an historical survey Complete clinical picture of the many manifestations n?t
are met with v 0U
th
are
colon diverticula.
absceco di
and further
Wl
S06
in association with diverticula of the which Maxwell
^
this would involve
a
Telling
series of lectures.
drew
I have
126
MR. CHARLES A.
endeavoured rather to to
dwell
disease.
on
the
MORTON
you my personal experiences and of case which simulates malignant
give
type
You will realise from what I have said that in-
past many apparent cures following colostomy for supposed inoperable carcinoma of the colon should have been grouped under this heading. the
