The neurogenic aspects of the aetiology of gastric and duodenal ulceration
Barron, Arthur F. M.
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In this thesis I have put forward the plea that tha cause of the distressing conditions of irritable "peptic" ulcer and the gastric neuroses is a neurogenic one. At times I have been lead away from the main track of my argument into discussions of the general aetiology and clinical and pathological findings of related conditions; but that was inevitable in such a debatable and complicated subject. It is not possible yet to come to a definite conclusion, but in my own mind at least, I am convinced that understanding is clearer, and the meaning of certain findings more obvious in the light of the neurogenic theory, than in that of any other. Much work and study must yet be given to the whole subject before the theory is finally either discarded or finds a general acceptance.However, I have summarised my main deductions and conclusions from a study of the literature and from my own personal observations, both clinical and experimentaL. hone the less, it must be understood that the neurogenic approach to the subject of peptic ulceration is still a comparatively new one and the considerationof the results of future experiments may well cause modification of some of the conclusions hereinunder put forth.1. The human stomach gains its nerve supply from two sources, the vagus (parasympathetic) and the sympathetic (through the coeliac plexus).2. The gastric vagal branches are very constant in position and di6tribution and the main branches can be identified at operations on the stomach.3. Relative overaction of the vagus produces hypersecretion, hypermotility, hyperacidity and pylorospt.sm.4. The main factor in the causation of "peptic" ulceration and the gastric neuroses is the combination of Relative vagal Overact ion and Eyperchlorhydria.5. Relative Vagal Overaction in the human being may be either constitutional (inherited) or acquired.6. Hyperchlorhydria is principally and in most cases the direct result of vagal stimulation. he usual level of gastric acid may be raised to an extent by the absence of the diluting and neutralizing factors in the diet, and /or derangement of the internal chemical mechanism for the maintenance of normal gastric acidity.7. A reasonable new assay of the treatment of !duodenal ulcer without stenosis in a young person, and of the gastric neuroses, would bea. by exhibition of the newer drugs of the belladonna series - ephedrine, or especialLy Benzedrine, which produce a relative diminution of parasympathetic activity;b. by exhibition of sedatives, especially pheno- barbitone and the bromides, which reduce auto- nomic activity as a whole;c. by vagal neurectomy, by resecting a small length of anterior gastric nerve, and of the posterior gastric nerve after it has given off its large right branch (which goes to supply the small intestine). The approach is through a high paramedial incision into the left xiphi -costal angle and exposure can easily be obtained as described by Latarjet (page 79, Figs. 2, 11, 4.2).The operation is feasible, and quite quickly performed; it does not entail the shock and consider- able anaesthetic duration of the usual abdominal operation where much handling of the gut takes place; it is not mutilating as t the partial gastrectomy often advised; and should the operation fail to pro- duce the expected results, the application of the routine medical treatment is not precluded, neither is the performance of gastroenterostomy or partial gastrectomy should such a major surgical procedure by any chance be deemed advisable.