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The Therapeutic Control of Recurrent Peptic Ulcer
THE THERAPEUTIC CONTROL OF RECURRENT PEPTIC ULCER FRANZ]. INGELFINGER,
M.D.*
AND ROBERT
E. Moss, M.D.t
THE patient with an uncomplicated peptic ulcer presents a rather startling therapeutic paradox. His immediate response to medical therapy is excellent; his outlook for the future, by contrast, is dark. The chances are more than fifty-fifty that his ulcer will again trouble him within two years, and the likelihood of a recurrence in five years is probably over 65 per cent.!' 2, 3 It follows that emphasis today need not be placed on the immediate therapy of the active ulcer, for which several satisfactory regimens have appeared in these pages,4, 5, 6, 7 but upon the ways and means whereby reactivation of a healed ulcer can be prevented. Recent studies with enterogastrone, 8 a gastro-inhibitory substance extracted from the small intestine, hold out the hope that such substances may eventually be used for the long-term therapy of the ulcer patient. Enterogastrone, however, is still in the experimental stage, and at present one must content himself with more indirect methods of combating ulcer recurrences. The methods outlined in this clinic are directed against those factors which are generally believed to play a part in the pathogenesis of a peptic ulcer. Both physician and patient may argue that some of the procedures are unnecessary, time-consuming and expensive, particularly since the patient under discussion has a healed ulcer and is free of symptoms. In view of the high incidence of recurrences, however, such argulnents cannot bear much weight. In the long run, time and money lost in taking care of a recurrent ulcer-possibly an ulcer complicated by bleeding or obstruction,-greatly exceed the loss incurred by adopting a program aimed at preventing the recurrence. Too vigorous a program, it is true, will be discouraging and will lead to deviations from the too narrow path. The best schedule calls for some effort on the part of the patient, but not for a wholesale abandonment of the pleasures of life.
From the Evans Memorial, Massachusetts Memorial Hospitals, and the Department of Medicine, Boston University School of Medicine, Boston. *Assistant Professor of Medicine, Boston University School of Medicine; Member of Department, Robert Dawson Evans Memorial; ·Physician, Medical Service, and Chief, Gastrointestinal Outpatient Clinic, Massachusetts Melnorial Hospitals. t Instructor in Medicine, Boston University School of Medicine; Assistant Physician, Robert Dawson Evans Memorial; Assistant Visiting Physician and Chief, Psychosomatic Medicine Outpatient Clinic, Massachusetts Memorial Hospitals. 1162
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How successful is a program of prevention apt to be? Obviously, no guarantee can be given; some ulcers will recur no matter how carefully the patient is handled. On the other hand, we believe that the methods here outlined will, in a large number of ulcer cases, reduce the chances, frequency and severity of recurrences. A SUGGESTED REGIMEN
The patient is assumed to have had a peptic ulcer, now healed and not causing any symptoms. Some parts of the regimen to be prescribed -i.e., those dealing with the patient's education and personality-. should actually be started during treatment for the active ulcer. 1. Education.-The basic facts of peptic ulcer should be explained to the patient. By giving him an appreciation of the causes and course of his illness, two objectives will be attained. First, he will not be subject either to the carelessness of ignorance, or to the worry occasioned by various misconceptions that he may harbor. Second, he will follow directions more intelligently and more cooperatively if he understands the purpose of the prescribed regimen. The exact terminology used by the physician in elucidating peptic ulcer naturally depends upon the patient's background, but the following major points can be expressed in language understandable to most laymen: (a) The exact cause of peptic ulcer is unknown, but physicians do know that an ulcer gets worse when the stomach is overly active and produces more than the usual quantities of acid. ( b) Excess activity and excess acid production by the stomach are particularly apt to occur under the influence of certain mental states and as a result of poor dietary habits. Therefore, the aim of ulcer prevention is adjustment of the mental states and elimination of poor habits. In addition, gastric acidity can be diluted and partially neutralized by the frequent intake of suitable foods and, if needed, ll1edicines. (c) Individual peptic ulcers can be cured quite readily, but the tendency of the patient to get an ulcer cannot be cured: ulcers can and do reappear under the proper conditions. Hence, if the patient is to avoid a ·recurrence, he must be ready to follow a moderate form of treatment for years. For ·purposes of reassurance, the pa:tiehtis told that duodenal ulcers never become cancerous.' Whether he should be warned of complications-i. e., perforation, bleeding and obstruction-is a debatable point. Tp mention these dangers ina blunt or threatening fashion will serv'e no purpose but to make the patient unduly apprehensive. On the other hand,' he should be informed of the possibility of bleeding so that he may acquire the habit of observing his stools routinely for signs of melena or blood. ' ~ .. Ps~chot·herapy.-That .peptic ulc~r ~atients present striking similarIties In appearance and· In personalIty IS generally recognized. Most
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therapeutic regimens, consequently, advocate treating the individual as well as the ulcer. How can this be done? Simple admonitions to "take things easily" and to "stop worrying" are not sufficient; the" patient obviously would rest and free himself of worry' if he could. On the other hand, it is neither necessary nor practical to refer most ulcer patients to a trained psychiatrist. Much can be accomplished by the physician who grasps the essentials of the ulcer patient's personality and who is willing to practice some of the simpler technics of psychotherapy. Description of the Personality.-Freudian psychoanalysis9 indicates. that the ulcer patient has a strong wish to be ,cared for and loved as he ,vas in infancy. As a result of the early infantile association of being loved with being fed, he desires food as a symbol of security and affection, a desire which maintains the stomach in a constantly active state. Such an attitude is incompatible with the striving of the adult for independence and activity. Hence, the wish to be cared for and fed is repressed into the unconscious, while the conscious mind is occupied in overcompensatory fashion with desires to be the efficient, responsible, conscientious, aggressive leader. As a result, marked conflict is present within the individual and is evidenced by chronic emotional tension. Approaching the problenl on the conscious level by the interview method, Draper and his associates10 have reached similar conclusions which they express somewhat differently. Ulcer patients, according to these authors, are extremely conscientious victims of chronic fear, who are driven to strive constantly toward some goal regardless of the difficulties encountered. Their driving fear stems from their dimly sensed awareness of the "feminine component" (passive, receptive tendencies) in their make-up which seems to threaten their ability to play successfully the masculine role in life. This "basic male fear" presses thenI to reassure themselves by overemphasizing their virile, aggressive tendencies. Thus, the male ulcer patient suffers from a deep-seated conflict which is manifested in an excessive load of anxiety-apprehensive anticipation-and concomitant bodily tension. Plainly herpust be restlessly active, worrisome and unable to relax. A sinlilar e~otional pattern usually characterizes the female ulcer patient, although the underlying conflicts are influenced by the difference jn sex. ' Correlation ~f Gas.t,ric Physiology and Perso~~lityRe~ptions.-Sug gestive observations of far~reaching inlpor~a~c~.-hC1.v:e b~.eJ;l, ~ade by' Wolf and Wolff1! ' on the stomach of the~'"s:~bje~~,~:T(jm, throug~ .whose gastrostomy they were able to study the physIologic chang~~ in gastric function .occasioned by varied stimuli. In response to acute aggressive feelings and anxiety, his gastric Illucosa bec~IJ.le engorged and much redder than usual, the levels of free acid secretion and total volume' of gas,tric juice were three times nornlal, and' there was a
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vigorous increase in gastric motor activity. Similar changes of hyperemia, hypersecretion, hyperacidity and hypermotility occurred and persisted during periods of proloned anxiety and resentment; nor did these effects subside during sleep. Tom's emotional reactions, in short, caused his stomach to assume a state of preparedness for the reception and digestion of food. Further, in normal subjects and in patients with the clinical diagnosis of peptic ulcer, gastritis and duodenitis, Mittelmann and Wolff12 showed that hypermotility, hypersecretion and hyperacidity occurred in a setting of ,anxiety and resentment.· Such functional disturbances persisted throughout the duration of these emotions and did not abate during sleep. While these changes were present, subjective complaints of pain and epigastric burning were likewise present. The difference between the reactions of the normal subjects an,d those of the patients was simply a matter of degree. These observations point toward the local mechanisms for translating emotional reactions into gastroduodenal functionai disorders which presumably lead to symptoms and structural changes. They also point the way toward effective management of the patient. Psychotherapeutic Method.-1\1uch, then, must be known about the patient in order to understand what influences are affecting his stomach. He should, accordingly, be interviewed privately, ina leisurely, friendly manner that will convey to him the impression that one is interested in him as a person. To encourage him to talk freely about himself, he is asked to describe the onset and course of his symptoms in detail, as these are generally uppermost in his mind. By simple questioning, he can be led to elaborate upon the setting, environmental and subjective, in which symptoms first appeared, persisted or recurred. It is important to. ask him how he felt at these times, what he thought about, how he gQt along with others, how well he was succeeding in his work, and how he vie\ved his future. ' EXAMPLE 1.-The, value of probing closely into the setting in which a symptom first occurs is exemplified by a patient convalescing from a subtotal gastrectomy for obstructing duodenal ulcer. The patient reported that he had begun to vomit as soon as he got horne from the hospital and. had vomited frequently, especially after taking orange juice, during the succeeding three weeks. When asked what the orange juice had reminded him of, he recalled that it had upset him repeatedly prior to operation and that he had suddenly thought of this while drinking it. Further inquiry revealed that vomiting had actually begun two days prior to discharge, shortly after he had taken orange juice at breakfa~t. All the previous night, he remembered, he had felt "jittery," and had slept poorly, beca\1se he had been given an intravenous iniection (a liver function test) the afternoon before. This injection had been given with little explanation; he had immediately concluded that something was still wrong with him and had become acutely anxious; he had thought he could taste the material injected and that it tasted like vomitus. Against this background, the orange juice, which he had been taking daily without distress, precipitated his vomiting. Following discharge, he could not lose the fear that something was atniss, and the gastrointesdnal tension was perpetuated, relieved somewhat by periodic vomiting. The elic-
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iting of this chain of events opened the way to simple explanation of the purpose of the injection, and to reassurance as to the good result obtained by his operation. Thereafter, the patient ceased, to be trou'bled by vomiting and was able to drink orange juice \vith impunity.
Usually, an outline of the habitual enlotional patterns of the patient during the period of his illness can be obtained at the first interview. This outline suffices for the preliminary formulation of the pati~nt's problem in terms that he can understand. One shows him by summarizing the evidence he has presented that he has an underlying ·sense of insecurity which is conscious to him as anxiety. This anxiety forces him into a state of constant preparedness for action, manifested by general bodily tension and an inability to relax. The patient usually means these things when he says that he always worries. Experience indicates that any eagerness on the part,of the physician to give a more penetrating interpretation early in therapy is unwise. The patient will seldom accept anything more than a rough sketch of the problem, and may well be driven away by an attempt to give him deeper insight quickly. · However, expanding the forlllulationby pointing out that the patient resembles in his personality make...up a. great ,multitude of peptic ulcer bearers adds to its force and appears to give him a sense of relief by showing him that he has many fellow-sufferers. He is then more easily convinced that his type of personality can lead to overactivity of the stomach. He shows n1uch interest in gaining a clearer picture of the mechanism that produces his symptom,s and is, consequently, receptive to instructions aimed at ,giving him relief. ' EXAMPLE 2.-The beneficial effect upon acute symptoms of the above approach is well exemplified in the case of a 44-year old white man whose ulcer symptoms dated back twenty years. He had been admitted to the hospital because of symptoms indicating severe pyloric obstruction. Constant aspiration of stomach contents for three days, followed by a strict feeding regimen and nightly aspiration, resulted in little relief of pain. The patient was interviewed on the seventh day and the relationship between his anxious, aggressive attitude and his. ulcer symptoms was pointed out. He was then given a brief description of the effects of this attitude upon his stomach. The impression this made upon him was striking: he concluded that he could "let go" of much of his anxiety, at least temporarily, and that his aggressiveness was really hurting only himself. Thereafter, his symptoms were greatly alleviated, despite the later finding at operation that the obstruction was largely due to scar tissue.
At the end of the first visit, the procedure to be followed subsequently is outlined to the patient. He will be seen weekly, preferably for one hour at each visit, during which he will be asked to talk in greater detail and with complete frankness about himself" Chrono.,. logical order is not essential, as significant relationships will come out eventually no matter where he starts. Questions may frequently be necessary, 'at first, to keep him going, or to bring out further details. As the story of his significant interpersonal relationship unfolds, he i~
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given a summarizing interpretation at the end of each interview. His appreciation of the reasons behind his early and persisting insecurity will gradually deepen, and he will realize how this feeling of insecurity determined his emotional reactions and, hence, his behavior and health throug~out his life. The'development of insight, in this fashion, generally relieves a patient of much of his anxiety with concomitant lessening of his gastric overa~tivity. The patient, however, must be helped to apply his new knowl~dge and to understand his reactions in varied situations coming up in his daily living. It is this "working-through" of his problem in as many ramifications as possible that gradually effects a lasting change in attitude which can be summed up as growth in emotional maturity. In ~ddition, he may be started on a program designed to train him in the art of bodily relaxation. For the intelligent patient a satisfactory recommendation is that he obtain a copy of You Must Rela~ by Jacobson13 and start putting its principles into practice. Much simplified adaptations of these principles may be presented to the patient who seems unlikely to benefit from reading the book. The physician, finally, emphasizes that peptic ulceration is the end result of a long chain of circumstances involving the patient's total personality; that successful treatment requires reeducation of his emotional responses as well as a medical regimen; that there is no shortcut to the desired result; and that the length of time necessary to effect readjustments in his personality will be dependent upon his cooperation. 3. Diet.-A fairly liberal diet can be offered to the patient with a healed ulcer (Table 1). Much more important than the type of food, however, is regularity of eating habits. The patient must eat at the same. times every day. This rule has to be stressed particularly to traveling salesmen and others whose work is apt to interfere with regular eating habits. Actually, there are very few occupations which cannot be harmonized with regular food ingestion. Interval feedings of milk must be taken regularly in the middle of the forenoon, in the middle of the afternoon, and at bedtime. If the interval between the evening meal and bedtime is long, an additional glass· of milk in the middle of the evening is advisable. Except when asleep, the patient should never go more than three hours without taking food or drink. Milk is without doubt the substance most suitable for interval feedings, but compromises may be made with the patient's taste by using flavoring, eggnogs, custards, junkets, or vegetabl~ purees made with milk. With the milk, plain crackers or cake may be taken if the patient so desires. On the other hand, the patient must understand that other foodstuffs-particularly coffee and soft drinks-are not acceptable substitutes for milk. . Certain foods present particular problems. Caffeine-containing beverages are known to stimulate gastric secretions;14 hence allowing a
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cup of coffee at breakfas~ (Table 1) may seem questionable. Usually, however, an adequate amount of other food taken in the morning will dilute- and partially neutralize whatever extra acid is secreted in response to the coffee. The same arguments apply to citrus fruits and their juices. The practice of diluting orange juice half-and-half with TABLE I.-DIET FOR THE PATIENT WITH A HEALED PEPTIC ULCER
Soups: Pureed vegetable soups, preferably diluted with milk. Chicken or meat broths, either clear or with rice. Clam or fish chowder made with milk and potatoes (no onions). Meats: As desired, except spiced or pickled meats, very tough meats, or sausages. Fowl: As desired. Fish: As desired except spiced, kippered or fried fish. Avoid sardines. Shellfish: As desired except crab meat. Potatoes, Rice, Noodles, Macaroni, Spaghetti: As desired. For sauces, plain tomato sauce made from canned tomato soup and grated cheese may be used. Bread: Finely milled bread, whether wheat or rye. Avoid bread containing coarse material or seeds of any type. Griddle cakes may be used. Plain crackers made of well-milled flour. Vegetables: Avoid raw vegetables. Peas, string beans, squash, asparagus, carrots, beets, spinach, lima beans, tender cauliflower may be used as they are ordinarily cooked. Any other vegetable should be pureed, or strained if it contains seeds. Eggs: As desired. Cheese: Cream, cottage, muenster, Swiss, mild (white) American. Avoid cheese spreads. Butter, Oleomargarine: As desired. Sugar, Jelly, Honey, Maple Syrup: As desired. Milk, Cream, Cocoa: As desired (flavoring may be added). Cereals: Any cooked cereal not containing bran. Corn flakes, puffed rice, wheat flakes, dry oatmeal products. Fruit: Apple sauce, ripe banana, baked apple (avoid skin), stewed prunes, canned pears and peaches as desired. Orange, tomato, grape, or prune juice; grapefruit or orange halves, sliced peaches may be used if taken on the full stomach, immediately after a meal. Coffee or Tea: One cup of either may be allowed with breakfast. Desserts: Fruit as above, junket, jeHo, custard, ice cream, rice or cornstarch puddings (no raisins), fruit whips, gelatine products, plain cakes and cookies (no nuts). A-void the following: All spices, catsup, mustard, "hot" sauces, relishes, pickles, spicy dressings or stuffing. Alcohol. Nuts. Carbonated beverages.
hot water has little to recol1unend it, for the only posItIve effect of this procedure is partial destruction of the heat-labile vitamin C contained in the juice. If the patient experiences heartburn or any other gastrointestinal symptoms after breakfast, it is probabJy wise to omit both coffee and citrus fruits. Some patients make a practice of "testing" prohibited foods; i.e.,
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they. eat, let us say, sausage and sauerkraut, experience .no ill effects, and understandably reach the conclusion that they need no longer deprive thelllseives of the pleasures of sausage and sauerkraut. --rhe patient ITlust be cautioned against such "testing." He must realize that \\!hen his ulcer is healed, he can probably get away for the moment with eating anything, hut that repeated ingestion of undesirahle foods 111ay contribute to an eventual ulcer recurrence. Vitamins are adequately supplied by the diet. If the patient is unabJe to tolerate citrus fruits, he requires a daily supplement of 75 mg. of cevitamic acid. Alcohol presents a problem in the treatment of ulcer. It is undoubtedly a stimulant of gastric secretion. On the other hand, some feel that its r~laxing effects on the mind more than offset its damaging effects in the stomach. It is our belief that relaxation can be achieved more beneficially by other and safer means, and that ulcer patients should entirely abstain from alcoholic drinks. 4.· Smoking.-Over one hundred years ago, Cruveilhier15 observed that ulcer patients become so irritated at their dietary restrictions, that "there even arrives a period when such stimulants as game succeed much better than white meats." An analogous situation obtains with respect to smoking. Those ulcer patients who can stop smoking without too much effort should certainly do so. But if the attempt to give up smoking leads to an intolerable increase in tension, the denial of tobacco may do the individual's gastrointestinal tract more harm than good. As a compromise, he is allowed to smoke when his stomach is full (i.e., when the presence of food may counteract any noxious effect that smoking may exert), but never when his stomach is empty. This advice runs counter to some very positive statements in the literature,5, 16 but not all are agreed on the detrimental effects of smoking in the ulcer patient. 17 5. Medications.-Except as indicated under Preparedness, no medications are indicated. 6. Exercise.-Physical exercise, whether during the pursuit of his occupation or at sports, does not harm the patient with a healed ulcer. As is true of all his activities, however, physical fatigue or strenuous activity to which the patient is not accustomed are to be avoided. 7. Follow-up.-After the emotional problems have been satisfactorily worked out, the patient should be seen once every three months to obtain information not only of his progress, but also concerning his adh~rence to the prescribed regimen. Often a little reassurance by the physician is helpful in keeping the patient satisfied with and faithful to his treatment. At the time of each check-up, a hemoglobin determination and a guaiac test for occult blood in the stools are indicated. Repeated roentgenographic studies are not necessary in following a du<;>denal ulce~, provided symptoms remain in abeyance. On the other h(ll}d, i~ is probably wise to observe the progress of a large duodenal
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ulcer by repeating the x-ray studies about one year after the original demonstration of the ulcer. Gastric ulcers present a different follow-up problem because the possibility of neoplasm is ever present, even in gastric ulcers which show complete healing, as judged by disappearance of symptoms and of abnormal roentgenologic findings. I8 In such cases, the patient should be seen at monthly intervals for six months, at bimonthly periods for the next half year, and then every three months. If symptoms, weight loss or occult bleeding occur, immediate reexamination by roentgenologic means is indicated. If the patient remains asymptomatic, repeat x-ray studies should be performed every three months for one year. Only by such careful observation can one decide whether one is dealing with a malignant or benign gastric ulceration. 8. Preparedness.-Some patients notice a seasonal incidence of their ulcer recurrences. Others realize that their symptoms are often preceded by certain circumstances: colds, emotional upsets, fatigue, and so forth. Hence, the patient is advised to adopt a more intensive therapeutic regimen under the following conditions: (a) At the beginning of a season which, on the basis of past experience, he associates with recurrent ulcer symptoms. ( b) Whenever he is suffering from an acute respiratory infection. (c) Whenever he is severely fatigued, or when he is performing more than his usual amount of work. (d) Whenever his emotional tension is heightened, as evidenced by insomnia, restlessness, increased irritability, or "nervousness." The intensified regimen which is given to ulcer patients under the conditions listed above consists of: . (a) Strict adherence to the interval feedings and diet as given, except that coffee and citrus foods are eliminated completely. (b) Tincture of Belladonna, 12 minims (0.8 cc.) three times a day immediately after meals and at bedtime. (Belladonna has been prescribed at various times with respect to meals; we give it immediately after meals in the hope that it may be effective at a time when ulcer symptoms occur: one to two hours after food ingestion. The optimum dose is one which barely causes a faint dryness of the mouth.) (c) An antacid, consisting either of: (1) Aluminum hydroxide gel-2 dranls (8 cc.)
or
(2) A powder-l dram (4 gm.) Calcium Carbonate 1 part Magnesium Carbonate 1 part Bisnluth Subcarbonate 2 parts To be taken one hour after meals and at bedtime.
(d) Increased physical rest: earlier bedtime, rest on week-ends, can-
cellation of social activities and work which is not essential.
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The intensified regimen must be initiated before symptoms begin. By this means, circumstances which presumably play a role in precipitating a recurrent ulcer may often be prevented from bringing about their lamentable results. If symptoms arise in spite of all efforts to the contrary, the patient should notify his physician immediately. TABLE 2.-INSTRUCTIONS FOR THE PATIENT \VITH A HEALED PEPTIC ULCER
. Under certain circumstances, peptic ulcer can recur in persons who are subject to this disorder. You can reduce the chances of such a recurrence, however, by following these simple rules: ' 1. Stick to your diet. If you wonder whether a certain food is allowable, ask the doctor. Do not "test" foods to determine whether they cause symptoms or not. II. Drink a glass of milk regularly half-way between meals and at bedtime. You may take simple crackers with the milk if you so desire. III. Your ulcer is particularly apt to recur: 1. In the (physician fills in season of recurrence, if any). 2. \Yhen you ha~e .colds, .sore throats, coughs. If you take medicines for these illnesses, take them with milk. 3. When you are physically fatigued or doing more than your usual amount of work. 4. When you are emotionally upset, or more irritable, sleepless or "nervous" than usual. IV. Hence, whenever you are exposed to any of thecircumstanc~s listed under III, you should' automatically take steps to prevent an ulcer recurrence: 1. Be very careful to observe points I and II. 2. Take 2 teaspoonfuls of one hour after meals and at bedtime (4 times daily). 3. Take 12 drops of Tincture of Belladonna in a half a glass of water just after meals and at bedtime (4 times daily). 4. Go to bed earlier than usual; you do not necessarily have to sleep, but it is important for you to get extra rest in bed. Rest on weekends. Cancel social activities and such work as is non-essential. 5. Observe this intensified form of treatment for at least one week. As a rule, it should be observed as long as the aggravating factors listed under III are present. V. If you have any ulcer symptoms, notify your doctor immediately.
In addition to the diet, a printed list of instructions (an example is given in Table 2) can be given to the patient with advantage, for his memory of verbal instructions may fade with appalling rapidity. SUMMARY
Although an uncomplicated peptic ulcer responds excellently to sound medical treatment, ulcers will recur within five years in well over one-half the patients. Therapeutic emphasis should therefore be placed on the prevention of recurrences. At present, no specific means is available for this purpose. On the other hand, the frequency and severity of recurrent peptic ulcers can often be reduced by a practical regimen which opposes some of the factors concerned in the patho-
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genesis of peptic ulcer, but which is not too arduous for the patient to observe. The proposed regimen embodies the following points: (1) education of the patient, (2) psychotherapy, (3) dietary management with interval feedings, (4) regulation concerning alcohol, tobacco and exercise, (5) follow-up observations and (6) preparedness, so that the patient who is exposed to a circumstance. known to aggravate peptic ulcer adopts an intensified therapeutic regimen before any symptoms develop. BIBLIOGRAPHY
1. St. John, F. B. and Flood, C. A.: A Study of the Results of Medical Treatment of Duodenal Ulcer. Ann. Surg., 110:37, 1939. 2. Holland, A. L. and Logan, V. W.: A Brief Report of a Follow-up Research
in Peptic Ulcer Covering Twenty Years. Tr. Am. Therap. Soc., 41:86, 1941. 3. Heuer, G. J.: The Treatment of Peptic Ulcer. Philadelphia, J. B. Lippincott Co., 1944. 4. Miller, T. G.: The Medical Treatment of Peptic Ulcer. M. CLIN. NORTH AMERICA, 128(2) :403 (March) 1944. 5. Held, I. W.: Management of the Peptic Ulcer Patient. M. CLIN. NORTH AMERICA, 126(3) :654 (May) 1942. 6. Emery, E. S., Jr.: The Treatment of the Patient With an Uncomplicated Peptic Ulcer. M. CI..IN. NORTH AMERICA, 128(5): 1164 (Sept.) 1944. 7. Ingelfinger, F. J.: The Treatment of Gastric and Duodenal Ulcer. M. CLIN. NORTH . l. \MERICA, 125 (5): 1363 (Sept.) 1941. 8. Ivy, A. C.: The Prevention of Recurrence of "Peptic" Ulcer: An Experimental Study. Gastroenterology, 3.:443, 1944. 9. Alexander, F.: The Influence of Psychologic Factors Upon Gastro-intestinal Disturbances: A Symposium. I. General Principles, Objectives, and Preliminary Results. Psychollalyt. Quart., 3.:501, 1934. 10. Draper, G., Dupertuis, C. W. and Caughey, J. L., Jr.: Human Constitution In Clinical Medicine. New York, Paul B. Hoeber, Inc., 1944, pp. 206-238. 11. Wolf, S. and Wolff, H. G.: Human Gastric Function: An Experimental Study of a Man and His Stomach. New York, Oxford Univ. Press, 1943. 12. Mittelmann, B. and Wolff, H. G.: Emotions and Gastroduodenal Function: Experimental Studies On Patients With Gastritis, Duodenitis, and Peptic Ulcer. Psychosom. Med., 4:5, 1942. 13. Jacobson, E.: You Must Relax. New York, Whittlesey Rouse, 1942., 14. Roth, J. A., Ivy, A. C. and Atkinson, A. J.: Caffeine and "Peptic" Ulcer: Relation of Caffeine and Caffeine-Containing Beverages to the Pathogenesis, Diagnosis and Management of "Peptic" Ulcer. J.A.M.A., 126:814, 1944.
15. Cruveilhier, J.: Anatomie Pathologique du Corps Rumain. Vol. I, Xe
Livraison. Paris, ]. B. Bailliere, 1835.
16. Ehrenfeld, I. and Sturtevant, M.: The Effect of Tobacco Smoking on Gastric Acidity. Am. ]. M. Sc., 201:81, 1941. 17. Schnedorf, J. G. and Ivy, A. C.: ~he Effect of Tobacco Smoking on the Alimentary Tract. ].A.M.A., 112:898, 1939.
18. Palmer, W. L. and Humphreys, E. M.: Gastric Carcinoma: Observations on Peptic Ulceration and Healing. Gastroenterology, 3:257, 1944.
M.D.*
AND ROBERT
E. Moss, M.D.t
THE patient with an uncomplicated peptic ulcer presents a rather startling therapeutic paradox. His immediate response to medical therapy is excellent; his outlook for the future, by contrast, is dark. The chances are more than fifty-fifty that his ulcer will again trouble him within two years, and the likelihood of a recurrence in five years is probably over 65 per cent.!' 2, 3 It follows that emphasis today need not be placed on the immediate therapy of the active ulcer, for which several satisfactory regimens have appeared in these pages,4, 5, 6, 7 but upon the ways and means whereby reactivation of a healed ulcer can be prevented. Recent studies with enterogastrone, 8 a gastro-inhibitory substance extracted from the small intestine, hold out the hope that such substances may eventually be used for the long-term therapy of the ulcer patient. Enterogastrone, however, is still in the experimental stage, and at present one must content himself with more indirect methods of combating ulcer recurrences. The methods outlined in this clinic are directed against those factors which are generally believed to play a part in the pathogenesis of a peptic ulcer. Both physician and patient may argue that some of the procedures are unnecessary, time-consuming and expensive, particularly since the patient under discussion has a healed ulcer and is free of symptoms. In view of the high incidence of recurrences, however, such argulnents cannot bear much weight. In the long run, time and money lost in taking care of a recurrent ulcer-possibly an ulcer complicated by bleeding or obstruction,-greatly exceed the loss incurred by adopting a program aimed at preventing the recurrence. Too vigorous a program, it is true, will be discouraging and will lead to deviations from the too narrow path. The best schedule calls for some effort on the part of the patient, but not for a wholesale abandonment of the pleasures of life.
From the Evans Memorial, Massachusetts Memorial Hospitals, and the Department of Medicine, Boston University School of Medicine, Boston. *Assistant Professor of Medicine, Boston University School of Medicine; Member of Department, Robert Dawson Evans Memorial; ·Physician, Medical Service, and Chief, Gastrointestinal Outpatient Clinic, Massachusetts Melnorial Hospitals. t Instructor in Medicine, Boston University School of Medicine; Assistant Physician, Robert Dawson Evans Memorial; Assistant Visiting Physician and Chief, Psychosomatic Medicine Outpatient Clinic, Massachusetts Memorial Hospitals. 1162
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How successful is a program of prevention apt to be? Obviously, no guarantee can be given; some ulcers will recur no matter how carefully the patient is handled. On the other hand, we believe that the methods here outlined will, in a large number of ulcer cases, reduce the chances, frequency and severity of recurrences. A SUGGESTED REGIMEN
The patient is assumed to have had a peptic ulcer, now healed and not causing any symptoms. Some parts of the regimen to be prescribed -i.e., those dealing with the patient's education and personality-. should actually be started during treatment for the active ulcer. 1. Education.-The basic facts of peptic ulcer should be explained to the patient. By giving him an appreciation of the causes and course of his illness, two objectives will be attained. First, he will not be subject either to the carelessness of ignorance, or to the worry occasioned by various misconceptions that he may harbor. Second, he will follow directions more intelligently and more cooperatively if he understands the purpose of the prescribed regimen. The exact terminology used by the physician in elucidating peptic ulcer naturally depends upon the patient's background, but the following major points can be expressed in language understandable to most laymen: (a) The exact cause of peptic ulcer is unknown, but physicians do know that an ulcer gets worse when the stomach is overly active and produces more than the usual quantities of acid. ( b) Excess activity and excess acid production by the stomach are particularly apt to occur under the influence of certain mental states and as a result of poor dietary habits. Therefore, the aim of ulcer prevention is adjustment of the mental states and elimination of poor habits. In addition, gastric acidity can be diluted and partially neutralized by the frequent intake of suitable foods and, if needed, ll1edicines. (c) Individual peptic ulcers can be cured quite readily, but the tendency of the patient to get an ulcer cannot be cured: ulcers can and do reappear under the proper conditions. Hence, if the patient is to avoid a ·recurrence, he must be ready to follow a moderate form of treatment for years. For ·purposes of reassurance, the pa:tiehtis told that duodenal ulcers never become cancerous.' Whether he should be warned of complications-i. e., perforation, bleeding and obstruction-is a debatable point. Tp mention these dangers ina blunt or threatening fashion will serv'e no purpose but to make the patient unduly apprehensive. On the other hand,' he should be informed of the possibility of bleeding so that he may acquire the habit of observing his stools routinely for signs of melena or blood. ' ~ .. Ps~chot·herapy.-That .peptic ulc~r ~atients present striking similarIties In appearance and· In personalIty IS generally recognized. Most
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therapeutic regimens, consequently, advocate treating the individual as well as the ulcer. How can this be done? Simple admonitions to "take things easily" and to "stop worrying" are not sufficient; the" patient obviously would rest and free himself of worry' if he could. On the other hand, it is neither necessary nor practical to refer most ulcer patients to a trained psychiatrist. Much can be accomplished by the physician who grasps the essentials of the ulcer patient's personality and who is willing to practice some of the simpler technics of psychotherapy. Description of the Personality.-Freudian psychoanalysis9 indicates. that the ulcer patient has a strong wish to be ,cared for and loved as he ,vas in infancy. As a result of the early infantile association of being loved with being fed, he desires food as a symbol of security and affection, a desire which maintains the stomach in a constantly active state. Such an attitude is incompatible with the striving of the adult for independence and activity. Hence, the wish to be cared for and fed is repressed into the unconscious, while the conscious mind is occupied in overcompensatory fashion with desires to be the efficient, responsible, conscientious, aggressive leader. As a result, marked conflict is present within the individual and is evidenced by chronic emotional tension. Approaching the problenl on the conscious level by the interview method, Draper and his associates10 have reached similar conclusions which they express somewhat differently. Ulcer patients, according to these authors, are extremely conscientious victims of chronic fear, who are driven to strive constantly toward some goal regardless of the difficulties encountered. Their driving fear stems from their dimly sensed awareness of the "feminine component" (passive, receptive tendencies) in their make-up which seems to threaten their ability to play successfully the masculine role in life. This "basic male fear" presses thenI to reassure themselves by overemphasizing their virile, aggressive tendencies. Thus, the male ulcer patient suffers from a deep-seated conflict which is manifested in an excessive load of anxiety-apprehensive anticipation-and concomitant bodily tension. Plainly herpust be restlessly active, worrisome and unable to relax. A sinlilar e~otional pattern usually characterizes the female ulcer patient, although the underlying conflicts are influenced by the difference jn sex. ' Correlation ~f Gas.t,ric Physiology and Perso~~lityRe~ptions.-Sug gestive observations of far~reaching inlpor~a~c~.-hC1.v:e b~.eJ;l, ~ade by' Wolf and Wolff1! ' on the stomach of the~'"s:~bje~~,~:T(jm, throug~ .whose gastrostomy they were able to study the physIologic chang~~ in gastric function .occasioned by varied stimuli. In response to acute aggressive feelings and anxiety, his gastric Illucosa bec~IJ.le engorged and much redder than usual, the levels of free acid secretion and total volume' of gas,tric juice were three times nornlal, and' there was a
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vigorous increase in gastric motor activity. Similar changes of hyperemia, hypersecretion, hyperacidity and hypermotility occurred and persisted during periods of proloned anxiety and resentment; nor did these effects subside during sleep. Tom's emotional reactions, in short, caused his stomach to assume a state of preparedness for the reception and digestion of food. Further, in normal subjects and in patients with the clinical diagnosis of peptic ulcer, gastritis and duodenitis, Mittelmann and Wolff12 showed that hypermotility, hypersecretion and hyperacidity occurred in a setting of ,anxiety and resentment.· Such functional disturbances persisted throughout the duration of these emotions and did not abate during sleep. While these changes were present, subjective complaints of pain and epigastric burning were likewise present. The difference between the reactions of the normal subjects an,d those of the patients was simply a matter of degree. These observations point toward the local mechanisms for translating emotional reactions into gastroduodenal functionai disorders which presumably lead to symptoms and structural changes. They also point the way toward effective management of the patient. Psychotherapeutic Method.-1\1uch, then, must be known about the patient in order to understand what influences are affecting his stomach. He should, accordingly, be interviewed privately, ina leisurely, friendly manner that will convey to him the impression that one is interested in him as a person. To encourage him to talk freely about himself, he is asked to describe the onset and course of his symptoms in detail, as these are generally uppermost in his mind. By simple questioning, he can be led to elaborate upon the setting, environmental and subjective, in which symptoms first appeared, persisted or recurred. It is important to. ask him how he felt at these times, what he thought about, how he gQt along with others, how well he was succeeding in his work, and how he vie\ved his future. ' EXAMPLE 1.-The, value of probing closely into the setting in which a symptom first occurs is exemplified by a patient convalescing from a subtotal gastrectomy for obstructing duodenal ulcer. The patient reported that he had begun to vomit as soon as he got horne from the hospital and. had vomited frequently, especially after taking orange juice, during the succeeding three weeks. When asked what the orange juice had reminded him of, he recalled that it had upset him repeatedly prior to operation and that he had suddenly thought of this while drinking it. Further inquiry revealed that vomiting had actually begun two days prior to discharge, shortly after he had taken orange juice at breakfa~t. All the previous night, he remembered, he had felt "jittery," and had slept poorly, beca\1se he had been given an intravenous iniection (a liver function test) the afternoon before. This injection had been given with little explanation; he had immediately concluded that something was still wrong with him and had become acutely anxious; he had thought he could taste the material injected and that it tasted like vomitus. Against this background, the orange juice, which he had been taking daily without distress, precipitated his vomiting. Following discharge, he could not lose the fear that something was atniss, and the gastrointesdnal tension was perpetuated, relieved somewhat by periodic vomiting. The elic-
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iting of this chain of events opened the way to simple explanation of the purpose of the injection, and to reassurance as to the good result obtained by his operation. Thereafter, the patient ceased, to be trou'bled by vomiting and was able to drink orange juice \vith impunity.
Usually, an outline of the habitual enlotional patterns of the patient during the period of his illness can be obtained at the first interview. This outline suffices for the preliminary formulation of the pati~nt's problem in terms that he can understand. One shows him by summarizing the evidence he has presented that he has an underlying ·sense of insecurity which is conscious to him as anxiety. This anxiety forces him into a state of constant preparedness for action, manifested by general bodily tension and an inability to relax. The patient usually means these things when he says that he always worries. Experience indicates that any eagerness on the part,of the physician to give a more penetrating interpretation early in therapy is unwise. The patient will seldom accept anything more than a rough sketch of the problem, and may well be driven away by an attempt to give him deeper insight quickly. · However, expanding the forlllulationby pointing out that the patient resembles in his personality make...up a. great ,multitude of peptic ulcer bearers adds to its force and appears to give him a sense of relief by showing him that he has many fellow-sufferers. He is then more easily convinced that his type of personality can lead to overactivity of the stomach. He shows n1uch interest in gaining a clearer picture of the mechanism that produces his symptom,s and is, consequently, receptive to instructions aimed at ,giving him relief. ' EXAMPLE 2.-The beneficial effect upon acute symptoms of the above approach is well exemplified in the case of a 44-year old white man whose ulcer symptoms dated back twenty years. He had been admitted to the hospital because of symptoms indicating severe pyloric obstruction. Constant aspiration of stomach contents for three days, followed by a strict feeding regimen and nightly aspiration, resulted in little relief of pain. The patient was interviewed on the seventh day and the relationship between his anxious, aggressive attitude and his. ulcer symptoms was pointed out. He was then given a brief description of the effects of this attitude upon his stomach. The impression this made upon him was striking: he concluded that he could "let go" of much of his anxiety, at least temporarily, and that his aggressiveness was really hurting only himself. Thereafter, his symptoms were greatly alleviated, despite the later finding at operation that the obstruction was largely due to scar tissue.
At the end of the first visit, the procedure to be followed subsequently is outlined to the patient. He will be seen weekly, preferably for one hour at each visit, during which he will be asked to talk in greater detail and with complete frankness about himself" Chrono.,. logical order is not essential, as significant relationships will come out eventually no matter where he starts. Questions may frequently be necessary, 'at first, to keep him going, or to bring out further details. As the story of his significant interpersonal relationship unfolds, he i~
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given a summarizing interpretation at the end of each interview. His appreciation of the reasons behind his early and persisting insecurity will gradually deepen, and he will realize how this feeling of insecurity determined his emotional reactions and, hence, his behavior and health throug~out his life. The'development of insight, in this fashion, generally relieves a patient of much of his anxiety with concomitant lessening of his gastric overa~tivity. The patient, however, must be helped to apply his new knowl~dge and to understand his reactions in varied situations coming up in his daily living. It is this "working-through" of his problem in as many ramifications as possible that gradually effects a lasting change in attitude which can be summed up as growth in emotional maturity. In ~ddition, he may be started on a program designed to train him in the art of bodily relaxation. For the intelligent patient a satisfactory recommendation is that he obtain a copy of You Must Rela~ by Jacobson13 and start putting its principles into practice. Much simplified adaptations of these principles may be presented to the patient who seems unlikely to benefit from reading the book. The physician, finally, emphasizes that peptic ulceration is the end result of a long chain of circumstances involving the patient's total personality; that successful treatment requires reeducation of his emotional responses as well as a medical regimen; that there is no shortcut to the desired result; and that the length of time necessary to effect readjustments in his personality will be dependent upon his cooperation. 3. Diet.-A fairly liberal diet can be offered to the patient with a healed ulcer (Table 1). Much more important than the type of food, however, is regularity of eating habits. The patient must eat at the same. times every day. This rule has to be stressed particularly to traveling salesmen and others whose work is apt to interfere with regular eating habits. Actually, there are very few occupations which cannot be harmonized with regular food ingestion. Interval feedings of milk must be taken regularly in the middle of the forenoon, in the middle of the afternoon, and at bedtime. If the interval between the evening meal and bedtime is long, an additional glass· of milk in the middle of the evening is advisable. Except when asleep, the patient should never go more than three hours without taking food or drink. Milk is without doubt the substance most suitable for interval feedings, but compromises may be made with the patient's taste by using flavoring, eggnogs, custards, junkets, or vegetabl~ purees made with milk. With the milk, plain crackers or cake may be taken if the patient so desires. On the other hand, the patient must understand that other foodstuffs-particularly coffee and soft drinks-are not acceptable substitutes for milk. . Certain foods present particular problems. Caffeine-containing beverages are known to stimulate gastric secretions;14 hence allowing a
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cup of coffee at breakfas~ (Table 1) may seem questionable. Usually, however, an adequate amount of other food taken in the morning will dilute- and partially neutralize whatever extra acid is secreted in response to the coffee. The same arguments apply to citrus fruits and their juices. The practice of diluting orange juice half-and-half with TABLE I.-DIET FOR THE PATIENT WITH A HEALED PEPTIC ULCER
Soups: Pureed vegetable soups, preferably diluted with milk. Chicken or meat broths, either clear or with rice. Clam or fish chowder made with milk and potatoes (no onions). Meats: As desired, except spiced or pickled meats, very tough meats, or sausages. Fowl: As desired. Fish: As desired except spiced, kippered or fried fish. Avoid sardines. Shellfish: As desired except crab meat. Potatoes, Rice, Noodles, Macaroni, Spaghetti: As desired. For sauces, plain tomato sauce made from canned tomato soup and grated cheese may be used. Bread: Finely milled bread, whether wheat or rye. Avoid bread containing coarse material or seeds of any type. Griddle cakes may be used. Plain crackers made of well-milled flour. Vegetables: Avoid raw vegetables. Peas, string beans, squash, asparagus, carrots, beets, spinach, lima beans, tender cauliflower may be used as they are ordinarily cooked. Any other vegetable should be pureed, or strained if it contains seeds. Eggs: As desired. Cheese: Cream, cottage, muenster, Swiss, mild (white) American. Avoid cheese spreads. Butter, Oleomargarine: As desired. Sugar, Jelly, Honey, Maple Syrup: As desired. Milk, Cream, Cocoa: As desired (flavoring may be added). Cereals: Any cooked cereal not containing bran. Corn flakes, puffed rice, wheat flakes, dry oatmeal products. Fruit: Apple sauce, ripe banana, baked apple (avoid skin), stewed prunes, canned pears and peaches as desired. Orange, tomato, grape, or prune juice; grapefruit or orange halves, sliced peaches may be used if taken on the full stomach, immediately after a meal. Coffee or Tea: One cup of either may be allowed with breakfast. Desserts: Fruit as above, junket, jeHo, custard, ice cream, rice or cornstarch puddings (no raisins), fruit whips, gelatine products, plain cakes and cookies (no nuts). A-void the following: All spices, catsup, mustard, "hot" sauces, relishes, pickles, spicy dressings or stuffing. Alcohol. Nuts. Carbonated beverages.
hot water has little to recol1unend it, for the only posItIve effect of this procedure is partial destruction of the heat-labile vitamin C contained in the juice. If the patient experiences heartburn or any other gastrointestinal symptoms after breakfast, it is probabJy wise to omit both coffee and citrus fruits. Some patients make a practice of "testing" prohibited foods; i.e.,
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they. eat, let us say, sausage and sauerkraut, experience .no ill effects, and understandably reach the conclusion that they need no longer deprive thelllseives of the pleasures of sausage and sauerkraut. --rhe patient ITlust be cautioned against such "testing." He must realize that \\!hen his ulcer is healed, he can probably get away for the moment with eating anything, hut that repeated ingestion of undesirahle foods 111ay contribute to an eventual ulcer recurrence. Vitamins are adequately supplied by the diet. If the patient is unabJe to tolerate citrus fruits, he requires a daily supplement of 75 mg. of cevitamic acid. Alcohol presents a problem in the treatment of ulcer. It is undoubtedly a stimulant of gastric secretion. On the other hand, some feel that its r~laxing effects on the mind more than offset its damaging effects in the stomach. It is our belief that relaxation can be achieved more beneficially by other and safer means, and that ulcer patients should entirely abstain from alcoholic drinks. 4.· Smoking.-Over one hundred years ago, Cruveilhier15 observed that ulcer patients become so irritated at their dietary restrictions, that "there even arrives a period when such stimulants as game succeed much better than white meats." An analogous situation obtains with respect to smoking. Those ulcer patients who can stop smoking without too much effort should certainly do so. But if the attempt to give up smoking leads to an intolerable increase in tension, the denial of tobacco may do the individual's gastrointestinal tract more harm than good. As a compromise, he is allowed to smoke when his stomach is full (i.e., when the presence of food may counteract any noxious effect that smoking may exert), but never when his stomach is empty. This advice runs counter to some very positive statements in the literature,5, 16 but not all are agreed on the detrimental effects of smoking in the ulcer patient. 17 5. Medications.-Except as indicated under Preparedness, no medications are indicated. 6. Exercise.-Physical exercise, whether during the pursuit of his occupation or at sports, does not harm the patient with a healed ulcer. As is true of all his activities, however, physical fatigue or strenuous activity to which the patient is not accustomed are to be avoided. 7. Follow-up.-After the emotional problems have been satisfactorily worked out, the patient should be seen once every three months to obtain information not only of his progress, but also concerning his adh~rence to the prescribed regimen. Often a little reassurance by the physician is helpful in keeping the patient satisfied with and faithful to his treatment. At the time of each check-up, a hemoglobin determination and a guaiac test for occult blood in the stools are indicated. Repeated roentgenographic studies are not necessary in following a du<;>denal ulce~, provided symptoms remain in abeyance. On the other h(ll}d, i~ is probably wise to observe the progress of a large duodenal
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ulcer by repeating the x-ray studies about one year after the original demonstration of the ulcer. Gastric ulcers present a different follow-up problem because the possibility of neoplasm is ever present, even in gastric ulcers which show complete healing, as judged by disappearance of symptoms and of abnormal roentgenologic findings. I8 In such cases, the patient should be seen at monthly intervals for six months, at bimonthly periods for the next half year, and then every three months. If symptoms, weight loss or occult bleeding occur, immediate reexamination by roentgenologic means is indicated. If the patient remains asymptomatic, repeat x-ray studies should be performed every three months for one year. Only by such careful observation can one decide whether one is dealing with a malignant or benign gastric ulceration. 8. Preparedness.-Some patients notice a seasonal incidence of their ulcer recurrences. Others realize that their symptoms are often preceded by certain circumstances: colds, emotional upsets, fatigue, and so forth. Hence, the patient is advised to adopt a more intensive therapeutic regimen under the following conditions: (a) At the beginning of a season which, on the basis of past experience, he associates with recurrent ulcer symptoms. ( b) Whenever he is suffering from an acute respiratory infection. (c) Whenever he is severely fatigued, or when he is performing more than his usual amount of work. (d) Whenever his emotional tension is heightened, as evidenced by insomnia, restlessness, increased irritability, or "nervousness." The intensified regimen which is given to ulcer patients under the conditions listed above consists of: . (a) Strict adherence to the interval feedings and diet as given, except that coffee and citrus foods are eliminated completely. (b) Tincture of Belladonna, 12 minims (0.8 cc.) three times a day immediately after meals and at bedtime. (Belladonna has been prescribed at various times with respect to meals; we give it immediately after meals in the hope that it may be effective at a time when ulcer symptoms occur: one to two hours after food ingestion. The optimum dose is one which barely causes a faint dryness of the mouth.) (c) An antacid, consisting either of: (1) Aluminum hydroxide gel-2 dranls (8 cc.)
or
(2) A powder-l dram (4 gm.) Calcium Carbonate 1 part Magnesium Carbonate 1 part Bisnluth Subcarbonate 2 parts To be taken one hour after meals and at bedtime.
(d) Increased physical rest: earlier bedtime, rest on week-ends, can-
cellation of social activities and work which is not essential.
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The intensified regimen must be initiated before symptoms begin. By this means, circumstances which presumably play a role in precipitating a recurrent ulcer may often be prevented from bringing about their lamentable results. If symptoms arise in spite of all efforts to the contrary, the patient should notify his physician immediately. TABLE 2.-INSTRUCTIONS FOR THE PATIENT \VITH A HEALED PEPTIC ULCER
. Under certain circumstances, peptic ulcer can recur in persons who are subject to this disorder. You can reduce the chances of such a recurrence, however, by following these simple rules: ' 1. Stick to your diet. If you wonder whether a certain food is allowable, ask the doctor. Do not "test" foods to determine whether they cause symptoms or not. II. Drink a glass of milk regularly half-way between meals and at bedtime. You may take simple crackers with the milk if you so desire. III. Your ulcer is particularly apt to recur: 1. In the (physician fills in season of recurrence, if any). 2. \Yhen you ha~e .colds, .sore throats, coughs. If you take medicines for these illnesses, take them with milk. 3. When you are physically fatigued or doing more than your usual amount of work. 4. When you are emotionally upset, or more irritable, sleepless or "nervous" than usual. IV. Hence, whenever you are exposed to any of thecircumstanc~s listed under III, you should' automatically take steps to prevent an ulcer recurrence: 1. Be very careful to observe points I and II. 2. Take 2 teaspoonfuls of one hour after meals and at bedtime (4 times daily). 3. Take 12 drops of Tincture of Belladonna in a half a glass of water just after meals and at bedtime (4 times daily). 4. Go to bed earlier than usual; you do not necessarily have to sleep, but it is important for you to get extra rest in bed. Rest on weekends. Cancel social activities and such work as is non-essential. 5. Observe this intensified form of treatment for at least one week. As a rule, it should be observed as long as the aggravating factors listed under III are present. V. If you have any ulcer symptoms, notify your doctor immediately.
In addition to the diet, a printed list of instructions (an example is given in Table 2) can be given to the patient with advantage, for his memory of verbal instructions may fade with appalling rapidity. SUMMARY
Although an uncomplicated peptic ulcer responds excellently to sound medical treatment, ulcers will recur within five years in well over one-half the patients. Therapeutic emphasis should therefore be placed on the prevention of recurrences. At present, no specific means is available for this purpose. On the other hand, the frequency and severity of recurrent peptic ulcers can often be reduced by a practical regimen which opposes some of the factors concerned in the patho-
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genesis of peptic ulcer, but which is not too arduous for the patient to observe. The proposed regimen embodies the following points: (1) education of the patient, (2) psychotherapy, (3) dietary management with interval feedings, (4) regulation concerning alcohol, tobacco and exercise, (5) follow-up observations and (6) preparedness, so that the patient who is exposed to a circumstance. known to aggravate peptic ulcer adopts an intensified therapeutic regimen before any symptoms develop. BIBLIOGRAPHY
1. St. John, F. B. and Flood, C. A.: A Study of the Results of Medical Treatment of Duodenal Ulcer. Ann. Surg., 110:37, 1939. 2. Holland, A. L. and Logan, V. W.: A Brief Report of a Follow-up Research
in Peptic Ulcer Covering Twenty Years. Tr. Am. Therap. Soc., 41:86, 1941. 3. Heuer, G. J.: The Treatment of Peptic Ulcer. Philadelphia, J. B. Lippincott Co., 1944. 4. Miller, T. G.: The Medical Treatment of Peptic Ulcer. M. CLIN. NORTH AMERICA, 128(2) :403 (March) 1944. 5. Held, I. W.: Management of the Peptic Ulcer Patient. M. CLIN. NORTH AMERICA, 126(3) :654 (May) 1942. 6. Emery, E. S., Jr.: The Treatment of the Patient With an Uncomplicated Peptic Ulcer. M. CI..IN. NORTH AMERICA, 128(5): 1164 (Sept.) 1944. 7. Ingelfinger, F. J.: The Treatment of Gastric and Duodenal Ulcer. M. CLIN. NORTH . l. \MERICA, 125 (5): 1363 (Sept.) 1941. 8. Ivy, A. C.: The Prevention of Recurrence of "Peptic" Ulcer: An Experimental Study. Gastroenterology, 3.:443, 1944. 9. Alexander, F.: The Influence of Psychologic Factors Upon Gastro-intestinal Disturbances: A Symposium. I. General Principles, Objectives, and Preliminary Results. Psychollalyt. Quart., 3.:501, 1934. 10. Draper, G., Dupertuis, C. W. and Caughey, J. L., Jr.: Human Constitution In Clinical Medicine. New York, Paul B. Hoeber, Inc., 1944, pp. 206-238. 11. Wolf, S. and Wolff, H. G.: Human Gastric Function: An Experimental Study of a Man and His Stomach. New York, Oxford Univ. Press, 1943. 12. Mittelmann, B. and Wolff, H. G.: Emotions and Gastroduodenal Function: Experimental Studies On Patients With Gastritis, Duodenitis, and Peptic Ulcer. Psychosom. Med., 4:5, 1942. 13. Jacobson, E.: You Must Relax. New York, Whittlesey Rouse, 1942., 14. Roth, J. A., Ivy, A. C. and Atkinson, A. J.: Caffeine and "Peptic" Ulcer: Relation of Caffeine and Caffeine-Containing Beverages to the Pathogenesis, Diagnosis and Management of "Peptic" Ulcer. J.A.M.A., 126:814, 1944.
15. Cruveilhier, J.: Anatomie Pathologique du Corps Rumain. Vol. I, Xe
Livraison. Paris, ]. B. Bailliere, 1835.
16. Ehrenfeld, I. and Sturtevant, M.: The Effect of Tobacco Smoking on Gastric Acidity. Am. ]. M. Sc., 201:81, 1941. 17. Schnedorf, J. G. and Ivy, A. C.: ~he Effect of Tobacco Smoking on the Alimentary Tract. ].A.M.A., 112:898, 1939.
18. Palmer, W. L. and Humphreys, E. M.: Gastric Carcinoma: Observations on Peptic Ulceration and Healing. Gastroenterology, 3:257, 1944.