I..Peptic Ulcer

A history of early and often punitive treatments.

An ulcer is a defect in an otherwise intact and usually smooth surface. There are gastric ulcers and duodenal ulcers and there are also ulcers on legs afflicted with circulatory disease.

Ulcers happen in mouths and in places unmentionable on a family oriented web site! Our subject in this column is peptic ulcers, which occur in the last part of the stomach and its neighbor, the first part of the duodenum.

The diagnosis and treatment of ulcer disease has evolved extensively in the last fifty years, and the course of this progression to current thinking is interesting enough to review. The cause of the condition was first thought to be something in the personality and / or life style of the victim. Typically, we expected an ulcer patient to be a hard-working, hard worrying person with a lot of responsibilities and not enough time to deal with them and no time for a "proper" diet.

Poor people weren't supposed to get ulcers in their stomachs because they didn't really experience the stresses of the successful. Smoking cigarettes and drinking alcohol were considered important causative factors (Smoking is still known to be an aggravator of peptic ulcers.)

Patients dying of very serious diseases, such as extensive burns, often had stomach ulcers demonstrated at autopsy, confirming theories that stress was an important factor in ulcer genesis. When it became fairly easy to look into peoples' stomachs (and other parts) with flexible "scopes", doctors discovered the important role played by aspirin and other anti-inflammatory drugs in causing multiple stomach ulcers. (Interestingly, complications from therapy for arthritis (and pain in general) are the only way to get into serious trouble from these maladies. Stomach ulcers, usually not symptomatic, may bleed or perforate with disastrous consequences.)

Back to peptic ulcers ca 1940, always thought to be associated with too much acid, too much stress, and a bad diet. Diagnosis relied on the "upper GI" fluoroscopy examination, a test of only modest accuracy. Treatments were first directed at neutralizing acid, and baking soda was the first thing available to lots of poor miserable souls. They, and their doctors, didn't realize that there was always a big rebound surge of acid in the stomach after a dose of Arm And Hammer. In the middle of the last century, better antacids began to show up, and they became the ulcer treatment of first choice, along with the "Sippy Diet."

Dr. Sippy (who we believe really existed somewhere!) invented a routine for the treatment of newly diagnosed peptic ulcer which became the mainstay of hospital based therapy. It consisted of almost constant ingestion of a liquid antacid alternating with half-and-half milk and cream. Nothing else. For days! If symptoms subsided, the patient was slowly re-introduced to real food, most of it white and soft. Mush and soft-boiled eggs come to mind. This treatment usually had to be repeated twice a year, in the Spring and the Fall, when ulcer symptoms worsened.

Then, along came surgical treatment, based on the concept that most acid was produced in the second part of the stomach. Get rid of that, and the ulcer might go away! Enter Dr. Bilroth, whose operations (appropriately enough, called Number I and II) became the benchmark of appropriate therapy for unresolved peptic disease. Surgery did "cure" some people, but there was a load of complications afterward.

Ever hear of "dumping syndrome?" That happens to anyone whose stomach is sort of bypassed and who then eats certain foods. (For some, almost any food will do the trick.) "Dumping" makes one shakey and sweaty and is generally unattractive. By the way, post-ulcer-surgery patients often got skinny beyond their wildest dreams, and could never regain any significant weight.

As if surgery weren't enough punishment for an ulcer patient, medicines were invented to decrease stomach acid and other (presumably) unwanted activity. The first of these were "natural" (hallelujah!) and came from plants like Jimson Weed. Given in a big enough dose, they could make one die, or wish he were dead. Smaller doses were calculated, and presented to patients for relief of their pain and other symptoms, and there was some success. A couple of newer relatives were developed, drugs with longer duration and possibly fewer side-effects, but all of them caused extra grief. Among these added "bonuses", dry mouth, blurred vision, and inability to urinate led the way.

The doctors' world chugged along for a few years using medicines which barely worked and surgery that was mutilative and not too helpful either. Something better was needed, and a candidate for this honor appeared in the laboratory of a famous surgeon from Minnesota (not a particular hotbed for ulcer disease, which isn't supposed to affect relaxed Norwegian farmers). This man, Dr. Owen Wangensteen, had already developed a lot of stuff for treating GI patients, some of it really more appropriate for a torture chamber. He came up with the idea of freezing part of the stomach to reduce acid production! (There was a lot of, "What will they think of next??")

Freezing didn't exactly take the medical / ulcer world by storm, but it did get everyone's attention, and a lot of otherwise normally behaved doctors used it or recommended it for their patients. When you aren't having a lot of success with what's on hand, you look for alternatives, right? Fortunately for everyone except Dr. Wangensteen, the procedure never gained a lot of acceptance. After a few people either died or got very seriously worse post-freeze-therapy, the method was abandoned. You see, good things do happen from time to time.

Next time, we'll continue the saga of the peptic ulcer, with the story of revolutions in both diagnosis and therapy, in Peptic Ulcer II.