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ARTICLE
Year : 1977  |  Volume : 23  |  Issue : 2  |  Page : 53-63

The logic of dyspeptic ulcer


Department of Anatomy, Seth G.S.Medical College, Parel, Bombay 400012, India

Correspondence Address:
M L Kothari
Department of Anatomy, Seth G.S.Medical College, Parel, Bombay 400012
India
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Source of Support: None, Conflict of Interest: None


PMID: 614415

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 :: Abstract 

The cause and cure of a peptic ulcer are where medicine is least likely to look for-in medicine's irreverence for the vitally evolved acid, stomach and the pylorus, and in man's indifference towards their irrepressible urges, and needs. The so-called peptic ulcer is the dispensable tip of a dyspeptic iceberg, the dyspepsia, with or without duodenitis, giving rise to a symptom-complex that bears little correlation with what the physician can observe, in­vestigate or measure. Medicine's unabashed ignorance. of dyspepsial duodenitis/ulcer allows one to fall back on the patient for setting himself right. The best thing about the dyspeptic complex is its readiness to disappear. Dyspepsia, duodenitis, ulcer therefore re­present a state of ill-being, and not of pathology, visceral or psychic.



How to cite this article:
Kothari M L, Kothari JM. The logic of dyspeptic ulcer. J Postgrad Med 1977;23:53-63

How to cite this URL:
Kothari M L, Kothari JM. The logic of dyspeptic ulcer. J Postgrad Med [serial online] 1977 [cited 2020 Jun 6];23:53-63. Available from: http://www.jpgmonline.com/text.asp?1977/23/2/53/42795


A recent article [32] in the BMJ drove home the point that modern medicine': strongpoint is its unmitigated ignorance about all the major problems it contend: to be researching upon and solving. Such holy ignorance allows medical men to do all that they fancy, for a la Albert Camus no one is wrong when no one is right Peptic ulcer has been one such problem, the illogic of which was presented ear­lier. [31] We now present incontrovertible scientific data to emphasize that what has been plaguing human stomachs and duodena is not peptic ulcer, but a symp­tom-complex that can only be labelled a dyspepsia, [10],[24],[39],[51] a culmination of which can be an ulcer. Also underscored is the fact that an appreciation of the marvels of human GI tract can empower medical men to rely more on their patient's gut-feelings and the resilience of their gut to set their dyspeptic problems right. Since the field to be covered is vast, it is imperative to present only the points on the various aspects.

Phylogeny

1. Stomach, pylorus, pepsin, and HCL -targets of an ulcer-therapist-are the most consistent vertebrate features from fishes to ferrets, mouse to man. [16],[46] Even the J-shape of the gastrum is a common feature "in forms as far apart phylogene­tically as sharks and man." [46]

2. Stomach, through its pylorus is the guardian-angel of the sanctum sanctorum formed by the small intestine beyond, tak­ing care to see that the latter gets just the right thyme, right in every conceiv­able way. [7],[12],[21],[28],[46]

3. The fact that the so-called peptic ulcer is only a man's privilege acquits the alleged culprits, on strength of the ex­perimentalistic assumption that man and mouse are no different.

4. It is therefore likely that man's ulcer is a manifestation of his avoidable quarrel with his integral phylogeny, the quarrel springing from his being "civiliz­ed" [17] and thus hurried, harried, and a little too rational to be natural. JBS Hal­dane has remarked somewhere that a man is too careful about what he puts in his car, and not one-tenth as careful about what he puts into himself, and how.

5. Man with his exaggerated orificial pleasures is an animal that is ever ready to transgress the "Pray, do not eat/drink now" call from within. The socialization of the orificial instinct in man has robbed him of the life-giving/bliss-giving role of food. With the intrinsic rhythm and urges connived at, he has made dyspepsia into a virtue that supports an entire industry manufacturing digestants.

Anatomy

The enormous vascularity, innervation -"a unique vagal dowry" [13] -muscula­ture and the presence of the only defi­native [46] sphincter of the gut viz., pylorus, bespeak Nature's rule that all these are there as they are needed. So is true of the chief and the parietal cell mass. Sto­mach, pylorus and duodenum behave as unit [12],[28] -the gastroduodenal pump. "The exact mechanism of control of the transfer of stomach contents through the pylorus into the duodenum is still not fully clarified." [19]

Physiology

1. "0! it is excellent/To have a giant's strength, but it is tyrannous/To use it like a giant." A la Shakespeare, stomach foes not use its powerful musculature for bushing things into the delicate duode­ium. "By far the greater part of the work s utilized in mechanical digestion, serving .o macerate the food particles and break :hem up into small fragments." [12] Stomach, as it were, gizzards the food (and wishes that man's teeth could ease its task).

2. Pyloric antrum, canal, and sphincter are ultrasensitive mechanisms that know food from a fly, gruel from gravel, high pH from low pH, osmolar variations, che­mical composition and so on. A primitive response is to shut down the sphincter whenever it is felt that the contents can­not be passed on into the small intestine. May be, it is this that prevents too rapid a loading of the circulation by fat.

3. Notwithstanding the above, patency of the pylorus [7],[12],[21],[50] is a rule, allowing whatever acid is produced in the stomach to be passed on into and quickly neutra­lized by the first part of duode­ium. [7],[15],[19],[21] "Recent investigations of the disposal of acid by the human duo­denum indicate that there is a marked capacity of the duodenal mucosa to dis­pose off acid by the combined mechanisms of neutralization, dilution, and insorption directly through the duodenal mucosa." [49]

4. Modern medicine knows everything about HC1 secretion except why it is there --like the sentry in Quiller-Couch's Zarina's Violet. HCl secretion-the hunch­back of Gastre Dame-obliges the body with a quick input, molecule for mole­cule, of bicarbonate into the blood which then is secreted by the pancreatico-bi­liary-intestinal system. [33] HCl secretion gives a net gain of alkali when (a) amphoteric foods (protein) neutralize the gastric HCl, and (b) gastric HCl is thrown out by vomiting. HC1 secretion is a good indicator of the state of acidosis/alkalosis: In the former [27] as may be induced by HC1 infusion, the rate of HCl secretion goes up; in the latter, as may be induced by NaHCO 3 ; infusion, the rate goes down. [33] The increased secretion of HCI in states of burns, stress, pulmonary in­sufficiency etc. is a reflection of the acido­tic state to which the body is subject. In the GI turnover of acids and alkali, HC1 secretion sets the pace. [33] The ravages [3] of ulcer surgery are partly because of the removal of this pacemaker.

4. The pyloric-duodenal interrelation­ship is such that acid in that area acts as an antacid by inhibiting gastric secretion of HCL .[4] (Here lies one cause of the failure of medicinal antacids). Even the rate of gastric emptying is controlled by the duo­denal receptors, which are supposed to be working less effectively in duodenal ulcer cases, as compared to normal people. [48]

5. The GI tract is "the principal endo­crine organ of the body" [43] there being more endocrine cells in the stomach, in number and types, than in the pitui­tary. The increasingly recognized gut hormones control everything that the gut does-peristalsis, sphincteric ac­tion, secretion, digestion, absorption, and more. Some of the hormones find way into the general circula­tion to possibly produce such symptoms as migraine and headache associated with GI-upsets and stress. Many a psychoso­matic problem associated with a visceral (peptic) ulcer is a function of hormone­mia. The hormones probably account for Palmer's observation that "All visceral lesions cause the same symptoms." [41] back­ed by the fact that "The trouble with the gastrointestinal tract is that it is so repe­titious, both anatomically and physiolo­gically." [41]

Etiology

1. In incriminating [26],[27],[40],[44] acid-pep­sin for ulceration, medicine tells only hall the truth (!). "A biopsy taken through the gastroscope heals as quickly when the acidity is high and continuous as in cases of hypochlorhydria." [5] Wide surgical inci­sions and mucosectomized gastric areas heal rapidly. [17] The other half of the truth; then, that medicine fails to tell is the realization that peptic ulcers have "a re­markable tendency to heal," [35] in the teeth of the very acid-pepsin that allegedly caused them. May be, acid-pepsin helps healing of peptic ulcers.

2. Virchow raised the problem: If acid-pepsin are responsible, why not the 360 o and the length and breadth of sto­mach and duodenum? Why should an ulcer be localized [5],[16],[38] to a single small, punched out area? Why is acute perfo­ration of an ulcer not seen in more than 2 per cent of patients [26] ? And why does the perforation-hole itself remain so small despite the alleged peptic onslaught? And having occurred, why does even a per­forated ulcer heal, [26] a la Hermon Taylor, without a thing being done to the cul­prits? Dear Aunt Acid, [2] doesn't after all seem to be as unkind as portrayed ulce­rologically.

3. Granting that acid-pepsin are etio­logic, de-etiologizing the patient medical­ly or surgically makes the matter worse. The illogic peptic dogma "no acid, no ulcer" perpetuates "yes acid, yes ulcer," a notion fed by such elegant ads-"In few minutes his antacid will stop work­ing. What Then?" [1] What use is an anta­cid, if it stops working in a few minutes?

Normality of Distribution

1. Like in all other fields of modern medicine, ulcerologists know (and treat) hyperchlorhydria/hypochlorhydria with­out knowing/defining the missing middle -euchlorhydria.

2. Average acid output is in no way normal acid output. "The range and not the average is the reality." [6]

3. HCl secretion is a biologic trait that is, like most other traits, normally distri­buted, [11] in its intensity. Cases of ulcer/ hyperacidity fall equally on either side of the midpoint of the bell-shaped curve. "It is clear that among men and women with duodenal ulcer the lower levels of gastric secretion are equally common." [11]

4. The same individual has "hyperaci­dity" at 1.0 p.m. say, and no acidity 15 minutes after, on its own. What truly he has had, and may have again, is acidity -the consciousness of having acid with­in. Once and forever, the term hyper­acidity [40] can be logically replaced by the level-non-committal acidity.

5. The normality of distribution ex­tends to the age incidence of the onset of gastroduodenal ulceration, as well the age incidence of ulcers found at autopsy. "The peak of age incidence of gastroduo­denal ulcer is the same as the period of arterio-sclerosis and other serious diseases of old age." [54] Just as the tails of the Gaus­sian curve stretch to infinity, [45] "new" cases of ulcer occur in the youngest to the oldest. [54] As far as HCl secretion and its alleged by-product ulcer go, we are dealing with a biologic phenomenon about which, like cancer or coronary, no one seems to know anything.

6. Point 5 above could drive home the point that not heredity but polygenic in­heritance [45] mediates the so-called suscep­tibility to acidity and ulceration. The other side of the coin is that these are the people who need to be a bit extra careful about their gastroduodenal phy­siology.

Pathology

1. With all the symptoms, the so-called ulcer is so often absent. [10],[39],[51]

2. The much-prized ulcer has turned out to be the dispensable tip of the dys­peptic iceberg; it is a late event[10],[39],[51] in the history of an individual's dyspepsia, a final evidence that he and his physician have failed the patient's complexer-than-a-computer gastroduodenal region.

3. "The most important lesson has been that a great deal of organic gastro­intestinal diseases-ulcers, tumours, gall stones, etc.-never cause symptoms or cause symptoms only very late in the course of things. The most seasoned clini­cian must continuously wonder how orga­nic lesions of the same location, size and nature can produce symptoms of such differing intensities and apparent impor­tance in different patients." [41] The Boy­-dian [5] stock-title The Relation of Symp­toms of Lesions is of little help in gastro­duodenology.

4. The most natural tendency of an ulcer is to burn itself out. John Fry, [18] M.D., F.R.C.S., from a wide experience with peptic ulcer found in his general practice, gave a profile of the disease to conclude that, apart from the natural re­missions uninfluenced by medical treat­ment, there was "a very definite likeli­hood, in both duodenal and gastric ulcers, for the condition ultimately to 'burn it­self out' naturally and spontaneously." This natural burning out cures the ulcers in doctors without any operation, [31] but the medicos have no such patience [44] for their patients' ulcers. Such authoritarian-ism was long enunciated by Mayo. [37] "Un­fortunately, only a small number of pa­tients with peptic ulcer are financially able to make a pet of an ulcer"-a teach­ing that is yet to burn itself out in surgi­cal training.

Clinical Features

1. Ulcerology has not escaped medi­cine's text-bookish [26],[27],[35],[44] attempts at typicalizing what is, ulcer or no ulcer, so atypical [41],[51] at an individual level.

2. The atypicality arises from the abi­lity of the disturbed gut-dyspepsia-to promote symptoms, visceral/psychic/ somatic, ranging from heaviness to har­riedness, distension to depression, vomit­ing to vanity, nausea to nervousness, and flatulence to flushes.

3. Dyspepsia is the most compelling feature; the overall symptomatology is varied, each symptom fleeting in charac­ter from hour to hour, with very little correlatable pathophysiology to account for the presence or the absence of a symp­tom or a sign.

4. Dyspepsia defies definition. In more general terms, it is the absence of instinc­tive friendliness with food and drinks ­the welcome to food is reluctant, the after­food feeling is one of unease. There is an inability, a la Harris, [22] of the person and his GI tract to declare, "I'm OK, You're OK."

5. Much against Hurstian concept of diatheses, [40] ulcer/dyspepsia is every hu­man's privilege: "As far as we know, the disease is available to all, at any moment. This means that it must be due to a phy­siologic deficiency or excess-some abnor­mal activity that is quickly available among the physiologic functions of everyone, to throw some built-in protec­tive device out of balance." [41] More about it anon, but it could be suggested right here that the protection lies in pyloric patency that allows no damming back of acid. Should it occur, and should the sto­mach with its might force the acidic con­tents as a jet directed towards the duo­denum, duodenitis/dyspepsia/ulcer could occur. Restoration of pyloric patency cuts down the onslaught permitting relief/ healing to occur.

6. The symptomatogenesis at the gas­tropyloroduodenal level is more functional than structural. The finer individual nuances of muscle tension, hormonal re­lease, acid/alkali secretion, receptor­function, etc., create a situation that can be hellish for the patient without the clini­cian realizing why. The one consistent thing that produces pain is the stretching of gut. [41] It is a part of the common, non­medical teaching to keep one's stomach filled much below its brim. The unease of an overfilled stomach could be ascribed (a) to the tightly shut pylorus on one hand, and (b) the stomach musculature kneading and chyming its contents, against high intraluminal tension, on the other. Hormoneria may also be respon­sible.

7. Increasing recognition is now being accorded to the fact that dyspepsia [16],[24],[39],[51] is far more common than duodenitis, which probably is commoner than and precedes the clinically dispensable mani­festation of an ulcer. The most important wage of dyspepsia is not an ulcer, which occurs late in a dyspeptic's life, but the gnawing absence of joie de vivre.

8. "Dyspepsy and cheerfulnes do not go together." [25] A dyspeptic is incapable of meeting the world in bouyant spirits, declaring, a la Kalidas: Look to this day, this wonderful day. Dyspeptic gut, through a primitive mechanism that may be important for our survival in the biologic past, grips the mind viciously through the vagal dowry, creating an odd affective mixture of irri­tation, depression, fear, listlessness, and above all, a sense of ill-being. While our intellect functions in the newest and the most highly developed part of the brain, our emotions continue to be dominated by a relatively crude and primitive cere­bral system . [36] "This situation provides a clue to understand the difference bet­ween what we `feel' and what we `know'." [36] A dyspeptic, with or without an ulcer, knows he shouldn't be irritated, but he can't help his feelings . He is in a dyspeptic vice.

Investigations

1. With the irrelevance" of acid estimation, the right place for the nasogastric tube and the suction-pump is in the museum.

2. Histamine-stimulated MAO [30] is highly academic, but hardly useful.

3. The "time-honoured method" of radiologic investigations is blighted by as many as 30 per cent false-negatives and 37 per cent false-positives. [47] To wit, listen to a physician-patient: "The pain was rip­ping me apart while they were working on me in the X-ray department, but the pictures failed to show the crater. So I was dicharged cured." [20]

4. Endoscopy [39],[51] can help only if it can , detect a lesion, which may still be irrelevant.

5. Investigations on how effective the surgeon's knife has been in destroy­ing [23],[31] the patient's physiology helps nei­ther the patient nor the physician, as far as the patient's well-being goes.

Therapy

1. The glorious failures of therapy are iterated here to stress that a patient must treat himself.

2. Drugs, a la Sir Colenso Ridgeon in Shaw's The Doctor's Dilemma, are a dys­peptizing delusion. How could the con­sistently unpalatable-nauseating-anta­cids do any good to the gastroduodenum that is in no mood ever to welcome the insipid pulp of mentholated AI(OH) 3 ?

3. Unpalatability is a peremptory in­ner judgment on the inacceptability of a thing. So for any diet fad-Sippy's or Bippy's. The evanescent relief afforded by antacids springs from the temporary elevation of pH that eases the task of pyloroduodenal region, possible reduction of muscle spasm, and thus, of pain.

4. Gastric irradiation, [42] supercooling etc., deserve to be mentioned only to be condemned for the barbarity.

5. Surgery [14] cures, by complicat­ing [3],[23],[26],[31],[44] the problem.

6. An ulcer often heals despite the pa­tient and his physician.

7. "The warmth of clinical art rather than cold science is still required to man­age the patient with a peptic ulcer." [18]

Epistemology

1. "But nature gives her observer cause only for admiration at the simpli­city with which she works, and for asto­nishment at the proneness of the human wit to explain any phenomenon which appears remarkable by means of infinitely greater and more incomprehensible wond­ers." [8]

2. Simplicity of approach, even when compelled by logic and/or biorealism, is not a particular weakness of modern medicine, thriving as it does on the Bom­bay-to-Calcutta-via-Rome approach-a gimmickry that makes the medical men look very learned, the patient's problems insolubly complex, and the remedial measures expensive and intricate. [9] As a starting point, a 6-worded aphorism can help ulcerology a great deal: If ulcers could heal, ulcers can.

3. As a historian of science once put it., "Isn't it amazing how many things there are that aren't so?" Quoting thus, Alan Watts [53] cajoles us further: "The world becomes intelligible through amaz­ing reversals of common sense, and, as Whitehead saw, the notions most worth questioning are just those which are most taken for granted. Science, too, is the game of hide-and-seek, for the scientist most skilful in basic research has the peculiar flair for realizing that the best hiding places are those where no one would think of looking: they are usually right out in the open. How often an im­portant discovery floors us with its sim­plicity, with the feeling of, "Well, why didn't I see that; it was right under my nose!"

4. The solution to the dyspeptic/ulcer­ous problem is truly under our nose-in the area it occurs, /afflicts. Some of the needed ingredients of the solution com­prise (a) teleologism that compels us to realize that HCl, pylorus, and vagal dowry are no mistakes of our maker, (b) corrected causalism that clears acid-pep­sin of any guilt, (c) humility that what is not thought of/done upon doctors' GI tract will not be exercised [31] on the pa­tients, and (d) the Hippocratic invoca­tion of Primum non nocere-the treat­ment of ulcer should not exceed, in men­tal, physical, visceral and material cost the problems it allegedly gives rise to.

5. The 9 times greater projection of the gastroduodenum on the human brain rather than the other way round should drive home the point that the CNS is not the cause [26],[27],[44] of dyspepsia; ulcer, but its helpable victim.

6. Medicine had better diagnosed the pillars of unwisdom [29] upon which its im­pressive edifice rests. A principal monu­mental superstition, a la Koestler, [29] is medicine's measurementism parameter­ism-"that the only scientific method worth that name is quantitative measure­ment; and, consequently, that complex phenomena must be reduced to simple elements accessible to such treatment, without undue worry whether the specific characteristics of a complex phenomenon, for instance man, may be lost in the pro­cess." The solution to the problems under discussion does not lie in our measuring MAO or urinary enterogastrone, but in knowing the ease, disease of a patient. This would entail a greater reliance on what a patient feels, and not on what a gadget shows, and a greater respect for the "intangibles and unapproachables" [29] of a patient's symptomatology.

7. The philosophism inherent in such an approach is ulcer-realistically defend­ed by Palmer: [41] "The time has come in ulcer therapy for more philosophy and less technology."


 :: Hypotheses Top


Phylogenic

1. The gastric production of HCl as "the universal acidifying agent" [16] is a design in acid-base-regulation. [33]

2. In absence of food, the natural py­loric patency permits the acid secreted to be totally and immediately neutralized in the duodenum. For a while that the py­lorus closes, the body gains in alkali be­cause of the HCl secreted and retained in the stomach.

3. Nature's master-stroke, in fortify­ing body's alkali reserves through HCI secretion, lies in making stomach the ren­dezvous for the powerful HCI and the ingested, usually-alkaline life, called food. The alkali-gain is so much as to spill over the rigorously-conserving kid­ney, seen as the post-prandial alkaline tide in the urine. Man has a penchant for working against this scheme by consum­ing fermented/denaturalized foods that are poor in their alkali content.

4. The man-made alkalies-the so-­called antacids-are no substitutes for the alkaline foods for the simple reason that the highly sensible pyloroduodenal region has evolved in the company of amphoteric foods, and not through the courtesy of Aluminium Hydroxide gel.

5. Since acid-base-regulation affects every cell in the body, gastric HCl secre­tion is a target of all the systems of the body including the endocrines. [30]

Physiologic

1. The GI tract is a neuromusculohor­monal ensemble whose spokesman is the gastroduodenal region whose message, I'm OK, is conveyed by a code called appetite-Life's lust for life.

2. Equally, this inner voice is as un­reserved and irrepressible in declaring I'm NOT OK by coding for the lack of appetite, a feeling that is beyond words but always accompanied by a sense of ill-being.

3. The enormous vagal dowry, apart from performing the medically-despised release of gastrin to promote acid secre­tion, is there to mediate visceropsychic bliss, or the absence thereof. Such bliss is every vertebrate's right.

4. The stomach could be looked upon as the Import House of a city called an individual. The sensitive but obstinate pylorus is the arch-angel that takes care of not only the gut beyond, but such processes as fat/carbohydrate metabolism, as also, say, the distantly placed bone marrow. The uniformly cold response that stomach accords to most wonder-drugs is, may be, one way of pylorus and Nature telling medicine that, any day, the error of omission is preferable to that of com­mission.

5. Although the stomach can accom­modate to a oral orgy by distending to the point of resting its greater curvature on the urinary bladder, it best functions in the optimally-stretched state. The optimality is individual-specific-a state that should not encroach on the consciousness. Overeating is now recognized as a definitive form of Selyean stress.

6. Fasting-an empty stomach-is the most physiologic way of resting the gut and curing dyspepsia/ulcer. "At the same time I decided to break another rule of orthodox medicine, the one that says that the stomach of an ulcer patient should never be empty, I had an appetite of a horse, so I decided to suppress it. In other words I was going to do the very opposite to what I had been doing until then." [20] This confession by a medical man [20] who cured himself of a bad ulcer could be paraphrased for public use: Al­ways have the appetite of a horse, but never hog. Let that sense of ease and comfort that accompanies unsatiated appetite prevail.

Eupeptic

1. Teeth, time and temperateness are indispensable tools for being kind to one's stomach.

2. Despite hitherto denial by modern medicine, eupepsia is a physiologic state, held as the starting-point of all health, by non-allopathic medical sciences.

3. In matters of oral import, the best guide is WIDD: When In Doubt, Don't.

4. Like the Pascalian heart, the sto­mach has its own secret reasons for likes and dislikes about food. When in diffi­culty, the wisdom of the stomach is supe­rior to the rationalization by the intellect.

5. As socializing elements, food and . ' or drinks are eupeptic only to the degree that they do not overstrain the entero­static (alimentostatic) mechanisms.

Dyspeptic

1. Man is not born dyspeptic; he trains himself to be so. Children rarely show off the dyspeptic demeanor.

2. Dyspepsia is dis-ease, not disease; disappearance is its cardinal quality.

3. Dyspepsia is a long-protracted, re­current warning that eventually paves way for gastroduodenitis which long-con­tinued can end up in an ulcer.

4. The symptomatology of dyspepsia is a manifestation of a number of interact­ing influences-muscle spasm, mucosal irritation, hormonal overaction and so on. The symptomatology is incapable of being analyzed by modern medicine.

5. Dyspepsia is an agent that makes hell out of an inherent heaven. Milton (and Lord Krishna in Gita) could be paraphrased to state that not so much the mind, but it is one's gut that makes heaven or hell.

Ulcer: Causative/Curative

1. An ulcer is a medal honouring long, dyspeptic service.

2. Yet, each ulcer, like Mr. Dolittle in My Faid Lady [34] , is willing, wanting, waiting to heal.

3. It is neither acid-pepsin (for DU) nor bile (for GU) that causes ulceration, but the way they are delivered.

4. The gastric-might, the pyloric-tight and the duodenal target account for DU. Whenever the situation is such as forces the stomach to push against pyloric re­sistance, acid-pepsin is delivered as a jet on to a point in the duodenum. It is pos­sible that gastric distension alters the di­rection of pyloric canal so that the jet, instead of jumping into the duodenal lumen, hits on the duodenal wall.

5. The ability of fasting to restore eupepsia may be exploited towards ulcer­healing-a thing practised successfully in the past. [31]

6. The complications of an ulcer are mere consequences of the continuation of factors that produce an ulcer.

The Greek invocation-Gnothi seauton -Know thyself could be practically para­phrased as a Gnothi gastroduodenum­Know (thy) stomach and duodenum. The acceptance of ignorance is the beginning of one's knowledge. Medicine's such ac­ceptance, vis-a-vis dyspepsia/ulcer can mean ushering in an era of the realization that some of these problems are so highly individualistic that they are best managed by the patient himself. The patient may fail, but the physician will always. Such a concept hits directly at physicianly omnipotence. It is time we had hit more widely.

 
 :: References Top

1.Advertisement. BMJ., 3, vii, 1973.  Back to cited text no. 1    
2.Advertisement. New Engl. J. Med., 289, xxvii, 1973.  Back to cited text no. 2    
3.Alexander-Williams, J.: Sequelae of peptic ulcer surgery. J. Applied Med., 1: 29-33, 1975.  Back to cited text no. 3    
4.Anderson, S.: Gastric and duodenal mechanisms inhibiting gastric secretion of acid. In, Handbook of Physiology, Section 6: Alimentary Canal, Volume II. Ed. Code, C. F., and Heidel, W. American Physiologi­cal Society, Washington, pp. 865-877, 1967.  Back to cited text no. 4    
5.Anderson, W.: Peptic ulcer. In, Boyd's Pathology for the Surgeon. Kothari Book Depot, Bombay, pp. 205-216, 1967.  Back to cited text no. 5    
6.Ardrey, R.: The Social Contract. Collins. London, p. 41, 1970.  Back to cited text no. 6    
7.Atkinson, M., Edwards. D. A. W., Honour, A. J. and Rowlands, E. N.: Comparison of cardiac and pyloric sphinc­ters. A manometric study. Lancet, 2: 918-922, 1957.  Back to cited text no. 7    
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11.Booth, M., Hunt, J., Miles, J. M. and Murray, F. A.: Comparison of gastric emptying and secretion in men and women with reference to prevalence of duodenal ulcer in each sex. Lancet, 1: 657-662, 1957.  Back to cited text no. 11    
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22.Harris, T. A.: I'm OK-You're OK. Pan Books, London, 1969.  Back to cited text no. 22    
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25.Jackson, J.: Quoted in Familiar Medical Quotations. Ed. Strauss, M. B., Little, Brown & Co., Boston, p. 239, 1968.  Back to cited text no. 25    
26.Jones, F. A., Gummer. J. W. P., and Lennard-Jones, J. E.: Peptic ulcer, In, Clinical Gastroenterology. Blackwell, Oxford, pp. 469-547, 1968.  Back to cited text no. 26    
27.Kirsner, J. B.: Peptic ulcer. In, Cecil­Loeb Textbook of Medicine. Ed. Beeson. P. B. and McDermott, W.W. B. Saun­ders, Philadelphia, pp. 859-880, 1967.  Back to cited text no. 27    
28.Kleiner, 1. S. and Orten, J. M.: Diges­tion. In, Biochemistry. C. V. Mosby, Saint Louis, pp. 288-328, 1966:  Back to cited text no. 28    
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34.Lerner, A. J.: My Fair Lady. Penguin, Middlesex, p. 48, 1965.  Back to cited text no. 34    
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36.MacLean, P.: Psychosomatic disease and the 'visceral brain'. Psychosom Med., 11: 338-353, 1959.  Back to cited text no. 36    
37.Mayo, W. J.: Quoted in, Familiar Medi­cal Quotations. Ed. Strauss, M. B., Little, Brown and Co., Boston, p. 646, 1968.  Back to cited text no. 37    
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41.Palmer, E. D.: Functional Gastrointesti­nal Disease. Williams & Wilkins, Balti­more, 1967.  Back to cited text no. 41    
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45.Roberts, J. A. F.: Human variation, mullifactorial inheritance, and common diseases. In, An Introduction to Medical Genetics. Oxford Univ. Press, London, pp. 223-255, 1970.  Back to cited text no. 45    
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47.Scott-Harden, W. G.: Radiological in­vestigation of peptic ulcer. J. Applied Med., 1: 15-19, 1975.  Back to cited text no. 47    
48.Shay, H.: The pathologic physiology of gastric and duodenal u!cer. Bull. N.Y. Acad. Med., 20: 264-291, 1944.  Back to cited text no. 48    
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51.Spiro, H. M.: Visceral viewpoints: Moynihan's disease? The diagnosis of duodenal ulcer. New Eng. J. Med., 291: 567-569, 1974.  Back to cited text no. 51    
52.Today's Drugs. British Medical Associa­tion, London, pp. 143-147, 1971.  Back to cited text no. 52    
53.Watts, A. W.: The Two Hands of God. Collier Books, Toronto. 1963.  Back to cited text no. 53    
54.White, F. W,: The incidence of gastro­duodenal ulcer. In, Peptic Ulcer. Ed. Sandweiss, D. J., W. B. Saunders, Phila­delphia, pp. 18,5-195, 1951.  Back to cited text no. 54    




 

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