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New Zealand Medical Services in Middle East and Italy

Surgery in Mobile Surgical Unit, 23 November–5 December 1941

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
Head 11 8 2 2 4
Chest 35 20 1 6 7
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
Burns 4 3 1* 1
Spine with paralysi 4 4 4
Minor cases 10 3

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.


Compound fractures:


Fractured femurs had travelled well in Tobruk plasters and also in Thomas splints. Plaster sores had been caused when plaster bandages had been incorporated with the Thomas splint and insufficient padding used under the plaster. Plaster spicas gave generally unsatisfactory results. Sufficient absorbent dressing was necessary under the plaster to prevent damming back of the secretions in the wound.


Fractured legs travelled well in plaster.


Fractured arms had mostly been treated in slings and simple splints.


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.