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{"id":28217,"date":"2024-01-11T11:00:42","date_gmt":"2024-01-11T16:00:42","guid":{"rendered":"https:\/\/circulatingnow.nlm.nih.gov\/?p=28217"},"modified":"2024-02-12T15:46:51","modified_gmt":"2024-02-12T20:46:51","slug":"selecting-a-surgical-solution-for-ulcers","status":"publish","type":"post","link":"https:\/\/circulatingnow.nlm.nih.gov\/2024\/01\/11\/selecting-a-surgical-solution-for-ulcers\/","title":{"rendered":"Selecting a Surgical Solution for Ulcers"},"content":{"rendered":"<p><em>By Christopher Crenner ~<\/em><\/p>\n<p>Can one surgical problem have more than one surgical solution? A version of this question vexed surgeons in the 1950s and 1960s. There had long been one basic way to remove an appendix. But for duodenal ulcers, it was a different story.\u00a0 At midcentury, American surgeons were operating on the complications of duodenal <a href=\"https:\/\/medlineplus.gov\/pepticulcer.html\">ulcers<\/a> nearly as often as appendicitis. But for ulcers, no two surgeons were guaranteed to use the same operation in the same situation. Uncertainly reigned. In 1951, the writer <a href=\"https:\/\/catalog.nlm.nih.gov\/permalink\/01NLM_INST\/1o1phhn\/alma993368083406676\">John Parr<\/a> riffed that his own ulcer was so bothersome that he might have to undergo an operation like a \u201chigh posterior Finsterer-Lake-Lahey modification of the Mikulicz-Kr\u00f6nlein-Hofmeister-Reichel-Polya improvement of the Billroth II gastrectomy.\u201d Parr was kidding, but he had done his homework. Those were references to several different ulcer operations.<\/p>\n<figure id=\"attachment_28222\" aria-describedby=\"caption-attachment-28222\" style=\"width: 242px\" class=\"wp-caption alignleft\"><a href=\"https:\/\/i0.wp.com\/circulatingnow.nlm.nih.gov\/wp-content\/uploads\/2024\/01\/Henry-Harkins-1952_101417733.jpg?ssl=1\"><img data-recalc-dims=\"1\" loading=\"lazy\" decoding=\"async\" data-attachment-id=\"28222\" data-permalink=\"https:\/\/circulatingnow.nlm.nih.gov\/2024\/01\/11\/selecting-a-surgical-solution-for-ulcers\/henry-harkins-1952_101417733\/\" data-orig-file=\"https:\/\/i0.wp.com\/circulatingnow.nlm.nih.gov\/wp-content\/uploads\/2024\/01\/Henry-Harkins-1952_101417733.jpg?fit=966%2C1200&ssl=1\" data-orig-size=\"966,1200\" data-comments-opened=\"1\" data-image-meta=\"{"aperture":"0","credit":"","camera":"","caption":"","created_timestamp":"0","copyright":"","focal_length":"0","iso":"0","shutter_speed":"0","title":"","orientation":"1"}\" data-image-title=\"Henry-Harkins-1952_101417733\" data-image-description=\"\" data-image-caption=\"<p>Henry N. Harkins, 1952<br \/>\nNational Library of Medicine #101417733<\/p>\n\" data-medium-file=\"https:\/\/i0.wp.com\/circulatingnow.nlm.nih.gov\/wp-content\/uploads\/2024\/01\/Henry-Harkins-1952_101417733.jpg?fit=242%2C300&ssl=1\" data-large-file=\"https:\/\/i0.wp.com\/circulatingnow.nlm.nih.gov\/wp-content\/uploads\/2024\/01\/Henry-Harkins-1952_101417733.jpg?fit=824%2C1024&ssl=1\" class=\"size-medium wp-image-28222\" src=\"https:\/\/i0.wp.com\/circulatingnow.nlm.nih.gov\/wp-content\/uploads\/2024\/01\/Henry-Harkins-1952_101417733.jpg?resize=242%2C300&ssl=1\" alt=\"Black and white photograph of a white man in a tie and glasses.\" width=\"242\" height=\"300\" srcset=\"https:\/\/i0.wp.com\/circulatingnow.nlm.nih.gov\/wp-content\/uploads\/2024\/01\/Henry-Harkins-1952_101417733.jpg?resize=242%2C300&ssl=1 242w, https:\/\/i0.wp.com\/circulatingnow.nlm.nih.gov\/wp-content\/uploads\/2024\/01\/Henry-Harkins-1952_101417733.jpg?resize=824%2C1024&ssl=1 824w, https:\/\/i0.wp.com\/circulatingnow.nlm.nih.gov\/wp-content\/uploads\/2024\/01\/Henry-Harkins-1952_101417733.jpg?resize=768%2C954&ssl=1 768w, https:\/\/i0.wp.com\/circulatingnow.nlm.nih.gov\/wp-content\/uploads\/2024\/01\/Henry-Harkins-1952_101417733.jpg?resize=840%2C1043&ssl=1 840w, https:\/\/i0.wp.com\/circulatingnow.nlm.nih.gov\/wp-content\/uploads\/2024\/01\/Henry-Harkins-1952_101417733.jpg?w=966&ssl=1 966w\" sizes=\"auto, (max-width: 242px) 100vw, 242px\" \/><\/a><figcaption id=\"caption-attachment-28222\" class=\"wp-caption-text\">Henry N. Harkins, 1952<br \/><a href=\"http:\/\/resource.nlm.nih.gov\/101417733\"><em>National Library of Medicine #101417733<\/em><\/a><\/figcaption><\/figure>\n<p>The influential surgeon Henry Harkins, whose <a href=\"https:\/\/findingaids.nlm.nih.gov\/repositories\/ammp\/resources\/harkins\">professional papers<\/a> I recently reviewed at the National Library of Medicine (NLM), suggested in 1959 that there were at least 8 basic approaches to <a href=\"https:\/\/openi.nlm.nih.gov\/detailedresult?img=PMC2933631_1752-1947-4-272-1&query=&req=4\">surgery on chronic duodenal ulcers<\/a>. He went on to suggest that \u201cno one can foretell whether any one of these operative procedures will outstrip the others in preference.\u201d This kind of uncertainty made ulcers a special challenge for midcentury academic surgeons like Harkins.<\/p>\n<p>And ulcers were a high-profile problem. Ulcer disease was quite prevalent the U.S. during this period. According to a widely cited figure, as many as one in ten adults would suffer from duodenal ulcers. The disease also became a widely shared part of postwar popular culture. Your boss was typically either causing you an ulcer, or he was developing one. Yet, without powerful antacids or antibiotics, patients with ulcers went on to surgery with surprising frequency. Fortunately, operations for ulcers were achieving modest successes, producing low enough rates of operative mortality and complications to rival major abdominal operations for the gallbladder and appendix. Yet, as John Parr suggested, no one operation reigned, and sadly none was able to achieve reliable long-term cures. Ulcers tended to recur after surgery, even years later. This combination of a common problem, good short-term success, with too frequent late failures drove academic surgeons in urgent effort to find a better way.<\/p>\n<figure id=\"attachment_28220\" aria-describedby=\"caption-attachment-28220\" style=\"width: 792px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/i0.wp.com\/circulatingnow.nlm.nih.gov\/wp-content\/uploads\/2024\/01\/nlm_nlmuid-101597439-img.jpg?ssl=1\"><img data-recalc-dims=\"1\" loading=\"lazy\" decoding=\"async\" data-attachment-id=\"28220\" data-permalink=\"https:\/\/circulatingnow.nlm.nih.gov\/2024\/01\/11\/selecting-a-surgical-solution-for-ulcers\/nlm_nlmuid-101597439-img\/\" data-orig-file=\"https:\/\/i0.wp.com\/circulatingnow.nlm.nih.gov\/wp-content\/uploads\/2024\/01\/nlm_nlmuid-101597439-img.jpg?fit=1265%2C1636&ssl=1\" data-orig-size=\"1265,1636\" data-comments-opened=\"1\" data-image-meta=\"{"aperture":"0","credit":"","camera":"","caption":"","created_timestamp":"0","copyright":"","focal_length":"0","iso":"0","shutter_speed":"0","title":"","orientation":"0"}\" data-image-title=\"nlm_nlmuid-101597439-img\" data-image-description=\"\" data-image-caption=\"<p>Advertisement by graphic designer Lester Beall in Scope, vol. 1, no. 7, 1944<br \/>\nNational Library of Medicine #101597439<\/p>\n\" data-medium-file=\"https:\/\/i0.wp.com\/circulatingnow.nlm.nih.gov\/wp-content\/uploads\/2024\/01\/nlm_nlmuid-101597439-img.jpg?fit=232%2C300&ssl=1\" data-large-file=\"https:\/\/i0.wp.com\/circulatingnow.nlm.nih.gov\/wp-content\/uploads\/2024\/01\/nlm_nlmuid-101597439-img.jpg?fit=792%2C1024&ssl=1\" class=\"wp-image-28220 size-large\" src=\"https:\/\/i0.wp.com\/circulatingnow.nlm.nih.gov\/wp-content\/uploads\/2024\/01\/nlm_nlmuid-101597439-img.jpg?resize=792%2C1024&ssl=1\" alt=\"A full page color magazine advertisement illustrating heartburn with a man's silhouette overlaid on a wood grain background with flames.\" width=\"792\" height=\"1024\" srcset=\"https:\/\/i0.wp.com\/circulatingnow.nlm.nih.gov\/wp-content\/uploads\/2024\/01\/nlm_nlmuid-101597439-img.jpg?resize=792%2C1024&ssl=1 792w, https:\/\/i0.wp.com\/circulatingnow.nlm.nih.gov\/wp-content\/uploads\/2024\/01\/nlm_nlmuid-101597439-img.jpg?resize=232%2C300&ssl=1 232w, https:\/\/i0.wp.com\/circulatingnow.nlm.nih.gov\/wp-content\/uploads\/2024\/01\/nlm_nlmuid-101597439-img.jpg?resize=768%2C993&ssl=1 768w, https:\/\/i0.wp.com\/circulatingnow.nlm.nih.gov\/wp-content\/uploads\/2024\/01\/nlm_nlmuid-101597439-img.jpg?resize=1188%2C1536&ssl=1 1188w, https:\/\/i0.wp.com\/circulatingnow.nlm.nih.gov\/wp-content\/uploads\/2024\/01\/nlm_nlmuid-101597439-img.jpg?resize=1200%2C1552&ssl=1 1200w, https:\/\/i0.wp.com\/circulatingnow.nlm.nih.gov\/wp-content\/uploads\/2024\/01\/nlm_nlmuid-101597439-img.jpg?resize=840%2C1086&ssl=1 840w, https:\/\/i0.wp.com\/circulatingnow.nlm.nih.gov\/wp-content\/uploads\/2024\/01\/nlm_nlmuid-101597439-img.jpg?w=1265&ssl=1 1265w\" sizes=\"auto, (max-width: 792px) 100vw, 792px\" \/><\/a><figcaption id=\"caption-attachment-28220\" class=\"wp-caption-text\">Advertisement by graphic designer Lester Beall in <em>Scope<\/em>, vol. 1, no. 7, 1944<br \/><a href=\"http:\/\/resource.nlm.nih.gov\/101597439\"><em>National Library of Medicine #101597439<\/em><\/a><\/figcaption><\/figure>\n<p>The crisis over ulcers exposed fundamental questions about the relationship between surgical knowledge and practice. An ever-changing spectrum of new, revised, and competing operations heightened tension between efforts to innovate and the stable habits of practice. Such challenges drew new attention to the methods for analyzing and confirming good results. Some of the earliest attempts at systematic, long-term follow up of operative outcomes and the initially controversial use of randomized, controlled trials of surgical operations took place in ulcer research.<\/p>\n<figure id=\"attachment_28223\" aria-describedby=\"caption-attachment-28223\" style=\"width: 233px\" class=\"wp-caption alignright\"><a href=\"https:\/\/i0.wp.com\/circulatingnow.nlm.nih.gov\/wp-content\/uploads\/2024\/01\/Raymond-Postlethwait-1949_101439758.jpg?ssl=1\"><img data-recalc-dims=\"1\" loading=\"lazy\" decoding=\"async\" data-attachment-id=\"28223\" data-permalink=\"https:\/\/circulatingnow.nlm.nih.gov\/2024\/01\/11\/selecting-a-surgical-solution-for-ulcers\/raymond-postlethwait-1949_101439758\/\" data-orig-file=\"https:\/\/i0.wp.com\/circulatingnow.nlm.nih.gov\/wp-content\/uploads\/2024\/01\/Raymond-Postlethwait-1949_101439758.jpg?fit=930%2C1200&ssl=1\" data-orig-size=\"930,1200\" data-comments-opened=\"1\" data-image-meta=\"{"aperture":"0","credit":"","camera":"","caption":"","created_timestamp":"0","copyright":"","focal_length":"0","iso":"0","shutter_speed":"0","title":"","orientation":"1"}\" data-image-title=\"Raymond-Postlethwait-1949_101439758\" data-image-description=\"\" data-image-caption=\"<p>Raymond Postlethwait, 1949<br \/>\nNational Library of Medicine #101439758<\/p>\n\" data-medium-file=\"https:\/\/i0.wp.com\/circulatingnow.nlm.nih.gov\/wp-content\/uploads\/2024\/01\/Raymond-Postlethwait-1949_101439758.jpg?fit=233%2C300&ssl=1\" data-large-file=\"https:\/\/i0.wp.com\/circulatingnow.nlm.nih.gov\/wp-content\/uploads\/2024\/01\/Raymond-Postlethwait-1949_101439758.jpg?fit=794%2C1024&ssl=1\" class=\"size-medium wp-image-28223\" src=\"https:\/\/i0.wp.com\/circulatingnow.nlm.nih.gov\/wp-content\/uploads\/2024\/01\/Raymond-Postlethwait-1949_101439758.jpg?resize=233%2C300&ssl=1\" alt=\"Black and white photograph of a white man in a jacket and tie, signed Ray Postlethwait in ink.\" width=\"233\" height=\"300\" srcset=\"https:\/\/i0.wp.com\/circulatingnow.nlm.nih.gov\/wp-content\/uploads\/2024\/01\/Raymond-Postlethwait-1949_101439758.jpg?resize=233%2C300&ssl=1 233w, https:\/\/i0.wp.com\/circulatingnow.nlm.nih.gov\/wp-content\/uploads\/2024\/01\/Raymond-Postlethwait-1949_101439758.jpg?resize=794%2C1024&ssl=1 794w, https:\/\/i0.wp.com\/circulatingnow.nlm.nih.gov\/wp-content\/uploads\/2024\/01\/Raymond-Postlethwait-1949_101439758.jpg?resize=768%2C991&ssl=1 768w, https:\/\/i0.wp.com\/circulatingnow.nlm.nih.gov\/wp-content\/uploads\/2024\/01\/Raymond-Postlethwait-1949_101439758.jpg?resize=840%2C1084&ssl=1 840w, https:\/\/i0.wp.com\/circulatingnow.nlm.nih.gov\/wp-content\/uploads\/2024\/01\/Raymond-Postlethwait-1949_101439758.jpg?w=930&ssl=1 930w\" sizes=\"auto, (max-width: 233px) 100vw, 233px\" \/><\/a><figcaption id=\"caption-attachment-28223\" class=\"wp-caption-text\">Raymond Postlethwait, 1949<br \/><a href=\"http:\/\/resource.nlm.nih.gov\/101439758\"><em>National Library of Medicine #101439758<\/em><\/a><\/figcaption><\/figure>\n<p>Henry Harkins was in the thick of these developments. He was the first chair at a new, growing academic surgical program\u2013mirroring others around the country that would embrace ulcer disease as a key area for experimentation and innovation. New infusions of postwar funding backed the development of surgical laboratories and experimental clinical trials. One of Harkins\u2019 correspondents, <a href=\"https:\/\/pubmed.ncbi.nlm.nih.gov\/?term=Postlethwait+RW&cauthor_id=4578736\">Raymond Postlethwait<\/a>, mounted a massive, multicenter clinical trial, randomizing over 1300 ulcer patient to compare four different ulcer operations across twelve hospitals in the system of the Department of Veterans Affairs. The project folded under its weight, but made clear certain challenges of how randomization would function in surgical science.\u00a0 <a href=\"https:\/\/findingaids.nlm.nih.gov\/repositories\/ammp\/resources\/harkins\">The Harkins Papers<\/a> and related collections at the NLM help in exploring ulcer surgery as an early testing ground for the fit of experimental surgery in the burgeoning academic training programs of the time. The manifold choices facing ulcer surgeons also made ulcer research an early site for the deployment of randomized trials in surgery\u2014exposing many surgeons for the first time to their power as an experimental tool and the special challenges they posed in applying them to the scientific craftwork of surgical care.<\/p>\n<p><em><a href=\"https:\/\/www.kumc.edu\/ccrenner.html\"><img data-recalc-dims=\"1\" loading=\"lazy\" decoding=\"async\" data-attachment-id=\"28227\" data-permalink=\"https:\/\/circulatingnow.nlm.nih.gov\/2024\/01\/11\/selecting-a-surgical-solution-for-ulcers\/crenner-christopher\/\" data-orig-file=\"https:\/\/i0.wp.com\/circulatingnow.nlm.nih.gov\/wp-content\/uploads\/2024\/01\/crenner-christopher.jpg?fit=163%2C225&ssl=1\" data-orig-size=\"163,225\" data-comments-opened=\"1\" data-image-meta=\"{"aperture":"13","credit":"","camera":"NIKON D2X","caption":"","created_timestamp":"1380672907","copyright":"","focal_length":"70","iso":"125","shutter_speed":"0.008","title":"","orientation":"1"}\" data-image-title=\"crenner-christopher\" data-image-description=\"\" data-image-caption=\"\" data-medium-file=\"https:\/\/i0.wp.com\/circulatingnow.nlm.nih.gov\/wp-content\/uploads\/2024\/01\/crenner-christopher.jpg?fit=163%2C225&ssl=1\" data-large-file=\"https:\/\/i0.wp.com\/circulatingnow.nlm.nih.gov\/wp-content\/uploads\/2024\/01\/crenner-christopher.jpg?fit=163%2C225&ssl=1\" class=\"alignleft wp-image-28227\" title=\"Christopher Crenner\" src=\"https:\/\/i0.wp.com\/circulatingnow.nlm.nih.gov\/wp-content\/uploads\/2024\/01\/crenner-christopher.jpg?resize=100%2C138&ssl=1\" alt=\"Formal photograph of a white man in a shirt and tie.\" width=\"100\" height=\"138\" \/><\/a>Christopher Crenner, MD, PhD, is a Professor and the Chair of the department of History and Philosophy of Medicine at the University of Kansas Medical Center and a 2020 <a href=\"https:\/\/www.nlm.nih.gov\/hmd\/get-involved\/debakey-fellowship.html\">NLM Michael E. DeBakey Fellow in the History of Medicine<\/a>. <\/em><\/p>\n","protected":false},"excerpt":{"rendered":"<p>By Christopher Crenner ~ Can one surgical problem have more than one surgical solution? A version of this question vexed<\/p>\n","protected":false},"author":19605840,"featured_media":28226,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_coblocks_attr":"","_coblocks_dimensions":"","_coblocks_responsive_height":"","_coblocks_accordion_ie_support":"","advanced_seo_description":"","jetpack_seo_html_title":"","jetpack_seo_noindex":false,"jetpack_post_was_ever_published":false,"_jetpack_newsletter_access":"","_jetpack_dont_email_post_to_subs":false,"_jetpack_newsletter_tier_id":0,"_jetpack_memberships_contains_paywalled_content":false,"_jetpack_memberships_contains_paid_content":false,"footnotes":"","jetpack_publicize_message":"","jetpack_publicize_feature_enabled":true,"jetpack_social_post_already_shared":true,"jetpack_social_options":{"image_generator_settings":{"template":"highway","enabled":false},"version":2}},"categories":[42333869,12763,51014],"tags":[24741,24742,58980,668,57544],"class_list":["post-28217","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-archives-manuscripts","category-collections","category-guests","tag-1950s","tag-1960s","tag-fellowship","tag-research","tag-surgery"],"jetpack_publicize_connections":[],"jetpack_featured_media_url":"https:\/\/i0.wp.com\/circulatingnow.nlm.nih.gov\/wp-content\/uploads\/2024\/01\/Hearturn_Scope_101597439_feature.jpg?fit=900%2C401&ssl=1","jetpack_likes_enabled":true,"jetpack_sharing_enabled":true,"jetpack_shortlink":"https:\/\/wp.me\/p3xcDk-7l7","jetpack-related-posts":[],"amp_enabled":true,"_links":{"self":[{"href":"https:\/\/circulatingnow.nlm.nih.gov\/wp-json\/wp\/v2\/posts\/28217","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/circulatingnow.nlm.nih.gov\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/circulatingnow.nlm.nih.gov\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/circulatingnow.nlm.nih.gov\/wp-json\/wp\/v2\/users\/19605840"}],"replies":[{"embeddable":true,"href":"https:\/\/circulatingnow.nlm.nih.gov\/wp-json\/wp\/v2\/comments?post=28217"}],"version-history":[{"count":8,"href":"https:\/\/circulatingnow.nlm.nih.gov\/wp-json\/wp\/v2\/posts\/28217\/revisions"}],"predecessor-version":[{"id":28244,"href":"https:\/\/circulatingnow.nlm.nih.gov\/wp-json\/wp\/v2\/posts\/28217\/revisions\/28244"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/circulatingnow.nlm.nih.gov\/wp-json\/wp\/v2\/media\/28226"}],"wp:attachment":[{"href":"https:\/\/circulatingnow.nlm.nih.gov\/wp-json\/wp\/v2\/media?parent=28217"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/circulatingnow.nlm.nih.gov\/wp-json\/wp\/v2\/categories?post=28217"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/circulatingnow.nlm.nih.gov\/wp-json\/wp\/v2\/tags?post=28217"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}} |