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Clinical investigation of the small bowel at The Mount Sinai Hospital began with David Adlersberg's arrival in 1931. His research interests were in bile acids, cholesterol, carotene, and vitamin A. In 1952, he was given a Nutrition Laboratory and later, a Nutrition Clinic. His vitamin A tolerance test and interest in malabsorption led him to a comprehensive study of sprue, the separation of the tropical and non-tropical forms, and their different etiologies and treatments. Adlersberg's work was complemented by (a) Marshak and Wolf's radiologic examination of the small bowel (especially in sprue and other malabsorption disorders); (b) Gerson s perfusion experiments; and (c) Friedman, Waye and Wolf's motility studies. Lieber and his colleagues explored the deleterious effects of alcohol on the function and structure of the small intestine. Gerson explored the nutrition of patients with Crohn's disease of the small intestine, especially after extensive resection or bypass leading to ascorbic and folic acid deficiencies and hypergastrinemia.

Inflammatory bowel diseases have been a major interest of generations of Mount Sinai Hospital gastroenterologists. Although clinical descriptions of diarrhea with or without blood go back thousands of years, clear distinctions between enteritis and ulcerative colitis were possible only in the 19th century. At that time, many case reports were published of, in retrospect, classical regional enteritis. The term "ulcerative colitis" dates from 1888; the introduction of the electric sigmoidoscope soon after made it possible to make proper diagnosis of ulcerative colitis and distinguish it from infective dysentery, membranous mucous or catarrhal colitis, and nervous diarrhea. Doctors at The Mount Sinai Hospital adopted this diagnostic approach in the 1870s and 1880s, and were particularly interested in patients with tuberculosis-like ileocecal disease without tubercle bacilli. Articles were written by Weiner in 1914, Moschcowitz and Wilensky in 1923 and 1927, and Goldfarb and Suissman in 1931. Dr. A.A. Berg, in 1925, encouraged his assistant Leon Ginzburg to conduct a study of the inflammatory granulomatous diseases of the bowel, when Ginzburg and Gordon Oppenheimer were working in Dr. Paul Klemperer's laboratory. Initial reports came in 1927 and 1928, but Ginzburg and Oppenheimer "in conjunction with Dr. Burrill B. Crohn" presented a definitive paper, "Non-specific Granulomata of the Intestine," on May 2, 1932, to the American Gastro-Enterological Association. On May 13, 1932, Dr. Crohn presented a paper on "Terminal Ileitis" to the American Medical Association; this was published later that year with the title "Regional Ileitis: A Pathologic and Chronic Entity," under the authorship of Crohn, Ginzburg and Oppenheimer.

Much of what we know about the role of immunopathologic mechanisms in causing Crohn's disease and ulcerative colitis originated from research at The Mount Sinai Hospital. The authors were privileged to have been able to share in this undertaking, along with many others, including Moschcowitz, Klemperer, Otani, Crohn, Ginzburg, Oppenheimer, Garlock, Lyons, Marshak, Janowitz, Aufses, Waye, Greenstein, Sachar, Meyers, Gelernt, Mayer, Lichtiger and Kornbluth. In medical history, elucidation of disease processes is often serendipitous. Transplant surgery was successful because of the discovery by Hitchings and Elion of 6-mercaptopurine (6-MP) and azathioprine, which inhibited rejection. And the concept of immunosuppression slowly evolved into possible treatment of any disease thought to be caused by autoimmunity. This includes those diseases of the bowel seen so frequently at The Mount Sinai Hospital: ileitis, granulomatous colitis, ileocolitis, and ulcerative colitis. This paper depicts the progressive role of immunosuppressive drugs, from corticosteroids to 6-mercaptopurine, cyclosporine and anti-tumor necrosis factor, in both the treatment and understanding of the pathogenesis of Crohn's disease and ulcerative colitis. Major contributions to these treatments have come from physicians and surgeons with roots at The Mount Sinai Hospital.

In the middle third of the 20th century, Mount Sinai radiologists were able to describe and establish specific radiologic criteria for the diagnosis of many gastrointestinal diseases. They then delineated specific radiologic patterns to diagnose such diverse conditions as inflammatory bowel disease of the small bowel and colon, protein-losing disorders, vascular disease of the small bowel, benign and malignant tumors, metastases and lymphoma of the gastrointestinal tract. Richard H. Marshak, Bernard S. Wolf, and Mansho T. Khilnani were the leaders in these radiologic investigations which established criteria that enabled generations of subsequent radiologists to arrive at definitive diagnoses.

Almost certainly, the physicians and surgeons of The Mount Sinai Hospital cared for patients with inflammatory bowel disease prior to 1932. However, the accepted beginning of the surgery of granulomatous inflammatory bowel disease (IBD) and Crohn's disease (CD) at our institution occurred when the landmark paper by Crohn, Ginzburg, and Oppenheimer was published in 1932. As a major referral center for patients with both medical and surgical complications of IBD, the surgical service has had a long and abiding interest in the disease. This review highlights the major contributions of our staff to the management of this illness over the past 67 years. Despite major innovations in both medical and surgical management of patients with Crohn's disease, individuals suffering from this condition are ideally managed by a multidisciplinary team.

An evolution in our understanding of the inflammatory bowel diseases (IBD), ulcerative colitis and Crohn's disease, correlates with increased knowledge of the function of the mucosal immune system. In the early 1960s and 1970s, IBD was considered to be an autoimmune disease in which there was a directed attack by humoral and cellular elements of the immune system against intestinal tissues. These studies did not withstand the test of time, and from the 1970s through the 1990s there was a growing appreciation that defects in cellular immunity, not auto-reactive in nature, played a larger role in disease pathogenesis. Research at Mount Sinai focused in on these cellular T cell defects and helped pave the way for the current model of disease pathogenesis.

The first case of cancer in inflammatory bowel disease (IBD) was reported at The Mount Sinai Hospital in 1925 in a patient with ulcerative colitis (UC). In 1956, carcinoma of the jejunum was described in a patient with regional enteritis (Crohn's disease [CD]). IBD cancers are preceded by dysplasia, and the relative risk increases with duration of the IBD. CD cancers are more proximally distributed than are UC cancers. Both tend to occur at the site of the overt disease and both develop at earlier ages (47 UC, 50 CD) than in the de novo colorectal cancer (70 years). The absolute cumulative colon cancer frequencies (8% UC, 7% CD) are identical after 20 years, emphasizing the importance of regular surveillance in both types of IBD. Moreover, the increased risk of colon cancer exists in patients with CD even when CD is confined to the small bowel, and patients with IBD have increased risks of developing extraintestinal and reticuloendothelial tumors in both CD and UC, as well as ano-vulval and malignant melanoma in CD. Colitic colorectal cancers are often diffuse, extensive, multiple and right-sided with insidious presentation. The prognosis is no worse after operation than that of de novo colon cancer. Most small bowel cancers in CD are adenocarcinomas, rather than sarcomas, and present at a younger age, more diffusely and more distally than de novo cancers, usually making them undiagnosable at a curable early stage; indeed, two-thirds present with intestinal obstruction. Strictures of the colon are common in patients with IBD, and they have a 10-fold risk for colon cancer, 30-fold for UC, and 6-fold for CD. The risk increases with disease duration. The indications for surgery are absolute, relative and incidental, and the procedures include segmental resection, total proctocolectomy, subtotal colectomy and palliative procedures.

The clinical diseases of ulcerative colitis (UC) and Crohn's disease (CD) were defined by 1932-1933. After that, the major conceptual developments were the recognition that regional enteritis could clearly involve the colon, and that cancer and toxic megacolon could occur in both CD and UC. In the last half of the 20th century the main thrust of gastroenterology at The Mount Sinai Hospital has been in inflammatory bowel disease (IBD), with contributions to extra-intestinal manifestations, measurement of clinical activity in CD, the natural history of the placebo arm of controlled trials, complications and therapy with corticosteroids, 5-ASA, 6-mercaptopurine, immunomodulators and cyclosporine. Actuarial life tables were introduced for postoperative recurrence and re-operation rates, as well as for quality of life analysis. Two forms of CD were defined, perforating and non-perforating, and the role of the fecal stream was explored in light of the higher risk of recurrence after operations with anastomosis as compared with ileocolostomy.

Gastroenterology grew as a subspecialty in Germany in the 19th century. In the 1880s and 1890s, Austrian and German clinics were attended by American physicians who, on returning to the U.S., founded the American Gastroenterological Association in 1897. The creation of a subspecialty board, however, had to wait until 1941. At The Mount Sinai Hospital, Dr. A.A. Berg was appointed Surgeon in 1899. His practice focused on the alimentary tract, which in 1910 became one of the four surgical specialties. In 1914, further subdivision led to the stomach and duodenum becoming additional specialties. In 1917, wards were endowed for Dr. Berg's specialty. The first Mount Sinai physician to have an interest in gastroenterology was Morris Manges, but the first to limit his practice to gastroenterology was Dr. Edward Aronson, for whom a specialist outpatient division was formed in 1913. Aronson died in 1922 and was succeeded by Dr. Burrill Crohn, who was followed in 1934 by Dr. Asher Winkelstein; all three collaborated closely with the surgeons, physiologists and biochemists. In 1958, Dr. Henry Janowitz became chief of the Division of Gastroenterology; he was succeeded in 1983 by Dr. David Sachar, who was followed in 1999 by his associate Dr. Steven Itzkowitz. In 1958 Dr. Fenton Schaffner became chief of the Division of Hepatology (now headed by Dr. Paul Berk), and in 1979 Dr. LeLeiko became chief of Pediatric Gastroenterology.

In 1852, The Jews Hospital was founded for the increasing number of Jews in New York. It opened in 1855 with 45 beds on West 28th Street; 92% of the patients were indigent. In 1864, the hospital formally became nonsectarian and, in 1866, changed its name to The Mount Sinai Hospital. The medical staff was primarily Jewish, because until relatively recently, it was difficult for Jewish doctors to obtain postgraduate training or specialist posts at major New York hospitals. As the Jewish population moved uptown, so did The Mount Sinai Hospital: in 1870 to 66th Street, and in 1904 to 100th Street, with 456 beds, growing with new buildings and services to the current 1100 beds, 50,000 discharges, 400,000 inpatient days and 300,000 outpatient visits each year. Services increasingly became specialized, and then subspecialized. Key innovations included the choice of interns by competitive examination (1872), an advisory Medical Board (1872), the Nurse Training School (1881), the library (1883), the Alumni Association (1896), a professional medical hospital administrator (1903), research laboratories (1904), clinicopathological conferences (1905), the Social Services Department (1906), postgraduate teaching programs (1923), full-time chiefs of clinical services (1944), the dedication of the Mount Sinai School of Medicine (1968), and the merger in 1998 into the Mount Sinai-New York University Medical Center.

The Department of Pediatrics at The Mount Sinai Hospital was founded more than 120 years ago. During the ensuing years it had five outstanding leaders, Drs. Abraham Jacobi, Henry Koplik, Bela Schick, Horace Hodes, and Kurt Hirschhorn. The evolution of its beginning as a "small" clinic to its present position as one of the outstanding pediatric centers in this country reflects its interest in and devotion to the care of children.