What can we learn from the history of peptic ulcers?
"The merry-go-round goes 'round and 'round,
The children laughed and laughed and laughed,
So many were going 'round and 'round,
That the merry-go-round collapsed."
Traditional Nursery Rhyme
The cause of most peptic ulcers only became recognized as Helicobacter pylori in the 1980s. The history behind this is interesting though. If I were to say it took since 1975 for this to be recognized, you might think thats not too long. If I were to comment on the widespread adoption of antibiotic therapy for peptic ulcers was delayed for one to two decades, that would again not be surprising. The sad fact is that it took over 108 years for H. pylori to be recognized as the cause of most peptic ulcers, and a decade or more for the therapy to be widely adopted. H. pylori was isolated in 1875 in Germany but I don't think it was identified. (Overton, White) In the next decade it was recognized that these bacteria were closely associated with peptic ulcers. (White) I will return to this topic later.
During mid to late nineteenth century time the influence of disease concepts like hysteria were growing. Many diseases were thought to be psychogenic. Charcot, a French neurologist, correctly claimed that many patients with unexplainable symptoms had lesions in the brain that did not show up on autopsy. He reasoned that the technology did not exist to identify them yet, but that it would some day be possible to do so.
Some years later Charcot became involved in hypnotism. Since he could mimic many symptoms using hypotic suggestion in healthy people, he adopted the idea that there might not be lesions, that instead there could be a mental problem causing these symptoms. Charcot's ideas were to have an impact on a young Sigmund Freud, and led to new and thoroughly psychogenic interpretations of hysteria and other disorders.
The symptoms Charcot often described would today frequently be recognized as epilepsy or other brain injuries. Charcot was originally right in deducing that he simply did not have the diagnostic capacity to identify the injury. His later ideas are still claimed to be valid in one form or another, but they have have in fact never been validated.
According to Overton, the word "functional" had long been used to indicate an unidentified failure of physical function, as well as for psychological illness. The opens a potential for misinterpretation of the word "functional". In addition to "functional" applying to symptoms which were simply unexplained, with an understanding that this was because the science had not advanced enough to explain them, it became used to describe psychogenic factors influencing function. In other words, there was nothing physically wrong, it was all in the mind. This confusion is at least two centuries old.
Peptic Ulcers Cured by Antibiotics: 1948
During the first half of the twentieth century many diseases were considered to be psychogenic. This included diseases like diabetes, rheumatoid arthritis and multiple sclerosis. Peptic ulcers were also considered to have a psychogenic cause, primarily stress, although the spicy food theory was also popular.
In 1948 the Mt. Sinai Hospital discovered it could treat peptic ulcers with antibiotics. I have been unable to confirm this using a second source - an original publication would have been nice. News Medical had this to say about a Greek doctor: "John Lykoudis, a general practitioner in Greece, treated patients for peptic ulcer disease with antibiotics, beginning in 1958, long before it was commonly recognized that bacteria were a dominant cause for the disease." In 1961 he filed a patent for treatment of peptic ulcers using antibiotics. I am aware of other unsuccessful trials of antibiotic therapy in the mid twentieth century, but only a small range of antibiotics were tested.
Some of the story behind this was reviewed by Smith in Biopsychosocial Medicine (White, pages 77-98) and Simon Wessely had this to say about it (page 99): "There will undoubtedly be many people, including, for example, those who one might call 'CFS activists', who would have loved every word you were saying." This is overstating the case, yet Smith did warn that psychosomatic approaches to treat physical illnesses would have only a limited impact.
In Peptic Ulcer: Rise and Fall there is discussion of an association between salt consumption as well as smoking with H. pylori. Salt intake and smoking are of course social behaviors as well as chemical factors. However it is not thought they are causes but modifying factors, that alter the risks and presentation of the disease. Furthermore social factors play a part in the transmission of H. pylori, especially crowded or unsanitary living conditions. So it is probably accurate to say there are social aspects in H. pylori induced peptic ulcers. Some studies indicate there may also be genetic predispositions and a potential impact from refined foods especially highly refined wheat.
By 1981 a number of researchers were finally aware of a potential bacterial link. The first successful culture by any of these scientist was April 14th, 1982, in the Royal Perth Hospital, Western Australia. By 1983 the realization that treating H. pylori might cure peptic ulcers was well underway, and the work of a team of scientists (which included Barry Marshall, a hero of mine) began to change the treatment of peptic ulcers to the current day.
Here is what McColl had to say about a delay in using antibiotic combination therapy to treat peptic ulcers, in 2002 (Peptic Ulcer: Rise and Fall, p 107):
"McColl: I think there were serious problems here in implementing this new treatment, even once there was good scientific evidence that it was appropriate. And I think there were three factors that influenced this. One was clearly a professional prescribing inertia, people weren’t used to thinking of ulcers being due to infection, and the profession as a whole were not ready for it, and they didn’t like it. The second was that there was no pharmaceutical company promoting it. Most new treatments are promoted by pharmaceutical companies, but there was no new drug here to promote, there was no profit. Worse, there was every reason why the pharmaceutical companies in the gastrointestinal field should block this or should encourage it not to be developed, because it was going to undermine their main income. [section omitted] ... I was not to speak to the press about this, because one of the pharmaceutical companies had complained. Now there was a sense there that pharmaceutical industries were even working through British medical societies to discourage the release of scientific knowledge that was relevant to clinical treatment. The way in which this new treatment became adopted, was not from the profession down, it was from the patients up. And it was through the press getting hold of this story and through their programmes and newspapers, that the patients demanded this new treatment. I think there is a problem when introducing a new treatment that cures a chronic condition from which the pharmaceutical companies were receiving a large income due to their drugs that controlled, rather than cured, the disease." [My bolding]
Continue to Part 2.
Here we go round the Merry-go-round. Part One
Blog entry posted by alex3619, Aug 12, 2012.
About the Author
I am a long term ME patient with many complications. While I have pushed research advocacy since 1993, I become political around 2009. My current project is a book called "Embracing Uncertainty". Uncertainty in medical science seems anathema to too many doctors. "I do not know" is something more doctors should be honest about.