PEPTIC ULCER

733 wrong to start treatment at

a

level

on

the ladder higher

than that to which the patient has fallen. For instance, in treating injuries associated with loss of movement in the ankle-joint, it is common practice to see working lathes or patients employed upon treadle-machines, looms, or some similar apparatus. The treadle-action of the foot is entirely different from the walking reflex and before it can become automatic paths of reflex action have to be established which tend to interfere with the well established stepping reflex. The tendency, therefore, is to inhibit the return of the normal walking reflex which is essential to complete recovery. But in addition to this interference, the exercise is badly chosen because it involves the top section of the ladder and must produce fatigue at an earlier stage than would have been the case if a well-established walking reflex had been used to produce the desired movement. I invite you to try the action now of forcibly raising and lowering the ankle of one foot as in working a treadle. Before you have done it half a dozen times you will become conscious of the strain in the muscles of the front of the leg : it would probably have taken you many hours of walking to get this same effect. Almost as simple to use as the conditioned reflex in the training and development of muscle will be found impulsive movement, and perhaps this is easier to develop in men by the use of ball exercises than in any other way. Catching a fast-moving ball is generally impulsive action. An exercise which I find particularly valuable in restoring the power of upward movement of the arm at the shoulder is to instruct a group of men to bounce a football on the floor of the gymnasium hard enough to reach the ceiling. This is not easily done, and it will be found that with the patient’s attention directed on the downward movement the arm is raised higher and higher by impulsiveaction. Finally, we come to the question of vocational exercise associated with the patient’s work. This aspect of treatment must only be attempted when its practice will not produce any of those factors which inhibit the conditioned reflexes which are the foundation of his skill. As an example take the carpenter who has an injured wrist and is asked to use a screwdriver. The normal action of driving a screw is for him a conditioned reflex, but pain inhibits this reflex action and it does so in this way. In the first turn made perhaps the normal conditioned reflex was obtained, but with it pain ; the movement now becomes a conscious movement and the anticipation of pain produces a static contraction of muscle to resist the anticipated movement and this inhibits the conditioned reflex with resultant incoördination of muscle action and loss of power. But the effect does not end there. With pain and work linked in the man’s mind, fear is born-the fear of incapacity for work-and this fear still further inhibits the conditioned reflex. It has been a mistake, therefore, to attempt to restore the conditioned reflex of the man until the arm has become relatively free from those factors of pain and stiffness which would inevitably inhibit the desired action. Once full and painless movement has been restored by diversional exercises the conditioned reflex of normal work may be used in muscle development, but even then it must be remembered that it should never be continued to the length of producing fatigue. What has been said of vocational therapy applies equally to so-called " light work." The light work clause was introduced- into workmen’s compensation legislation in the hope that it would assist in rehabilitating the injured man. That its effect has been the reverse is due to the fact that the principles which I have been endeavouring to define have not been followed out. The man has been given work of a lighter character in his own trade before he is sufficiently free from pain and while still liable to early fatigue. As a result he develops inhibition of his previously work-conditioned reflexes, leading to increased clumsiness and to despondency. If he has not been employed at the lighter forms of his old job, all too often he has been given work which involves industrial de-grading-a bricklayer becomes a tea-boy-and one of his worst fears is realised. His mind now becomes so concentrated upon the injured part that subconscious movement becomes almost impossible and the most rapid road to recovery-restoration through exerciseis barred to him. Light work may play a part in rehabilitation : (1) if it is divorced entirely from the man’s original work ; (2) ii it is interesting and does not involve any conscious effort

with the injured part or cut across any of the fundamental or acquired conditioned reflexes ; (3) if it does not cause local or general fatigue ; and (4) if it be prescribed only for a strictly limited number of days. SUMMARY

down the ladder of power. The surgeon, taking the man at the level at which he finds him, must help him step by step upwards to full rehabilitation. The aim of treatment is to restore power, not only to the injured part but to the whole body. The restoration of power can only be achieved by exercise wlxich in turn produces a flow of " more and better " blood and hastens tissue repair. But the flow of blood must be regular and not in fits and starts, so that exercise must be prolonged throughout the hours of the ordinary working day instead of for half an hour three times a week. In order to make such exercise possible without inducing fatigue, the exercises should be based upon established reflex action : at first the fundamental reflexes, then the conditioned reflexes, and finally impulsive action. In the patient psychological effort must be reduced to a minimum because this effort produces fatigue at a stage much earlier than it would otherwise occur. Normality (i.e. the use of conditioned reflexes) must be encouraged. Normal working boots should be worn and sticks and crutches disallowed. Bad habits of grasp and grip and gait are prevented or corrected by leading the patient back step by step up through his reflexes. All this requires great psychological effort, but this effort must be made by the surgeon on behalf of his patients ; and for him, like them, "getting fit is a whole-time job."

Injury precipitates

a man

REFERENCES

Bainbridge, F. A. The Physiology of Muscular Exercise, London, 1931, p. 109. Fearing, F. Reflex Action, Baltimore, 1930. Fulton, J. F. Physiology of the Nervous System, London, 1938, p. 142. Griffiths, H. E. Quoted from Post. Grad. med. J. 1943, 19. Injury and Incapacity, London, 1935. Howell, W. H. Text-book of Physiology, London and Philadelphia, 1936, p. 149. McConnel, J. K. Shorter Convalescence, London, 1940. Michell, in Allbutt’s System of Medicine, London, 1909, vol. vi, p. 199; and Schneider E. C. and Havens, Amer. J. Physiol. 1915, 36, 239. Sherrington, C. S. J. Physiol. 1897. Starling, E. H. Principles of Human Physiology, London, 1936, p. 263. —

PEPTIC ULCER PROGNOSIS IN ROYAL AIR FORCE PATIENTS

A. F. ROOK, O B E, F R C P,

D P H

AIR-COMMODORE AND CONSULTANT IN MEDICINE IN THE RAF

MucH has been written since the

beginning of the

war

about indigestion in Service personnel and a review- of this published work has recently been made by Dunn (1942). Figures have been -given to show the incidence of indigestion among patients admitted to various hospitals, although it is unlikely that the general incidence will be known until after the war, owing to the fact that the strengths of units and formations are secret. So far as the Royal Air Force is concerned- it has been reported that the incidence of indigestion in members of aircrew is higher than in ground personnel, and that the invaliding rate, since the outbreak of war, on account of digestive disorders has been about 17 % of those discharged for all diseases. In civil life, despite the large number of men and who suffer from peptic ulceration, comparatively few appear to be chronic invalids and most manage to carry on. some probably settling into sheltered occupaIn contradistinction to this it seems to be tions. generally agreed that -peptic ulceration ig a bar to service in the armed forces (Crohn 1941, Chamberlain 1942), and according to Hinds Howell (1942) in all three British Services most cases of proved ulceration have been invalided, a minority only returning to duty after The proportion of cases returning a course of treatment. to duty is probably largest in the RAF : firstly, because the proportion of skilled technicians is high and every attempt is made to keep valuable men ; secondly, because the opportunity of placing these men in sheltered appointments and even allowing them to live in their own homes is greater in the RAF than in the women

734 other Services. It was hence felt that an inquiry into the after-histories of patients with peptic ulceration who had returned to duty might be of value as a guide to future procedure. DISPOSAL IN THE RAF

Though peptic ulceration was a common condition in the wards of RAF hospitals before the war (just 100 cases with this diagnosis passing through one RAF hospital in the two years 1937-38), it was not a major problem as regards flying personnel because of the care with which they were selected. A history suggestive of peptic ulceration, or of recurring indigestion, has long been a cause for rejection of candidates for flying duties because the stress of flying has been found so often to lead to recurrence of symptoms. In the yearly report on the health of the Royal Air_ Force, last issued in 1937, peptic ulceration was not treated separately but was included under the heading of " other diseases of the digestive system." It is, therefore, not possible to state exactly how many officers and men were invalided for peptic ulceration under peace-time conditions, but in the 5 years 1933-37 it was not more, and may have been rather less, than 32 out of a yearly strength averaging just over 40,000. Under a heading which included all diseases of the digestive system only 39 were invalided in the 5-year period, just over 3% of those discharged for all diseases, the rate varying but little from year to year and showing no tendency to rise. Since the war this figure has risen to 1’7 %. The methods of disposal of cases of peptic ulceration in the RAF were formulated before the onset of the war. They have stood the test of time and, substantially unaltered, are still in use. The men of prime importance in the RAF are the pilots and the other members of aircrew. Their training is long and expensive and their care and the maintenance of their physical efficiency is the first duty of the RAF Medical Service. While the value to the Service of the trained airman may not be so great as that of a pilot, the importance of conserving technicians cannot be overestimated, and every attempt is made to prevent these men from being invalided. The unskilled or untrained airman with symptoms of peptic ulceration is often better in civil life. TABLE I-TO SHOW DIAGNOSIS, RANK, AGE-GROUPING, DURATION OF SYMPTOMS AND PRINCIPAL CRITERION OF DIAGNOSIS IN 41 OFFICERS AND 153 AIRMEN

(194 CASES)

In the case of pilots with peptic ulceration return to is gradual and many months, with complete freedom from symptoms, must elapse before a full flying category can be regained. In peace-time, after a full course of treatment and convalescence, the patient After was kept on ground duty usually for 9 months. this period, which was nearly a year from the original illness, limited flying was allowed, the limitations usually being for height and duration of flight. A ceiling of 8000 feet and flights of not more than 2 hours’ duration were the limitations usually imposed, although there After a further was often variation in individual cases. 6-12 months the position was again reassessed and if symptoms were absent with few dietetic restrictions, a full flying category was usually allowed, but overseas service was still prohibited. These cases tend to break down in hot climates and a period of freedom from all symptoms, usually for about 4 years, has been insisted upon before passing for overseas service. Since the war these periods have been cut down to some extent in cases which have reacted well to treatment, but in every instance a gradual return to flying duty is recommended.

flying

1942,

TABLE II-TO SHOW POSITION IN THE AUTUMN OF ABOUT 2 YEARS AFTER ORIGINAL DECISION TO RETAIN THE OFFICER OR AIRMAN IN THE SERVICE

Air-gunners, air-observers and other non-piloting members of aircrew are dealt with on similar lines, with a tendency to return earlier to flying duties. The policy of conservation of trained personnel must be remembered when studying the prognosis of these cases for it makes the outlook of those of higher rank and longer service appear more favourable than it really is. In any survey of the after-histories of cases

of peptic ulcer in the Service it must not be assumed that valuable personnel who remain uninvalided have done better from a medical point of view than others of less importance who have been invalided for similar disabilities. It is easier for those of higher rank-such as sergeants and above-to control their diets or to obtain rest if symptoms appear, for their work is usually of a supervisory or sedentary nature. The aircraftman has no such advantage. On discharge from hospital all patients who. have been under treatment for peptic ulceration are given instructions as to their diet and future regime, but only those who want to stay in the Service will make a real attempt to regulate their life so that they can carry on. It is never worth while attempting to retain a patient who has had definite peptic ulceration and who wants to return to civil life. As a consequence those who are retained have usually a high sense of duty and good morale. Many people have suggested the formation of companies or units in which men suffering from chronic indigestion could be collected and given special dietetic facilities. An attempt to do this on a small scale in the RAF met with administrative and other difficulties and was abandoned. To make a success of such a scheme the airmen chosen would have to be psychologically of the best type, for it is doubtful if any amount of special dieting or medical supervision will offset the foolishness of a man who will not look after his own health.

735 TABLE III-COMPARISON OF PRINCIPAL FEATURES IN DIAGNOSIS I AND HISTORY OF AIRMEN WHO ARE STILL SERVING AND THOSE WHO HAVE BEEN INVALIDED

X-ray evidence and when studying the case-histories patients one is struck by the inconsistency of the X-ray reports. In one instance a patient was examined on two separate occasions by different radiologists, both of whom diagnosed duodenal ulceration. At operation, shortly after the second X-ray examination, the duoon

of these

denum

found to be normal with no evidence of It has thus been difficult to ensure that all cases had actual ulceration, especially as the radiological reports came from different hospitals, with different radiologists of varying competence and varying standards. In every case the symptoms were considered by the medical officer in charge of the patient to point to peptic ulceration. Where complications were absent, a barium meal had always been done and the radiologist, either as the result of finding a niche or a crater, or because of deformity tender on palpation, had indicated that ulceration was likely. When there appeared to be doubt as to the diagnosis the case was not included in the series. In tables I and III the principal criteria on which the diagnosis was based have been indicated. was

scarring.

ANALYSIS OF CASES

Some of the headings in the tables, such as rank, age and branch or trade, are given solely to show the distribution within the group, for as the total number at risk is unknown and as they are a selected group it is useless to attempt to draw conclusions from the figures. After approximately 2 years all the officers were still serving though only 5 (12 %) have regained their full category (table ir). Nearly half have been made permanently unfit for service overseas. In the case of CLINICAL MATERIAL airmen, at the end of the period nearly three-fifths were still serving and about two-fifths have been invalided. The medical records of over 1300 cases, diagnosed as The higher the rank of the airman the more likely was peptic ulceration and reported during the first 18 months he to be able to carry on satisfactorily for reasons of the war, have been examined. Many of these cases discussed. Thus four-fifths of the non-comalready were invalided but a number were retained. The casehistories of all officers and men who were retained were missioned officers were still serving, but for aircraftmen scrutinised and all those in which the diagnosis seemed the figure is less than half ; 4 airmen were released from Service for reasons other than ill health and 1 was reasonably certain were selected for special study. They killed. formed a group of 194 officers and airmen-avery The proportion of duodenal to gastric ulcers is a little selective group, so that no attempt has been made to over 4 to 1. This is a rather lower figure than is given draw conclusions as to the incidence of peptic ulceration, by Wade (1942) for Royal Navy patients or by most of either in general or in any particular section, in the by him, whose figures for Service analysis which follows. Guidance in disposing of patients the authors quoted patients average 5 to 1. It is, however, higher than with peptic ulceration has been the sole aim. the figures given by either Hutchison (1941) or Hinds Certain factors which tended to make for selective Howell (1942) who give ratios of 3 to 1 and 2’5 to 1 In first the must be mentioned. the place sampling medical officers who gave the original decision, that it respectively. In the group studied, so far as this proportion is concerned, the sample appears to be a was worth while trying to retain a patient in the Service, fair one. must have chosen the better type of man who had The higher age-incidence of the officers as compared reacted well to treatment. Secondly, when examining with the airmen is almost certainly a reflection of the the histories and selecting the cases to be followed up greater proportion of officers in the higher age-groups. an attempt was made, so far as possible, to ensure that The diagnoses accepted by the invaliding medical diagnosis was correct. This inevitably meant that boards were: duodenal ulcer, 43; gastric ulcer, 8; patients who had suffered from one of the easily recogpeptic ulcer, 2;and duodenitis, chronic dyspepsia, nised complications of ulceration would be included, as pernicious anaemia, schizophrenia and psychopathic the diagnosis was then almost certain. As a result the personality, 1 each. incidence of complications in the group is higher than it should be in a fair sample. This has probably given a RETURN TO FLYING too favourable picture as a number of these patients had few symptoms of indigestion and as soon as the comOf the 194 cases 26 were members of aircrew, 22 plication had been treated they were again symptomless. officers and 4 airmen (pilots, 23; observers, 1; airIn a few instances, when studying the original medical gunners, 2). Diagnosis: duodenal ulcer, 20 (77%); history records, some of the subsequent history was gastric ulcer, 6 (23%). known and may have biased the decision as to whether or not the case should be included in the group. It is Flying category in the autumn of 1942 not thought, however, that this has caused any serious Full flyingvitiation of the sample. 5 (a) at home and abroad °

’

......

t

DIAGNOSIS

One of the difficulties immediately encountered in any inquiry relating to peptic ulceration is what criteria of diagnosis are to be laid down. The standards acceptable at a special gastric centre cannot be reached at the

ordinary hospital.

Many cases are diagnosed as gastric or duodenal ulceration by station medical officers on symptoms alone, and possibly never reach hospital for

X-ray examination. While symptoms may

often be typical it is doubtful accurate diagnosis can be made on them in the absence of complications without some method of confirmation. Too much reliance can, however, be placed

if

an

(b)

at home

Limited

only ........

flying Temporarily unfit for flying Permanently unfit for flying

........

....

....

4 5 4 8

Of the 26 members of aircrew included in the series has been invalided. After roughly 2 years about half have got back to some form of flying duty, 9 of them having regained the full flying category. It would thus appear that the policy of giving adequate treatment and a really good chance to resume duty has been fully justified. The great preponderance of pilots is to some extent explained by the fact that at the beginning of the war the number of aircrew other than none

736

pilots

was

the exact

relatively small, though

cannot be given.

One officer perforated

proportion

gastric ulcer while flying alone, managed to land safely and after treatment returned again to flying duties. There is no evidence in the group studied that perforation or the other acute complications are more frequent in aircrew than in ground personnel.

SLIDE-TEST

a

BESSIE

FOR COAGULASE-POSITIVE STAPHYLOCOCCI

CADNESS-GRAVES, M SC,

ROBERT WILLIAMS, B SC,

MB LOND

MEDICAL RESEARCH COUNCIL

G. J. HARPER

UNIT, BIRMINGHAM

ACCIDENT

HOSPITAL

Perforations 5 in 26 36 in 168 16 in 71

Aircrew All ground personnel.... Ground personnel*

.......

....

All

MB MANC

EMS PATHOLOGIST TO LONDON SECTOR 1V

cases cases cases

complications

(19%) (21%)

(23%) °

Aircrew 9 in 26 All ground personnel.... 54 in 168 Ground personnel* 23 in 71 * Age 30 or below ........

....

cases cases cases

(35O) (32%) (32%)

.

INDICATIONS FOR INVALIDING

Although figures are too small for any but the most tentative conclusions, it was thought that a comparison of the case-histories of the airmen still serving and those who had to be invalided might give some indication of the type of patient unsuitable for retention in the Service (table III). In giving a prognosis in a case of peptic ulceration it is often considered that youth and short duration of symptoms are a good omen. The figures for the invalids, few though they be, do not bear out these opinions. Actually, in the younger age-groups-up to 30 yearsa greater percentage occurs in the invalided group (53%) than in the serving group (42 %), suggesting that the older men are more likely to carry on than the younger. This premise must not, however, be accepted too literally, for the older age-group contains more noncommissioned officers and skilled tradesmen who have better opportunity to control their diet and who are guarded so far as possible from invaliding because of their great value to the Service. It seems that previous duration of symptoms has little effect on the ability of a patient to return to Service life and that none of the various criteria of diagnosis is of help in disposing of the case after treatment. the

-

A. A.

MILES,

M A CAMB P R C P

PROFESSOR OF BACTERIOLOGY (LOND. UNIV.) AT UNIVERSITY COLLEGE HOSPITAL MEDICAL SCHOOL

THE examination of plate cultures for coagulase-positive staphylococci necessitates the cultivation of suspected colonies in broth, and a coagulase test on the resulting broth culture, both time-consuming procedures. Much (1908) first noted that if an attempt was made to suspend coagulase-positive staphylococci in plasma, the cocci were rapidly clumped. Birch-Hirschfeld (1934) found that thick suspensions of over 100 strains of coagulasepositive staphylococci were all rapidly clumped in human plasma. She records no tests with coagulase-negative cocci. The phenomenon resembles specific agglutination, and has been called non-specific agglutination by some workers. However, to avoid all possible confusion with the established specific slide agglutination test first developed for the staphylococci by Cowan (1939) the term " clumping " is to be preferred as a description of the reaction. The relation of the clumping to the presence of staphylocoagulase is not fully clear, but if there was complete correlation between the results of coagulase tests and of plasma-clumping tests, the clumping test, which can be performed in less than a minute, much time in the identification of potentially staphylococci. The evaluation of this reaction as a test for the rapid identification of Staph. pyogenes was started by one of us (B. C.-G.) and it will be convenient to discuss the results of this investigation first.

would

save

pathogenic

°

SERIES I

The clumping test is simple. The suspected colony is. emulsified in a drop of water on a slide, and the emulsion gently mixed with a drop of plasma. Coagulase-positive staphylococci—i.e., the Staph. pyogenes of Cruickshank I——COMPARISON OF PLASMA CLUMPING AND PLASMA COAGULASE TESTS ON STAPHYLOCOCCI FROM HUMAN SOURCES

TABLE

SUMMARY

fate, as regards service in the RAF, of 194 of peptic ulceration allowed to return to duty has been followed for about 2 years. After this time just two-thirds of the group were still serving and about a third had been invalided. About half of those patients who were members of aircrew returned to flying duties. In this group of cases, selected as being worthy of retention in the Service, the subsequent history suggests that help in disposal may be obtained from the rank, for the higher the rank the more likely the patient to be able to carry on. Neither the length of history nor any of the various criteria of diagnosis appears to offer any guidance as to whether or not an airman, after treatment for peptic ulceration, is likely to withstand Service life. I wish to thank Air Marshal Sir Harold Whittingham, Director-General, Royal Air Force Medical Service, for making the medical history records available for study, and Dr. A. Bradford Hill for advice with the statistical analysis. The

cases

-

REFERENCES

Chamberlain, D. T. (1942) J. Amer. med. Ass. 120, Crohn, B. B. (1941) Amer. J. digest. Dis. 8, 359. Dunn, W. H. (1942) War Med. 2, 967. Hinds Howell, C. A. (1942) Brit. med. J. i, 692. Hutchison, J. H. (1941) Ibid, ii, 78. Wade, H. J. (1942) Lancet, ii, 636.

254.

INSTITUTE OF CHEMISTRY.-At 6 rM on Wednesday, June 16, 30, Russell Square, London, W.C.1, Mr. W. T. J. Morgan, D Sc, reader in biochemistry in the University of London at the Lister Institute, will address the London and South Eastern counties section of the institute on some recent advances in at

immunochemistry.

(1937)-are precipitated after 5-15 seconds in the form easily visible white clumps. With other species of cocci, the suspension remains uniformly turbid. Fresh human plasma from sedimentation-rate blood specimens was available each day, so that the risk of false positives with older plasma (Christie and Keogh 1940) was avoided. Parallel coagulase tests were made by mixing equal volumes of plasma and ofan 18-hour broth culture of the organism in a small tube, and reading of

the result after 4 and 24 hours incubation at 37° C. Each batch of plasma was tested with a known positive and known negative staphylococcus. The parallelism of the two tests with 442 strains of staphylococci from pathological sources is shown in table i. Two strains only, grown from urine, were feebly positive in the tube test, and negative on the slide. In the remaining 440, of which 280 were Staph. pyogenes, correspondence is complete. These results were obtained after a year’s preliminary trial, and illustrate the dependability of the technique in the hands of one practised observer. -