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Radiology in Duodenal Ulceration
778 immune response will
no
doubt be answered in due
Although this news sounds very hopeful, there are points which should discourage over-optimism. Firstly, a big effort has clearly been needed to prepare and test enough vaccine for quite a small number of people. Each batch of vaccine will need rigorous tests before it can be safely used, and it may be some two
time therefore before these vaccines are available in any quantity. Secondly, though some immunologists believe that the development of resistance to infection and the presence in the serum of antibody to the infecting agent (so often found in close association
with one another) are in fact indissolubly linked, The this has yet to be proved in poliomyelitis. low of paralytic poliomyelitis in the community means that very large numbers of people must be immunised before it can be confidently concluded that a vaccine not only produces an antibody response but also protects against paralysis.
prevalence
in Duodenal Ulceration THE only satisfactory way of establishing the presence of a duodenal ulcer, other than by laparotomy, is by the radiographic demonstration of unmistakable changes. These changes are usually limited to the first part of the duodenum, though they may occasionally be found in the second part.l The radiographic
Radiology
evidence may be conclusive, when an ulcer crater is seen ; inferential, when the duodenal cap is deformed but no ulcer crater is recognisable : or indirect and equivocal, when irritability of the duodenal cap, pylorospasm, radiographic evidence of gastritis " ; or other unconvincing signs are present. Only the conclusive and the inferential radiographic signs point with a high degree of probability to the presence of an ulcer. Radiography, though revealing an ulcer, may not reveal an unsuspected cause-for example, a "
pancreatic neoplasm. Clearly radiographic
examina-
tion is most useful as a check on medical treatment in It cases where a crater has previously been seen. must be remembered, however, that duodenal ulcers are often multiple : STURTEVANT and SHAPIRO2 reported finding twenty-five ulcers in one case at necropsy, yet more than two craters are rarely recognised radiographically. Thus a patient’s symptoms may continue after the healing of an observed ulcer crater, because of the persistence of another ulcer, unrecognised
radiographically. At the Royal Society
of Medicine on March 20, Dr. GEORGE SiMOJsr and Dr. G. H. DU BouLAY reported that, following stringent criteria, they satisfied themselves that an ulcer crater was present in 47% of 134 consecutive patients with clinical and radiographic evidence of duodenal ulceration. They pointed out that mistaken identification of a crater may be followed by operation at which a supposed crater is found ; and this may be a false confirmation of an inaccurate radiographic observation. They examined their patients repeatedly for six months from the first examination. In 38 of their 63 cases where an ulcer was present the crater size changed in parallel with the symptoms ; but in others symptoms persisted despite apparent healing of the ulcer, or else the size 1. 2.
of the ulcer remained the same though symptoms relieved-in 1 instance symptoms disappeared but the ulcer crater became larger. In the 71 cases where they demonstrated no ulcer crater at any examination, no association could be established between alterations in the shape of the deformed duodenal cap and relief or exacerbation of symptoms. Their observations led them to doubt whether, once the patient has gained clinical relief, further radio. graphic examination is useful ; for, even though this may show an ulcer crater, it is questionable whether further strict treatment is worth while. With duodenal ulceration, radiography, they declared, is primarily a diagnostic procedure ; but a further examination is justified possibly after treatment has relieved symptoms, and certainly if the pattern of symptoms changes. Preoperative radiography, they suggested, is of little value. Mr. HAROLD EDWARDS, as a surgeon, was concerned to see whether a patient had earned the right to an operation. Structural change, not the presence of an ulcer, was the important factor in the decision. From experience at operation he doubted whether radiological opinion on the presence of an ulcer crater was completely reliable. Patients with duodenal ulcer do not as a rule come to the radiologist until symptoms have been present for some time, and possibly the duration has some influence on healing. Dr. F. PYGOTT said that in a series of 104 cases observed for fifteen months he had observed healing in 17 % of cases where symptoms had been present for less than 3 years, in 7% of cases where symptoms had been present for 3-10 years, and in none where symptoms had been present for more than 10 years. It would seem that little or nothing is to be gained by routine radiographic control of medical treatment of duodenal ulceration. The main value of radiography is in diagnosis, in the detection of compheations, and in the exclusion of a second lesion arising independently. In selected cases-occasional examinations after clinical cure, or after relapse has been controlled, may be justified ; but the results must be interpreted with reserve. A general policy on these lines would greatly alleviate the heavy pressure on radiology departments, and would enable more useful work to be done without detriment to the patient. were
course.
Prieskel, E. Brit. J. Radiol. 1952, 25, 632. Sturtevant, M., Shapiro, L. L. Arch. intern. Med. 1926, 38,
Uterine Cancer and Vaginal Smears THOUGH malignant cells had been detected in vaginal smears by PAPANICOLAOU as long ago as 1928, the of recog was not nising early seriously proposed as a diagnostic aid until 1941. Since then a great deal of work has been done, and there is much evidence on which to base a judgment of the method. Superficial epithelial cells in the female genital tract routine examination of or
are
to
uterine
cyclical changes and
cancer
constant exfolia
tion, which is particularly evident when the cells
are
and are therefore dividing rapidly. In such cases, normal and abnormal cells, shed mainly from vaginal epithelium, cervix, and uterine body, with an occasional cell from fallopian -tubes and ovaries, accumulate in the vagina, and they can be
malignant
1. 41.
subject
smears as a means
recurrent
New Cancer Diagnosis. In Proceedings of the 3rd Race Betterment Conference, 1928; p. 528. Quoted by Papanicolaou, G. N. Amer. J. Obstet. Gynec. 1946, 51, 316.
Papanicolaou, G. N.
no
doubt be answered in due
Although this news sounds very hopeful, there are points which should discourage over-optimism. Firstly, a big effort has clearly been needed to prepare and test enough vaccine for quite a small number of people. Each batch of vaccine will need rigorous tests before it can be safely used, and it may be some two
time therefore before these vaccines are available in any quantity. Secondly, though some immunologists believe that the development of resistance to infection and the presence in the serum of antibody to the infecting agent (so often found in close association
with one another) are in fact indissolubly linked, The this has yet to be proved in poliomyelitis. low of paralytic poliomyelitis in the community means that very large numbers of people must be immunised before it can be confidently concluded that a vaccine not only produces an antibody response but also protects against paralysis.
prevalence
in Duodenal Ulceration THE only satisfactory way of establishing the presence of a duodenal ulcer, other than by laparotomy, is by the radiographic demonstration of unmistakable changes. These changes are usually limited to the first part of the duodenum, though they may occasionally be found in the second part.l The radiographic
Radiology
evidence may be conclusive, when an ulcer crater is seen ; inferential, when the duodenal cap is deformed but no ulcer crater is recognisable : or indirect and equivocal, when irritability of the duodenal cap, pylorospasm, radiographic evidence of gastritis " ; or other unconvincing signs are present. Only the conclusive and the inferential radiographic signs point with a high degree of probability to the presence of an ulcer. Radiography, though revealing an ulcer, may not reveal an unsuspected cause-for example, a "
pancreatic neoplasm. Clearly radiographic
examina-
tion is most useful as a check on medical treatment in It cases where a crater has previously been seen. must be remembered, however, that duodenal ulcers are often multiple : STURTEVANT and SHAPIRO2 reported finding twenty-five ulcers in one case at necropsy, yet more than two craters are rarely recognised radiographically. Thus a patient’s symptoms may continue after the healing of an observed ulcer crater, because of the persistence of another ulcer, unrecognised
radiographically. At the Royal Society
of Medicine on March 20, Dr. GEORGE SiMOJsr and Dr. G. H. DU BouLAY reported that, following stringent criteria, they satisfied themselves that an ulcer crater was present in 47% of 134 consecutive patients with clinical and radiographic evidence of duodenal ulceration. They pointed out that mistaken identification of a crater may be followed by operation at which a supposed crater is found ; and this may be a false confirmation of an inaccurate radiographic observation. They examined their patients repeatedly for six months from the first examination. In 38 of their 63 cases where an ulcer was present the crater size changed in parallel with the symptoms ; but in others symptoms persisted despite apparent healing of the ulcer, or else the size 1. 2.
of the ulcer remained the same though symptoms relieved-in 1 instance symptoms disappeared but the ulcer crater became larger. In the 71 cases where they demonstrated no ulcer crater at any examination, no association could be established between alterations in the shape of the deformed duodenal cap and relief or exacerbation of symptoms. Their observations led them to doubt whether, once the patient has gained clinical relief, further radio. graphic examination is useful ; for, even though this may show an ulcer crater, it is questionable whether further strict treatment is worth while. With duodenal ulceration, radiography, they declared, is primarily a diagnostic procedure ; but a further examination is justified possibly after treatment has relieved symptoms, and certainly if the pattern of symptoms changes. Preoperative radiography, they suggested, is of little value. Mr. HAROLD EDWARDS, as a surgeon, was concerned to see whether a patient had earned the right to an operation. Structural change, not the presence of an ulcer, was the important factor in the decision. From experience at operation he doubted whether radiological opinion on the presence of an ulcer crater was completely reliable. Patients with duodenal ulcer do not as a rule come to the radiologist until symptoms have been present for some time, and possibly the duration has some influence on healing. Dr. F. PYGOTT said that in a series of 104 cases observed for fifteen months he had observed healing in 17 % of cases where symptoms had been present for less than 3 years, in 7% of cases where symptoms had been present for 3-10 years, and in none where symptoms had been present for more than 10 years. It would seem that little or nothing is to be gained by routine radiographic control of medical treatment of duodenal ulceration. The main value of radiography is in diagnosis, in the detection of compheations, and in the exclusion of a second lesion arising independently. In selected cases-occasional examinations after clinical cure, or after relapse has been controlled, may be justified ; but the results must be interpreted with reserve. A general policy on these lines would greatly alleviate the heavy pressure on radiology departments, and would enable more useful work to be done without detriment to the patient. were
course.
Prieskel, E. Brit. J. Radiol. 1952, 25, 632. Sturtevant, M., Shapiro, L. L. Arch. intern. Med. 1926, 38,
Uterine Cancer and Vaginal Smears THOUGH malignant cells had been detected in vaginal smears by PAPANICOLAOU as long ago as 1928, the of recog was not nising early seriously proposed as a diagnostic aid until 1941. Since then a great deal of work has been done, and there is much evidence on which to base a judgment of the method. Superficial epithelial cells in the female genital tract routine examination of or
are
to
uterine
cyclical changes and
cancer
constant exfolia
tion, which is particularly evident when the cells
are
and are therefore dividing rapidly. In such cases, normal and abnormal cells, shed mainly from vaginal epithelium, cervix, and uterine body, with an occasional cell from fallopian -tubes and ovaries, accumulate in the vagina, and they can be
malignant
1. 41.
subject
smears as a means
recurrent
New Cancer Diagnosis. In Proceedings of the 3rd Race Betterment Conference, 1928; p. 528. Quoted by Papanicolaou, G. N. Amer. J. Obstet. Gynec. 1946, 51, 316.
Papanicolaou, G. N.