The medical anecdote below is a suitable introduction and eye-opener to understanding how difficult it can be, and how long it can take, to alter the conventional wisdom in medicine. Don’t discard it as irrelevant to the title of this two-part feature.
Peptic ulcers of the stomach and first part of the small bowel (duodenum) were a major health problem in the past – why not so much now? The answer is, in fact, one of the most interesting landmarks in modern medicine.
These ulcers were a major problem because they were common, potentially fatal due to complicating internal haemorrhage or peritonitis, and difficult to cure.
They were difficult to cure because the exact cause was not clearly understood. It had been known for a long time that they were associated with excess acid production in the stomach and it was argued that the excess acid could produce a breach and then an ulcer in the stomach or duodenal wall (that’s why they were called ‘peptic’, to distinguish them from cancerous ulcers). It was also thought that an anxious personality, the stress of worry or anger, spicy foods or smoking were responsible for the excess acid production and resulting ulcer.
Medical treatment consisted of drinks or tablets that diminished the stomach acid (antacids), a bland diet and possibly an anti-anxiety drug.
If all this failed to cure the ulcer, complicated surgical operations were devised to either diminish the size of the stomach to lessen the acid production, to cut out the ulcer, or to divert the acidic stomach contents to a different part of the small bowel.
Surgical pathology departments in large hospitals used to examine and report on at least one or more of these ulcer operation specimens every week. Then suddenly no more peptic ulcer specimens arrived in pathology laboratories for examination. What had happened?
The pharmaceutical industry had finally developed drugs that effectively blocked stomach acid production, and peptic ulcers healed like magic – a landmark in pharmaceutical drug development and in gastrointestinal medicine.
However, an even bigger landmark was to follow. It soon became apparent that although these new drugs stopped acid production and healed ulcers quickly, these ulcers recurred in about half the cases sometime after the drug was stopped.
The even bigger landmark arrived in the form of an Australian physician, Robert Marshall, who claimed that, experimenting on himself and on a colleague, he had found that excessive stomach acid production was due to a bacterial infection of the stomach.
Medicine will continue to have controversies raging between different proponents of medical science hypotheses and clinic data interpretations
He indicated that a peculiar bacterium, called Helicobacter pylori, had the ability of colonising the lining of the stomach causing it to become inflamed and to produce excess acid.
However, this claim went against the conventional medical wisdom that the stomach was sterile most of the time because no bacteria could survive in its acid.
I was present at the London conference where Marshall presented his claim with supporting clinic evidence. He showed that the ulcer patients he treated with antibiotics were almost always cured without recurrences, compared to the patients who were treated with only acid-suppressing drugs and no antibiotics, about half of whom suffered ulcer recurrence.
He therefore proposed that the ultimate cause of practically all peptic ulcers was infection with Helicobacter bacteria (via contaminated water or food), and that therefore the real cure was antibiotics to remove the bacteria from the stomach.
Marshall was booed off the podium. I have never experienced such behaviour in a British medical meeting. Marshall’s claim that the centuries-old mystery of peptic ulcers was simply a bacterial stomach infection, which generations of scientists and doctors had missed, and which was simply curable with antibiotics, went against conventional wisdom and was too much to suddenly take in and accept. In fact, it took about two decades for Marshall’s antibiotic regime to become standard treatment of Helicobacter gastritis and peptic ulcers.
I’ve chosen to outline this almost unbelievable landmark in modern medicine to emphasise how difficult and how long it can take to alter conventional medical wisdom and, therefore, as a useful prelude to tackling the much bigger problem of diet, blood cholesterol, blood sugar and cardiovascular disease.
It should have prepared you to understand that medicine has had, still has and will continue to have, serious controversies raging between different proponents of medical science hypotheses and clinic data interpretations affecting diagnosis and treatment.
Why should this be? Serious chronic diseases, such as cardiovascular disease (mainly heart attacks and strokes), tend to have a complicated set of different causative factors – these contribute to controversies not only in diagnosis and treatment but also in preventive strategies.
Cardiovascular disease remains the number one cause of morbidity and mortality in the developed countries and its relationship to diet, blood cholesterol and blood sugar, interpretation of blood cholesterol and glucose tests, preventive strategies and statin treatment have been, and remain, in hot debate.
The public, I feel, is entitled to a glimpse into the gist of the current controversies, which will be discussed in part two.
(To be continued)
Professor Albert Cilia-Vincenti is a practising pathologist and chairman of the Academy of Nutritional Medicine (UK), a former scientific delegate to the European Medicines Agency, a London and Malta university teacher and a pathology services director to a British Healthcare Trust and to the Maltese health service.