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  IN THIS Article
 ::  Abstract
 ::  The NEDLOG rule
 ::  Etiologism
 ::  Dysteleology
 ::  Straight-Line-So...
 ::  Latrogeny
 ::  Calling One's Ge...
 ::  Experimentalism
 ::  Peptic or Dyspeptic?
 ::  Hyperacidity
 ::  Vagi, Dyspepsia,...
 ::  References

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ARTICLE
Year : 1977  |  Volume : 23  |  Issue : 1  |  Page : 1-9

The illogic of peptic ulcer


Department of Anatomy, Seth G.S.Medical College, Parel, Bombay 400012, India

Correspondence Address:
M L Kothari
Department of Anatomy, Seth G.S.Medical College, Parel, Bombay 400012
India
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Source of Support: None, Conflict of Interest: None


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 :: Abstract 

The unmitigated failure of peptic ulcer therapy has prompted this overview of the epistemologic and logical fallacies of the prin­ciples and practice of ulcerology. The illogic, rooted in the very term peptic ulcer, assumes a crescendo momentum, to the detri­ment of the patient. Like many other fields, ulcerology is causali­stically oriented, culminating in cure-all drives against the assum­ed cause-the acid-pepsin complex. A plea is made, on grounds scientific, to view the situation from a different angle, holding the ulcer as dyspeptic, and as such irrelevant to the pathology, clinical features and treatment.



How to cite this article:
Kothari M L, Kothari JM. The illogic of peptic ulcer. J Postgrad Med 1977;23:1-9

How to cite this URL:
Kothari M L, Kothari JM. The illogic of peptic ulcer. J Postgrad Med [serial online] 1977 [cited 2020 Oct 21];23:1-9. Available from: https://www.jpgmonline.com/text.asp?1977/23/1/1/42785


"Reason guides medical practice," said an enthusiast. "No," declared a wag, "It's fashion that governs it." The truth of the latter is seen in its most devastat­ing form in the treatment of what has been conveniently called peptic ulcer. Asher, [4] in Talking Sense, describes the "Seven Sins of Medicine." Ulcerologists perpetrate similar sins which may be listed, at the outset, as

1. The exercise of NEDLOG rule

2. Etiologism

3. Dysteleology

4. Technocracy of straight-line-solu­tions

5. latrogeny

6. Calling one's geese swans

7. Experimentalism.

The need to appreciate the illogic of peptic ulcer has been well-stated by Pal­mer. [28] "Obviously the path we have been following for many years has led to no final answers on the ulcer matter, nor does it offer any hope that it ever will. Progress can be initiated only by challeng­ing current concepts, of course. My plea is simply that physicians dare to do some original thinking about ulcer." A subse­quent publication "The Logic of Dys­peptic Ulcer" [23] provides a reasoned, documented apposite to the present article.


 :: The NEDLOG rule Top


Erik Erikson, the psychiatrist-philosopher, lays down, in Hippocrates Revisited [15] "the Golden Rule which advocates that one should do (or not do) to an­other what one wishes to be (or not to be) done by." In the management of pep­tic ulcer, physicians have practised the reverse of the Golden Rule-the Nedlog Rule.
"One highly significant fact that show­ed how the Physicians and Surgeons it Rochester really felt about the operations for duodenal ulcer was that in all my 25 years at the Mayo Clinic I can re member only one of the many member; of the staff with an ulcer who was operated on, and he was driven to it late in life by a complication." This is a damaging judgment against ulcerologists by none else than Walter Alvarez. [2] The scanning of the hospital records, in Born bay or Barcelona, is unlikely to reveal anything otherwise. Curative surgery for peptic ulcer was invented by the physician but for the patient. Let us listen to a doctor-patient: [19] "Two colleague; who were surgeons, called in one day to pay a social visit. They told me that sooner or later I'd have to have my stomach removed and the sooner the better The thought of a partial gastrectomy was anathema to me. I didn't see the sense sacrificing a perfectly good stomach because of a little ulcer that could hardly be seen . . . and when I read about the postgastrectomy syndrome in the BMJ my mind was made up." Doctors have the advantage they read BMJ; their patients don't.

The Nedlog Rule may be defined as the therapeutic authoritarianism that enables a clinician to readily do something on a patient that he would rarely, if no never, get done on himself. The reason for this, vis-a-vis ulcerologists, are not hard to seek. A leading text Clinical Gastroenterology [22] remarks that operations for peptic ulcer entail considerable interference with the anatomy and the physiology of the upper alimentary tract and it is not surprising that a proportion of subjects suffer from minor or major complications following surgery. "An unexpectedly high proportion of pa­tients," Jones et al [22] added, "treated for alcoholism have previously had a partial gastrectomy; the same is probably true for patients with drug addiction." Which gastroenterologist or physician, knowing of the dumping syndrome, diarrhea, per­nicious anemia, alcoholism, and drug addiction, would rush into where angels may fear to tread!


 :: Etiologism Top


Modern medicine thrive [36] on causa­lism, an endless exercise in weird etiolo­gism that hunts for the cause of cancer, coronary heart disease, diabetes, sene­scence and what the human body may have, with the evergreen hope of either nipping the cause in the bud (preven­tion) or of providing an appropriate anti­cause, (cure). "All philosophers, of every school, imagine that causation is one of the fundamental axioms of science, yet, oddly enough, in advanced science, such as gravitational astronomy, the word `cause' never occurs. . . . The Law of Causality, I believe, like much that passes among philosophers, is a relic of a bygone age, surviving like the monar­chy, only because it is erroneously sup­posed to do no harm." (Russell [33] ) The robust survival of causalism in medicine is, a la Bertrand Russell, [33] an evidence of medicine not being an advanced science. Anyone doubting the foregoing could read Burnet's Genes, Dreams and Reality, [6] and Malleson's Need Your Doc­tor Be So Useless? [26] Modern medicine is not a science, but a vast empiricistic en­terprise.

Factors floated as causing peptic ulcer are many, but we could mention seeming­ly the most likely one-STRESS. The facile assumption that peptic ulcer is a stress-disease is probably as remote from the truth as the view that malaria is caused by vapours arising from the swamps. [12]

Yet another favourite etiology is the uxorial one: "The view that a peptic ulcer may be the hole in a man's stomach through which he crawls to escape from his wife has fairly wide acceptance." (Anderson). [3] Therefore, declared another physician, a patient treated for peptic ulcer must change his life as well as his wife. [30] Life, wife, stress, acid, pepsin-not one of these can satisfy the fundamental tenet of causalism [16] that necessitates an invariant relation of events in which the effect must follow the cause, every time. The italicized tenet is betrayed by the ulcer, which, by its very nature, is wait­ing, wanting and willing to heal and often does so in the teeth of the very cause that caused the ulcer. It is like in cancer: Whatever that is claimed as causative, can be claimed with undiminished vehe­mence as curative.


 :: Dysteleology Top


Dysteleology is the assumed absence of purpose in Nature. [35] It allows hubristic medicine to put Nature in the dock, to assume her guilt, and to declare HCI, breast or prostate as "A design nightmare for which Nature should hang her head." [31] Were it given to scientists, they would have long ago chopped off the hanging head of mother Nature!

Vis-a-vis peptic ulcer, dysteleology is the prevalent gastroenterologic doctrine, that medicine's failure to understand the raison d'etre of stomach, pylorus, vagi, and hydrochloric acid secretion is suffi­cient license to forever destroy one or all of these, in a given patient. Such an ap­proach can be effectively cloaked by euphemisms like "curative surgery" or as "pyloroplasty." The very term pyloro­plasty presupposes pyloric error; the procedure achieves no plasty but pyloro­lysis; the net gain to the patient is the loss of a physiologic marvel called the pylorus. "Although there is a tempta­tion to regard pyloroplasty as a non-de­structive operation there is accumulating evidence to the contrary." [11] The same authors [11] describe pyloroplasty as ulce­rogenic, by its giving rise to an "incon­tinent stomach." The authors [11] added that these effects were to "virtually the same extent after both pyloroplasty alone and complete vagotomy and pyloro­plasty."


 :: Straight-Line-Solutions (SLS) Top


Modern ulcerology is a highly advanc­ed diagnostic and therapeutic technocracy evolved out of what Gene Marine calls The Engineering Mentality: [27] "It comes about because, somehow, (we) have be­come fascinated with technique as the answer to everything. Our dawn and twilight devotions are in homage to `know-how', and the straight-line-solution is our way of dealing with the questions of life, from seduction to South Viet­nam." The SLS-oriented technocrat spots a "problem" and sets about remedying it, come what may. If the blood pressure is up, keep it down; if it is down, push it up. Until recently, for example, patients of hypovolemic shock were given vasopres­sors, and their blood pressure readings rose strikingly, to the satisfaction of all concerned, "except of the patients, who died." [38] If the portal venous pressure is up, go down and create an Eck fistula. What about the severe liver anoxia and the ammoniacal intoxication of the brain? Let the liver and the liver manage.

In ulcerology, the villain-of-the-piece is gastric HCI and no technocratic SLS has been spared-from the relatively benign antacids to the drastic measures of charring the stomach by irradiation, freezing it by supercooled alcohol, chop­ping it, a la Visick, to the point of leav­ing just a little fundic cuff hanging from the esophagus, and sacrificing the vagi. It was found that when vagi go, the py­lorus ought to, hence pylorolysis called pyloroplasty. And to imagine that all the foregoing has been actively practised de­spite a "not-guilty" judgment in favour of HCl, announced way back in 1959: "Anyone seeking in a court of law to prove `acid aggression' responsible for peptic ulceration would be dismissed after two-minutes' cross-examination with a stern admonition not to waste the court's time." [31]

The story goes a little further. The alleged culprit has been discharged with honour. [28] HC1 has been shown to help ulcer patients. Newly-hospitalized patients with active duodenal ulcer were given 2 bedside bottles-one of Al (OH) 3 gel and the other of dilute HC1. The two `drugs' were presented to each patient, as alternative products for treating ulcer. The patient was asked to try one, and then the other in two ounces doses from time to time, and then to use whichever for him worked better. No other drug nor any special diet was given. All pa­tients made fine progress, but their preferences differed. Of 230 patients so doubly-treated, 31 could see neither as useful, 106 felt better with Al (OH) 3 and as many as 93 preferred HCI. Palmer [28] re­marked that both the antacid and the acid were little more than placebos-2 ounces of dilute HCl is not much acid, nor 2 ounces of medicinal Al(OH) 3 is much of an antacid. The whole trial drove home the point that ulcer patients can be treated "successfully" either with acid or antacid, neither having anything to do with the efficacy of treatment.


 :: Latrogeny Top


Allopathy, etymologically, is the art of curing one disease, by causing another. [35]­ Ulcer therapy represents an acme of scientific allopathy, having in its repertoire measures ranging from dietary invalidism or diarrhea to the dumping syndrome, and anemia to alcoholism. Pal­mer [28] observes that "classical therapy creates dietary invalidism, an illness that may be worse than ulcer disease." The insipidity of antacids, the gastric revul­sion of forced milk feeding, the visceral atonia of vagolytics, the distension and diarrhea of vagotomy, and so on, are things that can be best described only by doctors who had had the privilege of being so treated, a privilege, alas, granted only to a few who seemingly haven't lifted their pen in protest.

The therapeutic efficacy of iatrogeny, much like the counterirritant effect of a pain balm that works by shifting the at­tention of a patient from one disease to another, when well worked-out may pro­vide iatrogeny a respectable place in the therapeutic armamentarium of a physi­cian treating, say, ulcer, cancer, or schi­zophrenia. A patient thrown from the fire into the frying pan is most likely to forget the fire because of the overwhelm­ing presence and effect of the frying pan. The foregoing principle of iatrogeny-as­therapy can be ably assisted by the pla­cebo effect not just of the drugs, but of surgery as well.
"Surgery as Placebo," a 1961 article by Beecher [5] cites considerable evidence to drive home the point, the placebo effect being the greater the more dramatic the surgery. The supreme indication of ulcer surgery is the failure of medical therapy, a conceptual sequence that foresuggests the patient that when drugs fail, surgery steps in to succeed. Since placebo [10],[35] (L. "I will please") has a strong pharmacolo­gic ring about it, surgeons as a class find it extremely difficult to realise the placebo effect of surgery, unless they listen to Day [9] : "Apart from poisoning by stealth, there is no form of therapy from which the effects of suggestion can be entirely eliminated." As a pertinent example, Beecher 5 cites ligation of internal mam­mary artery to improve coronary flow­an operation that worked only through its placebo effect.


 :: Calling One's Geese Swans Top


Asher [4] alludes to Crawshay-William's The Comforts of Unreason-unreason breeding "comfortable concepts." An im­portant comfortable concept, Asher points out, is the therapeutic assumption that since what is given is treatment, it must be effective. The next step, a la Lewison [25] is to assume that one's therapeutic geese are truly swans, smarter than the geese in any other farm. Hence the innumer­able drug regimens and curative opera­tions, all being equal, but some being, depending on the therapist, more equal.

A properly controlled prospective therapeutic trial on the leading elective surgical procedures for duodenal ulcer exposed the myth of any goose being more swanish than another. [14],[18] An edi­torial annotations [14] declared that the find­ings "cast doubt on sweeping statements made by advocates of their own parti­cular favourite procedure in the surgery of duodenal ulceration." Whatever the marginal advantages, they were more than offset by the fact that "the results of all operations tended to deteriorate gradually with the passage of time." [18]

A word about the "bewildering ple­thora of antacids available," which re­lieve ulcer pain but which affect neither the healing of an ulcer nor its recur­rence. [28],[37] To be effective, any popular antacid must be given in a very large quantity, and at hourly, if not shorter intervals. [21],[28],[37] Thompson [37] makes 2 im­portant observations: (a) "The ideal antacid is still not available," and (b) "no antacid is completely without side effects." Palmer [28] may sound harsh when he concludes that giving a patient "diet and antacids" is just a gesture-spurious and dishonest, working, when it does, only by its placebo effects.

Yet antacids alone cost the USA over 100 million dollars a year. [37] What held true in Alvarez's time at Mayo Clinic, [2] holds true today. Day in and day out, stomachs are chopped and vagi are cut -of the patient. Why this must-treatism? Asher [4] gives the answer. "It is better to believe in therapeutic nonsense, than openly to admit therapeutic bankruptcy." So the wheels of medicine keep on mov­ing, be it cardiology or cancerology. [24]


 :: Experimentalism Top


In a reputedly scientific book Search for New Drugs, [32] wherein the quest is for agents effective against all leading problems faced by modern medicine, a recurring refrain is the absence of ideal animal experimental model. Ulcerology is no exception. Yet, the book is at pains to describe the available major and prac­tical techniques for "the rapid and effec­tive screening of potential therapeutic agents." [37] In the laboratory too, it is much better to believe in experimental nonsense, than to admit experimental bankruptcy. It is little wonder, then, that anticancer drugs are 100 per cent effective in the laboratory and are 100 per cent ineffective by the bedside. [17]

Peptic ulcer, as medicine has under stood it, is strictly a human privilege; what experimental models oblige with are simple gastric erosions that have not an iota of similarity with the human condition in terms of number, location, pathologic features, and natural history. Yet since the experimental ulcers serve research labs, drug industry and the FDA they must be created by ingenious tech­niques that reek with intellectual com­promise. The means employed, "to name a few"' are ligation of pylorus (Shay ulcer), stress, ulcerogenic (erosion genic!) drugs, Mann-Williamson proce­dure, induction of chronic ribloflavin de­ficiency, stimulation or destruction of localized areas in the brain, and porta­caval shunting.


 :: Peptic or Dyspeptic? Top


The dictionaries [10],[35] are against the semantic misappropriation peptic ulcer; Peptic (Gr. Peptikos) means digestive or related to digestion. Peptic ulcer becomes digestive ulcer, a connotation that car make no sense. Even the clinical clinging to the word ulcer is wrong. [28],[34] The cardinal clinical reality and presentation is not ulcer, but dyspepsia, a term that encompasses the absence of commonly-experienced-but-yet-to-be-described epigastric bliss/euphoria on one side, and the presence of epigastric discomfort fullness, pain, burning on the other Dyspepsia is symptomatic dysgastria-dyspylorosia-dysduodenia. Ulcer is a dispensable symbol for this larger dyspeptic reality. It need not be there. If present, it; right appellation is dyspeptic-dyspeptic ulcer. "Essential for understanding gastroduodenal ulcer as a clinical disease is the concept that the crater is simply a manifestation and is rather unimportant to the whole illness. Unfortunately the crater is the only manifestation that can be detected and measured by a labora­tory test, and so the disease was named for it. One may reasonably insist that the presence of a crater is not necessary for the diagnosis of ulcer disease. If the underlying whole-body disease is present, it makes little difference to the diagnosis whether or not the manifestation is also present. It is not the ulcer that is causing the illness but the illness that is causing the ulcer." (Palmer [28] ). Spiro [34] views it a little differently, preferring to call the syndrome eponymously as Moynihan's disease. Dyspepsia, duodenitis, and duo­denal ulcer, he points out, are parts of the same spectrum. Over 80 per cent of dyseptic patients having no X-ray find­ings, eventually develop radiologically demonstrable crater within 6 to 27 years. Isn't it in fitness of things that peptic ulcer be called dyspeptic ulcer? The very etiologic word peptic misleads the thera­pist into wrecking the peptic mechanism comprising acid and pepsin. The appella­tion dyspeptic would surely serve as a deterrent against a surgical blade ready to chop the stomach or cut the vagi.


 :: Hyperacidity Top


Albutt [1] lamented that "Our path is cumbered with guesses, presumptions and conjectures." He wrote these words about hypertension, but which are equally ap­plicable to gastric hypersecretion and hy­peracidity. In the very first page of his masterly monograph High Blood Pres­sure, [29] Pickering makes it clear that the term hypertension is wrong because no one knows the dividing line between eu­ and hypertension. Nosophilic medicine has bred much of the hypo-this and hy­per-that by disregarding the Ardreyan advice that the range, and not the aver­age, is the reality. Barring such timorous situations as Zollinger-Ellison syndrome, HCl output exhibits a range, each point on the graph being normal for the owner. Cleave [8] rightly points out that "the law of adaptation indicates that the produc­tion of hydrochloric acid must be just as perfectly attuned to the requirements of the individual as is, for example, the power in his arms or his legs or any other part of his anatomy. Far from constitut­ing a liability, the production of large amounts of acid in the stomach, passing under the term `hyperchlorhydria', should be regarded as a most necessary asset." Pylorus, normally patent, allows the acid secreted to be passed on into the duo­denum where it is immediately neutralis­ed. Any situation-and these are many for the sensitive mechanism that is pylo­rus-that prompts the pylorus to close down creates automatically a damming­up of acid with resultant feeling of "hy­peracidity."

What really, then, gives rise to hyper­acidity is not hypersecretion but, if you insist on the prefix hyper-, hypercollec­tion. The same can set up a vicious cycle, for acid accumulation forces pylorus to close tighter, designed as it is to protect the duodenum and small intestine from being damaged by too strong an acid in­put. [20] The pyloric wisdom of shutting down ought to be respected, and no fur­ther food load be added, lest its task be­comes more complicated. It is little taught physiologic truism that the pylorus is a reliable and sufficiently vociferous spo­kesman of the state of the gut beyond: "In general, it probably can be stated that most of the control of the pylorus is ex­ercised by the small intestine. As long as the duodenum and remainder of the small intestine are empty and are in a receptive state for chyme, apparently the pylorus relaxes, and the stomach con­tents empty easily, but irritation, excess fats, overloading, etc., can all make the small intestine less receptive for chyme and cause increased contraction of the pylorus. Therefore, even though the dis­crete details of the control of the pyloric sphincter are not known, the philosophy of this control appears quite evident ." [20] Fasting as a satisfactory and successful treatment of peptic ulcer and hyperaci­dity was extensively practised for 50 years after its introduction in 1875. [8] The clinical experience of a husband report­ing his revulsion a t "regular milk therapy" forced upon him by his wife at the instance of the clinician is not un­common. The doctor-patient referred to earlier [19] put it well: "With this careful and faultless treatment I became progres­sively worse. . . . I got worse and worse and fatter and fatter." Ultimately the cure for him came with the decision to "break another rule of orthodox medi­cine that the stomach of an ulcer patient should never be empty."


 :: Vagi, Dyspepsia, Eupepsia Top


Finally, a word about vagotomy, which is but a glorified form of sensory neu­rectomy. The vagus is 90 per cent affe­rent, just 10 per cent efferent. This makes the gastroduodenal projection on the CNS at least 9 times greater than the other way round, making peptic ul­cer/hyperacidity symptomatology a manifestation of visceropsychic disease rather than otherwise. It accounts for the overpowering mental symptoms accom­panying dyspepsia-irritability, depres­sion, headache, lack of concentration and confidence, and what not.

The enormous gastroduodenal projec­tion on the CNS works two ways-on one hand it produces dyspepsia, but equally on the other hand, it mediates eupepsia- peptic bliss which ulcerologists have not described, violating thus the Asherian [4] advice that one can't describe the abnormal without first describing the normal. Dictionaries [10],[35] , go at length in describing dyspepsia; eupepsia is not given a place, [35] or is described as "the presence of nor­mal amount of pepsin in the gastric juice." [10] Eating food illustrates the bio­logic principle of life assimilating life. Eupepsia is the visceropsychic readines to welcome the guest-life, and having ingested the guest-life, to feel really nice till the guest turns host through diges­tion and absorption. Should it be any more surprising that individuals surgical­ly deprived of this ability to enjoy eupepsia turn to alcohol and drugs [22] to find some raison d'etre of their existence?

 
 :: References Top

1.Albutt, C.: Quoted by Asher, R., in, Talking Sense. Pitman Medical, London, p. 45, 1972.  Back to cited text no. 1    
2.Alvarez, W. C.: "Incurable Physician" -An Autobiography. The World's Work, Kingswoad, Tadworth, Surrey,p. 155, 1964.  Back to cited text no. 2    
3.Anderson, J. A. D.: Quoted in, Familiar Medical Quotations. Ed. Strauss, M. B., Little, Brown & Co., Boston. p. 646,1968.  Back to cited text no. 3    
4.Asher, R.: Talking Sense. Pitman Medi­cal, London, 1972.  Back to cited text no. 4    
5.Beecher, H. K.: Surgery as placebo.J.A.M.A., 176: 1102-1107, 1961.  Back to cited text no. 5    
6.Burnet, F. M.: Genes Dreams and Re­alities. Medical and Technical Publi. Co., Bucks, 1971.  Back to cited text no. 6    
7.Celestin, L. R.: Gastric physiology. In, Basic Gastro-enterology by Naish, J. M.. and Read, A. E. John Wright, Bri­stol, pp. 38-46, 1965.  Back to cited text no. 7    
8.Cleave, T. L.: Peptic Ulcer. John Wright, Bristol, 1962.  Back to cited text no. 8    
9.Day, G. H.: Quoted in Familiar Medical Quotations. Ed. Strauss, M. B., Little Brown & Co., Boston, p. 637, 1968.  Back to cited text no. 9    
10.Dorland's Illustrated Medical Dictionary.W. B. Saunders, Philadelphia, London, 1957.  Back to cited text no. 10    
11.Douglas, M. and Duthie, H. L.: Pylo­roplasty alone in the management of patients with a negative exploration for duodenal ulcer. Brit. J. Surg., 59: 783­787, 1972.  Back to cited text no. 11    
12.Editorial: Geography of peptic ulcer. Brit. Med. J., 2: 688, 1959.  Back to cited text no. 12    
13.Editorial: Gastric ulcer and ulcer equa­tion. Lancet, 1: 1131-1133, 1959.  Back to cited text no. 13    
14.Editorial: Surgical treatment of duodenal ulceration. Brit. Med. J., 2: 776-777, 1968.  Back to cited text no. 14    
15.Erikson, E. H.: The golden rule and the cycle of life. In, Hippocrates Revisited. Ed. Bulger, R. J., Medcom Press, New York, pp. 181-192, 1973.  Back to cited text no. 15    
16.Fuller, B. A. G.: A History of Philo­sophy. Oxford & IBH Publishing Co., Calcutta, p. 11/159, 1955.  Back to cited text no. 16    
17.Garb, S.: Cure for Cancer. A National Goal. Springer Publishing Co., New York, p. 105, 1968.  Back to cited text no. 17    
18.Goligher, J. C., Pulvertaft, C. N., De Dombal, F. T., Conveyers, J. H., Du­thie, H. L., Feather, D. B., Latchmore. A. J. C., Harrop Shoesmith, J., Smiddy, F. G. and Willson-Pepper, J.: Five-to eight-year results of Leeds/York con­trolled trial of elective surgery for duo denal ulcer. Brit. Med. J., 2: 781-787.1968.  Back to cited text no. 18    
19.Greene, R.: Duodenal ulcer. In, Sick Doctors, William Heinemann, London, pp. 94-97, 1971.  Back to cited text no. 19    
20.Guyton, A. C.: The stomach, pancreas, and biliary system. In, Textbook of Medi­cal Physiology. W. B. Saunders, Phila­delphia, London, pp. 726-744, 1956.  Back to cited text no. 20    
21.Hollander, D. and Harlan, J.: Antacids vs placebos in peptic ulcer therapy: Con­trolled doubleblind investigation. J.A.M.A., 226: 1181-1185, 1973.  Back to cited text no. 21    
22.Jones. F. A., Gummer. J. W. P. and Lennard-Jones, J. E.: Peptic ulcer. In, Clinical Gastroenterology. Blackwell, Oxford, pp. 469-547, 1968.  Back to cited text no. 22    
23.Kothari, M. L. and Kothari, Jyoti M.: The Logic of dyspeptic ulcer. (to be published) Journal of Postgraduate Medi­cine. April, 1977.  Back to cited text no. 23    
24.Kothari, M. L. and Mehta, Lopa A.: The Nature of Cancer. Kothari Medical Publications, Bombay, 1973.  Back to cited text no. 24    
25.Lewison, E. F.: Prophylactic versus therapeutic castration. In, Breast Cancer, Early and Late. Year Book Medical Pub­lishers, Chicago, p. 363, 1970.  Back to cited text no. 25    
26.Malleson. A.: Need Your Doctor Be So Useless? George Allen & Unwin. London. 1973.  Back to cited text no. 26    
27.Marine, G.: The engineering mentality. In, Project Survival. Playboy Press, Chicago, Illinois. pp. 205-219. 1971.  Back to cited text no. 27    
28.Palmer. E. D.: Functional Gastrointesti­nal Disease. Williams & Wilkins, Balti­more, 1967.  Back to cited text no. 28    
29.Pickering, G.: High Blood Pressure. Churchill, London, p. 1, 1968.  Back to cited text no. 29    
30.Pinto, I.: Seminar on cardiac rehabilita­tion in J.M.T., G. S. Medical College. 13th July, 1974.  Back to cited text no. 30    
31.Ratcliff, J. D.: I am John's prostate. Reader's Digest, India, May, 1972, p. 41.  Back to cited text no. 31    
32.Rubin, A. A. (Ed.): Search for New Drugs. Marcel Dekker, New York, 1972.  Back to cited text no. 32    
33.Russell, B.: Quoted by, Frank, P., in. Philosophy of Science. Prentice-Hall. N. J., p. 260, 1.957.  Back to cited text no. 33    
34.Spiro, H. M.: Visceral viewpoints: Moynihan's disease? The diagnosis of duodenal ulcer, New Eng. Jour. Med.. 291: 567-569, 1974.  Back to cited text no. 34    
35.The Random House Dictionary of the English Language: Ed- Stein, J., Random House, New York, 1967.  Back to cited text no. 35    
36.Thomas, L.: Notes of a biology-watcher. New Eng. Jour. Med.. 294: 599-600. 1976.  Back to cited text no. 36    
37.Thompson, J. H.: Gastrointestinal dis­orders-peptic ulcer. In, Search for New Drugs. Ed. Rubin, A. A., Marcel Dek­ker, New York, pp. 116-200, 1972.  Back to cited text no. 37    
38.Todd, J. W.: Theory and practice. Lan­cet, 1: 33-34, 1972.  Back to cited text no. 38    




 

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Online since 12th February '04
© 2004 - Journal of Postgraduate Medicine
Official Publication of the Staff Society of the Seth GS Medical College and KEM Hospital, Mumbai, India
Published by Wolters Kluwer - Medknow