New Zealand Medical Services in Middle East and Italy
SURGICAL WORK AT BASE HOSPITALS
SURGICAL WORK AT BASE HOSPITALS
2 NZ General Hospital
The surgical work performed in the hospitals during the period consisted largely of the treatment of ordinary conditions as met with in a civilian population of healthy young males, such as the repair of herniae, operations for appendicitis, the treatment of piles and varicose veins. More serious conditions such as malignant disease were seen only in small numbers. There were three cases of seminoma testes. Some cases of tubercular epididymitis showed acute symptoms with early abscess formation. Genito-urinary cases were common, and it was fortunate that Lieutenant-Colonel Ardagh1 had taken overseas his own special instruments, as these were not otherwise available.
After the Libyan campaign of December 1940 and January 1941 there was a lull in admissions, and in May 1941 the hospital had reached a low bed state of 256 in preparation for casualties from Greece and Crete. During the month two convoys of Australians were admitted from Tobruk, and two convoys of 131 and 375 from Greece and Crete raised the bed state to 967 on 1 June. In spite of these numbers only 58 battle casualties were operated on during May. Most of the casualties admitted during June were light cases and nearly all the heavy cases were evacuated to New Zealand on HS Maunganui on 10 June, so that only 32 operations on battle casualties were performed in July. The battle casualties did not call for the expected volume of work following the campaigns in Greece and Crete, as comparatively few of the serious cases were brought back. Altogether, 371 of the wounded (three-fifths of the total) became prisoners of war in Greece, and 1039 (two-thirds of the total) became prisoners of war in Crete.
A report by Lieutenant-Colonel Ardagh on the 617 battle casualties admitted to 2 NZ General Hospital from Tobruk, Greece, and Crete in April, May, and June 1941 shows that there were 849 page 232 main wounds. Of these 592 were of the soft tissues, 347 being of the limbs. There were 167 fractures, 67 being of the hand and forearm, and only five of the femur. There were only seven major amputations, none of the lower limb. There were no penetrating wounds of the head and only two penetrating abdominal wounds. There were 12 penetrating wounds of the chest, one of which developed an empyema. There were 18 injuries to the peripheral nerves, only one being in the lower limb. One death occurred in the hospital from secondary haemorrhage in the large veins of the neck. One case of tetanus from Crete recovered. A high percentage of the ruptured eardrum cases developed suppurative otitis media. There were only three cases of fracture of the jaw, all with excellent results following inter-maxillary wiring and later dental splinting.
The review shows quite clearly the very small number of serious casualties admitted, mainly due to the impossibility of evacuating the heavy cases from Greece and particularly from Crete, and also because such cases reaching Egypt were retained in British hospitals, particularly in Alexandria.
Lieutenant-Colonel Ardagh said:
We have again watched with great interest the effect of the early application of sulphanilamide paste to battle casualty wounds. The vast majority of the group had no sulphanilamide paste and it is the unanimous opinion of our surgical staff that so far as our close and controlled observations indicate, there is no reason to believe that sulphanilamide paste offers any advantage whatever: on that point we are quite convinced. Although we do not feel justified in condemning its use, we are firmly of the opinion that it causes unhealthy and sluggish granulating wounds without in any way preventing suppuration and infection. These remarks apply only to the use of sulphanilamide as a local application. In cases where sulphanilamide chemotherapy plus sulphanilamide local has been employed, we believe the beneficial results can be ascribed to chemotherapy alone.
During the period from July to September our hospitals admitted only 77 battle casualties, many of them being re-admitted from the Convalescent Depot and the majority light cases. There was only one fracture of the femur and three amputations, one of the thigh, and two of the upper arm. Four operations were successfully carried out for aneurysm. The total number of battle casualties of all forces admitted to the Helwan hospital from October 1940 to August 1941 was 1268, and there were six deaths.
Due to climatic conditions there was more than the ordinary percentage of ear, nose, and throat conditions. It was thought that swimming, especially in the fresh-water baths at Maadi and Helwan, was responsible for much of the infection. Otitis externa was very common, as was sinus infection. It had early been noted that old otitis media cases with perforation of the drum frequently flared up page 233 in Egypt with fresh discharge, and advice was sent to the New Zealand authorities to exclude such cases from drafts for overseas service. In battle casualties ruptured eardrums from blast commonly occurred and it was soon learnt that active treatment, especially syringing, in the forward areas produced infection in the majority of cases, but with simple toilet, and the active treatment delayed until the arrival at base under the control of a specialist, the cases did well and little deafness resulted.
There was little acute eye trouble, but a great deal of work was concerned with the supply of glasses for defective eyesight and in the treatment of eye infections. Eye wounds were not very common.
1 Brig P. A. Ardagh, CBE, DSO, MC, m.i.d.; born Ngapara, 30 Aug 1891; surgeon; 1 NZEF 1917–19, Capt 3 Fd Amb; wounded three times; in charge surgical division 2 Gen Hosp, Aug 1940–Oct 1941; CO 1 CCS Nov 1941–May 1942; ADMS 2 NZ Div May 1942–Feb 1943; DDMS 30 Corps Feb 1943–Apr 1944; died (England) 6 Apr 1944.
Auxiliary Departments of Hospitals
At Helwan 2 General Hospital had an X-ray department and full investigations could be carried out, though difficulty arose with fluctuations in the local power supply. The bacteriological laboratory was kept busy and steadily increased the scope of the work undertaken. It proved to be a very essential service to assist with the treatment of tropical disease, especially of dysentery. From April 1941 biochemical estimations were also carried out. It is interesting to note that only one positive diphtheria case was found during the year. A specialist anaesthetist was on the staff at Helwan and full use was made of intravenous and spinal anaesthetics, which proved very suitable in the hot climate. Pentothal was very much used. Physiotherapy was available with trained staff and full use was made of the massage department for orthopaedic and other cases. An ultratherm was presented to Helwan at that time by Watson Victor, Ltd. A dietitian was appointed to the hospital staff in April 1941 and proved of great value in the preparation of special diets for such cases as diabetes and dysentery. There was at first some difficulty in arranging smooth working with the army cooks, but this was soon overcome.
A dental department which was started in December 1940 was very fully employed. Extractions were frequently referred to the hospital from the camps, and conservative dentistry was carried out to render dentally fit as many of the patients as possible before discharge. A great deal of extra work was entailed in the replacement of artificial dentures lost in Greece and Crete. Fractured jaws were dealt with by inter-maxillary wiring for two weeks, followed by the application of a modification of the Hammond splint. The results drew high praise from Colonel W. A. Hailes, Consultant Surgeon to the AIF.
A splint-maker was posted to the staff in April 1941, and gradually a small department was set up and proved very useful in page 234 the making and adjustment of splints, adjustments to boots, and in metal and leatherwork generally. Such a department is indispensable in a hospital with an overseas force. Provision for one was made by 1 General Hospital when the unit left New Zealand, but the lack of any provision in the army establishment prevented its development, though the very experienced mechanic was able to gain further experience in England in a special orthopaedic hospital under Brigadier Bristow, RAMC.
The out-patient service was very extensively developed at Helwan and covered all branches – surgery, medicine, orthopaedics, eye, ear, nose, throat, massage, and dental. The service was open to the RMOs at the NZEF camps as well as to other forces in the area. It was thought at first that too much use was made of the department by RMOs and that some patients relished the day's visit to the hospital, but undoubtedly it was of great value that cases of doubtful diagnosis or those needing specialist treatment should have had the opportunity of seeing specialists under conditions allowing of first-class treatment. RMOs were later encouraged to attend the clinics and undoubtedly benefited thereby.
The institution of an occupational therapy service was started in December 1940 by Colonel Spencer, who was very enthusiastic in its development for psychoneurotic as well as physically disabled patients. He advocated occupational therapy for the treatment of psychological disorders such as anxiety neurosis, as a distraction for patients with mental disorders, for orthopaedic surgery to train individual muscle groups, and for patients confined to bed over long periods for the preservation of morale and provision of escape from tedium. Fortunately, an enthusiastic group of women resident around Cairo, under the leadership of Mrs Washbourn, undertook the work, which was at first confined to the anxiety neurosis cases and proved very successful. Colonel Spencer considered that wholetime officers for this work were necessary both in the general hospitals and at the Convalescent Depot. The work developed considerably at Helwan, and later was instituted at the other hospitals and the Convalescent Depot as recommended by Colonel Spencer.
At Helmieh, where it had taken over the site of 1 General Hospital at the end of March, 3 General Hospital spent some months developing the hospital site and setting up its special departments. The laboratory and physiotherapy departments were opened in April, the operating block in May, the X-ray department in June, and the dental department in October. The hospital was disorganised by a widespread sandfly fever epidemic amongst the staff in June, the effects persisting into August and necessitating restriction of admissions. Some 400 battle casualties from Crete, mostly lighter cases, were admitted in May.
Patients in British Hospitals
Considerable numbers of New Zealand patients were admitted to British hospitals at this and all periods while the Division was in North Africa. In September the daily average was 11 officers and 211 other ranks, while in October it was 7 officers and 293 other ranks. This necessitated periodical visits by our consultants to the British hospitals to facilitate the return of the more serious cases to our own hospitals, and with a view to the boarding of cases for return to New Zealand. The scattering of our patients caused some administrative difficulties, including the despatch of mail.
Activities of the Consultants
On their return from Greece the Consultant Surgeon and Consultant Physician visited the different medical units, and when their appointments were made full-time the scope of the work increased. Regular weekly visits were paid to the hospitals, convalescent depot, and camp units; regular visits were also paid to British hospitals where New Zealand patients were being treated; and contact was kept with the consultants of other forces. Visits to the British hospitals, besides ensuring the early transfer or boarding of patients requiring return to New Zealand by hospital ship, were also of value as a liaison and in the exchange of ideas, especially with regard to new developments of treatment or technique. The scope of work undertaken by our hospitals, particularly with regard to surgical operations, was kept under review, and consultation on doubtful cases arranged with the staffs concerned. For instance, secondary operations on nerve injuries in Egypt, which were banned by the AIF, required the prior authority of the consultant, and similar arrangements were made concerning goitre and some orthopaedic cases. In general, it was agreed that operations of no urgency on patients who would have to be evacuated to New Zealand in any case were better postponed until they reached New Zealand.
Extra equipment required or desired by medical units was listed and efforts made to procure supplies either through the army channels or from commercial firms in Cairo, though supplies from the latter source were very poor. Fortunately, the army equipment was quite sufficient except for some exceptional items.
Both consultants were busily occupied with boarding and the approval of boards, and in October, on their recommendation, the boarding form was altered.
Joint Council of Order of St. John and Red Cross Society
The administration of the supplies and money sent over by the Patriotic Fund Board and the Joint Council of the Order of St. John page 236 and Red Cross Society from New Zealand was in the hands of Colonel MacCormick till May 1941, when Colonel Waite1 arrived to set up a separate department which functioned till the end of the war. The supplies were of the greatest value to the hospitals in supplementing the regular army medical stores. Linen for the operating theatres, special dressings, invalid food, bags with toilet necessities to replace those lost by casualties, and very many other items were all invaluable. Grants of money were also made to medical units to buy articles locally, and also at times to obtain equipment not procurable from army sources. Some furnishings for patients' and sisters' common rooms were bought in this way.
The sick and wounded fund of the Joint Council proved especially valuable in procuring extra equipment for the rest homes and other units not on ordinary army establishment.
The many dentures lost or broken on hard biscuits in Greece and Crete were all quickly replaced in Egypt. From May to July 18,000 troops were examined and half were found to require treatment. Over six thousand fillings and 1200 extractions were performed, while 1500 new dentures were supplied and a similar number repaired. By August the whole Division was dentally fit and all dentures replaced. The equipment lost in Greece was replaced from New Zealand and the Mobile Dental Unit was reconstituted by 1 August.
Re-formation of 1 General Hospital
Considerable reorganisation of hospital units took place in August. The arrival of the 6th Reinforcements allowed the re-formation of 1 General Hospital as an active hospital, and steps were taken to effect this. The male staff was gathered together from their relieving duties with other medical units and began training. Following the disruption of the hospital during the evacuation of Greece, and the loss of so many medical personnel in 2 NZEF, the authorities in New Zealand suggested that the hospital should not be re-established. Brigadier MacCormick, however, with the strong support of DMS MEF, stood out strongly for the retention of the three hospitals, and fortunately for the future of the medical services of 2 NZEF the hospital was retained. The staff of the hospital had been very usefully employed in the meantime reinforcing other medical units.page 237
On 10 August Lieutenant-Colonel Stout and Lieutenant-Colonel Boyd were appointed full-time consultants with the rank of colonel and were attached to DDMS, Headquarters 2 NZEF. They had been acting part-time in these capacities from January 1941 and remained as consultants until 1945. Colonel Pottinger1 became the new officer commanding 1 General Hospital on 10 August, while Majors H. K. Christie and E. G. Sayers were placed in charge of the surgical and medical divisions.
Other appointments made at this time were Lieutenant-Colonel Cottrell as officer-in-charge medical division 2 General Hospital, Major Russell2 as DADMS HQ 2 NZEF, Major Kirker as Registrar 2 General Hospital, and Major Noakes3 as Senior Medical Officer, Maadi Camp, while on 26 June the DDMS 2 NZEF, Colonel MacCormick, had been promoted to the rank of brigadier.
2 Lt-Col J. Russell, m.i.d.; born Scotland, 28 Oct 1896; Deputy Director-General, Mental Hospitals, Wellington; Captain 1st Gordon Highlanders, First World War; Registrar Gen Hosp Oct 1940–Aug 1941; DADMS 2 NZEF Aug 1941–Nov 1945.
Shortage of Specialists
Reorganisation presented many difficulties, especially, as was inevitable, when more of the most capable and experienced surgeons and physicians were promoted to administrative positions. This was found to be a recurring feature in later years. At this stage there was a pressing shortage of physicians. No. 3 General Hospital had only one general physician on its staff, after a rearrangement of physicians following a conference called by DDMS 2 NZEF on 28 August. For the Division the ADMS was asking for more senior officers instead of the very junior type he had been receiving, although many of the latter eventually proved most successful regimental and field ambulance medical officers.
There arose in the medical services of the 2 NZEF a feeling that an insufficient number of senior and specialist physicians was being sent overseas. DDMS 2 NZEF had no doubt that a similar position would arise very shortly in regard to trained surgeons, and suggested to DGMS Army Headquarters that representations on the matter be made to the ONS Medical Committee. He thought that if the New Zealand branches of the Australasian Colleges of Surgeons and Physicians were to review the number of trained specialists in 2 NZEF and eliminate those who were necessarily engaged in administrative capacities, they would not be satisfied that an adequate proportion of skilled clinicians had been supplied. The page 238 position as regards specialists in eye, ear, nose, and throat, radiologists, and bacteriologists would also be serious if any one of these became a casualty.
An effort was made in September to obtain medical officers from England, and two surgeons were obtained.
The senior members of the hospital staffs were promoted to the rank of major at this time, thus removing some of the anomalies inherent in the rigid establishments. In the New Zealand Medical Corps there was no provision for specialist appointments dependent on the qualifications of the officer such as existed in the RAMC, the only appointments being those defined in the hospital establishments, such as that of divisional officer, and the provision for a limited number with the rank of major in the unit.
In the RAMC, on the other hand, officers were given the rank of major when they were qualified as specialists in different branches of the profession by the possession of senior academic qualifications such as the FRCS. This resulted in many young officers with recent qualification and short experience holding the rank of major, whereas in the New Zealand Medical Corps, in which a considerable number of older men volunteered early for service, there were several leading practitioners of the highest qualifications and with long experience who held the rank of captain; the majority of them later became divisional or commanding officers of hospitals. In course of time, with the recruiting mainly of the younger men, the position rectified itself, though some anomalies still remained, such as the inability of any of the specialists to be ranked higher than major if they could not function as divisional officers.
Clinical meetings were held regularly in our general hospitals and addresses were given both by visiting medical officers and members of our own corps. This had an educative and stimulating effect, undoubtedly improving the quality of our professional work.
1 NZ General Hospital Takes Over Helwan Hospital
At least one New Zealand general hospital was required to change its location in view of the impending offensive in the Western Desert. As 1 General Hospital had been in the Greek campaign, it was proposed that that unit should take over the Helwan hospital from 2 General Hospital, whose staff would open a hospital on the lines of communication at Garawla in the Western Desert.
The DDMS 2 NZEF attended a ceremonial parade of 1 General Hospital on 8 September, and remarked that the occasion was a particularly pleasing one as it marked a definite stage in the reconstruction of a valued unit of the New Zealand Medical Service. No. 1 General Hospital had given good service in the United page 239 Kingdom and in Greece, but for a time it was doubtful if the unit could be re-formed. The original members of the unit left no doubt about their desire in the matter and the gaps in the ranks had been filled by well-trained reinforcements.
Prior to the taking over of the administration of the Helwan hospital by 1 General Hospital, the DDMS paid a tribute to the work done by 2 General Hospital during the previous twelve months. Each month he was able to report to DGMS at Army Headquarters the hospital's smooth running and its staff's cheerful acceptance of all extra responsibilities and a high standard of nursing and clinical care. The reason for the move was that constant and sometimes monotonous duty under conditions of the Egyptian climate made a change advisable, and it was also desired to give 2 General Hospital a turn as a ‘mobile’ general hospital of 2 NZEF.
No. 1 General Hospital then began to take over Helwan hospital, the advance party going there on 15 September and an equal proportion of 2 General Hospital's staff going to Maadi. The changeover was completed smoothly three days later and the work of the hospital continued without interruption. The NZANS posted to 2 General Hospital remained at Helwan, while the officers and other ranks went to Maadi. The number of patients admitted to the hospital during the year had approached ten thousand.
At their new site on the northern boundary of Maadi Camp the staff of 2 General Hospital benefited greatly from the change to an open-air life.
Review of Work at Helwan
When 2 General Hospital came to hand over to 1 General Hospital at Helwan, a review was made of the hospital's work over eleven months from October 1940 to September 1941. Total admissions were 9501, and discharges 9212. Patients came from the following forces: 2 NZEF 7598; 2 AIF 1125; British Army 273; RAF 108; RAAF 7; Union Defence Force 19; Royal Navy 1; and Italian prisoners of war 367. Operations performed amounted to 3172. New Zealand deaths were 28 out of a total of 41. Causes of death were battle wounds 6, accidents 6, and disease 29. Outpatient department consultations were given in 6997 cases, with 6446 subsequent visits. There were 2213 massage treatments given.
In his review Colonel Spencer made the following interesting comment:
It took us medical officers many weeks to become acquainted with ways and means, channels of communication, adapting our therapeutic ideas and demands to the supplies available to an Army hospital on active service, particularly in a sphere where supplies were of necessity almost always short. There were times when some felt that medical and surgical considerations page 240 were being sacrificed to the insatiable demand made by some Army department for returns and still more returns. But, as time passed, the reason for these returns became more and more obvious; and now it is realised by all that with a turnover of patients that exceeds by far that of civil hospitals; of patients, moreover, who are here today and gone tomorrow, and whose whole economic future may be altered by the care with which their cases have been recorded while under treatment in hospital, the clerical side of our work has taken on a new interest, and is no longer regarded as a burden.
There is always the danger of a unit becoming too ‘set’, and we realised that the conditions under which we had been working had been as near to those of a civilian hospital as would be possible in an Army on active service. Since the unit moved out to their new camp we are unanimous that the change-over has been for the good of all concerned. Officers and men alike have already lost that feeling of staleness that was becoming apparent due to the sameness of work day after day under the trying conditions of an Egyptian summer. This applied perhaps more to the Other Ranks who had carried the weight of the hospital work, which had to go on whether the staff were up to establishment or not.
Provision of Mobile Surgical Unit
A mobile surgical unit, based on the head and chest units organised in England at the beginning of the war by Professor H. Cairns and Mr A. Tudor Edwards, was equipped in England in 1940. The unit was formed as a result of a generous gift of £2500 by Mr A. Sims of Christchurch. The senior surgeon 1 NZ General Hospital, later Consultant Surgeon 2 NZEF, Lieutenant-Colonel Stout, was given authority to purchase equipment in England and make arrangements for the construction of a special van fitted up to hold all the equipment. The surgical instruments and appliances as listed in the British units were supplemented so as to render it possible for the unit to undertake any type of forward surgery, as it was appreciated that head and chest cases would form only a portion of the cases to be dealt with.
Operating theatre equipment was obtained from Morris Motors at Oxford; surgical instruments were purchased from several firms in London, with the permission of the Ministry of Health; a lighting unit and an electric suction apparatus was also obtained. A diathermy machine was not purchased as at that time it was held that the machine would interfere with wireless transmission from aeroplanes. Special water tanks were obtained. The special van was built in Cairo on an army truck chassis, being designed to carry the equipment and to provide lighting and a generous supply of water.
The surgical instruments and other equipment were fitted into separate boxes so that, if necessary, all the equipment could be taken out of the van and carried in an ordinary truck.page 241
There was no similar unit in the British Army, and all the original British head and chest units had been lost in France. The surgical units organised in Spain for forward surgery were used as a basis for the establishment considered necessary for the new unit, and eventually a special establishment was finalised on 1 May 1941. Autoclaves from captured Italian stocks and an X-ray plant purchased with Red Cross funds were added.
An establishment of 5 officers and 29 other ranks, as well as 9 ASC drivers, was drawn up and tentage and ordnance equipment for a self-contained unit were requisitioned. Transport consisted of four lorries in addition to a staff car, a motor cycle, and the special van. A water cart was also supplied. The unit was able to work two surgical teams with full equipment for all types of forward surgery. It was first set up in Maadi Camp, where it carried out preliminary training. It was inspected on 22 July 1941 by the Consultant Surgeon, MEF, Major-General Monro, who reported that: ‘I regard it as a “war surgeon's dream” from the surgical point of view. Its advantage lies in its mobility, independence in regard to transport and the excellent power plant in the surgical lorry.… A closer study of the economic factors is still necessary.… It is my opinion, however, that the answer to many of the problems can be found in this N.Z. unit or one on the lines of the British unit recently assembled at 15 Gen. Hosp.’
The DMS 2 NZEF also reported that, ‘Inspection shows—
That the unit is very handsomely equipped for doing surgery,
Has ample transport,
Has reached a high state of efficiency in all departments of its work.’
The unit rapidly reached a high degree of keenness and efficiency. Some doubt, however, was expressed by British administrative officers concerning the desert-worthiness of the van. The unit was ready for service during the Second Libyan Campaign. It was agreed by the DDMS Western Desert Force that the unit should function close to an MDS. He was impressed by its completely desert-worthy conditions, and this estimate proved correct. The unit worked alongside the MDS during the fateful Second Libyan Campaign, was captured along with the other main medical units but carried on unmolested by the enemy till rescued, and then, after evacuating its patients to the medical centre behind the frontier, was attached to the British forces for the remainder of the campaign.
The unit which resembled the New Zealand MSU most was 1 Mobile Military Hospital, a gift to the British Army from the United States of America. This consisted of several very elaborately fitted-up special vans providing operating theatre, sterilising equipment, X-rays, cooking van, and supply vans, all on wheels with page 242 tentage for personnel and patients. This unit was utilised in the desert, but never in the divisional area, and was not entirely satisfactory.
The establishment of the Mobile Surgical Unit is given below:
|Detail||Personnel Offrs||WO II||S-Sgt||Sgt||R and F||Total|
|Surgeons (Majors or Capts) (a)||2||2|
|Anaesthetists (Capts or Lt)||2||2|
|Medical Officer (Capt or Lt) (b)||1||1|
|CSM and Wardmaster||1||1|
|Attached NZASC Drivers||9 (d)||9|
|Total—Mobile Surgical Unit, including attached||5||1||1||1||35||43|
|Car, 4-seater, 4-wheeled||1|
|Lorry, 3-ton, 4-wheeled, special body||1|
|Lorries, 3-ton, 4-wheeled||4|
|Truck, water cart||1|
Formation of CCS
The 7th Reinforcements arrived in Egypt on 19 October and comprised 18 NZANS, 15 medical officers, and 166 other ranks, all of whom were sorely needed to strengthen existing units and form new units in the Medical Corps.
It was now possible to finalise the long-deferred formation of a casualty clearing station which, as 1 NZ CCS, was officially gazetted as a unit of 2 NZEF on 1 November 1941. The medical and ordnance equipment of the unit had not been received by this date, but it was known to have left the United Kingdom some time previously, and six trucks had arrived from New Zealand. The staff of the unit, except the medical officers and sisters, was assembled under Lieutenant-Colonel Ardagh. It was attached to 2 General Hospital at Garawla and underwent valuable training in setting up a tented hospital under desert conditions.
Anzac War Relief Ambulances
Towards the end of June ten ambulances provided by the Anzac War Relief Committee of New York arrived in Egypt. They were suitable only for base duties, but they filled a long-felt want, especially in Maadi Camp, where transport for medical requirements had been a harassing matter ever since 4 Field Ambulance had moved out with its transport in September 1940. All camp and hospital work had had to be done with two to four ambulances only.
Abolition of Rank of Staff Nurse
The Matron-in-Chief 2 NZEF, in her report on the NZANS for June 1941, mentioned that a Royal Warrant had abolished the rank of staff nurse. This, it was thought, would bring about greater contentment in the nursing service and would greatly simplify the choice of suitable ward sisters by enabling them to be drawn from a larger pool. Some sisters were excellent nurses but not good administrators in large wards.
Promotion of NCOs
It was also decided at the conference of senior medical officers on 10 June that future promotions of NCOs above the rank of corporal should be on a corps and not a unit basis. Various anomalies had arisen through: (a) excessive losses in some units; (b) formation of new units; (c) arrival of reinforcement NCOs. The new system would ensure that the claims of all suitable men were considered for promotions. For the purpose a complete nominal roll was compiled. The system could not be of complete general application in that certain NCOs were specialists such as dispensers and radiological and laboratory technicians.
Promotion of NCOs was always a vexed question. In order to prevent difficulties and disappointments DDMS 2 NZEF had recommended to DGMS Army Headquarters on 8 October 1940 that all reinforcement NCOs should be given temporary rank only. This would allow for reduction of rank if need be in fairness to experienced men who had preceded them overseas.
When the 6th Reinforcements arrived at the end of July 1941 a high proportion of NCOs was noted, namely 28 to 197 other ranks. Even though the ranks were temporary there was considerable difficulty, and some disappointment, to the reinforcement NCOs who were reduced in rank, as well as to established units who had to absorb these NCOs, even at reduced rank, and so block promotion to men who had done good work in the unit. As was understandable, the units who had served throughout Greece and Crete had quite marked feeling on the matter, although some of the new arrivals page 244 had served with 8 Brigade in Fiji. DDMS 2 NZEF had to ask that the number and rank of reinforcement NCOs be kept as low as possible after their arrival by a board nominated by him which, as far as possible, should consist of OC 1 Camp Hospital, the Officer-in-Charge NZMC Training Cadre, an officer with experience of field ambulance work, and an officer from one of the general hospitals.
This system was applied fairly successfully with the 7th Reinforcements, but with a break of over a year before the arrival of the 8th Reinforcements, some of whom had substantive rank, the system was not so rigorously applied then or at later dates. Consequently, there were always grounds for a certain measure of discontent on the question. Unit promotion also came to be the accepted rule instead of corps promotion, except for first appointments to commissions.
Problem of Down-Graded Men
A new medical position was established on 9 May when Major Kirker was instructed to assume the duties of senior medical officer Maadi Camp. In addition to the supervision of regimental medical officers with base units, he was responsible to DDMS 2 NZEF for the administration of medical boarding at Maadi.
New forms were introduced at that time. Form NZEF 22 was printed and used from 12 May onwards in place of Form NZ 179 previously used for medical boarding, and Form NZEF 51 introduced to get confirmation from his unit of statements made by a man relating to injuries sustained in the forward areas.
A conference of senior officers convened by the DDMS 2 NZEF in Maadi Camp on 27 June studied the question of graded men. The DDMS represented that he had never been satisfied that due regard had been taken of the recommendations of medical boards as to employment of Grade III men. He thought that there should be a special officer appointed to see that men were employed as soon as possible in suitable capacities, thus avoiding disappointment and deterioration in the graded men due to periods of inactivity. It was decided that a return should be secured from all base units indicating the number of Grade II and Grade III men employed. Later, it would be decided whether the least employable of the graded men should be returned to New Zealand on the grounds of ‘services no longer required’ as well as of medical unfitness.
As opposed to conditions in England in the First World War, there was no doubt that the morale of graded men tended to deteriorate in Egypt. The long delays before shipment of some of page 245 those actually placed on the New Zealand roll also led to some degree of resentment.
Numbers of soldiers of the 5th Reinforcements appeared before medical boards soon after their arrival in Egypt, and it was obvious that many men who should never have been passed for service out of New Zealand had been sent overseas. A list prepared on 4 July 1941, which was not claimed to be complete by any means, showed seven who had been immediately graded IV for return to New Zealand on account of pre-enlistment disabilities. It was pointed out at the time that, quite apart from the waste of the country's money and the time of those charged with the men's training, the sending of unfit troops overseas caused great inconvenience, and the efficiency of units was impaired.
During July 155 men were sent by commanding officers to ADMS NZ Division for regrading, and of these 149 were transferred to Base for reboarding. Orthopaedic cases, particularly flat feet, predominated and an unduly high proportion were cases from late reinforcements. This suggested the necessity for stricter medical examinations in New Zealand. The ADMS NZ Division commented that, to say the least, it was most uneconomic to train and equip men, send them overseas, and then, as soon as they reached the Division, start them on their homeward journey to New Zealand.
Instances were still brought to notice of men who should never have been accepted for service overseas. Cases with histories of head injuries, epilepsy, asthma, and peptic ulcer were quite common. The DDMS was of the opinion that there should be used in New Zealand on medical examination a questionnaire covering the more common pre-enlistment disabilities.
Major Coverdale at that time stressed the desirability of retaining in the Division the many men whose eyesight was unsatisfactory for shooting but who could be used for other or non-combatant duties. He stated that the men deteriorated badly if sent back to Base, and further suggested that ophthalmic investigation at mobilisation camps in New Zealand would result in the elimination of unsatisfactory men from overseas drafts.
Graded men presented a problem in the Middle East from 1941 onwards. Their numbers steadily increased and it became more and more difficult to provide them with congenial employment. From 1 April to 30 June medical boards were held on 594 soldiers, of whom 36 were placed in Grade I, 44 in Grade Ia, 102 in Grade II, 42 in Grade III, and 370 in Grade IV for return to New Zealand. The analysis of only two months' medical boards—for July and August 1941—shows that 892 men appeared before medical boards in this period, and of these 86 were placed in Grade I, 56 in Grade page 246 Ia, 247 in Grade II, 38 in Grade III, while 465 were graded for return to New Zealand. The most common disabilities in the last group of 465 were: functional nervous disease 76; organic nervous disease 29; accidental injuries 33; battle casualties 31; arthritis 37; gastro-intestinal disorders 25; peptic ulcer 17; otitis media 24; asthma 21; skin disease 21; respiratory disease 23; and rheumatic fever 11.
An analysis of the 600 graded men, other than those already on the New Zealand roll, at Maadi Camp on 30 September 1941 showed that 113 were Grade Ia, 415 Grade II, and 72 Grade III. Their disabilities were: foot disabilities 126; functional nervous diseases 70; accidental injuries 66; arthritis 41; cardio-vascular disorders 36; eye disabilities 33; otitis media 25; deafness 24; fibrositis 20; mental dullness 19; dermatitis 15; asthma 14; battle casualties 12; respiratory diseases 11; organic nervous diseases 11; gastro-intestinal disorders 10; others 67—total 600.
This was regularly carried out both by the staffs of the general hospitals and also by specially constituted boards at Maadi Camp Hospital where, at first, the consultants acted on the boards till they took over the approval of the boards from the DDMS. From 250 to 500 cases were boarded or reboarded each month. Reboards might take place after three or six months. That the graded men held in base camps were always a problem in Egypt is not surprising considering that a large proportion of them had a functional basis. Suitable employment at Base was difficult to arrange, and deterioration was inevitable when a man had no interest in his work, especially in the debilitating climate. Knowledge of conditions in the forward areas proved highly desirable in the medical men constituting the boards and they had to be carefully chosen.
Attention was drawn to another aspect of the unfitness of troops by CO 2 General Hospital, Colonel Spencer, in July when, referring to the numerous out-patient attendances for opinions of specialists at the hospital, he said:
.… It would appear that COs of units are still very apt to try to get rid of men on medical grounds who are unsuitable as soldiers, or for other reasons. Pressure thus applied on a junior RMO is very difficult to resist. On the other hand, we feel that it cannot be too strongly impressed upon newly appointed RMOs that their mana with their troops depends to a large extent on the care with which they look after them in sickness; that they will not always have consultants handy to whom to refer their cases, and that the sooner they develop independence in diagnosis and initiative in treatment, the quicker they will gain the confidence of officers and men of their unit. The assessment of character is not so easy. Close harmony page 247 between combatant and medical officers is of the greatest value in this respect, but here again the sooner an RMO learns to distinguish between real and feigned illness, the greater will be the respect in which he is held by all ranks.
Enemy Air Raids on Canal Zone
During the greater part of 1941, especially after the close of the Crete campaign, the Canal Zone was subjected to sporadic and sometimes relatively intensive nuisance raids from enemy aircraft based on Crete and the Dodecanese. No sooner had the Convalescent Depot's equipment been brought up to strength and the physiotherapy department developed, than this disturbing and locally disruptive enemy activity made itself felt in the Moascar region. There was sporadic night bombing of the Ismailia district during the full moon. Other nearby areas suffered and attempts were made by the enemy to sow mines in the Suez Canal. This led to considerable disruption of the Convalescent Depot's routine, and also to a call by Canal Zone Headquarters for convalescent personnel to supply larger armed parties for security duties. The bombing of Ismailia was rapidly followed by the mass evacuation of Egyptian civilians and the almost total cessation of contract services such as dhobi, swill, garbage, and the like. The Egyptian staff in Naafi canteens, supply depots, and other installations was similar depleted, until emergency transport could be arranged to take them nightly to the purely Egyptian towns like Zagazig which were immune from enemy attack. Those who witnessed the evening trains pulling out of Ismailia station, with the native camp employees, their families, and impedimenta clinging to every available space from the couplings of the carriages to the cooler parts of the engine, may well have occasion to recall this as affording a sense of humour and relief from the irritations of the disturbed tempo of convalescent life. Nevertheless, a nuisance value was attained by the enemy. With the increasing intensity of the raids, the Convalescent Depot itself suffered direct hits, as for example that on the MI Room, and its staff helped to extinguish fires in nearby lines and RE dumps, the New Zealanders distinguishing themselves in the course of these duties.
On the night of 4–5 August bombing raids on Ismailia called for assistance from members of the staff of the Convalescent Depot to help the Egyptian hospital cope with the influx of civilian casualties. Surgical teams arrived later from British military hospitals outside the area.
On 11 August there was a concentrated and sustained air raid on Abu Suweir aerodrome nearby. At the Convalescent Depot slit trenches had been prepared, tents were dug in, and considerable attention was given to PAD preparations. On 14 August flares and page 248 two sticks of bombs were dropped in the area around the depot headquarters and a direct hit was scored on the medical inspection room, which was completely wrecked except for the end housing the dental department. A fire which began in a group of native shops near the massage department was dealt with, and this undoubtedly saved the depot from considerable bombing which subseqently was concentrated around a fire in an adjacent area.
Despite the ordeal, personnel in the depot behaved with extreme coolness. Stretcher parties functioned normally between bombings and brought into the treatment centre the five casualties which occurred in the depot. These were mainly light wounds from shell fragments, but one man received a serious chest wound. Three of the more serious cases were evacuated to 54 General Hospital by ambulance. In no case did casualties occur among men in slit trenches.
After these raids the Area Commander instructed that as many troops as possible should be dispersed at night (an instruction which one group of New Zealand convalescents had earlier anticipated). Some 300 convalescents with a small cadre of staff were transferred each night to Chevalier Island, where a reception hospital was subsequently opened to obviate sending patients to general hospitals in the district for minor sickness. Under these conditions the depot scarcely functioned along intended lines. Sleep was interrupted and a few men started to sleep out of camp. Morale tended to suffer, and some who might otherwise have readjusted themselves well from mild anxiety states were found to exhibit marked exacerbations of their symptoms. A decision was made to return the less stable of these to the quieter Maadi area, 180 in this category being evacuated in three days. This reduced the numbers in the Convalescent Depot to a point at which there were barely sufficient A grade or B1 grade men to supply the necessary number of pickets and guards for depot buildings, stores, and other duties for which the Convalescent Depot had been made locally responsible.
At the end of the first week in September there were heavy air raids. The 54th British General Hospital was severely damaged and rendered untenable. The continued bombing raids, apart from the risk to personnel, had minimised the value of 1 Convalescent Depot as an institution for recuperation from injury and illness. The main factors were the loss of sleep and a general atmosphere of disturbance and uneasiness. The expedient of removing some of the patients and staff to another location at night afforded only partial relief. It was felt that removal of the whole depot to Maadi Camp would provide, at least for the time being, a location free from air raids. No other site being available, it was decided that the depot should be established at Maadi during the winter months and that page 249 possibly by March 1942 some alternative location might be found. The move took place on 10 October 1941.
Coinciding with the transfer of the depot, Lieutenant-Colonel Tennent was appointed CO 4 Field Ambulance and relinquished his command to Lieutenant-Colonel Noakes, whose appointment was to continue until the end of the war in Italy in 1945.
An investigation of the functioning of the Convalescent Depot with regard to the type of case likely to benefit by treatment there was carried out by the Consultant Surgeon and Consultant Physician in September. They considered that patients who were incompletely diagnosed, severe cases with disabilities difficult to assess, hysterical cases and possible malingerers, and those for whom no special treatment was required and whose ultimate fitness was doubtful, should not be sent by the hospitals to the depot. Those thought suitable were the more normal cases likely to make uninterrupted progress and men awaiting return to New Zealand. It was considered that it was unfair to the staff of the depot to send them chronic and difficult cases, which were much better retained and dealt with at the hospitals.
A visit was paid at that time to 2 British Convalescent Depot at El Ballah, where no sick men were admitted and massage was not encouraged, but where all men were fit for concentrated physical training prior to return to their units. The distinction in the administration of the RAMC depots and our own persisted throughout the war, both systems having their special advantages.