War Surgery and Medicine
Early in 1943 the Consultant Physician 2 NZEF, Colonel Boyd, was asked by the DMS 2 NZEF to investigate the typhus epidemic as far as circumstances would permit, and he was fortunate in being able to make an extensive tour with the Director-General of Health in the Egyptian Government, covering many native villages around Cairo, Benha, Tanta and Alexandria. They visited the isolation hospitals and numerous emergency tented hospitals, and out of some thousand cases personally examined close on four hundred.
The clinical features of these cases were very similar to those encountered amongst the few cases admitted to New Zealand General Hospitals. In many cases there is a prodromal period of slight pyrexia and malaise lasting twenty-four to forty-eight hours. The temperature then drops to normal and the patient feels perfectly fit. Some twenty-four to thirty-six hours later the true fever develops.
The onset is sudden, the temperature rising rapidly to fairly high levels, 102 to 105 degrees F., and the patient at once feels very ill. He has generalised aches and pains, and often, but not always, some degree of headache, usually frontal. To begin with, the pulse is usually in keeping with the temperature, but later becomes relatively slow. By the second or third day the face is congested and the eyes suffused. The tongue soon becomes dry and coated; by the eighth or ninth day it is almost diagnostic of the disease—dry with a dirty brown or blackish fur, and tremulous. The patient at this stage is usually unable to protrude it, and his speech is thick and indistinct. Most patients are dull or stupid by the second day and delirium may occur at any stage.
The rash appears on the fourth or fifth day, first on the sides of the chest and abdomen, and quickly spreads over the trunk and limbs. It consists of dirty pink blotches of varying size and tiny punctate dark red petechiae. By the ninth or tenth day most patients are quite deaf, and the limbs are tremulous. The more page 560 toxic case lapses into a ‘typhoid’ state, like that of typhoid fever, but without the tumid abdomen. The spleen is palpably enlarged in only 25 per cent of cases.
The temperature drops about the twelfth to fourteenth day, usually by a rapid lysis. Numerous variations have been described in the type of temperature chart, but they are of little or no diagnostic or prognostic significance.
The disease may be suspected, but cannot be diagnosed with certainty till the rash appears. The white blood count gives no help, and the Weil-Felix reaction gives no help at the time it is really wanted.
There was during the war no specific treatment. Good nursing was the main essential. Sulphonamides and penicillin were useful for secondary infections but seemed to have no effect on the disease itself.
In Italy the New Zealand Division's anti-typhus measures were increased. The mobile shower unit of 4 Field Hygiene Company was busily engaged in showering an average of 450 men a day, and the company's disinfestor was used for the disinfestation of clothing and blankets, while the Mobile Laundry and Bath Unit functioned to capacity. The establishment of 4 Field Hygiene Company was revised in the summer of 1944 to include the anti-malaria control units, with the provision that they become anti-typhus sections in winter when there was a threat of typhus. In the winter of 1944 these sections carried out a limited spraying of divisional sleeping quarters with DDT, and 4 Field Hygiene Company constructed a power dusting unit for the dusting of all showered soldiers and their clothing. Supplies of DDT-impregnated shirts became available and were issued to troops more likely to be exposed to risk of infection, while arrangements were made with the Laundry Unit for the dusting of blankets before re-issue. Anti-louse powders were readily available. Louse infestation in the Division increased in the winter of 1944, but no cases of typhus occurred among New Zealand troops during the time they were in Italy.
There was an epidemic of typhus among civilians in Naples from December 1943 to February 1944, but it was speedily terminated by rigorous methods of control. At the time the city was placed out of bounds to New Zealand troops who were in the area prior to attacking Cassino, but members of other forces on duty in the city escaped infection by carrying out adequate preventive measures. There were 1600 civilian cases but no British Army cases other than one deserter.
The lesson learned in Naples was that, even under conditions ideal for the spread of typhus such as existed in Naples, typhus page 561 can be quickly and effectively controlled by the energetic search for cases and contacts, the large-scale use of insecticide powders applied inside clothing by dust guns, the enforcement of routine preventive measures such as restriction of travel, closure of public places, and intensive propaganda which encouraged a lousy population to crowd into dusting stations. An army, even when employing large numbers of civilians, can live and work in an overcrowded, typhus-ridden city with freedom from infection, provided preventive measures are conscientiously carried out.
One of the powder insecticides used was AL 63, containing derris and naphthalene, and it was found effective for louse control but DDT (dichlor-diphenyl-trichlorethane) was found to be superior by reason of its more persistent action and also because it was non-irritating.