Emotional antecedents of perforation of ulcer

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Emotional Antecedents of Perforation

of Ulcers of the Stomach

and Duodenum

PIETRO CASTELNUOVO-TEDESCO, M D.

After a detailed psychiatric study of 20 patients representing consecutive admissions it

is concluded that, generally, emotional factors were intimately involved in ulcer perfora-tions. However, the importance of diet, alcohol, activity, and other concurrent diseasealso was noted. Perforation usually occurred as a climax to a period of emotional turbu-lence when the patient faced situations which, consciously or unconsciously, he felt tobe grossly damaging to his self-esteem and to which he reacted, predom inantly, w ithimpotent rage. The perfection prodrome is described and interpreted as a depressiveequiva lent. The ulcer patie nt's ordinal position in his family as the youngest or middlechild and his difficulties in relation to his father are emphasized. Particularly where noother serious disease coexists, perforation should be taken as presumptive evidence thatthe patient has tried unsuccessfully to resolve an emotional crisis and that appropriatepsychiatric help p iobably is indicated as part of the total treatment

A HE PSYC HIATR IC LITER ATUR E w h i c h has

flourished extensively on the subjects of

pep t ic u lce r , somehow has avo ided dea l -

ing to any ex ten t w i th its compl ica t ions ,

and par t i cu la r ly wi th the p rob lems of per -

fo ra t ion . Th i s is su rp r i s ing because in a

n u m b e r of ways per fo ra t ion p resen t s it-

self as a subject ideal ly sui ted for p sycho-

somat ic inves t iga t ion . It is an even t w i th

sharp , sudden onse t , c l ea r ly de l inea ted in

t ime , and a majo r emer gency of ca tas -

From the Boston City Hospital, Boston, Mass.The author is gratefu l to Dr. C harles G. Child,

III , Dr. John J. Byrne, and Dr. J. EnglebertDunphy for permitting access to the patientswith perforated ulcer treated on their services.The author, also, wishes to thank Dr. PhilipSolomon for his interest and encouragement.

Received for publication Sept. 27, 1961.

trophic proportions occurring usually not

more than once or twice in a patient's life.

Thus it rises sharply above the tedium of

everyday discomforts and the endless

fluctuations of distress which a patient

with chronic peptic ulcer usually experi-

ences and, over the course of years, learns

to accept. In the latter instances the

epigastric complaints become so much a

part of the individual's style of life, thatthe relevant emotional factors also grow

deeply embedded in the structure of the

patient's personality, and are, therefore,

less accessible to investigation.

The study of the emotional antecedents

of perforation reported here was under-

taken with the hope that it might prove

informative not only regarding perfora-

tion per se, but also regarding the more

398



CASTELNUOVO-TEDESCO

basic life problems of the ulcer patient.It was thought that perforation mightprove akin to an experiment occurring innature.

Review of the Literature

In 1932, Harvey dishing 2 1 said: "Asatisfactory, all embracing explanation of

acute and chronic ulcerations of the stom-ach and duodenum is yet to be found."This statement still holds true today, eventhough in the intervening years our un-derstanding of the physiological mecha-nisms that underlie such ulcerations hasincreased. Ther e is now general recogni-tion of the significance of vagal hyper-activity, a view first promoted by R okitan-sky102 and later re-emphasized by dish-ing,-1 who boldly connected the origin ofthe vagal impulses to stimulation of theparasym pathetic centers in the hypothala-

mus. In addition, during the past 10 years,through the writings of Selye,108- lo n

Gray4"-48 and others/'1 ' 7(i' » • ni

- n l ) much

has been said about stress, the role of thepituitary-adrenal axis, and the effects ofthe adrena l cortical hormones in bringingabout gastric hypermotility and hyper-secretion, gastrointestinal ulceration and,at times, perforation. Ellison et al.

30 pointout that in most cases these two mecha-nisms probably operate simultaneouslyand in a complementary fashion.

Clinically, perforated ulcer has been

known to be associated with a wide varie-ty of conditions. One of the more fre-quent and better established associationsis that with disease of the central nervoussystem of varied etiology and location.21 '3f>. 39, 44, 43, 3d, 57, 63, 86, 05, 107 J(- Jj as b e e n

noted also following trauma 35 ' 3s>i 44' 88>

ii7, i3o (-0; o r surgery21 ' 30 ' 44 on, the centralnervous system. Globus44 believes thatthe nervous system is "equipotential" andthat "almost any region can be the focalpoint of development of the pathologicprocess which may express itself in acutegastrointestinal ulcerations." He cites

VOL. XXIV NO . 4 1962

399

cases in which the spinal cord only wasinvolved and disagrees with Cushing's be-lief that the hypothalamus is the "site ofpredilection" for the causation of gastro-intestinal erosions. Perforation has beenreported following snakebite,15 ' 37 withassociated involvement of the nervoussystem, and also following major seizuresinduced with Metrazol01 ' 118 or with elec-

tncity.

58

-

9S

One might recall in this con-nection Early's report27 that one electro-shock treatment has greater trophic ac-tion on the adrenal cortex than 50 mg. ofACTH. Since Curling (1842),20 the oc-casional occurrence of perforated ulcerfollowing extensive body burns has beenwell recognized.34 ' °2'82> sn'<J 4 Perforationhas been reported also with tumors of theadrenal cortex17 and quite frequently dur-ing treatment with ACTH and cortisone"1

14 , 2 1 3 1 3 9 , 4 4 , 46, 4 9 , 5 1 5 2 , 7 6 , S 3 , I I S , 11 ) o r

prednisone 83 34 for other conditions. Oc-casionally it has been noted during treat-ment with phenyl butazone1- 10 and withderivatives of Rauwolfia serpentina.

125

A well-established connection has beenobserved with non-insulin-producingislet-cell tumors of the pancreas5- 24- -• •

2a'so, as, 5.-,, id2. las ( t h e So-called Zollinger-Ellison syndrome) and, not frequently,with pulmonary disease,81 ' so ' )2 especial-ly tuberculosis, and following pulmonarysurgery.'" It is not uncommon in alco-holics3'"'1 7Ti 84 and has been noted follow-ing paracentesis.77 It has occurred oc-casionally following myocardial infarc-tion,1-' s s S9-11 0 congestive hea it failure,35

and cardiac surgery.10-7I) It has been seenwith multiple perforating gastrointestinalulcers,"1 40 ' 5 0 with gastrointestinal hemor-rhage, obstruction, or both,88- 92- 101- ]2°with chronic ulcerative colitis;8"1 113 an din connection with a malignanc y. Mooreand Fuller02 report that of 82 patientswith multiple simultaneous complicationsof peptic ulcer (perforation, hemorrhage,obstruction) 11 had malignant tumors ofwhich 5 were bronchogenic carcinoma.Perforation is a rare occurrence during



4 ULCER PERFORATION

pregnancy 60- c s' 7 I and during labor.61

Finally, it has been observed in a few mis-cellaneous situations—for example, fol-lowing air encephalography,86 after in-gestion of a barium meal for radiographyof the uppe r gastrointestinal trac t,28 '36 ' 67'io3, 100, in following therapeutic irradia-tion of a testicular malignancy,32 afterherniorraphy,85 and as a sequel to instru-

mental perforation of the esoph agus

22

an dto esophagectomy.13 Perforated gastriculcer was seen following a severe crush-ing injury to the chest,70 and after frac-tures of the long bon es. 80 '1] 9 '1S O One sus-pects that factors of stress may haveplayed a role in these latter instances, bu tfor the most part these considerations didnot come to the minds of authors of theoriginal reports.

In addition, perforation occurs "spon-taneously," often in persons without pre-vious ulcer symptoms and presumably

healthy. The assumption generally hasbeen made, often tacitly, that perforationis nothing more than ulceration that hasreached its logical conclusion, its finalnadir. Yet questions as to why only 7 percent, approximately, of chronic ulcers per-forate, why some individuals have severeulcer symptoms for years without havinga perforation, while others, apparentlyhealthy, suffer a perforation suddenly,with hardly a warning, have never beenadequately answered or studied. Thetrue connection between acute and chron-ic ulcerations remains to be worked out.

Another much neglected area has to dowith the role of emotional factors in per-foration, especially in those cases, consti-tuting a majority, where there is no otherserious concurrent illness. The problemseldom has been studied directly, butsome investigations indirectly point upfactors and situations which undou btedlymust have had emotional significance.For example, Hamperl53 reported an in-crease in perforations in Russia duringthe famine of the early 1920's. The secondworld war offered further opportunity to

observe the effects of a major social up-heaval on the occurrence of perforation.Several important articles came fromEngland, where, in various parts of thecountry, clinicians noted a sudden andremarkable increase in the frequency ofperforation. Steward and Winser,110 whowere medical students at that time, madea study of the admissions to 16 London

hospitals. They found that in the secondweek in September, 1940, when seriousraiding on London began, there was astriking, statistically significant, increasein the number of patients who presentedthemselves because of a perforated ulcer.Soon confirmatory reports were forthcom-ing from other parts of England.99 ' 100 'us , 127 Hljngworth et al.

6i had similar find-ings in Western Scotland even though, asthey noted, this part of the country hadnot been subjected to heavy air raids.They imputed anxiety about the w ar situ-ation, overwork and, possibly, undernu-trition.

Meanwhile, in Austria87 ' 112 and inFrance , physicians were repo rting similarobserva tions. In Paris in 1941, the in-crease in the nu mber of acute ulcerationswas so striking that Lambling and Bris-

Sy8o fej(. |us tified in speaking of an "epi-demie d'ulceres." Here, too, there wereno bombings or air raids, but the socialupheaval was considerable.

The only psvehiatric study aimed spe-cifically at elucidating the emotional fac-

tors in perforation or hematemesis hasbeen tha t by Davies and Wilson23 in 1939.Their findings in the two conditions weresimilar. They discovered that in the greatmajority of cases perforation or hemate-mesis had occurred following either anacute emotional stress or the exacerba-tion of a chronic, long-standing stress.The authors noted that the time betweenthe precipitating event and one or the oth-er gastrointestinal complication was usu-ally "a matter of days " Thev emphasizedthe impo rtance of increased responsibilityand of "acute uncertainty." They noted

PSYCHOSOMATIC MEDICINE



C A ST EL N U OVO- T ED ESC O 401

that "when there is acute uncertaintywhether they [the patients] can getthrough a situation or not, to give in, toresign and admit defeat is incompatiblewith their make-up."

Other authors8. 26. «• 75- 9T- 105^ m inconnection with their study of the psycho-logical characteristics of ulcer patientshave reported occasional instances in

which the patient happened to suffer aperforation, but their attention has notbeen directed specifically to this problem.Frequently the cases which these authorschose to report are ones where the circum-stances surrounding the perforation wereparticularly dramatic. For example, Al-varez4 cites the case of a woman whoadored her daughter-in-law, but who onone occasion inadvertently offended her.This brought down a storm of abuse"which nearly killed her." The next dayher long-healed ulcer flared up and per-

forated. Kapp et al.

12

report the case of a17-year-old boy, very devoted to his par-ents, who while away from home for thefirst time received a telegram stating tha this mother was gravely ill. He asked hisboss for his wages so that he could returnhome immediately. The latter, however,refused to pay him until he had finishedout the week. "He met the decision of hisboss without outward or even consciousappropriate feeling or behavior." How-ever, 15 min. later his ulcer perforated.

Present Study

Materials and Methods

This report is based on a study of 20patients unde r the age of 65, representingconsecutive admissions to the BostonCity Hospital for perforated ulcer. Threepatients below the age of 65, however,were excluded as unsuitable for anamnes-tic psychological investigation: 2 wereforeign-born, with a severe languageproblem, and the third, a chronic alco-holic, had a Korsakoff syndrom e. The

VOL . XXIV NO . 4 1962

sample was limited arbitrarily to 20 pa-tients, of whom 17 were men and 3 wom-en .

The patients, seen over a period of ap-proximately 9 months, were admitted inrotation to one of Boston City Hospital'sthree surgical services, and treated bylaparotomy and plication of the perfora-tion. Thu s, in all instances except one

(where the patient was treated conserva-tively ), the diagnosis of perforated ulcerwas proved by direct inspection at sur-gery. In the latter case, nevertheless, ade-quate evidence was available regardingthe correctness of the diagnosis. In 3 in-stances, the ulcer was found to be in thestomach and, in the remainder of thecases, in the duodenum.

The purpose of this study was to ob-tain information which wou ld be "psycho-biologically true"—i.e., that would reflect,in addition to the data of emotional sig-

nificance, the role of dietary, physiologi-cal, social, and other factors and give acomprehensive picture of the man and hisdisease. The method for gathering dataconsisted of daily interviews at the bed-side. The interviews w ere kept largelyunstructured and were aimed at obtain-ing dynamically relevant informationwith emphasis on the present illness andthe anteced ents of the perforation. Allpatients, except 3, with whom this wasnot possible, were first seen by the authoras soon as they presented themselves foradmission and prior to surgery. There-after, each patient was seen daily: theshortest total contact was approximatelylM hours, the longest, 25 hours. Most pa-tients were seen for about 8 hours each.No attemp t was made to offer treatm ent,except that which was implicit in the in-terviewer's attitude of interest and con-cern. As often as possible, the relativesand friends who visited each patient inthe hospital also were seen; it was foundthat they were able to provide useful, cor-roborative, or complementary informa-tion. Following each interview, detailed,



4 2 U L C ER PER F OR A T ION

practically verbatim, notes weie kept andthese were later organized into a unifiedstory. The word peptic purposely hasbeen avoided in the title of this paperwhen referring to ulcers of the stomachand duoden um. This was done out orconsideration for the view, frequentlyheld, that chronic "peptic'' ulcers andacute "stress" ulcers are quite different

entities . In this sample no effort w as ma deto separate one type from the other.

The case reported below is similar inscope, format, and type of dynamic ma-terial to those not reported. All the casereports h ave be en placed on file for refer-ence with the Library of Congress.

Case Report

Case 9The patient, a 25-year-old white, single

mechanic, was admitted to the hospital in theearly hours of the morning because of severe,diffuse abdominal pain which had begun sud-denly the preceding evening, while the patientwas at home writing a letter to his father.Earlier that day, after work, the patient hadrushed off to some evening classes at a localuniversity, and later, after a hasty supper, hehad sat down to write to his father. The onsetof the pain had been startlingly sudden: thepatient had had no abdominal distress that dayup to that point. Soon, however, he vomitedand the pain then radiated to the left shoulder.The patient thought that this was probably theresult of constipation or indigestion, and felt"foolish" coming to the hospital, but finally

presented himself for admission when the painhad become so severe that he could achieve amodicum of comfort only by lying down withhis thighs fully flexed.

The patient had never had any abdominaldistress until 2 months before admission, whenhe was discharged from military service. Sincethen, intei mittently, he had been troubled bymild epigashic cramping or gnawing pain, re-lieved by food or even a cup of coffee Thisdiscomfort had been so mild that he had at-tributed it to hunger pangs and he had notthought of himself as being sick.

Youthful for his age, the patient was a blondyoung man with clean-cut looks and an eam-

est, dependable, somewhat bashful manner.He was in great pain and frightened, but layveiy still and maintained an ail of polite roi-mality.

A diagnosis of perforated peptic ulcer wasmade, and the patient was tieated conseiva-tively with continuous gastric suction, intia-venous fluids, sedatives and analgesics, andprophylactic antibiotics. Although in this in-stance, the diagnosis of perforated peptic ulcei

was not proved by direct demonstration atsurgeiy, it was adequately established by thehistory, the typical physical findings, and theX-iay finding, on admission, of fiee air underthe diaphr agm . In addition, two Gl series per-formed later during the hospitalization re-vealed a distinct duodenal ciater.

The patient was bom in Ireland in a smalltown of about 600 peisons, where his fatherwas the town butch er. His father, in his latefifties and in good health, was a quiet, cool-headed man with a dry, caustic wit, and agreat deal of self-contiol.

The patient's mother died of hypertensionand uremia when he was 12 yeais old She hadbeen in the hospital 5 months when she camehome to die, but the patient had not ieahzeduntil the very end that she was not going tolive. When she died he was upset and cried,but he a dded that perhaps he was not as upse:as he should have been. He explained this re-maik by saying that the full impact of herdeath ha d leached him only later. Even thoughhe had been a teen-ager at the time, he did notremem ber her well. He said that she was tall,dark-haired, and that she often scolded himfor one thing or another. Immediately headded, but with a note of disbelief in his voice,that he had been told that he had been her

favorite. Th e patien t had 2 sisters, 26 and 16yeais old The older was emotional and scatter-brained, and as a child had been sickly becauseof anemia. The younger one was more niggedand sanguine and something of a tom-boy Onegot the impression that the mother had fusseda good deal ovei the older daughtei, giving hermost of her attention. After the mo thei'sdeath, the father had hired a series of house-keepeis to take care of the house and the chil-dien, but the patient could not tecall any oneof them in any detail.

In high school the patient had been a goodstuden t Already , while in school, and thenaftei giaduation, he had woiked with his




CASTELNUOVO-TEDESCO 4 3

father foi 5 years as a butcher, but he was notas interested in this as in tinkering with cars,about which he had learned by watching theowner of the town garage. The n, for about 3years, he worked for a construction company,first m Ireland and later in England. He hadgone to England because of a desire to traveland "see the world." For the same reasons hehad come then to the United States where,shortly aftei his arrival, he had been drafted.

As a serviceman he was stationed in Europe,which he appreciated because it gratified fur-ther his desire for travel. It ha d been hissecret hope, in fact, that he might be sent toSouth America

His father had never acknowledged or un-derstood the patient's wish for travel and edu-cation, and had always maintained that heshould settle down as a butcher in his hometown. It had been difficult for the patie nt toleave home: "I practically had to run away."Yet there were times when, privately, the pa-tient agreed with his father: perhaps, in thelong run, he would return home and be abutcher. Each time the father wrote to him,

he would inquire when he was coming home.The patft$t had taken to ignoring these ques-tions and usually made his replies cheerful andcasual. It was just such a letter tha t the patientwas writing to his father when his ulcer per-forated.

For 3 days before coming to the hospital thepatient had felt in an unusual state of mind:he had had "no ambition" and had felt de-pressed, so much in fact that he had made amental note of it in spite of being unable to ac-count for it. Late r in the hospital he said itmust have been due to the ulcer, but he has-tened to add that he had not felt sick or tired

at all, but simply depressed. Norma lly he was;"very ambitious." He always did the very besthe knew how and took pride in his accomplish-ments. If he had some free time he wouldlook around t he shop for things to do. Often,on his own initiative, he would take inventory.Instead, during the 3 days that preceded ad-mission, he barely had been able to do whatwas required of him, and this feeling had beenmost marked on the day before coming to thehospital He could not reme mbei anything likethis in the recent past.

After leaving military service the patient hadgone to work in a garage as a general mechanicand deliver)' man. This job was the first that

VOL XXIV NO . 4 1962

had been offered to him. He earned $80 perweek and his boss, a young man, was good towork for. Two nights a week, from 6 to 9:1 5P.M., the patient attended a local universitywhere he was taking a few courses, with thehope of obtaining in 4-6 years' time a degree inengineering. On the nights when the patien tattended school he had to rush from work tothe university, and delay his supper until about10 P.M. Often, whila in class, he had been con-

scious of hunger pains and upper abdominaldistress.The patient had been living in the apait-

ment of an aunt who, at the time, was in Flori-da for the winter. He did his own cooking, butfound this expensive. Between work, school1,cooking, shopping, and keeping the apartmentin order, the patient had felt very pressed andas if he had no time for himself.

The patient was questioned furthei abouthis "ambitiousness" and his desire for a profes-sional education. His manner was very modestand leticent. He answered that there wer eonly three things that he really wanted, asteady job, marriage, and an "average, normallife." Wh en it was pointed out to him that h ealready had a steady job and that he did notneed a university degree to fulfill his other twowishes, he balked a little and seemed irritated.With some difficulty he w as able to say finallythat he really wanted a better paying job andperhaps a junior manag ement position. Witha sudden loss of reticence he adde d that his bigambition was to design machinery, but thenwent on to say that he had been feeling somepressure from his studies. He was taking threecourses, but was doing well in only two. Thesewere only preliminary courses, designed to testhis general aptitude. How ever, if he was seri-ous in his plans for an engineering degree, he

1 1 1 1 O O

would be expected soon to take six couises. H eadmitted that he had had a terrible time decid-ing whether he really wanted to commit him-self to such a demanding program. H e feltthat there was no point undertaking it unlesshe could be fairly sure of success. His class-mates had warned him that the program was arigorous one and that many failed. He realizedthat if he undertook it he would have to workvery hard for the next several years, and giveupi—as he saw it—practically all social life.Already he seldom had time for a date . Ho wthen would he find a girl to marry? Yet, if h eobtained his degree he would be able to get a





CASTELNUOVO-TEDESCO 405

phasize d. The feeling exists in some qua r-ters that when an alcoholic suffers a per-foration, this is simply or largely the re-sult of alcoholic excess and dietary neg-lect. My impression is that this is not so.The patients in this series who were alco-holics or heavy drinkers all had subjectedtheir gastrointestinal tract to largeamoun ts of alcohol for periods of 15-20 or

more years, and in most instances hadbeen remarkably free of gastrointestinalcomp laints, and p articularly of those com-plaints which we know to be diagnosticof ulcer disease. In all alcoholic patients,the perforation occurred at a time in lifewhen the patient was trying desperatelyto cope with situations to which he wasparticularly vulnerable and for which hehad no defense. One patient (Ca se 5) , infact, clearly shows by his history that inindividual instances emotional factors canbe more significant than alcoholism inbringing about exacerbations of a chronicpeptic ulcer. This man was 38 years oldand single. His mother was controllingand restrictive, his father was a nonentityand always quite distant. He had an old-er brother of whom he was very enviousbecause he was the mother's favorite. Incollege the patient had studied chem istryand later had gone to law school, but hehad never managed to take the bar exami-nations. By the time of his admission, al-cohol had got the best of him; his job:golf caddy. He had had a peptic ulcer fora number of years. When he lived at

home with his parents, where he resentedthe preferential treatment given to hisbrother and feared his mother's domina-tion, his ulcer was consistently a ctive eventhough he drank very seldom, ate an ap-propriate diet, and got plenty of rest.When he lived by himself in town and en-joyed a feeling of independence and ofhaving to account only to himself, he wassymptom-free even thoug h he drank dailyin large amounts, his diet consisted large-ly of fried fish, and his living habits weregenerally dissolute. When circumstances


made it necessary for him to return home,his ulcer became active again. This wholepattern went through two full cycles andwas so striking that the patient himselffinally came to the conclusion th at it musthave some meanin g. It is worth recallinghere Williams's12* findings in a follow-upstudy of 100 cases of perforated pepticulcer. He noted tha t "diet, alcohol and to-

bacco in the majority of cases are not themost important factors governing recur-rences; psychic disturbances and lack ofcooperation on the part of the patient,however, play significant roles."

In 2 patients some other concurrentdisease was associated with the develop-ment of an ulcer and with the final per-foration. One of these (Case 6 ) was foundto have early pulmonary tuberculosis,which had contributed to his complaintsof anorexia, weight loss, and fatigue, andprobab ly had facilitated the development

of an ulcer. The other (Case 12) wasshown at surgery to have a large retro-peritoneal sarcoma which soon, despitesurgical removal, brough t abo ut his death.This patient, too, had been treated forpulmonary tuberculosis, but at the timeof his final admission this disease hadbeen arrested for several years. It was myfeeling in this instance that the emotionalcontributors to perforation were not out-standing and, instead, that the perfora-tion was closely related to the growth ofthe sarcoma, even though the mechanismof this relationship remained obscure. Ifmedical attention is turned to this prob-lem, other cases may come to light wherethe development of an ulcer or an in-crease in its activity will be found to beassociated with an abdominal malignan-cy. The Zollinger-Ellison syndrome mayrepresent only one instance, now betterrecognized, of a more general problem.

In 7 of the 20 cases, it was noted thatother me mbers of the patient's family alsohad had an ulcer. One such patient (Case18) developed a perforation at the age of40, the same age at which her father had





C A ST EL N U OVO- T ED ESC O 4 7

suggested. Rather than the lack of grati-fication of passive needs being the crucialmatter, the crux probably lies in the feel-ings of impotent rage which the patientapparently develops in situations wherehe senses that he is helpless and about tobe defeated. One must point out em-phatically that usually the patient is notaware that he is struggling with these

feelings. Often, also, he is rema rkably un-aware that he is enmeshed in a situationthat unconsciously he perceives to behighly threatening to his self-esteem andsense of manly integrity. Thu s, in half thecases, the patient did not recognize thathis perforation was preceded by certainstressful events; in the remaining half heconsidered them largely coincidental andtended to de-emphasize their significance.The patient's predicament results fromhis inability either to deal effectively withthe stressful situation or to react to it witha depression. His defensive operations,which depend heavily on the use of de-nial, do not permit him, as in the case ofpersonalities differently organized, tocope with his anger and frustration by be-coming temporarily depressed. One getsthe impression that th e patient cannot lethimself become aware of the sense of de-feat and the bitter, vengeful anguishwhich his circumstances seem to convey;to do so might bring about a major dis-organization of the persona lity. Instea dhe protects himself by various means,principally by denial and also by a flight

into activity and by developing a perfora-tion. With regard to the tendency of theulcer patient to seek refuge in activity, itwould seem significant that 8 of the pa-tients in this series went through a periodof vagabondism during their youth; theyroamed the country and covered thou-sands of miles in an effort to leave beh indthe restlessness and dissatisfaction thatthey carried inside.

The significance of the perforationprodrome lies, I think, in its adaptive and"restitutive" function. The prodrome rep -

VO L XXIV NO . 4 1962

resents an attempt on the part of the in-dividual to handle the narcissistic blowand to maintain homeostasis. However,on account of the severity of the stressfulsituation and the vulnerability of the indi-vidual, the restitutive attempt fails in acertain percentage of cases, with the re-sult that perforation supervenes. The pa-tient does not take the original stressful

situation "lying down"; he responds to itvigorously and this response constitutesthe perforation prodrome. In almostevery instance it is possible to show thatthe patient reacted with an increase inactivity, which manifests itself in a varie-ty of ways: by more time spent workingor drinking, or by a more intense, fre-quently frantic, social participation. Per-haps, as in the hypomanic p atient, all thisactivity helps to exclude awareness of theblow to his narcissism which the indi-vidual has suffered and to avoid the acutepain of a full-blown dep ression. Th eperforation prodrome may be understood,in part, as a kind of depressive equivalent.Evidence that this defensive -maneuveragainst depression is not totally success-ful is to be found in the frequency withwhich patients experienced some tension,depression, or fatigue in the period pre-ceding the perforation. Some might wantto explain these nonspecific complaints asbeing due to the ulcer and to the fact th atthe individual did not feel well on ac-count of his abdominal distress. How-ever, the histories clearly show that in

several instances the patient was free ofdigestive symptoms up to the very onsetof the perforation, and th at in many othercases the ulcer symptoms had beentrifling and had not been recognized bythe patient as evidence of disease. I wasamazed to find how often perforation hadcome about, unexpected and unan-nounced, in individuals who were essen-tially in good health . Only 4 of the pa-tients had previously well-documentedulcers. In the 2 instances where the pa-tient had sought the advice of a physician



4 8 ULCER PERFORATION

shortly before the perforation, their trou-ble had been attributed to gall bladderdisease. Other authors11 '7S i 97 have beenimpressed by the apparent relationshipbetwee n ulcer disease and depression, but

frequently the clearly reactive nature of

the depression has been missed, and in-

stead it has been considered a manifesta-tion of an endogenous process, as manic

depressive psychosis has been presumedto be. No evidence for a relationship to

manic depressive psychosis has beenfound in this study .

Following the perforation, when the

patient is forced by circumstances to

place himself totally in the care of a physi-cian and can finally allow himself to put

an end to his frantic activity, he often ex-

periences a sense of relief, akin to beingfreed suddenly of an unbearable burden.It is not uncommon to hear patients say

that they are glad that their ulcer finally

perforated and thankful for the letup inthe struggle and for the opportunity to

rally their energies. Impressive, too, is

the regularity with which ulcer symptomssubside temporarily following repair of

the perforation and for the remainder of

the patient's h ospitalization, even thoughthe surgeon has closed the tiny leak in

the bowel without, however, removingthe ulcer. Certainly, other aspects of

treatment (continuous gastric suction for

2 or 3 days following surgery, bland diet,abundant rest) also contribute to the pa-

tient's new sense of well being; yet one

must not underestimate the benefit whichhe obtains from having been removed,temporarily, from the arena of his strug-gles, and the relief from guilt he has

achieved through his ordea l. Usually the

perforation has social consequenceswhich remind one of the aftermath of a

suicide attempt. In both situations, the

environment is forced to intervene and

frequently it alters its attitude toward the

patient and his struggles in a way thatcontributes at least temporarily to his

sense of relief. The patient's relatives, if

only b ecause of guilt, often come to real-ize that he needs help and express con-

cern and consideration in a new and spe-

cial way. The patient regularly experi-ences this intervention as a "shot in the

arm" and responds by regaining his self-

confidence and losing his depression.Davies and Wilson23

in 1939 already had

remarked upon this phenomenon and

noted that "wounded in the battle of life,there is an armistice and with it the possi-bility of a new orientation." One muststress the word possibility which theseauthors used advisedly because, althoughan attempt at a new o rientation is madewith considerable regularity, this comesto fruition only in the lucky instances(Cases 1, 17, and 20)—primarily thosewhere the environment changed its out-

look toward the patient. There are alsounlucky instances (Cases 13, 15, 16, and

18) where no adequate reorientation oc-

curs, due to the rigidity of the patient or

the harshness of the environment. Hereafter a brief armistice, the battle resumeswith renewed intensity, and the patientsoon again is harassed by symptoms(Cases 13,15 ). T hus,Illingwo rthetal.in a follow-up study of 733 patients who

had survived perforation of a peptic ulcer,found that 40 per cent had relapsed with-in one year and 70 per cent after 5 years.They agreed with Williams126 that the

longer the history of ulcer symptoms priorto perforation the poorer the progress fol-

lowing it.

Attention to the longitudinal history of

these patients and their emotional devel-opment highlights the difficulties which,with few exceptions, they have had in

their relationships with their fathers. T hisis important, especially since, in the past,various authors3' 8

- 74

' 9e

- 97

' 105 stressing

orality as a theoretical concept and the

equation love = food, have tended, at

least by implication, to emphasize the pa-

tient's relationship to the mother. Thisemphasis has found boldest expression in

the writings of Garma42 '4S who feels that




C A ST EL N U OVO- T ED ESC O 4 9

the ulcer is the (bad, incorporated)mother. However, an explanation of theemotional conflicts of the ulcer patientprimarily in terms of the vicissitudes ofthe mother-child relationship seems in-com plete. In this series, 8 of the 17 malepatients had lost their father before reach-ing adolescence on account of death, di-vorce, or desertion. In the instances where

no such loss had taken place, the rela-tionship between father and son hadbeen, almost uniformly, a distant one,with little warmth, intimacy, or ad equa tepaternal guidance. Several of the pa-tients had strong, conscious feelings ofbitterness and resentment toward theiifathers, and this was often associatedwith traits of rebelliousness and defen-sive self-assertiveness. At the same timeone usually gained the impression thatthese patients were wanting in theirmasculine identification and that this

process had never been successfully ac-complished. It is worth rec alling in thisconnection that Draper,26 one of theearly writers, stressed certain features,which he labelled feminine, in the consti-tution of ulcer patients and was impressedby a "fundamental conflict between themasculine and feminine component." Ac-tually, feminine characteristics are not asimpressive as a certain uneasiness andeffort with which the ulcer patient fulfillsthe masculine role. The strong passiveand depend ent needs w hich, according tomost authors, are fundam ental in the emo-

tional makeup of the ulcer patient, ap-pear to be a reflection not only of thebasic dependence on the mother, but alsoof the unsatisfactory mascu line identifica-tion. The latter factor, in turn, tends toaccentuate the dependence on the moth-er, and to facilitate and intensify thestrength of oral-receptive wishes. In 5cases in this series, these dependentwishes had their object predominantly inmen—i.e., in the father or a brother ortheir substitutes—and the patient came togrief through an exacerbation of symp-

VOL XXIV NO . 4 1962

toms when these relationships were dis-turbed. Weisman,122 Chapman et al.

is

and Ruesch104 also have suggested thatdifficulties in the relationship with thefather may be of etiologic significance.Chapman et al., who worked withchildren and adolescents, noted that: "Ineach case the relationship between thepatient and the father was a distant and

emotionally ineffective one. . . . It wasalmost as if the father had abandon ed thechildren to a pathologic relationship withthe mother. . . ."

Worth noting, too, is the tendency, ap-parent in this series, for the ulcer patientto be the youngest child or, most often, amidd le child in his family. Of 20 patien tsonly one was an oldest child. Five were ayoungest child, 13 were a middle child,and in one case the ordinal position wasnot known. Frequ ently as adults they stillhad distant, difficult, or outspoken ly com-

petitive relationships with their siblings.One gained the impression that competi-tion with both older and younger sib-lings and the problem of being super-seded by the birth of younger siblingshad made the future ulcer patient un-usually vulnerable to situations contain-ing these ingredients. This helps to ex-plain the am bitiousness, the need to striveand to improve one's lot in the worldwhich many, including myself, havefound to be recurring traits in ulcer pa-tients; it helps also to explain why ulcermay be a disease which affects preferen-

tially the latecomer in the family.Ruesch,104 who studied carefully 62 pa-tients with chronic duo denal ulcer, foundthat ". . . ulcer bearers tend to be theyounger or youngest children in the fami-ly" and that "sibling rivalry is a frequent-ly noted problem and one of considerabledynamic importance." On this last pointthere is no clear agreement in the litera-ture.69 ' 73 This may have to do, in part,with the natur e of the control groups withwhich the investigators chose to com paretheir ulcer patien ts. Yet it would seem



4 ULCER PERFORATION

that the quality of the relationship be-tween siblings, as revealed by a carefuldynamic study of each case, is more tell-ing than coefficients of correlation ob-tained on large groups superficiallystudie d. In this connec tion, it is worthrecalling that in the early psychoanalyticstudies by Alexan der,2'3 Van der Heide,12 1

Levey,83 and Wilson,128 the importance

of sibling rivalry is clearly described eventhough in the final theoretical discussionthese factors seem inadequately empha-sized.

With respect to the treatment of pa-tients with a perforated peptic ulcer, themain issue can be stated simply. The p er-foration of an ulcer means, in the majori-ty of instances, that the p atient is in d eeptrouble, that he has struggled with a situ-ation which he did not know how to re-solve by himself an d th at he h as lost, or atleast suffered a setback. It follows that he

ough t to have some help. Giving help tothe ulcer patient is not easy, as Weis-man 12 8 has pointed out, but the difficul-ties are surmountable. At any rate, bothfor the sake of the patient's future well-being and the cause of good medicine, itwould seem useful to pay some attentionto his struggles and to look into the stateof his affairs, carefully.

Summary

The emotional factors involved in theperforation of ulcers of the stomach andduodenum and, particularly, the immedi-ate emotional antecedents of perforationare discussed on the basis of a detailedpsychiatric study of 20 patients under theage of 65 represen ting consecutive admis-sions for gastric or duodenal perforation.The patients were selected only on thebasis of a proved diagnosis of perforatedulcer and of age (less than 65), and noton prima facie evidence that emotionalfactors might be significant. Eac h pa-tient was seen in psychiatric interviews

for an average of approximately 8 hours,the purpose of the interviews being pri-marily investigative. Information was ob-tained also about other items of pre-sumed etiologic relevance, such as diet,use of alcohol, amount of rest, hereditarypredisposition, and other concurrent dis-ease.

The material obtained appears to indi-

cate that emotional factors were intimate-ly involved in the perforation in a largemajority of the cases, although the im-portance of other factors also was noted.It is felt that current medical opinion mayhave overemphasized the importance ofalcoholic excess in ulcer formation andperforation. In the instances where thepatient was a heavy drinker or a chronicalcoholic, perforation occurre d, as in non-alcoholic patients, as a climax to a periodof emotional turbulence when the patientwas faced with situations which, con-

sciously or unconsciously, he felt to begrossly damaging to his self-esteem andto which he reacted, predominantly, withimpotent rage.

The perforation prodrome has been de-scribed and it is felt it may represent akind of depressive equivalen t. Th e situa-tions and stresses to which the ulcer pa-tient seems especially vulnerable havebeen discussed with reference to recur-ring basic conflicts. Em phasis has beenplaced on the observation that the ulcerpatient tends to be a middle or youngestchild, noticeably competitive with hissiblings, yet threatened by this competi-tion. Note has been taken that the maleulcer patient usually has had duringchildhood an unsatisfactory relationshipwith his father, with inadequate mascu-line identification as one of its results. T hesuggestion is made that, especially whereno other serious disease coexists, perfora-tion be taken as presumptive evidencethat the patient has been trying to resolvean emotional crisis and that appropriatepsychiatric help be offered as part of thetotal treatment.




CASTELNUOVO-TEDESCO 411

The pertinent psychiatric, medical andsurgical literature has been reviewed.

Harbor G eneral Hospital1124 W. Carson St.

Torrance, Calif.

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Course in Postgraduate Gastroenterology

The Annual Course in Postgraduate Gastroenterology of the American College

of Gastroenterology will be given at the Morrison Hotel in Chicago, 111., Nov. 1-3,1962.The College is most happy to announce that after a 3-year absence the mo derato rs

for the course will again be Dr. Owen H. Wangensteen, C hairman and Hea d of theDepartment of Surgery of the University of Minnesota School of Medicine, andDr. I. Snapper, Director of Medical Education, B eth-El Hospital, Brooklyn, N. Y.

Th e faculty for the course will be drawn from the medical schools in and arou ndChicago. The subject matter to be covered, from th e medical as well as the surgicalviewpoint, is essentially the diagnosis and treatment of gastrointestinal diseases, andwill include comprehensive discussions of diseases of the mouth, esophagus, stom-ach, pancrea s, spleen, liver and g allbladder, and colon and rec tum. A clinical ses-sion will be held at the Cook County Hospital, in addition to presentation of theseveral papers.

For further information and enrollment write to the American College of G astro-

enterology, 33 West 60th Street, New York 23, N. Y.


Documents

Emotional antecedents of perforation of ulcer