Evacuation of Wounded

From the Alamein line air transport was utilised from the MDS area, both by air ambulance and by transport planes. Two of the latter were destroyed by the enemy and few air ambulances were available. Abdominal cases and chest cases with disturbance of respiration were held, but head cases, spinal injuries, and fractures travelled well and were saved much pain and exhaustion.

Red Cross Protection

The protection of the Red Cross was utilised for the divisional medical units and the evidence is that it was respected by the enemy. The transport planes destroyed when being used to evacuate wounded were not marked with the Red Cross, and ambulance planes so marked were not molested. Deliberate bombing of medical units did not occur, though bombing of our forces was common at this period and was responsible for many casualties.

The Work of the Regimental Medical Officers

The RMOs were faced with difficulties and serious discomforts in their work during this period. Their equipment varied considerably, some having a 15-cwt truck, some a three-tonner, but generally an ambulance was also attached to each battalion. In some cases a 3-ton truck had been especially fitted up for the RAP. Four-wheel-drive vehicles were obtained if possible, as sandy areas had to be negotiated and the desert surface was often very rough. Unit trucks and Bren carriers were utilised to take the wounded to the RAP and ambulances to transport them to the ADS. Frequently ambulances were utilised in front of the RAP.

Casualties from minefields and from bombing were frequent. The minefields caused many casualties amongst the ambulance page 360 personnel when the ambulances were used away from the cleared tracks. Large Red Cross flags were flown by the RAPs, and large crosses painted on top of the 3-ton trucks.

Wound treatment was simple and splinting, except of the simplest kind, was generally left to the ADS. Speed of evacuation was the aim. The sand and heat were oppressive and there was only the minimum supply of water.

Surgery During the Campaign

The pre-Alamein period of the desert campaign is notable for the developments in the surgical treatment of the wounded in the forward areas. Very important innovations were made to enable efficient surgery and post-operative nursing to be carried out at the main dressing stations of the field ambulances. The difficulty of evacuating serious cases over the rough, trackless desert made it impossible to defer operation till the casualty could be brought back to the CCS. The fluid and uncertain military situation made it impossible for the forward (British) CCS to be stabilised and undertake operative work. In fact, the CCS was completely withdrawn a few days after its hurried withdrawal to the Alamein line. The full responsibility for forward surgery for 2 NZ Division was thus undertaken by our active MDS. Fortunately, all our MDSs possessed extra equipment for this purpose and, particularly, each field ambulance had surgeons capable of performing major surgery. Surgical teams had been made available previously during the desert campaigns by the RAMC, and more had recently been supplied. Some of these British teams were attached to our active New Zealand MDS from 10 July till 8 August. During that period there were normally two extra teams attached. One was the Greek unit under Captain Taylor, RAMC, with its specially equipped operating van; the other, from 15 CCS, was supplied after that unit's withdrawal from the battle area. These teams were constituted of capable, well-trained surgeons experienced in forward surgery, all of whom combined well with our units and did most excellent work, dealing with the abdominal and other serious cases, while our own surgeons usually dealt with the less serious cases. The disadvantages of the lone surgical team were not present as there were always at least three teams available in the MDS and, if required, further help was available from the resting MDS.

At the end of July a surgical team under Major S. L. Wilson was sent forward from our New Zealand CCS. This team at first worked in conjunction with the British teams, but later, when operations quietened down, it enabled the British teams to be released. The adequate provision for surgery by means of these teams, concentrated page 361 as they were in one forward operating unit, was an eminently satisfactory development at this period. There was a well-sustained evacuation of cases from the MDS, mainly by ambulance over the rough and uneven desert, but partly by air from airstrips alongside the operating unit. Unfortunately, experience showed that air evacuation of abdominal cases shortly after operation, and of serious chest cases, was very dangerous, and this led to arrangements being made to retain the abdominal cases up to ten days at the MDS. For this purpose a section of 1 NZ CCS was attached to the active MDS. This section consisted of nursing orderlies, beds, and bedding, as well as the surgical van with lighting and sterilising units, and these facilities were thereafter always available when required in the field ambulances.

The surgical teams at that time were all conscious of difficulty in lighting, sterilisation, and the nursing of serious cases after operation. Arrangements were made so that, in the event of the MDS having to move quickly, a section of a field ambulance under an officer would immediately take over the patients and nurse them until they were fit to move to the CCS.

Resuscitation

The field ambulances were supplied with equipment for the giving of blood and plasma and personnel had been trained for this purpose. In one field ambulance dental mechanics proved eminently suited to this work. In the early part of the campaign blood drawn from seventy donors was used, and serum was also given. The position was markedly improved on 19 July when Captain D. D. Muir, RAMC, with his British field transfusion unit was attached to our active MDS. For transfusions there were then available highly skilled personnel and an ample and regular supply of blood from the base unit in Cairo. This blood was supplied to ADSs as well. It was noted that there were only a few minor reactions in the forward areas and that blood produced a much more satisfactory result than serum.

The OC British Transfusion Services provided boxes containing four bottles of liquid blood plasma and two sterile giving sets for issue to RMOs. Fifteen such sets were issued to the RMOs, thus providing a useful reserve for the Division. Serum, plasma, and saline solution had previously been given regularly at ADSs and, in anticipation of further operations, supplies of blood were similarly arranged. Blood supplies from 6 British Mobile Transfusion Unit were sent to ADSs daily in insulated containers packed with ice. Any unused blood was returned in twenty-four or forty-eight hours to the refrigerator and fresh supplies sent in exchange, thus avoiding wastage by deterioration.

Sterilised Dressings

A further development that contributed to good results was the provision of sterilised dressings and theatre supplies, packed by the team of NZMC orderlies attached to 63 British General Hospital and by our own base hospitals.

Wound Treatment

As regards wound treatment, the utilisation of sulphanilamide, both locally to the wound and also by the mouth, was standardised and a special label introduced for the recording of dosage given during the evacuation to the Base.

Vaseline gauze was the normal wound dressing and this was available sterilised and in ample supply. Tulle gras dressings were also supplied.

Splinting

Fractured femurs were generally evacuated in Thomas splints, with posterior plaster slabs and circular plaster bandages incorporated with the splint, giving excellent stability and comfortable travelling. Fractured arms generally had light plaster splints applied. Fractured spines were sent down in body plasters. Difficulties were encountered in applying these plasters, and also plaster spicas, without a plaster table.

Treatment of Special Cases

Heads: These cases were mostly sent to the base unit in Cairo for operative treatment. In some cases early suture at the MDS was successful.

Chests: The suture of the sucking wounds proved unsatisfactory, being generally septic when seen at the base hospitals. Firm pads kept in place either by elastoplast or by a few strong silkworm sutures tied over the pad were therefore utilised.

Abdomens: Early evacuation militated against satisfactory results. The exteriorisation of the colon was utilised for colonic injuries. Sulphadiazine was first utilised for introduction into the peritoneum at operation. Gastric suction and continuous intravenous glucose and saline became routine treatment.

Amputations: These were numerous. Skin traction was frequently applied in the early stages and some cases lightly sutured over a tulle gras roll had done well. Generally the wounds were clean.

Burns: Tanning had ceased to be employed. Instead, sulphanilamide in small quantities and tulle gras dressings were applied. At the base hospital our saline bath unit was utilised for treatment of these cases.

Infection

There was less sepsis in the wounds than in the previous campaign owing to early operation and possibly to local sulphonamides. There were some cases of gas infection but none of the septicaemic variety, the cases seen being associated with deficient blood supply resulting in local gangrene of muscle groups. Amputations, however, even of the arm, had to be done for gas gangrene.

Anaesthesia

Pentothal was commonly used both for induction and for the shorter cases. Gas and oxygen was utilised by some of the surgical teams. Ether was used for the more severe cases.

General

The results generally were excellent and the experience gained in the Second Libyan Campaign had been used to assure first-class results. The work of our forward units earned high praise from senior British officers and British units on the L of C and at the Base. To this result the excellent British surgical teams attached to New Zealand medical units contributed greatly, as did the courageous work of the AFS drivers and other ambulance personnel.

The combination of skilled surgeons, adequate resuscitation, and markedly improved nursing facilities made a great difference in the surgical results obtained, and this was noted and commented on by all observers at Base. Colonel Ardagh, ADMS 2 NZ Division, a capable surgeon and a very able and forceful administrator, was largely responsible for the co-ordination and efficiency of the forward surgery in our Division at that period.

Standard of Surgery

The Consultant Surgeon, Middle East Force, in his report at the time, had the following comments to make on surgery generally during the summer battles of 1942:

.… The surgeons at base units had nothing but praise for the work of their colleagues in the forward units, and few criticisms were forthcoming. I formed the impression that there was yet a further improvement in the standard of the work, and several divisional surgeons voluntarily stated that they thought the work was ‘first-class’. It was certainly an impressive sight to see so many severely wounded men looking remarkably well and free from pain, at all events, in these, the earlier days of their incapacity. From officers and other ranks who were casualties, I heard no complaints, in fact, much praise of the medical services.

During the period July to September 1942, including the battle of Alamein, Major S. L. Wilson was senior surgeon of a surgical page 364 team attached to New Zealand field ambulance dressing stations. He operated continuously during long periods without rest, providing major surgery for the most seriously wounded, with outstanding skill and devotion. This, taken in conjunction with his previous service, frequently under conditions of the greatest danger, was a most distinguished and meritorious contribution to battle surgery and earned him the DSO.

Hygiene and Sanitation

A remarkable feature of the period after the Division's return to the desert was that the Field Hygiene Section was not with the Division as a complete unit from the end of June until 19 November. When the main body of 4 Field Hygiene Section reached the Mersa Matruh area at the end of June, it had to hand over its vehicles to 27 (MG) Battalion as transport was in short supply and the Division was to adopt a mobile role. As they would be an encumbrance, the workshop and disinfestor sections of the unit were sent back to Maadi. The ten NCOs and men remaining with the Division were attached to 4 and 5 Field Ambulances and the OC, Major W. J. Boyd, became liaison medical officer on the staff of the ADMS. After 5 July there were left with the Division only the five NCOs and men with 4 Field Ambulance.

Before the end of July the Division was beginning to be pestered by a fly plague. At the end of July six members of 4 Field Hygiene Section were recalled to the Division, making eleven NCOs and men attached to the medical units, but still without transport or equipment. Sanitary appliances had to be improvised from discarded petrol tins and ammunition boxes, the only tools available being broken bayonets and tent mallets. The workshop at Maadi lent its support by the wholesale construction of fly-traps and incinerator latrine lids, made according to the unit's own design, and by making up gallons of fly poison, which began to arrive in quantity in the middle of August. On 11 August the members of the unit in the Division were reformed as a unit at Headquarters Rear Division. Activities of the section at this period were not confined to 2 NZ Division, assistance being given to the new British divisions which had just arrived from the United Kingdom. Having little idea of field sanitation and not being acclimatised, these units were experiencing a fairly heavy incidence of dysentery.

In August the blistering heat of summer, the dust, and the flies were at their peak. Despite the most vigorous counter-action, the flies clustered everywhere. To some extent the fly problem was uncontrollable owing to unburied dead lying beyond the reach of page 365 burial parties, and to the prevailing wind blowing directly from the Italian lines and bringing flies with it.

The area then occupied by the troops had been fairly thickly populated by native tribes and was therefore so contaminated that fly-breeding was encouraged. The coastal sector, particularly along the railway, had always been the most thickly populated area, and this suffered most from flies. Vehicles had a great attraction for flies, and each one of the thousands of trucks running from the coastal sector, particularly from supply points, contributed its not inconsiderable quota to those already living and multiplying in the divisional area.

Hygiene measures within the Division were made as complete as possible from the first. Owing partly to lack of materials and partly to the rocky nature of the ground, deep-trench latrines were not practicable except in certain rear areas. Shallow-trench latrines were used and changed every twenty-four hours, with the copious use of oil and cresol following burning-out with petrol. All refuse was burnt before burial. Fly netting at first was in short supply and was issued only to cooks' trucks, RAPs, and dressing stations. Flytraps and poisons were not available in the initial stages at Alamein, but were put to good use when they were forthcoming early in August.

To make matters worse a cloud of mosquitoes, A. Pharoensis, covering an area at least 10 miles in diameter, was blown by an east wind from Wadi Natrun and the Delta over the battlefield on 28 July, and no one was exempt from their voracious bites, which raised nasty blisters on the skin. Fortunately, when the wind changed the mosquitoes disappeared. Later, inquiry in Alexandria revealed that the mosquito phenomenon was not unknown, and it was obvious that the mosquitoes had been wind-borne.

Campaign Against Flies

The fly menace, with its accompanying incidence of diarrhoea, had reached such alarming proportions by early August that a rigorous drive was developed against it. A New Zealand Division routine order of 7 August directed units to construct as many flytraps as possible and gave details for their construction in an appendix. A conference presided over by ADMS 2 NZ Division was held at Divisional Headquarters on 9 August to discuss measures to be taken in the campaign, and a copy of the minutes of the meeting was forwarded to all units. Colonel Ardagh explained that the conference had been called to increase the comfort of troops and to diminish the risk of sickness. Diarrhoea during the week had risen to 1000 cases, fortunately only of a mild nature, as page 366 evacuations totalled only 38 as against 51 for the previous week. The cycle of infection was explained and measures for prevention suggested to and discussed by unit representatives.

The following day the intensified campaign against flies was well under way. A truck arrived from Headquarters 2 NZEF, Maadi Camp, with 150 fly-traps, 20 gallons of formalin, and eight pounds of sodium arsenite which were delivered to units. On 11 August part of 4 Field Hygiene Section was reformed as a unit to play its major part in the campaign.

Models of improvised fly-proof latrines made from petrol tins, fly-traps of various kinds, and soak-pits were made and demonstrated to all units. For those units which were new to the desert, special lectures and demonstrations had been arranged and these had produced most gratifying results. A demonstration area was prepared at Rear HQ NZ Division and representatives of all units visited it. As a result they were able to produce appliances suitable to local conditions. Stress was laid on improvisation and nothing was shown that could not be made with petrol tins, a bayonet, and a shovel. Methods described in textbooks were of no use when the materials were not available; but the principles could be embodied in improvisation from salvage. Education was the responsibility of the medical services, but it was the responsibility of the unit to see that a high standard of hygiene and sanitation was maintained at all times. It was the thoughtlessness and carelessness of the individual which endangered health in situations where manpower was the most important factor.

The greatest handicap to a total anti-fly campaign had been the lack of material. It had to be recognised that while everything possible might be done to prevent breeding and to minimise infection, the psychological effect of killing flies and actually seeing them die was a great one. There was a pathological and psychological battle. The mere presence of flies has an effect on both morale and comfort which is almost as important as the danger of infection. Before the end of August the improved state as regards flies was most gratifying.

In regard to other sanitation arrangements, urinals were constructed of tin so as to form a pipe leading into a soakage pit under the sand—the desert-lily pattern.

Soakage pits were also dug at each vehicle and special pits, made from two petrol tins, constructed for cookhouses. All the pits were flushed daily with petrol. Altogether, the unprecedented conditions led to both a keen appreciation of the necessity for adequate sanitary measures and remarkable ingenuity and success in designing methods of dealing with the difficulties that arose.

Rations

Rations and the handling of them were specially investigated in view of the fly menace. Inspections carried out along the supply line from the field maintenance centre to units showed that precautions precluded the possibility of infection of food, except perhaps for bread, which was uncovered until it reached the field maintenance centre. The conclusion reached by OC 4 Field Hygiene Section after conversing with personnel of all units was that great satisfaction was felt concerning the rations. The standard was good and the supply sufficient. With the rations, plus those extras which most units provided out of regimental funds, it was considered that the diet was adequate.

While the men endured the discomforts of the desert a continuous stream of vehicles moved backwards and forwards over sandy desert tracks, great clouds of dust in their wake. They brought forward increasing quantities of food, water, and ammunition. The main items in the rations were bread, biscuits, bully beef, tinned stew, tinned sausages, cheese, and margarine. Then, with improved organisation, came fresh tomatoes, lettuce, melons, marrows, potatoes, onions, and limes. The water ration was small—one water-bottle and then one gallon a day for each man—for drinking, washing, and cooking; occasionally the issue was increased to permit of a real wash. In spite of all they had gone through, the men were comparatively fresh—fit, lean, and very brown, but not hard.

Health of Troops

The incidence of diarrhoea and dysentery steadily dropped from its high level of July and early August, though it was still considerable. Its fall coincided with the reduction of flies consequent upon the strenuous measures instituted; other factors to be considered also were that the height of the late summer fly season was passing as the weather grew cooler, and that a certain amount of acquired immunity existed among the troops.

During August supplies of castor oil and sodium sulphate were short, but they improved again later. Sulphaguanadine became available in the Middle East Force in restricted quantities at this time and a supply was sent to the Division at the end of August for trial in the forward areas. It was found to be most effective.

After two and a half months of continuous fighting the troops were becoming more susceptible to minor illnesses, including septic skin conditions and sore throats. Infective hepatitis made its appearance and rose to epidemic proportions by October. There had been a number of cases of malaria, but most infections seemed to page 368 have been contracted amongst troops detached from the Division and temporarily stationed in the Nile Delta or in Maadi Camp.

Infective Hepatitis

Infective hepatitis first appeared in the Division at the end of September and then spread throughout Eighth Army. The disease was also present amongst the enemy troops at this time. It appeared that contact with infected troops or ground was responsible, and the infection arose when New Zealand troops took over from Italian troops ground that was grossly fouled and infested with flies. The flies and the difficulties of ensuring efficient sanitation added to the risks of infection.

Evacuation from the forward areas to the base, with a convalescence of four to six weeks, was proved necessary as cases retained in the Division were very slow to recover normal health. The disease caused serious wastage in the Division and it appeared that New Zealand personnel were particularly susceptible to the infection. No specific treatment was available, and rest and careful dieting was the routine.

Although hepatitis was only very rarely associated with severe illness or death, it caused marked debility with a slow convalescence and occasionally there was a relapse which necessitated invaliding.

It was found that the incidence in the different units was proportionate to the time they were stationed in the Alamein line. The Maoris had a much lower incidence. The epidemic began to decline in November when the Division passed out of the contaminated area after the Battle of Alamein, and the colder weather assisted in the control of the flies.

The number of cases reported in 2 NZEF during the period was as follows: June, 14; July, 23; August, 34; September, 146; October, 941; November, 793.

Physical Exhaustion

At this time psychoneurotic cases were being evacuated from the Division labelled as ‘battle casualties’. This led to difficulties as such designation was undesirable from the military standpoint, and inaccurate medically. At a conference of senior medical officers it was decided that the psychoneurotic cases should be carefully allocated to different categories according to their aetiology. Only those cases recorded by the RMO, on specially prepared forms, as having suffered from some definite battle injury or severe strain would in future be labelled as battle casualties, and in these cases the diagnosis of ‘physical exhaustion’ would be appropriate for those without any definite physical injury. (At this time GHQ MEF page 369 added ‘physical exhaustion’ to the official nomenclature of diseases.) The large majority, consisting of anxiety neurosis cases, would not be labelled as ‘battle casualties’ but as ‘sick’. It was found that the physically exhausted soldiers generally responded rapidly to a short period of rest in comfortable surroundings at Base or in rest camps. The designation of anxiety cases as ‘battle casualties’ could have had far-reaching consequences, not only possibly conferring the honour of a wound stripe but also possibly affecting the question of pension, and in any case detracting from the connotation of the words ‘battle casualty’ and ‘wounded’. A number of these cases were admitted from forward areas to 1 Camp Hospital, Maadi, owing to the full bed state of the general hospitals.

Base Medical Units

The epidemic of infective hepatitis placed a big strain on base medical units, particularly 1 General Hospital and also 2 General Hospital, 1 Camp Hospital, and 1 Convalescent Depot. On 2 October there were over 1000 patients in hospital at Helwan; on the 4th there were 1149 patients, by the 8th 1256, on the 11th 1288, until the highest total of 1327 in-patients was reached on 20 October. Extra tents were erected in ‘Spencerfield’ and jaundice patients admitted there direct, but large numbers of less seriously ill patients had to be transferred to Maadi Camp Hospital. With battle casualties and other admissions, 1 General Hospital had an average daily bed state for the month of October of 1136, the highest average ever reached by the hospital during the war. The course of infective hepatitis was mild, but complications seen were severe pruritis, haematemesis, persistent pyrexia, and prolonged icterus, with relapses within one or two weeks of discharge. One case which died of cholaemia was found at post-mortem to have a paratyphoid C infection of the gall bladder.

Within a short time of becoming established at Kfar Vitkin, halfway between Tel Aviv and Haifa, in April 1942, 1 Convalescent Depot entered a period of maximum expansion as convalescent wounded and infective hepatitis patients reached the unit from hospital. With the wounded there was a large number with lesions requiring daily dressings, while two stoves intended to cook for 250 men each were called upon to supply the cooking requirements of 700 per stove. Sisters and cooks from 2 General Hospital helped with these duties while the hospital was in Palestine. During August there was an average of 285 patients daily attending the medical treatment room. The peak number of 1423 patients was reached on 30 August. The number of convalescents in the depot page 370 remained fairly constant around 1100, with occasional drops after an evacuation train to 1000, until late in October.

The Convalescent Depot had to contend with a number of difficulties, especially when it had such a big influx of patients in August. It was a major problem to feed 1400 patients from limited cookhouses and long queues for meals were an inevitable result. Sleeping accommodation, too, was fairly primitive with only groundsheets and palliasses supplied, but the shortage of timber made it almost impossible to provide any bedboards or frames, although some beds and bedboards were procured in October. Sleeping accommodation at British convalescent depots was similar. At no time during the period of maximum expansion was there any disturbance of morale. The unit was reorganised at this time into five companies varying in strength from 200 to 250. The staff was but little augmented and all departments acquitted themselves remarkably well.

23 NZ Field Ambulance

Maadi Camp Hospital had persisted since the days of the First Echelon and had never been given an adequate establishment as it was felt that it could carry on with reinforcement personnel. Now that reinforcements were no longer forthcoming it was felt that it would be reasonable to set up a proper establishment, even if it was unlikely that it could be maintained at full strength. This was done in September and the unit became 23 NZ Field Ambulance, which designation it had originally been given at the end of June as part of the reserve formation organised in Maadi Camp. In October the unit expanded to 400 beds to take convalescent infective hepatitis cases from 1 General Hospital and so make room for battle casualties from the big offensive at El Alamein.

2 NZ Field Transfusion Unit

A special truck equipped with a refrigerator for the storage of blood had been ordered by the New Zealand Government in January and arrived at the end of September. Steps were immediately taken to form a Field Transfusion Unit, such as the British unit which had proved so valuable in the Western Desert battles. Great assistance was given by OC 1 British Base Transfusion Unit in the assembling of equipment and training of staff and the unit was able to play its part in the advance from El Alamein.

Return of Brigadier MacCormick

On 11 September Brigadier MacCormick returned from New Zealand and on 18 September resumed the appointment of DMS 2 NZEF. Brigadier Kenrick returned to New Zealand on 15 October page 371 on a tour of duty following arduous and distinguished service in the field in the campaigns in Greece, Crete, and the Western Desert and latterly in administration as DMS 2 NZEF.