Intestinal Plumbing

For several years surgeons of the Mayo Clinic "have been becoming more & more fearful of operating on the keen, nervous, active, hard-living, 'go-getting', sales-manager type of man" who comes to them with an intestinal ulcer. That type is apt to develop another ulcer soon after the operation. Especially is this so if the man is of Jewish ancestry. The Jew seems to be particularly subject to a severe type of recurrent ulcer. Dr. Walter Clement Alvarez, Mayo internist, makes these observations in a thoroughgoing review of peptic ulcer, published last week in the American Journal of Surgery. For more than 50 years able men have been struggling with peptic ulcer.

A few minutes after the food enters, the stomach secretes hydrochloric acid and pepsin which digest the food into a sour semifluid called chyme. The stomach churns this chyme, pumps it through a valve called the pylorus (gatekeeper) into the duodenum.

The duodenum, eleven inches long, is the beginning of the long small intestine. Here enter juices from the gall-bladder and pancreas. Those juices with the help of the duodenum's own alkaline secretions (mainly sodium bicarbonate), reduce the sour chyme's acidity. While this chemistry is going on, the duodenum pumps the mix forward into the next section of the intestine, the 8 ft. jejunum. During passage through the jejunum the alkalinization of the chyme ordinarily completes itself. The chyme becomes chyle, a creamy, nourishing substance which, while welling through more yardage of intestine, passes into the blood through lymphatic structure called lacteals.

Peptic ulcers occur in the stomach, duodenum and jejunum. Those parts of the anatomy are to the surgeon what a washbowl, water trap and waste pipe are to a master plumber. The surgeon can remove parts of the stomach, duodenum and jejunum. He can remove any one of them entirely if necessary. In extremity he can take all three out and keep the patient alive for a time by fluids through rectum or veins. But the surgeon's ordinary plumbing for peptic ulcer is to cut out the diseased section of stomach, or diseased length of duodenum or jejunum. Then he solders up the hole. The method Dr. Alvarez prefers gives the stomach an artificial outlet. The ulcerated section of the duodenum or jejunum is cut out, the healthy ends are sewed together and to the stomach's artificial opening. Thus the jejunum connects directly with the acid stomach, gets a protective alkaline seepage from the connected duodenum. By this procedure the Mayo Clinic avoids many a secondary ulcer in the jejunum.

Surgery can remove ulcers. But what causes them? There are several theories but none satisfies Dr. Alvarez and his Mayo colleagues entirely "because they do not explain the peculiarities of the disease as it occurs in man. Thus they do not tell us why in this country men are more subject to the disease than women, and why in some other parts of the world men and women are equally affected. They do not explain why jejunal ulcer is seen ten times as often in men as in women, and they do not help us to understand why today, in America, duodenal ulcer is so much more common than gastric ulcer when in some parts of Europe the reverse appears to be true now or to have been true in the past. They do not explain why duodenal ulcer tends to come in the twenties and thirties and why gastric ulcer tends to come in the thirties and forties. They do not explain why gastric ulcers usually cease growing when they are 2.5 cm. [1 in.] in diameter and why duodenal ulcers are only half as large. . . . Why also are ulcers so often single? . . . Furthermore there is no entirely satisfying explanation of the fact that perhaps 19 out of 20 ulcers are to be found in either one of two small areas?"

Hardening of the stomach arteries explains some ulcers in old men. More likely nervous spasms of those arteries weaken parts of the stomach, permit corrosion to get a start. Infection of the teeth, tonsils, prostate, appendix, gallbladder, liver--any focal infection--is often related to ulcers. Dr. Alvarez believes that "most of us probably suffer from time to time with acute ulcers of infectious origin, just as we suffer with canker sores. . . . The fortunate thing is that . . . these lesions promptly heal." Basically most ulcers are due, Dr. Alvarez feels certain, to nervous tensions and emotional storms, a relationship which Dr. Harvey Cushing suggested last year (TIME, April 20, 1931). To convince the profession will require painstaking study of large groups of people by someone well grounded in physiology, psychology and anthropology.

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