New Zealand Medical Services in Middle East and Italy
REVIEW OF MEDICAL WORK OF THE DIVISION
REVIEW OF MEDICAL WORK OF THE DIVISION
The arrangements made for the treatment of the casualties were based on the attachment of an ADS to each brigade to carry out the first-aid treatment whenever the brigade might be engaged in very mobile battle. At the MDS arrangements were made to carry out the more elaborate forward surgery. To enable this to be done, the page 286 newly formed MSU was attached to the active MDS with the role of operating on specially selected cases such as abdomens, chests, and heads. It had very elaborate equipment, similar to that of the head and chest units in Britain, which had been brought from England by the Second Echelon, and to this instruments were added for abdominal and general surgery.1 A truck had been specially fitted up in Cairo to contain the equipment as well as special lighting plant, suction, and tanks to hold extra water. The unit was self-contained. The OC, Major Furkert, was a skilled surgeon and Major S. Wilson was one of our ablest young surgeons in the Middle East Force. The whole staff was hand-picked.
In the ambulances themselves there were many capable medical officers and some quite capable surgeons. It was fortunate that this was so, as the Division under the circumstances of the battle had to undertake the full responsibility of the forward surgery. The field ambulance surgical teams dealt with the routine wounds, and the MSU had referred to it specially selected cases. This arrangement, however, lasted only a very short time as it was found that in the rush it was impossible to restrict the work of the MSU, and, as had happened before, in France and in the Desert, the specialist teams in the forward areas had to deal with far more general than special cases. The surgeons were, in any case, general surgeons so were well able to fit in with the conditions.
At that period wound treatment consisted in the surgical cleansing of the wound, the local application of sulphanilamide, the dressing with vaselined gauze and the use of enclosed plaster splints, the method recommended by Trueta. This treatment was carried out in the MDS, and generally no further forward surgery was necessary and the patients were staged along their journey to Egypt in the different units, being fed and bedded and having their dressings changed as required, though, with the plaster technique, change of dressings was infrequent.
The prolonged journey, however, was very exhausting to the more serious cases and the constant shifting aggravated any infection that might have been present. The first part of the journey by ambulance or truck across the desert to the railhead was particularly trying, and was associated with the constant danger of interference by enemy mobile columns. The surface was rough and at times the convoys had to be speeded up. The nights were cold, and at times there were insufficient blankets available. The adequate resuscitation of the serious cases was gravely interfered with by lack of water, especially during the period when the MDSs were captured. Some page 287 blood had been sent up to the forward areas but not to the divisional areas. Plasma had been supplied, four bottles, to each field ambulance, and citrate solution for locally drawn blood. There was also supplied a quantity of distilled water for use with the plasma, but the supply of this was somewhat restricted. Plasma was given in the MDS and the MSU, and some blood was given from local donors. Morphia was available, and fresh supplies were obtained from captured enemy stores.
The nature of the work performed in the ADS is shown in a very valuable report by Major Harrison, who was in charge of the only uncaptured medical unit, 4 ADS. This ADS treated altogether 448 casualties, 360 being New Zealanders. There were 15 deaths, 10 being New Zealanders, and casualties in the ADS itself were 1 killed and 9 wounded. Harrison stated that he limited his treatment to the ligation of arteries, amputation of shattered limbs, splinting of fractures, suture of sucking wounds of the chest, and aspiration of haemothorax. At times when casualties had to be retained for twenty-four to forty-eight hours, more extensive surgical procedures were carried out, such as excision of wounds, drainage of infected wounds, and removal of obvious foreign bodies. Treatment of shock was difficult owing to the shortage of water and hot-water bottles. Often there was a shortage of acriflavine lotion and once of morphia. Kramer wire splinting proved very valuable, and when supplies ran short they were replenished from captured enemy equipment. The majority of the cases dying in the ADS were badly shocked on admission, and practically all suffered from great loss of blood. Only one plasma infusion was given, and it was impossible to give transfusions after dark. The majority of anaesthetics given were sodium pentothal.
Harrison gave a classification of the wounded men as under:
(a) Parts affected:
|Face and neck||32|
(b) Complications and deaths:
|2||deaths (both traumatic amputations with marked shock and blood loss).|
|Head:||9||had fractured skull.|
|3||of these died.|
|Face and Neck:||4||fractures of facial bones.|
|2||involving air passages died; in one case the great vessels were severed.page 288|
|Chest:||6||sucking wounds of which one died.|
|5||other deaths from extensive damage.|
|Abdomen:||15||had intra-abdominal damage, several with portions of viscera extruding from the wound.|
|2||died in the ADS.|
|Buttocks:||3||had intra-abdominal damage, one dying.|
|Lumbar region:||All wounds superficial.|
This ADS had to treat the casualties from the attack by 20 Battalion on 27 November, and many of these were hit in the early afternoon and stayed out in no-man's-land until after dark, suffering more wounds as they lay, and were in a bad way when brought in. Twelve of them died shortly afterwards, either in the MDS, in Tobruk, or in some other medical centre. Their main wounds were as follows:
|Face and neck||2|
Major King's detachment, with the help of an RAMC officer, operated on twenty-two severely wounded Germans left behind by General Rommel. Two of these, having had tourniquets on for three days, required amputation of the legs. All the cases had been wounded two or three days before and had received little, if any, medical attention. The Germans concentrated on the minor casualties so as to fit them for further service and neglected the severe cases. Rommel's large mobile force was stated to have very few medical officers attached and no field ambulance.
Major King reported that as much surgery as possible was done at his unit because of the very questionable contact with the CCS over a rough desert track. He operated on all cases except abdomens. The small supplies of glucose saline and plasma were soon used up. No blood was used. Sterile tulle gras, prepared by the unit before the campaign, was available, each dressing being wrapped in cellophane from cigarette packets. Some German dressings were used—these were of fine paper. All available plaster-of-paris was used up in the splinting of fractures.
Major Furkert in his reports of the work of the MSU gave a clear picture of the conditions under which forward surgery was carried out during the campaign. During the period of capture water was cut down to a pint per head, and the lack of water undoubtedly increased the mortality, especially of the abdominal cases. Dehydration noticeably accelerated death by 4 December. An enemy filter was used for the theatre water, which was re-used indefinitely. No patients were washed and no linen was cleaned. Only once in a page 289 fortnight was water drawn, and without the unit reserve work would have been impossible.
Supplies of kerosene and spirit were very short, and both sterilisation and heating became difficult. There were insufficient blankets for the large numbers of wounded, and this caused some distress as the weather was cold. Selection of cases became impossible and few casualties were admitted who had been wounded less than twenty-four hours, and many wounds were three days old. But, in spite of this, fulminating infection was rare. Very few abdominal cases were seen. Shortage of ether, morphia, and plaster-of-paris was serious. Food consisted of vehicle battle rations, and shortage of water made the use of Red Cross comforts difficult. Evacuation to the CCS after the relief necessitated twelve hours' actual desert travelling.
Surgery in Mobile Surgical Unit, 23 November–5 December 1941
Patients admitted 190; patients operated on 112; post-operative deaths 15 (omitting 4 killed by shellfire after operation); other deaths 30, including 5 from shellfire, 1 under anaesthetic induction, and 13 who were either so late or so shocked that they could not be brought to operation.
|Type||Total Cases||Operations||Post-op Deaths||Non-op Deaths||Total Deaths|
|Abdomen, incl. pelvis||21||16||6*||5||11|
|Comp fract large bones, etc.||53||43||6*||4*||10|
|Amputations (some traumatic)||16||13||2||3||5|
|Severe flesh wounds||36||19||2*||1||3|
|Spine with paralysi||4||4||4|
In the MDS area a great deal of operative treatment was carried out by surgical teams formed from the ambulances' own personnel. Records show that by 4 December some wounds were showing evidence of severe infection. Moreover, the elastoplast extensions applied to fractured femur cases peeled off in eight to nine days and had to be replaced by a piece of wire inserted in front of the tendo Achilles above the ankle. On 5 December patients were becoming desperate for water; some developed projectile vomiting and were unable to keep down even sips of water. There was no intravenous glucose saline left and insufficient water for rectal drips. Some patients developed swollen and cracked tongues, which were extremely painful, besides sores of the lips. At that date there was only 30 gallons of water left for the 860 casualties as well as the page 290 medical personnel. Several patients seemed to die of cold as the supplies of kerosene failed. Bed sores were common, with no means of washing the patients' backs or blankets. (The relieving convoys arrived on 6 December with food and water.)
Behind the divisional area the medical centre of Minqar el Zannan dealt with cases as they were evacuated from the forward areas, but the urgent surgical treatment had already been carried out at the MDS level and it was only the cases unfit for further evacuation that needed to be dealt with. Otherwise, the CCS acted as a staging and sorting post, and sent cases back to the general hospitals either at Matruh or further back in Egypt. At 2 NZ General Hospital sited at Garawla, only 228 casualties were admitted, 180 of them in one convoy. It was noted that 57 of these were profoundly exhausted and dehydrated. There had been insufficient blood for transfusion in the forward areas and the majority of the serious cases required blood transfusion on arrival. Infection was common and at times severe. The amputation stumps which had been sutured were unsatisfactory. The plaster spicas had caused bad sores. There had been serious delays in evacuation from the forward areas. Few abdominal cases were seen.
The battle casualties admitted to 2 NZ General Hospital consisted mostly of cases of multiple wounds classified as: Soft-tissue wounds 145, fractures 29, heads 12, chests 14, abdomens 6, amputations 6, burns 4. It was noted that the chest wounds with simple stitching did well and those with elaborate toilet did badly. Sulphonamides did not appear to have lessened infection and sutured amputation wounds were septic. Thirty-eight of the cases were given an average of two pints of blood. Five deaths occurred, three of them within twelve hours of admission.
It was stated that the placing of general hospitals on the Line of Communication had saved several lives, and that if it had been possible to site them still farther forward it would have saved the severe cases from the extreme exhaustion noted on admission to the hospital at Garawla.
Reports were obtained both from our own base hospitals in Egypt and from the British hospitals to which the large majority of our casualties were primarily admitted. Observations were also made by the Consultant Surgeon 2 NZEF, who paid frequent visits to the British hospitals, and also by the Consultant Surgeon MEF. The following is a summary of these observations and criticisms:
Excision of wounds: This had generally been adequate and had proved valuable in preventing infection.
Drainage of wounds: In many infected cases insufficient drainage had been provided.page 291
Primary suture of wounds: Such wounds were stated to be almost always septic and breaking down and the patients were toxic.
Amputations: The amputation of a mangled limb was often seen to produce a dramatic improvement in the patient's condition. Amputation had often been carried out at the site of election and primary suture performed. Sepsis had almost invariably followed, with breaking down of the stump. All reports urged the necessity of performing the primary amputation as near the wound as possible and leaving the skin unsutured. There had been a lack of skin traction in many of the unsutured stumps. Secondary amputations at Base, carried out for secondary haemorrhage and severe infection, had been common.
Chests: Open pneumothorax cases travelled badly. Only one New Zealand sucking chest case was seen at Base.
Heads: Head wounds adequately excised and sutured with drainage did well.
Plasters: Skin-tight plasters had proved dangerous and their use was condemned.
Abdomens: The Consultant Surgeon 2 NZEF noted that no New Zealand abdominal cases were seen by him in visits to the base hospitals.
Tetanus: No cases had been reported throughout the Army.
Gas gangrene: Nine cases had been reported in the Army, none being seen in New Zealand cases at Base, though two were reported at the MDS centre.
Burns: Tanning treatment was being carried out and 10 per cent silver nitrate solution was being used in some British hospitals.
Sulphonamide: Oral administration had been unsatisfactory during evacuation. A special chart for marking dosage was advised.
The picture was one of serious injuries, severe sepsis, frequent secondary haemorrhage and amputations.page 292
In summarising the treatment of casualties in the Second Libyan Campaign it can be stated that, as far as the New Zealand Division was concerned, primary surgery was carried out in our own field ambulances and in our MSU. Wound débridement was done, with the wound dusted with sulphanilamide and left open and, if necessary, drained. Plaster splints were applied to fractures of the leg and forearm. Thomas splints were applied to the thigh fractures and the upper arm largely treated in simple splint with a sling.
The MSU dealt with the abdomens, the chests, the heads, and many of the amputations. Early evacuation of all cases was aimed at, but circumstances prevented this and the majority of the wounded were captured and immobilised for eight days, when they suffered severely from lack of water. Eventually the casualties were evacuated by many stages to Alexandria and the Canal Zone, and finally transferred to our own hospitals in Cairo.
There had been a large proportion of very serious wounds, and the unsettled condition of the divisional area and the prolonged and many-staged evacuation had resulted in a rather heavy mortality and severe infection, largely streptococcal, in many of the cases. Conditions in the forward areas undoubtedly prevented early surgical débridement in the large majority of the cases. Although the primary mortality of the abdominal and chest wounds was not heavy as recorded by the MSU, it was noted that only three abdominal cases were seen at Base, and very few chest cases, so it can be surmised that there was a heavy mortality in these cases during evacuation.
The performance of sites of election amputations with suture in the forward areas was noted to give rise to serious infection and disastrous results at the Base. Neglect of skin traction in unsutured stumps was also common.
Splinting in the forward areas was excellent. The Tobruk plaster for fractured femurs had proved its value though the Thomas splint also gave good results. The limited blood transfusion available had been of great value under the difficult conditions. The Mobile Surgical Unit had completely justified itself in saving the lives of many severely wounded men, and the surgical treatment in the forward areas had been soundly carried out.
Staffing of Ambulance Trains and Naval Carriers
The DMS General Headquarters, British Troops in Egypt, suggested that, in view of the very general shortage of medical personnel in the Middle East Force, 2 NZEF should take its share in line of communication services such as ambulance trains and ambulance carriers (naval). DDMS 2 NZEF, therefore, agreed to the formation of an ambulance train unit, comprising one medical officer and page 293 fourteen men, and an ambulance transport unit of three medical officers and thirty men. The latter unit was to be employed in the Mediterranean on the Warsawa, a Polish ship of 3000 tons, but was never actually used for this purpose owing to the ramming of the ship at Alexandria. An ambulance transport was defined as ‘a ship which carries cargo on the outward journey and casualties on the return journey’.
The ambulance train unit functioned from 28 November 1941 until 21 January 1942 and earned commendation for its efficient work.
A party of NZMC personnel comprising one medical officer and ten other ranks was detached for duty on the Hospital Ship Somersetshire, which evacuated casualties from forward areas on the Mediterranean coast to Alexandria. This group returned to Maadi on 6 March 1942.
During December our New Zealand general hospitals were very busy coping with the Libyan casualties, though these were mostly transferred from British hospitals after treatment there. In all, 985 battle casualties and 1540 sick were admitted to hospital in the month from 2 NZEF, and of these 809 were transferred from British hospitals, a special effort being made to transfer all movable cases before Christmas. These battle casualties were mainly minor cases, though there were some severe compound fractures. Eight amputations were reported in our hospitals. During January most of the other battle casualties were transferred from British hospitals, some of them having already been medically boarded. Our head injury cases were dealt with by the neurosurgical unit at 15 Scottish Hospital, Cairo, but arrangements were made to transfer the cases to 1 General Hospital and recall Major McKenzie1 from the unit to look after them. Our facio-maxillary cases were mostly treated in the British special centre at Alexandria.
Practically all the serious cases were returned to New Zealand on HS Maunganui at the end of January, some sooner than they normally would have been, but the hospital ship was very well staffed to deal with them.
A review of the Division's wounded who reached the base hospitals and survived was made from medical board papers by the Consultant Surgeon. There was a considerable number of very severe wounds, including fractures of the long bones and amputations, with asso- page 294 ciated nerve injuries. Only three abdominal cases with bowel injury had survived, all having been operated on in the Mobile Surgical Unit. Few cases of injury to the skull, brain, or chest were admitted to base hospitals, but eye injuries were common and involved ten enucleations. Joint injury associated with subsequent streptococcal infections had been serious but not very frequent. Secondary haemorrhage was reported in twelve cases, in eight of which the bleeding vessel had been ligatured.
Most of the amputations had been necessitated largely by the original severity of the wound, and subsequent amputations had been due largely to damage to the blood supply of the limb. Severity of the wound was the reason for twenty-nine amputations, vascular damage for five, gas gangrene for five, sepsis for two, and haemorrhage for two. It appeared that nearly all the amputations had been inevitable from the beginning and that very few could possibly have been prevented under any conditions; and certainly in very many cases amputation was prevented by excellent treatment and great patience.
The fractures of the long bones showed excellent results and the majority of cases were evacuated to New Zealand in very good condition. The condition of the cases generally reflected great credit on the surgical staffs of British and New Zealand hospitals responsible for their treatment.
Battle casualties boarded and evacuated to New Zealand showed the following types of wounds (a case of multiple wounds being included more than once): Heads 20; chests 27; abdomens 3; amputations 47; nerve injuries 50; burns 3; fractures—femur 40, tibia and/or fibula 49, radius and/or ulna 22, humerus 41, jaw 4, spine 1, pelvis 5, patella 4, scapula 7, clavicle 6—a total of 179 wounded.
A surgical conference was held in Cairo in February 1942 to evaluate the results of treatment following the Libyan campaign. Papers were read by two of our officers and an account of the work of the Mobile Surgical Unit was also given. Points emphasised at the conference included the value of the Tobruk type of splint for fracture of the femur; the necessity to perform only temporary amputations, preserving the maximum amount of healthy tissue with non-suture of the wound, and the ligature of the vessel at the site of bleeding in secondary haemorrhage; and the referring of head cases to the Base for definitive operative treatment. Two series of abdominal injuries were reported—one from the First Libyan Campaign of 25 cases, with 40 per cent recoveries, and one from the Second Libyan Campaign of 33 cases, with 33 per cent recoveries.
Suggestions for improvements in forward surgery were made at that time by the Consultant Surgeon MEF as follows: More plasma page 295 should be supplied, and blood should be made available to the divisional units; sulphonamide in powder form should be supplied in tins ready for use, and as tablets added to the field dressing package; vaseline gauze or tulle gras should be prepared and sterilised in tins at the base hospitals and sent forward to field units for the treatment of burns. It was pointed out that the futility of operating in severely shocked cases at an early stage was sometimes not realised by medical officers in the forward areas, whose duty was primarily to resuscitate, and then to evacuate, the wounded for definitive surgery elsewhere.
Work of NZ units at Alexandria and Garawla
The detachment of 3 General Hospital, which, under Lieutenant-Colonel Button as OC and Miss Hennessy as Matron, took over two wards of the Anglo-Swiss hospital at Alexandria on 23 November, admitted its first patients on 4 December. They were forty-one patients who had arrived by ship from Tobruk. The number of patients grew to 171 at the end of the month. Many of the patients had passed through up to six medical units in the field before arriving at the hospital. With adequate draining of septic wounds and splinting, together with sulphonamide by mouth, all cases progressed satisfactorily. The detachment functioned at Alexandria until 28 April 1942, by which time it had treated 626 patients—315 of them from the Western Desert, 146 from New Zealand units in the Alexandria area, 114 from 1 NZ Convalescent Depot, and 51 from 2 NZ Rest Home. Its period of useful work was terminated by the move of the Division to Syria and the need for the detachment to rejoin its parent unit for service in that area.
In its four months at Garawla to March 1942, 2 General Hospital admitted 3266 patients, including 228 battle casualties from the Libyan campaign. New Zealand patients were in the minority, numbering 990. The hospital experienced numerous dust-storms and occasional rain, but it was never subjected to air attack. The reason for this as volunteered by a prisoner patient, one of the crew of a German bomber shot down nearby, was that the hospital was recognised by enemy pilots, as well as by Allied pilots, as a useful landmark from which to get their bearings, and that it would be a handicap to bomb it. (This presumably was a reason additional to the primary one of the observance of the Geneva Convention.)page 296
* Means one patient killed by shellfire.