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Chapter XII

Contents

CHAPTER XII

Diseases of the Gastrointestinal Tract

Herrman L. Blumgart, M.D., and Louis Zetzel, M.D.

Napoleon's dictum concerning the relation between military effectiveness and the gastrointestinal tract remains valid. An army still marches on its stomach, despite improvements in mechanized transportation in modern warfare.

Before full mobilization of U.S. military forces, reports came from British1 and Canadian2 as well as from German3 sources, indicating the seriousness of disturbances of the gastrointestinal tract in both garrison and field troops. British reports indicated that the chief cause of illness in their expeditionary force in France was dyspepsia. This term was used to include both organic and functional disturbances of digestion, with an incidence of peptic ulcer of approximately 50 percent. Of all medical cases in large British hospitals, 20 percent were found to have dyspepsia.4 In England, this high percentage was not reflected in the civilian population, although, during the period of large air raids,5 there was an increase in the complications of peptic ulcer, such as perforation and bleeding. Although no definite statistics were available concerning the incidence of peptic ulcer among German military forces, several observers concluded that it had increased during 1942 and 1943.6 In the population of Germany, in contrast to civilian England, there was an apparent increase in gastrointestinal disorders, as attested by the figures of 16.2 percent of all admissions to one large Berlin hospital, compared to 6.5 percent 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.
7Brühl, 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 of Gastroenterology and Proctology of the American Medical Association suggested to The Surgeon General that a section of gastroenterology should be created in the Division of Internal Medicine.8 In accordance with this recommendation, experienced gastroenterologists were soon assigned to the various base hospitals in the United States, and a section of gastroenterology was included in the official tables of organization for general hospitals. In 1940, this was amplified to include the authorization of a gastroenterologist in all station hospitals with more than 800 beds. The American Medical Association's Committee on Military Preparedness, as well as the American Gastroenterological Association, prepared lists of qualified men recommended for active duty. However, the number of internists with special training in gastroenterology thus made available was far from adequate to meet the requirements.

Among registrants-The procedure of the examining physicians on selective service and Army induction boards was governed by MR (Mobilization Regulations) 1-9, issued by the War Department. The mounting incidence in Army hospitals of soldiers with organic digestive diseases, the onset of which antedated their military life, made it evident that during the early period of mobilization registrants with disqualifying digestive disorders were not being adequately screened. In the majority of cases, the histories obtained were grossly inadequate. Some men, motivated by a desire to serve regardless of disqualifying disease, withheld medical data. Others, in spite of a history of organic disease substantiated by hospital records, were told that the Army could make adequate provision for their disability in service.

In Army hospitals-In the Zone of Interior, station hospitals, serving large groups of men in various phases of training shortly after induction, had approximately 3 to 6 percent of all admissions in the gastroenterologic section. Moreover, these figures did not include all those with gastrointestinal symptoms, since many with functional disorders were admitted to other sections of the hospital, such as the neuropsychiatric or general medical sections. The vast majority of these men had not yet been in combat, but they were sufficiently far removed from civilian life to feel the impact of the mental and physical problems involved in such a separation. Furthermore, a review of many studies from various Army hospitals in the United States soon disclosed that, in approximately 90 percent of patients with peptic ulcer, either an actual diagnosis had been made before induction or the symptoms were so characteristic at the time of induction that the diagnosis should have suggested 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 Some improvement was brought about by directives making it possible for induction boards to hospitalize, for a period not exceeding 3 days, any registrant who, in the opinion of the examining physician, required special study of the gastrointestinal tract.

In discussing digestive disorders among British soldiers, Hurst10 suggested three subdivisions for the gastroenterologic section in an army hospital. Division A was to be a diagnostic ward, where patients would be kept until the diagnosis was definitely established; division B was to be reserved for patients suffering from confirmed organic disease; and division C, for those with functional dyspepsia. Such subdivisions were found to be useful in Army hospitals and were generally adopted where adequate facilities were available.11 This distinction prevented possible alterations in a history of functional disease by a patient in contact with patients with organic disease. It prevented groups who were being separated from the service from emphasizing to others the amount of secondary gain to be derived from the persistence of symptoms.

Evaluation of data-In evaluating the significance of statistics for organic and functional cases of dyspepsia derived from station and from general hospitals, the differences in the sources of admission to these two types of institution must be borne in mind. Until the facilities of general hospitals in the United States were reserved for treatment of oversea casualties only, these hospitals had served as the final point in the channel of evacuation in the Zone of Interior, and only those individuals offering special problems in treatment or administration were referred to them. Accordingly, patients with functional disorders were seldom seen in general hospitals. This distinction is reflected in a higher relative incidence of organic to functional disorders of the gastrointestinal tract in these hospitals.

In weighing the statistical evidence, variables in clinical interpretation must also be taken into account, particularly in the early reports.

There are many dissimilarities between medical practice in the Army and in civilian life, which alter the usual relationship between patient and physician. These had to be borne in mind in evaluating the patient's history and response to therapy, as well as in deciding his ultimate disposition. The transition to military service proved extremely difficult for many medical officers. Throughout the physician's civilian career, the individual patient had remained the center of his medical attention, and the establishment 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).


310

a definitive diagnosis, as an indispensable preliminary step in treatment, was a constant goal. It was often difficult to adjust himself to the change engendered by the emergency, which emphasized the rapidity with which the maximum number of soldiers might be restored to military effectiveness, with necessarily less regard for the immediate effect upon the individual.

The patient in military service was not able to choose his physician but found himself under the care of a stranger whose only mark of proficiency in his eyes was the dubious one of rank. The young and inexperienced medical officer often reacted to this apparent lack of confidence by ordering numerous investigations. In civilian practice, a patient's response to various dietary regimens may be observed diagnostically without radically altering his occupation. But the soldier had to be hospitalized for such studies, at the risk of impairing his eventual military effectiveness. The medical officer soon became aware of the greater responsibility imposed upon him by his authority to make radical changes in the patient's environment, even to the extent of returning him to civilian life. He learned to rely upon an adequate history and physical examination, ordering special studies when these were indicated by the clinical evidence.

To some extent the relative incidence, in the hospital census, of organic to functional disturbances of the gastrointestinal tract, varied with the clinical acumen of the examining physician. As this was sharpened by experience, the variable factor was correspondingly reduced.

PEPTIC ULCER

Incidence

Many of the factors influential in initiating symptoms of peptic ulcer could be found in the various aspects of Army life.12 In susceptible persons, a combination of factors-physical exhaustion, overt anxiety, and irregular meals of unpalatable food, plus a rebellious attitude caused by forced idleness-produced the aberrations of gastric physiology associated with the clinical picture of peptic ulcer. On the basis of available studies, however, the incidence of peptic ulcer in the Army was in large part a reflection of the incidence of this disorder in the adult population13 (table 60). It has been noted (p. 308) that, in approximately 90 percent of patients with ulcer first seen in station and general hospitals in the United States, the symptoms antedated the patient's induction into the service. Accordingly, these statistics cannot be interpreted as evidence against the thesis that the emotional problems and physical 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 so predisposed during their civilian existence (see pp. 313-317).

After many of the patients with ulcer had been eliminated during the various phases of training leading to oversea duty, it was not surprising 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

TABLE 60.-Admissions for ulcer of the duodenum and stomach in the U.S. Army, pre-World War II and World War II, by area and year, 1937-41 and 1942-45, respectively

[Rate expressed as number of admissions per annum per 1,000 average strength]

Area and year


Duodenal ulcer

Stomach ulcer


Number of cases

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


Total Army

63,753

2.50

6,174

0.24


retically all of these should have been rejected before embarkation, such a goal could only be approximated, since many either had mild symptoms or had concealed them. According to a survey conducted in MTOUSA (Mediterranean Theater of Operations, U.S. Army), the incidence of peptic ulcer from September 1944 to April 1945 was 2.04 per 1,000 per annum, or only 1 per 1,000 whose symptoms first came on after induction.14 If one is to evaluate properly the effect of Army life-especially under field and combat conditions overseas-in the production of peptic ulcer, it would be useful to compare this figure of 1 per 1,000 with that for ulcer in a similar age group in civilian life, 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.15 Since this statistical sample of registrants covers a period (November 1940 through May 1941) when many cases escaped detection before induction, this figure (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 manifested during 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 which the 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 per 1,000 per annum.16 Better diagnostic technique 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.


312

available probably contributed to the apparent increase in incidence in World War II (table 60).

One of the most intensive surveys was that made in the Mediterranean theater from 1943 to 1945. The diagnosis was peptic ulcer in 0.54 percent of dispositions made on 272,026 patients in 11 general hospitals. This is in contrast to the average incidence of 3.5 percent of the total number of admissions to general hospitals in the Zone of Interior. Of 211,534 dispositions made in 21 station hospitals in the Mediterranean theater, 0.27 percent were for peptic ulcer.

In examining patients with complaints referable to the upper quadrant of the abdomen, many variable factors might be expected in clinical interpretation and roentgenographic confirmation. Nevertheless, the reported percentages of peptic ulcer found were remarkably constant. In large station hospitals in the United States, the average was 10 percent, varying from 7.2 to 12.9 percent. For reasons previously mentioned, the incidence of peptic ulcer in general hospitals in the Zone of Interior was much greater-approximately 30 percent of patients with complaints referable to the upper quadrant of the abdomen. The corresponding figures for station and general hospitals in the Mediterranean theater were 5.9 and 10.2 percent, respectively (p. 322). These figures are strikingly similar to those reported by Eusterman and Balfour17 who found 13 percent of ulcers among 16,000 civilian patients whose gastrointestinal symptoms warranted roentgenographic examination.

During the North African campaign, hospital staffs were commonly impressed by a higher incidence of peptic ulcer than was subsequently found in the entire theater. This may have been caused by the poor diets prevalent during the early stages of this campaign, but more probably it reflected the poor screening of men for shipment overseas in the early days of the war. In support of this opinion were the findings of Halsted and Weinberg18 at the Fifth U.S. Army Gastrointestinal Clearing Center (p. 318) in Italy between 1944 and 1945, showing an incidence of peptic ulcer of only 3.4 percent of 183 combat infantrymen with chronic epigastric distress. At this later date, screening before embarkation had been greatly improved, and the men sent into combat represented a better selected group.

Diagnostic Techniques and Criteria

History and roentgenograms.-The diagnosis of peptic ulcer was usually made on the basis of a characteristic history, favorable response 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 the stomach or the duodenum. The typical history of dull, gnawing epigastric pain, occurring from 30 to 90 minutes after meals, frequently waking the patient from his sleep, relieved by food, periodic in type, with remissions of variable length, was obtained in approximately 80 percent of patients.19 An atypical history was usually obtained in younger soldiers who had had symptoms of relatively short duration. The longer history of ulcer, the more classical were its features. Repeated hospitalization often resulted in the patient's history assuming a more typical form, possibly on the basis of frequent discussion with patients with proved ulcer. Therefore, unless the history was taken very early in the course of the disease, and immediately after admission to the hospital, its significance was dubious unless roentgenographic confirmation was available. For this reason, roentgenographic evidence was considered indispensable in most groups in which diagnosis of peptic ulcer was made.

Laboratory data.-The advisability of doing gastric analyses on all patients with digestive complaints was questioned by many observers.20 In general, this procedure was not considered worth the effort unless there was roentgenographic evidence of a gastric ulcer; under this circumstance, the repeated absence of free hydrochloric acid after the administration of histamine would constitute strong evidence against the benign nature of the lesion. Otherwise, the degree of the acidity appeared to be of no significance in the diagnosis or the treatment of peptic ulcer. Gastric analysis, however, was defended by others21 who believed that such an analysis, adequately performed, furnished information on gastric motility and on the presence of parasites in the gastric sediment.

Unless properly interpreted in relation to the clinical picture and the antecedent diet, the routine test for blood in the stools often led to unnecessary and prolonged hospitalization with increased anxiety on the part of the patient, which intensive investigation and subsequent negative findings often failed to allay.

Clinical Response-Psychogenic Factors

All reports, with one exception,22 on 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 satisfactory response to treatment.

Two groups of patients, in each of which approximately 10 percent had failed to respond well to the usual regimen, were studied, one by Cheney23 the other by Gianelli and Bellafiore.24 Most of the patients became asymptomatic for the first time on a diet to which had been added eggs, butter, peanut butter, lettuce, watercress, parsley, broccoli, romaine, and avocadoes-all foods said to be rich in anti-ulcer factor. This anti-ulcer factor was designated vitamin "U."

In general, the response to treatment was so rapid and so uniform that it served as one of the most important criteria in the differential diagnosis of peptic ulcer from functional dyspepsia. This prompt response is not in itself, however, evidence against the possible influence of psychogenic factors 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 tangible prescription in the physician's order book, there were many other changes from the conditions of his previous environment, including physical rest, relief from strict field discipline, and the knowledge that the most important hurdle to rehabilitation had been taken with the commencement of medical care.25

In the various theaters of World War II, there was afforded an opportunity to study the personality of patients with organic and functional dyspepsia and to evaluate the influence of the different aspects of their military life on the initiation or the aggravation of symptoms. The fact that in the Zone of Interior the symptoms of peptic ulcer had originated during civilian life in approximately 90 percent of the patients makes it easy to understand that those individuals differed very little from the usual patients with ulcer seen in civilian life. In contrast, the patient with ulcer who was first seen overseas may well have been an individual with an entirely different personality and physical constitution, since he had previously withstood the rigors of civilian 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 consecutive patients with ulcer was conducted at the 6th General Hospital, Casablanca, in the North African theater, between March 1943 and January 1944, in an effort to determine whether the nervous tension of military life was a factor in the occurrence of the course of the disease.26 These 200 patients represented one-third of all patients admitted to this hospital with digestive complaints during that period. Such a high rate of ulcers was explicable by the fact that the 6th General Hospital functioned as a final 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 to the Zone of Interior and thus received a large quota of patients with ulcer in the North African theater. Later in 1944, the 6th General Hospital was moved to Rome, Italy, and it then received a different type of evacuee-one who was only a few days removed from the front. At that time (between 1 July and 1 November 1944), only 8 percent of the chronic dyspeptics were found to have ulcers.

The patient with ulcer, in the series of 200 cases, rarely volunteered information regarding the degree of his epigastric pain and seemed unconcerned with other somatic complaints. He was found to be aggressive, independent, and often anxious to return to duty after his original discomfort had been relieved. Only in response to direct questioning was a history obtained and then given in succinct, clear-cut fashion without elaboration. Admittedly, this examination of the patient's personality was superficial from the psychiatric point of view and more extensive investigation might well have disclosed important neurotic features. However, the observations are comparable, and the results in striking contrast, with observations made on functional dyspeptics, which were based on the same criteria. Only 5 percent of the 200 patients in this particular study overseas demonstrated definite psychoneurosis in association with peptic ulcer. This figure corresponds closely to the results (4.2 percent) obtained in the study of patients with peptic ulcer in the Mediterranean theater as a whole between 1943 and 1945.27

It should be noted that aside from these observations in which a special effort was made to study the association of the two conditions,28 it is probable that any statistics gleaned from hospital records or disposition boards did not show the true incidence of this association, since there was a tendency on the part of ward officers to omit mention of functional disorders in the presence of well-established organic disease.

The patient with ulcer seen in the United States presented on the whole a totally different picture with reference to any associated neurosis. Flood's29 figures of definite overt anxiety and psychoneurosis in at least 50 percent of his patients were fairly representative of findings in station hospitals. Again, in one large staging area in the United States, psychoneurosis was found in 23 percent of patients with ulcer.30

The objective data-Thus, in men in whom peptic ulcer first appeared or became troublesome during military service, there was no striking correlation found between the organic disease and the psychopathic disorders. As to the incidence of ulcer under combat conditions, it has been noted (p. 311) that, in the Mediterranean theater from September 1944 to April 1945, it was only 1 per 1,000 in whom symptoms were first manifested after induction. 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 from 11 general hospitals and 0.27 percent of dispositions from 21 station hospitals in the Mediterranean theater. Moreover, the incidence of complications during military service was remarkably low, as reported from station hospitals, both in the United States and overseas. The average figure of many reports indicated the occurrence of gross hemorrhage or perforation in approximately 4 percent of peptic ulcers.31 In general hospitals, the incidence of these complications was two to three times as high because of the selective nature of their patients.32

No radical departure in treatment of complications was introduced; thus for bleeding, conservative measures-such as gradual increases in a strict Sippy diet or various modifications of a full Meulengracht diet-were employed with excellent results. The mortality for perforated ulcers was very low because, undoubtedly, a select group of patients-in relation to their general physical condition and the ready availability of treatment-was involved.

Evaluation of evidence.-The reason advanced by most patients for the onset or the recurrence of their digestive symptoms was inability to tolerate Army rations. In many instances, however, these symptoms actually began at the port of embarkation or while the men were being transported overseas, at a time, that is, when their food was satisfactory both in quality and in quantity. Many of the men ate field rations without developing complaints under conditions of oversea activity, until they experienced additional strain, such as repeated air raids.

The high incidence of ulcer among base troops, as compared with men recently in combat, in part indicates the effect of frustration and regimentation, with frequent periods of inactivity. In 70 percent of the patients seen by Halsted and Weinberg (p. 312), a definite correlation was established between aggravation or recurrence of symptoms and the increased nervous tension associated with embarking for overseas. The important effect of such a projected journey upon the incidence of peptic ulcer was suggested by the studies made at a large staging area where men were observed in the final steps of their preparation for duty overseas.33 In this group was recorded the highest percentage in any American series of peptic ulcer-34 percent in patients with digestive complaints.

Summary.-There is, thus, no overwhelmingly conclusive evidence of psychogenic factors in the initiation or exacerbation of peptic ulcer during oversea service. However, the possible influence of such factors is not ruled out. In less selected groups of men, in the Zone of Interior, there was a high incidence of peptic ulcer under conditions of frustration 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 aggravation under the strain of embarkation. On the other hand, men who had weathered induction, Army life in the United States, and transport, before presenting evidence of ulcer, may well have been, as they seemed to be at clinical examination, of a type more resistant to psychological stress. Nevertheless, as evidence of peptic ulcer did appear in them under the strains of combat, it cannot be assumed that the psychogenic element was completely absent, but probably in such men a more severe strain was required as the precipitating factor. These considerations had to be taken into account in separating such men from service, or in giving them special assignments.

Disposition

With very few exceptions, once the diagnosis of peptic ulcer was established, these patients were considered to be totally and permanently unfit for any further military service and were discharged for physical disability (table 61). An occasional exception was made in the case of highly trained individuals with special skills, if facilities were available to secure them proper diet. Some question had been raised concerning the advisability of such a general rule, since it often resulted in the separation from service of individuals who were extremely able, aggressive, and ambitious, while a greater number of men who had functional complaints without organic basis, and were considerably less effective soldiers, were often retained. Halsted in particular advocated the retention in a limited service capacity of the well-trained soldier who had proper morale and a desire to remain in the Army.

Although some such individuals might properly have been salvaged, patients with ulcer must be regarded as subject to exacerbations of symptoms when some untoward element is introduced into their environment, and the prolonged hospitalization required by such symptoms made further attempts at service applicable to only a very few (table 62). This, at least, was the experience with those patients in whom the diagnosis was established while in the Zone of Interior, representing, as they pre-

TABLE 61.-Percentage distribution of admissions for peptic ulcer in the U.S. Army, by type of disposition, 1942-45

[Preliminary data based on sample tabulations of individual medical records]

Type of disposition


Ulcer of duodenum

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 per admission for peptic ulcer, 1945

 


Duodenal ulcer


Number of
days lost


Stomach ulcer


Number of
days lost

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 civilian life.34 Those whose ulcers were first manifested under field conditions overseas may well have been more suitable for modified service.

Head, Wilen, and Fradkin (p. 311), on the basis of their survey in the Mediterranean theater, were so impressed with the superior quality of the average patient with ulcer seen overseas that, influenced by the mildness of the disease and the relatively low incidence of complications, they recommended further trial of duty in exceptional cases during an acute manpower crisis. However, their selections for such duty had to meet the following criteria: (1) Complete relief of symptoms while on a regular diet after a preliminary treatment with a bland diet; (2) absence of complications and other diseases, such as psychoneuroses and anxiety states; (3) absence of roentgenographic evidence of activity after therapy; and (4) assignment to noncombat unit organizations. They were particularly struck with the results obtained during the early part of the Italian campaign when, because of a manpower crisis, 54 patients with ulcer who had met the criteria just listed were returned to duty. During a subsequent period of observation, averaging 9½ months, only eight patients (15 percent) required further hospitalization.

The recommendation had been made that radical surgery be performed on naval personnel whose ability made them particularly valuable to the Navy35 and whose ulcers developed during service. Such procedures, however, were not generally resorted to among Army personnel; it was felt that, in the absence of complications that would by themselves warrant surgery, it was impractical and of questionable value to treat patients by such an empirical method.

FIFTH U.S. ARMY GASTROINTESTINAL CLEARING CENTER

The gastrointestinal clearing center was organized by order of the surgeon of the Fifth U.S. Army and functioned in Italy from 23 October 1944 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 It was instituted to counteract the loss of effective manpower resulting from overhospitalization of men with psychosomatic disorders. Patients were sent directly to the clearing center instead of being sent to base hospitals in a stream of evacuation moving farther and farther from the front.

The pivotal men in this organization were an experienced clinician, a gastroscopist, a trained psychiatrist, and a competent roentgenologist. As soon as a diagnosis of organic disease seemed probable, the patient was transferred to a base hospital for further disposition. In the event of overt psychoneurosis, the psychiatrist made the recommendation for disposition. All mild functional cases were returned to duty without any unnecessary delay, but not until they had been given the benefit of a thorough but prompt examination and discussion.

One group of 113 patients with chronic dyspepsia was studied intensively by means of history, physical examination, gastroscopy, gastrointestinal roentgenograms, and neuropsychiatric consultations. Among these, only four (3.5 percent) were found to have peptic ulcers. Of the remaining 109 patients, 41 percent showed slight to moderate abnormalities of the gastric mucosa on gastroscopic examination. In six patients, an ulcer was suspected from the history and the physical examination, but none was found. Although typical symptoms were found by Halsted and Weinberg in only 72 percent of proved cases of peptic ulcer in another series of 200 cases (p. 314), roentgenographic and gastroscopic examinations in this group revealed no ulcer or other gastric lesions in any patient in whom it had not previously been suspected clinically. Thus, it was shown that roentgenographic facilities were not indispensable in making a diagnosis in a forward area.

Of 442 patients studied at the clearing center during 6 months, 74 percent were returned to full duty, 11 percent to limited service, while 15 percent (including hepatitis, and doubtful cases, with no definite evidence of organic disease nor of psychoneurosis) were sent to a base hospital. Over half (286 cases) were designated psychogenic dyspepsia. Of these, 79 percent were returned to full duty and 15 percent to limited service, the average length of hospitalization being 7.8 days.

For comparison, there is the record of the 6th General Hospital, when it was removed from Casablanca to Rome, where 55 percent of similar cases were returned to full duty, after an average hospital stay of 39 days. Halsted could find no significant factor to account for the lower percentage except the longer hospitalization.

Contrasting both records with the earlier experience of the 6th General Hospital in Casablanca, many factors could account for the high incidence 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, this hospital was a funnel of evacuation of such cases to the Zone of Interior; many of the patients were base troops, who had been poorly screened during the early war period; others reached this hospital some weeks after leaving combat units. In Italy, the patients were for the most part combat infantrymen who were received on the day, or within a few days, of leaving their units.

Thus, experience had taught the value and the methods of prompt diagnosis and prompt disposition. As demonstrated by the Fifth U.S. Army Gastrointestinal Clearing Center, this was good therapeutics. Soldiers more willingly returned to duty, and were less liable to relapse of psychogenic symptoms, when they felt that their complaints had been given competent and thorough attention. Evaluation and management of cases were more effective both from the medical and from the military standpoint.

FUNCTIONAL GASTROINTESTINAL DISORDERS

Incidence

Gastrointestinal symptoms without demonstrable lesions were responsible 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 the skill and judgment of the Medical Corps. Of the psychosomatic disabilities, functional gastrointestinal disorders37 composed the largest single group. Aside from the emotional factors, the alterations in diet and regimen of life frequently induced digestive symptoms, particularly in new recruits and subsequently among those on oversea rations.

The problem of dyspepsia or gastroduodenal disorders in World War I was apparently less important, since there is almost no reference to them in the history of "The Medical Department of the United States Army in the World War." During the period between 1 April 1917 and 31 December 1919, the occurrence of "other diseases of the stomach," evidently including dyspepsia, was reported as 31,491, a rate of only 0.26 per 1,000. The significance of these statistics is confused, however, by the lack of uniform diagnostic criteria. That the problem was greater than these figures indicate was 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 or another 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 the Second World War, one finds that before 1944 dyspepsia as such was included in the miscellaneous group "other diseases of the stomach." However, individual reports indicated the magnitude of the problem at various installations in the Zone of Interior and overseas.

Thus, Annis and Eldridge39 at the Station Hospital, Camp Blanding, Fla., stated that the vast problem of functional gastrointestinal disease and psychoneurosis had been by far the outstanding cause of admission to that hospital. The incidence of these gastric neuroses had fluctuated in accordance with age groups (rising when older men were inducted, particularly those with dependents) and with the prevailing state of hostilities (declining immediately after the attack on Pearl Harbor).

Pulsifer40 reported that gastrointestinal disorders were responsible for 45 percent of admissions to the general medical wards of the Station Hospital, Camp Livingston, La. In 43 percent of these patients, definite emotional causation was evident, and no organic lesions were demonstrable. Of 100 consecutive patients who had been discharged from the neuropsychiatric service, gastrointestinal complaints had caused the hospitalization of 48. Immediate discharge from the Army had been recommended for 82 of these 100 patients. The duration of the disabling presenting symptoms was recorded as from childhood in 46 of the 82 patients, and averaged 5 years in the remaining 36. Tidy41 reported that in 1941 Graham and Kerr found that the history of symptoms in 80 percent of functional disorders antedated military service in the British forces, and he himself reported similar figures for 1942.

An interesting and carefully conducted survey was reported by Skobba42 from the Lawson General Hospital, Atlanta, Ga. Of all the patients admitted to the gastrointestinal service at this hospital up to 1 August 1942, one-third (137) had no evidence of organic disease. These patients were subjected to roentgenographic examinations of the entire gastrointestinal tract, gallbladder, proctoscopic and gastroscopic examinations, gastric analyses, stool examinations, and neuropsychiatric consultations. Of these 137 patients, 75 showed no evidence of any neuropsychiatric condition. The remaining 62 had gastrointestinal symptoms that were related to psychoneuroses in 18, to a constitutional psychopathic state in 33, and to mental deficiency in 11 patients. Of the enlisted men who were admitted as patients to the neuropsychiatric service, those having pain, vomiting, or diarrhea were studied. Patients with only vague gastrointestinal symptoms were not included. There were functional gastrointestinal complaints in 20 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 of the mentally defective.

The magnitude of the problem of dyspepsia in an oversea theater was vividly portrayed by Head, Wilen, and Fradkin in the report of their experience in the Mediterranean theater (p. 311). In 11 general hospitals in which 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 21 station hospitals, in which 9,813 roentgenographic examinations were made, only 5.9 percent were positive for ulcer. A rough comparison with experiences elsewhere is presented in table 63. It may be inferred that the difference between 100 percent and the percentages in this table denotes roughly the number of patients with dyspepsia.

The true incidence of dyspepsia was not accurately portrayed by the foregoing figures; the actual occurrence was apparently far greater, for numerous personnel with these symptoms were not hospitalized. These reports indicated, however, that the problem was widespread and that, if more stringent diagnostic criteria based on history and physical examination had been employed, many patients would not have been hospitalized and many others would not have burdened the roentgenographic facilities of the Army installations.

TABLE 63.-Percentage of peptic ulcer in hospital patients with dyspepsia

Reports


General hospitals

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: Differential Diagnosis

Symptoms.-The symptoms of functional gastrointestinal disorders comprised numerous manifestations. Upper abdominal distress, heartburn while eating or immediately thereafter, regurgitation of acid, sensation of fullness, nervousness, fatigability, and anorexia were characteristic. Distress at night was rare. Ingestion of food only occasionally gave relief; indeed, it frequently caused exacerbation of symptoms. Occasional vomiting was a frequent complaint. Characteristically, numerous other symptoms


  323

were described, as follows: Headache, pains in the chest, backache, burning sensation in the eyes, palpitation, weakness, and disturbed sleep. The symptoms in the great majority of men antedated entry into the Army, at times extending back to childhood. Exacerbations of the complaints were often related to periods of emotional stress and strain.

In evaluating such symptoms, a careful history and physical examination, with a psychiatric consultation when indicated, established a reasonably accurate diagnosis in the great majority of cases without recourse to hospitalization for roentgenographic or other studies. For this, a sound psychiatric orientation was required of the medical officer, and usually sufficed. In the few doubtful cases, the opinion of a psychiatrist was invaluable and, by being so restricted, could be the more carefully considered. The psychodynamics of dyspepsia were excellently described by Halsted and also by Pulsifer (p. 321) who concluded that the clinician should be able to distinguish psychogenic disturbances from organic disease with fair accuracy by means of the history and physical examination alone.

Roentgenographic examination.-The vast number of soldiers with gastrointestinal symptoms obviously precluded complete laboratory and roentgenographic examinations and these, indeed, proved to be of limited value. Accurate examination required not only the services of an experienced roentgenologist but also elaborate equipment for spot films and other techniques. Without these facilities, organic lesions would be missed or transient fluoroscopic abnormalities might be taken for pathological lesions. In about 10 percent of the cases, however, reasonably accurate differential diagnosis between psychogenic and organic disease could not be made without gastrointestinal fluoroscopy. Among 113 consecutive patients with dyspepsia who were given roentgenographic examinations at the Fifth U.S. Army gastrointestinal center, as part of an intensive clinical and gastroscopic study, Halsted reported that only 4 patients had an ulcer; these were correctly diagnosed on the basis of the history and the physical examination.43 From their history, six additional patients were believed to have ulcer, but roentgenographic studies were negative. In no instance, among another group of 190 patients with dyspepsia who had had roentgenographic examination, was an ulcer demonstrated when the clinical diagnosis was psychoneurosis. It thus appears 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 of exacerbations actually occurring during military service.

On the other hand, a thorough physical examination required but little more time than a superficial one, and was of inestimable value. Signs pointing to the diagnosis were frequently found, and if the diagnosis of psychogenic or functional disorder was finally made, the patient had the reassurance that serious disease had not been overlooked by a cursory examination.

43See footnote 36 (3), p. 319.


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In a station hospital in the Zone of Interior, Magnes44 found that 73 percent of the soldiers referred for hospitalization could be successfully diagnosed and treated in the outpatient service on the basis of a careful history and physical examination. The other 27 percent were fluoroscoped as ambulatory patients. Halsted, in his extensive experience, found that a thorough history supported by the results of physical examination in 90 percent of his patients was adequate independently of other studies.

History.-There was no better index of the skill and wisdom of a medical officer than the quality of the history elicited from a patient with gastrointestinal symptoms. Practically all neuroses expressed themselves in part by "body language," and all organic disease imposed psychological problems, in either case requiring sound clinical judgment. A history limited to the presenting complaint usually wasted, rather than saved, time.

Some pitfalls in taking the history have been pointed out by Rosenak and Foltz.45

There may be some slight variation from the so-called typical ulcer story which will suggest to the experienced physician that an ulcer is not apt to be present. The frequent occurrence of early morning pain is such a phenomenon. Alvarez had often warned that the ulcer patient does not present this symptom and it has been our experience that the dyspeptic soldier who complains of burning pain in the epigastrium upon arising even though he obtains relief from eating, probably has no ulcer.

Feelings of distress with varied pains and aches, but without preeminence of one, were more characteristic of dyspepsia than of ulcer.

The presence or absence of gastrointestinal symptoms first in civilian life, then during the soldier's military service, plus the possible relation to stresses and strains were ascertained. When these symptoms continued with varied intensity but without real remission, they were more likely to be psychogenic than organic. Symptoms of brief duration increased the probability of organic disease.

Halsted46 has summarized, as follows, the implications 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, it is safe to adopt the following point of view in the diagnostic evaluation of such patients in the Army area: If the symptomatology does not fit in with any organic disease, if the physical examination is negative, and if simple clinical examinations such as measurement of temperature, examination of urine, stool and blood count are all normal one should then disregard symptomatology and make a psychiatric appraisal. The answer will usually be found in this sphere. If one makes an exhaustive search for an organic explanation of symptoms by prolonged medical investigation harm will be done to the 70 percent of patients who have psychogenic dyspepsia. Furthermore many men will be lost for further useful military service. The occasional diagnostic error which may be made is not likely 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 Psychogenic Origin. Management of Forward Areas. Proc. Conference Army Physicians, Central Mediterranean Forces, 1945, pp. 131-134.


325

Comparison of the symptomatology of peptic ulcer and psychogenic 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 antacid treatment was in striking contrast to the characteristically poor response in the functional dyspeptic. This response served as one of the most important, although insufficiently regarded, criteria of differential diagnosis.47 The symptoms of peptic ulcer nearly always abated in a few days, if the patient had frequent feedings and antacid medication, but the symptoms of a psychogenic gastric disorder usually were not materially influenced by such measures.

TABLE 64.-Differential diagnosis between peptic ulcer and psychogenic dyspepsia


Symptomatology


Peptic ulcer


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 the individual patient with functional dyspepsia was of sufficient potential value to the Army to warrant the effort and time expended for salvage. Functional gastrointestinal disorders, including particularly the classic complaints of dyspepsia, were frequently witnessed among new recruits. The manifold psychological adjustments as well as the rigid regimen and the change in diet were important factors. Many men with transient problems of adjustment and the resulting vague gastrointestinal complaints were readily rehabilitated into useful soldiers. In contrast, individuals who, in the course of their previous civilian life, had such complaints for many years offered less promise. It was not surprising that the patients with the most intractable forms of dyspepsia had 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 Armed Forces, and many had to be released after varying periods of training.

New recruits who had such symptoms before they were acclimated to Army routine could usually be dealt with satisfactorily in their own units. Symptomatic treatment in the dispensary, reassurance, and other forms of psychotherapy safeguarded these individuals from fixation of their attention on such diagnostic terms as gastritis, duodenitis, or even dyspepsia. Persistence of symptoms, in spite of therapy, suggested the desirability of more intensive study of the emotional factors by a trained psychiatrist outside of the hospital. The possibility that dyspepsia was a manifestation of well-marked psychoneurosis 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. The answer depended not only on the evaluation of the patient but also on extraneous considerations. Among these were the needs of the Army for manpower, the opportunities of placement for limited service, the soldier's special capabilities, and the need of the Army for his particular qualifications.

Divergent viewpoints were expressed regarding the general advisability of attempting to salvage the confirmed dyspeptic. Thus, Annis and Eldridge48 stated: "Regarding functional dyspepsia as a whole, the Army provides neither the time, the environment, nor the facilities necessary to attempt what is at best the extremely difficult, and often unsuccessful, task of rehabilitation."

On the other hand, certain carefully planned and well-organized efforts to rehabilitate such patients were inaugurated. Goldbloom and Schildkrout49 at Camp Kilmer, N.J., organized a regimen for the rehabilitation of the chronically dyspeptic soldier. One hundred patients were studied and comprehensive investigations of the digestive and psychiatric symptoms were completed in the hospital. The soldiers were then discharged for duty in various echelons of the camp but were brought regularly to the hospital for their meals. By followup studies and conferences, it was sought to improve 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. Of these, only 14 were placed on full duty, 21 were retained on the regimen, 3 were transferred to a general hospital, and 4 were discharged from the Army.

It was evident, from a survey of common experience in the Army, that no broad generalizations regarding disposition of all cases could be made concerning a group that comprised such heterogenous conditions as were included under the term "dyspepsia." The constitutionally inadequate had to be dealt with on the basis of their fundamental and fixed inadequacy rather 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.


327

screening, earlier diagnosis, and swift disposition on the basis of ineptitude or constitutional inadequacy-when indicated-would have prevented much wastage of professional skill and facilities.

Summary

Briefly, then, one may say that, in Army experience with gastrointestinal disorders, the large percentage of patients without organic disease but with poor morale, including those with definite psychoneurosis, was in 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 of sufficient severity, the incidence was low, and the response to treatment good.

Gastrointestinal symptoms without demonstrable lesion caused great loss of effective manpower in World War II and comprised the largest single group of psychosomatic disabilities.

In such cases, those who responded favorably to symptomatic therapy and firm but understanding discussion of their problems, for the most part 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 if excessive medical care and elaborate investigation were avoided.

On the other hand, the dyspeptic whose symptoms were the reflection of deeply rooted anxiety had to be regarded as a psychiatric problem, diagnostically and therapeutically, and disposition made accordingly. Patients intermediate between these groups were frequently encountered. Decision in such cases could be difficult and was often postponed for prolonged observation, with or 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 viewed through the gastroscope was not clear. Some observers regarded the mucosal changes as organic disease and ascribed the patient's symptoms to these abnormalities. Hurst (p. 309), for instance, stated that gastritis is an organic disease as definite as ulcer and that it is most undesirable to confuse it with functional gastric disorders, which have no organic basis.

Extensive military experience led to the conclusion that definite clinical syndromes could not be ascribed to the different types of gastritis.51 Erosive or ulcerative gastritis and possible chronic hypertrophic gastritis at times might produce symptoms, but no clear-cut clinical correlation was generally possible. Moreover, the limits of the normal variations of the gastric mucosa had not been sufficiently established to permit accurate appraisal of what was abnormal.

Even the gastroscopic description in pathological terms could be verified histologically in only about 50 percent of the cases.52 That the gastroscopic findings were a reflection of a functional state was suggested by the observations of Wolf and Wolff.53 With episodes involving anxiety, hostility, and resentment, the mucosa became red, the acid production was sharply accelerated, and vigorous contraction began. With hypermotility and hypersecretion, the gastric mucosa became engorged and turgid, and the folds became thicker and succulent, presenting the picture of hypertrophic gastritis as seen by gastroscopists.

The foregoing observation, which suggested that hypertrophic and other forms of gastritis could be temporary and functional, was in accord with the experience of others. Fitzgibbon and Long54 found that 2 of 40 healthy students, or 5 percent, had hypertrophic changes. Berk55 examined 50 patients with upper abdominal distress diagnosed as psychoneurotic by competent psychiatrists. All had failed to show abnormalities roentgenographically, and some had therefore been given prior to admission, the diagnosis gastritis. On gastroscopic examination, approximately 30 percent showed gastritis; if those who exhibited merely patches of the superficial variety were excluded, only 20 percent showed chronic gastritis worthy of note. Berk concluded that no set of clinical symptoms inevitably indicated the presence of chronic gastritis. These studies were in accord with those of other observers.56

51See footnote 4, p. 307.
52Berk, J. E.: Trends and Shortcomings in the Approach to Gastro-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 of Healthy Individuals; A Preliminary Report. Gastroenterology 1: 67-71, January 1943.
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.


329

A similar experience was reported by Cutler and Walther57 and from the Central Pacific Area.58

In one group 264 soldiers (average age 29) with upper abdominal complaints of variable duration (1 month to 17 years) were gastroscoped. X-ray examinations of stomach and duodenum were negative. The stool examinations were negative. Cholecystography was made in 11 percent of cases 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 gastritis revealed the hypertrophic variety. These patients presented a pattern of complaints very similar to those found in peptic ulcer. They were benefited by alkalis and antispasmodics.

The greater majority revealed the superficial and atrophic type of gastritis. It is interesting to note that clinically a conspicuous feature was the lack of uniformity of digestive complaints. The symptoms were of a bizarre nature, implicating several systems. Thus, nervous tremors, poorly localized headaches, dyspnea, precordial pain, giddiness, and arthralgias were among the common complaints. No correlation existed between the degree or extent of gastritis and the avowed incapacity of the soldier to perform duty. The nature of the gastroscopic picture could not serve, therefore, as the only factor in determining the ultimate disposition of the patient as to future usefulness in the service.

Many of these cases of chronic gastritis were seen by the neuropsychiatrist 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 mild atrophic gastritis; all others were normal.

A third group of 36 soldiers (average age 29) with positive findings of duodenal ulcer were studied, 52 percent showed superficial, atrophic or a combined superficial and atrophic gastritis with duodenal ulcer.

From these observations, the following conclusions were drawn:

1. Asymptomatic subjects may show evidence of gastric mucosal changes by gastroscopy.

2. Chronic gastritis is much more prevalent in patients with chronic upper abdominal distress.

3. Apart from the hypertrophic group which clinically simulated peptic ulcer, the largest group of patients with chronic gastritis showed no uniform symptom complex. Because of the frequency of associated complaints unrelated to the gastrointestinal tract it was difficult to believe that the gastritis was the only etiologic factor.

4. A predominance of psychogenic factors was present in this group; the possibility therefore exists that the changes in gastric mucosa points to a more basic disturbance of psychiatric importance.

5. A useful guide to the general fitness of the "gastric soldier" was preferably an accurate evaluation of the severity of the psychogenic factors rather than the appraisal of the gastritis per se.

Of 22 patients, gastroscoped in a naval hospital, who had chronic dyspepsia without ulcer, 11 had a normal gastric mucosa and 11 had some form of gastritis; 5 of these were classified as mild or insignificant.59 Psychiatric

57Cutler, J. G., and Walther, J. E.: The Significance of Chronic Gastritis in an Army General Hospital. Gastroenterology 5: 112-116, August 1945.
58History of Internal Medicine in the Central Pacific in World War II. [Official record.]
59See footnote 35, p. 318.


330

evaluation revealed that 11 of the 22 had a marked neurosis and 6 a mild neurosis; 5 were normal, but it was noted that 2 of the latter were high strung and restless.

Annis60 and Gold61 each reported that about 35 percent of patients with nonulcerative dyspepsia in Army installations in the Zone of Interior showed definite gastroscopic changes.

Of considerable significance were the results (reported by Halsted) of a survey62 conducted by two internists, one of whom was a skilled gastroscopist, aided by a psychiatrist, a clinical psychologist, and a radiologist. A total of 109 patients with chronic nonulcerative dyspepsia were examined. Of these, 59 percent had a normal gastric mucosa; 26 percent showed slight abnormalities, consisting of redness and increased highlights; and 15 percent showed more marked changes, with edema and adherent mucus. The changes were regarded as signs of chronic superficial gastritis. In nine patients, spasm of the antrum or midbody was seen without changes in the mucosa. There were no instances of hypertrophic or atrophic gastritis. Psychiatrically, no differences were noted between the group showing gastroscopic changes and the group with a normal mucosa. It was believed that the benign changes noted gastroscopically were 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, clinical management, and disposition of patients with chronic or recurrent dyspepsia. The procedure proved to be helpful, however, under the same circumstances as in civilian life. Occasionally, it enabled the medical officer to reach a decision as 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 With Dyspepsia at an Army Hospital. Gastroenterology 1: 254-257, March 1943.
62See footnote 36 (3), p. 319.
63See footnote 9 (2), p. 309.

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