In Reply.—The premise that humans are prone to abuse the lining of the stomach and duodenum by the inhalation or ingestion of harmful substances is correct. The concept that a cause-and-effect relationship between this abuse and the failure of certain therapeutic (both medical and surgical) approaches to the treatment of these ulcers is less clear.
Let us assume that a given population of patients with duodenal ulcers are treated by simple gastroenterostomy. During the following decade approximately 35% of these patients will manifest an anastomotic ulceration. According to Dr Peterson, many of these patients have suffered from recurrent ulcer disease because of failure to modify their smoking and/or dietary habits. If this hypothesis were valid, I would expect that the next operative approach for the new anastomotic ulceration would be equally unsuccessful. Unless there is an underlying hormonal cause for the disease, eg, Zollinger-Ellison syndrome, the addition of a