JMS Pearce
Hull, England

Crohn’s disease was described on several occasions before Crohn’s seminal publication in the Journal of the American Medical Association¹ with his two colleagues in 1932. Many reports of a Crohn’s-like condition have claimed priority.

Giovanni Battista Morgagni (1682–1771) of Padua, the pioneer of pathological anatomy, in De sedibus, et causis morborum per anatomen indagatis (Seats and causes of disease investigated by anatomy) (1761)² described a young man who for fourteen years had diarrhea and abdominal pain and died of intestinal perforation and peritonitis. Necropsy showed the terminal ileum and colon were inflamed, ulcerated, with large mesenteric lymph nodes.³

In an excellent historical review, Banerjee and Peters record many historic descriptions, including early nineteenth-century cases.⁴ Combe and Saunders in 1813 demonstrated a patient at the Royal College of Physicians who had a stricture and thickening of the ileum—the ileum was “contracted for the space of three feet to the size of a turkey quill.” John Abercrombie in 1828 described a thirteen-year-old girl with inflammatory thickening of the terminal ileum and proximal colon with skip lesions.⁵ The history and pathological findings suggest a diagnosis of juvenile Crohn’s ileitis. His book describes many cases of inflammatory disease of the ileum (and colon) with “false membranes,” ulceration, perforation, and gangrene.

Samuel Wilks In 1859 suggested that idiopathic colitis should be separated from epidemic dysentery. In Lectures on Pathological Anatomy with Moxon he also described ulcerative colitis. Wilks described pathology typical of Crohn’s disease in a patient, Miss Bankes:

In the small intestine nothing remarkable was observed until the lower end of the ileum was reached, when at about three feet from its termination in the caecum, the mucous membrane commenced to exhibit an inflammatory response. In the caecum, inflammation of the most acute and violent character was observed…⁶

These accounts are clearly those of inflammatory bowel disease (IBD), many decades before the papers of Dalziel, Crohn, and others (vide infra). The main clinical problem was distinguishing the disease from the more common dysentery, ileocecal tuberculosis, and appendicitis.

Around the turn of the twentieth century, many more instances emerged.⁴ In his textbook The System of Medicine (1893), Thomas Clifford Allbutt described cases of chronic inflammation of the ileum, distinct from ileal tuberculosis. Osler’s The Principles and Practice of Medicine (1902) also reported patients with ileitis. The Polish surgeon Antoni Lesniowski described in 1903 patients with inflammatory lesions and strictures of the small intestine, including one with a fistula; the term “Lesniowski-Crohn disease” is used in some European countries. Moynihan (1907) and Mayo Robson (1908) in Leeds both recounted chronic inflammatory masses of the cecum or large bowel simulating malignancies. Tietze likewise described and reviewed inflammatory masses of the bowel.⁷

Thomas Kennedy Dalziel (1861–1924), a Glasgow surgeon, in 1913 described an important series of nine cases of “chronic interstitial enteritis”:

Twelve years ago I saw a professional colleague suffering from obstruction of the bowels previous to which he had had for several weeks numerous attacks of colic, slight attacks of diarrhoea with no tenderness over the abdomen, …As vomiting was persistent I opened the abdomen and found the whole of the intestines, large and small alike, contracted and rigidly fixed…That the wall of the whole intestine was chronically inflamed there could be no doubt… The clinical symptoms in all the cases were similar, the characteristic and most striking feature being most violent colic, causing vomiting and occasionally an escape of some blood, also constant mucus from the bowel… [The bowel had] the consistence and smoothness of an eel in a state of rigor mortis, and the glands though enlarged are not caseous.

All of his nine cases had lesions in the ileum with inflammatory cells and granulomata; he emphasized the absence of tuberculous caseation. Some had strictures and intestinal obstruction. Two patients with small bowel and colonic involvement had a fatal outcome. Five recovered after operation. He concluded:

As far as I am aware the disease has not been previously described, but it seems probable that many cases must have been seen and have been diagnosed as tuberculous.⁸

Dalziel was knighted for services to the Royal Army Medical Corps in the First World War.

Before Crohn et al., Moschowitz and Wilensky, also from the Mount Sinai Hospital, described in 1923 four patients with non-specific granulomata of the intestine, one involving the terminal ileum, and almost certainly Crohn’s disease.⁹ This was cited by Crohn, although the papers of Lesniowski and Dalziel were not.

Crohn’s paper

Burrill B. Crohn (1884–1983), with Leon Ginzburg and Gordon D. Oppenheimer from Mount Sinai Hospital in New York, presented a communication to the American Gastro-Enterological Association at the eighty-third annual session of the American Medical Association, May 13, 1932, titled: “Terminal Ileitis: Its Clinical Manifestations.” They promptly published the condition in fourteen patients, aged seventeen to fifty-two, as “regional ileitis” (Fig 1., the authors given in alphabetic order):

Albert A. Berg, who declined to be a co-author, had treated thirteen of these patients surgically.¹⁰ According to Ginsburg, Crohn contributed two patients, Ginsburg and Oppenheimer twelve.¹¹ The surgical pathology disclosed was a “subacute or chronic necrotizing and cicatrizing inflammation of the terminal ileum…beginning at the ileocecal valve,” as well as transmural inflammation, strictures, and fistulae. This work undoubtedly founded the modern understanding of the disease.⁴ A year later, Ginsburg and Oppenheimer, with but a one-line mention of Crohn, published a more detailed account.¹² Ginsburg afterwards, with no little opprobrium,* said Crohn had not explained the absence of the names of Ginzburg and Oppenheimer from the program that Crohn submitted for the original presentation.¹¹

Lockhart-Mummery and Morson later described a large series of twenty-five cases of Crohn’s disease (regional enteritis) of the large intestine and showed clinical and pathological criteria and the distinction from ulcerative colitis.¹³ Several instances of localized or regional colitis were published illustrating the overlap and confusion with ulcerative colitis,¹⁴ both now classed as immune inflammatory bowel diseases (IBD). The exact cause remains elusive, but Crohn’s disease is now considered multifactorial with genetic predisposition, gut microbial imbalance, immune dysregulation, and environmental factors leading to intestinal inflammation.

A gentle, dedicated physician, Crohn eschewed the eponymous use of his name: he used the title Regional Ileitis in his papers. The 1932 publication was important, as were his many later contributions to the knowledge of the disease, so perhaps justifying the controversial eponym.¹⁵

Amongst colleagues at Mount Sinai who contributed to the accounts of the disorder were the surgeon AA Berg, pathologist Paul Klemperer, and co-authors Ginsburg and Oppenheimer. Crohn had a successful practice in gastroenterology and was elected president of the American Gastroenterological Association in 1932. He received numerous professional awards and wrote three books, Affections of the Stomach (1927), Understand Your Ulcer (1943), and Regional Ileitis (1947, second edition 1958). He also published many articles on regional ileitis and colitis, as well as on the physiology of the stomach, pancreas, and gall bladder. Crohn continued medical practice until he was ninety, and died in 1983 aged ninety-nine.

End note

* Interestingly, a photograph (Fig 2.) of Ginzburg and Crohn at the 50th Anniversary IBD symposium at Mount Sinai in May 1982 shows them embracing each other in apparently friendly fashion.

References

1. Crohn BB, Ginzburg L, Oppenheimer GD. Regional ileitis: a pathologic and clinical entity. Journal of the American Medical Association 1932;99:1323-9.
2. Morgagni GB. De Sedibus et causis morborum. Venice 1761. English translation, London: A Miller, T Cardelle and Jonston-Payne, 1769.
3. Mulder DJ, Noble AJ, Justinich CJ, et al. A tale of two diseases: The history of inflammatory bowel disease. J Crohn’s and Colitis 2014;8:341-8.
4. Banerjee AK, Peters TJ. The history of Crohn’s disease. Journal of the Royal College of Physicians of London 1989; 23:121-4.
5. Abercrombie J. Pathological and Practical Researches On Diseases of the Stomach, the Intestinal Canal, the Liver, and Other Viscera of the Abdomen. 3^rd edition, London: John Murray, 1837, pp. 230-9.
6. Wilks S. Morbid appearances in the intestine of Miss Bankes. Lond Med Gaz 1859;2:264-5.
7. Tietze A. Entzundlichen Geschwuelste des Dickdarms. Ergeb. Chir. Orthop. 1920;12:212. Cited by Crohn.1
8. Dalziel TK. Chronic interstitial enteritis. British Medical Journal 1913;2:1068-70.
9. Moschowitz E, Wilensky AO. Non-specific granulomata of the intestine. Am J Med Sci 1923;166:48-66.
10. Brahmajosyula A. A historical review of Crohn’s disease. Hektoen Int. Winter 2023. https://hekint.org/2023/01/23/a-historical-review-of-crohns-disease/
11. Ginsburg L. Regional Enteritis: Historical Perspective. Gastroenterology 1986;90(5):1310-11.
12. Ginsburg L, Oppenheimer GD. Non-specific granulomata of the intestines (inflammatory tumors and strictures of the bowel). Ann Surg 1933;98(6):1046-62.
13. Lockhart-Mummery HE, Morson BC. Crohn’s disease (regional enteritis) of the large intestine and its distinction from ulcerative colitis. Gut 1960;1(2):87-105.
14. Watkinson G, Thompson H, Goligher JC. Right-sided or segmental ulcerative colitis. British Journal of Surgery 1960;47(204):337-51.
15. Van Hootegem P, Travis S. Is Crohn’s Disease a Rightly Used Eponym? J Crohn’s and Colitis. 2020;14(6):867-71.