Cochrane AL, Blythe M (2004). Sickness in Salonica.
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© Max Blythe, Wootton House, Barns Hay, Old Marston, Oxford OX3 0PN. E-mail: profmaxblythe@aol.com


Cite as: Cochrane AL, Blythe M (2004). Sickness in Salonica. JLL Bulletin: Commentaries on the history of treatment evaluation (http://www.jameslindlibrary.org/articles/sickness-in-salonica/)


This article is based on a chapter in Cochrane AL, Blythe M. One Man’s Medicine: an autobiography of Professor Archie Cochrane. London: BMJ, 1989, pp 61-72, and has been reproduced, with permission, in The James Lind Library.

 

The old cavalry barracks were in an appalling state of repair and grossly overcrowded with about 10.000 prisoners, including Yugoslavs, Greeks, Cretans, Cypriots, Palestinians, Arabs, Indians, Australians, New Zealanders, English, Scots, Irish, and Welsh, and of course the Spaniards from Layforce. My first impressions were lack of food and lack of sleep. The diet consisted of one cupful of unsweetened coffee for breakfast, one plate of vegetable soup with a vestige of meat at midday, and two slices of bread (or a large biscuit) at night. Sleep was wrecked in two ways: by bed bugs, and by having, at first, to sleep on long sheets of wire netting, stretched in three tiers over wooden struts. There was an unmusical twang when anyone moved, and in the night there was a hideous cacophony.

There was a large hospital with about 200 beds. Surgeon Lieutenant Singer, a charming doctor from New Zealand, was in charge. He appeared to be doing a good job under difficult conditions. I joined the hospital to help out, and quite soon, to my surprise and embarrassment, was appointed chief doctor by the Germans as Singer had had an inevitable row with them. He was, fortunately, very good about it and my knowledge of German helped communications, not only with our hosts but also with the Jugoslavs. I soon realised what a thankless job I had.

The one great asset I had were the orderlies, a mixture partly from a section of the Friends Ambulance Unit (Quakers) and others from Australia, New Zealand, the UK, and Yugoslavia. They were all devoted workers but chief praise must go to the Quakers, who were magnificent. Amongst them was Bill Miall, who later worked with me in Cardiff, became director of the MRC Epidemiological Unit in Jamaica, and is now at the MRC unit at Northwick Park. Another was Duncan Catterall, now director of the Venereology Unit at the Middlesex Hospital.

Life at the beginning of July was just tolerable. A typical day was as follows: reveille 5.30 am; parade 6 am (this often lasted an hour, for the Germans seemed incapable of counting correctly); then there was time for the “acorn” coffee and any bread one had managed not to eat the night before; then sick parade for other ranks (there were often 200, of which I did half); then another sick parade for the officers (we were lucky to finish by 10.30 am); then a ward round (I often had 100 medical cases); then I did a short sanitary round to try and keep the latrines working. At midday we had our soup, which did not take long to swallow. I rested until 1 pm when I either went to make complaints to the Germans – a rather profitless task as they always claimed that Salonica was a transit camp and that all prisoners of war would soon be sent to Germany (it is true that all officers, except two or three medical officers, were soon despatched to Germany, to be followed later by the Jugoslavs) or tried some crude psychotherapy on those suffering from severe battle neuroses. I saw them in my room alone and encouraged them to tell me about their experiences and fears. They soon started crying, which I encouraged. The sessions often lasted some time and the men often fell asleep afterwards. It seemed effective in most cases. At 4.30 pm we ran a skin sepsis clinic. After that I did another medical round, then got my two slices of bread and went on parade at 7 pm. Next followed an “outpatients” for those who had been working in the town. Then there was curfew, after which it was dangerous to go out. You could get shot. In the evenings I was tired but had difficulty in sleeping because of the bed bugs. I sometimes talked to the Yugoslavs, but more often to the Quakers. Sometimes to comfort myself I wrote verse. There is one poem I still like. It combines my generation’s guilt at not preventing the war and my personal guilt I felt when travelling to Edinburgh too late to see my mother before she died in 1937.

SIMILARITY
The track was hard as fate,
The train was singing:
“She must not die”
(I’d loved but not enough)
The wheels were ringing
“She cannot die”
(I’d tried but not enough)
and then I came too late.

Now prisoner, down in Greece,
The news is stinging.
We’re down and out
(I’d loved but not enough)
The “goons” are grinning
of Russian rout.
(I’d tried but not enough)
and there is no more peace.

There were some other curious incidents in those early days. The first was my only success. I still felt responsible for the Spaniards who had been in Layforce and were worried about what would happen to them when prisoners of war and give personal details. I promised to be there with them and argue that they were in the British Army and must be treated as British prisoners of war. As we began to march up to get registered I was suddenly inspired. I decided that all the Spaniards had been born in Gibraltar! I held a hurried discussion with them and the whole registration went off without the Germans raising one eyebrow. The Spaniards were delighted and I felt a mild glow, but I had another problem on my hands – a really unpleasant one – a traitor. He was an English regular sergeant major, about twice my size and very muscular. He had a German wife, and on capture expressed his willingness to join the German Army. He lived with the Germans but moved freely in the camp and had a devastating effect on morale. It fell to my lot to see him, read a quote from King’s Regulations, and promise that I would try and see that he was court martialled after the war. He roared with laughter throughout and I felt rather foolish. I checked up after the war. He was killed on the Eastern Front.

Another incident showed the effect of chronic hunger. During my sanitary round I found a padre, whom I had met earlier in Alexandria, taking food out of clothes stupidly left in the barracks while the owner was out working in Salonica. I went up to him and said, “You must not do this. It’s stealing.” He answered without any show of embarrassment, “Why? I’m hungry.” I know no better example of the awful effect of hunger. There was another level at which hunger showed its ill effects – the language and dreams of the British Army. The language of the British Army must have bored others as well as myself by its compulsive sex orientation. This disappeared completely in three weeks on the German diet of 600 calories per day. The talk was only of beef steak and milk chocolate. I remember a tough sergeant major telling me all about a dream he had had about a Cadbury’s bar.

After this early period (I remember saying I could only last out four weeks) the situation deteriorated in two different ways – disease and shooting. Both climaxed at about the same time. I know how near to breakdown I was driven.

Dealing with the shooting first. There had always been some intermittent shooting at night, but it slowly increased. Whenever I complained the Germans said that if no one left the barracks at night there would be no shooting. I wanted permission for prisoners to go to the outside latrines when necessary as the inside ones were often insufficient, with results that can only be imagined. They refused.

In August the bad month when everything happened, night shooting increased and then day shooting started, and for some reason it was concentrated on the hospital. The first shot put a bullet into the roof of the dental clinic and brought down plaster on the head of the New Zealander dentist when he was extracting a tooth. A few days later a bullet whizzed through my hair when I was doing my inpatient round. I remember that my right hand had just felt the outline of the spleen in a case of malaria. I have never felt the same about spleens since! On each occasion, of course, I made my routine complaints. The Germans apologised and said it was all a mistake and that it would not happen again, but of course it did.

Then came a day I shall never forget. It was in August. I had nearly finished my inpatient round when a terrified orderly told me that another orderly, a New Zealander, had been shot in the arm at the door of the hospital. I rushed to the Germans to organise his transport to the local hospital for surgical emergencies. The wounded orderly later lost his arm. I was on my way back when news came that two more orderlies had been shot, a Yugoslav and another New Zealander. They both had serious abdominal wounds. Again I was successful in arranging ambulance transport, but the German doctors refused to speak to me. I was in a rage. The Germans refused to see me at 1.30, the usual time, so I had a while to cool down a little. I could not understand why they were shooting at us.

Still worse was to come. One of the orderlies died – though the other made a more or less complete recovery. That night there was a lot of noise. A German sentry called me out and led me to a lavatory in one of the barracks. There I saw blood, faeces, and naked human flesh, illuminated by flash light. I vomited. I remember hearing the German sentry telling his sergeant that he had thrown a hand grenade into the latrine because of verdächtiges Lachen (suspicious laughter). I collected some devoted orderlies and together we treated the wounded and cleaned up the mess. Fortunately the wounds were not serious, but I spent a sleepless night. The final insult came the next morning when I was ordered to attend a German parade during which the Kommandant congratulated the sentries on their vigilance. I took the rest of the morning off.

Surprisingly, at 1.30 pm I received an order to appear before the Germans. Usually it was hard work persuading them to see me. It was curious that both the Kommandant and his deputy were present. I also sensed some disagreement between them, for I noticed that they were sitting fairly far apart. They asked me if I had anything to say. I had recovered from my wild rage and decided to try another line. I said in fluent German – and in German I have rather an upper class accent – how much I had admired German culture in the past. I mentioned the usual names – Goethe, Heine, Beethoven, and Mozart – and how much had been contributed to medicine through Robert Koch and, more recently, the discovery of the sulphonamides. How shocked I was therefore to find Germans, in breach of the Geneva Convention, trying to starve prisoners of war to death, murdering medical orderlies, and attempting to shoot dentists and doctors. There was a short silence, after which the Kommandant said the past might have been unpleasant though necessary, but the future would be much better. And this time he was right.

The medical troubles started slowly, with skin sepsis, dysentery, and sandfly fever. The Germans gave us an old pink solution for skin sepsis and some curious pills for dysentery; both medications were ineffective. They gave us aspirin for sandfly fever, which is, fortunately, a self-limiting disease. There was a little malaria for which we got a small quantity of quinine. I thought we could survive, but then came the deluge: epidemics of diphtheria, typhoid and hepatitis. I was not too bad at diagnosing the cases. To my credit I diagnosed the early diphtheria cases and even got the first typhoid case right. The “rose” spots were unmistakable. But what could I do about them? The Germans would give me no help, either in treatment or prevention. I had to watch the epidemics go through the camp. I was terrified and sleepless night after night; but in the event very little happened. Those with diphtheria developed frightening neurological complications but no one died. The only intervention I could think of was the forceful removal of the membranes twice a day to be sure no one suffocated. I told those with typhoid to lie still on their own faeces and I would see they were well hydrated and given as much glucose as I could get out of the Germans, and in fact only one died. Hepatitis was a different story. Everyone wanted it because it stopped hunger although it made one itch. I had it myself and it gave me my first good night’s sleep for a long time, but it did not stop me worrying about the long term consequences.

Then came the final blow. Towards the end of July I noticed an increasing number of prisoners complaining of heavily swollen ankles – ankle oedema. This seamed to effect the British most seriously. The few remaining Indians, Yugoslavs, and other non-British prisoners were less affected. I also noticed that cooks were not affected, and assumed, I hope reasonably, that the cause was nutritional. I diagnosed hypo-proteinaemic oedema (famine oedema) and asked the Germans to measure the protein level of the blood. They refused, saying it was all due to the sun. I asked for senior physicians who had been captured and whom I knew were in Athens, to be brought in to advise me. I was conscious of my own ignorance. They refused, saving “Ärzte sind überflüssig” (“doctors are superfluous“). In retrospect, I think they were probably right, but it made me angry at the time and I was driven to write some verse:

SUPERFLUOUS DOCTORS
“Superfluous doctors” – what a phrase to rouse
Dulled prison fires to flicker with the muse
And build a brave new world. There, would be
No famines, wars, or other acts of God
To break the Peace on Earth. No! Man would turn
From wanton killing of his cousin’s kin
To face his very foes, and Science and Art,
With Labour an ally, would fight and kill
Want and its very fears, disease, its very roots,
Squalor and filth and loneliness and pain,
And then let doctors quit the centre stage
To usher in the prophylactic age.
But death was near and hunger, and prisoners’
Dreams were rare.
The doctor in Salonica sat down and tore his hair.

We were soon seeing more than 20 new cases of severe oedema every day, and the figures were rising. As soon as the pressures of the diphtheria outbreak had subsided we had established a simple procedure for assessing disease incidence levels. This was based upon the efforts of a disabled Quaker colleague (he had been at King’s College Cambridge), who sat through all sick parades and to whom doctors reported their findings. In the case of all the main diseases diagnostic checks were then carried out in the hospital and incidence levels calculated. This we did using the prisoner of war population figures supplied to the cookhouse by the Germans.

It was through this crude epidemiological procedure that my fears and problems grew rapidly. In fact, the rate of incidence rose so dramatically that I felt obliged to change the diagnostic criteria to disguise the fact. To qualify for inclusion in the incidence figures oedema now had to be “pitting” oedema above the knee. Many people saw the figures and I did not want a panic to add to the troubles we already had. Even then the number kept rising, and I became desperate. I knew I must do something, despite the Germans’ lack of concern, and I examined the problem from a number of directions. Then I remembered having read somewhere of “wet beriberi,” caused by vitamin B deficiency, which resulted in severe oedema. For a time I must have convinced myself that I was witnessing an epidemic of “wet beriberi,” for I decided to do an experiment modelled on that of James Lind, one of my medical heroes. I chose 20 men, all in their early twenties, all emaciated and with oedema above the knee. I put 10 in each of two small wards. They all received the standard rations, but those in one ward were given a supplement of yeast three times a day (I had to use my own reserve of Greek money to get it on the black market). In the other ward they got one vitamin C tablet each day (I had kept a small reserve for an emergency). I had meant to measure the volume of urine passed, but that proved impossible. I could obtain no buckets, so I had to fall back on “frequency” measurements. Each man counted the number of times he passed water in 24 hours.

I kept the whole thing secret. I expected, and feared, failure. I noted the numbers each morning. There was no difference between rooms for the first two days; on the third day there was a slight difference; and on the fourth it was definite. In addition, eight out of the ten men in the “yeast room” felt better, while no one felt better in the “vitamin C room.” I wrote it up carefully and took it to the Germans at 1.30pm. I must have presented an odd figure, in tattered khaki shirt and shorts. My face was emaciated and deeply jaundiced, but it was surrounded by a mass of red hair and an impressive red beard. The oedema round my knees was all too obvious.

I told them what had been done and what the results were. I claimed that it was proof of a serious deficiency disease, “wet beriberi,” in the camp. I suggested some of the dire consequences that would result if nothing was done and became very emotional. I suddenly realised that I had truly shaken the Germans. One reason for this was the fact that the younger German doctor had heard of the trial of lemon juice in the discovery of the cure of scurvy. He even asked what I wanted in a very civilised way. I said, “A lot of yeast at once, an increased diet as soon as possible, and the rapid evacuation of the camp.” And the Germans promised to do their best. I felt elated as I left them, but I was as depressed as ever by the time I reached the hospital. I did not think the promises would be kept. I did not really believe in “wet beriberi” and was horrified that I had, for a time, deceived myself and the Germans. I was, deep down, sure it was famine oedema. I was also aware that it was a pretty awful trial, so I did not talk about it further. I merely closed it down by giving all those in the “vitamin C room” a good helping of yeast. Afterwards I returned to my room and wept. The outlook seemed hopeless.

But the miracle happened. The next morning a large amount of yeast arrived; in a few days the rations were increased to provide about 800 calories a day; and the evacuation of the camp was speeded up. The results of my trial were even more miraculous. They are shown in figure 4, which illustrates something of the speed with which the incidence of famine oedema declined after supplies of yeast arrived, an improvement which preceded the slight upgrading of the diet. Unfortunately I cannot pinpoint the date from which yeast was added to the diet. My notes were taken away from me when I left Salonica – but not the original graph, from which figure 4 has been prepared. Nevertheless, it is possible for me to be accurate to within a day or so, because the climax of the shootings, which I can date, coincided with the trial period. On this basis I have placed the arrival of yeast supplies three to four days before the main peak (point B) in the oedema curve.

In retrospect it is impossible not to accept a causal relationship between, on the one hand, the rapid fall in incidence and rapid clinical improvement of the cases and, on the other, consumption of yeast and the slight improvement in diet. Although I am almost certain now that the condition was hypoproteinaemic oedema and not “wet beriberi,” the mystery still remains as to why it appeared and disappeared so quickly. The simplest explanation is that it was the protein in the yeast that did the trick, but there could well have been something else.

Figure 4 The weekly incidence of sickness figures for hypoproteinaemic oedema in the Salonica prisoner of war camp, July-October 1941. The broken line indicates the point from which the author adopted a change in classification procedure to produce, as he explains in the text, the artificial low shown for mid-August.

fig4

As regards the trial, I have always felt rather emotional about it and ashamed of it. I have seldom referred to it since. It was a poor attempt. I was testing the wrong hypothesis, the numbers were too small, and they were not randomized. The outcome measure was pitiful and the trial did not go on long enough. On the other hand, it could be described as my first, worst, and most successful trial.

Whatever the cause, a vast change came over the camp in September and October. The shooting stopped; the oedema disappeared; we were less hungry; and the evacuation of the camp started. (The Germans did not tell me that the delay in evacuation was due to the Germans’ rapid advance into the Soviet Union.) We all began to relax a little. I started playing bridge and even once played for bread – winner takes all. I have never played so well.

After a time we were even able to discuss the “bad old days.” One subject which always came up was which nationality had behaved best during the bad period? There was a curious unanimity that the New Zealanders were the best and the Australians the worst.

The next big event was the evacuation to Salonica of the prisoner of war hospital in Athens. The doctors, orderlies, and patients arrived, in the charge of Lieutenant Colonel Le Soeuf, an Australian surgeon whom I liked and respected. With him was my old friend, Bill Foreman, who I was to see so much of in the future. I have never handed over responsibility more willingly.

The camp was not completely evacuated until 30 November, but I had a much happier life. I was able to write a letter home, and to add a PS, “Love to Sonia. ALC” (an anagram of Salonica), which amused my sister. Later we even got British Red Cross parcels, and the effect was amazing. A lot of people seemed to be drunk on tea, while wondering what to eat first. We felt, for the first time, that we were not altogether forgotten. There was a charming Scots doctor called Johnny (I have forgotten his other name), who improved my bridge enormously. I noticed that I had had no attacks of migraine since arriving in Salonica, but if this was a cure I preferred the disease.

August in Salonica was perhaps the grimmest month in my life – so bad that I almost gave up. I managed to survive, chiefly, I think, because I had responsibility and was able to write (bad) verse. The following poem, “Duet for Two Voices,” was written in the depths of despair.

My Body
A
My eyes and ears, back, arms and leaden feet
send to the brain their neutral neural waves;
They cross the synapse, surge and meet
To etch in blood, and weariness and graves,
A martial chaos, gluttonous in defeat.
B
Oh, Christ, make memory blank.
Give cloud in clear!
What fool or blackguard gave me eyes to see
Or ears to hear.
My Heart
A
My heart is tired of war and all its
Lonely boredom under redcapped fools,
Comma’ed by steel of blitz,
With pity for the men, the patient tools,
And fear for them – for me – in sudden fits.
B
And yet this heart would gladly die for England.
Oh, Christ, you fool, you’re still that fat and filthy fag,
On the touch line
Shouting “Up, up School.”
My Mind
A
My mind can pierce the cause of war today
And see the moneyed marrow of its ills,
The way the Marxists say – can see much good can grind from
martial mills,
And can approve the end, but not the way.
B
And so the intellectual picks his doubts,
But never clean.
Oh, Christ! Decide! Come left or right!
There’s no room in between.
The “I”
A
And then the “I” – the body, heart and mind.
What can it do to make a perfect whole
Of doubt, divided, blind.
How can it ease the tumult of a soul
By treating sick? By trying to be kind?
B
“Christ that my love were in my arms
and I in my bed again!”