The Treatment of Gastric and Duodenal Ulcer
BMJ (Clinical Research Edition)
The evidence bearing on the general results of treatment of gastric and duodenal ulcers is derived from statistics of follow-up departments. I shall confine myself, so far as possible, to those statistics which deal with the results of both surgical and medical treatment in the same hospital or in the same groups of patients, not those which are based on the practice of a single physician or surgeon. The results of follow-up investigations are usually divided into several grades according to
... des according to whether they are satisfactory or unsatisfactory, and although different classifications are used they agree fairly well, on the whole, with each other. Sonme, but not many, of the records use the word " cure " for the most successful result. Criteria of a "Cure" We may consider what should be the criteria of a " cure." First the presence of an ulcer must be established. Even so long ago as 1924 Sherren said that clinical diagnoses were correct in. 75 per cent. of the cases on which he operated; and it is clear that with the advance of radiology diagnosis is becoming more and more accurate. Broster, a few years ago, stated that diagnosis by x rays alone was accurate in 80 per cent. of cases. The diagnosis of ulcer now is probably correct in 90 per cent. of cases. The second point in regard to the' use of the word cure is that we must know that the ulcer has been healed. Medically, we do not see the ulcer, and we cannot tell if it is healed even when x-ray examination shows that a crater previously present has disappeared. After gastro-enterostomy there will be the same doubt as to whether or not the ulcer is cured. Thirdly, will the treatment undertaken ensure that the ulcer will not recur, or that another ulcer will not develop elsewhere?' No layman would agree that we had cured ulcer of the stomach if he was told that he might develop another one a few inches away. We are unable to guarantee immunity from the recurrence of symptoms. A fourth point, and one of importance, is that the treatment must not, in itself, produce any specific bad results, such as, for example, alkalosis or gastro-jejunal ulcers, and it should not have a high mortality. The use of the word cure, in the strict sense, can scarcely be justified, but it is often employed in cases in which radiographs have become normal and in which symptoms have been absent for a long time. Results lndica,ted by "Follow-up" The first results to be considered are those of the followup department of St. Bartholomew's Hospital, whicl, were published last year. This department was new in 1929, and the results are those of careful observation for one to five years. Table I gives the figures for chronic ulcers. Since many of the cases will have been followed only for short periods, the figures will not show relapses, failures, or other sequelae in full. Grades I and II may be regarded as " satisfactory " from the patient's point of view and Grade III as " unsatisfactory." Cases in Grade IV must be regarded as complete failures, and to these must be added the cases with a fatal termination.