who will cure my ulcers?

1282

the arteriogram; but others demonstrated the diseasedarea by scanning when aortography had failed, and focalareas of ischaemia were identified. s

The dose of radiation to the kidney is quite small.Although 100-150 C oP03Hg are given, with a physicalhalf-life of forty-five days, the effective half-life withinthe body is quite short, averaging three hours, and theradiation to the kidney is less than 0-5 rad.2 Recently19’Hg, with a half-life of sixty-five hours, has been usedto label chlormerodrin, 10 and this should reduceradiation still further.One disadvantage of renal scanning is the initial cost

of the apparatus. Technical knowledge of the scanner isnecessary, and the instrument must be carefully cali-brated. Interpretation presents some difficulties, since itis hard to determine the kidney outline precisely: a plainfilm of the abdomen or an excretory pyelogram can behelpful accompaniments, and where possible these

investigations should precede the scan. Despite thesereservations, the scan has much to commend it, for it canspare many patients the more hazardous procedures ofaortography and split function studies. It is certainlya useful addition to the methods of investigating kidneyabnormalities.

10. Sodee, D. B. J. nucl. Med. 1963, 4, 335.

Annotations

WHO WILL CURE MY ULCERS?

THE surest way to empty the room at a medical meetingis to announce that the next subject for discussion is thesurgical treatment of peptic ulceration. The malady itselfis common enough, but its operative treatment has for thepast half-century been hotly disputed to the point ofboredom. In 1923, Sir Berkeley Moynihan (as he thenwas) wrote: " The after-results of gastroenterostomy forduodenal ulcer are excellent. Over 90% of cases tracedconsider themselves perfectly well. In the remainder thediscomforts may almost be regarded as negligible." Hewas right in saying that gastroenterostomy will alwaysheal a duodenal ulcer; but it brings anastomotic ulcers,

. afferent-loop syndromes, and (sometimes) metabolicdisturbances in its train-or, as is often the case, in atrain arriving some years later.When surgeons became fully aware of the complications

they turned to partial gastrectomy, the promising operationmuch favoured by the brilliant Viennese school of sur-geons-von Eiselsberg, von Haberer, and Finsterer. Foralmost twenty-five years this operation held undisputedsway; and the only debatable points that were raised insurgical gatherings were technical variations, such as thevirtues and defects of antecolic and retrocolic anastomoses,the pros and cons of the Billroth i and Billroth II proce-dures, the amount of stomach to be resected, and suchirrelevancies as the proper suture material for the anasto-mosis. But on the main point there was general agreement:partial gastrectomy was the most satisfactory operation forduodenal and gastric ulceration. Moynihan wrote:

" The

operation that I regard with the utmost composure asthoroughly satisfactory for the great majority of cases isgastrectomy. It is safe to a degree one would hardlyexpect. In 10 years the mortality has been 1-6%."Moynihan was echoed all over the world by the surgeons

who came after him. And then came ominous rumblingsthat culminated in a storm of criticism. Patients had been

largely cured of the pain of their ulcers, but now they werebeginning to complain of the symptoms of intestinal hurryand dumping, of afferent-loop syndromes, of metabolicdisturbances, of failure to gain weight, and even sometimesof a recurrence of ulceration at the anastomosis.

But a new star (or it might be apter to say a man-madesatellite) was arising. In Chicago, Dragstedt was proclaim-ing the virtues of an oddly named operation-vagotomy.This, he said, was an attack based on physiologicalprinciples rather than a crude anatomical onslaught. Theensuing years saw battle between the defenders of gastrec-tomy and the advocates of vagotomy: statistics were flungaround like snowballs; recurrence-rates became weapons;for gastrectomy enthusiasts, dumping became a nastyword. There were minor skirmishes. Should vagotomybe combined with antrectomy instead of pyloroplasty?Was gastroenterostomy or pyloroplasty the better drainageprocedure in vagotomy ? Deafened by the clamour of rivalschools and overcome by graphs and charts, delegates tosurgical conferences made for the nearest tea-room.The dust is beginning to settle. Vagotomy and pyloro-

plasty-the parvenu operation-has become respectable.More than respectable perhaps; for in a new boot I

Burge, one of its stoutest supporters in this country, writes:"

Vagotomy probably cures all cases of duodenal ulcera-tion ... if nerve section is complete and the antrumdrained adequately, then there are no recurrences follow-ing this simple operation ... there is no more need to per-form gastrectomy for gastric ulcer than for duodenalulcer.... Vagotomy and pyloroplasty seems to cure allcases of benign lesser curve gastric ulceration." Moreover,hiatus hernia, peptic oesophageal stricture, and cardio-spasm, in Burge’s opinion, are all suitably dealt with bymeans of this operation. If older surgeons hear faintechoes of former panegyrics, they can scarcely be blamedfor concluding that this is where they came in. Yet some

things must be said. Vagotomy is not always a simpleoperation. Selective vagotomy, the operation devised byBurge, is even less simple. Few surgeons will endorse theview that it is the operation of choice for gastric ulcer, andfewer still will agree that the pyloric-channel syndrome isthe precursor of lesser-curve ulcers. In the end, the com-ments of Williams 2 and Stammers 3 are probably the mostapposite: " Let us not too rapidly abandon gastrectomyand begin a vagotomy bonanza "; and " the metabolicconsequences of [vagotomy and pyloroplasty, and vago-tomy with antrectomy] must be watched carefully for 5 to15 years afterwards ".There is a time for gastrectomy and a time for vagotomy

and pyloroplasty, a time for vagotomy and antrectomy,and sometimes even-heresy of heresies-a time for

gastroenterostomy. In the surgeon’s armoury there aremany weapons.

CANTERBURY TALE

LAST week we discussed the new criteria for membershipof the College of General Practitioners. These come undertwelve " heads of information ", only one of which is a"

test of knowledge ", while most relate to experience andto such tangible signs of achievement as degrees and dip-lomas, and published or submitted work. One, however,1. Vagotomy. By HAROLD SURGE, M.B.E., M.B., F.R.C.S. London: Edward

Arnold. 1964. Pp. 270. 60s.2. Williams, J. A. Lancet, Aug. 8, 1964, p. 310.3. Stammers, F. A. R. ibid. Aug. 22, 1964, p. 416.