EDITORIAL 149

the ulcer stomach, the gastric juice contains more than the "normal" quanlily of acid, that acid is present over an ex- tended digestion-period or both. Such assumptions appear in disregard of a literature recording innumerable series of reliable studies of gastric "test-meals" where normal or de- creased acidity or even achlorhydria has been associated with gastric ulcer. Well-known it is, that when ulcer lies in the duodenum, gastric free Hcl is apt to average considerably higher than when ulcer is of the stomach. Except in in- stances of pyloric stenosis, in which circumstances gastric secretions may not escape into the duodenum, it is rare that titration figures quantitatively estimating free Hcl cannot be equalled or excee4ed by titratiogl figures upon healthy sub- jects of similar ages and sex, or where ulcer is duodenal. Certainly, no one has yet brought forth evidence that degree of free Hcl bears any direct relationship to time required for healing in "peptic" ulcer, gastric or duodenal.

Clinicians of adequate experience and devoid of "acid blind spots" in their therapeutic eyes, frequently enough, have noted in their hospital records startlingly rapid com- pfications when ulcer patients are in most favorable situa- tions with respect nursing and food and when alkalies have been administered sufficiently to have brought about phys- iologic fatigue of the acid secreting glands--medicinal achlorhydria.

There is more than a suspicion that excess alkali is harmful, locally, to gastric and duodenal mucosae. It is well known that the first response to the exhibition of alkali is excessive free acid secretion: the stomach is attempting to neutralize the administered alkali--a "foreign body"--and restore nor- mal conditions for gastric digestion. After a period, peculiar to each individual and depending upon the chemical attri- butes of the alkali exhibited, the acid-secreting glands pour out a fluid in which the free Hcl gradually decreases while its mucus content increases. Eventually, there occurs "phys- iologic fatigue" of the acid-secreting glands: these glands cease excreting or their excretion is mucus. If mucus is ex- creted gradually it becomes more viscid and is excreted more slowly. Quite likely, this mucus has a protective value to the "open" ulcer--certainly, the proponents of mucin therapy would appear so to believe. If, when mucus has become the

• only product of what were acid-secreting glands, large vol- umes of excess alkali are administered--and particularly if they be administered constantly--the mucus, being soluble in excess alkali at body temperature, is "dissolved." In such circumstances, it loses whatever protective properties it may have been exerting. The denuded stomach mucosa lies bare to excess alkali--a physiologically foreign substance in the stomach and an agent apparently capable chemically of irritating "raw" mucous membrane or surfaces which, through ulcer occurrence already have been denuded of mucosa--certainly an agent inimical to tissues which have lost their normal epithelial protection and their mucus coat. One should not wonder that complications may occur under a medicinally maneuvered achlorhydria:--it is strange that they do not appear oftener. If the stomach did not quickly empty itself via the pylorus or by vomitus or if the thera- peutist did not employ gastric lavage in his "routine," doubt- less the injurious effects of excess alkali or of continuous alkalinization would be observed more frequently.

In normal digestion, the intermittent reflux, of pancreatic juice and bile to the stomach often may be observed. Where gastric tonus is increased and especially when powerful spasms of the pars pylorica are present, the sudden relaxation of spasm is a not to be neglected influence in what one may call "aspiration" of duodenal juices into the stomach. Such intruding secretions bathe the common ulcer-bearing area of the pars pyIorica. Whether or no acidity is present in stomach contents, the inflow of pancreatic juice and bile exerts a potent "digestant" activity upon damaged mucosa or visceral wall--more so if, previously, the gastric contents have been rendered alkaline by medicines. There is greater than a hint of evidence, investigative and clinical, that the

reflux of duodenal contents is a potent factor in retarding the healing of gastric ulcer. Certainly, after gastroenterostomy has been performed, should the jejunal loop permit stagna- tion of its contents, duodenal juices, inflowing through the anastomatic stoma, would appear definitely to have signifi- cance towards the causation of gastro-jejunal ulcer at points where surgical traumata have been exhibited or where slowly- disintegrating sutures interfere with normal cellular activity and repair. Few stomachs are free from regurgitated jejunal juices following the performance of gastro-jejunostomy.

In achlorhydria and in stomachs exhibiting normal gastric secretion, when mural, pre-ulcer lesions have diminished the physiologic function and defense of the mucosa or submucosal strala, there is reason to believe that, in certain circum- stances, bacteria-laden saliva becomes implanted at points of local damage, the bacteria proliferate there and, by their ]ytic properties, contribute to ulcer formation or its continuance. Similarly, bacteria brought by blood or lymph-streams to a pre-ulcer, mural defect may digest tissues in which the "X-factor" of protection is missing.

Finally, it should be recalled that when mural tissue--- particularly mucosa--has had its defense lowered or such has been lost, the peptid-splitting enzyme existing in normal blood-serum, holds possibilities for digesting the available protein derivitives of "divitalized" cellular structures. Herein may lie one of the chief etiologic factors in the causation of spontaneously arising "peptic" ulcer of man.

Apart from considerations regarding the significance of free Hcl towards gastric or duodenal ulcer, evidence rapidly is accumulating which indicates that certain quantitative variations in the secretion of pepsin (probably also of tryp- sinP) may exert more potent destruction of previously "divitalized" mural tissue than is to be expected from the action of free Hcl. Certainly, the work of Babkin and the Magill University Group suggests that newer methods for the quantitative estimation of gastric and duodenal enzymes disclose variations in ferment volume and ferment action which previously had been but meagerly known or appreci- ated. If future studies bear out the promise of those thus far available, one may rightly style gastric ulcer "peptic and, probably, duodenal ulcer "tryptic." Be that as it may, cor- rect appreciation of long-known facts and full cognizance of the newer investigations does much to diminish the accuracy of the dictum "No acid, no ulcer." But acceptance of newer interpretations and consideration of newer, available facts does much to disturb the smugness of those whose gastric and duodenal ulcer horizon--ethological and therapeutic--has been limited to the juggling of data on acidity and alkalinity.

F.S.

T H E S I Z E O F T H E J O U R N A L

The Editors and Publishers have been gratified in receiving much favorable comment with respect to the page size of the Journal. Many readers have inquired the reason for the adoption of so large a format. The chief reasons are that this large size page lends itself much better than smaller sizes to the display of illustrations and effects considerable economies in printing production. It is generally held by modern printers that the two column page promotes easy reading. Further, a great deal more reading matter can be served to the subscriber in this particular format than in any other size which meets the standard production requirements of the publication printer.

It has been the aim of the Editorial Staff to produce a Journal of distinctive appearance, and, judging by the hun- dreds of letters received, the ideal has been reached. We do not think that the size of the Journal, or of reprints can be, in any way, a handicap. Certainly any inconvenience caused in filing is more than compensated for by the advantages just mentioned. Every reader is invited to make his com- ments on this matter, should he feel inclined to do so.

F . S .