The Human Side of Gastric Ulcer

The Human Side of Gastric Ulcer. 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?.

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.

Roy upham