YOUR Chairman requested me to present a paper on ulcer and asked that I bring the subject up-to-date.
I feel that no approach to the ulcer problem at the present time would be appropriate without a consideration of the economic phase. Alvarez recites the story of his first ulcer patient, a tailor in San Francisco, whom be sent to the hospital and gave him the routine four weeks ulcer treatment and discharged him relieved of all symptoms. On arriving home the patient found that the man he had left in charge of his business had stolen all his bolts of cloth, appropriated all the cash proceeds and run away with his wife.
The patient immediately, reported to the Doctors office and said, “Doctor, after four weeks in the hospital I have all my pain back and I am as bad as I was before and worse because I have spent all my money.” This take has a distinct bearing on the subject because it emphasizes two important points-First, that the treatment of ulcer must be adjusted to the economic status of the patient, and, second, that psychic factors, anxiety neurosis, are probably not only important etiologic factors, but the greatest of factors which bring about a relapse of the condition.
The present views on etiology will be discussed briefly, but before doing so, I fee that certain phases relative to the disease itself should be touched upon.
I feel certain that many of you who have handled a fair number of cases of ulcer cannot help but realize, on reviewing your results, that there have been a considerable number of recurrences, relapses of yours cures. Crohn of Mount Sinai Hospital, was the first to point out that at that institution relapses in increasing numbers have been taking place with the passage of years, and we have arrived at the present time at the stage where, with this knowledge and the experience we have had with these cases, we believe that peptic ulcer is a constitutional disease,e that recurrences take place not only after medical treatment, but also after surgery, and when they follow surgery they are even more terrifying distressing.
Peptic ulcer is, we believe, a constitutional disease which tends to recur and it is our duty as physicians to recognize this fact, and the patient should be given to understand that in no small measure his ulcer will be with him throughout the period of his life and that it is the obligation of the physician to enable him to live with this constitutional tendency and avoid recurrences as far as possible, or to extend the intervals between the periods of relapse.
There is a definite familial tendency towards ulcer, and there also is a large group of ulcers which are devoid of symptoms. It has been conservatively estimated that 5 per cent of those in adult life have ulceration, which means that there is that percentage of people in this room with ulcer, and if we include those who are suffering evident symptoms, the number is probably double that cited.
If we believe that it is a fact that ulcer is a constitutional disease, we of the profession must assume a more charitable attitude towards one another. The consulting room of the chiropractor, the voodoo healer and charlatans of all descriptions is filled with these people because we have not given the individual the proper conception of the battle he must wage against his disease.
The attitude of the profession towards each other in the matter of their cures must merge upon a broader plane. Patients with recurrences, on entering the consulting room, must be informed that their previous advisers have with skillful means and all the knowledge available to the profession done the best possible to promote a cure, and that relapses are in a great measure due to the carelessness of the patients themselves in the care of their digestive tracts and their healed ulcers.
From the distinct surgical wing of the profession I hear a word of protest that surgery will cure peptic ulcer. It has been my privilege to work with and observe practically all the distinguished surgeons who are doing resections, which, by the way, probably is the ideal operation because it removes the acid-bearing area of the stomach, and their mortality rate is not as low as they honestly believe it to be. Furthermore, if the cases were followed, as they should be, over a five-year period, their percentage of failures would be found to be inordinately high.
Ah! But I hear that gastro- enterostomy carries no such mortality, but here again it is upon dishonest figures that the premise has been founded. Therefore, I believer that the figure quoted by Lewisohn of 40 per cent of recurrences of ulcer following gastro-enterostomy is conservative, and if the cases which have been subjected to gastro-enterostomy were followed as they should be and the recurrent ulcers followed over a ten-year, period, the mortality rate in gastro-enterostomy would be found to be as high as that of partial resection.
We must admit, much as it is distressing to the most careful student working on this subject, that at the present time our results are not as creditable as those in many other lines of treatment.
I have nothing but praise for a contribution such as that of Bloomfield, which appeared in the Journal of the American Medical Association in the April, 1935 issue.
After reviewing our present methods of diagnosis of gastric malignancy, Bloomfield came to the following conclusions:.
“First, it is impossible by clinical observation to determine early cancerous changes in an apparently benign peptic ulcer. The various criteria, while statistically followed, are subject to so much variation that they cannot be depended on in the individual case even though great size of the lesion points strongly to cancer. Hence, if prophylactic surgery is to be used, one should consider every gastric ulcer as malignant in posse if not in ease and one should excise them all. But the surgical risks of such wholesale gastric resection are distinctly greater than the hazard of ulcer being or becoming malignant.
“The only practical attitude to adopt, therefore, is to regard small apparently innocent gastric ulcers as in fact benign until evidence to the contrary is weighty enough to arouse serious suspicions, and to accept the fact that a certain number of inevitable tragedies will occur. They will occur in the future as they have in the past, not necessarily because physicians are careless, but because they are helpless in the face of an insoluble problem of diagnosis”.
This is parallel and daring position concerning cancer of the stomach similar to that which we have taken in the introduction of this paper covering ulcer of the stomach.
I do not believe that there has been a better description of etiology of gastric ulcer than that of Eusterman-First, the factor to tissue; second, the factor of aggression and defense; third, the systemic factors.
Quotation from an article by the author:.
The factor of trauma has been very recently brought out by the report of a number of acute ulcers resulting from injury. Chronic trauma is exemplified by a disturbance of circulation. The factor of aggression and defense is indicated by tissues which normally could resist gastric chyme being overcome by hyperacidity and, on the contrary, normal acidities, producing damaging effects by diminished resistance of the gastric or duodenal tissues.
The systemic favor is evidenced by the constitutional diathesis and also by the fact that ulcer in more prevalent in individuals who are under a constant nervous and mental strain which produces abnormal systemic reaction in their gastric mucous membrane from vagus irritation. The ambitious, intensive, driving, high-strung individual is far more prone to ulcer than the phlegmatic.
A review of the gastric history of 200 negroes who lived under unhygienic conditions, whose mouths were filled with focal infection and whose food was improperly chosen and improperly prepared, showed but one case of ulcer in the group. The explanation of this can only lie in the worry and anxiety which is an inherent trait of the American negro.
Focal infection is, of course, one of the factors of tissue injury by direct contact or thrombosis, and it is the interrelation of these various factors which produces the results which we have come to recognize as peptic ulcer. In some cases one factor which is very much in the predominance is focal infection; in others it is the nervous strain with the coincident vagotonia and spasm; and in still others, it is the inherent systemic factors which are exemplified by arteriosclerosis and other blood vessel changes.
From a study of the etiology it will be found that the dominant factors very in different locations. The flexible gastroscope has demonstrated the presence of gastric catarrh as an antedating element in many of the cases in Europe, and could one expect otherwise with the heavy foods and the free use of malt beverages so characteristic of the inhabitants of Central Europe?.
The factor of cerebral irritation has been emphasized through the work of Cushing and is exemplified by the large number of cases that arise from the haste, hurry and pressure of American life and the attendant anxiety, financial pressure, loss of income, marital infelicity and domestic disturbances. When a woman who has married a man for his money has a gastric ulcer and the man, because of the crash of 1929 or some other catastrophe, has lost all his financial resources the mental trauma of eating three meals a day across the table from the new unsuccessful provider will prevent the most effective cure from being successful.
The treatment of ulcer divides itself into the selection of surgical and medical cases.
Cases recommended for surgery are of five varieties:.
First perforating ulcer.
Second, cases in which there is repeated haemorrhage.
Third, cases of organic obstruction at the pylorus.
Fourth, carcinomatous degenerations of ulcer.
Fifth, intractable or recurrent ulcer.
It will consume all the time that has been allotted to me to discuss each of these types individually.
For diagnosis you are referred to other discussions.
In a general way, ulcer itself can be divided into the superficial type, the penetrating type, and the perforating type. The first is medical absolutely, the second is usually medical, and the third is surgical absolutely.
In so far as symptomatology is concerned, little that is new has appeared in the past year. At the office we are placing more and more dependence upon area and of tenderness just beneath the palpating finger during the time of fluoroscopy.
I am more and more convinced from the work that I saw in Egypt last year and the work that has been done during the past year, that through the medium of the flexible gastroscope small ulcers can be demonstrated in the stomach which are incapable of diagnosis by any clinical methods or any x-ray means that we have at our disposal at the present time.
These distinctly show tenderness upon pressure and this finding, in association with a hyperacid gastric juice and an increased amount of contents of high acidity in the fasting stomach, make positive the diagnosis, and this can be readily substantiated by the flexible gastroscope.
Quoting again the title of this paper, “The Human Side of the Ulcer Problem,” we approach the selection of the medical type of cure, and I am unalterably opposed to home treatment if it is any way possible to arrange the family budget so that the patient can be cared for in a hospital. In my own cases I am still an advocate-and in this I am supported by Smithies-of complete rest of the stomach over a period of a week by means of rectal alimentation. With properly selected nutrient enemas, given by the drip method, the patient is not a subject of scientific starvation, but through absorption from his colon his water base and metabolism can be kept at a fair state of balance.
The continued application of heat to the abdomen by means of poultices, electric pads, thermal lights and cold compresses at night is substantiated by some of the newer views which will be considered later, covering the use of nonspecific protein therapy. Following a week of rectal treatment, we are ready to add to the stomach food that neutralizes and passes readily-frequent feedings of skimmed milk, Cream of Wheat, farina, malted milk, given at intervals of two hours, interrupted as in the Sippey habit by medicines in the interval hours.
Medications divides itself into groups, of which the first is to neutralize acidities, namely, sodium bicarbonate, calcium carbonate, and magnesium oxide. These head the list, but in our hands balanced does of tribasic calcium phosphate and tribasic magnesium phosphate have proved equally satisfactory. To coat the surface of the ulcer bismuth subcarbonate, bismuth subnitrate bismuth subgallate, and aluminum hydroxide are of value. To promote healing of the ulcer dilute solutions of silver nitrate, sixteen grains to two ounces of water, of which fifteen drops are given three times a day a half-hour before meals, for three days, then twenty drops the second three days a half-four before meals, and then twenty-five drops a half- hour before meals, and then twenty-five drops a half-hour before meals. The silver nitrate is then discontinued for fear of producing argyria.
The fats of olive oil are, of course, the greatest reduces of gastric secretion and are also soothing-a wineglassful before meals is the old Cohnheim treatment and is still of value, particularly efficacious in the postoperative recurrences in marginal ulcers after gastrojejunostomy, and at times tincture of iodine, five drops to a half-glass of water on an empty stomach, aids in the cure of ulcer. Needless to say, the greatest inhibitor of gastric secretion is belladonna, which is given in increasing doses of from five to fifteen drops three times a day; it reduces spasm and diminishes the amount of hyperacidity.
About two years ago we took up the use of atropine methyl bromide in one milligram doses. This drug reduces secretion without producing the effects that follow the use of belladonna. This was imported drug and we are still using it. In this country the drug is known as novatropine. The bromide element probably also serves as a sedative. During the last year we have been using syntrope, made by Roche, for similar purposes.
This tablet at present is not on the market, but we have found it to be very effective. We doubt, however, if the dose has been so far definitely determined. We have been using larger doses than those that are recommended by the manufactures, but they claim that the drug produces no toxic effect and this had has been borne out by our experience with it.
The factor which is, of course, stressed on all sides and in all the articles on ulcer is that of high hyperacid contents of the stomach. For this reason we have reduced the salt content as low as possible. The questions of hyperacidity, as you are aware, presents two important phases, namely, the useful practice kin some cases of passing a tube at night to rid the stomach of all gastric contents before the patient retires. This was a definite element in the old Sippey treatment, and if the patient is tube-trained, it is very effective.
Winkelstein of Mount Sinai Hospital, has endeavored to combat the same procedure by placing a tube in the stomach during the night and allowing milk to percolate in all night in order to neutralize acidity. This can be accomplished in the hospital in some cases, but, as a rule, it is an annoying procedure to the patient and we have attempted to accomplish the same thing by waking the patient at night and giving him a small amount of milk with alkali.
In the use of alkalies care must be observed, when they are given over a prolonged period, to see that the condition of alkalosis does not develop. If the acid base balance is studied by means of laboratory tests, this can be accurately guarded against, but where this is not possible there are six symptoms which indicate the onset of alkalosis:.
First, distaste for milk, and this many precede the other symptoms by several days; second, headache; third, nausea; fourth, vomiting; fifth, dizziness; sixth, aching pains in the muscles and joints.
The development of the above-mentioned symptoms calls for the immediate discontinuance of alkalies and the institution of suitable measures to combat the acidosis.
Mucin flashed across the horizon two years ago and the funds to carry on experiments with this preparation were provided by the Carnegie Foundation, and it was an interesting coincidence that when it was placed on the market one of the first patients I used it on was intimately associated with the Carnegie family. The difficulty of handling mucin is its extreme distaste, and this is best overcome by mixing it thoroughly with an electric. beater in milk.
The early preparations were contaminated with histamine which defeated the very purpose for which mucin was designed. More recently, tablets of vegetables mucin-in reality, preparations of ocher-have come into popularity, but neither of these substances has in any way replaced the alkali protective substances enumerated.
Whether you are proponents of the theory that vaccines produce their effect by the formation of definite immune bodies, or whether you class them as examples of a nonspecific protein therapy have flashed across the horizon and have attained great popularity in the treatment of ulcer. Most of the reports, however, are poorly substantiated as this is part of a general treatment. Probably the most satisfactory study has been carried out by Levine of New Orleans. His contribution on the use of hemoprotein (Brooks) has seemed to indicate that it has a certain definite value.
The milk fat proteins, such as aloan and omidan, undoubtedly establish a leukocytosis if they are given in sufficient doses. Recently, working along entirely different line,s a preparation called lariostidin, has been produced by Roche. The principles of the treatment were the fact that when, through experiments, the duodenal contents were shunted into the ileum and there was no enterokinase to stimulate the protein action of tripsinagen, there was a deficiency of histadin, and in the absence of histadin gastric ulcer developed. It is on this theory that lariostidin, which is a histadin preparation, is given. In a air group of cases we have been unable to determine any specific effects from the employment of this remedy.
Synodal, another intravenous drug containing emetin, is mentioned only to condemn it.
We feel that hypodermic procedures should perhaps be limited to the first-named preparation, that of hemoprotein, and if a hypodermic is to be used, it is quite advantageously used by employing the old standby, cacodylate of soda in large doses, or suitable doses of iron, arsenic and strychnine.
The homoeopathic remedy has not been dwelt upon because of the request of your Chairman that this subject be brought up-to-date. During the last year, to my knowledge, there have been no contributions which are outstanding relative to the use of the homoeopathic remedy. Nothing new has been offered, and while on the subject I might quote from a previous article by the author in which the following occurs:.
“I do not believe that it is proper homoeopathic medicine to prescribe a remedy and allow such a factor as apical abscesses about teeth to remain unattended to, expecting reaction to the medicine. It is but a step from etiology to treatment and I believe it behooves the homoeopath to consider all the adjuvant treatments as part of his obligation to the patient. Appropriate methods of diagnosis, painstaking, and scientific, must be carried out for the benefit of the individual, and when the scientific methods through etiologic and diagnostic means have been thoroughly applied, it is then and only that the homoeopathic remedy should be applied.
As has been stated in other places, it is my conception that some of the beneficial effects which are obtained by remedies applied by the dominant school are due to homoeopathic action, and this has been demonstrated by the superior effects obtained from the use of large doses of a 30th x potency subcarbonate”.
In conclusion, I desire to remark that it is my belief that it would be inappropriate at this time to present symptoms and indications for a long group of homoeopathic remedies concerning which many of my hearers are far better prepared to discuss than I.
However, I feel that in the limited time that was allotted to me for the presentation of this subject, the purpose of this paper will have been achieved if I have made evident the constitutional recurrent nature of ulcer, the fact that the much- lauded surgery carries with it a mortality rate and complications far exceeding that of medicine, and that the patient, aware of the fact that he has an inherent tendency towards recurrence his ulcer, will consider the period of treatment to include his span of life and will from time to time-at least at six- month periods-return and carry on treatment by means such as we have indicated.
If this can be done, we will have fulfiled our obligations to our patients, and with the knowledge thus acquired they will have increased confidence on their medical advisers. If we succeed in this it will be distinct step in the direction of turning back into scientific medical hands that large group of patients who through ignorance seek questionable assistance in places that are devoid of confidence.
CHAIRMAN WELLS: We certainly appreciate Dr. Uphams very authoritative and comprehensive review of the treatment of this very important disease. He has covered, I think, and given us his opinion on almost all of the recognized methods of treatment, and certainly it ought to be very valuable to us.