With the First Red Cross Mission to Serbia

    At the beginning of the war, Mr James Johnston Abraham was an experienced General Surgeon. He was born in Ulster, Northern Ireland in August 1876 but qualified in Dublin and practised as a General Surgeon in London. He  applied to join the RAMC in 1914.   

    The following extract from his autobiography, "Surgeon's Journey" describes how he was refused by the RAMC, as being too senior, but was readily accepted for the Red Cross Mission by the famous surgeon, Sir Frederick Treves.  

    He served in Serbia in charge of The First British Red Cross Serbian Mission in 1915 and graphically describes the inadequate medical facilities in that poor country and how these few medical facilities were swamped by the great Typhus Epidemic of 1915.    [The description of his journey from England to Serbia has been edited as it was mainly concerned with non-medical descriptions of his journey through Malta, Greece and  Salonika by sea and by rail to Serbia where he was posted to Skopjlie (Uskub).]

    At that time medical services for Serbia were almost non-existent.  The overcrowded insanitary  conditions in this country produced fertile breeding grounds for louse infection and led to the great Typhus Epidemic of 1915 that killed tens of thousands of Serbian and  Austrian soldiers and civilians.  

    In 1915, the cause of Typhus was unknown, although the louse as a vector was suspected. It was not until 1921 that the Rickettsia group of organisms were identified as the causative factor. During WW1 there was no known cure and the mortality approached 15 - 20%.  It was recognised that the mortality was higher in older patients and in patients over the age of 50 -60 it approached 50%; that is why Mr Abraham warned Dr. R. 0. Moon against  offering his services to treat Typhus.

    The onset of Typhus is rapid with high fever, vomiting and headache and pains in the back and limbs.  A typical rash appeared on the 4th or 5th day as rose-red spots on the trunk, spreading to the limbs.  Apathy and drowsiness may lead to delirium which can be noisy and violent. Diarrhoea can lead to dehydration. Bedsores occurred when the nursing arrangements were poor, as they were in Serbia, and this led to considerable disability.  Lung complications of  broncho-pneumonia were common and frequently led to death.

 Dr M G Miller, Editor

    Next day I made for the War Office and was directed to A.M.D.1, if I remember aright. This I found was a small office; and, to my surprise, sitting at the desk was one of my old house-surgeons in a captain's uniform. We greeted each other warmly.

"What can I do for you, sir?" he said.

" I want to join up," I answered, cheerfully. 

    He looked at me with obvious embarrassment. "Well, sir, that's really rather difficult. You see, sir, you're a bit old for us. You are over thirty, and we really only want young newly qualified men to do dressings in the front line. We don't need Fellows of the College. You're too heavy guns for us. The war will be over by Christmas."

    That was the sort of thing they were saying in the War Office at the end of August, 1914. I was very angry and very deflated, and I went to my rooms intensely depressed. Nobody wanted me with a war on. I was too old. I tried to work, but everything seemed flat and unprofitable. Nothing interested me except the news; and the news wasn't too good in spite of censorship. Days passed, and I grew more and more restless. Then one afternoon someone said to me:

"Never mind the damn silly War Office. Why don't you go to the Red Cross and St..John people?"

I did, and I was referred at once to Sir Frederick Treves, from whom I had a very different reception.

"We're wanting surgeons badly in Belgium, Abraham. Souttar, - you know Souttar - is there now. Would you care to go to Antwerp?"  "Delighted" I answered.

"Right. Well, come tomorrow and we'll fix you up!'

    Next day he said:  "Antwerp has fallen, as you know. What about Ostend or Dunkirk?"

"Anywhere, Sir Frederick."

    Ostend and Dunkirk fell just as it was arranged for me to go over. The Germans were sweeping across the Low Countries. The dream of a war over by Christmas was fading. I saw Treves again.  "Would you care to go to Serbia?" he said gravely. "We are fixing up a mission going out in a troopship in a few days. It will be very rough campaigning, and we can only send men of first-class physique. Could you get ready in five days?"

"Certainly," I said.  And in five days I was at Southampton on board the troopship, having settled my affairs, got leave of absence from my hospitals, and arranged for a colleague to look after my practice.

    Our unit was called 'The First British Red Cross Serbian Mission', and consisted of six medical officers and twelve St. John's Ambulance orderlies.

*****

    On our first day [in Skopjlie] we went to see the military hospital. In it was a most efficient Serbian medical officer. He was operating at great speed in a large out-patient department, surrounded by wounded, extracting bullets and pieces of shrapnel without any anaesthetic. We asked him why. He looked at us with lifted eyebrows. " I haven't time for anaesthetics," he said, in halting German.

    We soon found that this was true. Every day thousands of walking sick and wounded poured into the town. Every day train-loads left for Veles, Glievgeli and Monastir; and every day more train-loads arrived. No one was kept whose temperature was under 104 degrees Fahrenheit unless he was a compound fracture or obviously dying. The position was desperate.

    The Serbs were retreating daily, fighting back savagely. But they were outnumbered, they were short of artillery, guns, ammunition, and their one arsenal at Kraguievatz was threatened with capture. Things looked very black.

    We had been sent out by Sir Frederick Treves as an Advanced Dressing Station. The Serbs wanted us to run a hospital instead. And what they offered us were three great buildings, formerly tobacco warehouses. The largest, No. 1 Hospital, had three floors holding six hundred patients. There was no medical staff except one Russian woman doctor, no inside sanitary arrangements, no water laid on, no operating theatre. A few feeble electric lights dirtily illuminated each floor, and all the heating was by wood-burning stoves. The hospital was full, three patients to two beds. The men lay in their dirty field uniforms with their foul dressings unchanged for days. They were looked after by untrained 'sestras' and 'bolnitchers' (male orderlies). Not a window was open. The smell was appalling.

    No. 2 and No. 3 Hospitals had no lighting at all, and were filled with sick Austrian prisoners of war lying on straw, unattended. The Serbs were asking us - six doctors and twelve St. John's Ambulance orderlies - to run these three hospitals having more in-patients than the London [Hospital].   We said we couldn't do it.

    Banks and I went up to the top floor of No. 1 Hospital to reconnoitre. There we found the little red-haired Russian woman doctor, Dr. Kadish, doing dressings at a series of trestle tables. She said she started at nine each morning and worked until the light was too bad to carry on. She had been doing this alone for two months.  That was too much for us. We buckled to and helped her, and that settled it. We took on the impossible task, and we took her on as well.

    She was a wonderful little woman, and without her I realise we never could have carried on, for she spoke Serbian, Russian, German, French and English equally fluently; she had the heart of a Lion, and the infinite tenderness of a woman for the sick and suffering. She had been terrified that we would not want her, and pathetically relieved when we made her one of us. She stuck to us all through the horrible time that came later; she nearly died in our service; we fought for her life, and saved it. She is dead now, but none of us still alive will ever forget Esther Kadish.

    At first there was no time to go round the hospitals. Patients came to the dressing-tables or were carried there. If they did not come again we presumed they had died. For every day as we went into No. 1 Hospital we could see ten to twenty bodies laid out on stretchers, each wrapped in a blanket with a candle burning at his head. They were men from Northern Serbia with no one to mourn them, simply numbers on a casualty list.

    The pressure of work was so great we hardly had time to think. Once I opened a huge abscess in a man's armpit, but in doing so, unfortunately, I also opened an arteriovenous aneurysm behind it which spurted blood violently in my face. I plugged the big cavity hastily with iodoform gauze, stopped the haemorrhage, bandaged the man up, sent him away on his stretcher and started on the next case. Next day he was not brought again, so I was quite sure he had died. A fortnight later he was once more brought to the table. No dressing had been done in the interval. I loosened the stinking bandages very, very gingerly. Nothing happened. There was a good granulating wound, obviously healing.

    I said to the Little Red Woman: "Why is it that some patients come on stretchers daily and some, like this man, not for a fortnight?"  She flared up angrily.'It is the bolnitchers. If they do not get tips from the patients they will not bring them. And so they die. It is awful"

    I was shocked, but could do nothing, for no supervision was possible until we could start hospital rounds. And every time we thought we could start these rounds a fresh train-load of walking-wounded would be dumped on us from the front. The men poured in daily and the numbers never seemed to lessen, for as soon as they had a night's rest lying in the straw in their billets in disused mosques, gymnasia and school buildings, they were sent on south and new train-loads arrived from the north. 

    It seemed unending, and it went on for six weeks. Then suddenly it lessened; and we were able to do rounds at last and pay bed visits. We heard the Serbs had gained an immense victory and had captured 90,000 Austrian prisoners; but, we had been so plugged with propaganda we didn't believe it. It was true all the same. There had been a great victory. Whole Czech regiments had deserted the Austrians and marched over to the Serbs, complete with regimental bands and equipment. Luckily we did not know then what those ninety thousand prisoners were also bringing us; and we were happy.

    We had managed to get a theatre going; we were able to visit our patients in their beds. We had learnt enough Serbian to be able to ask simple questions; and we were now able to do some major surgery. It was mainly amputations for septic compound fractures, and ligaturing arteries for secondary haemorrhage. I never thought when I was doing operative surgery for the Fellowship that I should have to use any of the set operations except on the rarest occasions. For the surgery we were doing was the surgery of the Napoleonic Wars. We were ligaturing subclavians or brachials or femorals, popliteals or posterior tibial arteries, or doing the classical amputations we had learnt out of books.

    Amongst the Austrian prisoners recently captured were a large number of trained medical orderlies, infinitely better than the ignorant bolnitchers we had been depending on. Many of them were Czechs, for the Czechs were then Austrian citizens; a good many had been to the United States and could speak American English. Some two hundred were allotted to us. They were disciplined men and made excellent orderlies. We gave our St. John's orderlies sergeant's rank and allotted twenty men to each. And so we really got going. Christmas came. Everyone went about cheerfully saying "Christ is born. Christ is born", after the Serbian manner. At the turn of the year the work suddenly slackened. The fighting had died down. The Austrian defeat had been even greater than we had guessed. We were now able to examine and treat our cases with something resembling deliberation. We actually could operate at our leisure.

There was quite a lot of relapsing fever in the hospital, but we just had to ignore that. Some of the orderlies got it and recovered completely. One of the medical officers unfortunately got three attacks one after the other, and we had to send him home. But when our unit began to get diphtheria and smallpox it became more serious. Still we were not alarmed. We could cope with these also.

    And then we began to hear disquieting rumours about mysterious illnesses amongst the prisoners. Still nothing happened in our hospital to worry us. Then one day I had an Austrian sergeant brought up for dressing on whom I had done a double amputation the day before. When my orderly took off the dressing 1 saw something - something that filled me with horror. It was a rash. I knew that rash. I'd seen it in Connemara. The rumour was true. There was typhus fever in the P.O.W. camp. I had been told there were twenty cases already at the Polymesis - the fever hospital in the town. But the Serbs call relapsing fever 'teephoose', and typhoid 'teephoose', and typhus 'teephoose', so deliberately I had shut my eyes and banked on this ambiguity.

    My patient had typhus, and he was in my hospital. I knew there must be hundreds of contacts already from him in our overcrowded wards. I knew also that fifty per cent of our patients would get it and twenty-five per cent would probably die. It was clear our unit could hardly hope to escape and almost certainly some of us would die. We stopped operating. And then the trouble fell on us. My own special orderly, Edwardes, whom I particularly liked because he was so kind, so gentle with the patients, so absolutely dependable - Edwardes got it. We isolated him in the gate-house of the nunnery where we were quartered. We put a special orderly on to him. We did everything we could, with our chief physician in charge and Banks in consultation. He lived for seventeen days; he ought to have pulled through but he did not.

    The Serbs gave him a military funeral, complete with band playing the Dead March, and a salvo over the open grave. The Serb Commandant made a funeral oration over him which the Little Red Woman said was beautiful. I wept like a child. He was the first.  More followed until out of the original twelve orderlies we were down to eight. The doctors began next. The first was Benbow, one of our physicians. When he became delirious he was full of the most dangerous delusions, hid a Kruger pistol under his pillow and tried to use it. Holmes got it next. This was almost inevitable. He was our chief physician. He too became delirious. He thought his head was coming off, and somehow managed to get a heavy chain and padlock from somewhere, which he hung round his neck to keep it on. We borrowed Sister Fry, a nurse from the Lady Paget Mission. She was an old friend of mine from West London Hospital days, who volunteered to come to us in our extremity. It was a most courageous thing to do, for we wore naturally treated as pariahs. Then the Little Red Woman got infected and refused blankly to come into our quarters to be nursed. We pointed out to her that our quarters were already infected and carried her in by force. Then she broke down and wept with relief.  More orderlies got it. We put them in tents in the garden of the nunnery. I think that saved three from death.

    All attempts by military and civil authorities to conceal the cause of the spreading epidemic had now hem stopped. Up to this time they had refused to acknowledge the cause; but by now everyone knew we were in the throes of an immense epidemic of typhus. Historically it is a disease that has always swept over Europe in the wake of war, killing millions more than fire and sword. We knew there was no way of avoiding it. Typhus, the scourge of the Middle Ages, the decimator of Germany in the Thirty Years War, the enemy that helped frost and dysentery to annihilate Napoleon's army in the retreat from Moscow, the enemy that practically finished the Crimean War, the Morbus Hungaricus that always lurks in the Balkans, had fallen upon us.

    It is a disease we never see in England now. But it was rampant in the eighteenth century; and the memory of its devastating power is perpetuated in the custom still prevalent at she Old Bailey, where the judge of Assize is presented at the beginning of each session with a bunch of sweet-smelling herbs - now only a ceremony but one which was supposed to protect his predecessors from the fever carried into the Court by the wretched prisoners in the time of the early Georges. 

    The Austrian prisoners amongst whom it started died in thousands. From them it spread to the civil population. The hospitals filled. Nurses and doctors caught it and died. People died unattended in their homes. They died in the trains fleeing South. They died in the streets of the towns. It is said that over a million people were infected. Presently Banks and I were left with five orderlies. The number of victims was still great but the death-rate was falling a little.  We had stopped operating now for some time, and were able to discharge such of our surgical cases as had recovered and escaped infection.  Banks and I were therefore idle. So I transformed myself into a physician; and, after much bickering, was given the Military Cadet Barracks to run as a typhus hospital, with a hundred Austrian orderlies to do the nursing. This was a great improvement on my tobacco factory hospital. Sister Fry came as matron and she and I worked together. Banks remained at our old hospital looking after the surgical. cases that still had the disease. He also took care of our doctors, Benbow, Holmes and the Little Red Woman, all of them, luckily, recovering.

    At this juncture a London consultant, Dr. R. O. Moon, Physician to the National Hospital for Heart Diseases, arrived in Skop1je, and he came to see me, full of enthusiasm. He was a man of about fifty with a smartly trimmed grey beard; and I told him at his age I did not think he should risk treating typhus. This annoyed him extremely as he was a man of very Spartan habits who never wore an overcoat, winter or summer, and prided himself on his physical fitness. So he went away in high dudgeon and offiered his services to the Serb authorities. They promptly gave him the Polymesis Hospital, where the two previous doctors, both Greeks, had died of typhus. He took over, it was an extremely brave thing to do at his age. Three weeks later, however, I was called to see him. He was delirious - and did not recognise me. I took him into my hospital and looked after him. Eventually he recovered, but his memory from fourteen days after his arrival in Scop1je until well into convalescence was completely blank, and when we met in London years later he could not remember me and indeed this was characteristic of the disease - an almost total amnesia covering the period of the attack. Dr. Holmes, Dr. Benbow, and several of the orderlies could not remember quite a lot of queer things I told them they had done. The only doctors of our unit now working were Banks and myself, and we were both tired and depressed. Any day we knew the rash might come out on us. We used to smear our bodies with a mixture of 'Vaseline' and paraffin oil to keep the lice off us; and to this I attribute the fact that we both came through unscathed. For, though we did not know it then, the disease is carried by lice.

    But by this time I began to feel I could not go on much longer. In the hope that I might get help from our No. 2 Red Cross Mission, which had been posted to Vernjatskabanya, I took three days off, travelled to Nish and got through to our unit and the James Berry Mission. But they could not let me have any nurses or any of the hospital equipment I so badly needed. The work they were doing fully occupied them. I came back to my Barracks Hospital still more depressed and carried on. In the meantime, however, the Lady Paget Mission, which was also working in Skop1je, had decided to tackle typhus because there was no surgery left to do. Lady Paget herself took over another barracks across the campus from us, turned half the staff into a typhus fighting unit and busied herself getting her barracks scrubbed out and disinfected. just when she was ready to start, however, she too got typhus and came into my hospital.  It was now the end of February, and the almond trees came out in blossom. Spring was with us, and with spring quite suddenly the number of admissions began to decline, less and less arrived, and we actually had a few spare beds. The epidemic was declining, and we ceased to be overworked.

    Holmes and the Little Red Woman were convalescing and developing enormous appetites. So too was Benbow, the first victim amongst the doctors. They all came up to my windswept hospital to recuperate. But of course we were all very tired. I had come out to Serbia weighing twelve stone. I found I was now only 8 st. 4 lb. and could not eat. I asked Banks, who had little to do, to take over from me for a few days, and began to think. It was the first time for months I'd been able to do so. As it happened, a fresh unit from the Serbian Relief Fund in London had just arrived, full of enthusiasm, very eager to be of use, and they offered to take on our work. I suppose they saw we were about done and pretty useless. It was obvious, moreover, the epidemic was petering out. I knew that none of our doctors who had had typhus would be fit for any hard work for months. Our contract with the Red Cross was up, but I understood they would extend it if we wished. So I put it to the five orderlies, out of the original twelve of our unit, who were left. They all said they wanted to go home. None of them wished to sign on again. The unit as a driving force was dead. The men were tired. We were all tired. So I handed over thankfully to the Serbian Relief Fund and made arrangements to leave.

    A lot of people came to see us off. I could not sleep in the wagon-lit. I could not believe it was all over. At the frontier a smart Serbian officer came in to see me. He was very spick and span, very bright and cheery.  "Will you come back to Serbie?" he asked, politely.
"Perhaps," I answered, "next year!'  

"Ah. A year's time. It will be all over then. In two months the Russians will be in Buda Pesth."               

How little he knew. How little I knew. How little anyone knew. For that conversation was in March, 1915.

*****

    Fourteen days later we were in London; and I went to report to Sir Frederick Treves at the Combined Headquarters of the British Red Cross and the Order of St. John of Jerusalem. He listened with amazement to my story, for nothing of the epidemic had been allowed to pass the censorship because the Serbs feared they might be invaded if it was known they were so defenceless.

    Treves stared at me as I talked. When I had finished he said:

"This is most important. The D.G. (Director-General Army Medical Service) must hear of it."

 So I repeated the whole grim story to Sir Alfred Keogh at the War Office. He listened intently, cross-examined me closely and then sent message which brought a Staff Colonel into the room.

    Again I went over the same story to the three quiet men, who sat gazing at me, thin, drawn and weary in my battered Red Cross uniform.

    I did not know then that I was repeating my story to Kitchener's Military Secretary. But in 1919, when it was all over, Treves told me that the War Office had almost decided to send an expeditionary force up from Salonika into Serbia, and might have done so if it had not been for the epidemic. But the risk was too great. If they had, it is possible the Bulgars would not have come in on the German side, Germans then would not have been able to go to the aid of the Turks, Gallipoli would have been unnecessary and the campaigns in Mesopotamia and Palestine radically altered another example of how disease can change the course of history.