Precipitating factors in peptic ulcer.

THE CAUSE of peptic ulcer is unknown. Whatever the cause, it must be intimately linked with the mechanism by which the gastric and duodenal mucosa protects itself from the digestive action of its own chyme. Vulnerability to ulcer will increase if either acidity rises or mucosal resistance decreases; conversely, vulnerability to ulcer will lessen if acidity is reduced or mucosal resistance is enhanced. The standard method of treatment of peptic ulcer attempts to reduce gastric acidity and to enhance mucosal resistance by a careful dietary regimen, the avoidance of alcohol, coffee and cigarettes, and the use of drugs to lower acid. This treatment concentrates on factors operating locally in the stomach and, therefore, may be said to deal with "somatic" factors. In recent years there has been a growing skepticism about the value of a treatment confined to "somatic" factors. This skepticism is due principally to a recurrence rate of peptic ulcer of 80%.' While such treatment is of unquestioned value in the acute attack of ulcer, there is no evidence that it cures the disease, as shown by the high recurrence rate. Ingelfinger,2 a leading American gastroenterologist, writes: "The long-term medical management, in brief, is so unsatisfactory as to be virtually non-existent. Any change could hardly be for the worse." The growing dissatisfaction with the results of purely "somatic" treatment of peptic ulcer has resulted in a shift of emphasis from the treatment of the stomach to the treatment of the sick person and thus indirectly to reduce gastric secretion and enhance mucosal resistance. To accomplish this, treatment is concerned with the patient himself, his personality, his problems and his method of dealing with his problems; in other words, with "psychological" factors. This study is an attempt to examine and evaluate "somatic" and "psychological" factors in the clinical course of peptic ulcer. Patients suffering from chronic alcoholism were chosen for study because of their high exposure to "somatic" stress. They do, to the extreme, those things forbidden to a person with an ulcer, and towards the elimination of which the standard treatment of ulcer is directed. These patients usually have the worst possible dietary habits, both as to type of food eaten and regularity of meals. Their stomachs are exposed to the irritant action of alcohol and to increased secretion of hydrochloric acid secondary to the ingestion of alcohol. They have a heavy consumption of alcohol; they all invariably smoke heavily; and they usually