Konjetzny: A German Surgeon of the Past Century and his Pioneering Hypothesis of a Bacterial Aetiology for Gastritis, Peptic Ulcer and Gastric Cancer

Barry Marshall, together with his colleague Warren from Perth, is without any doubt the saviour of numerous patients from suffering from life-long disabling peptic ulcer disease. It is his merit to have published a most interesting book on the pioneers in the field of the bacterial genesis of peptic ulcer disease. Modestly he acknowledges many other illustrious scientists and their contributions in recognising an infectious aetiology of peptic ulcer disease [1]. However, in the 300 pages of the book the major pioneer in this field, the German surgeon Georg Ernst Konjetzny (Figures [1] and [2]), remains unmentioned. This fact is not surprising, since all of Konjetzny’s work in the early decades of the last century was written and published in German.

It is the aim of this article to supplement this interesting information.

Konjetzny was born on 26^th April 1880, in Gleiwitz, Germany which, since the end of the Second World War, became part of Poland. His destiny, according to his family’s aspirations should have been to study religion, however he opted for medicine and finished his studies in the year of 1906 in Breslau. Common for this era, his academic career started as an assistant in the Institute of Pathology in Chemnitz. It was his desire to become a surgeon with a profound knowledge of the morphology of pathologic organs which he had resected surgically. Therefore he studied the morphology of the gastric mucosa in resected specimens from patients with peptic ulcer or gastric cancer. He spent many years in the Department of Surgery of the University of Kiel under the supervision of Professor Anschütz. It was here that he became Professor of Surgery and moved to the University Clinic Eppendorf in Hamburg where he was elected as the Chief of the Department of Surgery and where he remained for the remainder of his active academic life. His scientific activity, on the occasion of his 70th birthday, was highlighted in a German medical journal [2] by an academic friend, Professor Prinz, who reported about his numerous research interests in all surgical specialities, such as traumatic injuries of the meniscus, the effect of drugs on the healing of surgical wounds, anthrax, gallbladder diseases, Hirschsprung’s disease, gunshot chest injuries, and aortic embolectomy as a heroic surgical procedure for that time. However, the main research field of Konjetzny continuously remained the pathogenesis of peptic ulcer and gastric cancer.

In 1923, he published an important paper entitled “Chronic Gastritis and Duodenitis as causes of Gastric and Duodenal ulcer” [3] (Fig. [3]). The current view of those times was that the intensive chronic inflammation found in the resected specimens of ulcer patients was a consequence of the peptic ulcer. Contrary to this view, Konjetzny postulated the intense chronic inflammation to be prior to peptic ulcer formation and he reported in this article on two patients with epigastric pain just a few months before a Billroth resection was performed. He argued that the chronic gastritis could hardly have arisen in such a short time and observed that these changes were located far away from the peptic ulcer itself. Furthermore, after examining the vessels in the close surroundings of the ulcer he could find no venous or arterial thrombosis leading to mucosal necrosis and ulceration. He declared that of the resected stomachs from patients with duodenal ulcer, which he had examined with his co-worker Kalima, all (100 % of the cases) showed severe gastritis.

Fig. 1 Konjetzny as he was 45 years.

On pages 614 and 615 of his study [3], he remarks: “By histological examination of specimens, stained with the Nicolle method, it was remarkable to observe a close correlation between the grade of gastritis and the amount of bacteria spreading on the mucosa. In the fundus region with little or no inflammation, I could not find any bacteria. Quite the contrary: in areas with severe gastritis we observed a loss of specific glands and the occurrence of a secondary atrophy both in the area of the crypts as well as in the necks of the glands. The bacteria were found massively in the gastric pits in those areas showing severe gastritis. The bacteria were not only observed on the mucosal surface and on the adjacent mucus layers, but more often in the peripheral regions of mucosa and in the central crypt tissue also (in German original text: im zentralen Zottengewebe). However, little bacteria were observed in the ulcer itself and it was completely undetectable in those areas with normal mucosa or in areas with secondary reepithelialisation after primary presence of mucosal lesions under these mucosal changes, it is to mention the presence of localised follicles, some times reaching the mucosal surface, containing round cell infiltrations with lymphocytes and leukocytes. These follicles represent a pathological condition by their high numbers and their remarkable extents” (Fig. [4] and 5 of the original article).

Konjetzny, after having made more morphologic studies on gastric mucosa, published two books, one on “Ulcer Formation in the Stomach, Duodenum and Jejunum” in 1947 [4], in which he presented his observations and arguments and refuted the hydrochloric acid theory as the cause of peptic ulcer formation. Notably, he was vehemently opposed to the opinion of all contemporary scientists of his time. He was especially hostile-minded against his colleague from the Department of Internal Medicine in Hamburg, who vehemently defended Schwarz’ theory of “No acid no ulcer” [5]. This led to some problems for the medical students of the University in Hamburg who were confused about the correct answer in their examinations.

His other book with the title “Gastric Cancer” was published in 1938 [6] and contained comprehensive knowledge of that time about gastric cancer with chapters on the clinic and diagnosis of early and advanced gastric cancer, signs of malignant gastric ulcer, surgery of gastric cancer, prognostic signs, the survival rate after resection as well as prophylaxis of gastric cancer. In the latter part, he concluded (page 262): “Ulcer and gastric cancer will be developed through silent inflammation of gastric mucosa. We are not able to distinguish between gastritis, which forms benign ulcer and that developing gastric cancer. When we were able to prevent gastritis or treat it, we would be able to prevent ulcer and gastric cancer: Prophylaxis of gastritis means prophylaxis against ulcer and gastric cancer”.

It is again remarkable that ulcer researchers before Warren and Marshall did not pay attention to Konjetzny’s gastritis theory of peptic ulcer. In the voluminous English language book with the title “Peptic Ulcer” consisting of 1144 pages, neither his name nor his theory are mentioned [7].

In his revolutionary letter to editor of Lancet in 1983 [8], Barry Marshall claimed: “The pathogenesis of these bacteria remains unproven but their association with polymorphonuclear infiltration in the human antrum is highly suspicious. If these bacteria are truly associated with antral gastritis, as described by Warren, they have a part to play in other poorly understood, gastritis associated diseases,” i. e., peptic ulcer and gastric cancer. The contents of this short communication with the observation of pathologist Warren [9] correspond exactly to the conclusion of the surgeon and pathologist Konjetzny.

I would like to conclude that, perhaps, due to the lack of an associated bacteriologist backing his considerations or due to the lack of effective drugs such as bismuth derivatives and antibiotics Konjetzny’s observations did not receive the deserved attention. Another explanation could also have been the lack of cross-communication between the German and English scientific literature at the time. However, whatever the reason for this unfortunate delay - the postponed discovery of H. pylori caused preventable suffering and death from this disabling disease for innumerable people.

Fig. 2 Konjetzny at his 70th birthday.

Fig. 4 Part of the original article[3].

Fig. 5 Continuation of the original article [3].

Fig. 3 The title of the publication of Konjetzny in 1923 [3].

References

• 1 Marshall B  (ed). Helicobacter Pioneers - Firsthand Accounts from the Scientists who Discovered Helicobacters 1892 - 1982.  Blackwell Publishing Asia Pty Ltd. 2002; 
• 2 Prinz E. Prof. Konjetzny zum 70. Geburtstag.  Neue Medizinische Welt. 1950;  21 1-4
• 3 Konjetzny G E. Chronische Gastritis und Duodenitis als Ursache des Magenduodenalgeschwürs.  Ziegler’s Beiträge zur Pathologischen Anatomie und zur allgemeinen Pathologie. 1923;  71 595-618
• 4 Konjetzny G E. Die Geschwürsbildung im Magen, Duodenum und Jejunum. Stuttgart; Ferdinand Enke Verlag 1947
• 5 Schwarz K. Über penetrierende Magen- und Jejunalgeschüre.  Beitr Klin Chir. 1910;  67 96-128
• 6 Konjetzny G E. Der Magenkrebs. Stuttgart; Ferdinand Enke Verlag 1938
• 7 Ivy A C, Grossman M I, Bachrach W H (eds). Peptic Ulcer. Philadelphia/Toronto; The Blakiston Company 1950
• 8 Marshall B. Unidentified curved bacilli on gastric epithelium in active chronic gastritis. Lancet 1983: i: 1273-1275
• 9 Warren J R. Unidentified curved bacilli on gastric epithelium in active chronic gastritis. Lancet 1983: i: 273