History of Coeliac Disease
2nd Century A.D.
The first description of childhood and adult coeliac disease was written in Greek by the physician Aretaeus of Cappodocia. His writings survived and were translated into English by Francis Adams for the Sydenham Society in 1856. The chapter on “The Coeliac Diathesis” describes fatty diarrhoea (steatorrhoea) for the first time in European literature and then goes on to give an account of several other features including weight loss and pallor, the way it affects both children and adults. The word ‘coeliac’ comes from the Greek word ‘koiliakos’ and means ‘suffering in the bowels’. In the translation, the chapter on the Cure of Coeliacs describes exactly those persons to be called coeliacs; “If the stomach be irretentive of the food and it pass through undigested and crude, and nothing ascends into the body, we call such persons Coeliacs.”
Samuel Gee, 1839-1911, a British Paediatrician, wrote in St Bartholomew’s Hospital Reports of 1888 under the heading, ‘The Coeliac Affection’ a vivid and accurate description of the clinical state we call coeliac disease. He described the condition as “a kind of chronic indigestion which is met with in persons of all ages”. He noted that because of the wasting, weakness and pallor of the patient, the bowel complaint might easily be overlooked. He went on to declare that regulation of food was important, suggesting that errors in diet might be the cause and concluded, “but if the patient can be cured at all, it must be by means of diet”.
Paediatricians in the U.K. during this time noted that fats were better tolerated than carbohydrates in the diet. Stages in the introduction of foods was at this time the only form of treatment. Breads, cereals and potatoes were the last foods to be reintroduced to the diet over a period of months to years. The treatment therefore was time consuming but did have beneficial results.
Not until after the Second World War was there a fundamental discovery made relating to the successful treatment of coeliac children and adults.
Professor Willem Dicke, a Dutch Paediatrician, demonstrated how children benefited dramatically when wheat, rye and oat flours were excluded from the diet and replaced with rice and maize flours. The discovery was due to the shortage of wheat grain during the war years in Holland. Dicke noticed that children with the condition who were being fed other foods in place of wheat were improving. After the war when wheat consumption recommenced, the children again deteriorate with the development of symptoms.
John W Paulley, a Physician from Ipswich, U.K. recognised the characteristic abnormality of the lining of the upper part of the bowel when taking samples during operations. Dr Paulley’s discovery concerning the abnormality of the bowel was confirmed as the most essential feature on which the diagnosis of the coeliac condition could be based. It was also a significant observation that if a patient complied with a strictly gluten free diet, the lining of the small intestine returned to normal.
Dr Margot Shiner, working in Hammersmith Hospital in London, developed a quick and safe method to perform oral biopsies of the lining of the upper bowel (the jejunum).
An American Army Officer, Colonel Crosby, working with an engineer, designed what we now know as the Crosby Capsule, a completely flexible tube which soon became the most widely used biopsy instrument in the world.
Following these two important advances coeliac disease could be easily diagnosed and treated. From the mid-1950s onwards an explosion in the understanding of the disorder occured which has continued to accelerate.
Cyrus L. Rubin and co workers demonstrated convincingly that coeliac disease in children and idiopathic or non tropical sprue in adults were identical diseases with the same clinical pathogen feature.
Physicians specialising in skin care discovered that patients with a particular type of itchy rash called Dermatitis Herpetiformis may also have gluten enteropathy. It was generally accepted that the intestinal villi returned to normal with a gluten free diet, but many investigators did not agree that the skin lesions were produced by gluten.
There has been little significant advancement in understanding why gluten has a destructive effect on the villi lining the small intestine. However, since the study of hereditary material (DNA), found in nuclei of individual cells of the body, molecular biology is now being applied to coeliac disease.
A blood test to measure anti gliadin antibodies in serum by enzyme immunoassay was developed. This blood test is less obtrusive than the jejunal biopsy but still does not exclude the need for biopsy.
The use of optic fibre for endoscopy replaced the Crosby Capsule.
Australian food labeling laws changed to adopt new gluten free standard of no detectable gluten (ie no wheat starch, malt extract, etc on gluten free diet).
Anti-endomysial antibody test widely available in Australia.
Tissue transglutiminase antibody screening test introduced in Australia.
Samuel Gee, Willem Dicke, John Paulley, Margot Shiner and other early workers who put coeliac disease on the map could not have imagined where their discoveries would lead. More and more fascinating information is being uncovered about coeliac disease which is being used for the benefit of those with the condition.