War Surgery and Medicine
CHAPTER 18 — Dyspepsia
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.
The discussion of the clinical aspects of dyspepsia as experienced in 2 NZEF is largely based on the investigation of Major Riley in 1942, and observations made from time to time by Colonel Boyd, the Consultant Physician.
Causes of Dyspepsia
Depression, anxiety, fatigue, and suggestion played an important part in the production of dyspepsia. Separation from home, true or imagined infidelity, family sickness, financial worry, or just boredom and discontent readily interfered with digestion. Army food, though not well tolerated by the soldier with a dyspeptic tendency, was not generally an important factor. As the Consultant Physician commented in 1942, ‘Many cases of nervous dyspepsia are not due to army diet or “ulcer diathesis” but to army life and certain psychological factors.’ The nervous strain of battle affected a few, and some men developed acute symptoms, such as retching or vomiting, during a battle.
Riley compared the ulcer (and ulcer-like) group with the nervous group. Just over a third of each group smoked more than twenty cigarettes daily, but only 10 per cent in each group admitted that they took more than an occasional alcoholic drink. A family history of dyspepsia was frequent in each group, and this affected a man in two ways. It provided him with a constitutional tendency to dyspepsia, with or without ulceration, and it also meant that he was surrounded in his early impressionable years by a stomach-conscious family. As one passed from the ulcer to the nervous group the influence of constitution gave place to that of environment. In the neurotic group depression, sleeplessness, and loss of appetite led to a loss of weight and energy. Food did not seem to be ‘digested properly’; the soldier told his friends that he had ‘no energy’. Sympathetically they suggested that he must have ‘a gastric stomach’. The unhappy fellow eagerly clutched at this hint of escape from his troubles, and after frequent calls at the Regimental Aid Post he eventually set out on the path that led to X-rays, test meals, and repeated admissions to hospital.
Pain was the chief symptom, although in the nervous group complaint of vomiting was just as frequent. Assessment of pain was page 625 difficult as it depends on the subjective sensibility, and the neurotic always tended to exaggerate his symptoms. In the ulcer and the ‘ulcer-like’ groups, pain was described as burning, aching, or gnawing. In the nervous group it was variously described as burning, aching, dragging, stabbing, pressing, sinking, cramping, and knot-like. Some actually likened it to a ‘lump of ice’, others to ‘turning rollers’ or ‘rattling nails’. In the ulcer cases, both duodenal and pyloric, pain tended to come on two hours after a meal and to disappear immediately afterwards. In the ‘ulcer-like’ group the time interval after meals was often less than two hours, while in 51 per cent of the neurotics pain and meals had no constant relationship. In the nervous group the situation of pain was variable, e.g., near the umbilicus, over the whole abdomen, in the iliac fossae, or if it happened to be epigastric, right across the epigastrium. In most of the ‘ulcer-like’ cases and in all the ulcers pain was felt in one small area of the epigastrium. Periodicity was less common in the nervous group, many of whom complained of ‘constant pain’ or ‘pain every day’. Alkalies relieved only 37 per cent of the nervous cases, while some even complained that it aggravated their pain. Appetite tended to diminish as one passed from the ulcer to the neurotic group.
Although many patients, especially the neurotics, complained of loss of weight, undernourishment was evident in only a few.
Dyspeptics were not treated as outpatients during the period of Riley's investigations, but were all admitted to hospital for thorough investigation for an average period of seven to ten days. Rest was enforced and a milk diet given.
A test meal was given with specimens withdrawn every half hour. The stools were examined for occult blood after four days, and then a full radiological examination was carried out for the whole intestinal tract, the chest being screened at the same time. A further barium meal was given in ten days in cases of doubt.
Cholecystography, sigmoidoscopy, warm stool examinations, and ENT and dental examinations were made when thought fit. Phenobarbitone thrice daily was given to those with evidence of neurosis.
Peptic Ulcers: A typical history was the first necessity before diagnosis of ulcer was considered. Burning pain in the epigastrium, heart-burn, and water-brash were the usual complaints. Localised tenderness was uncommon and hyperaesthesia noted only twice. Radiological examination was the most important procedure, but patience and caution were both needed. Pyloric ulcer was shown by page 626 persistent deformity. Duodenal ulcer was diagnosed if a deformity in the bulb was seen to be constant in appearance and was present on re-examination after seven to ten days' rest and milk diet. Twice only was a niche seen. No cases had a five-hour residue. Hyperchlorhydria was present in 4 per cent of ulcer cases. A therapeutic test of some value was the satisfactory response to rest and diet made by ulcer patients.
Organic Dyspepsia:Under this heading were included cases of ‘ulcer-like’ dyspepsia, including gastritis, duodenitis, achlor-hydric, or hyperchlorhydric, dyspepsia, with negative radiological findings. Symptoms were similar to the ulcer group. A few showed some radiological abnormality such as duodenal spasm or rapid emptying of the stomach; 16 per cent hyperchlorhydria, 13 per cent hypochlorhydria, and 8 per cent had achlorhydria. They responded well to treatment in most cases, and loss of appetite was less frequent than in the nervous group.
Nervous Dyspepsia: This group comprised patients suffering from obvious anxiety or hysteria, whose symptoms were not like those of a case of peptic ulcer. The history was generally confused and contradictory. Retching and vomiting was a common feature. A personal or family history of nervous disorder was usually obtained, and the patient's facial expression revealed his state of anxiety. Barium meals revealed no abnormality apart from rapid emptying of the stomach in a few cases. Fourteen per cent had hyperchlorhydria, 2 per cent had hypochlorhydria, and none achlorhydria. Appetite was capricious or absent, and response to rest and diet rare. Sedatives and occupational therapy were more effective than diet.
A diagnosis of ‘reflex dyspepsia’ was not made in any case.
The average duration of symptoms in the three groups was 7 years, 4 years, and 4¾ years respectively, the individual range being from 6 months to 18 years.
The relative values of diagnostic criteria as they proved themselves in 2 NZEF in Egypt were discussed by Riley. These were stated to be (in order of importance):
Haemorrhage or perforation.
Response to treatment.
Occult blood test.
Haemorrhage and perforation need not be discussed.
A history given by a patient was not necessarily reliable, since the common dyspeptic symptoms were well known and not infrequently discussed by soldiers. However, a patient's story and his reliability as a witness had to be assessed together.
X-ray examination was subject to the limitations of the apparatus available. The radiologist, however, was satisfied that he could say with some degree of certainty that a given stomach or duodenum was not the site of a chronic ulcer.
Ulcer cases and ‘ulcer like’ dyspeptics made some response to treatment while the neurotics were unaffected by rest, diet, and alkaline therapy.
The value of this test depended to some extent on the mechanical skill of the operator. The nervous group had the least number of abnormal acid curves. Achlorhydria was found only in the ‘ulcer like’ dyspeptic group.
This test proved insufficiently sensitive due to poor reagents.
Response to Treatment
The ulcer cases lost their symptoms a few days after the commencement of treatment, and were then given four to six weeks' rest and diet with alkalies, belladonna, and olive oil. Sixty-eight per cent were subsequently returned to New Zealand. The remainder, since they already held a position at the Base as clerk, doctor, quartermaster, or hospital orderly, were regraded II and retained in the overseas force provided they could look after themselves. All of these Grade II men managed satisfactorily at least during the succeeding nine months.
‘Ulcer like’ dyspeptics in most cases responded to four to six weeks' gastric regime, though a number relapsed when returned to ordinary diet. One probable case of gastritis recovered after his antrum had been drained, and denture fitted, and his stomach lavaged daily for three weeks.
The type of case in which fatigue and general debility played an important part responded well to ten days' rest and light diet, followed by a change of surroundings at a convalescent depot.
The nervous cases were retained in hospital for a short time only, since prolonged hospitalisation led to further introspection and neurosis. After ten to fourteen days' rest, with sedatives, explanation, and encouragement, and if necessary two to three weeks at a convalescent depot, an attempt was made to return the nervous dyspeptic to his unit—if he had not previously been in hospital for the same complaint. The dietetic aspect was not stressed in these cases, for it had little influence on their well-being.
Nearly 50 per cent of the ‘ulcer like’ and nervous dyspeptics were eventually regraded. Regraded men included the patient who was classified as a hopeless neurotic from the beginning, the patient whose symptoms recurred during convalescence, and the patient who after returning to his unit was again evacuated to hospital. Some regraded men of all types improved while performing lighter duties under more favourable conditions at the Base, but it is probable that over half of them continued to have symptoms. A quarter of these men had eventually to be returned to New Zealand—though the follow-up was not complete—and this applied especially to the nervous dyspeptic whose longing for home, once he had been regraded as unfit for the field, became intensified. This state of mind was greatly aggravated by boredom and lack of congenial occupation. His complaints increased in variety and intensity until he was sent home. It was fortunate that we were able to evacuate men of this type, for not only did their suitable employment create a difficult problem, but they were a bad influence amongst the troops at the Base.
Grade I: ‘Ulcer like’ or nervous dyspeptics who showed marked improvement after hospital treatment, with or without a period at a convalescent depot.
Grade IA (temporary grading only): Radiologically negative dyspeptics who required prolonged treatment but who were likely to be fit within three months.
Grade II: The usual grading for base duties overseas. It included ‘ulcer like’ or nervous dyspeptics who made only slight improvement after hospital treatment, with or without a period at a convalescent depot; and men who, after one admission to hospital, were again evacuated from their units. It also included ulcer cases amongst men whose rank or occupation enabled them to look after themselves.
Grade III (returned to New Zealand): ‘Ulcer like’ or nervous dyspeptics with persistent symptoms, who had had repeated hospitalisation, and who were incapable of base duties. Some of these men would improve in New Zealand and be able to remain in the home forces.
Grade IV (returned to New Zealand): Haematemesis. Malaena. Perforation. Previously operated-upon stomach or duodenum. Radiologically proven ulceration in men who had no special position or suitable occupation. Such men were regraded as being unfit for military service.page 629
As a result of his investigations Riley strongly recommended that the indefinite and nervous dyspepsias should be retained in their units and treated by the RMO. In his opinion (and this was strongly supported by Colonel Boyd, Consultant Physician 2 NZEF) hospitalisation aggravated the position.
Medical examiners for war pensions in New Zealand saw several cases of active tuberculosis in men returned to New Zealand for nervous dyspepsia and in one diagnosed overseas as probably a gastric ulcer. Some of the nervous dyspepsia cases had developed duodenal ulcer, thus showing a neurotic predisposition to peptic ulcer. Many again were later proved to have chronic amoebiasis even when there had been no previous suspicion of this infection.
With the high incidence of peptic ulcer in the community the development of the disease in any overseas force was inevitable, however careful the initial medical examinations might be.
The importance of dyspepsia in returned service personnel is shown by the totals of disabilities recorded by the War Pensions Branch up to 31 March 1949: dyspepsia, 1655, duodenal ulcer, 1063; and gastric ulcer, 49.
Important aspects of the problem of dyspepsia in army administration may be summarised as follows:
Dyspeptics with a definite and confirmed history of dyspepsia should not be accepted in the Army for overseas service.
If accepted on a lower grade for Home service they should be posted so that they can have their meals at home.
In the Army every effort should be made to retain and treat a man in his unit, and consultation should be arranged at that level. If a man is evacuated to Base he seldom returns to his unit.
If the history and assessment of the patient warrants it a man should be returned at once to New Zealand without prolonged investigation and treatment at Base.