The Little Bypaths

The disease of the large bowel that kept Secretary John Foster Dulles bedfast in Walter Reed Army Hospital last week (see NATIONAL AFFAIRS) was considered rare until the turn of the century. Since then, with X-ray techniques constantly improving, it has become clear that diverticulosis is one of the commonest disorders of the aging, though often it gives no trouble. But diverticulitis severe enough to send the victim to a hospital has become a routine diagnosis.

A diverticulum (Latin for a small bypath) of the large bowel is a little pouch or sac formed by pressure inside the gut, forcing the inner layer (mucosa) through a weak spot in the outer, muscular layers. It may be no bigger than a BB shot, or it may be the size of a plum with a stalklike neck. If the neck is extremely narrow, fecal matter forced into the diverticulum will stay there, setting up an ever-present threat of infection and making the condition harder to detect since the barium used to get X-ray contrast may not penetrate the diverticulum sufficiently. In the symptom-free stage of diverticulosis there may be dozens of small diverticula scattered along the colon.

In the "S" Bend. Though the colon averages 5 ft. in length, the vast majority of diverticula are found in its last 15 inches, known as the sigmoid colon be cause it bends in an S shape from the lower end of the descending colon to the upper part of the rectum. Most of the sigmoid colon is in the left lower quarter of the body. When a diverticulum becomes inflamed (diverticulitis), the symptoms suggest "left-sided appendicitis." Symptoms usually include diarrhea, gas distension and pain.

The diagnostician's biggest concern is to distinguish an acutely inflamed diverticulum from cancer of the colon, and this was especially important in Dulles' case since he had had a 1 3/4-in. piece of cancerous tissue removed from the large bowel two years ago. The danger of recurrence was, of course, great. Fortunately, in most cases, X rays taken after a barium enema show a distinctive picture of one or the other. In Dulles' case there was a characteristic, unmistakable diverticulum.

Further to rule out the possibility of concurrent cancer, the diagnostician inserts a sigmoidoscope--a metal tube, 10 in. long, with a light at the end--through the rectum and examines the lower sigmoid colon visually. Now being refined are more elaborate techniques for washing out the colon, then flushing it with a solution to pick up stray cancer cells which can be identified on a Papanicolaou smear under the microscope.

Peace & Quiet. With no sign of recurring cancer, and no indication that Dulles' diverticulum had perforated (which would spill the bowel contents into the abdominal cavity, set up a life-threatening infection), the doctors saw no need for surgery. They gave Dulles antibiotics to knock out the infection in the diverticulum and an antispasmodic to keep the gut still, put him on a low-residue diet to reduce its work. Beyond that, all the Secretary needed was bed rest and some unwonted peace and quiet.

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