Brit. J. prev. soc. Med. (1976), 30, 115-122

Peptic ulceration in menEpidemiology and medical care

MICHAEL CLARKE*, TONY HALILt, AND NICOLETE SALMONDepartment of Clinical Epidemiology and Social Medicine, St Thomas's Hospital Medical School, London

Clarke, M., Halil, T., and Salmon, N. (1976). British Journal of Preventive and SocialMedicine, 30, 115-122 Peptic ulceration in men: epidemiology and medical care. Estimatesof the population prevalence of peptic and duodenal ulceration in men aged between 25 and64 years were made in the London borough of Lambeth. The sampling frame for theseestimates was a 20% private census. The lifetime prevalence rate of proved peptic ulcer(haematemesis, gastric and duodenal ulcers as validated by operation or barium meal),adjusted for age and social class, was estimated to be 6 7%, while the similarly adjustedlifetime prevalence for duodenal ulcer was 4.4%. The lifetime prevalences increased withage but not significantly so. A social class gradient was demonstrated with the highestprevalence in social classes I and II. Previously described associations with blood group,secretor status, and serum pepsinogen were confirmed. Reported use of medical servicesincreased with increasing severity of symptoms. A large number of respondents, however,who reported symptoms reported no medical care. It seemed unlikely that those menwho reported symptoms and no medical care had demonstrable peptic ulcers.

Mortality from gastric and duodenal ulcerincreased during the first half of the twentiethcentury (Jennings, 1940; Tidy, 1945; Ivy, Grossman,and Bachrach, 1950). Since the 1950s duodenalulcer mortality, however, has declined. Crudemortality rates for duodenal ulcer in men duringthe period 1957-71 have fallen from 88 to 49 permillion population. Available measures of morbidityhave shown a similar decline; for example, theHospital In-Patient Enquiry's estimate of dischargerates from hospitals in England and Wales for pepticulcer shows a decline of from 23 4 per 10 000 in1957 to 16 2 in 1971. Sickness benefit claims follow asimilar pattern: between 1953-54 and 1971-72, therewas a decrease in the number of spells of absenceand days of absence from ulcers of the stomach andduodenum (Taylor, 1974). Both the morbidityand mortality data therefore suggest that theprevalence of peptic ulcer may have been declining.Hlowever, the only method by which this could bedemonstrated was to undertake a prevalence surveyin the community and compare the results withearlier prevalence studies.

Present address: Department of Community Health, University ofLeicester.

tPresent address: Institute of Education, University of London.

OBJECTIVES

In 1964 St Thomas's Hospital accepted responsi-bility for providing care for the population of thelocal district. Between 1967 and 1969 four communitysurveys were carried out; these aimed to help in theplanning of future health services by assessing anydiscrepancies between the need and demand forparticular forms of care (Holland and Waller, 1971).The present study was the last to be undertaken andhad the following objectives:

1. To determine the prevalence of peptic ulcerationin men aged between 25 and 64 years in northLambeth, and to investigate the relationshipbetween peptic ulcers and certain physiologicaland social variables.

2. To estimate what proportion of those withpeptic ulcer were in contact with medicalservices, in order to quantify the relationshipbetween need and demand.

3. To compare as sampling frames the St Thomas'sHospital private 20% census of July 1966 withthe General Register Office's 10% sample censusof April 1966.

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METHODThe survey carried out in 1968 in the six northern

wards of Lambeth was conducted in two stages.The first, or screening stage, consisted of a self-administered postal questionnaire consisting ofquestions derived from the work of Dunn (1959).Respondents were classified as having a positive ornegative history suggestive of duodenal ulcer, accor-ding to the responses to the screening questionnaire.Positive histories were defined as those in which therewas mention of a past history of ulcer or in which anepisode of stomach pain lasting for more than afew days had been reported, and which had beenrelieved by food or milk, or which had woken therespondent at night. A second stage sample was thenselected of some men who responded positively andsome men who responded negatively to the screeningquestionnaire. These men were visited in theirhomes, where various clinical measurements weremade and they were asked more detailed questions.These included their abdominal and respiratorysymptoms, past history of ulcer, smoking habits,medical care usage, some personal and social data.*Anyone reporting treatment in hospital, outpatientattendance for peptic ulcer, or investigations forsuspected peptic ulcer had these reports validatedagainst hospital notes. It was originally plannedthat all those who complained of symptoms highlysuggestive of peptic ulcer, but in whom the diagnosishad not been confirmed, would be offered an out-patient appointment for a barium meal examination.In the event, this proved impracticable as the first23 men with positive responses to all the symptomquestions who agreed to have a barium meal examina-tion were shown to have no radiological evidence ofulcer. This procedure therefore was abandoned onethical grounds.

SAMPLEThe sample for the survey was drawn for com-

parative purposes from two sources, the GeneralRegister Office 1966 (GRO) 10% sample censusand the 1966 St Thomas's Hospital private 20%sample census (Bennett and Kasap, 1970).The entire GRO 10% census population of 2 187

men between the ages of 25 and 64 years was sent aletter by the Registrar General, inviting participationin the study. Of these only 499 (22 * 8 %) replied andagreed to participate and a further 15 men weresubsequently found to have died, moved, or to beolder than 64 years so that the final number of peopleincluded in the GRO sample was 484, a response rateof 22- 1 % (Table I). The use of the GRO sample

Questionnaires are available from the authors on request

TABLE ISAMPLES AND RESPONSE RATES FOR STAGES I AND II

PrivateCensus GRO Total

Original study population.. 2641 2187 4828(100) (100) (100)

Completed stage I questionnaire .. 2109 484 2593(80) (22) (54)

Positive to screening .. .. (23 4) (26*9) (24 1)

Stage II sample .. .. .. 524 144 668(100) (100) (100)

Completed stage II .. .. 481 139 620(92) (97) (93)

Positive to screening .. .. (63*8) (66*9) (64*5)

Percentages are given in parentheses

census as a sampling frame proved to be the leastrewarding way of achieving a reasonable responserate. This was because the Registrar General was ableto provide only the names and addresses ofthose whohad agreed to participate. It was therefore notpossible to get into contact again with any individualwho failed to reply.From the private census, a sample was drawn of

2 641 men stratified by age and social class. Screeningquestionnaires were posted in October 1968 andsecond and third mailings to non-respondents tookplace two and four weeks later.

Table I shows that 2 593 men, 2 109 from theprivate census and 484 from the GRO sample,responded and completed questionnaires. Theproportion positive to screening in the two groupswas similar, 23 *4% and 26 9%.

Altogether 64% of the men who were classifiedpositive and 11 % who were classified negative inthe first stage were used as the sample in the secondstage. The total thus selected for Stage II was 668,and 620 responded, of whom 400 (64 5%) were

initially positive and 220 negative (Table I).

DEFINrrION OF PEPTIC ULCERATIONThe definitions used in the prevalence estimates

were similar to those used by Doll, Jones, andBuckatzsch (1951) and were based on reported pasthistory of ulcer or any combination of symptoms.The 620 cases were divided into three groups:major, minor, and no dyspepsia.

1. No dyspepsia-individuals with no mention ofany complaint relating to abdominal symptoms(namely, stomach pain, heartburn, bloated or

full feeling, belching, or nervous stomach).

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2. Minor dyspepsia-individuals with a stomachcomplaint not included in the major dyspepsiagroup.

3. Major dyspepsia-individuals either with aproved history of duodenal ulcer, gastric ulcer,peptic ulcer, or haematemesis (validated fromhospital notes), or individuals who had stomachpain classified as a definite ache or pain, whichcould be relieved by food, milk, or alkali andwhich awakened the respondent at night, oftenor occasionally.

Lifetime and six-month period prevalences werecalculated using the following definitions:

(a) Lifetime prevalence-any history of dyspepsiaor peptic ulceration;

(b) Six-month period prevalence-any symptomsof dyspepsia or symptoms from a known ulcerduring the previous six months.

Serum pepsinogen estimations were made usingthe method of Ilic and Spray (1966).

RESULTSFor the men assigned in the second stage of the

study to the categories of major dyspepsia and nodyspepsia, responses corresponded closely to those inthe first stage (Table II). Of the 179 men who reportedmajor dyspepsia in Stage II, 174 (97 '2%) werepositive to screening in Stage I. Of the 111 whoreported no dyspepsia in Stage II, 92 (82 * 9 %)reported no dyspeptic symptoms in Stage I. With theminor dyspepsia group the screening questionnairediscriminated less adequately.We investigated the distribution of responses in

the private census sample by age and social class foreach question on symptoms in Stage IT, since it waspossible that different questions might show age orsocial class trends in opposing directions. No trendswere demonstrable.

TABLE IICORRESPONDENCE BETWEEN STAGE I SCREENINGRESULT AND DEGREE OF DYSPEPSIA FOUND AT STAGE II

Stage II Dyspepsia Status

Stage I Screening Result Major Minor None Total

Positive .. .. 174 207 19 400

Negative .. .. 5 123 92 220

Total .. .. .. 179 330 111 620V. Positive ...... .. (97-2) (62 7) (17 l) (64 5)

BLOOD GROUP AND SECRETOR STATUSPrevious work had demonstrated an association

between peptic ulcer and blood group and secretorstatus. Table III shows the associations betweenvarious levels of dyspepsia and these variables. Ofthose with major dyspepsia 49% were in blood group'0,, as compared with 39% of those in the nodyspepsia group.The results of the secretor status investigations

also followed the expected pattern, with the majordyspepsia group having a higher proportion of non-secretors (27%) than the minor dyspepsia group(22%) and the no dyspepsia group (19 %). Neitherthe blood group nor the secretor status distributionwas significantly different between the three levels ofdyspepsia.

SERUM PEPSINOGENThe mean levels of serum pepsinogen were a little

higher in the major dyspepsia group than in the othertwo groups-52 9 IU/I in the major dyspepsia group,compared with 50 IU/I in the minor and no dyspepsiagroups (Table III). The differences were notstatistically significant.

PREVALENCE RATESIn order to detect any relationship between social

class, age, and the categories of dyspepsia quantal

BLOOD GROUP, SECRETOR STATUS, SERUMTABLE III

PEPSINOGEN, AND LEVEL OF DYSPEPSIA (LIFETIME PREVALENCE)

Negative Secretor Serum PepsinogenBlood Group 'O' Status (mean levels lU/l)

Dyspepsia Status _____________No. % No. % No. Mean ± SD

Major .. .. 179 49*2 179 26-8 164 52 9 ± 20-1Duodenal ulcer . . 70 50*0 70 25*7 62 49*4 ± 20*5

Minor .. .. 330 39 7 330 21-5 295 50-1 ± 22-6None .. .. ill 387 ill 18*9 89 49*9 ± 27*6

x2 = 4-95 (NS) x2 = 2-90 (NS)

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response regression analyses were undertaken of theresponses of the men interviewed in the second stageofthe study (Naylor, 1964). This was necessary beforeestimating population prevalence rates so as todetermine whether adjustment for age and socialclass was required. The social class effect was foundto be significant for major and minor dyspepsia at the5% level, while the age effect was significant for allconfirmed ulcers and duodenal ulcers. The observedsocial class differences in the frequency ofreported major dyspepsia followed a linear trend,being highest in social classes I and II and lowest insocial class V. The social class trend for minordyspepsia was also linear but in the oppositedirection to that for major dyspepsia. In general, thefrequency of ulcers increased with age. Althoughassociations with social class and age were notdemonstrated in all categories of dyspepsia, ageand social class adjustments were made in all theprevalence estimates.

Prevalence rates and their standard errors were

computed with the following factors taken intoconsideration. First, changes in classification fromfirst stage to second stage due to the sensitivity andspecificity of the screening questionnaire in detectingthe various categories of dyspepsia identified at thestructured interview. Secondly, the disproportionatesampling fractions, 64% of positives and 11 % ofnegatives, that were used in selecting the secondstage sample. Finally, the composition of the firststage sample which was a stratified sample withdisproportionate sampling fractions in each stratum.For the prevalence estimations, only the privatecensus sample responses were used. There were tworeasons for this; first, the GRO sample was notrepresentative of the general population because ofthe low response rate, and secondly, the social classstatus of the members of the GRO sample was

unknown at the screening stage.

Table IV shows the estimated lifetime prevalencerates for minor and major dyspepsia adjusted fordifferences in age and social class between the

TABLE IVESTIMATED PREVALENCE RATES (% AND ± SE) AGE ANDSOCIAL CLASS ADJUSTED, IN MEN AGED 25 ro 64 YEARS

Private Census PrevalenceEstimates

Lifetime prevalence:DyspepsiaMinor .. .. .. 508 2-2Major .. .. .. 10-4 1-2

UlcerProved .. .. .. 67 1*0Duodenal . .. .. 4 ± 09

Six-month prevalenceDyspepsiaMinor .. 355 ± 2*0Major .. 2-1 ± 06

UlcerProved . .. .. 1*4* 0*5Duodenal . .. 07*± 04

*Estimates based on fewer than 15 individuals

sample and the Borough of Lambeth. Half thepopulation reported symptoms of minor dyspepsia,while 10% reported major dyspepsia symptoms atsome time during their life. Within this latter group,

6-7% were shown to have proved peptic ulcers; ofthese, two-thirds were duodenal ulcers. The six-monthprevalence rates for major dyspepsia and for pepticand duodenal ulcers were approximately one-fifththe lifetime prevalence rates.When prevalence rates were considered by age

(Table V), little difference was seen between thegroups. The lowest lifetime prevalence rate formajor dyspepsia and ulcers was in the 35-44 year agegroup and the highest in the 55-64 year age group.

Age adjusted lifetime prevalence rates by socialclass are shown in Table VI. Prevalence rates forminor dyspepsia are similar in social classes I-IVand somewhat higher in social class V. In all othercategories the prevalence rates in social class V are

lower than in the other social class groups.

TABLE VESTIMATED LIFETIME PREVALENCE RATES (% AND ± SE) BY AGE (SOCIAL CLASS ADJUSTED)

Dyspepsia/Ulcer Category Age in Years

25-34 35-44 45-54 55-64

DyspepsiaMinor .. .. .. 51-6 51 506 4-1 62-1 4-2 40 2 ± 4-1Major .. .. .. 91 2-9 8-1 2-1 11-5 2-4 12-8 ± 2-3

UlcerProved .. .. .. 4-9 2-3 4-2 1-8 6-9 2-0 10-4 ± 2-2Duodenal .. .. 33 ± 18 2-7 15 4-5 16 6-7 ± 1*9

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TABLE VIESTIMATED LIFETIME PREVALENCE RATES ('% AND ± SE) BY SOCLAL CLASS (AGE ADJUSTED)

Dyspepsia/Ulcer Social ClassCategory

I + 11 III III IV VNon-manual Manual

DyspepsiaMinor .. .. 46-0 ± 6-8 41-4 i 5-6 48-4 3 7 50-2 ± 4-6 73-1 i5-1Major .. .. 15-1 ± 4-0 12-6 ± 3-7 9.9 ± 1-9 11-4 ± 2-5 4-6 ± 2-9

UlcerProved .... 8-8 ± 3-5 8-9 i35 6-2 i 1-6 7-2 ± 1-8 3-8 ± 2-8Duodenal .... 7-8 ± 3-4 7-2 i 3-4 3-7 i 1-3 4-0 i1-4 1-4 ± 1-3

RATIO OF THE PREVALENCE OF GASTRIC TO made of drugs and medical services during theDUODENAL ULCERS previous six months. Reported use of the health

In the present study those men who reported past service was compared with reports of dyspepsiahistories of dyspepsia or peptic ulceration (104) during the same period of time.and hospital attendance had these attendances Of the 620 men in the second stage of the study,validated against hospital notes. This information was 18 -4% reported using medication or being inused to calculate the ratio of gastric to duodenal contact with their general practitioner or a hospitalulcers. Duodenal ulcers were classified as such only during the previous six months (Table VII).if a definite diagnosis had been made; 70 such cases Medication or contact with medical serviceswere identified. 'Gastric ulcers' have been taken to increased with the severity of the reported symptoms.include both previously diagnosed gastric ulcers

onraioloical Of the 13 men who were known to have ulcers(12), peptc ulcers (12) (as defined and to have suffered recent dyspepsia, more thanreports but for which films were not available), and half (eight) reported taking no medication in thehaematemeses (10) in which no underlying disease last six months. Of the 23 men with major dyspepsia,could be demonstrated. The ratio of the combinedagastric and unspecified peptic ulcers to duodenal a similar proportion reported no medication.gati an unpcfe peptic uler to duoena

However, 14 of these individuals had made previousulcers (age and social class adjusted) in this study was H1:*1-9. contact with the medical services (seven had* *1-9. negative barium meals, four claimed to have had

USE OF HALTH SERVICES barium meals although no hospital records could beIn the second stage of the study, all the men who traced, and three had undergone surgery for peptic

were interviewed were asked what use they had ulcer). Of the remaining nine men with major

TABLE VIIMEDICAL CARE FOR ULCER OR GASTRITIS BY VARYING LEVELS OF DYSPEPSIA DURING A SIX-MONTH PERIOD

Dyspepsia During Previous Six MonthsMedical Care l_

During Previous Six MonthsNone Minor Major Proved Ulcers Total

(without surgery)

None .. .. .. .. 274 210 14 8 506(95-8) (70-5) (60-9) (61-5) (81-6)

Medication only (self and GP prescribed) . . 7 38 3 2 50(2-5) (12-8) (13-0) (15-4) (8-1)

GP contact (with or without medication) . . 3 27 5 1 36(1-0) (9-1) (21-7) (7-7) (5-8)

Hospital (in- or outpatient, with or withoutGP contact, and/or medication) .. 2 23 1 2 28

(0-7) (7-7) (4-4) (15-4) (4-5)

Total . .. .. .. 286 298 23 13 620(100-0) (100-0) (100-0) (100-0) (100-0)

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dyspepsia who had never been investigated, twofailed to attend for barium meal examination as partof the study, in three cases the general practitionercould not be traced, and in two cases the generalpractitioner said there was not enough evidence tojustify a barium meal. Finally, for two men thegeneral practitioner agreed that the patients shouldhave a barium meal but the programme of examina-tions was cancelled (because of 23 consecutivenegative examinations) before these patients couldbe contacted. Overall five of the 23 men (23 %) withmajor dyspepsia had never received, or had not beengiven the opportunity to receive, basic diagnosticmedical care. This could be seen as a minimalestimate of medical need that was not being met.A maximal estimate of unmet medical need couldbe regarded as the 22 men out of 36 (66%) whoreported major symptoms and yet reported no

medical care within the six months.

DISCUSSIONSeveral difficulties are encountered in any pre-

valence study of peptic ulceration. First thebarium meal examination, the definitive test, mayfail to outline the ulcer (Hodgkin et al., 1970) andgive false negative results in individuals with highsymptom scores. Secondly, the use of a questionnaireas an indirect measure ofulceration has the limitationof a low sensitivity. Dunn (1959), for example, indeveloping a screening technique tested manycommon symptom combinations occurring induodenal ulceration but was able to achieve onlya maximum sensitivity of 0-62 and a specificity of0 94-0 97 for the most discriminating group ofsymptoms. Epstein (1969) achieved a highersensitivity (0O85) using the same questions, but thestudy was undertaken on a highly selected group ofpatients referred for a barium meal examination.In this study, nearly all the men (97 *2%) whoreported major dyspepsia in the second stage of thestudy were classified as positive to screening in the

first stage, while most of those (82 9%) whoreported no dyspepsia at interview had beenscreened in the first stage as negative. However, in23 men who were positive to screening, with highsymptom scores, no new ulcers were detected onbarium meal examination. The final difficulty isthat past histories of peptic ulceration are oftendifficult to validate as hospital records may be lost,or for research purposes may be incomplete orambiguous. Each of these factors acts in the samedirection and tends to result in an underestimationof the true prevalence of peptic ulcer.The association between grades of dyspepsia,

duodenal ulcer, and blood group was similar tothat reported by Aird et al. (1954). Similarly it hadbeen shown (Clarke et al., 1956; Doll, Drane, andNewell, 1961; Hanley, 1964) that ABH non-secretorshad a greater liability to ulceration than secretors.Our results agree with these findings.The overall lifetime prevalence for peptic ulcer in

men aged between 25 and 64 years in the LondonBorough of Lambeth was found to be 6e7%.Comparative prevalence rates for some of the otherstudies published between 1947 and 1964 are givenin Table VIII. Such comparisons are difficult tomake because of the differences in the health status ofthe groups studied and the criteria used for definingulcers. In several of these studies, selected popu-lations have been surveyed either in terms ofoccupation (Doll et al., 1951) or of particularcircumstances such as the study by Knutsen andSelvaag (1947) which was carried out in Norwayduring the occupation in 1942. Despite theseproblems, it is perhaps useful to compare studiescarried out between 1947 and the present time tosee if it is possible to detect any gross changes inprevalences. As can be seen from Table VIII, thereis little evidence of any large change in overall preva-lence rates between these various studies.

Lifetime prevalence figures by age for minordyspepsia were lowest in the oldest age group. Thismay be explained by errors in recall or because such

TABLE VIIISTUDIES OF PEPTIC ULCER PREVALENCE IN MEN

Age Group PrevalenceYear Study Population (Ycars) (Y.,)

1947 Knutsen and Selvaag Ration applicants (Dramenn, Norway) 20-59 4-2

1951 Doll et al. .. Selected occupational groups (England) 25 + 5 2

1964 Fry GP list (Beckenham, Kent) All ages 6*6

1968 Weir and Backett GP lists (NE Scotland) 15+ 10-2

Present study Random sample of private census (Lambeth) 25-64 6*7

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minimal symptomatology was accepted as 'normal'by an older age group. The somewhat higherprevalence of confirmed ulcers and duodenal ulcersin the older age groups is similar to the findings ofDoll et al. (1951). Lifetime prevalence figures bysocial class show higher proportions of majordyspepsia and proved ulcer in the higher socialclasses. Doll et al. (1951) reported no such differencesalthough in their study men with duodenal ulcer insocial classes I, II, and III did have a somewhathigher standardized morbidity ratio than men insocial classes IV and V. There are a number ofpossible explanations for this study showing adifferent trend. First, it was undertaken almost 20years after the study by Doll et al. (1951) and theoccupational classification they used was developedin 1934. Secondly, the population in this study wasdifferent, being based on a random sample of ametropolitan borough, whereas Doll et al. (1951)used selected occupational groups. Thirdly, it ispossible there may be an earlier and higher detectionrate for duodenal ulcer for men in social classes I,II, and III in Lambeth, since men in these socialclasses tend to use medical services more often thanthose in the lower social classes (Palmer et al., 1969).Finally, these figures may indicate a real change inthe pattern of duodenal ulcer prevalence betweenthe social classes.

Assessing the use of medical services reported bythe respondent is difficult because there are nostandards available to indicate the appropriate useof such services. In the present study, only approxi-mately 30% of those who have had some gastro-intestinal complaint reported taking some actionduring the six months. This finding may be typicalbecause Kosa, Alpert, and Haggerty (1967) hadalso noted that people grossly underestimated theirmorbid conditions when compared with the findingsof medical examinations. Although Wadsworth,Butterfield, and Blaney (1971) found that wheresymptoms caused by peptic ulcer were reported,71% of these respondents used some medication(five out of seven individuals), in this study only39% of those with major dyspepsia and confirmedulcers reported receiving or taking medical treatment(14 out of 36 individuals).The medical care findings indicated that although

most individuals with symptoms sought no care atall, the tendency to consult increased with theseverity of symptoms. It is important to note,however, that none of the men with high symptomscores investigated by barium meal was found tohave a peptic ulcer, which would indicate that at themore severe levels of disease those in need of serviceshad already received them. It is possible that themedical profession are not able to recognize many

patients with peptic ulcers until perforation,haematemesis, or other clinically specific eventsoccur. Hodgkin et al. (1970), from their experienceof dyspeptic complaints in general practice, suggestedthat the 'main difficulty in estimating aetiology andprevalence is that a barium meal may fail to outlinean existing ulcer'. They quoted other sources whichestimated that as many as 33% of ulcers might bemissed by radiology.The results of the use of health services also

showed a discrepancy between complaints reportedand medical care received in that 12 men reportedno symptoms but did report medical care (Table VII).In order to interpret this finding, it is necessary toconsider the design of the questionnaire. To collectthe information on gastrointestinal complaints,respondents were asked whether they had had'stomach pain, bloated feeling, belching, heartburn,or nervous stomach' during the last six months.Later in the questionnaire they were asked if theyhad used any form of medical care and for whatreason. The reasons for consultation were thenclassified according to whether these complaints wererelated to 'ulcer' or 'gastritis.' The question whichasked for the reason for consultation was open-ended, and in many cases the responses were theindividuals' own diagnoses. Consequently a com-parison between these reports and those based onpositive or negative responses to a specific symptomlist might be expected to produce some discrepancies.When the 12 men who reported contacting medicalservices but reported no symptoms were investigatedfurther, they were found to have sought care forcomplaints such as persistent flatulence and non-specific stomach upsets.

In general the medical care study showed thatconsultations and medication increased as thereported symptoms increased. There were however,many respondents who reported symptoms but nomedical care. However, in view of the series ofnegative barium meals on men with high symptomlevels, it seems that those who reported symptomsbut no medical care were unlikely to suffer seriousdisease that was amenable to treatment.

This study was supported by the Department ofHealth and Social Security. We should like to thankMr S. G. Nicholas for his help in the preparation of thedata; Professor G. Wetherley-Mein, Miss V. H. Glassand others in the Haematology Department; Dr D. W.Pierce of the Radiology Department for performing thebarium meal examinations; Dr G. Walker, who at thetime of the study was on the staff of the ChemicalPathology Department of St Thomas's Hospital, for thepepsinogen examinations, and Sir Francis Avery-Jonesand Dr Max Wilson for their comments and suggestionson the manuscript. We are particularly indebted to

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Professor W. Holland and all members of the Depart-ment of Clinical Epidemiology and Social Medicine,especially Dr A. E. Bennett, for their help and encourage-ment.

Requests for reprints: M. Clarke, MB, MFCM, DPH,Department of Community Health, University ofLeicester, 161 Welford Road, Leicester LE2 6BF.

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