War Surgery and Medicine
IN the Second World War dyspepsia among New Zealand troops overseas was an important cause of disability, as well as being a frequent reason for initial rejection. This experience was shared by other forces. In the First World War neither peptic ulcer nor dyspepsia of other types formed a problem of any magnitude, and the frequency of gastro-duodenal disorders in the later war was rather surprising. Investigations showed that in a majority of cases symptoms had dated from civilian life, and that there had been a very considerable increase in dyspepsia among civilians between the wars. The stresses and strains of modern life had no doubt played their part.
In the code of instructions for Medical Boards provision was made for rejecting cases of definite ulcer of the stomach or duodenum, but the mere complaint of indigestion with abdominal pain, even if extending over some years, was not a bar to placing the man in the grade for which he was otherwise suitable.
If a man had never consulted a doctor, had a healthy appetite, but stated that he occasionally had a little indigestion which did not worry him much, he was accepted. This resulted in a few men reporting sick in camp who, after X-ray, were found to have a duodenal ulcer. Gastric ulcer, however, was found to be very uncommon. On the introduction of conscription large numbers of men produced radiological evidence of duodenal ulcer and were placed in Grade III, ‘not fit for camp’. This experience led to a revision of the code of instructions, and the revised code issued in the middle of 1942 laid down that ‘if a Board is satisfied from the man's history, supported by medical evidence, that he has at any time suffered from a peptic ulcer, then he should not be placed higher than Grade III—unfit to live in camp.’ Any doubt as to diagnosis or an unfavourable history had to be verified by X-ray and gastric analysis tests.
The ulcer cases were not admitted to camp because applications for pensions had been received, supported by medical certificates, that the ulcer had been caused or aggravated by service, and pensions had been granted to many of them.
In a total of 714 soldiers reboarded after entering camp in New Zealand up to 30 April 1940 there were 16 cases of peptic ulcer, 2 of gastro-enteritis, and 4 of dyspepsia.page 622
In a survey of 1000 soldiers rejected from the Army in New Zealand and 2 NZEF up to January 1942 (630 from overseas and 370 in New Zealand) Hill and Goodson found that 8 per cent were rejected for disorders of the digestive system. This cause ranked fourth in the list of major causes, whereas in the Canadian and Australian Forces it was first and third respectively, as revealed by similar surveys. It was stated: ‘Of 270 men rejected from the Canadian E.F. for digestive disorders, 251 were due to peptic ulcer—31 per cent of all rejections. This high figure was said to be due to a policy of returning home (from United Kingdom) all cases of peptic ulcer. The British E.F. policy is to return to civil life not only all proved cases but also the so-called functional dyspeptics with a long-standing history of gastric disturbance.’
A survey in 1943 in the United Kingdom showed that peptic ulcer was one of the major causes of wastage attributable to disease, whether the yardstick applied was its proportionate contribution to invalidings (13 per cent), deaths due to sickness (5 per cent), or to man-day wastage (1.3 per cent).
In a survey made by the National Service Department of the causes of rejection for military service in 1942 and 1943 in New Zealand it was found that stomach and duodenal disorders accounted for the rejection of 1.18 per cent of the recruits, a figure which placed this cause sixth in the common causes of rejection. The percentage of rejection advanced rapidly with the increasing age of the men examined.
As far as 2 NZEF was concerned, the problem of dyspepsia was early brought into prominence. In this connection the Consultant Physician of 2 NZEF, reporting on the Army Medical Conference, Cairo, in April 1942, said: ‘The views put forward by various speakers on digestive disorders confirmed the conclusions arrived at in the special investigations which we have been making at 1 NZ General Hospital. Nervous dyspepsias are four times more numerous than organic. The organic cases first develop symptoms at a much earlier age than we have been accustomed to think, and a large majority originate in civil life.’
In a detailed analysis of 100 cases of dyspepsia admitted to 1 General Hospital from 2 NZEF as a whole from October 1941 to June 1942, Major C. G. Riley found that there were 18 cases of chronic ulcer, 37 cases of ‘ulcer-like’ dyspepsia without radiological evidence of a chronic ulcer, 40 cases of obvious nervous dyspepsia, and 5 miscellaneous cases. Of the chronic ulcer cases, two-thirds were returned to New Zealand and one-third downgraded for base duties; of the radiologically negative dyspepsias, one-quarter were returned to New Zealand and one-quarter graded page 623 for base duties; while of the nervous dyspepsias, just under one-fifth were returned to New Zealand and the same proportion graded for base duties. From the total of 100 patients 55 were down-graded, and of these, 32 were returned to New Zealand and 23 graded for base duties overseas. Some of the latter were subsequently returned to New Zealand. The average length of service in the Middle East for each group was twelve months or more.
Accurate hospitalisation figures are not available to show whether there was an increase in dyspepsia after the campaigns of Greece and Crete. It is probably significant to note that cases increased suddenly in July 1942 when 2 NZ Division, which had been in Syria, joined the Eighth Army, which had its back to the wall at El Alamein after the fall of Tobruk. This increase persisted until July 1943, by which time victory had been won in North Africa and long-service personnel were proceeding to New Zealand on furlough. Available records show the regimental units from January 1943 onwards, and it is to be noted from these that there was an undue proportion of cases of dyspepsia from base units. Probably a number of these were graded men who were re-hospitalised.
A very common cause of persistence of symptoms in graded men at Base was uncongenial work. Recommendations made by medical boards in regard to suitable work were not always implemented.
In Italy the number of cases of dyspepsia admitted to hospital remained steady and was not unduly large, the only noticeable increase being in December 1944, the final winter of the war, when the static warfare and frustration probably played their part.
Very large numbers were admitted to medical units with some type of digestive disorder, often minor in nature, and a large proportion of these were treated in field medical units and discharged direct to their units. Records show that the total such were 2768 in 1943, 3155 in 1944, and 2707 in 1945.
|Admitted to Hospital, 1941–45||Invalided to NZ, 1940–45|
|Dyspepsia (nervous and functional)||153||28|
In 2 NZEF (IP) there were 210 patients admitted to medical units for ‘peptic conditions’ from June 1943 to July 1944, and of these, 42 were returned to New Zealand and 71 graded for base duties.