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The illogic of peptic ulcer ML Kothari, Jyoti M KothariDepartment of Anatomy, Seth G.S.Medical College, Parel, Bombay 400012, India
Correspondence Address: Source of Support: None, Conflict of Interest: None PMID: 615252
The unmitigated failure of peptic ulcer therapy has prompted this overview of the epistemologic and logical fallacies of the principles and practice of ulcerology. The illogic, rooted in the very term peptic ulcer, assumes a crescendo momentum, to the detriment of the patient. Like many other fields, ulcerology is causalistically oriented, culminating in cure-all drives against the assumed cause-the acid-pepsin complex. A plea is made, on grounds scientific, to view the situation from a different angle, holding the ulcer as dyspeptic, and as such irrelevant to the pathology, clinical features and treatment.
"Reason guides medical practice," said an enthusiast. "No," declared a wag, "It's fashion that governs it." The truth of the latter is seen in its most devastating form in the treatment of what has been conveniently called peptic ulcer. Asher, [4] in Talking Sense, describes the "Seven Sins of Medicine." Ulcerologists perpetrate similar sins which may be listed, at the outset, as 1. The exercise of NEDLOG rule 2. Etiologism 3. Dysteleology 4. Technocracy of straight-line-solutions 5. latrogeny 6. Calling one's geese swans 7. Experimentalism. The need to appreciate the illogic of peptic ulcer has been well-stated by Palmer. [28] "Obviously the path we have been following for many years has led to no final answers on the ulcer matter, nor does it offer any hope that it ever will. Progress can be initiated only by challenging current concepts, of course. My plea is simply that physicians dare to do some original thinking about ulcer." A subsequent publication "The Logic of Dyspeptic Ulcer" [23] provides a reasoned, documented apposite to the present article.
Erik Erikson, the psychiatrist-philosopher, lays down, in Hippocrates Revisited [15] "the Golden Rule which advocates that one should do (or not do) to another what one wishes to be (or not to be) done by." In the management of peptic ulcer, physicians have practised the reverse of the Golden Rule-the Nedlog Rule. "One highly significant fact that showed how the Physicians and Surgeons it Rochester really felt about the operations for duodenal ulcer was that in all my 25 years at the Mayo Clinic I can re member only one of the many member; of the staff with an ulcer who was operated on, and he was driven to it late in life by a complication." This is a damaging judgment against ulcerologists by none else than Walter Alvarez. [2] The scanning of the hospital records, in Born bay or Barcelona, is unlikely to reveal anything otherwise. Curative surgery for peptic ulcer was invented by the physician but for the patient. Let us listen to a doctor-patient: [19] "Two colleague; who were surgeons, called in one day to pay a social visit. They told me that sooner or later I'd have to have my stomach removed and the sooner the better The thought of a partial gastrectomy was anathema to me. I didn't see the sense sacrificing a perfectly good stomach because of a little ulcer that could hardly be seen . . . and when I read about the postgastrectomy syndrome in the BMJ my mind was made up." Doctors have the advantage they read BMJ; their patients don't. The Nedlog Rule may be defined as the therapeutic authoritarianism that enables a clinician to readily do something on a patient that he would rarely, if no never, get done on himself. The reason for this, vis-a-vis ulcerologists, are not hard to seek. A leading text Clinical Gastroenterology [22] remarks that operations for peptic ulcer entail considerable interference with the anatomy and the physiology of the upper alimentary tract and it is not surprising that a proportion of subjects suffer from minor or major complications following surgery. "An unexpectedly high proportion of patients," Jones et al [22] added, "treated for alcoholism have previously had a partial gastrectomy; the same is probably true for patients with drug addiction." Which gastroenterologist or physician, knowing of the dumping syndrome, diarrhea, pernicious anemia, alcoholism, and drug addiction, would rush into where angels may fear to tread!
Modern medicine thrive [36] on causalism, an endless exercise in weird etiologism that hunts for the cause of cancer, coronary heart disease, diabetes, senescence and what the human body may have, with the evergreen hope of either nipping the cause in the bud (prevention) or of providing an appropriate anticause, (cure). "All philosophers, of every school, imagine that causation is one of the fundamental axioms of science, yet, oddly enough, in advanced science, such as gravitational astronomy, the word `cause' never occurs. . . . The Law of Causality, I believe, like much that passes among philosophers, is a relic of a bygone age, surviving like the monarchy, only because it is erroneously supposed to do no harm." (Russell [33] ) The robust survival of causalism in medicine is, a la Bertrand Russell, [33] an evidence of medicine not being an advanced science. Anyone doubting the foregoing could read Burnet's Genes, Dreams and Reality, [6] and Malleson's Need Your Doctor Be So Useless? [26] Modern medicine is not a science, but a vast empiricistic enterprise. Factors floated as causing peptic ulcer are many, but we could mention seemingly the most likely one-STRESS. The facile assumption that peptic ulcer is a stress-disease is probably as remote from the truth as the view that malaria is caused by vapours arising from the swamps. [12] Yet another favourite etiology is the uxorial one: "The view that a peptic ulcer may be the hole in a man's stomach through which he crawls to escape from his wife has fairly wide acceptance." (Anderson). [3] Therefore, declared another physician, a patient treated for peptic ulcer must change his life as well as his wife. [30] Life, wife, stress, acid, pepsin-not one of these can satisfy the fundamental tenet of causalism [16] that necessitates an invariant relation of events in which the effect must follow the cause, every time. The italicized tenet is betrayed by the ulcer, which, by its very nature, is waiting, wanting and willing to heal and often does so in the teeth of the very cause that caused the ulcer. It is like in cancer: Whatever that is claimed as causative, can be claimed with undiminished vehemence as curative.
Dysteleology is the assumed absence of purpose in Nature. [35] It allows hubristic medicine to put Nature in the dock, to assume her guilt, and to declare HCI, breast or prostate as "A design nightmare for which Nature should hang her head." [31] Were it given to scientists, they would have long ago chopped off the hanging head of mother Nature! Vis-a-vis peptic ulcer, dysteleology is the prevalent gastroenterologic doctrine, that medicine's failure to understand the raison d'etre of stomach, pylorus, vagi, and hydrochloric acid secretion is sufficient license to forever destroy one or all of these, in a given patient. Such an approach can be effectively cloaked by euphemisms like "curative surgery" or as "pyloroplasty." The very term pyloroplasty presupposes pyloric error; the procedure achieves no plasty but pylorolysis; the net gain to the patient is the loss of a physiologic marvel called the pylorus. "Although there is a temptation to regard pyloroplasty as a non-destructive operation there is accumulating evidence to the contrary." [11] The same authors [11] describe pyloroplasty as ulcerogenic, by its giving rise to an "incontinent stomach." The authors [11] added that these effects were to "virtually the same extent after both pyloroplasty alone and complete vagotomy and pyloroplasty."
Modern ulcerology is a highly advanced diagnostic and therapeutic technocracy evolved out of what Gene Marine calls The Engineering Mentality: [27] "It comes about because, somehow, (we) have become fascinated with technique as the answer to everything. Our dawn and twilight devotions are in homage to `know-how', and the straight-line-solution is our way of dealing with the questions of life, from seduction to South Vietnam." The SLS-oriented technocrat spots a "problem" and sets about remedying it, come what may. If the blood pressure is up, keep it down; if it is down, push it up. Until recently, for example, patients of hypovolemic shock were given vasopressors, and their blood pressure readings rose strikingly, to the satisfaction of all concerned, "except of the patients, who died." [38] If the portal venous pressure is up, go down and create an Eck fistula. What about the severe liver anoxia and the ammoniacal intoxication of the brain? Let the liver and the liver manage. In ulcerology, the villain-of-the-piece is gastric HCI and no technocratic SLS has been spared-from the relatively benign antacids to the drastic measures of charring the stomach by irradiation, freezing it by supercooled alcohol, chopping it, a la Visick, to the point of leaving just a little fundic cuff hanging from the esophagus, and sacrificing the vagi. It was found that when vagi go, the pylorus ought to, hence pylorolysis called pyloroplasty. And to imagine that all the foregoing has been actively practised despite a "not-guilty" judgment in favour of HCl, announced way back in 1959: "Anyone seeking in a court of law to prove `acid aggression' responsible for peptic ulceration would be dismissed after two-minutes' cross-examination with a stern admonition not to waste the court's time." [31] The story goes a little further. The alleged culprit has been discharged with honour. [28] HC1 has been shown to help ulcer patients. Newly-hospitalized patients with active duodenal ulcer were given 2 bedside bottles-one of Al (OH) 3 gel and the other of dilute HC1. The two `drugs' were presented to each patient, as alternative products for treating ulcer. The patient was asked to try one, and then the other in two ounces doses from time to time, and then to use whichever for him worked better. No other drug nor any special diet was given. All patients made fine progress, but their preferences differed. Of 230 patients so doubly-treated, 31 could see neither as useful, 106 felt better with Al (OH) 3 and as many as 93 preferred HCI. Palmer [28] remarked that both the antacid and the acid were little more than placebos-2 ounces of dilute HCl is not much acid, nor 2 ounces of medicinal Al(OH) 3 is much of an antacid. The whole trial drove home the point that ulcer patients can be treated "successfully" either with acid or antacid, neither having anything to do with the efficacy of treatment.
Allopathy, etymologically, is the art of curing one disease, by causing another. [35] Ulcer therapy represents an acme of scientific allopathy, having in its repertoire measures ranging from dietary invalidism or diarrhea to the dumping syndrome, and anemia to alcoholism. Palmer [28] observes that "classical therapy creates dietary invalidism, an illness that may be worse than ulcer disease." The insipidity of antacids, the gastric revulsion of forced milk feeding, the visceral atonia of vagolytics, the distension and diarrhea of vagotomy, and so on, are things that can be best described only by doctors who had had the privilege of being so treated, a privilege, alas, granted only to a few who seemingly haven't lifted their pen in protest. The therapeutic efficacy of iatrogeny, much like the counterirritant effect of a pain balm that works by shifting the attention of a patient from one disease to another, when well worked-out may provide iatrogeny a respectable place in the therapeutic armamentarium of a physician treating, say, ulcer, cancer, or schizophrenia. A patient thrown from the fire into the frying pan is most likely to forget the fire because of the overwhelming presence and effect of the frying pan. The foregoing principle of iatrogeny-astherapy can be ably assisted by the placebo effect not just of the drugs, but of surgery as well. "Surgery as Placebo," a 1961 article by Beecher [5] cites considerable evidence to drive home the point, the placebo effect being the greater the more dramatic the surgery. The supreme indication of ulcer surgery is the failure of medical therapy, a conceptual sequence that foresuggests the patient that when drugs fail, surgery steps in to succeed. Since placebo [10],[35] (L. "I will please") has a strong pharmacologic ring about it, surgeons as a class find it extremely difficult to realise the placebo effect of surgery, unless they listen to Day [9] : "Apart from poisoning by stealth, there is no form of therapy from which the effects of suggestion can be entirely eliminated." As a pertinent example, Beecher 5 cites ligation of internal mammary artery to improve coronary flowan operation that worked only through its placebo effect.
Asher [4] alludes to Crawshay-William's The Comforts of Unreason-unreason breeding "comfortable concepts." An important comfortable concept, Asher points out, is the therapeutic assumption that since what is given is treatment, it must be effective. The next step, a la Lewison [25] is to assume that one's therapeutic geese are truly swans, smarter than the geese in any other farm. Hence the innumerable drug regimens and curative operations, all being equal, but some being, depending on the therapist, more equal. A properly controlled prospective therapeutic trial on the leading elective surgical procedures for duodenal ulcer exposed the myth of any goose being more swanish than another. [14],[18] An editorial annotations [14] declared that the findings "cast doubt on sweeping statements made by advocates of their own particular favourite procedure in the surgery of duodenal ulceration." Whatever the marginal advantages, they were more than offset by the fact that "the results of all operations tended to deteriorate gradually with the passage of time." [18] A word about the "bewildering plethora of antacids available," which relieve ulcer pain but which affect neither the healing of an ulcer nor its recurrence. [28],[37] To be effective, any popular antacid must be given in a very large quantity, and at hourly, if not shorter intervals. [21],[28],[37] Thompson [37] makes 2 important observations: (a) "The ideal antacid is still not available," and (b) "no antacid is completely without side effects." Palmer [28] may sound harsh when he concludes that giving a patient "diet and antacids" is just a gesture-spurious and dishonest, working, when it does, only by its placebo effects. Yet antacids alone cost the USA over 100 million dollars a year. [37] What held true in Alvarez's time at Mayo Clinic, [2] holds true today. Day in and day out, stomachs are chopped and vagi are cut -of the patient. Why this must-treatism? Asher [4] gives the answer. "It is better to believe in therapeutic nonsense, than openly to admit therapeutic bankruptcy." So the wheels of medicine keep on moving, be it cardiology or cancerology. [24]
In a reputedly scientific book Search for New Drugs, [32] wherein the quest is for agents effective against all leading problems faced by modern medicine, a recurring refrain is the absence of ideal animal experimental model. Ulcerology is no exception. Yet, the book is at pains to describe the available major and practical techniques for "the rapid and effective screening of potential therapeutic agents." [37] In the laboratory too, it is much better to believe in experimental nonsense, than to admit experimental bankruptcy. It is little wonder, then, that anticancer drugs are 100 per cent effective in the laboratory and are 100 per cent ineffective by the bedside. [17] Peptic ulcer, as medicine has under stood it, is strictly a human privilege; what experimental models oblige with are simple gastric erosions that have not an iota of similarity with the human condition in terms of number, location, pathologic features, and natural history. Yet since the experimental ulcers serve research labs, drug industry and the FDA they must be created by ingenious techniques that reek with intellectual compromise. The means employed, "to name a few"' are ligation of pylorus (Shay ulcer), stress, ulcerogenic (erosion genic!) drugs, Mann-Williamson procedure, induction of chronic ribloflavin deficiency, stimulation or destruction of localized areas in the brain, and portacaval shunting.
The dictionaries [10],[35] are against the semantic misappropriation peptic ulcer; Peptic (Gr. Peptikos) means digestive or related to digestion. Peptic ulcer becomes digestive ulcer, a connotation that car make no sense. Even the clinical clinging to the word ulcer is wrong. [28],[34] The cardinal clinical reality and presentation is not ulcer, but dyspepsia, a term that encompasses the absence of commonly-experienced-but-yet-to-be-described epigastric bliss/euphoria on one side, and the presence of epigastric discomfort fullness, pain, burning on the other Dyspepsia is symptomatic dysgastria-dyspylorosia-dysduodenia. Ulcer is a dispensable symbol for this larger dyspeptic reality. It need not be there. If present, it; right appellation is dyspeptic-dyspeptic ulcer. "Essential for understanding gastroduodenal ulcer as a clinical disease is the concept that the crater is simply a manifestation and is rather unimportant to the whole illness. Unfortunately the crater is the only manifestation that can be detected and measured by a laboratory test, and so the disease was named for it. One may reasonably insist that the presence of a crater is not necessary for the diagnosis of ulcer disease. If the underlying whole-body disease is present, it makes little difference to the diagnosis whether or not the manifestation is also present. It is not the ulcer that is causing the illness but the illness that is causing the ulcer." (Palmer [28] ). Spiro [34] views it a little differently, preferring to call the syndrome eponymously as Moynihan's disease. Dyspepsia, duodenitis, and duodenal ulcer, he points out, are parts of the same spectrum. Over 80 per cent of dyseptic patients having no X-ray findings, eventually develop radiologically demonstrable crater within 6 to 27 years. Isn't it in fitness of things that peptic ulcer be called dyspeptic ulcer? The very etiologic word peptic misleads the therapist into wrecking the peptic mechanism comprising acid and pepsin. The appellation dyspeptic would surely serve as a deterrent against a surgical blade ready to chop the stomach or cut the vagi.
Albutt [1] lamented that "Our path is cumbered with guesses, presumptions and conjectures." He wrote these words about hypertension, but which are equally applicable to gastric hypersecretion and hyperacidity. In the very first page of his masterly monograph High Blood Pressure, [29] Pickering makes it clear that the term hypertension is wrong because no one knows the dividing line between eu and hypertension. Nosophilic medicine has bred much of the hypo-this and hyper-that by disregarding the Ardreyan advice that the range, and not the average, is the reality. Barring such timorous situations as Zollinger-Ellison syndrome, HCl output exhibits a range, each point on the graph being normal for the owner. Cleave [8] rightly points out that "the law of adaptation indicates that the production of hydrochloric acid must be just as perfectly attuned to the requirements of the individual as is, for example, the power in his arms or his legs or any other part of his anatomy. Far from constituting a liability, the production of large amounts of acid in the stomach, passing under the term `hyperchlorhydria', should be regarded as a most necessary asset." Pylorus, normally patent, allows the acid secreted to be passed on into the duodenum where it is immediately neutralised. Any situation-and these are many for the sensitive mechanism that is pylorus-that prompts the pylorus to close down creates automatically a dammingup of acid with resultant feeling of "hyperacidity." What really, then, gives rise to hyperacidity is not hypersecretion but, if you insist on the prefix hyper-, hypercollection. The same can set up a vicious cycle, for acid accumulation forces pylorus to close tighter, designed as it is to protect the duodenum and small intestine from being damaged by too strong an acid input. [20] The pyloric wisdom of shutting down ought to be respected, and no further food load be added, lest its task becomes more complicated. It is little taught physiologic truism that the pylorus is a reliable and sufficiently vociferous spokesman of the state of the gut beyond: "In general, it probably can be stated that most of the control of the pylorus is exercised by the small intestine. As long as the duodenum and remainder of the small intestine are empty and are in a receptive state for chyme, apparently the pylorus relaxes, and the stomach contents empty easily, but irritation, excess fats, overloading, etc., can all make the small intestine less receptive for chyme and cause increased contraction of the pylorus. Therefore, even though the discrete details of the control of the pyloric sphincter are not known, the philosophy of this control appears quite evident ." [20] Fasting as a satisfactory and successful treatment of peptic ulcer and hyperacidity was extensively practised for 50 years after its introduction in 1875. [8] The clinical experience of a husband reporting his revulsion a t "regular milk therapy" forced upon him by his wife at the instance of the clinician is not uncommon. The doctor-patient referred to earlier [19] put it well: "With this careful and faultless treatment I became progressively worse. . . . I got worse and worse and fatter and fatter." Ultimately the cure for him came with the decision to "break another rule of orthodox medicine that the stomach of an ulcer patient should never be empty."
Finally, a word about vagotomy, which is but a glorified form of sensory neurectomy. The vagus is 90 per cent afferent, just 10 per cent efferent. This makes the gastroduodenal projection on the CNS at least 9 times greater than the other way round, making peptic ulcer/hyperacidity symptomatology a manifestation of visceropsychic disease rather than otherwise. It accounts for the overpowering mental symptoms accompanying dyspepsia-irritability, depression, headache, lack of concentration and confidence, and what not. The enormous gastroduodenal projection on the CNS works two ways-on one hand it produces dyspepsia, but equally on the other hand, it mediates eupepsia- peptic bliss which ulcerologists have not described, violating thus the Asherian [4] advice that one can't describe the abnormal without first describing the normal. Dictionaries [10],[35] , go at length in describing dyspepsia; eupepsia is not given a place, [35] or is described as "the presence of normal amount of pepsin in the gastric juice." [10] Eating food illustrates the biologic principle of life assimilating life. Eupepsia is the visceropsychic readines to welcome the guest-life, and having ingested the guest-life, to feel really nice till the guest turns host through digestion and absorption. Should it be any more surprising that individuals surgically deprived of this ability to enjoy eupepsia turn to alcohol and drugs [22] to find some raison d'etre of their existence?
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