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Background: Although dyspepsia has been described for thousands of years, few studies have analysed its incidence before the 19th century when peptic ulcer first became a major dyspepsia-producing disease., Methods: The incidence of alimentary disease around 1800 was examined in three private practices for the fee-paying middle class and in five public dispensaries for the poor in London, as well as in one dispensary in New York., Results: The proportions of attendances for alimentary disorders were identical, 16%, in each of the three groups. Diarrhoea and dysentery were twice as common in the London dispensary than in private practice, presumably because of poor sanitation. Dyspepsia showed a similar incidence in the London dispensary and private practice, but was only half as common in New York. Worms were three times more common in dispensary patients in New York than in London. The incidence of diarrhoea and dyspepsia indicated no significant time trends over 43 years. None of the alimentary causes of death showed peptic ulcer at necropsy, and both haematemesis and intestinal haemorrhage were rare., Conclusions: Around 1800, the infrequent deaths from alimentary conditions suggested that the ulcer epidemic had not yet started. Instead, it is probable that the dyspepsia was similar to the non-ulcer dyspepsia of today.

The occurrence of peptic ulcer increased rapidly in all Western countries from the 19th to the 20th century, attributed to a possible epidemic of Helicobacter pylori, a new pathogenic strain, or a change in host susceptibility. The early trends in hospital admissions for peptic ulcer and dyspepsia in London and New York during the 19th century are reviewed to test these hypotheses.

Objectives: Mortality data of peptic ulcer are mostly national and limited to the 20th century. The New York City data from 1804 have therefore been examined by both year of death and year of birth (cohort analysis), to consider whether the increases and subsequent decreases in deaths from gastric, followed by duodenal ulcer, can be attributed to Helicobacter pylori., Methods: The annual mortality reports of New York City described gastric ulcer from 1838 and duodenal ulcer from 1931. The age-specific death rates per 100,000 population were calculated in 10-yr periods both by year of death and by year of birth for each disease according to age and sex., Results: For gastric ulcer the period-of-death-age contours from the 1850s to the 1990s showed an increase to a mid-19th century plateau, but the cohort-age contours revealed a peak mortality for those born in the 1870s. Women born between about 1770 and 1880 showed a faster increase in mortality. For duodenal ulcer the period of birth contours showed a decline from a peak for those born in the 1880s and 1890s, with no sex difference., Conclusions: This urban study with data regarding deaths from gastric ulcer registered from 1838 and in those born from the 1770s, revealed by cohort analysis a peak in the 1870s, and for duodenal ulcer in the 1880s, comparable to national data worldwide. These time changes in fatalities are compatible with a change in the environment of children born in these decades, as, for example infection by a pathogenic strain of H. pylori.

Gastroenterology grew as a subspecialty in Germany in the 19th century. In the 1880s and 1890s, Austrian and German clinics were attended by American physicians who, on returning to the U.S., founded the American Gastroenterological Association in 1897. The creation of a subspecialty board, however, had to wait until 1941. At The Mount Sinai Hospital, Dr. A.A. Berg was appointed Surgeon in 1899. His practice focused on the alimentary tract, which in 1910 became one of the four surgical specialties. In 1914, further subdivision led to the stomach and duodenum becoming additional specialties. In 1917, wards were endowed for Dr. Berg's specialty. The first Mount Sinai physician to have an interest in gastroenterology was Morris Manges, but the first to limit his practice to gastroenterology was Dr. Edward Aronson, for whom a specialist outpatient division was formed in 1913. Aronson died in 1922 and was succeeded by Dr. Burrill Crohn, who was followed in 1934 by Dr. Asher Winkelstein; all three collaborated closely with the surgeons, physiologists and biochemists. In 1958, Dr. Henry Janowitz became chief of the Division of Gastroenterology; he was succeeded in 1983 by Dr. David Sachar, who was followed in 1999 by his associate Dr. Steven Itzkowitz. In 1958 Dr. Fenton Schaffner became chief of the Division of Hepatology (now headed by Dr. Paul Berk), and in 1979 Dr. LeLeiko became chief of Pediatric Gastroenterology.

The Annual Reports of the Mount Sinai Hospital from the 1850s, and the Mount Sinai Hospital Reports for 1897-1906, make it possible to trace the discharges of gastroenterological inpatients, and (for a few years) of outpatients. Fully computerized diagnostic data have only been available since 1986. In the 19th century, about 20% of the outpatients had digestive disorders, the commonest of which were gastralgia/gastritis/dyspepsia, gastroenteritis, oropharyngeal complaints and constipation. A similar proportion of inpatients had digestive diagnoses, but the four disorders listed above decreased markedly in the second half of the 19th century, so that by the turn of the century the commonest diseases were typhlitis (appendicitis), hemorrhoids and other anal problems. By the 1990s, digestive diseases accounted for only 5% of total admissions, hepatobiliary diagnoses being the commonest group. Some cancers such as gastric and esophageal showed little change, while colorectal increased markedly. Some newly recognized diseases, such as peptic ulcer, waxed and then waned, while colitis and regional enteritis came and have continued to increase. Other new diagnoses, such as autointoxication and visceroptosis, flashed into prominence and then disappeared totally, presumably because they were nondiseases.

Pancreatic secretion was first studied at The Mount Sinai Hospital by Crohn in 1912, but measurements of pancreatic enzymes in duodenal aspirate or feces were found unhelpful in diagnosis. Such pancreatic tests fell into disuse because of advances in radiology of the biliary tree in the 1920s. Once extracts of secretin and cholecystokinin-pancreozymin became available from Sweden in the 1930s, it became possible for the biochemist Franklin Hollander and the surgeon David Dreiling to develop pancreatic secretion tests into practical procedures for the diagnosis of benign and malignant diseases of the pancreas and biliary tree, and produce physiological studies of the mechanisms of ion transport. With more purified hormones, it became possible to measure maximum (alkaline) bicarbonate output of the pancreas analogous to the maximal acid response of the stomach to an augmented histamine test, and to determine whether patients with duodenal ulcer had decreased neutralization of gastric acid in the duodenum. Clinical studies were also directed to the pathophysiology of acute relapsing and chronic pancreatitis and carcinoma. However, advances in imaging and endoscopy have now shifted the thrust of pancreatology.

In 1852, The Jews Hospital was founded for the increasing number of Jews in New York. It opened in 1855 with 45 beds on West 28th Street; 92% of the patients were indigent. In 1864, the hospital formally became nonsectarian and, in 1866, changed its name to The Mount Sinai Hospital. The medical staff was primarily Jewish, because until relatively recently, it was difficult for Jewish doctors to obtain postgraduate training or specialist posts at major New York hospitals. As the Jewish population moved uptown, so did The Mount Sinai Hospital: in 1870 to 66th Street, and in 1904 to 100th Street, with 456 beds, growing with new buildings and services to the current 1100 beds, 50,000 discharges, 400,000 inpatient days and 300,000 outpatient visits each year. Services increasingly became specialized, and then subspecialized. Key innovations included the choice of interns by competitive examination (1872), an advisory Medical Board (1872), the Nurse Training School (1881), the library (1883), the Alumni Association (1896), a professional medical hospital administrator (1903), research laboratories (1904), clinicopathological conferences (1905), the Social Services Department (1906), postgraduate teaching programs (1923), full-time chiefs of clinical services (1944), the dedication of the Mount Sinai School of Medicine (1968), and the merger in 1998 into the Mount Sinai-New York University Medical Center.

From the late 19th century, Mount Sinai gastroenterologists declared their scepticism of the efficacy of all recommended treatments of peptic ulcer, and looked forward to trials which could distinguish between sequence and consequence, between association and causation. The rationale of all the early studies was to reduce gastric acidity, but it soon became clear that any neutralization by single doses of antacids was brief and ineffective. Winkelstein s demonstration that patients with duodenal ulcer had higher acidities not only before and after meals but also through the night hours led him to introduce a new treatment, the alkalinized intragastric milk drip together with atropine. One of the earliest controlled clinical trials at Mount Sinai compared different antacid regimes and showed that pH values above 3.5 were achieved in only about half of the patients on the various drips. When the new anticholinergic drugs were developed in the 1950s, they were found to produce sustained hypoacidity and were tried as maintenance treatment, as an alternative to acid-lowering operations. The third Mount Sinai approach was to attack the machinery of the acid-producing cell itself by an inhibitor of the enzyme producing hydrogen ions. In 1939, this enzyme had been thought to be carbonic anhydrase, but when Janowitz and Hollander tested its inhibitor, acetazolamide, and showed marked but very brief acid inhibition, they concluded that its action was too brief to be therapeutically useful. The problem was to be solved decades later by H2 receptor blockers from Britain and H+K+ATPase inhibitors from Sweden.