CHAPTER XII
Diseases of the Gastrointestinal Tract
Herrman L. Blumgart, M.D., and Louis Zetzel, M.D.
Napoleon's dictum concerning the relation between militaryeffectiveness and the gastrointestinal tract remains valid. An army stillmarches on its stomach, despite improvements in mechanized transportation inmodern warfare.
Before full mobilization of U.S. military forces, reportscame from British1 and Canadian2as well as from German3 sources, indicating theseriousness of disturbances of the gastrointestinal tract in both garrison andfield troops. British reports indicated that the chief cause of illness in theirexpeditionary force in France was dyspepsia. This term was used to include bothorganic and functional disturbances of digestion, with an incidence of pepticulcer of approximately 50 percent. Of all medical cases in large Britishhospitals, 20 percent were found to have dyspepsia.4In England, this high percentage was not reflected in the civilian population,although, during the period of large air raids,5there was an increase in the complications of peptic ulcer, such asperforation and bleeding. Although no definite statistics were availableconcerning the incidence of peptic ulcer among German military forces, severalobservers concluded that it had increased during 1942 and 1943.6In the population of Germany, in contrast to civilian England, there was anapparent increase in gastrointestinal disorders, as attested by the figures of16.2 percent of all admissions to one large Berlin hospital, compared to 6.5percent before the war.7
1Graham, J. J., and Kerr, J. D. O.: Digestive Disorders in the Forces. Brit. M.J. 1: 473-476, 29 Mar. 1941.
2Urquhart, R. W. I., Singleton, A. C., and Feasby, W. R.: The Peptic Ulcer Problem. Canad. M.A.J. 45: 391-395, November 1941.
3Geronne, A.: Ueber das Ulcus Pepticum im Kriege mit Bemerkungen zu seiner Pathogeneses und Therapie. Deutsche med. Wchnschr. 69: 121-126, February 1943 [Abstract in Bull. War Med. 4: 39, September 1943.]
4Tidy, H. L.: Dyspepsia in the Forces. Proc. Roy. Soc. Med. 34: 411-417, May 1941; also J. Roy. Army M. Corps 77: 113-122, September 1941.
5Stewart, D. N., and Winser, D. M. de R.: Incidence of Perforated Peptic Ulcer: Effect of Heavy Air-Raids. Lancet 1: 259-261, 28 Feb. 1942.
6See footnote 3.
7Br?hl, W.: Die Behandlung des Ulcus und der Gastritis im Kriege. Klin. Wchnschr. 21: 951-954, 24 Oct. 1942. [Abstract in Bull. War Med. 3: 338-339, February 1943.]
308
ORGANIZATION AND EARLY FINDINGS
In 1917, a committee from the Section ofGastroenterology and Proctology of the American Medical Association suggested toThe Surgeon General that a section of gastroenterology should be created in theDivision of Internal Medicine.8 Inaccordance with this recommendation, experienced gastroenterologists were soonassigned to the various base hospitals in the United States, and a section ofgastroenterology was included in the official tables of organization for generalhospitals. In 1940, this was amplified to include the authorization of agastroenterologist in all station hospitals with more than 800 beds. TheAmerican Medical Association's Committee on Military Preparedness, as well asthe American Gastroenterological Association, prepared lists of qualified menrecommended for active duty. However, the number of internists with specialtraining in gastroenterology thus made available was far from adequate to meetthe requirements.
Among registrants-The procedure of the examiningphysicians on selective service and Army induction boards was governed by MR(Mobilization Regulations) 1-9, issued by the War Department. The mountingincidence in Army hospitals of soldiers with organic digestive diseases, theonset of which antedated their military life, made it evident that during theearly period of mobilization registrants with disqualifying digestive disorderswere not being adequately screened. In the majority of cases, the historiesobtained were grossly inadequate. Some men, motivated by a desire to serveregardless of disqualifying disease, withheld medical data. Others, in spite ofa history of organic disease substantiated by hospital records, were told thatthe Army could make adequate provision for their disability in service.
In Army hospitals-In the Zone of Interior, stationhospitals, serving large groups of men in various phases of training shortlyafter induction, had approximately 3 to 6 percent of all admissions in thegastroenterologic section. Moreover, these figures did not include all thosewith gastrointestinal symptoms, since many with functional disorders wereadmitted to other sections of the hospital, such as the neuropsychiatric orgeneral medical sections. The vast majority of these men had not yet been incombat, but they were sufficiently far removed from civilian life to feel theimpact of the mental and physical problems involved in such a separation.Furthermore, a review of many studies from various Army hospitals in the UnitedStates soon disclosed that, in approximately 90 percent of patients with pepticulcer, either an actual diagnosis had been made before induction or the symptomswere so characteristic at the time of induction that the diagnosis should havesuggested itself to ex-
8Kantor, J. L.: Digestive Disease and Military Service, With Special Reference to the Medical Department of the United States Army. J.A.M.A. 120: 254-261, 26 Sept. 1942.
309
amining physicians.9 Someimprovement was brought about by directives making it possible for inductionboards to hospitalize, for a period not exceeding 3 days, any registrant who, inthe opinion of the examining physician, required special study of thegastrointestinal tract.
In discussing digestive disorders among British soldiers,Hurst10 suggested three subdivisions for thegastroenterologic section in an army hospital. Division A was to be a diagnosticward, where patients would be kept until the diagnosis was definitelyestablished; division B was to be reserved for patients suffering from confirmedorganic disease; and division C, for those with functional dyspepsia. Suchsubdivisions were found to be useful in Army hospitals and were generallyadopted where adequate facilities were available.11This distinction prevented possible alterations in a history of functionaldisease by a patient in contact with patients with organic disease. It preventedgroups who were being separated from the service from emphasizing to others theamount of secondary gain to be derived from the persistence of symptoms.
Evaluation of data-In evaluating the significance ofstatistics for organic and functional cases of dyspepsia derived from stationand from general hospitals, the differences in the sources of admission to thesetwo types of institution must be borne in mind. Until the facilities of generalhospitals in the United States were reserved for treatment of oversea casualtiesonly, these hospitals had served as the final point in the channel of evacuationin the Zone of Interior, and only those individuals offering special problems intreatment or administration were referred to them. Accordingly, patients withfunctional disorders were seldom seen in general hospitals. This distinction isreflected in a higher relative incidence of organic to functional disorders ofthe gastrointestinal tract in these hospitals.
In weighing the statistical evidence, variables in clinicalinterpretation must also be taken into account, particularly in the earlyreports.
There are many dissimilarities between medicalpractice in the Army and in civilian life, which alter the usual relationshipbetween patient and physician. These had to be borne in mind in evaluating thepatient's history and response to therapy, as well as in deciding his ultimatedisposition. The transition to military service proved extremely difficult formany medical officers. Throughout the physician's civilian career, theindividual patient had remained the center of his medical attention, and theestablishment of
9(1) Berk, J. E., and Frediani, A. W.: The Peptic Ulcer Problem in the Army. Gastroenterology 3: 435-442, December 1944. (2) Chamberlin, D. T.: Military Gastro-Enterology; The First Year. South. M.J. 36: 523-528, July 1943. (3) Flood, C. A.: Peptic Ulcer at Fort George G. Meade, Md. War Med. 3: 160-170, February 1943. (4) Kirk, R. C.: Peptic Ulcer at Fort Sill. Am. J. Digest. Dis. 10: 411-413, November 1943. (5) Loder, H. B., and Kornblum, S. A.: Duodenal Ulcer in a Large Army Camp; Incidence and Statistical Analysis. Mil. Surgeon 96: 492-497, June 1945. (6) Magnes, M.: A. Gastro-Intestinal Outpatient Service. Bull. U.S. Army M. Dept. 85: 99-103, February 1945. (7) Schildkrout, H.: Management of Dyspeptic Soldier in a Staging Area. War Med. 6: 151-157, September 1944. (8) Thomas, H. M., Jr.: Peptic Ulcer in the Army. South. M.J. 36: 287-291, April 1943. (9) Zetzel, L.: Experiences With Peptic Ulcer in an Army Station Hospital. Gastroenterology 3: 472-479, December 1944.
10Hurst, A.: Digestive Disorders in Soldiers. Am. J. Digest. Dis. 8: 321-323, September 1941.
11See footnote 9 (9).
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a definitive diagnosis, as an indispensablepreliminary step in treatment, was a constant goal. It was often difficult toadjust himself to the change engendered by the emergency, which emphasized therapidity with which the maximum number of soldiers might be restored to militaryeffectiveness, with necessarily less regard for the immediate effect upon theindividual.
The patient in military service was not ableto choose his physician but found himself under the care of a stranger whoseonly mark of proficiency in his eyes was the dubious one of rank. The young andinexperienced medical officer often reacted to this apparent lack of confidenceby ordering numerous investigations. In civilian practice, a patient'sresponse to various dietary regimens may be observed diagnostically withoutradically altering his occupation. But the soldier had to be hospitalized forsuch studies, at the risk of impairing his eventual military effectiveness. Themedical officer soon became aware of the greater responsibility imposed upon himby his authority to make radical changes in the patient's environment, even tothe extent of returning him to civilian life. He learned to rely upon anadequate history and physical examination, ordering special studies when thesewere indicated by the clinical evidence.
To some extent the relative incidence, in the hospitalcensus, of organic to functional disturbances of the gastrointestinal tract,varied with the clinical acumen of the examining physician. As this wassharpened by experience, the variable factor was correspondingly reduced.
PEPTIC ULCER
Incidence
Many of the factors influential in initiating symptoms ofpeptic ulcer could be found in the various aspects of Army life.12In susceptible persons, a combination of factors-physical exhaustion,overt anxiety, and irregular meals of unpalatable food, plus a rebelliousattitude caused by forced idleness-produced the aberrations of gastricphysiology associated with the clinical picture of peptic ulcer. On the basis ofavailable studies, however, the incidence of peptic ulcer in the Army was inlarge part a reflection of the incidence of this disorder in the adultpopulation13 (table 60). It has been noted (p.308) that, in approximately 90 percent of patients with ulcer first seen instation and general hospitals in the United States, the symptoms antedated thepatient's induction into the service. Accordingly, these statistics cannot beinterpreted as evidence against the thesis that the emotional problems andphysical hardships of Army life, at least for troops in the Zone of Interior,were insufficient to produce symptoms of ulcer in most men, except those sopredisposed during their civilian existence (see pp. 313-317).
After many of the patients with ulcer had been eliminatedduring the various phases of training leading to oversea duty, it was notsurprising that in the combat zone the percentage of those with "old"ulcers dropped to 50 percent of the total number with ulcer. Although theo-
12See footnote 9 (9), p. 309.
13Wolf, S., and Wolff, H. G.: Evidence on the Genesis of Peptic Ulcer in Man. J.A.M.A. 120: 670-675, 31 Oct. 1942.
311
[Rate expressed as number of admissions perannum per 1,000 average strength]
Area and year |
| Stomach ulcer | ||
| Rate | Number of cases | Rate | |
| 1937-41 |
|
|
|
|
Total areas | 4,606 | 2.06 | 907 | 0.41 |
| 1942-45 |
|
|
|
|
Continental United States | 49,979 | 3.39 | 4,709 | 0.32 |
Overseas | 13,774 | 1.28 | 1,465 | .14 |
|
| 63,753 | 2.50 | 6,174 | 0.24 |
retically all of these should have been rejected beforeembarkation, such a goal could only be approximated, since many either had mildsymptoms or had concealed them. According to a survey conducted in MTOUSA(Mediterranean Theater of Operations, U.S. Army), the incidence of peptic ulcerfrom September 1944 to April 1945 was 2.04 per 1,000 per annum, or only 1 per1,000 whose symptoms first came on after induction.14 If one is to evaluateproperly the effect of Army life-especially under field and combat conditionsoverseas-in the production of peptic ulcer, it would be useful to compare thisfigure of 1 per 1,000 with that for ulcer in a similar age group in civilianlife, such as registrants for selective service between the ages of 21 and 36.Among 19,923 registrants, of whom all but 2.1 percent were in this age group,4.4 per 1,000 were rejected for peptic ulcer.15Since this statistical sample of registrants covers a period (November1940 through May 1941) when many cases escaped detection before induction, thisfigure (4.4 per 1,000) is probably too low, but it is, nonetheless,conspicuously higher than the incidence (1 per 1,000) of ulcers first manifestedduring military service. It should be noted also, in making this comparison,that there was a lack of reliable data about the interval of time during whichthe civilian registrants developed their ulcers.
During World War I, from 1 April 1917 to 31 December 1919,the reported incidence of peptic ulcer among all the troops was only 0.68 per1,000 per annum.16 Better diagnostictechnique subsequently made
14Report, Head, D. P., Wilen, C. J. W., and Fradkin, N. F., to Surgeon, MTOUSA, subject: Survey of the Peptic Ulcer Problem in MTOUSA, 1943-45.
15Analysis of Reports of Physical Examination: Summary of Data From 19,923 Reports of Physical Examination. Medical Statistics Bulletin No. 1, National Headquarters, Selective Service System, Washington, D.C., 10 Nov. 1941.
16The Medical Department of the United States Army in the World War. Washington: Government Printing Office, 1925, vol. XV, pt. 2, p. 578.
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available probably contributed to the apparent increase inincidence in World War II (table 60).
One of the most intensive surveys was that made in theMediterranean theater from 1943 to 1945. The diagnosis was peptic ulcer in 0.54percent of dispositions made on 272,026 patients in 11 general hospitals. Thisis in contrast to the average incidence of 3.5 percent of the total number ofadmissions to general hospitals in the Zone of Interior. Of 211,534 dispositionsmade in 21 station hospitals in the Mediterranean theater, 0.27 percent were forpeptic ulcer.
In examining patients with complaints referable to the upperquadrant of the abdomen, many variable factors might be expected in clinicalinterpretation and roentgenographic confirmation. Nevertheless, the reportedpercentages of peptic ulcer found were remarkably constant. In large stationhospitals in the United States, the average was 10 percent, varying from 7.2 to12.9 percent. For reasons previously mentioned, the incidence of peptic ulcer ingeneral hospitals in the Zone of Interior was much greater-approximately 30percent of patients with complaints referable to the upper quadrant of theabdomen. The corresponding figures for station and general hospitals in theMediterranean theater were 5.9 and 10.2 percent, respectively (p. 322). Thesefigures are strikingly similar to those reported by Eusterman and Balfour17who found 13 percent of ulcers among 16,000 civilian patients whosegastrointestinal symptoms warranted roentgenographic examination.
During the North African campaign, hospital staffs werecommonly impressed by a higher incidence of peptic ulcer than was subsequentlyfound in the entire theater. This may have been caused by the poor dietsprevalent during the early stages of this campaign, but more probably itreflected the poor screening of men for shipment overseas in the early days ofthe war. In support of this opinion were the findings of Halsted and Weinberg18at the Fifth U.S. Army Gastrointestinal Clearing Center (p. 318) in Italybetween 1944 and 1945, showing an incidence of peptic ulcer of only 3.4 percentof 183 combat infantrymen with chronic epigastric distress. At this later date,screening before embarkation had been greatly improved, and the men sent intocombat represented a better selected group.
Diagnostic Techniques and Criteria
History and roentgenograms.-The diagnosis of pepticulcer was usually made on the basis of a characteristic history, favorableresponse to a proper therapeutic regimen, and confirmatory roentgenographic evi-
17Eusterman, George B., and Balfour, Donald C.: Stomach and Duodenum. Philadelphia: W. B. Saunders Co., 1935, p. 259.
18Halsted, J. A., and Weinberg, H.: Peptic Ulcer Among Soldiers in the Mediterranean Theater of Operations. New England J. Med. 234: 313-320, 7 Mar. 1946.
313
dence of an actual niche or persistent deformity in thestomach or the duodenum. The typical history of dull, gnawing epigastric pain,occurring from 30 to 90 minutes after meals, frequently waking the patient fromhis sleep, relieved by food, periodic in type, with remissions of variablelength, was obtained in approximately 80 percent of patients.19An atypical history was usually obtained in younger soldiers who had hadsymptoms of relatively short duration. The longer history of ulcer, the moreclassical were its features. Repeated hospitalization often resulted in thepatient's history assuming a more typical form, possibly on the basis offrequent discussion with patients with proved ulcer. Therefore, unless thehistory was taken very early in the course of the disease, and immediately afteradmission to the hospital, its significance was dubious unless roentgenographicconfirmation was available. For this reason, roentgenographic evidence wasconsidered indispensable in most groups in which diagnosis of peptic ulcer wasmade.
Laboratory data.-The advisability of doing gastricanalyses on all patients with digestive complaints was questioned by manyobservers.20 In general, this procedure was notconsidered worth the effort unless there was roentgenographic evidence of agastric ulcer; under this circumstance, the repeated absence of freehydrochloric acid after the administration of histamine would constitute strongevidence against the benign nature of the lesion. Otherwise, the degree of theacidity appeared to be of no significance in the diagnosis or the treatment ofpeptic ulcer. Gastric analysis, however, was defended by others21who believed that such an analysis, adequately performed, furnishedinformation on gastric motility and on the presence of parasites in the gastricsediment.
Unless properly interpreted in relation to the clinicalpicture and the antecedent diet, the routine test for blood in the stools oftenled to unnecessary and prolonged hospitalization with increased anxiety on thepart of the patient, which intensive investigation and subsequent negativefindings often failed to allay.
Clinical Response-Psychogenic Factors
All reports, with one exception,22on patients with peptic ulcer treated
19(1) See footnote 9, p. 309; footnote 13, p. 310; footnotes 14, 15, and 16, p. 311; footnotes 17 and 18, p. 312. (2) Rush, A.: Gastrointestinal Disturbances in Combat Area; Preliminary Observations on Peptic Ulcer. J.A.M.A. 123: 389-391, 16 Oct. 1943.
20See footnote 9 (4) (5) (9), p. 309; footnote 14, p. 311; footnote 18, p. 312; and footnote 19 (2).
(2) Alvarez, W. C.: What Value Has Gastric Analysis? Gastroenterology 1: 534-536, May 1943. (3) Rosenak, B. D., and Foltz, L. M.: Digestive Diseases in a Station Hospital Overseas: Observations Over a Two-Year Period, Gastroenterology 4: 213-227, March 1945. (4) Schindler, R.: Gastroenterology in Army; Methods of Examination and Disposition of Cases. War Med. 2: 263-276, March 1942; correction 2: 504, May 1942.
21(1) Berk, J. E.: The Case for Gastric Analysis in Military Hospitals, Gastroenterology 1: 1064-1065, November 1943. (2) Chamberlin, D. T.: Gastric Analysis in an Army Hospital. Gastroenterology 1: 533-534, May 1943.
22See footnote 9 (3), p. 309.
314
either in the United States or overseas showed a satisfactoryresponse to treatment.
Two groups of patients, in each of whichapproximately 10 percent had failed to respond well to the usual regimen, werestudied, one by Cheney23the other by Gianelli and Bellafiore.24Most of the patients became asymptomatic for the first time on a diet towhich had been added eggs, butter, peanut butter, lettuce, watercress, parsley,broccoli, romaine, and avocadoes-all foods said to be rich in anti-ulcerfactor. This anti-ulcer factor was designated vitamin "U."
In general, the response to treatment was so rapid and souniform that it served as one of the most important criteria in the differentialdiagnosis of peptic ulcer from functional dyspepsia. This prompt response is notin itself, however, evidence against the possible influence of psychogenicfactors on the activity of an ulcer. When a soldier was admitted to a hospital,although the change in dietary management may have been the only tangibleprescription in the physician's order book, there were many other changes fromthe conditions of his previous environment, including physical rest, relief fromstrict field discipline, and the knowledge that the most important hurdle torehabilitation had been taken with the commencement of medical care.25
In the various theaters of World War II, there was affordedan opportunity to study the personality of patients with organic and functionaldyspepsia and to evaluate the influence of the different aspects of theirmilitary life on the initiation or the aggravation of symptoms. The fact that inthe Zone of Interior the symptoms of peptic ulcer had originated during civilianlife in approximately 90 percent of the patients makes it easy to understandthat those individuals differed very little from the usual patients with ulcerseen in civilian life. In contrast, the patient with ulcer who was first seenoverseas may well have been an individual with an entirely different personalityand physical constitution, since he had previously withstood the rigors ofcivilian life and life with the Army in the Zone of Interior without developing,or without admitting, symptoms of peptic ulcer.
Comparative studies.-A study of 200 consecutivepatients with ulcer was conducted at the 6th General Hospital, Casablanca, inthe North African theater, between March 1943 and January 1944, in an effort todetermine whether the nervous tension of military life was a factor in theoccurrence of the course of the disease.26These 200 patients represented one-third of all patients admitted to thishospital with digestive complaints during that period. Such a high rate ofulcers was explicable by the fact that the 6th General Hospital functioned as afinal point in
23Cheney, G.: Peptic Ulcer and Nutrition. Mil. Surgeon 95: 446-454, December 1944.
24Gianelli, V. J., and Bellafiore, V.: Fundamental Importance of Diet in the Treatment of Peptic Ulcer in an Army General Hospital, With Special Reference to Vitamin "U" Therapy. M. Clin. North America 29: 706-713, May 1945.
25See footnote 9 (9), p. 309.
26See footnote 18, p. 312.
315
the chain of evacuation of Army personnel from overseas tothe Zone of Interior and thus received a large quota of patients with ulcer inthe North African theater. Later in 1944, the 6th General Hospital was moved toRome, Italy, and it then received a different type of evacuee-one who was onlya few days removed from the front. At that time (between 1 July and 1 November1944), only 8 percent of the chronic dyspeptics were found to have ulcers.
The patient with ulcer, in the series of 200 cases, rarelyvolunteered information regarding the degree of his epigastric pain and seemedunconcerned with other somatic complaints. He was found to be aggressive,independent, and often anxious to return to duty after his original discomforthad been relieved. Only in response to direct questioning was a history obtainedand then given in succinct, clear-cut fashion without elaboration. Admittedly,this examination of the patient's personality was superficial from thepsychiatric point of view and more extensive investigation might well havedisclosed important neurotic features. However, the observations are comparable,and the results in striking contrast, with observations made on functionaldyspeptics, which were based on the same criteria. Only 5 percent of the 200patients in this particular study overseas demonstrated definite psychoneurosisin association with peptic ulcer. This figure corresponds closely to the results(4.2 percent) obtained in the study of patients with peptic ulcer in theMediterranean theater as a whole between 1943 and 1945.27
It should be noted that aside from theseobservations in which a special effort was made to study the association of thetwo conditions,28 it is probable that any statistics gleaned fromhospital records or disposition boards did not show the true incidence of thisassociation, since there was a tendency on the part of ward officers to omitmention of functional disorders in the presence of well-established organicdisease.
The patient with ulcer seen in the United States presented onthe whole a totally different picture with reference to any associated neurosis.Flood's29 figures of definite overt anxietyand psychoneurosis in at least 50 percent of his patients were fairlyrepresentative of findings in station hospitals. Again, in one large stagingarea in the United States, psychoneurosis was found in 23 percent of patientswith ulcer.30
The objective data-Thus, in men in whom pepticulcer first appeared or became troublesome during military service, there was nostriking correlation found between the organic disease and the psychopathicdisorders. As to the incidence of ulcer under combat conditions, it has beennoted (p. 311) that, in the Mediterranean theater from September 1944 to April1945, it was only 1 per 1,000 in whom symptoms were first manifested afterinduction. Again, from 1943 to 1945, peptic ulcer
27See footnote 14, p. 311.
28See footnote 18, p. 312.
29See footnote 9 (3), p. 309.
30See footnote 9 (7), p. 309.
316
accounted for 0.54 percent of dispositions of patients from11 general hospitals and 0.27 percent of dispositions from 21 station hospitalsin the Mediterranean theater. Moreover, the incidence of complications duringmilitary service was remarkably low, as reported from station hospitals, both inthe United States and overseas. The average figure of many reports indicated theoccurrence of gross hemorrhage or perforation in approximately 4 percent ofpeptic ulcers.31 In generalhospitals, the incidence of these complications was two to three times as highbecause of the selective nature of their patients.32
No radical departure in treatment ofcomplications was introduced; thus for bleeding, conservative measures-such asgradual increases in a strict Sippy diet or various modifications of a fullMeulengracht diet-were employed with excellent results. The mortality forperforated ulcers was very low because, undoubtedly, a select group of patients-inrelation to their general physical condition and the ready availability oftreatment-was involved.
Evaluation of evidence.-The reason advanced by mostpatients for the onset or the recurrence of their digestive symptoms wasinability to tolerate Army rations. In many instances, however, these symptomsactually began at the port of embarkation or while the men were beingtransported overseas, at a time, that is, when their food was satisfactory bothin quality and in quantity. Many of the men ate field rations without developingcomplaints under conditions of oversea activity, until they experiencedadditional strain, such as repeated air raids.
The high incidence of ulcer among base troops, as comparedwith men recently in combat, in part indicates the effect of frustration andregimentation, with frequent periods of inactivity. In 70 percent of thepatients seen by Halsted and Weinberg (p. 312), a definite correlation wasestablished between aggravation or recurrence of symptoms and the increasednervous tension associated with embarking for overseas. The important effect ofsuch a projected journey upon the incidence of peptic ulcer was suggested by thestudies made at a large staging area where men were observed in the final stepsof their preparation for duty overseas.33 Inthis group was recorded the highest percentage in any American series of pepticulcer-34 percent in patients with digestive complaints.
Summary.-There is, thus, no overwhelminglyconclusive evidence of psychogenic factors in the initiation or exacerbation ofpeptic ulcer during oversea service. However, the possible influence of suchfactors is not ruled out. In less selected groups of men, in the Zone ofInterior, there was a high incidence of peptic ulcer under conditions offrustration and
31(1) See footnote 9 (3) (4), p. 309; footnote 14, p. 311; and footnote 18, p. 312. (2) Annis, J. W., and Eldridge, F. G.: Military Gastroenterology. South. M.J. 36: 791-798, December 1943.
32(1) See footnote 9 (1), p. 309. (2) Chamberlin, D. T.: Peptic Ulcer and Irritable Colon in the Army. Am. J. Digest. Dis. 9: 245-248, August 1942. (3) Chamberlin, D. T., and Wallace, W. C.: Perforated Peptic Ulcer in an Army General Hospital. Mil. Surgeon 92: 193-196, February 1943. (4) Harrell, W. B., and Wilson, R. O.: Ruptured Peptic Ulcer Among United States Troops in Panama (Report of 10 Cases). Mil. Surgeon 96: 336-342, April 1945.
33See footnote 9 (7), p. 309.
317
anxiety and a high incidence of recurrence or aggravationunder the strain of embarkation. On the other hand, men who had weatheredinduction, Army life in the United States, and transport, before presentingevidence of ulcer, may well have been, as they seemed to be at clinicalexamination, of a type more resistant to psychological stress. Nevertheless, asevidence of peptic ulcer did appear in them under the strains of combat, itcannot be assumed that the psychogenic element was completely absent, butprobably in such men a more severe strain was required as the precipitatingfactor. These considerations had to be taken into account in separating such menfrom service, or in giving them special assignments.
Disposition
With very few exceptions, once the diagnosis of peptic ulcerwas established, these patients were considered to be totally and permanentlyunfit for any further military service and were discharged for physicaldisability (table 61). An occasional exception was made in the case of highlytrained individuals with special skills, if facilities were available to securethem proper diet. Some question had been raised concerning the advisability ofsuch a general rule, since it often resulted in the separation from service ofindividuals who were extremely able, aggressive, and ambitious, while a greaternumber of men who had functional complaints without organic basis, and wereconsiderably less effective soldiers, were often retained. Halsted in particularadvocated the retention in a limited service capacity of the well-trainedsoldier who had proper morale and a desire to remain in the Army.
Although some such individuals might properly have beensalvaged, patients with ulcer must be regarded as subject to exacerbations ofsymptoms when some untoward element is introduced into their environment, andthe prolonged hospitalization required by such symptoms made further attempts atservice applicable to only a very few (table 62). This, at least, was theexperience with those patients in whom the diagnosis was established while inthe Zone of Interior, representing, as they pre-
[Preliminary data based on sample tabulationsof individual medical records]
Type of disposition |
| Ulcer of stomach |
Death | 0.2 | 1.3 |
Disability discharge | 75.1 | 53.8 |
Return to duty | 22.3 | 43.9 |
Other | 2.4 | 1.0 |
318
TABLE 62.-Average number of days lost peradmission for peptic ulcer, 1945
|
| | | | |
With obstruction | 108 | With obstruction | 139 | |
Without obstruction | 65 | Without obstruction | 74 | |
| ||||
| With perforation | 92 | With perforation |
| 96 |
sumably did, the average patient with ulcer seen in civilianlife.34 Those whose ulcers werefirst manifested under field conditions overseas may well have been moresuitable for modified service.
Head, Wilen, and Fradkin (p. 311), on the basis of theirsurvey in the Mediterranean theater, were so impressed with the superior qualityof the average patient with ulcer seen overseas that, influenced by the mildnessof the disease and the relatively low incidence of complications, theyrecommended further trial of duty in exceptional cases during an acute manpowercrisis. However, their selections for such duty had to meet the followingcriteria: (1) Complete relief of symptoms while on a regular diet after apreliminary treatment with a bland diet; (2) absence of complications and otherdiseases, such as psychoneuroses and anxiety states; (3) absence ofroentgenographic evidence of activity after therapy; and (4) assignment tononcombat unit organizations. They were particularly struck with the resultsobtained during the early part of the Italian campaign when, because of amanpower crisis, 54 patients with ulcer who had met the criteria just listedwere returned to duty. During a subsequent period of observation, averaging 9?months, only eight patients (15 percent) required further hospitalization.
The recommendation had been made that radical surgery beperformed on naval personnel whose ability made them particularly valuable tothe Navy35 and whose ulcers developed duringservice. Such procedures, however, were not generally resorted to among Armypersonnel; it was felt that, in the absence of complications that would bythemselves warrant surgery, it was impractical and of questionable value totreat patients by such an empirical method.
FIFTH U.S. ARMY GASTROINTESTINAL CLEARING CENTER
The gastrointestinal clearing center was organized by orderof the surgeon of the Fifth U.S. Army and functioned in Italy from 23 October1944 to 23 April 1945 under the direction of Maj. (later Lt. Col.) James
34See footnote 9 (1) (2) (9), p. 309; and footnote 31 (2), p. 316.
35Montgomery, H., Schindler, R., Underdahl, L. O., Butt, H. R., and Walters, W.: Peptic Ulcer, Gastritis and Psychoneurosis Among Naval Personnel Suffering From Dyspepsia. J.A.M.A. 125: 890-894, 29 July 1944.
319
A. Halsted, MC.36 Itwas instituted to counteract the loss of effective manpower resulting fromoverhospitalization of men with psychosomatic disorders. Patients were sentdirectly to the clearing center instead of being sent to base hospitals in astream of evacuation moving farther and farther from the front.
The pivotal men in this organization were an experiencedclinician, a gastroscopist, a trained psychiatrist, and a competentroentgenologist. As soon as a diagnosis of organic disease seemed probable, thepatient was transferred to a base hospital for further disposition. In the eventof overt psychoneurosis, the psychiatrist made the recommendation fordisposition. All mild functional cases were returned to duty without anyunnecessary delay, but not until they had been given the benefit of a thoroughbut prompt examination and discussion.
One group of 113 patients with chronic dyspepsia was studiedintensively by means of history, physical examination, gastroscopy,gastrointestinal roentgenograms, and neuropsychiatric consultations. Amongthese, only four (3.5 percent) were found to have peptic ulcers. Of theremaining 109 patients, 41 percent showed slight to moderate abnormalities ofthe gastric mucosa on gastroscopic examination. In six patients, an ulcer wassuspected from the history and the physical examination, but none was found.Although typical symptoms were found by Halsted and Weinberg in only 72 percentof proved cases of peptic ulcer in another series of 200 cases (p. 314),roentgenographic and gastroscopic examinations in this group revealed no ulceror other gastric lesions in any patient in whom it had not previously beensuspected clinically. Thus, it was shown that roentgenographic facilities werenot indispensable in making a diagnosis in a forward area.
Of 442 patients studied at the clearing center during 6months, 74 percent were returned to full duty, 11 percent to limited service,while 15 percent (including hepatitis, and doubtful cases, with no definiteevidence of organic disease nor of psychoneurosis) were sent to a base hospital.Over half (286 cases) were designated psychogenic dyspepsia. Of these, 79percent were returned to full duty and 15 percent to limited service, theaverage length of hospitalization being 7.8 days.
For comparison, there is the record of the 6th GeneralHospital, when it was removed from Casablanca to Rome, where 55 percent ofsimilar cases were returned to full duty, after an average hospital stay of 39days. Halsted could find no significant factor to account for the lowerpercentage except the longer hospitalization.
Contrasting both records with the earlier experience of the6th General Hospital in Casablanca, many factors could account for the highincidence of peptic ulcer found there (33 percent) and for the poor re
36(1) See footnote 19, p. 313. (2) Halsted, J. A.: Clearing Company for Gastrointestinal Disease. Bull. U.S. Army M. Dept. 88: 90-95, May 1945. (3) Halsted, J. A.: The Management of Patients With Gastric Complaints in the Army Area. M. Bull. Mediterranean Theat. Op. 3: 178-185, June 1945.
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sults of attempted rehabilitation. At that time, thishospital was a funnel of evacuation of such cases to the Zone of Interior; manyof the patients were base troops, who had been poorly screened during the earlywar period; others reached this hospital some weeks after leaving combat units.In Italy, the patients were for the most part combat infantrymen who werereceived on the day, or within a few days, of leaving their units.
Thus, experience had taught the value and the methods ofprompt diagnosis and prompt disposition. As demonstrated by the Fifth U.S. ArmyGastrointestinal Clearing Center, this was good therapeutics. Soldiers morewillingly returned to duty, and were less liable to relapse of psychogenicsymptoms, when they felt that their complaints had been given competent andthorough attention. Evaluation and management of cases were more effective bothfrom the medical and from the military standpoint.
FUNCTIONAL GASTROINTESTINAL DISORDERS
Incidence
Gastrointestinal symptoms without demonstrable lesions wereresponsible for great loss of effective manpower in World War II. Dyspepsia,along with its psychosomatic counterparts-backache, headache, arthralgia,myalgia, and functional cardiovascular symptoms-constantly challenged theskill and judgment of the Medical Corps. Of the psychosomatic disabilities,functional gastrointestinal disorders37 composed the largest single group. Asidefrom the emotional factors, the alterations in diet and regimen of lifefrequently induced digestive symptoms, particularly in new recruits andsubsequently among those on oversea rations.
The problem of dyspepsia or gastroduodenal disorders in WorldWar I was apparently less important, since there is almost no reference to themin the history of "The Medical Department of the United States Army in theWorld War." During the period between 1 April 1917 and 31 December 1919,the occurrence of "other diseases of the stomach," evidently includingdyspepsia, was reported as 31,491, a rate of only 0.26 per 1,000. Thesignificance of these statistics is confused, however, by the lack of uniformdiagnostic criteria. That the problem was greater than these figures indicatewas suggested by Kantor's report38 that,after eliminating those patients admitted for harboring intestinal parasites,more than one-third of all cases were found to be suffering from one form oranother of gastrointestinal neurosis.
37Includes dyspepsia, gastric neurosis, abdominal neurasthenia, disordered action of the stomach, and soldier's stomach.
38Kantor, J. L.: Experience With a Gastrointestinal Service in an Army Hospital. Mil. Surgeon 46: 507-513, 1920.
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Seeking dependable statistics on the overall incidence in the Army in theSecond World War, one finds that before 1944 dyspepsia as such was included inthe miscellaneous group "other diseases of the stomach." However,individual reports indicated the magnitude of the problem at variousinstallations in the Zone of Interior and overseas.
Thus, Annis and Eldridge39at the Station Hospital, Camp Blanding, Fla., stated that the vast problem offunctional gastrointestinal disease and psychoneurosis had been by far theoutstanding cause of admission to that hospital. The incidence of these gastricneuroses had fluctuated in accordance with age groups (rising when older menwere inducted, particularly those with dependents) and with the prevailing stateof hostilities (declining immediately after the attack on Pearl Harbor).
Pulsifer40 reportedthat gastrointestinal disorders were responsible for 45 percent of admissions tothe general medical wards of the Station Hospital, Camp Livingston, La. In 43percent of these patients, definite emotional causation was evident, and noorganic lesions were demonstrable. Of 100 consecutive patients who had beendischarged from the neuropsychiatric service, gastrointestinal complaints hadcaused the hospitalization of 48. Immediate discharge from the Army had beenrecommended for 82 of these 100 patients. The duration of the disablingpresenting symptoms was recorded as from childhood in 46 of the 82 patients, andaveraged 5 years in the remaining 36. Tidy41 reported that in 1941 Graham andKerr found that the history of symptoms in 80 percent of functional disordersantedated military service in the British forces, and he himself reportedsimilar figures for 1942.
An interesting and carefully conducted survey was reported bySkobba42 from the Lawson GeneralHospital, Atlanta, Ga. Of all the patients admitted to the gastrointestinalservice at this hospital up to 1 August 1942, one-third (137) had no evidence oforganic disease. These patients were subjected to roentgenographic examinationsof the entire gastrointestinal tract, gallbladder, proctoscopic and gastroscopicexaminations, gastric analyses, stool examinations, and neuropsychiatricconsultations. Of these 137 patients, 75 showed no evidence of anyneuropsychiatric condition. The remaining 62 had gastrointestinal symptoms thatwere related to psychoneuroses in 18, to a constitutional psychopathic state in33, and to mental deficiency in 11 patients. Of the enlisted men who wereadmitted as patients to the neuropsychiatric service, those having pain,vomiting, or diarrhea were studied. Patients with only vague gastrointestinalsymptoms were not included. There were functional gastrointestinal complaints in20 percent of the constitutionally psychopathic patients, in 27
39See footnote 31 (2), p. 316.
40Pulsifer, L.: Psychiatric Aspects of Gastrointestinal Complaints of the Soldier in Training. Mil. Surgeon 95: 481-485, December 1944.
41Tidy, H.: Peptic Ulcer and Dyspepsia in the Army. Brit. M.J. 2: 473-477, 16 Oct. 1943.
42Skobba, J. S.: Functional Gastro-Intestinal Conditions. South. M.J. 36: 528-533, July 1943.
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percent of the psychoneurotic patients, and in 20 percent ofthe mentally defective.
The magnitude of the problem of dyspepsia in an overseatheater was vividly portrayed by Head, Wilen, and Fradkin in the report of theirexperience in the Mediterranean theater (p. 311). In 11 general hospitals inwhich 14,451 roentgenograms of the upper gastrointestinal tract were taken,positive evidence of ulcer was found in 10.2 percent, or 1,747 patients. In 21station hospitals, in which 9,813 roentgenographic examinations were made, only5.9 percent were positive for ulcer. A rough comparison with experienceselsewhere is presented in table 63. It may be inferred that the differencebetween 100 percent and the percentages in this table denotes roughly the numberof patients with dyspepsia.
The true incidence of dyspepsia was not accurately portrayedby the foregoing figures; the actual occurrence was apparently far greater, fornumerous personnel with these symptoms were not hospitalized. These reportsindicated, however, that the problem was widespread and that, if more stringentdiagnostic criteria based on history and physical examination had been employed,many patients would not have been hospitalized and many others would not haveburdened the roentgenographic facilities of the Army installations.
TABLE 63.-Percentageof peptic ulcer in hospital patients with dyspepsia
Reports |
| Station hospitals |
| Percent | Percent |
Berk, Tilton General | 40 | --- |
Chamberlin, Lawson General | 31 | --- |
British (various reports) | 55 | --- |
German | 33 | --- |
Kirk, Fort Sill | --- | 12.9 |
Annis, Camp Blanding | --- | 10.0 |
Zetzel, Camp Berkeley | --- | 7.2 |
Rush, South Pacific | 19 | --- |
Mediterranean theater | 10 | --- |
Cumulative, 1943-45 | --- | 6.0 |
Clinical Manifestations of Dyspepsia: DifferentialDiagnosis
Symptoms.-The symptoms of functionalgastrointestinal disorders comprised numerous manifestations. Upper abdominaldistress, heartburn while eating or immediately thereafter, regurgitation ofacid, sensation of fullness, nervousness, fatigability, and anorexia werecharacteristic. Distress at night was rare. Ingestion of food only occasionallygave relief; indeed, it frequently caused exacerbation of symptoms. Occasionalvomiting was a frequent complaint. Characteristically, numerous other symptoms
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were described, as follows: Headache, pains in the chest,backache, burning sensation in the eyes, palpitation, weakness, and disturbedsleep. The symptoms in the great majority of men antedated entry into the Army,at times extending back to childhood. Exacerbations of the complaints wereoften related to periods of emotional stress and strain.
In evaluating such symptoms, a careful history and physicalexamination, with a psychiatric consultation when indicated, established areasonably accurate diagnosis in the great majority of cases without recourse tohospitalization for roentgenographic or other studies. For this, a soundpsychiatric orientation was required of the medical officer, and usuallysufficed. In the few doubtful cases, the opinion of a psychiatrist wasinvaluable and, by being so restricted, could be the more carefully considered.The psychodynamics of dyspepsia were excellently described by Halsted and alsoby Pulsifer (p. 321) who concluded that the clinician should be able todistinguish psychogenic disturbances from organic disease with fair accuracy bymeans of the history and physical examination alone.
Roentgenographic examination.-The vast number of soldierswith gastrointestinal symptoms obviously precluded complete laboratory androentgenographic examinations and these, indeed, proved to be of limited value.Accurate examination required not only the services of an experiencedroentgenologist but also elaborate equipment for spot films and othertechniques. Without these facilities, organic lesions would be missed ortransient fluoroscopic abnormalities might be taken for pathological lesions.In about 10 percent of the cases, however, reasonably accurate differentialdiagnosis between psychogenic and organic disease could not be made withoutgastrointestinal fluoroscopy. Among 113 consecutive patients with dyspepsia whowere given roentgenographic examinations at the Fifth U.S. Armygastrointestinal center, as part of an intensive clinical and gastroscopicstudy, Halsted reported that only 4 patients had an ulcer; these were correctlydiagnosed on the basis of the history and the physical examination.43Fromtheir history, six additional patients were believed to have ulcer, butroentgenographic studies were negative. In no instance, among another group of190 patients with dyspepsia who had had roentgenographic examination, was anulcer demonstrated when the clinical diagnosis was psychoneurosis. It thusappears that the diagnostic error in such cases is statistically insignificant,nor is it likely to be serious in itself in view of the low incidence ofexacerbations actually occurring during military service.
On the other hand, a thorough physical examination requiredbut little more time than a superficial one, and was of inestimable value. Signspointing to the diagnosis were frequently found, and if the diagnosis ofpsychogenic or functional disorder was finally made, the patient had thereassurance that serious disease had not been overlooked by a cursoryexamination.
43See footnote 36 (3), p. 319.
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In a station hospital in the Zone of Interior, Magnes44 foundthat 73 percent of the soldiers referred for hospitalization could besuccessfully diagnosed and treated in the outpatient service on the basis of acareful history and physical examination. The other 27 percent were fluoroscopedas ambulatory patients. Halsted, in his extensive experience, found that athorough history supported by the results of physical examination in 90 percentof his patients was adequate independently of other studies.
History.-There was no better index of the skill and wisdomof a medical officer than the quality of the history elicited from a patientwith gastrointestinal symptoms. Practically all neuroses expressed themselves inpart by "body language," and all organic disease imposed psychologicalproblems, in either case requiring sound clinical judgment. A history limited tothe presenting complaint usually wasted, rather than saved, time.
Some pitfalls in taking the history have been pointed out byRosenak and Foltz.45
There may be some slight variation from the so-called typicalulcer story which will suggest to the experienced physician that an ulcer is notapt to be present. The frequent occurrence of early morning pain is such aphenomenon. Alvarez had often warned that the ulcer patient does not presentthis symptom and it has been our experience that the dyspeptic soldier whocomplains of burning pain in the epigastrium upon arising even though he obtainsrelief from eating, probably has no ulcer.
Feelings of distress with varied pains and aches, but withoutpreeminence of one, were more characteristic of dyspepsia than of ulcer.
The presence or absence of gastrointestinal symptoms first incivilian life, then during the soldier's military service, plus the possiblerelation to stresses and strains were ascertained. When these symptoms continuedwith varied intensity but without real remission, they were more likely to bepsychogenic than organic. Symptoms of brief duration increased the probabilityof organic disease.
Halsted46 has summarized, as follows, theimplications of statistics for differential diagnosis:
Because of the low incidence of organic disease and the high incidence of neurosis among soldiers complaining of chronic gastric complaints, itis safe to adopt the following point of view in the diagnostic evaluation ofsuch patients in the Army area: If the symptomatology does not fit in with anyorganic disease, if the physical examination is negative, and if simple clinicalexaminations such as measurement of temperature, examination of urine, stool andblood count are all normal one should then disregard symptomatology and make apsychiatric appraisal. The answer will usually be found in this sphere. If onemakes an exhaustive search for an organic explanation of symptoms by prolonged medicalinvestigation harm will be done to the 70 percent of patients who havepsychogenic dyspepsia. Furthermore many men will be lost for further usefulmilitary service. The occasional diagnostic error which may be made is notlikely to be serious in the case of chronic stomach complaints among soldiers.
44See footnote 9 (6), p. 309.
45See footnote 20 (3), p. 313.
46Halsted, J. A.: Gastro-Intestinal Disorders of PsychogenicOrigin. Management of Forward Areas. Proc. Conference Army Physicians, CentralMediterranean Forces, 1945, pp. 131-134.
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Comparison of the symptomatology of peptic ulcer andpsychogenic dyspepsia, as tabulated by Halsted, is shown in table 64.
Response to treatment.-As has been pointed out (p. 314),the favorable response of the patient with peptic ulcer to dietary and antacidtreatment was in striking contrast to the characteristically poor response inthe functional dyspeptic. This response served as one of the most important,although insufficiently regarded, criteria of differential diagnosis.47 Thesymptoms of peptic ulcer nearly always abated in a few days, if the patient hadfrequent feedings and antacid medication, but the symptoms of a psychogenicgastric disorder usually were not materially influenced by such measures.
TABLE 64.-Differential diagnosis between peptic ulcer and psychogenic dyspepsia
|
|
|
| ||
| Pain | Dull ache from 1 to 3 hours after meals. | Burning, immediately after meals. | ||
| Night pain | Common | Infrequent. | ||
| Relief by food or alkali | Usual | Unusual. | ||
Vomiting | Uncommon | Common. | ||
Appetite | Good | Usually poor. | ||
Remissions | Present | Absent. | ||
| ||||
| Relief by hospital treatment | Usual | Rare. | ||
| Other somatic symptoms | Rare | Frequent. | ||
| Psychiatric features | Aggressive, independent, minimizes symptoms, no anxiety, socially successful. | Outwardly submissive, dependent, emphasizes symptoms, anxiety close to surface, maladjusted socially. |
Disposition
The central problem was concerned with whether or not theindividual patient with functional dyspepsia was of sufficient potential valueto the Army to warrant the effort and time expended for salvage. Functionalgastrointestinal disorders, including particularly the classic complaints ofdyspepsia, were frequently witnessed among new recruits. The manifoldpsychological adjustments as well as the rigid regimen and the change in dietwere important factors. Many men with transient problems of adjustment and theresulting vague gastrointestinal complaints were readily rehabilitated intouseful soldiers. In contrast, individuals who, in the course of their previouscivilian life, had such complaints for many years offered less promise. It wasnot surprising that the patients with the most intractable forms of dyspepsiahad symptoms long antedating their entry into the
47See footnote 9 (9), p. 309.
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service. They finally were of but little service to the ArmedForces, and many had to be released after varying periods of training.
New recruits who had such symptoms before they wereacclimated to Army routine could usually be dealt with satisfactorily in theirown units. Symptomatic treatment in the dispensary, reassurance, and other formsof psychotherapy safeguarded these individuals from fixation of their attentionon such diagnostic terms as gastritis, duodenitis, or even dyspepsia.Persistence of symptoms, in spite of therapy, suggested the desirability of moreintensive study of the emotional factors by a trained psychiatrist outside ofthe hospital. The possibility that dyspepsia was a manifestation of well-markedpsychoneurosis or of constitutional inferiority was kept in mind. In each case,the cardinal question was whether a person was fit for service as a soldier. Theanswer depended not only on the evaluation of the patient but also on extraneousconsiderations. Among these were the needs of the Army for manpower, theopportunities of placement for limited service, the soldier's specialcapabilities, and the need of the Army for his particular qualifications.
Divergent viewpoints were expressed regarding the generaladvisability of attempting to salvage the confirmed dyspeptic. Thus, Annis andEldridge48 stated: "Regarding functional dyspepsia as a whole, the Armyprovides neither the time, the environment, nor the facilities necessary toattempt what is at best the extremely difficult, and often unsuccessful, task ofrehabilitation."
On the other hand, certain carefully planned andwell-organized efforts to rehabilitate such patients were inaugurated.Goldbloom and Schildkrout49 at Camp Kilmer, N.J., organized a regimen for therehabilitation of the chronically dyspeptic soldier. One hundred patients werestudied and comprehensive investigations of the digestive and psychiatricsymptoms were completed in the hospital. The soldiers were then discharged forduty in various echelons of the camp but were brought regularly to thehospital for their meals. By followup studies and conferences, it was sought toimprove morale and arrive at a better understanding of each man's problems.Of the entire group of 100, 42 patients were classified as having dyspepsia. Ofthese, only 14 were placed on full duty, 21 were retained on the regimen, 3 weretransferred to a general hospital, and 4 were discharged from the Army.
It was evident, from a survey of common experience in theArmy, that no broad generalizations regarding disposition of all cases could bemade concerning a group that comprised such heterogenous conditions as wereincluded under the term "dyspepsia." The constitutionally inadequatehad to be dealt with on the basis of their fundamental and fixed inadequacyrather than on the basis of their superficial symptoms. More thorough
48See footnote 31 (2), p. 316.
49Goldbloom, A. A., and Schildkrout, H.: Dyspepsia Regimen; Method of Rehabilitation. War Med. 6: 24-26, July 1944.
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screening, earlier diagnosis, and swift disposition on thebasis of ineptitude or constitutional inadequacy-when indicated-would haveprevented much wastage of professional skill and facilities.
Summary
Briefly, then, one may say that, in Army experience withgastrointestinal disorders, the large percentage of patients without organicdisease but with poor morale, including those with definite psychoneurosis, wasin contrast with the small percentage of patients with peptic ulcer,particularly after those with preexisting lesions had been screened out.Although exacerbations of peptic ulcer were induced in some men under strains ofsufficient severity, the incidence was low, and the response to treatment good.
Gastrointestinal symptoms without demonstrable lesion causedgreat loss of effective manpower in World War II and comprised the largestsingle group of psychosomatic disabilities.
In such cases, those who responded favorably to symptomatictherapy and firm but understanding discussion of their problems, for the mostpart were the men who experienced symptoms soon after entering on active duty,during the period of becoming acclimated to Army diet and the new mode of life.Transient problems of adjustment with vague gastrointestinal complaints,occurring at later periods of active service, likewise responded favorably ifexcessive medical care and elaborate investigation were avoided.
On the other hand, the dyspeptic whose symptoms were thereflection of deeply rooted anxiety had to be regarded as a psychiatric problem,diagnostically and therapeutically, and disposition made accordingly. Patientsintermediate between these groups were frequently encountered. Decision in suchcases could be difficult and was often postponed for prolonged observation, withor without repeated trials at various duties.
GASTRITIS AND GASTROSCOPY
Such wide divergence of opinion existed regarding the incidence and significance of abnormal gastroscopic findings that the subject seems worth discussing in a separate section. Even the term "gastritis" was surrounded by confusion. Some authors designated abdominal distress as gastritis in the absence of ulcer or other organic disease although gastroscopy had not been performed. Generally, however, the word was used to refer to changes in the gastric mucosa visualized through the gastroscope. Such changes were estimated to occur in about 25 percent of all patients suffering from abdominal distress50 and were usually classified as (1) superficial, (2) atrophic, or (3) hypertrophic.
50See footnote 20 (4), p. 313.
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The clinical significance of the morphologic findings viewedthrough the gastroscope was not clear. Some observers regarded the mucosalchanges as organic disease and ascribed the patient's symptoms to theseabnormalities. Hurst (p. 309), for instance, stated that gastritis is an organicdisease as definite as ulcer and that it is most undesirable to confuse it withfunctional gastric disorders, which have no organic basis.
Extensive military experience led to the conclusion thatdefinite clinical syndromes could not be ascribed to the different types ofgastritis.51 Erosive or ulcerative gastritis and possible chronichypertrophic gastritis at times might produce symptoms, but no clear-cutclinical correlation was generally possible. Moreover, the limits of the normalvariations of the gastric mucosa had not been sufficiently established to permitaccurate appraisal of what was abnormal.
Even the gastroscopic description in pathological terms couldbe verified histologically in only about 50 percent of the cases.52 Thatthe gastroscopic findings were a reflection of a functional state was suggestedby the observations of Wolf and Wolff.53 With episodes involvinganxiety, hostility, and resentment, the mucosa became red, the acid productionwas sharply accelerated, and vigorous contraction began. With hypermotility andhypersecretion, the gastric mucosa became engorged and turgid, and the foldsbecame thicker and succulent, presenting the picture of hypertrophic gastritisas seen by gastroscopists.
The foregoing observation, which suggested that hypertrophicand other forms of gastritis could be temporary and functional, was in accordwith the experience of others. Fitzgibbon and Long54 found that 2 of 40healthy students, or 5 percent, had hypertrophic changes. Berk55 examined 50patients with upper abdominal distress diagnosed as psychoneurotic by competentpsychiatrists. All had failed to show abnormalities roentgenographically, andsome had therefore been given prior to admission, the diagnosis gastritis. Ongastroscopic examination, approximately 30 percent showed gastritis; if thosewho exhibited merely patches of the superficial variety were excluded, only 20percent showed chronic gastritis worthy of note. Berk concluded that no set ofclinical symptoms inevitably indicated the presence of chronic gastritis. Thesestudies were in accord with those of other observers.56
51See footnote 4, p. 307.
52Berk, J. E.: Trends and Shortcomings in the Approach toGastro-Intestinal Diseases; Review Based on Experience in an Army General Hospital. Pennsylvania M.J. 47: 897-901, June 1944.
53See footnote 13, p. 310.
54Fitzgibbon, J. H., and Long, G. B.: Gastroscopic Study ofHealthy Individuals; A Preliminary Report. Gastroenterology 1: 67-71, January1943.
55See footnote 52.
56(1) Ruffin, J. M., Brown, I. W., Jr., and Clark, E. H.: The Occurrence of Gastritis as Diagnosed by Gastroscopy in Gastric Neuroses. Am. J. Digest. Dis. 7: 414-417, October 1940. (2) Howard, J. T.: Gastroscopy and Use of Gastroscope in the Military Services. War Med. 3: 274-281, March 1943.
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A similar experience was reported by Cutler and Walther57 andfrom the Central Pacific Area.58
In one group 264 soldiers (average age 29) with upperabdominal complaints of variable duration (1 month to 17 years) weregastroscoped. X-ray examinations of stomach and duodenum were negative. Thestool examinations were negative. Cholecystography was made in 11 percent ofcases and was found to be negative.
1. 106 patients (40 percent) showed chronic gastritis.
2. 138 patients (52 percent) had normal gastric mucosa.
3. 13 patients (5 percent) revealed mucosal hemorrhage.
4. 7 patients (3 percent) had mucosal erosions.
Only a small number of the 40 percent with chronic gastritisrevealed the hypertrophic variety. These patients presented a pattern ofcomplaints very similar to those found in peptic ulcer. They were benefited byalkalis and antispasmodics.
The greater majority revealed the superficial and atrophictype of gastritis. It is interesting to note that clinically a conspicuousfeature was the lack of uniformity of digestive complaints. The symptoms were ofa bizarre nature, implicating several systems. Thus, nervous tremors, poorlylocalized headaches, dyspnea, precordial pain, giddiness, and arthralgias wereamong the common complaints. No correlation existed between the degree or extentof gastritis and the avowed incapacity of the soldier to perform duty. Thenature of the gastroscopic picture could not serve, therefore, as the onlyfactor in determining the ultimate disposition of the patient as to futureusefulness in the service.
Many of these cases of chronic gastritis were seen by theneuropsychiatrist and were reported to have a definite psychoneurosis.
A second group of 33 asymptomatic volunteers (average age 25)were gastroscoped and considered as controls. Only 3 showed a patchy mildatrophic gastritis; all others were normal.
A third group of 36 soldiers (average age 29) with positivefindings of duodenal ulcer were studied, 52 percent showed superficial, atrophicor a combined superficial and atrophic gastritis with duodenal ulcer.
From these observations, the following conclusions weredrawn:
1. Asymptomatic subjects may show evidence of gastric mucosalchanges by gastroscopy.
2. Chronic gastritis is much more prevalent in patients withchronic upper abdominal distress.
3. Apart from the hypertrophic group which clinicallysimulated peptic ulcer, the largest group of patients with chronic gastritisshowed no uniform symptom complex. Because of the frequency of associatedcomplaints unrelated to the gastrointestinal tract it was difficult to believethat the gastritis was the only etiologic factor.
4. A predominance of psychogenic factors was present in thisgroup; the possibility therefore exists that the changes in gastric mucosapoints to a more basic disturbance of psychiatric importance.
5. A useful guide to the general fitness of the "gastricsoldier" was preferably an accurate evaluation of the severity of thepsychogenic factors rather than the appraisal of the gastritis per se.
Of 22 patients, gastroscoped in a naval hospital, who hadchronic dyspepsia without ulcer, 11 had a normal gastric mucosa and 11 had someform of gastritis; 5 of these were classified as mild or insignificant.59 Psychiatric
57Cutler, J. G., and Walther, J. E.: The Significance ofChronic Gastritis in an Army General Hospital. Gastroenterology 5: 112-116,August 1945.
58History of Internal Medicine in the Central Pacific inWorld War II. [Official record.]
59See footnote 35, p. 318.
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evaluation revealed that 11 of the 22 had a marked neurosisand 6 a mild neurosis; 5 were normal, but it was noted that 2 of the latter werehigh strung and restless.
Annis60 and Gold61 each reported that about 35percent of patients with nonulcerative dyspepsia in Army installations in theZone of Interior showed definite gastroscopic changes.
Of considerable significance were the results (reported byHalsted) of a survey62 conducted by two internists, one of whom was a skilledgastroscopist, aided by a psychiatrist, a clinical psychologist, and aradiologist. A total of 109 patients with chronic nonulcerative dyspepsia wereexamined. Of these, 59 percent had a normal gastric mucosa; 26 percent showedslight abnormalities, consisting of redness and increased highlights; and 15percent showed more marked changes, with edema and adherent mucus. The changeswere regarded as signs of chronic superficial gastritis. In nine patients, spasmof the antrum or midbody was seen without changes in the mucosa. There were noinstances of hypertrophic or atrophic gastritis. Psychiatrically, no differenceswere noted between the group showing gastroscopic changes and the group with anormal mucosa. It was believed that the benign changes noted gastroscopicallywere circulatory in origin, the result of chronic anxiety.
Thus, in summary, a gastroscopy was not, in Army experience,an indispensable or even a necessary adjunct in the evaluation, clinicalmanagement, and disposition of patients with chronic or recurrent dyspepsia. Theprocedure proved to be helpful, however, under the same circumstances as incivilian life. Occasionally, it enabled the medical officer to reach a decisionas to the presence of a neoplasm or of a radiologically doubtful ulcer63 and,at times, to diagnose the source of an otherwise unexplained gastric hemorrhage.
60Annis, J. W.: Gastritis in Military Service.Gastroenterology 2: 85-92, February 1944.
61Gold, R. L.: Gastroscopic Findings in Patients WithDyspepsia at an Army Hospital. Gastroenterology 1: 254-257, March 1943.
62See footnote 36 (3), p. 319.
63See footnote 9 (2), p. 309.
