page 627

Work at the ADS

Buildings were taken over by the ADSs at this period because of the severe wintry weather and the impossibility of using tents in the muddy, waterlogged country. The buildings enabled the ADS to provide warmth, comfort, and resuscitation even in bad weather.

During the early period the active MDS was very close to the RAPs and a large proportion of the casualties was admitted direct to the MDS; much the same conditions were present when 4 MDS moved into Faenza later. At other times the ADS was called upon to carry out treatment in cases of delayed evacuation.

The Work at the MDS

This varied a good deal, depending on the use made of the CCS. For the first attack on Rimini the active MDS took over the functions of the CCS, except for certain types of cases which were sent on to the Canadian CCSs. The MDS operated on the large majority of the cases and evacuated them direct to 1 General Hospital at Senigallia by ambulance car.

Later, the MDS situated at Faenza was called upon to deal with many casualties before sending them on to the CCS at Forli, but operation was undertaken only on the very urgent of the major cases, and on the minor cases which could be passed quickly through to Senigallia. The performance of almost all the forward surgery at the MDS, followed by rapid evacuation to 1 General Hospital, did not produce as good results as those obtained during the second period when the CCS took over the bulk of the work in the forward area.

Work at the CCS

This unit was under command of ADMS 2 NZ Division during this period. It was out of action during practically the whole of the first period before the Division went out to rest.

After the CCS took over from the MDS on 18 October at Igiea Marina it dealt with over 600 cases, including 174 battle casualties, in twelve days. The unit then moved to a large school at Forli, and during December 762 cases, including 572 battle casualties, were admitted. The unit was strengthened by the attachment of a British FSU as well as of our own FSU and FTU, and also of Captain Hodgkiss, an experienced chest surgeon.

During October 15 abdomens were operated on, with 6 deaths. There were 10 penetrating abdomens with 4 deaths, and 5 thoraco-abdomens with 2 deaths. Included in the cases were 5 prisoners of war, with 2 deaths. During December at Forli 20 abdomens were page 628 operated on, with 8 deaths. Many severe mine wounds were encountered and many amputations had to be performed.

The conditions were almost ideal; central heating was available and the seriously ill patients were held till their condition for evacuation was perfectly satisfactory.

The Work of the Field Surgical Unit

The unit, under Major D. P. O'Brien, was attached to the active MDS during September and up till 18 October, and again for the last four days of November. For the rest of the time it was attached to 1 NZ CCS. During the whole period 230 operations were performed as follows:

	Operations Performed				Deaths
	Oct	Nov	Dec	Total	Oct	Nov	Dec	Total
Abdominal	5		14	19	1		3	4
Abdomen and thoracic	1		1	2
Chests	4		4	8
Heads
Major amputations	1		4	5
Fractures long bones	31	3	35	69	1			1
Ligation major blood vessels		1	1	2
Major joints	2		8	10
Gas gangrene	1		6	7			2	2
Wounds, severe	7		18	25
Burns	1	1	1	3
Secondary suture wounds	1	1		2
Minor operations	46	10	22	78
	——	——	——	——	——	——	——	——
	100	16	114	230	2		5	7

Analysis of Deaths Prior to Evacuation

Time	Cause	Oct	Nov	Dec	Total
24 hours	Shock	1			1
24 hours	Blast	1			1
24 hours	Gas gangrene			2	2
24 hours	Pulmonary oedema			1	1
10 days	Anuria			1	1
20 days	Peritonitis			1	1
		——	——	——	——
		2		5	7

page 629

Work of the Field Transfusion Unit

This unit was attached either to the active MDS or to the CCS throughout the period. There was some difficulty with blood during the first period and many bottles had to be discarded. Conditions improved later, and little difficulty arose during the Faenza offensive when 117 transfusions were given.

Shortage of Medical Officers

The shortage was becoming more marked during the early part of this period and in September the Division was twelve officers short. The commencement of New Zealand leave for medical officers accentuated the position. The most serious shortage was in the senior officers, and especially in those qualified for senior professional work in the hospitals and the CCS. The position was relieved later by the arrival of reinforcements from New Zealand, many of whom had served in the Pacific zone.

Surgery at 1 General Hospital

For the first month from the date of its opening at Senigallia at the beginning of September, 1 General Hospital performed surgery of the type usually done at the CCS, many wounds having their first surgical treatment there. Most of the wounded arrived in very good condition after their treatment at the field units and their journey back along the fairly smooth coast road, exceptions being men with compound fractures of the femur where infection had not been controlled by penicillin. Two of these had to have above-knee amputations following secondary haemorrhage from the popliteal artery.

Six cases of gas gangrene were encountered in September, one of the septicaemic type being the only death. The others recovered following excision of the muscle groups involved. Gas gangrene had been more commonly met with during the campaign in Italy and occasional severe cases arose, especially in late cases. Penicillin proved to be very useful when combined with adequate surgical excision. A much higher proportion of wounds was subjected to primary surgical treatment, partly as a precautionary measure against gas gangrene and partly to ensure success when subjected to delayed primary suture.

Delayed primary suture was performed for many wounds, use being made of either calcium penicillin, sulphanilamide powder, or proflavine powder. Results were good but there was often slight infection of the stitch holes. It was found that the third or fourth day was the optimum time for suture. Whenever possible the deep fascia was closed by means of figure-of-eight sutures, including the page 630 skin and the fascia. Where this was possible healing was more satisfactory and the scars less adherent.

Two cases of rectal wounds which had not been detected in the forward units were seen, colostomy and drainage of the pelvic cellular tissues being carried out. Both had severe accompanying wounds and neither had intra-peritoneal involvement.

The notable feature of the September casualties was the infrequency of grossly infected wounds and, consequently, diminished toxaemia.

A feature of the later casualties was the large number of leg and thigh amputations, mainly the result of mine wounds, a considerable number of traumatic amputations having been sustained. A small number of cases of gas gangrene, but none of tetanus, was seen. In the larger wounds, including fracture cases, parenteral penicillin was given for some days to ensure the control of infection. All types of cases were dealt with except fractures of the femur, which were evacuated as soon as possible to 3 General Hospital at Bari for definitive treatment. In October 200 operations out of a total of 500 were performed for suture of wounds.

Intramuscular penicillin was being used freely by this time for severe bone and joint cases and in chests. There were remarkably few deaths at this period. The two unit surgeons, Lieutenant-Colonel Bridge and Major A. W. Douglas, carried the heavy load of surgery in the hospital at this time, though for a period a surgeon from 2 General Hospital was attached to the unit and gave valued assistance. Some diphtheritic infection of wounds occurred and proved a serious complication.

Surgery at 3 General Hospital

The majority of the wounded admitted to 3 General Hospital had already had wound suture performed at 1 General Hospital, Senigallia. Fractured femurs, however, were especially sent to Bari for wound suture. The closure of colostomies was also carried out when possible. Foreign bodies were also removed in some of the chest cases.

Surgery at 2 General Hospital

The comparatively small number of wounded transferred from 1 and 3 General Hospitals had had wound suture already performed, so that little surgery was done at Caserta.

Neurosurgical Cases

The head cases were sent from the field ambulances to the special advanced head centre attached to 83 British General Hospital at page 631 Riccione, where facio-maxillary and eye cases were also dealt with. They were later evacuated to head centres at Loreto, Bari, and Naples and then finally admitted to our base hospitals at Caserta or Bari.

Review of Surgery

The Consultant Surgeon 2 NZEF, Colonel Stout, in October 1944 reviewed the developments of surgery in the Italian campaign.

The large majority of deaths was due directly to the severity of the injury and the primary shock produced thereby. This was shown in both the chest and abdominal cases, in which a large number of the wounded were brought in dead to the field ambulances, and practically all the others who died did so in the first forty-eight hours.

Undoubtedly the most valuable form of treatment was transfusion of blood, given early and sustained till operative treatment was possible. The giving of blood during transit in the ambulance had proved of great value. The early administration of glucose saline, both to combat dehydration and also to act as a preventative of anuria, was being carried out.

In mangled limbs, commonly seen after mine injuries, early application of a tourniquet just above the damaged area to prevent bleeding and toxic absorption, followed by early amputation through healthy tissue, had become the routine. The dramatic improvement following the removal of the devitalised tissue was vouched for by many experienced surgeons.

Anuria, generally the direct result of severe and prolonged shock, had caused many deaths and no treatment was of any avail.

Infection was being combated by adequate primary wound excision and the local and parenteral administration of penicillin. Gas gangrene had become more common but, except in a few fulminating cases, cleared up well with adequate surgery and penicillin.

Delayed primary suture of wounds had become the routine in simple wounds, in amputations, and in fracture cases and the results were satisfactory.

Chest cases with more thorough primary wound treatment and intrapleural penicillin had very rarely become septic.

Thoraco-abdominal cases showed a lower mortality when dealt with through the chest. A tendency to delay operation a little too long in abdominal cases had been noted, the pendulum having swung too far. In colon injuries the double loop colostomy was being carried out except in caecal injuries, where simple marsupialisation was all that was considered necessary. Rectal injuries associated with buttock wounds were common and sometimes apt to be over-looked. There had been an unusual number of abdominal wounds page 632 associated with evisceration of the bowel, and a more conservative approach was suggested in these cases which were almost invariably fatal.

Knee-joint cases did well with intra-synovial penicillin and adequate splintage.

Fascial incision following ligature of the popliteal and lower femoral arteries was successful in saving some limbs. A case of primary ligature of the lower part of the femoral artery dealt with by fascial split at that time was fully recorded by Major Owen-Johnston, and the subsequent progress for a period of years has been ascertained. Major Owen-Johnston wrote following the operation that:

If ischaemic gangrene does not develop in this case then I think that it can be accepted as a very good test of the efficacy of fasciotomy of the leg aponeurosis in preventing the onset of ischaemia where the popliteal or lower femoral artery has been tied in battle casualties.¹

The importance of early and frequent hand movements in all arm injuries was fully recognised.

In burns the problem was recognised as one of shock, and adequate plasma was the essential form of treatment. Simple dressings without anaesthesia were carried out, and penicillin utilised both locally and parenterally.

Climate

The winter in northern Italy was relatively severe, very wet and cold conditions being experienced. The plain of the Po valley became very muddy, making tank action generally impossible. There were occasional hard frosts, and light snow fell on the plains with heavier falls on the hills. The first fall of snow was experienced on 11 November both at Senigallia and Fabriano.

Health and Hygiene

In an effort to keep the sick rate of the Division as low as in the previous Italian winter, it was arranged that all men not actually in the most forward positions should have reasonably comfortable living conditions. All the field medical units, including 1 Mobile CCS, were well provided for in excellent buildings, and patients were treated under better conditions than had been possible the previous year.

page 633

Combatant units out of the line were also able to make use of buildings and so provide for the comfort of the troops in the wet and cold conditions. Each man was issued with five blankets and five pairs of socks, and extra battle dress and underclothing were held by all units to allow frequent changes during the wet weather. Gumboots, leather jerkins, and duffle coats were also available.

Actually, owing to a reduction in the number of cases of infective hepatitis and fevers, the sick rate in the winter months showed a decline on the rate during the summer months. Accidental injuries, too, were fewer with the comparative immobilisation of the Division.

The quartering of troops in houses, however, made hygiene a much greater problem. The houses were usually also occupied by Italian civilians, it being found impossible to evacuate all civilians from the divisional areas. There then arose the problem of skin diseases, and other infectious diseases such as diphtheria, contracted from close living with an uncontrolled and relatively poor civilian population. Unit discipline down to the platoon or section level ensured the best control, but hot showers, adequate disinfestation, and the use of insecticide powder were all enforced on men in the forward areas. It was found better to dust the man and his clothes with insecticide rather than spray the billets, although this was done where possible. Living in towns and villages, where drains had been destroyed by shelling and bombing and where wells were thus contaminated, also raised problems, but rigid inspection and policing by 4 Field Hygiene Company ensured an adequate measure of control.

Rations: These were as a rule excellent, with fresh vegetables generally procurable, but in November there was less fresh food and ascorbic acid tablets were used.

Water: Adequate filtering and chlorination of water from the village wells, with rigid inspection, was carried out. The wells were mostly large and deep and the water satisfactory. There was a shortage of water carts and of trained staff for water duties, and fresh personnel had to be trained.

Refuse: At first deep pits were used and burnt out regularly. Later, controlled tips were developed, but constant supervision was necessary as there was a tendency to use them for fluid refuse.

Latrines: Deep-trench latrines were used when possible and buckets were sometimes used.

Showers: Buildings were found to be essential for showers during the winter weather. The showers were freely provided.

Malaria Control: General measures were limited to spraying of buildings with DDT and flysol. The troops used nets and repellent page 634 cream, and mepacrine tablets were taken every evening, generally under the control of an NCO, till the end of the season.

Typhus Prevention: This was of considerable importance as the billeting of the troops led to a marked increase in infestation by lice and pediculi. The enemy troops were also known to be heavily infested with lice. An anti-typhus unit was formed out of one of the anti-malaria units and was active in spraying out billets with DDT. Spraying squads were attached to ADSs. It was considered, however, that the personal dusting of the troops with insecticide was more effective and this was carried out. No typhus infection was encountered.

Sickness

Some general deterioration of the health of the troops was noted during this period, but this did not lead to any marked increase in the numbers evacuated sick. It was shown more in the lack of resistance to skin infections and mild general infections. The dominating factor was the marked epidemic of infective hepatitis which subsided during the winter.

Numbers of ‘Fever NYD' cases were evacuated from units. Many of these cases were diagnosed later as infective hepatitis, others as sandfly fever, very few as malaria.

Upper respiratory infections increased during the winter but pneumonia was never very prevalent or serious.

Diarrhoea and dysentery were much less common.

As much of the illness was minor, a considerable number of those evacuated from the divisional units were returned to their units from the field ambulances within a few days. During October 500 men, one-third of the sickness cases, were held at the MDS at Riccione and returned to their units. This number did not include cases of hepatitis as these were all evacuated to the base hospitals. The numbers per 1000 per day evacuated beyond the RAPs were 2·54 from July to September and 2·67 from October to December.

Prevalent Diseases

Infective Hepatitis: This disease completely dominated the medical picture, accounting in September for as many as 60 per cent of the medical cases. The New Zealand Division had the highest rate in Eighth Army. The Maoris were, as in previous epidemics, relatively unaffected. The number of cases reported during the period was: September 654, October 587, November 474, and December 206—a total of 1921. There was a sharp drop in incidence in January.

At 1 General Hospital, where the divisional cases were first admitted to hospital, a thousand cases were admitted during the last page 635 quarter of the year. The chief feature was the generally mild nature of the disease. In no case had there been any cause for anxiety, and on the average the icterus had been only moderately severe and tended to clear rapidly. Prolonged pyrexia had not occurred, nor had there been the abdominal distension seen in previous years. Pruritis was relatively more common. Dyspeptic symptoms had been almost universal and fevers generally low and of minor significance. It had been observed that there was no jaundice in a considerable number of cases and the diagnosis depended on the dyspeptic symptoms and typical onset, together with an enlarged liver. In these cases the dyspepsia was prolonged, difficult to relieve by the usual means, and tended to recur on leaving hospital. It had been noticed that men who had had jaundice in previous years, or who had been exposed in previous epidemics, tended to have milder attacks with only transient jaundice. It was noted also that the cases became more severe as the epidemic progressed. The liver was almost always enlarged, the spleen rarely so. Bronchitis and broncho-pneumonia were frequently associated with hepatitis. Special fat-free diets were prepared and skimmed milk powder was supplied to the hospitals. Extra protein and vitamins were provided.

Colonel Boyd, New Zealand consultant physician, made the following observations at that time:

Though it is perhaps not the final knock-out blow to the droplet infection theory in this disease, a considerable advance in our knowledge has recently been made by the demonstration of the infective agent in the urine and faeces. Filtrates were taken from both sources by Maj. Van Rooyen of the 15th (Scottish) Gen. Hosp., Cairo. The War Office having refused permission to carry the experiment further, the material was sent to Major J. Paul of the American Virus Commission who gave the filtrates orally to a number of volunteers. At the same time samples of blood serum from hepatitis cases were sent and these were fed to volunteers or injected parenterally. The results were:

Filtrates by mouth: Hepatitis developed on 22nd day.

Serum by mouth: Hepatitis developed on 35th day.

Serum parenterally: Hepatitis developed on 65th day.

The shorter period in the case of filtrates is, of course, likely to be due to heavy concentration of the virus in a small quantity of the carrying medium. In the case of blood serum the dose probably more closely approximates what occurs naturally. These discoveries largely elucidate many previously puzzling problems, e.g., the very low incidence among hospital staffs and nursing personnel, the relatively high incidence among British officers in the forward areas owing to the use of community mess dishes; the low degree of spread in such isolated formations as gun or tank crews who have their individual dixies, and the lack of epidemic spread in our prisoner of war camps. They explain too the part played by winds, dust, and flies in spreading the infection.

I mention these matters because I think it worthy of record that these experiments were initiated by Maj. Van Rooyen (who acknowledges the page 636 fact) as the result of the epidemiological work done at 1 NZ Gen. Hosp. by Lt.-Col. Kirk and his colleagues.

There were 1139 cases admitted to 3 General Hospital during the quarter, mainly transferred from 1 General Hospital. It was noted that a number of the patients had had severe attacks with residual liver enlargement which necessitated down-grading. The average stay in hospital was twenty-nine days, and another twenty-one days were spent in the Convalescent Depot. Half the medical cases admitted to the convalescent depots were suffering from hepatitis. (See table.)

Infective Hepatitis 2 NZEF, Jan 1941 - Dec 1944

Year	Jan	Feb	Mar	Apr	May	Jun	Jul	Aug	Sep	Oct	Nov	Dec	Total
1941	20	15		4	19	45	84	56	33	55	48	38	417
1942	52	16	3	6	17	8	13	47	374	952	695	341	2524
1943	85	37	23	14	18	30	36	35	52	40	62	144	576
1944	163	147	89	70	41	54	141	279	623	587	474	206	2874

Respiratory Infections: There was no increase in these cases during the colder months and no recrudescence of the epidemic of atypical pneumonia as experienced at Cassino. At 1 General Hospital a falling-off in admissions was noted when the really cold weather became established. Sinusitis was common. All forms of pneumonia occurred. Primary atypical pneumonia was often recognised in cases which would otherwise have been classed as PUO. Broncho-pneumonics formed the majority of the remaining chest cases. Only one case of empyema was reported. There were five cases of pulmonary tuberculosis and four of tuberculous pleural effusion.

Dysentery: There was a marked drop in the incidence of diarrhoea in the Division, only 160 cases being admitted to medical units during the last quarter of the year. There were only 33 cases of dysentery evacuated. The cases of diarrhoea and dysentery admitted to 1 General Hospital fell from 48 in October to 16 in December. At 3 General Hospital the chronic cases of amoebic dysentery became a problem and investigation showed that there were many of these cases arising in Italy. During October 35 cases were reported, in November 34, and in December 39. The condition gave rise to general debility and prolonged treatment was required. The average period in 3 General Hospital of cases of diarrhoea was reported to be 14 days; of bacillary dysentery, 11 days; and of amoebic dysentery, 42 days.

Colonel Boyd, Consultant Physician 2 NZEF, in a lecture on the aftermath of infections contracted overseas, expressed the opinion that amoebiasis was likely to be the main problem in New Zealand page 637 and that the condition would give rise to difficulties in diagnosis. The main lesions encountered would be: (a) hepatitis and hepatic abscess; (b) caecal; (c) rectal. It had been found that in those developing hepatitis, 25 per cent had had previous treatment for amoebic dysentery, 25 per cent had never had any bowel symptoms, and 50 per cent gave negative results on investigation. Hepatic abscess generally developed in the upper and posterior part of the right lobe. Pain on the right side over the region of the liver was often present. The condition had often been mistaken for carcinoma of the stomach.¹

Diphtheria: The mingling with the civilian population consequent on billeting of the troops resulted in sporadic cases of diphtheria. In the last quarter of the year 26 cases were reported in the Division and 37 at 1 General Hospital. During December there were 29 cases in the wards of the hospital as well as 6 cases of wounds infected with KLB. The infection was generally mild and responded to 48,000 units of serum. The cases did not clear up rapidly, a condition noticed previously in Egypt, where it was often necessary to have a tonsillectomy carried out to obtain negative swabs. There were very few cases in the other hospitals.

Skin Diseases: Furunculosis was very common at this period, as were skin infections generally. Penicillin was used for the severe cases with good temporary results, but it did not stop relapses unless associated with general dietetic and vitamin treatment. Ultra-violet light was used with good results. Scabies and pediculosis showed a marked increase in the Division, again due to billeting.

Malaria: Only 27 cases were reported in the Division during the last quarter of the year as against 67 cases in the previous quarter. The total cases reported in 2 NZEF were:

	Sep	Oct	Nov	Dec
Italy	43	14	8	5
Egypt	16	16	2	1

Malaria had not been a problem at all in our force, not even after the seasonal stopping of mepacrine. This suggested excellent control within units.

Venereal Disease: There was a relatively low incidence of venereal disease during this period. There were 54 fresh cases in September, 48 in October, 71 in November, and 61 in December, and diagnoses were: syphilis 8; gonorrhoea 98; soft sore 27; balanitis 20; urethritis 53; penile sore 13; gonorrhoea and soft sore 3; prostatitis 4; and others 6. The majority of cases developed after leave, especially to page 638 Rome. The number of fresh cases was three times greater than those reported the year previously in Egypt. In October there were 800 cases under treatment and 100 final tests were completed during the month. Penicillin had been introduced for the treatment of both gonorrhoea and syphilis with excellent results. In December it was noted that the first apparent relapse following penicillin treatment for gonorrhoea had occurred, but it was suggested that this was a fresh infection. Fifteen cases of syphilis that had not completed two courses of arsenic injections were given 2,400,000 units of penicillin in seven and a half days in one and a half hourly injections. Cases of prostatitis were given intramuscular penicillin and also local penicillin by Ultzmann's syringe with good results. Hospitalisation had been reduced by the use of penicillin, syphilitic patients being retained for fourteen days, and cases of gonorrhoea for less than five days on an average. The urethritis cases showed no organisms but marked pus formation. The symptoms usually appeared three to five weeks after intercourse.

Hot showers were provided by the treatment centre for the patients in December. All brothels were placed out of bounds to the troops.

Anxiety States: One hundred and twenty-four cases were evacuated from the Division during the quarter to the end of December as against 174 in the previous quarter. The cases were all admitted to 1 General Hospital, which reported that they occurred mostly among new arrivals and mainly among the less willing.

Divisional Casualties, October-December 1944

	Sick	BC	Total
October	1648	332	1980
November	1478	30	1508
December	1342	574	1916
	——	——	——
	4468	936	5404

(Previous quarter, 6063)

Admissions to Divisional Units, October–December 1944

	Oct-Dec 1944	Jul-Sep 1944
Hepatitis	880	778
Fever NYD	494	808
ENT	282	217
Accidental Injuries	456	639
Diarrhoea	162	304
Dysentery	33	49
Diphtheria	26
Malaria		67
Exhaustion	124	174
VD	193	196

page 639

Admissions to 1 CCS, October–December 1944

	Sick	BC	Total	Deaths
18 Oct–30 Nov	443	174	617	8
1–31 Dec	190	572	762	14
	——	——	——	——
	633	746	1379	22

Types of Wounds as Seen at 1 CCS, October–December 1944

Bullet wounds	100	13·2	per cent
Shell''	435	57·8	per cent
Bomb	79	10·5	per cent
Mine	54	7·2	per cent
Mortar	85	11·3	per cent
	——	——
	753	100·0

Of these, multiple wounds 275

Admissions to 1 Gen Hosp, October–December 1944

	Oct	Nov	Dec	Total
Surgical Admissions				1747
Medical Admissions	1032	812	503	2347}4094
Principal Admissions—Battle Casualties				779
Hepatitis	489	369	137	995
Diarrhoea and Dysentery	48	38	16	102
Skins	74	47	49	170
Respiratory	78	58	37	173
Diphtheria	12	4	21	37
Anxiety States	19	57	46	122
Furunculosis	11	28	29	68

Evacuations from 1 Gen Hosp in October 1944

Evac. by hospital ship to Bari	1016
Evac. by hospital train	248
Evac. to reinforcement transit unit and unit	341
	——
	1605

Admissions to 2 Gen Hosp; October–December 1944

	NZ Cases	Others	Total
Admitted direct	67	60	127
Transferred from other medical units	417	246	663
	——	——	——
	484	306	790
Battle casualties	51	74	125

Admissions to 3 Gen Hosp, October–December 1944

Admitted direct	478
Transferred from other medical units	1373
	——
Total	1851

page 640

Admissions to other than New Zealand Hospitals

In September and October there were again considerable numbers of New Zealand patients temporarily in other hospitals. Some of these were in the forward areas in Canadian CCSs, in the British neurosurgical units, and in transit hospitals at Fano. In November a regular channel of evacuation through New Zealand units was functioning and the number was much smaller. Admissions to other hospitals were: September, 410; October, 528; November, 134; December, 151.

Deaths in New Zealand Medical Units, September–December 1944

There were very few deaths other than those occurring in the field ambulances and only two deaths in hospital in Italy other than from battle casualties, a remarkably small number in over 20,000 men in 2 NZEF in Italy. One of the two deaths followed an injury and the other was from a ruptured cerebral aneurysm.

	NZ	Other	Total
Deaths in FSU	4	3	7
Deaths in CCS	16	6	22
Deaths in 1 Gen Hosp	10	4	14
Deaths in 2 Gen Hosp	3		3
Deaths in 3 Gen Hosp	1		1
	——	——	——
	34	13	47

Casualty State 2 NZ Division, November 1943–November 1944 (NB: Accidental injuries are included in BC figures up to 31 January 1944.)

	Sick	BC	Acc. Inj.	Total	Discharged (RTU)
1943
18–30 Nov	260	228	(not recorded)	488	43
Dec	833	1,011	(not recorded)	1,844	228
1944
Jan	693	217		910	159
Feb	813	328	166	1,307	160
Mar	922	811	222	1,955	252
Apr	695	109	216	1,020	161
May	993	272	249	1,514	305
Jun	1,099	165	172	1,436	357
Jul	1,279	593	237	2,109	415
Aug	1,264	316	181	1,761	401
Sep	1,523	451	219	2,193	382
Oct	1,495	332	153	1,980	583
1–17 Nov	781		118	899	294
	——	——	——	——	——
Totals	12,650	4,833	1,933	19,416	3,740

page 641

Casualties in 2 NZ Division During Period of One Year in Italy up Till 17 November 1944

Battle Casualties (including killed and PW)	6,094
Sick	14,583
Evacuated for medical boarding	288
	——
	20,965
Returned to units from MDS	3,740
	——
Temporarily lost to the Division	17,225

The only permanent loss to the Division consisted of those men downgraded as unfit for further service in the Division and those evacuated to New Zealand. This would be a relatively small percentage of the total.

A total equal to the strength of the Division passed through the medical units in the year.

Main Categories	Cases of Fever NYD	2,039
	Cases of accidental injury	1,933
	Cases of Hepatitis	1,924
	Cases of VD	1,028
		——
		6,924

Patients in Medical Units–Percentage of Troops in 2 NZEF

	Italy	Egypt	Total Patients
1 Oct	10·62 (excluding BCs 4·94)	4·94	2947
31 Oct	9·96 (excluding BCs 7·84)	3·8	2698
30 Nov	9·81 (excluding BCs 8·38)	4·3	2847
31 Dec	9·75 (excluding BCs 6·98)	5·4	2720

The surgical work carried out at 2 NZ General Hospital, our forward base hospital, during 1944 is well illustrated by the following statistics:

Classification of missiles causing wounds, and also regional distribution of wounds and deaths, of the 2084 battle casualties admitted to 2 General Hospital from forward areas in 1944. (Lieutenant-Colonel J. M. Clarke)

Missiles Responsible	Patients	Percentage
GSW	276	13·24
SW (HE)	1072	51·48
Mortar	392	18·80
Grenade	146	7·00
Mine	148	7·10
Aerial bomb	25	1·19
Bayonet	1	0·04
Various	24	1·15
	——	——
	2084	100·00

page 642

Regional Distribution	Wounds	Percentage
Head wounds—Severe 51	123	5·9
Slight 72
Spine, involving cord 13	17	0·8
Spine, not involving cord 4
Neck, severe	3	0·1
Facio-maxillary	21	1·0
Eye	64	3·0
Blast effects—Ears	66	3·1
Other	24	1·2
Chest	53	2·5
Thoraco-abdominal	12	0·6
Abdominal	57	2·7
External genitalia	10	0·5
Major joints	117	5·6
Major nerves	103	4·9
Major vessels	52	2·5
Fractures, compound	352	16·9
Fractures, simple	8	0·4
Amputations—Major	55	2·75
Minor	15	0·75
Flesh wounds only	1153	55·3
Burns	15	0·75
Due to masonry	29	1·4

Deaths—
Due to abdominal wounds	9
Due to thoraco-abdominal wounds	1
Due to chest wounds	2
Due to uraemia	2
Due to pyaemia from infected wounds	2
	——
	16—0·8 per cent of total

Italy, 1944–Comparative Casualty Rates of Cases Admitted to all Medical Units (Rate per 1000 British troops per year taken as 100)

	British	Canadian	New Zealand	Indian	African	Total Force
Battle casualties	100	192	230	294	143	128
Accidental injuries	100	169	291	233	298	127
Burns	100	217	308	163	155	125
Diseases	100	153	161	83	110	107
All admissions	100	161	180	124	126	111

page 643

Diseases in Italy, 1944–Comparative Morbidity Rates of Cases Admitted to all Medical Units (Rate per 1000 British troops per year taken as 100)

	British	Canadian	New Zealand	Indian	African	Total Force
Malaria	100	76	12	29	33	88
Venereal disease	100	136	107	52	172	102
Infective hepatitis	100	353	677	59	98	142
Dysenteries	100	76	202	106	134	102
Diphtheria	100	163	135	6	34	100
Pneumonia	100	100	526	86	125	113
Influenza	100	967	354	148	235	204
Sandfly fever	100	13	68	46	94	86
Enteric fever	100	791	256	32	38	170
Tuberculosis	100	48	73	589	560	138
Helminthic diseases	100	238	1329	1757	33	267
Food poisoning	100	70	30	230	626	116
Nervous disorders (incl. exhaustion)	100	156	161	61	181	107
Skin diseases	100	132	185	108	94	106
IAT	100	130	179	114	127	107
All diseases	100	153	161	83	110	107