Helicobacter (1)
Professor Warren is a pathologist. When other physicians cannot find answers, they turn to him for microscopic readings—the undisputed king among doctors. To a pathologist, tissue damage must have a specific cause. That principle holds especially true when the damage progresses all the way to cancer. Peptic ulcers have another cause. That was Professor Warren’s conclusion.
How could a disease capable of producing such clear pathologic findings, even leading to cancer, be attributed solely to stress? That sort of thinking belonged to psychiatrists or rheumatologists, not to someone trained in pathology. It made no sense. The missing link simply had not been found yet. Whatever it was.
***
It had been a while since I last visited Dean Rich’s office. Even from the hallway outside, the rich aroma of aged Cuban cigars hung in the air. This must be one of the expensive ones; the smoke no longer made me cough as much. His secretary glanced up at me.
“You may go in now.”
She opened the door for me. I stepped inside. The moment I entered, the dean stubbed out his cigar in the ashtray and looked at me.
“Do you know how to perform upper endoscopy?”
“I do.”
“One of the gastroenterology professors broke his arm after colliding with a bicycle on his way here. We need someone to handle the backlog of endoscopies.”
The endoscopes used in this era differed from the ones I had practiced with in the future. The last time I saw one, the screen was still black and white. Still, I could manage. It was not a difficult procedure. I would examine the stomach for cancer or ulcers, and if anything suspicious appeared, I would take a small biopsy through the scope. Most cases would be normal—just routine screenings.
“Understood.”
“Good thing we have you. I was wondering whether we would have to cancel or postpone all the appointments.”
The dean sank into his chair with a sigh.
“Think about it from the patients’ side. How absurd would that be? The time and money it takes just to schedule one endoscopy.”
If the hospital canceled or rescheduled appointments because of its own problems, patients would suffer. Anyone who had been through it would know.
“Exactly… Thank you, truly.”
I bowed once more and left the office. My workload had increased, but I did not mind. This was also an opportunity for research. After all, there was a famous Nobel Prize connected to upper endoscopy—related to the cause of peptic ulcers.
***
This was the endoscopy suite. A nurse was organizing supplies on one side of the room. I powered on the endoscope and checked the syringe filled with medication. We would use diazepam as the sedative. It would not put patients completely under, only calm them. Most remembered the procedure afterward.
The first patient of the day entered my suite—a typical man in his forties.
“Hello.”
I greeted him. The moment he saw my face, he flinched.
“What? Where did Professor Smith go?”
“Ah, the professor broke his arm and cannot come in today. I will be performing your endoscopy.”
The patient lay down on the examination table on his side.
“When I was in Vietnam, we had an interpreter in our unit who looked just like you.”
“I see.”
“He stepped on a landmine and died. Are you a refugee from South Vietnam, Doctor?”
The Vietnam War had ended in 1975—only a few years ago. It was not surprising that anyone with black hair triggered such thoughts.
“Let’s proceed quickly.”
The patient remained on his side, still talking about the war. I nodded. Best to move fast. I injected the sedative into his vein, applied lidocaine gel to the endoscope, and slowly advanced it into his mouth. We had a long list of endoscopies today; there was no time to waste.
The esophagus appeared on the black-and-white screen. The endoscope handle from this era had an eyepiece, allowing direct viewing through fiber optics. Evaluating the stomach properly on a monochrome screen was not easy. I located an ulcer in the patient’s stomach while he continued speaking.
“Auuuuaaai. Ah?”
“Yes, that could be possible.”
I had no idea what he was saying. I answered vaguely. Some doctors developed the skill to understand mumbled words from sedated patients during endoscopy. I had not reached that level yet.
“Auuiaaaauaa.”
The words kept coming.
“Ah, I see. Does it hurt?”
The patient tried to shake his head. The nurse beside him held it steady.
“Please do not move your head.”
Anyway. While I worked, I found one gastric ulcer. It did not look dangerous, but every gastric ulcer carried a risk of progressing to stomach cancer. Skipping a biopsy would leave me uneasy. Through the black-and-white image, the open lesion was visible. I maneuvered the scope and carefully removed a small piece of mucosa from the ulcer margin.
“Euaaauaa.”
“Yes. I just took a biopsy from the ulcer. We will check whether there is any cancer. The chance is low, but if cancer appears, you would need stomach surgery.”
“Uuaa euaa?”
He seemed to be asking if it was serious.
“It is not serious. This is just part of a routine check. There is a good chance nothing is wrong, but if you have been having heartburn, I can prescribe medication for gastritis.”
The patient nodded—or tried to. The nurse reminded him again not to move. The endoscopy was finished. I placed the ulcer tissue into a specimen jar and withdrew the scope from his mouth.
“All done.”
The patient retched into the wastebasket and wiped his mouth with a tissue. Endoscopy always produced a lot of saliva, and swallowing was difficult. He looked at me as though he had something to say.
“Still… seeing people like you helping patients in the hospital… makes me think what we fought for across the ocean was not in vain.”
“Thank you for your service.”
I bowed to him.
***
The endoscopy work was complete. Today I had collected thirty gastric lesion specimens. In the pathology lab, I was processing the tissue samples from the stomach lesions. This was an important research project. Gastric ulcers mattered clinically because they could lead to stomach cancer. In the 1970s, ulcers were still believed to be caused by stress. Only half true.
Let me think through this slowly from the beginning. Why had physicians of that time failed to realize that Helicobacter pylori caused peptic ulcers? Multiple myeloma had been identified in the nineteenth century, and bacteria themselves in the seventeenth—yet this connection remained unknown. On the surface, it seemed like a simple problem.
I had been reviewing the existing literature. The first discovery of unusual bacteria in gastric ulcer tissue dated back to the nineteenth century—about eighty years ago. But even into the 1980s, the hypothesis that bacteria caused ulcers was not accepted. There were several reasons.
First, stomach acid was considered far too acidic for any bacteria to survive. Second, there was the staining problem. Doctors used Gram staining to look for bacteria, but Helicobacter pylori did not show up with Gram stain. So how had nineteenth-century physicians found it? They had used silver staining. Third, the culture problem. Helicobacter pylori was notoriously difficult to culture.
Even now, bacterial culture methods were divided into aerobic and anaerobic. Helicobacter pylori was microaerophilic. What did that mean? Even doctors in the 1980s did not fully understand it. No oxygen in the jar? It would die. Too much oxygen? It would die. It required a precise oxygen concentration. Liquid media? It would die. No serum? It would die. It needed semi-solid media with serum. And if you shook the jar, it died. The more I thought about it, the more irritated I became.
Anyway, it was a finicky organism. No wonder it went undiscovered for a hundred years. In fact, the scientists who eventually identified Helicobacter pylori spent years mistaking it for another bacterium called Campylobacter. Its spiral shape had been mistaken for a simple rod. Why did the difference between rod and spiral matter? That, too, was an interesting story. If you considered why a bacterium would evolve a long spiral form, the answer became clear—structure and function were—
While I was jotting these thoughts in my notebook, a pathology professor entered the lab. He looked surprised that I was still here after hours.
“Who are you, and what are you doing?”
“I am working on a cure for cancer.”
“I see… Carry on.”
The professor disappeared as quickly as he had appeared. It was true, yet he did not believe me. Regardless, I had processed enough samples. All that remained was to photograph the gastric tissue slides and propose the study to the leading ulcer experts of the 1970s. After all, there were people already researching this.