Gastric and duodenal ulcer treatment

NALYSIS of this subject by the A faithfu1 reader and patient Iistener, for an agreeable Iength of time, Ieads one to the consideration of three definite but somewhat overIapping issues. Firstly, there is the border warfare to estabIish a medico-chirurgical boundary Iine, a perennia1 parity conference, with the dipIomacy not aIways in evidence. SecondIy, there is a constant striving for standardization of procedure, an endeavor common to both medica and surgica1 interests. And thirdIy, one observes the effort to express the Iast word, that one may sIump back into the comforting embrace of the fuIIy crystaIIized idea. These curious smaI1 erosions of a sIight fraction of man’s vuInerabIe surface, a matter of indefmite consideration in past ages of medica knowIedge, were subjected first to an inteIIigent anatomica and pathoIogica1 consideration by CruveiIhier aImost exactIy a century ago. His treatment, compiIed from his own observation and the experience of others, discIoses that the modern method of non-surgica1 attack became authoritative at that time. In summarized form, he advocated twentyfour hours’ abstinence from food, to be foIIowed thereafter by severa teaspoonfuIs of miIk every four hours, to be augmented Iater by geIatinous or starchy foods, gaseous waters and soups. He advised the use of caIcined magnesia, carbonate of magnesia, Iime water, peppermint tea and the sucking of sugar to promote saIivary secretion. Note the earIy approva1 of the Iatest advances, nameIy, the superiority of caIcium carbonate over aIkaIies that cause aIkaIinization, the pharmacoIogic retardation of peristaIsis by essentia1 oiIs, and the utiIity of sugar as a salivary stimuIant. Expressing it briefly, for the requirements of this meeting, the proper nonsurgica1 approach of the probIem has been in evidence, with slight variation, for a hundred years. The empiric principIe of rest and frequent miIk plus feedings, the reversion to the caIcium of CruveiIhier, the abandonment of excessive aIkaIinization furnish a program of contracted scope and Iimited variety comprehensibIe to everyone. Experience in the so-caIIed medica conduct of this condition has eIicited vaIuabIe information on accompanying physica1 states, essentia1 CIassifactory tabuIations, differentia1 diagnostic facts and proper appreciation of psychoneurotic inff uences. But, from a Iong period of commendabIe appIication of the internist’s virtues of patience, fideIity and persistence, we have received scant reward. A smaI1 group of cases, probabIy best described as possessing acute uIcers, show satisfactory response and fuIfiI1 requirements as to proper criteria of cure. This group perhaps substantiates the dictum that medica treatment shouId be given a tria1 in most newIy discovered cases. But the great buIk of uIcers are of the chronic type with cIear pathoIogica1 characteristics. These a11 tend toward deveIopment of obstruction (34 per cent) gross hemorrhage (40 per cent) and perforation (6 per cent) in the duodena1 area, pIus maIignancy in the gastric area. In weighing the vaIue of the Iast factor one finds authority for any figure from 7 to 70 per cent. Regardless of whether this is a coincidenta or causa1 finding, about 2 per cent of operations performed pureIy on evidence of gastric uIcer discIose the presence of maIignancy. Our medica measures consistentIy usuaIIy retard this progress, but eIiminate pathoIogy but rareIy. With the resuIt not often suffIcientIy appreciated or admitted, that we have under our care a more comfortabIe patient but a sick individua1, a