Pollock, Alexander Chapman (2014) From dyspepsia to Helicobacter: a history of peptic ulcer disease. MD thesis. http://theses.gla.ac.uk/5114/ Copyright and moral rights for this thesis are retained by the author A copy can be downloaded for personal non-commercial research or study, without prior permission or charge This thesis cannot be reproduced or quoted extensively from without first obtaining permission in writing from the Author The content must not be changed in any way or sold commercially in any format or medium without the formal permission of the Author When referring to this work, full bibliographic details including the author, title, awarding institution and date of the thesis must be given Glasgow Theses Service http://theses.gla.ac.uk/ [email protected] From Dyspepsia to Helicobacter: A History of Peptic Ulcer Disease Alexander Chapman Pollock MB ChB, MPhil, MRCGP A thesis submitted in fulfilment of the requirements for the degree of MD to the University of Glasgow. School of Medicine Centre for the History of Medicine November 2013 © Alexander Chapman Pollock 2013 2 Abstract This thesis is a historical study of peptic ulcer disease from the sixth decade of the eighteenth century until the end of the twentieth. Symptoms of dyspepsia or indigestion have affected more than twenty percent of the British population for most of that period and attracted the involvement of many medical practitioners and others with the provision of health care. Within this group of symptomatic dyspeptic patients were to be found gastric and duodenal ulcers which were capable of causing serious health problems. However the prevalence of stomach and duodenal peptic ulcers has declined markedly during the time course of this thesis and now they are relatively uncommon. Although peptic ulcers may still have a fatal outcome, they now are considered to be curable conditions for the majority of patients who suffer from them in the developed world. This thematic history of gastric and duodenal ulcer examines how medical practitioners worked in a changing climate of novel ideas about disease, often aided or driven by technological developments, from the nineteenth century onwards. It begins with a humoural approach to the understanding of disease, which concentrated upon a patient’s personality, lifestyle choices and circumstances but this was gradually displaced from the end of the eighteenth century by the clinico-anatomical approach, which sought to identify a specific lesion as the ‘seat’ of the disease. In the nineteenth century, the discoveries of pathology, physiology, chemistry and bacteriology became incorporated in clinical medical practice, involving the laboratory in the investigation and treatment of many diseases. In the twentieth century, medical research became rooted in experimentation using scientific technology and engineering to equip investigators with new methods which changed the ways in which diseases were understood and treated. Although there were many innovations in theoretical concepts of disease aetiology and empirical treatments, many were subsequently rejected for reasons of ineffectiveness or possible harm to the patient, sometimes after long periods of use. In its first part, the thesis draws upon publications from 1769 until 1950, mostly in the form of scientific articles and books. In the second part, the oral testimonies of health care professionals involved with the management and treatment of gastric and duodenal ulcers are added. The recorded testimonies of 28 witnesses have been preserved in written form as a supplement to this dissertation. Peptic ulcer disease was initially perceived as a whole-body ailment which was centred on the stomach as its symptomatic location and its treatment was intended to alter humoural 3 imbalance or relieve symptoms. However after post-mortem examinations were increasingly performed from the seventeen-nineties, medical practitioners could see its complications in death and combine their findings with the clinical presentations of what was becoming recognised as a relatively common disorder. In the nineteenth century, physiologists investigated the workings of the stomach using vivisection and chemistry to analyse the stomach contents. The acid produced by the stomach was seen to play a part in ulcer genesis but there was no agreement as to what its precise contribution was for many years thereafter. Bacteriologists who found micro-organisms in the stomach assumed that they were pathogenically involved and subsequent experiments confirmed this. As a result of effective anaesthesia and antisepsis in the last decades of the nineteenth century, surgeons intervened increasingly in life-threatening complications of gastric and duodenal ulcers and their observations changed their perceptions of the diseases. In the twentieth century, opaque meal X-ray techniques began to allow doctors to see lesions inside the living stomach, as did improved endoscopes. In 1952, research suggested that stomach bacteria played no part in causing ulcers and further bacteriological research in the stomach was abandoned. By this time, surgeons had designed operations to reduce stomach acid production which healed most gastric and duodenal ulcers. Good therapeutic results were also achieved using medication and dietetic regimens, but it was recognised that only the surgeon could help patients who had failed to respond to medical treatments. In 1962 it was noted that deaths rates for gastric and duodenal ulcer were falling and fewer people were suffering from them, but they remained a serious cause of morbidity and mortality. A new acid-reducing operation was devised in 1969 that offered the hope that surgery could adequately treat ulcers without causing iatrogenic damage, and in 1976, a new drug was marketed which healed them if continuously taken. Then in 1983 it was asserted that peptic ulcers were caused by a bacterium which was later called Helicobacter pylori. In time and in the face of much opposition, it was shown that if this organism was eradicated in the stomach by medication then gastric ulcers and duodenal ulcers could be cured for the first time. This account of the history of peptic ulcer disease shows how medical practitioners adapted the theoretical basis of their medical practice as its evolved under the influence of scientific or societal changes and later abandoned concepts and therapeutic regimens which no longer were in accord with current thinking. Important issues which have arisen out of the testimonies include: medical involvement with the pharmaceutical industry, how doctors co-operate in the care of patients and how they respond to new theories and 4 equipment and techniques as they became available. The history of peptic ulcer disease over the past two hundred years as described in this thesis follows a broadly similar course to that of other diseases such as tuberculosis, syphilis and chronic renal disease which once dominated the lives of those who suffered from them and have largely become curable in recent years. This thesis is offered as an account of an equally fascinating and complex disease. 5 Dedication This thesis is dedicated to the memory of my mother and father, Jean and William Pollock of Motherwell, Lanarkshire. 6 Table of contents Abstract 2 Dedication 5 Table of contents 6 List of figures 7 Acknowledgements 8 Author’s declaration 9 Index to chapters 10 Thesis 19 Bibliography: Books 264 Bibliography: Journal articles 270 Bibliography: Other sources 300 Appendix 1: The Testimony Database 302 Appendix 2: List of Witnesses 303 Appendix 3: About the Author 304 7 List of figures Figure 1 103 Figure 2 152 Figure 3 155 Figure 4 177 Figure 5 228 Figure 6 235 8 Acknowledgements The author wishes to thank those who have encouraged and assisted him during the time taken for the production and completion of this thesis. Special thanks are accorded to my supervisors, Professor Malcolm Nicolson and Professor Lawrence Weaver, for their support and patience throughout this period of study and for their comments and suggestions which were always helpful. Thanks are due to the trustees of the Gartnavel Gastroenterology and Medical Trust which made a financial contribution towards the transcription costs of the recorded testimonies of the witnesses. The witnesses themselves listed in Appendix 2 are also thanked for their significant contribution to the research database which this thesis draws upon. Dr Darryll Green is thanked for his practical help with computer issues as is my fellow student Dr Kenneth Macaulay for his friendship and availability to discuss practical issues which concerned the production of the thesis. Finally to my long-suffering and loving wife Dr Myra Pollock, I say ‘thank you’ for your patient support during the years taken for my academic project. 9 Author’s declaration I declare that this dissertation is the result of my own work and has not been submitted for any other degree at the University of Glasgow or any other institution. Alexander Chapman Pollock 10 Index to chapters Chapter 1. 19 A history of gastric and duodenal ulcer in Britain: methodology, nosology and philosophy Introduction to thesis Introduction to chapter one 1. 1: The published record 1. 2. 1: Oral history as a tool for the historian 1. 2. 2: The participants 1. 3. Dyspepsia and the problem of diagnosis 1. 4: Nosology of gastric and duodenal ulcers in the nineteenth and twentieth centuries 1. 5: Fox’s classification 1. 5. 1: Atonic dyspepsia 1. 5. 2: Neurosis of the stomach 1. 5. 3: Acute gastritis or acute gastric catarrh 1. 5. 4: Chronic gastritis or obstinate chronic dyspepsia 1. 6: Dyspepsia revisited 1. 7. 1: Philosophies of health, disease and illness 1. 7. 2: Authors who have made a significant contribution to the history of peptic ulcer disease in the twentieth century Conclusion to chapter one 11 Chapter 2. 46 Management and treatment of gastric and duodenal ulcers in Britain in the eighteenth and nineteenth centuries Introduction to chapter two 2. 1: The Medical profession as it developed from the eighteenth century until 1858 2.