War-time study of peptic ulcer: with the account of an experiment in the rehabilitation and employment of men with healed peptic ulcers in the Royal Navy

Abstract

Digestive disorders, and peptic ulcer in particular, proved to be one of the chief medical problems in the armed forces of both combatant and neutral countries, during the 1939-45 War.

The wastage of manpower on account of chronic dyspepsia was sufficiently serious to cause the military authorities of some of the combatant nations to consider measures which might enable cases of peptic ulcer to be retained for limited military service. Although most of the attempts to retain such cases were unsuccessful, it was a common experience that a proportion. of men continued to give good service provided they could be granted special facilities with regard to their diet and working conditions.

In the Royal Navy, peptic ulcer was one of the three chief causes of invaliding during the recent war, and this constant loss of skilled men caused the Admiralty to consider "the employment of invalided men or men who would otherwise have been invalided, in particular healed gastric and duodenal ulcer cases, on maintenance work and manning harbour servicing craft' at the three Home Ports and the larger out -ports." In 1943, special dietetic facilities were established in two of the Royal Naval Depots in order to accommodate the increasing numbers of men who were being referred from hospital with the diagnosis of peptic ulcer, and the recommendation for a period of home shore service. These arrangements could. only be of a temporary nature, and while they did much. to ease the lot of the ulcer cases, difficulties arose through the lack of suitable employment for many skilled men and the absence of a uniform policy in the selection of cases.

In 1944, an experimental scheme for the rehabilitation and employment of cases of healed peptic ulcer was established in which the following conditions were fulfilled: - (1) Only proved cases of peptic ulceration were selected for employment in the scheme.

(2) All were fully trained and highly skilled men whose services were of value to the royal Navy, and who were willing to continue serving.

(3) Every man was employed in his proper category according to his training and experience; casual or makeshift work was avoided and a full day's work was carried out.

(4) The men lived together and were provided for as a single group and special arrangements were made for their medical and dietetic supervision. In all, 70 men were employed in the scheme and were personally observed over a period of twelve months.

At the end of this period 68.5 per cent. of the cases showed no evidence of active peptic ulceration, although they were not necessarily free from symptoms. During the period of observation 45 per cent. suffered from a recurrence of symptoms necessitating some loss of time off duty.

Studies of cases of peptic ulcer in the armed forces have shown that the clinical picture is often less well defined than might be supposed from the usual textbook description of the diseaso. Typical symptoms of gastroduodenal dyspepsia are not necessarily associated with the presence of demonstrable ulceration, while an active ulcer may occur with an atypical history.

Observation of the cases described in this thesis and of other cases in the royal Navy has suggested that the disease may show three main clinical pictures. rhe most common is the case with the typical history of attacks of post -prandial pain, relieved by food and alkalis, and with remissions of variable length between, the attacks. The history is usually of long standing, often dating from an early age, and complications may or may not occur. Another well recognised type is that in which few or no symptoms occur until the onset of a perforation or haemorrhage. Such a patient may then remain well until the occurrence of a further complication. It has been widely believed in the past that the prognosis after perforation is better than in any other form of peptic ulcer. This view is not supported by recent statistical studies and the histories of many cases in the royal Navy have confirmed the fast that symptoms of dyspepsia commonly recur relatively soon after a perforation. There appears to be however, a small group of cases in whom a chronic ulcer may be present in the absence of symptoms, the lesion remaining silent until the onset of a complication.

The third group consists of patients who are seldom free from dyspepsia and whose histories reveal no evidence of any remissions. Abnormal personality traits, usually of an obsessional type, are common in this type of case and the presence of an active peptic ulcer may be overlooked if psychoneurotic features are well marked.

The results of the experiment have clearly shown that it was possible to retain men with healed peptic ulcers for useful work in the Royal Navy, while under medical supervision and dietetic control. Although re lapses were not entirely prevented, it is considered that their severity was reduced and many men were able to continue on duty in spite of the presence of symptoms. It has also been shown that many patients do not necessarily remain free from dyspepsia even although their ulcers have apparently healed. The success of such an experiment depends on the careful selection of cases, and only those who are of stable personality and of good morale should be considered. Oases of doubtful morale and those who are unwilling to cooperate are likely to break down rapidly', and may also have an adverse effect on the other patients. Although dietetic control still remains the basis of any regime for the management of cases of peptic ulcer, even greater attention must be paid to the many other factors which may precipitate a recurrence of symptoms. While the regular routine of the regime greatly benefitted many of the Royal Naval cases, the most important single feature of the scheme was undoubtedly the regular interview with the medical officer, when any problems of health or environment could be discussed. In the management of this disease, the patient and' his environment must be viewed as a whole and the ulcer regarded as merely an incident in the natural history of the case. If such a view is taken, there is abundant scope for the application of wartime experience to the peacetime problem of dyspepsia in industry or on a national scale as a problem of social medicine.

In conclusion, it may be appropriate to quote a leading article from the British Medical Journal (l94 ) which states - "To separate the ulcer patient from his diathesis is like severing the fisherman from his soul,, and until we learn some new secret of Nature we must be content to try to teach the patient how best to live at peace with his ulcer - and to do this he must probably learn how to live at peace with himself." If the world as a whole were to attain this last ideal peptic ulcer might no longer be a problem to the medical profession.