War Surgery and Medicine
CHAPTER 14 — Respiratory Diseases
IT is not possible from the available records to reach any conclusion about the total incidence of infections of the respiratory tract in 2 NZEF. Acute coryza was universally prevalent, as it is in civil life. All but the most severe cases endured their discomforts philosophically and inevitably spread the infection to others. Canadian estimates of the loss of training time from acute respiratory disorders suggest that familiarity alone does not excuse a complacent attitude. Under training conditions it is possible that more energetic treatment and isolation where practicable would be well rewarded not only in shortening the period of relative disability and preventing complications in individual sufferers, but also in reducing the incidence of such infections in large bodies of troops.
The term ‘influenza’ was usually applied to short-term pyrexia, associated with symptoms of respiratory tract infection and occurring in epidemic form. Several outbreaks occurred in training camps in New Zealand, but only two of any significance among the troops of 2 NZEF. In March 1940 influenza occurred among the newly-arrived First Echelon in Egypt. A more serious epidemic involved the troops of the 5th Reinforcements travelling to the Middle East. In anticipation, all patients from 3 NZ General Hospital were transferred to 2 NZ General Hospital. When the convoy arrived on 13 May 1941 a special ambulance train took 290 cases of influenza, including 5 with pneumonia, direct to 3 NZ General Hospital. The incoming troops were segregated on arrival. A further 35 cases occurred in the next forty-eight hours, but the epidemic quickly abated and remained localised as a result of these precautions. There were no deaths from influenza in 2 NZEF.
There was a much higher incidence of influenza among troops in New Zealand than in those overseas, especially in the first half of the war. There was a widespread epidemic in the three main mobilisation camps in October 1939, and the numbers in each of the units of the First Echelon varied from 25 to 54 per cent of the strength of the units. The average period spent by page 578 the cases in camp hospitals was four days. It was found that the initial incidence was higher in tented units and that there was an improvement when extra tents were erected and the number per tent reduced from eight to six men. Factors lowering the resistance of the troops were, besides a certain overcrowding in tents and huts, dust arising from construction work in the camps, and the giving of TAB inoculations two or three weeks after the troops entered camp. Unit commanders were reminded of necessary preventive measures, including adequate air space and ventilation in sleeping quarters, provision for changes of wet clothing and ample drying facilities, and the avoidance of undue fatigue by graduated training.
It is recorded that there were 4685 cases of influenza from the main camps between January and September 1940, and in the winter of 1941 influenza was again very prevalent but mild in nature. In the winter of 1942, when many troops were mobilised for Home Defence, there were nearly 9000 cases recorded among troops, but the figures dropped in succeeding years to 736 in 1943, 369 in 1944, and 721 in 1945. Influenza was the most common cause of hospitalisation among troops in New Zealand. The number of deaths is not known, but for all respiratory disease from 1940 to 1944 the total deaths were only 17.
About 35 cases of bronchitis per month occurred in 2 NZEF during the period 1943–45. The earlier incidence was probably similar, with a tendency to increase slightly during the winter months.
There was, as expected, a definite relationship between the incidence of pneumonia and the wetness of the season. In March and April 1940 the incidence reached 2.8 per 1000 among troops of the First Echelon in Egypt. There were 49 cases during January and February 1941, of whom 2 died. Between 1 July 1941 and 31 March 1943 there were in all 218 cases of pneumonia, of which 164 were classified as lobar and 54 as bronchopneumonia. Six of the 164 cases of lobar pneumonia died (3.6 per cent). Many cases developed a serous effusion, but only in three did this proceed to empyema (1.8 per cent). The reduction of complications and the improved prognosis were directly attributable to the effective use of sulphonamides. In the earlier cases sulphapyridine was used: later sulphathiazole was preferred on account of its equal effectiveness with lesser toxicity. The dosage given was four tablets as soon as diagnosis was made and thereafter two tablets page 579 every four hours till the temperature dropped (usually thirty-six to forty-eight hours). Then two tablets t.i.d. till the temperature had been normal for two days. (Total was usually 18–24 gms. Each tablet equals .5 grammes.) The rapid symptomatic response to chemotherapy contrasted with the slowness of complete clinical and radiological resolution.
In July and August 1943, following the Nile flood, there were 258 cases of pneumonia. These cases were very toxic, with a tendency to more patchy distribution of consolidation.
Between January and June 1944, when 2 NZEF were exposed to the rigours of an Italian winter in the Cassino area and the mountain sectors, the incidence of pneumonia reached its highest figure (4.6 per 1000 in March 1944). Similarly in March and April 1945, as the Division prepared to launch the final spring offensive in Italy, an increased incidence was observed. In both these years the majority of the cases were classified as ‘primary atypical pneumonia’. A consecutive series of these cases, mainly in British troops, was closely studied at 2 NZ General Hospital during 1945. The clinical features and later agglutination studies showed that these epidemics of ‘atypical pneumonia’ were in fact Q fever due to infection with Rickettsia burneti. (See Chapter 15.) These cases ran a toxic course virtually uninfluenced by chemotheraphy or by penicillin, which became available to a limited extent at this stage.
In many cases of short-term pyrexia, classified clinically as ‘influenza’, radiological examination revealed small and slowly resolving areas of pneumonitis.
The recorded incidence of pleurisy was closely related to that of pneumonia. The number of cases was usually between 10 and 20 per cent of the number of cases of pneumonia.
It is of particular interest to compare this record of pneumonia in 2 NZEF with that of 1 NZEF during the First World War. From 1941 to 1945 there were in 2 NZEF 2012 cases of pneumonia, of whom 10 died. These figures include atypical pneumonia and Q fever, but even so the mortality (.5 per cent approximately) is in striking contrast with that observed in 1 NZEF, when of 1579 deaths from disease in 92,860 New Zealand troops, 578 were from pneumonia, 20 from pleurisy, and 152 from influenza, often with complicating pneumonia during the epidemic of 1916–17. This gives a grand total of 750 deaths from acute respiratory disease—almost 50 per cent of all deaths from disease. The conditions of active service in France in 1914–18 undoubtedly favoured respiratory infections, and the 1916–17 epidemic of influenza which heralded the pandemic of 1918 was of extreme virulence. page 580 The highest incidence of pneumonia in 2 NZEF was 4.6 per 1000 in March 1944, whereas the overall incidence in 1 NZEF was 6.1 per 1000. Even allowing for an increased incidence and greater virulence, the transformation in the mortality rate from pneumonia in the two forces is noteworthy and may reasonably be attributed largely to chemotherapy.
There has always been a tendency among medical practitioners, when all other therapeutic measures have proved unavailing, to suggest for the asthmatic a change of climate. That this attitude had contributed to the appearance of large numbers of known asthmatics in the Middle East was suggested by the fact that many of the sufferers reported that they had been assured that their asthma would not trouble them in Egypt. Early experience soon proved, however, that asthma tended to flare up in the Middle East, and recommendations were made to the medical authorities in New Zealand to exclude men with a history of asthma, mild or otherwise, from overseas drafts. Many asthmatics had to be boarded for return to New Zealand soon after arrival in Egypt. By March 1943, 146 asthmatics (3½ per cent of the total invalided) had been evacuated to New Zealand. The total number invalided during the war was 239.
Originally the policy was that every asthmatic should be sent home, since there was evidence of an increased tendency to attacks in Egypt even in asthmatics whose attacks were previously mild or infrequent. Later, as shipping space became restricted, a few of the milder cases were retained for base duties.
Asthma seldom entailed admission to hospital (only 106 cases from 1941 to 1945), though in January 1943 there were 15 cases in hospital, all from the recently arrived 8th Reinforcements. Eight of these were immediately placed on the New Zealand Roll. Some of these were definite, known asthmatics before enlistment. Others had recrudescences of asthma which had been for many years quiescent in New Zealand. Some known asthmatics were free of attacks and were able to give good service in the field. Experience showed, in general, that asthmatics and persons of allergic heredity did not react favourably to conditions in Egypt.page 581
During the seven months from August 1942 to February 1943, 37 cases of asthma in 2 NZEF were admitted to hospital for treatment. Of these, 19 had given no field service at all and only 3 were graded fit for full duties. The Consultant Physician expressed the view that, economically, it was questionable whether it was a wise policy to keep asthmatics in the Middle East, no matter how mild their attacks might at first appear to be. Recurring asthma bred the asthmatic ‘habit’ and men might become chronic asthmatics with a long-term pensionable disability.