New Zealand Medical Services in Middle East and Italy
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.)
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:
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.
(Previous quarter, 6063)
|Oct-Dec 1944||Jul-Sep 1944|
|18 Oct–30 Nov||443||174||617||8|
|Bullet wounds||100||13·2||per cent|
Of these, multiple wounds 275
|Principal Admissions—Battle Casualties||779|
|Diarrhoea and Dysentery||48||38||16||102|
|Evac. by hospital ship to Bari||1016|
|Evac. by hospital train||248|
|Evac. to reinforcement transit unit and unit||341|
|Transferred from other medical units||417||246||663|
|Transferred from other medical units||1373|
1 Colonel Boyd's opinion proved to be correct and chronic amoebiasis has been a cause of disability in a number of returned servicemen, but the number of new cases has diminished after some seven years. There were 148 cases accepted for pensions up to September 1949.