CHAPTER X
Nutritional Disorders
Herbert Pollack, M.D.
PERSPECTIVES AND PRELIMINARIES
It is often said that the U.S. Army and the people of theUnited States are the best fed in the world. A tremendous amount of the time andeffort of highly trained competent people was applied, with good results, to theration issue and to the menu planning for the Armed Forces during World War II.
Nevertheless, wars are unpredictable, and not infrequentlythe best laid plans fail of accomplishment. The fulfillment of normalnutritional requirements in a land of plenty with a highly efficienttransportation system presents relatively minor problems. In a war-torn landwith a complete breakdown of the normal channels of commerce, transportationdifficulties at times become unsurmountable and famine or starvation or lesssevere nutritional deprivations appear.
All degrees of malnutrition are present in the various partsof the world at all times. These deficiency syndromes are rather characteristicfor the regions where they exist; for example, beriberi among the rice-eatingpeoples, pellagra among the corn eaters, scurvy in the wheat eaters, proteindeficiency in those who eat the ground tubers, and caloric and proteindeficiency in the areas of crop failure. In time of war, nutritionalinadequacies in civilian populations are likely to be accentuated, and soldiersof a well-fed army may acquire similar disorders during captivity or under othercircumstances exposing them to local conditions.
Before World War II, the U.S. Army had never had to meet thenutritional problems incident to worldwide dissemination of troops in largeunits far from their sources of supply. Nevertheless, deficiency diseases didoccur occasionally,1 as follows:
1. In 1921, 11 cases of berberi with 1 death occurred amongnative troops in the Philippine Islands, and 3 cases occurred among nativetroops in Puerto Rico. In addition, there were 11 discharges among 20 PuertoRican soldiers with polyneuritis. All these cases were found to be related tothe consumption of overmilled rice.
2. In 1931, one case of berberi was reported in Philippinetroops; in 1932, two cases; and in 1934, two cases. In 1934, also, threecases of
1Annual Reports of The SurgeonGeneral, U.S. Army, 1921-39.
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pellagra occurred among troops in the continental UnitedStates-one in a Negro soldier at Fort Benning, Ga., and the other two in whitesoldiers, one in New Jersey and the other in Texas. These soldiers, each of whomhad 15 years of service, were all returned to duty.
3. A Filipino, admitted to hospital on sick report on 29April 1936, died on 12 September 1936 from beriberi.
4. In 1938, there was a case of pellagra at the GeneralDispensary in Boston. The patient, a warrant officer, was admitted to FortBanks, Mass., where he died.
5. In 1939, a case of pellagra was reported in troops incontinental United States.
These scattered cases of severe deficiency disease in theArmy occurred either in native troops subsisting on native foods or in personnelreceiving money allowances for rations, particularly warrant officers andnoncommissioned officers of the higher grades. The British, long accustomed tohandling native troops and their own men in the Near East, Middle East, and FarEast, had more experience than Americans in such matters.
During the First World War, the British observed many casesof scurvy among their troops in Mesopotamia. In June of 1918, a specialinvestigation was made of scurvy in the South African native labor corpscontingent serving in France under British jurisdiction, as 121 cases occurredamong 6,795 men.It was concluded that the chief cause was probably destruction of theantiscorbutic principle in the food by overcooking. In German prisoners of waron the island of Rousay off Scotland, the diagnosis of scurvy was firmlyestablished on 6 July 1917. In April of that year, a somewhat restricted rationscale had been introduced, omitting potatoes; also, purchase of food by theprisoners was forbidden on account of food shortages throughout the country.Previously, the prisoners had used money earned by their work to supplementtheir rations from local sources, buying bacon, which they ate raw, and otherarticles of food. Symptoms of scurvy appeared after about 7 weeks. Most of the men affected were those doing heavywork in the mines.
The Medical Department of the U.S. Army had been givenstatutory responsibility for the feeding of the soldier as it affects his healthand effectiveness as early as 1863, in an act revised in 1877.2The statute reads in part as follows:
The officers of the Medical Department of the Army shallunite with the officers of the line (under such rules and regulations as shallbe prescribed by the Secretary of War) in superintending the cooking done by theenlisted men; and the Surgeon General shall promulgate to the officers of saidCorps such regulations and instructions as may tend to insure the properpreparation of the ration of the soldier.
It was not, however, until July 1918 that The Surgeon Generalestablished the position of "nutrition officer" within the MedicalDepartment. The duties of the nutrition officer, as outlined in General OrdersNo. 67, War Department, 15 July 1918, were concerned with the quality, quantity,and proper storage of food, and with prevention of waste, with preparation ofmenus, and with miscellaneous matters relating to nutrition. Dur-
2Act of 3 March1863 (12 Stat. 744).
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ing World War I, the emphasis in the Surgeon General'sOffice was entirely on the technical side of the food and menu problems. Therewas no clinician assigned to this particular aspect of the work.
The nutritional problems of the First World War were stillfresh in the minds of only a few at the beginning of the Second World War, andthose few were for the most part not heeded. Nevertheless, between the twoconflicts, attention had gradually focused upon the shortcomings of the Armyrations, and some efforts had been made to correct them.3
In his 11 December 1926 letter to The Adjutant General, theQuartermaster General, Maj. Gen. B. F. Cheatham, pointed out the widevariations, as of 30 June of that year, in the ration allowances for the armedservices and, among these, the unfavorable position of the Army. Masters andfirst officers of the Army Transport Service were allowed $1 a day and the Navy,55 cents a day;the current Army garrison ration allowance was 36 cents a day and the Philippineration, 22 cents a day. He noted further: "The garrison ration is the sametoday as it was in 1908, although * * * the standard of living of the American peopleis much higher than that of eighteen years ago." On 3 January 1927, TheSurgeon General, in his endorsement to the Assistant Chief of Staff, G-4(logistics), stated that the current ration did not permit a serving of awell-balanced diet in the Army comparable with that of civilians in similarwalks of life, under the existing living conditions in the United States, andthat the ration allowance was not sufficient to permit the purchase of anadequate supply of foods rich in the essential protective substances, vitamins,without utilizing other funds.
In October 1923, Maj. Gen. M. W. Ireland, then The SurgeonGeneral, U.S. Army, described nutrition in the Army in the following terms:
The Army ration as now provided does supply sufficient andsuitable nourishment for the troops from the standpoint of balance and caloriccontent. That is, the ration contains a sufficient number of calories tosupply the needed energy and is balanced so as to prevent the occurrence ofdeficiency diseases. * * * Physiologicaland psychological reactions must be taken into account, and in order to obtain,in terms of body energy, the full value of the ration it must be of such anature that it will appeal to the troops and be eaten in sufficient quantities.
On 11 January 1927, Paul E. Howe, Ph. D., Bureau of AnimalIndustry, U.S. Department of Agriculture, then a lieutenant colonel in theSanitary Corps Reserve, submitted, to the Office of The Surgeon General, anexcellent critique on the ration of that time.
In 1929, a mess management course was instituted in the troopschools.
Just before the United States entered into World War II,Colonel Howe, having served a period of active duty from 26 July to 4 August1940, reported that the garrison ration at its field value was adequate as tocalories, proteins, phosphorus, iron, vitamin A, vitamin B1, andriboflavin and that it was fairly satisfactory with respect to calcium andvitamin C, but he had several very keen and pertinent remarks to make about theration-savings plan which was then in effect.
3Letter, Maj. Gen. B. F. Cheatham, The QuartermasterGeneral, to The Adjutant General, 11 Dec. 1926, subject: Increase inthe Ration Allowance-Regular Army and Philippine Scouts, with 1st endorsementthereto.
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By 26 September 1940, there is evidence of The SurgeonGeneral's awareness of the imminence of conflict and of his interest insetting up new rations for the troops. He had already obtained authority for theformation of the Food and Nutrition Subdivision in the Professional ServiceDivision of his office. Col. Paul E. Howe, SnC, became the first chief of thesubdivision, serving from 25 September 1940 to 12 April 1944.
Beginning with January 1941, a course for food and nutritionofficers of the Medical Department was given at the Army Medical School,Washington, D.C. Even as late as 7 February 1941, however, in a memorandum tothe Assistant Chief of Staff, G-4, on the proposed War Department circular onrations, the Office of The Surgeon General makes no mention of clinicalexamination of the troops who were going to consume the new ration.Unfortunately, too, little had been done to check the influence of the newertechniques of preservation on the nutrient content of foods. Early in the war,however, The Surgeon General, in recognition of the part played by goodnutrition in the maintenance of the health of troops, appointed clinicians tothe Nutrition Branch within his office.
This move presented something of an administrative problem.Maj. (later Col.) Herbert Pollack was the first Medical Corps officer assigned.There was no slot available for this assignment, and therefore Major Pollack wasostensibly on temporary duty in the replacement depot, but actually he worked ona temporary-duty basis in the Nutrition Branch. Subsequently, Col. John B.Youmans, MC, was made chief, serving from 12 April 1944 through the World War IIperiod. Colonel Youmans brought into the work a whole group of men primarilyinterested in the clinical aspects of nutrition.
THE RATION TESTS
Plans and organization.-In 1941,with the imminent onset of open warfare; plans were made to start ration trialsas rapidly as possible. The Surgeon General, being directly concerned with thenutritional status of the troops, worked closely with the Quartermaster Generalin designing rations to satisfy the field forces, who must, of course, becapable of fighting the war on the ground in any part of the wide world. Abattle may be fought in the mountains, in the deserts, in the rolling plains, orin the trackless, frigid wastes of arctic regions-each locale posing differentproblems for the maintenance of optimum nutrition of the soldier. A limitingfactor at all times is the logistic one. Munitions usually have priority overother supplies. This means that rations must be suitable in terms of stabilityand storage, under arctic or tropic conditions. Consideration must be given inpackaging, field utility, weight, cubic content, and nutrient content at thetime of consumption; that is, there must be no more than an acceptable rate ofdeterioration during the pipeline or
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the shelf storage. Acceptability and palatability must alsobe taken into account. Faced with these, at times, apparently conflictinginterests, the joint efforts of all concerned nevertheless succeeded in solvingmany of the more important problems. After World War II, personnel of bothoffices, The Surgeon General's and the Quartermaster General's, continued tocooperate in the work on the ration problems discovered during World War II. On6 November 1944, The Surgeon General opened the Medical Nutrition Laboratory inChicago, Ill. The laboratory, which has since moved to Denver, Colo., has grownand is now one of the most important agencies dealing with the nutritionalrequirements of troops in combat.
The purpose of the ration tests conducted by the American andCanadian Armies from 1941 to 1946 was to determine accurately the nutritionaladequacy of the various types of rations under the conditions under which thetroops would use them. The Canadians were somewhat the more aggressive in thesestudies and early in the autumn of 1942 had already begun their nutritionsurveys. In all, 16 important ration tests were carried out in places varyingfrom the desert training area in California up through the Canadian ArmyOperation MUSK OX in the Arctic. In addition, there were at least 15 separatesurveys of the troops during this period, these varying from a simpledetermination of nutrient intake to clinical observation. This is the first timethat direct clinical observations were made on the troops in the field and underexperimental conditions just to determine their health status under variousconditions of feeding. An excellent summary of this work was published in 1947.4
The underlying principles-Thebasic premise of the trials was that rations had to be evaluated in two aspects:(1) Suitability in terms of supplies and logistics, and (2) suitability in termsof effect on the soldier, on his physical fitness and military efficiency, withparticular emphasis upon the maintenance of the biochemical balances. Before thewar, and during the early days of World War II, much of the clinical thinkingwith respect to nutrition was distorted by overemphasis on vitamins. The sum ofwartime experience was to show that, except under conditions of capture andimprisonment, florid avitaminosis was, in fact, extremely rare in U.S. forces,whereas caloric deficiency with loss of weight was a cause of deteriorationamong soldiers. In the ration tests, it soon became apparent that the primaryproblems of the combat soldier's nutrition in order of importance actuallywere (1) maintenance of water and salt balance, (2) adequacy of caloric intake,(3) adequacy of protein metabolism, and (4) maintenance of vitamin intake.
Water-salt balance.-Maintenance of salt and waterbalance is so obvious that it is overlooked in many studies on nutrition. In thedays
4Johnson, R. E., and Kark, R. M.:Feeding Problems in Man as Related to Environment. An Analysis of UnitedStates and Canadian Army Ration Trials and Surveys, 1941-1946. QuartermasterFood and Container Institute for the Armed Forces, Research and DevelopmentBranch, Office of the Quartermaster General, Chicago, Ill., April 1947.
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before World War II, many officers in the desert trainingcenters attempted to condition the troops to withstand dehydration. Asexperience accumulated, this "water discipline" was abandoned by adirective,5 based upon the work of independent observers who agreedthat in any climate inefficiency and then exhaustion may come on in a few hoursfrom lack of water.6
The clinical syndrome of dehydration exhaustion was seenby a great many officers, althoughmany did not recognize its significance. A man may start a day's work in good condition.If water is not available or if the man does not consume it, thirst becomesnoticeable as a dry throat, then as a general subjective sensation ofthirstiness. As the negative fluid balance mounts, from any one of a number ofcauses-sweating from heat in the Tropics, sweating from nervousness inbattle, sweating from excessive clothing insulation in the Arctic, and so forth-theface begins to flush, muscular coordination begins to fail and, on a march,the individual begins to lag behind. When the thirst mounts, so that the soldieris actually tormented, discipline and training may be lost and the soldier thendiscards equipment, piece by piece.At this point, he will be found on physical examination to have a tachycardiaand a hyperthermia. The blood pressure drops and orthostatic hypotension setsin. Hallucinations begin, and the soldier may then collapse.His life now is in danger if he is not given treatment consisting of water,salt, and rest in the shade if possible. This type of exhaustion willinevitably occur in the best trained man if his water supply is cut off.
Caloric deficiency.-Clinical descriptionsof caloric deficiency in soldiers were well recognized and documented during theration tests. A composite picture of the effects of caloric deficiency in activeyoung men shows physical and mental disturbances beginningwith irritability and annoyance and progressing to a realphysical deterioration.7 When marked caloric deficits exist with highwork-output and when the environment is difficult, the signs and symptomsdevelop in the matter of a few days, but when there is only a minimum of caloricdeficiency weeks or months may go by before gross inefficiency appears. This wasseen in the B-ration test conducted at Camp Lee, Va.,1943, where the author was the medical officer in chargeof the physical welfare of the troops.
In the middle of the test period, we increased the workloadfrom 3,400 to 4,000 calories per day, on the average, without increase in food.* * * A radical change gradually occurred * * *. The men developed a submalarshrunken appearance; the eyes became dull; bodily movements became slower anddesire to participate in sports sharply declined, although there was no flagrantattempt at avoiding prescribed formation duties. Touch football and softballwere conspicuous by their absence in the early evenings and on
5Circular Letter No. 119, Office of The Surgeon General, U.S.Army, 3 July 1943.
6(1) Adolph, E. F.: Water Shortage in the Desert. Report No. 12, University of Rochester, Contract No. OEMcmr 206, for Committee on Medical Research, Office ofScientific Research and Development, 20 Oct. 1943. (2) Pitts, G. C., Johnson, R. E., and Consolazio,F. C.: Work in the Heat as Affected by Intake of Water, Salt, and Glucose. Am. J. Physiol. 142: 253-259,September 1944.
7(1) Pollack, H., Berryman, G., French, C., and Henderson, C.: Quartermaster Board Project S-44. The Expeditionary B Ration (Temperate) Test, Parts I and II,Quartermaster Board, Camp Lee, Va., 7 Sept. 1943. (2) Kark, R., McCreary, J. F., Johnson, R. E.,Melson, R. R., and Richardson, L. M.: Cold Weather Operational Trials of Rations Conducted at PrinceAlbert, Saskatchewan, Canada, January 2d to March 3d, 1944. A Report to The Standing Committee onNutrition, Department of National Defence, Canada. (3) Report, Armored Medical Research Laboratory, FortKnox, Ky., 10 Apr. 1944, Project No. 1-7, 1-15, 2-5, 2-14, Cold Weather Operations.
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Saturdays * * *. TheMedical Consultant Board agreed unanimously that practically all the menexhibited some degree of physical deterioration during the test period. Thespecific manifestations observed by the officer in charge of physical welfarewere poor muscular coordination, inability to carry out work of highintensity, falling out in the marches, nervousness, irritability, muscle achesand pains, insomnia, and other significant symptoms.
Unless officers were aware that gross loss of militaryefficiency and operational fitness could occur as a result of eating too littlefood, the results, in varying degree, of caloric deficiency were usuallyascribed to other deficiencies in the soldier, often of reprehensible nature.
As caloric deficiency increased in the test troops, thephysical signs of disturbed function became more obvious. Fatigue, sluggishness,lack of energy and drive, loss of muscular strength, the desire forrest, increasing sleeplessness, sensitivity to the cold, and tremors of thehands were noted; quarrelsomeness was evident. Loss of weight, of course,is manifested very early. Dizziness, nausea, vomiting, exhaustion, andcollapse are the late stages. Loss of weight at this point becomes veryobvious. The shrunken eyeballs, the dry mouth, the parched lips, the occasionalacetone odor to the breath, changes in tendon reflexes, and impairment inphysical fitness tests are observed fairly often. Recovery from early effectsof caloric deficiency are usually very prompt and dramatic, and the return ofmorale in the men can occur within the matter of a few hours.
During the Camp Lee tests, there was much discussion aboutthe nature and cause of the physical deteriorationobserved, and it was decided to give half the troops massive doses of syntheticvitamins. No convincing evidence was found that therapy with vitamins had anysignificant effect on the health and efficiency of the test troops underconditions of caloric insufficiency.
As will be seen later, caloric deficiency was the mostimportant nutritional problem both in American prisoners of war recovered fromthe enemy and in the "enemy armed elements" in prison camps of theUnited States.
Nitrogen balance and surgery.-Concerning this aspect ofnutrition, the surgical history of the Fifth Service Command by Col. Claude S.Beck, MC,8 is relevant. At the Wakeman General Hospital, Camp Atterbury,Ind., anutrition laboratory was established basically for the use of the surgicalservices. The nutritional status of the patient was regarded as a factor insurgery, much like hemoglobin and the blood picture in general, to a largeextent conditioning the healing of wounds and results of operation. Thelaboratory group was concerned particularly with the paralyzed patient. In thistype of injury, decubitus ulcers, secondary infections, and other complicationsare probably related to the nutritional status.
It may be recalled that just before our entry into WorldWar II, a committee of the National Research Council reported on the effect ofnutrition and nutritional status on recovery from wounds and illness. Thecommittee pointed out the importance of nitrogen balance and similarmetabolic studies in both the acute and chronic phases of disease and intrauma, since substantial loss in nitrogen occurs in many patients. This,of course,
8Beck, C. S.: Surgical History, Fifth Service Command.[Official record.]
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is enhanced by the large losses of protein and exudates andother secretions from the body. It was pointed out particularly that thegeneral metabolism of an individual who has sustained severe injury orillness is quite different from that of a healthy man and that hisnutritional requirements must be based upon the depletions that occurredduring the acute episode. For instance, a marked increase in urinarynitrogen was observed reaching a peak during the 3d and 10th day followingcompound fractures of the leg. When there is decreased food intake through anorexiaor other causes, the negative nitrogen balance can run as high as 30 grams ofnitrogen a day and over a period of time mounts up rapidly. The results wereseen in extensive loss of weight and wasting of tissues with debilitation andprolongation of the convalescent period. After a time, definite changes could beseen in the amount of protein in the circulating blood, particularly in thealbumin fraction of the plasma. At first, this circulating protein had apriority over all other forms and was maintained at the expense of tissuestores. As the tissue stores became depleted, plasma volume decreased withattendant hemoconcentration. After all compensatory mechanisms had beenexhausted, then the actual decrease in the circulating protein was noted.
The optimum daily intake for the average surgical patient wasset at 150 grams of protein with 3,600 calories or more. The physicians had toemploy heroic measures to achieve this objective. Acute deficiencies ofcirculating protein were corrected by the administration of plasma andsubsequently human albumin, which contributed a large quantity of circulatingprotein and enhanced the blood plasma. Beverages fortified with protein weredeveloped and used to supplement the hospital diets. Subsequently, to the closeof the war, this type of work has been carried on and extended even further.9
SPECIAL PROBLEMS IN THE FIELD
Nutritional difficulties were encountered by all Alliedtroops at one time or another. In the early stages of the war against Japan,diseases of all kinds were prevalent and severe in the Asiatic areas. During theOwen Stanley-Buna campaign in New Guinea, Australian troops were supplied atfirst under a schedule of priorities that placed ammunition first, blood second,and food third. Casualties from wounds and diseases, especially malaria, werevery heavy, and nutritional diseases including florid beriberi appeared. Owingto difficult conditions of supply, the diet had consisted mostly of tinned beefand biscuits for periods varying from 6 to 12 weeks.10 By the middleof the campaign, priority in supply was given first to blood, because of itssmall bulk; second, to food; and third, to ammunition. Many soldiers of Wingate'sForce in Burma had for 5 months lived on K-rations, supplemented by tea, sugar,jam, bully beef, and bread which were occasionally dropped to them. A medicalofficer reported that, of 209 men examined at the end of this time, 182 had lostup to 30 pounds and 27 had lost from 30 to 70 pounds. Deficiency diseases
9Pollack, H., and Halpern, S.: Therapeutic Nutrition. Bull.234 Nat. Acad. Sc. 1952.
10Director-General, Medical Services, Army, TechnicalInstructions No. 74, 26 Aug. 1943.
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such as pellagra and beriberi were recognized. One of Wingate'sunits in the Dehra Dun area was visited some months after they had last eatenK-rations. At the sight of a box of K-rations, carried by the visitors, two ofWingate's men vomited.
Europe and North Africa
Field trials for special rations were conducted in theseveral theaters of operations, particularly in ETOUSA (European Theater ofOperations, U.S. Army) where facilities were available to study the problemsthat arose. An extensive report11 from the European theater, dated July1943,showed findings similar to the ration trials in the United States. Theauthors of the report noted that none of the packaged rations were recommendedfor continued use by active troops for periods in excess of 10 days unlesssupplemented with additional food. The need for supplements was greatest in theC-ration. Much credit for the work on rations done in the European theater goesto Lt. Col. Wendell H. Griffith, SnC, Lt. Col. Charles G. Herman, QMC, and Maj.William H. Chambers, SnC.
The North African theater saw the first really extensive useof troops in the field and the first really severe test of the newly developedB-, C- and K-rations. The difficulties under which they were tested here wereeven greater than had been anticipated in designing the rations and werecompounded by misunderstanding of the ration systems and the use of rations.Medical officers in general were not thoroughly conversant with the signs andsymptoms of nutritional inadequacies. They had been exposed to overemphasis onvitamin requirements and were, for the most part, not proficient indifferentiating the numerous complaints that resemble nutritional inadequaciesbut that are basically due to other causes. In reviewing the report of Col.Perrin H. Long, MC,12 medical consultant in the North Africantheater, it becomes apparent that training of personnel in nutrition beforetheir assignment in the field would have saved much time and many mistakes.
In Essential Technical Medical Data and unit commanderreports and in surveys done by the headquarters personnel, there was evidence ofa tendency in the frontlines to blame a disproportionate amount of theirtroubles on the rations. Loss of weight regardless of other cause, whetheranxiety, supply difficulties, or climatic conditions causing anorexia, wasalmost invariably blamed on an inadequacy of the ration per se. Thisgeneralization is no better than most however; some of the problems were real.
11Field Trial, Special Rations. European Theater ofOperations, U.S. Army, July 1943.
12Report, Col. Perrin H. Long, MC,Medical Consultants Division, to Chief, Preventive Medicine Service, Officeof The Surgeon General, attn: Chief, Nutrition Branch, subject: The History ofNutrition in the North African Theater of Operations, 3 January 1943 to 1August 1944.
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For instance, the chief of the medical service of the 9thEvacuation Hospital states that disturbances noted in two patients withstomatitis were thought to be nutritional in origin and were, in fact, curedwith large amounts of vitamin supplements. The 77th Evacuation Hospital had onetypical case of pellagra developing in an officer who was eating coldC-rations; the diagnosis was verified by the consultant in medicine, NorthAfrican theater. In addition, six cases of polyneuritis due to thiaminedeficiency, several instances of ariboflavinosis, and several cases of spongybleeding gums ascribed to ascorbic acid deficiencies, had been seen in thathospital. In the 128th Evacuation Hospital, the chief of the medical servicereported two instances of vitamin A deficiency as manifested by cutaneouschanges and night blindness. A survey13was made of troops in theforward areas and evacuation hospitals of the Fifth U.S. Army on 26 November and4 December 1943. Almost all soldiers questioned in infantry, engineer, andother units said they had lost weight since the beginning of the Italiancampaign. Surgeons commented upon the decrease from the normal in body fat intheir patients, and some noted wasting and paleness of muscle substance. Loss ofhemoglobin was reported in a survey of the mucous membranes of the mouth andconjunctiva of troops in the forward areas, together with theclinical impression of exceptional pallor for men of the age group examined.
Increasing numbers of soldiers suffering from physicalexhaustion were seen in the forward area. These patients required copiousfeeding in addition to rest, thus confirming the view in the minds of themedical personnel that a state of undernutrition favors development of physicalexhaustion. It was noted, however, that frank vitamin deficiencies such asscurvy, pellagra, beriberi, and night blindness had been observed infrequentlyduring the previous year in the American troops in the North African theater.
Perhaps the one attempt at controlled observations onnutritional deficiencies in North Africa was that made by a flight surgeon ofthe American Air Forces and a medical officer in the Royal Air Force. Usingstandard dark-adaptation equipment and a slit lamp for determination ofcapillary loops for riboflavin deficiency, they made the following observations:
The Americans were well within normal limits, having a factorfor dark adaptation around 5 and a riboflavin factor of 1. The French had adark-adaptation factor of 14 and a riboflavin factor of 2. The English had adark-adaptation factor of 17 and a riboflavin factor of 3 plus and, inapproximately 10 percent of them, 4 plus. These medical officers note also that,on a diet ration, the concentration of ascorbic acid in the plasma is usually 1mg. per 100 cc. of blood or slightly higher. "This must not fall below 0.2mg. percent before wound healing is adversely effected." In a control groupof 17 soldiers admitted from local units, the range was from 0.2 to 1.1milligrams. None showed a depletion that would be significant in the healing ofwounds. Of 60 unselected battle casualties, 28 percent showed ascorbic acidlevels below 0.2 milligram. Of the 17 control patients, 11 were under 0.1 mg.percent and 5 were at 0; only 3 of the
13Essential Technical Medical Data, North African Theater of Operations,U.S. Army, for December 1943, dated 27 Jan. 1944, appendix V.
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60 patients showed vitamin C levels of 1 mg. per 100 cc. ofblood or over. It should be noted that one causative factor in the deficiencywas lack of facilities for feeding the troops during evacuation.
Isolated instances of vitamin C deficiency continued to benoted in the European theater.14 In the 495th AAA Gun Battalion, anofficer and several enlisted men showed signs of vitamin C deficiency. Thesecases were ascribed to failure by the men to eat breakfast, the meal thatchiefly supplied this vitamin, and the patients were, in fact, cured withtablets of ascorbic acid. In the Western District, United Kingdom Base, 15.2percent of 16,868 men inspected had bleeding gums. This was similarly ascribedto failure of soldiers to drink the fortified juices provided at breakfast.Nutritional disturbances could usually be accounted for not so much by thequality as by the distribution or consumption of the rations. On the whole,there were surprisingly few nutritional problems per se among troops in thistheater.
Atlantic Bases
Nutritional problems in the isolated areas of the Arctic andNorth Atlantic were not so great as one might anticipate. No unusual problemswere reported. Occasional cases of malnutrition were seen at the stationhospitals following the forced landings of planes in the wilds. The survivors,frequently without food for 5 or more days, would attempt to reach civilization.When they were rescued, their type of acute starvation was well known and washandled promptly and properly by the medical personnel. Of more general interestis the report from the 188th Station Hospital, dated 15 March 1944, on a surveyof anemia in soldiers with over 12 months of service in Greenland. Red cellcounts and hemoglobin determinations were made on 103 soldiers who had dwelt inGreenland for an average of 15 months. There were, of course, numeroussubjective complaints. Changes in weight were insignificant: 14 men had lost anaverage of 13 pounds; 13 men had gained an average of 13 pounds. The average redcell count was found to be 4.56 million. The average hemoglobin was 13.6 gm. per 100 cc. of blood. Of these men, 5 percent haderythrocyte counts below 4 million, 10 percent between 4.0 and 4.2 million, 17percent between 4.2 and 4.4 million, 22 percent between 4.4 and 4.6 million, 19percent between 4.6 and 4.8 million, and 12 percent between 4.8 and 5.0 million;16 percent had counts of over 5 million. Free hydrochloric acid was found ingastric secretions of all men with counts below 4 million. The controls, 16 menwho had just arrived from the United States and had served only 4 weeks inGreenland, had an average erythrocyte count
14(1) Annual Report, 495th AAAGun Battalion, 1945. (2) Survey, District Nutrition Officer, Western District,United Kingdom Base, to Surgeon, United Kingdom Base, Communications Zone,ETOUSA, 10 Jan. 1945.
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of 4.98 million, and their average hemoglobin was 15 gm. per100 cc. of blood. It was concluded that a mild chromic anemia existed amongapproximately 75 percent of the men who had served over a year in Greenland andthat the anemia was probably nutritional in origin. Those subject to the anemiahad symptoms that could be explained as largely psychic in origin. It wasrecommended that the vitamin content of the diet be increased as much aspossible and that multivitamin pills be made available to all men on this postand, what was most important, that if and when possible men with 1 year'sservice in Greenland should be reassigned to duty in the United States. It isdifficult to differentiate between the emotional problems of the men who wereconfined to the area and those problems that were truly due to nutritionaldisturbances.
From the U.S. Army Forces in the South Atlantic, basedprincipally on the Ascension Islands, only occasional cases of true deficiencydiseases were reported, and these were due mainly to failure to eat the rations.One patient, with very mild symptoms of pellagra, worked at night and during theday preferred sleeping to eating; he recovered completely with a change in dutyassignment plus adequate diet. In the Panama Canal-Trinidad sector in the SouthAtlantic, the battalion surgeon made this comment: "The general nutritionalstatus of the troops is adequate. Symptoms of vitamin deficiencies have beenfrequently noted but at present are mild in character." More than theaverage number of cases of gingivitis were seen by dental officers in menreporting from jungle outposts, where the standard ration was, not in itscomposition but in its consumption, inadequate to nutritional requirements. Inthese reports from individual surgeons, it is again noted that the reporting ofnutritional deficiencies in troops very largely depends upon the observer andhis interpretation of symptoms and their causes.
Nutritional problems in the Far East will be discussed later,since these for the most part concern prisoners of war and recovered prisoners,and that story properly begins in the European theater.
RECOVERED ALLIED MILITARY PERSONNEL, EUROPEAN THEATER
Before D-day, soldiers of American and Allied origin, insmall numbers but more or less continuously, filtered through belligerent andAllied countries in the attempt to rejoin their parent organizations. Most wereair force personnel who had been shot down while flying missions over enemy territory. Administratively, theyfell into two categories: Escapees, those who had been imprisoned; and evaders,those who had avoided imprisonment in enemy hands. It is not the purpose of thismedical report to discuss the methods by which these people outwitted the enemy.
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It is sufficient to say that much was made possible by themembers of the underground of the occupied countries. The theater ProvostMarshal had a small hotel in London located at 63 Brooke Street where thoseAmericans fortunate enough to elude the Nazis and reach England were processed.In March 1945, an installation was set up at the Hotel Francia in Paris whichprovided the means for the care and processing of these escapees and evaders.
With the liberation of France in September 1944, thepossibility of recovering Allied prisoners of war in overrun German camps becamereal, and administrative plans were made to take care of them. The ProvostMarshal instituted a RAMP (Recovered Allied Military Personnel) Division on 18December 1944. Unfortunately, planning did not include the Nutrition Branch ofthe Professional Services Division, Office of the Chief Surgeon, ETOUSA. TheSHAEF (Supreme Headquarters, Allied Expeditionary Force) policy with respect toRAMP's as outlined in paragraph 555 (b) of the "Handbook for MilitaryGovernment in Germany Prior to Defeat or Surrender," dated December 1944,was somewhat unrealistic in its approach to this problem. Allied prisoners ofwar, according to the Handbook, were to be "freed from confinement andplaced under military control or restriction, as may be appropriate pendingfurther disposition." In the early days of the war, under the conditionsdisclosed by escapees and evaders, this procedure might well have worked.However, Americans who were captured in the Ardennes bulge late in 1944 relatedthat they had been continuously on the march with hardly any rest and withpitifully inadequate nourishment. Obviously, these men, and others on the march,had suffered great hardships from which the Geneva Convention had not, asexpected, protected these prisoners of war. Hence, it was virtually impossibleto leave them where they were when the camps were overrun.
On 7 May 1945, the Supreme Commander, SHAEF, made thedecision that all American and British ex-prisoners-of-war should be evacuatedfrom the Army areas in the shortest possible time, regardless of any limitingcircumstances. CATOR (Combined Air Transport Operations Room), the agency thatcontrolled air transportation, was given as its first concern the movement ofthe prisoners of war to installations in the Communications Zone. Before thisdecision, the movement of supplies had priority with CATOR, and the prisoners ofwar were evacuated wherever camps were located close enough to the deliverypoints for supplies. This change in policy greatly accelerated evacuation ofliberated prisoners of war through administrative channels, and from a dailyrate of approximately 1,500 the number jumped to 30,000 on 9 May. Recognizedmedical cases were evacuated separately. By 22 April 1945, reception camps forthe handling of American and British RAMP's were established at Namur,Belgium, and at Reims and ?pinal in France.
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Camps for Care of Recovered Prisoners
The Lucky Strike Camp, situated near St. Val?ry on the northcoast of France, had already been designated as a transit camp. Camp Wings,close by the Lucky Strike area, served as the air terminus for the men evacuatedby air and also as a base camp for the British RAMP's. Eventually, an airstripwas built at Lucky Strike to relieve the load at Camp Wings. Evacuation from thetemporary camps became a sizable problem, and the rail and air facilities wereloaded to capacity. The Chief Surgeon made 29 hospital trains available to theProvost Marshal to help the administrative evacuation. Camp Lucky Strike wasselected as the installation that would have the greatest part of the workinvolved in the processing and evacuation of the RAMP's because of itsproximity to Le Havre and because it had a capacity expandable to 70,000.
Approximately 60,000 Americans were listed as prisoners ofwar in the hands of the Germans, but actually over 94,000 recovered prisonerswere evacuated through medical and administrative channels. These discrepantfigures are accounted for by the many thousands previously listed as missing inaction.
Arrival of First Liberated Prisoners
Sorting.-Camp Lucky Strike, then in the Northern Districtof Normandy Section, was set up as the reception area for the RAMP's beingsent through command, as distinguished from medical, channels. Lucky Strike hadbeen intended as a staging area for incoming ground force personnel duringhostilities, and much had to be done to adapt it for the present purpose. TheCamp proper was divided into four blocks, with a total capacity of about 40,000soldiers. Block D was set aside originally as the RAMP camp and, in a shorttime, was made an independent command responsible directly to the NorthernDistrict. Block C was set up as a possible 306th General Hospital to take careof convalescent RAMP's. RAMP's were flown from the forward areas to theairport at Le Havre where a 2,000-bed tent setup was made available. All RAMP'swere screened medically at the airport by the physicians of the 98th MedicalBattalion and by the dispensary officers from the Le Havre units under thedirection of the Northern District surgeon. Those few who came in by railtransport were sorted several hours out of Le Havre, and complete triage waseffected before the train arrived at the station. Of approximately 7,000 RAMP'sevacuated to Le Havre for the Lucky Strike area in the early days, 824 werehospitalized.
Of the total number arriving, there were about 2,400 Britishpersonnel, who were kept in Camp Wings for several hours and then transshippedto England, except those who, being too ill, were put into Ameri-
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can hospital channels. Of the entire number hospitalized,immediate triage at the landing field accounted for 390. Of these, the sickestwere taken directly to the 28th Station Hospital, Yvetot, France, about 30 milesfrom the airstrip; the rest were sent to the 179th General Hospital at Rouen.
The first batches of returning men were met as they alightedfrom the plane by the American Red Cross, who gave them hot coffee, doughnuts,peanuts, and a blanket. Transportation thence to the camp was by the usual Army6 x 6 truck, from 16 to 18 men in a truckload. Here, they were again screened bythe dispensary physician of the post aided by the medical officers of thegeneral hospitals staging in the areas. Up to Friday evening 13 April 1945,4,400 men actually reached Lucky Strike Camp. Of these, 425 were hospitalizedby the screening physicians on admission and at morning sick call at thedispensaries. They were admitted to the 77th Field Hospital set up on thecampsite. On Saturday morning, 14 April 1945, the 77th Field Hospital had acensus of 441 patients. (See also page 249.)
It may be recalled that all these men had been previouslyscreened in forward areas, where RAMP's were divided into those to beevacuated by medical or by command channels. Those sent to the Lucky Strike areahad been considered physically fit and ready to be sent home. Forward triage wasof course difficult at best, and subsequently many things happened. The trip byair, sometimes through great turbulence, was often enough to upset these men,whose balance was precarious at best. Then came the warm, but nutritionallyunsound, welcome by the Red Cross, which was, in fact, secondarily responsiblefor many cases.
Clinical problems-The dispensarysetup at Camp Lucky Strike was very adequate. There were three such medicalinstallations, each serving 10 packets or companies of 200 men each. There werefrom two to four physicians in each dispensary. On Saturday morning, 14 April1945, the sick call reached over 500 RAMP's, despite the fact that thepopulation of the camp that morning had fallen to 2,800 men, owing to theevacuation of 1,500 men for the Zone of Interior during the night. About 80percent of the men reporting on sick call had for their presenting complaintgastrointestinal disturbances; the rest, predominantly acute infections of theupper respiratory tract, pyodermias, and other skin conditions. Numerous men hadcomplaints referrable to polyneuritis, hyperesthesia, paresthesia, muscleatrophies, edema, and cheilosis. These were seen as complications of thepresenting gastrointestinal symptoms. The histories reveal that the acuterespiratory infections started in transit. Acute gastrointestinal symptoms alsostarted in transit and at the RAMP camp. It was known that the initial delousingwas not always completed before arrival at Camp Lucky Strike. It is to be notedparenthetically that many RAMP's were found to have originated from StalagXII-A(p. 252) where 22 cases of typhus fever in the Russian prisoners had beenreported.
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Among the 441 patients in the 77th Field Hospital on themorning of 14 April 1945, the commonest diagnoses were gastroenteritiscomplicating malnutrition, acute infections of the upper respiratory tract withmalnutrition, and pyodermias with malnutrition. Three percent of the RAMP'sadmitted required intravenous plasma therapy as an immediate supportive measure.As anticipated, the patients tolerated intravenous fluids very, very poorly. Twounits of plasma were the most given in one day. No whole blood was available.Vitamin supplies were very poor at that time and were not used as extensively asmight have been desired, but supplies arrived very shortly afterward. There wasa rather acute shortage also of paregoric, bismuth, and belladonna. In the firstgroup of patients admitted, X-rays of the chest were taken; the diagnosis ofpneumonia was made in 7 out of 55, and 1 case of active tuberculosis was found.
The 28th Station Hospital located nearby had admitted 57 RAMP's.One death had occurred shortly after arrival. The autopsy protocol revealed abronchial pneumonia complicating malnutrition. The serum proteins had beenestimated before this soldier's death as 2.5 gm. per 100 cubic centimeters.
Recommendations for therapy-The medical consultantat the Normandy Base Section, Lt. Col. (later Col.) Theodore L. Badger, MC,invited the nutrition consultant from the Office of the Chief Surgeon to giveorientation talks to the chiefs of the medical services of the hospitals in theNorthern District of Normandy Base. As a result of these conferences, certainrecommendations were made, based in large part upon observations made onrecovered prisoners in forward areas (p. 251). Briefly, the first proposal wasthat a system of two messes be set up in this RAMP reception area, with one toserve a bland diet ration to all newcomers for at least 48 hours, and optionallyafter that. At the Lucky Strike Camp, this was feasible and acceptable to theadministration and to the district surgeon. It was felt that muchhospitalization could be prevented and convalescence speeded by early generaldiet therapy for reeducation of the gastrointestinal tract. The secondrecommendation was to give the RAMP's short orientation talks on proper eatingas far forward as possible. A poster system for the messhalls was devised as avisual aid to this educational campaign. One of the most important recommendationswas that every effort be made to stop the American Red Cross and the ArmyExchange System from flooding these men with doughnuts, candy, apples, andpeanuts. One soldier ate 17 doughnuts on his trip back from the forward areaswith results that can be imagined. It was recognized that the acute vitamindeficiency syndromes were precipitated only after full feeding had started andso could not be anticipated, but preventive therapy should have been startedearlier.
Medical officers had in general to be oriented with respectto therapy of severe chronic malnutrition. Directives were issued by the Officeof the Chief Surgeon on advice from the medical consultant to the Nutrition
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Branch. These were basically concerned with avoidance ofintravenous therapy, the use of bland soft diets, and the avoidance of suchmedications as iron. Many physicians, when they found the deficiency anemias,immediately prescribed iron by mouth, but this therapy was not consideredrational in the presence of such great protein deficiencies. Also, qualities ofthe iron compounds irritating to the gastrointestinal tract precipitatedsecondary problems. Medical officers were further warned about details oftreatment of complicating infections. Extra vitamins would be required in thefebrile period. The early use of penicillin in adequate dosage should beencouraged. The use of the sulfonamides was to be considered on a very cautiousbasis because (1) they upset the gastrointestinal tract, and (2) thehemoconcentration, dehydration, and scanty urines called for much smaller doseson account of the minimal excretion and the possibility of precipitation in thegenitourinary tract.
A further recommendation was that the evacuation policy fromthe Communications Zone to the Zone of Interior be modified. It was found thatthe recovered prisoners, from 3 to 5 days after arriving from forward areas,were put on transports with no provision for special feeding. It was felt thatthe rough voyage would start nausea and vomiting in a large percentage of thesedebilitated people, resulting in unnecessary hazards to quick convalescence andpossibly endangering life itself. Furthermore, some of them being less than 15days from known typhus areas might possibly be carrying the disease during theincubating phase. The diphtheria rate also was high among them, and their rapidevacuation to the States risked carrying virulent diphtheria home quickly.
Transport commanders were accordingly informed by MedicalBulletin No. 1, dated 15 May 1945,15 thatvarious degrees of malnutrition had been found in the recovered Allied militarypersonnel. Although marked improvement had been accomplished under a rigidlycontrolled dietary program, complete rehabilitation would necessitate severalmore weeks of nutritional management. Accordingly, this program should becontinued both aboard ship and in the Zone of Interior. Foodstuffs to berestricted included particularly doughnuts, peanuts, citrus fruits, cauliflower,cabbage, the concentrated components of C- and K-rations, and highfat-containing foods. The general mess should be on a soft or bland diet bothbefore and during the voyage home. The Bulletin outlined in detail thevarious precautions that had been taken to protect the RAMP's fromgastrointestinal disturbances, which in so many cases were cause forhospitalization.
Incorporating the essential recommendations just discussed,Circular Letter No. 36, Office of the Chief Surgeon, ETOUSA, was published on 19April 1945. On 28 April 1945, with the cooperation of the Chief Surgeon
15Medical Bulletin No. 1, Office of the Surgeon, NorthernDistrict, Normandy Base Section, 15 May 1945.
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and the Chief Quartermaster, the special bland diet menu wasissued, and copies of the menu were distributed by the Adjutant General, ETOUSA,with instructions that the special menu was to be used as a basis for feedingrecovered malnourished U.S. and British Army personnel until the normal fieldration A menu could be tolerated.
Statistics gathered from medical units at the various RAMPcamps reiterated the need for taking such action and showed prompt results. Inone camp, where the operational 10-in-1 ration was fed on an emergency basis to1,000 recovered prisoners, 150 were hospitalized after the first meal for acutediarrhea, and a number of others reported on sick call for various gastriccomplaints. At another camp, there was an average daily sick call of over 20percent on ordinary Army rations, with 80 percent of the presenting complaintscharacteristic of enteritis. One week after the introduction of the blanddiet, the sick call rate dropped to 4.0 percent with only 15 percent of thecomplaints related to enteritis and with no instances of nausea and vomiting.
RAMP Camp in Action
By 10 May 1945, the Lucky Strike area had become very wellorganized. Reception into RAMP camp was in a designated area with a capacity ofabout 2,000 beds. The men were kept here for about 1 day after which they weretransferred to the processing areas for a minimum of from 1? to 2 days. Thecapacity of this latter was 4,000 beds. After processing, they proceeded to the"pending shipment" area for a minimum of 1 day, in actual experiencefrom 3? to 10 days. Each of thesedesignated areas had a different mess. The special bland ration was used by allthree except that Mess No. 1, in the reception area, eliminated dried fruits. Inaddition, there was a supplementary issue of one multivitamin capsule for eachman at each meal. Between meals, a nutritional bar was available for allpersonnel.
On 7 May, this bar served 460 gallons of eggnog, 320 gallonsof cocoa, 452 gallons of malted milk, and 128 gallons of tomato juice. Theaverage serving was approximately 12 ounces. In addition, the RAMP's arrivingat the camp after the evening meal were served 160 gallons of dehydrated peasoup and 1,400 cheese sandwiches made with white bread. Although no control wasmaintained at the nutrition bar for second helpings, the length of the linewas a deterring factor. In the mess, effective control was exercised bycharacteristically colored and marked cards issued by the tent commander tothe men in formation before each meal and surrendered as they passed throughthe gate to the mess. It was estimated that the average consumption was wellover 5,000 calories per man per day.
Inquiries made among the RAMP's and administrativepersonnel revealed excellent acceptance of the bland menu by the soldiers.Plate waste, as one would expect, was negligible. The messes were now inexcellent condition; concrete flooring for serving and mess tents werecompleted; ranges and utensils were supplied by the Quartermaster Generalwithout further delay and in adequate quantities. The problem of lack ofcommunications remained, however, and the post was frequently not ready fornew shipments as they arrived.
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After the RAMP's went through the first two areas, theywere sent, as stated previously, to the holding or "pending shipment"area. Here, the modified type-A ration was served. This holding area was nolonger under the control of the RAMP camp, having been returned to the controlof the Lucky Strike Post.
By the middle of May, the general health of the RAMP's wasmuch improved. The sick call rate had dropped to an average of 60 to 75 patientsdaily in an area whose population varied from 1,500 to 2,800, as contrasted withthe earlier rate of 200 for a population of 2,000. The chief complaints at thistime were boils, skin infections, cellulitis, and diarrhea; gastrointestinalsymptoms now accounted for only 1.8 percent of the total. Nausea and vomitingwere no longer presenting complaints. Infections of the upper respiratory tractwere only a minor problem. Triage was still done at Camp Wings located about 43miles from the RAMP camp. Hospital admissions were made directly from the triagearea, and by mid-May the rate was only about 10 percent of the incoming RAMP's.Earlier hospitalizations were over 20 percent, before the initial problems withthe American Red Cross had been solved. The common causes for hospital admissionat this time were acute respiratory infections (about 50 percent), diarrhea,cellulitis, and edema; 36 cases of hepatitis were picked up in 1 week. The 77thField Hospital continued to be busy through the middle of May and on the morningof 9 May had a census of over 300. Causes for admission were essentially thesame as before, except that in the routine X-ray films six patients with activetuberculosis had been detected. The nutritional deficiency syndromes remainedessentially as noted earlier. Problems of hospital care were greatly eased bythe decrease to the vanishing point, from over 80 percent 1 month previously, inthe number of patients with nausea and vomiting.
Clinical History: Statistics
Information gathered from 214 RAMP's by questionnaire from28 May through 6 June 1945 may be summarized statistically. In all, they had hadan average captivity of 143 days. Their average weight before capture was 163pounds, and their average present weight was 149 pounds. It was reported by 26that they had lost only from 5 to 15 pounds; 84 said they had lost from 15 to 25pounds; and 90 reported losses of over 25 pounds. It was noted that 187 of thesepeople had diarrhea during their incarceration; of these, 31 reported having haddiarrhea most of the time, 29 frequently, 69 occasionally, and 53 rarely. As forsymptoms, 90 reported they had had swelling of the legs while they were incaptivity and 20 of them still showed evidence at the time of the questionnaire;165 reported nocturia during their imprisonment. These figures are indicative tosome extent of the degree of malnutrition that was present among the RAMP'squestioned.
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In all, 82,320 RAMP's were evacuated through nonmedicalchannels. Spot-check surveys showed an average of 143 days in German camps andan average weight loss of 14 pounds. Of the RAMP's, 55.6 percent showedevidence of malnutrition, 42.5 percent had nutritional edema while in the Germancamps, and 25.8 percent complained of night blindness. Secondary hospitalizationwas 27.8 percent in mid-April but down to 2.5 percent by the middle of May.
Approximately 12,000 RAMP's were evacuated through medicalchannels. The 15th Hospital Center in the United Kingdom Base admitted 2,516RAMP's. Severe malnutrition was diagnosed in 412; the rest had malnutritionas a secondary diagnosis. The 179th General Hospital at Rouen admitted 837RAMP's. Severe malnutrition was present in 188. Of these, 42 had to be tubefed. It was found that the average weight loss of the prisoners from Stalag IX-Bwas 39.1 pounds per man and from Stalag IX-A, 28 pounds per man. The 217thGeneral Hospital, Paris, France, had 1,098 RAMP admissions. Of these, 275 wereseverely malnourished; others had malnutrition as a secondary diagnosis.There were eight autopsies done on the RAMP's who died in the CommunicationsZone.
The total deaths of recovered Allied military personnel inthe European theater may be detailed as follows:
In the week ending on 13 April 1945, there were 40 deathsreported. Two of these were from malnutrition, and one was from malnutritioncomplicated by bronchopneumonia. In the week ending on 20 April, there were 36deaths. One was caused by diphtheria with malnutrition, one by uremia withmalnutrition, two by pneumonia with malnutrition, and one by primarymalnutrition. For the week ending on 27 April, there were 42 deaths, of which 3were directly ascribed to malnutrition. For the week ending on 4 May, there were27 deaths, of which one was due to malnutrition.
STORY OF IMPRISONMENT
The beginning of the RAMP story had been a series ofconfusions and misinformation. The Nutrition Branch, Office of the ChiefSurgeon, had not been alerted to the possibility of the large-scale starvationthat was soon to be encountered. In the Stars and Stripes, Paris edition,of 26 March 1945, articles began to appear about the "living hell" andthe starvation within the German prisons, but only as referring to the civilianand political prisoners. At first, there was no mention of the American,British, French, Russian, and other Allied soldiers who were incarcerated inthese camps. On 30 March 1945, in the Paris edition of the Stars andStripes, a small article appeared, describing how 1,000 American and Britishprisoners of war for 6 hours made a desperate attempt to ward off attacking U.S.dive bombers. They took off their shirts and, with their naked bodies,spelled out POW in giant letters. The Paris edition of the Stars and Stripes,on
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5 April 1945, presented to the public the first concreteevidence that the American and British soldiers in the hands of the Germans hadbeen subjected to less than the requirements of the Geneva Convention.
This article began: "150 mile death march comes to endas the Sixth Armored Division liberates 800 Yanks." The writer compared itwith the infamous death march of the American and Philippine soldiers capturedby the Japanese on Corregidor. These 800 soldiers, taken as prisoners during theArdennes breakthrough, had been on the road for more than 3 months, stoppingonly when Nazi transportation officials pirated their ranks, forcing theAmericans to fill bomb craters and to haul trestle lumber. The prisoners of warwere fed one-sixth of a loaf of black bread and one can of potato soup daily.They suffered from dysentery and had lost up to 80 pounds in weight. Thebreakthrough had caught them in subzero weather. They had had no medicalattention. Lt. Col. Albert N. Ward, whose armored infantry battalion liberatedthe prisoners of war north of Friedberg, Germany, said: "As we entered the town the doughs looked like walkingskeletons staggering out to meet us. They were thin and emaciated and theywept." One soldier reported his poor treatment and said: "Afterthey had deposited their excreta on a manure pile, the Germans had dumped potatopeelings on the same heap. The men were so hungry they removed the potatopeelings, strung them on a wire, cooked and ate the spud skins." A soldierwho lost 80 pounds during the 3 months' labor trek said: "They dideverything possible to make life unbearable, threatening us with bayonets andfiring small arms over our heads whenever we fell out of the columns during themarches." (See pages 253-255.)
First observations.-Shortly after crossing the Rhine, asurvey team, consisting of Lt. Col. Wendell H. Griffith, SnC, Chief, NutritionBranch, Office of the Chief Surgeon, ETOUSA, Lt. Col. Herbert Pollack, MC, andCapt. Leonard Horn, MC, on verbal orders from the Chief Surgeon, were in theforward areas to make observations on the nutritional status of the Germancivilian population and to see what the problems with the recovered Alliedprisoners of war were to be. Their observations, based on a survey conductedfrom 4 to 11 April 1945, are summarized as follows:16
Trier, 4 April 1945.-The AlliedPrisoner-of-War Camp No. 1 contained about 1,500 RAMP's, mostly Russians.Food, supplied by the U.S. Army, consisted of one C-ration supplemented by 4.8ounces of bread and milk and sugar for coffee. Of these liberated soldiers, 150were sampled; 15 were examined in detail. The general picture was that of severeemaciation and of weight loss. Many had nutritional edema and other signs ofextensive deficiency. The Russian physician stated nevertheless that the men hadimproved considerably since their liberation and that most of their
16Essential Technical Medical Data,European Theater of Operations, U.S. Army, for April 1945, dated 14 June1945. Inclosure 30, Report of Nutritional Survey in Occupied Germany.
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edema had disappeared. Tuberculosis was noted as one of theimportant problems.
Diez, 5 April 1945.-Stalag XII-A contained over 4,000RAMP's, approximately half of whom were Russians. Several hundred American andBritish prisoners had been recovered at this camp, and the seriously ill hadalready been evacuated. Superficial examination of the remaining Americansrevealed a picture of general malnutrition and nutritional edema. In practicablyall of them, there were acute changes in the tongue, with the burning andsoreness characteristic of glossitis, and changes in the skin referable tovitamin A deficiency. In the Russian section of this camp, the conditions wereeven worse-22 cases of typhus fever had been reported; tuberculosis wasrampant and had been the cause of many deaths; emaciation was extreme; livingconditions were filthy; and sanitary facilities were entirely lacking.
Niedergrenzebach, near Ziegenhain, 7 April1945.-Stalag IX-A contained 1,200 American soldiers and many British,French, Russians and other nationals. The hospital had a capacity of 45 bedswhich were filled with American and British soldiers who were examinedcarefully. All showed marked loss of weight, changes in the skin, and tendernessin the calf of the leg; 10 had active cheilosis; and 16 showed acute glossitis.Hepatitis with jaundice was seen in several of these soldiers. Reflexes werehypoactive and unequal or irregular.The physician in charge of the dispensary, an American medical officer, saidthat many soldiers with peripheral palsy had been evacuated that morning throughmedical channels. Beriberi had been common, according to this officer, but noevidence of scurvy had been observed. American Red Cross parcels had beenplentiful at this camp up to a month before its capture. The German ration issuewas very deficient. Breakfastconsisted of a cup of ersatz coffee which the soldiers frequently used inlieu of hot water for shaving. Luncheon consisted of a ladle of vegetablesoup and a small portion of bread. The soup stock was made from bone from whichall meat had been removed. Pine needle infusions were added at times. Thedaily bread allowance was one 2-pound loaf for from five to seven men. Theevening meal consisted of bread and soup; two to four potatoes per man weresupplied several times each week. An extremely small piece of meat was issuedabout once a week. Eating grass was said to be customary. It was here that thepractice of bartering Red Cross cigarettes for food was first encountered.
Heppenheim, 10 April 1945.-This was the location of theinfamous APW (Allied Prisoner-of-War) Hospital where the official ration for theAmerican patients was said to be about 400 calories a day. Twenty Italians wereexamined, and all gave a history of edema. An Italian medical officer in thegroup stated that almost everyone had nyctalopia, nocturnal muscle pains andcramps, paresthesia, and a shuffling gait. Examinations revealed a few tonguechanges and in many cases healing ulcers of the buccal mucous
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membranes. Butterfly distribution of facial seborrhea wasseen as well as cheilosis and marked emaciation. The South Africans, in spite ofthe extensive marching that they had been forced to do, showed little beyondloss of weight. They, however, had had liberal supplies of Red Cross packages upto a recent date. One of their sergeants reported that the death rate on themarches had been very high. Edema had been very common; no scurvy was seen.
Conclusions.-The recovered Allied military personnelwere extremely malnourished and presented a feeding problem demanding emergencymeasures. These troops had not received humane treatment, and no attempt hadbeen made by the German authorities to maintain even the semblance of observanceof the Geneva Convention.
Board of inquiry-On the basis ofthe survey findings and the reports forwarded to SHAEF, the Supreme Commanderappointed a board of inquiry to go forward with the advancing armies and toinvestigate the treatment by the German Government of the American and Britishprisoners of war at the time they were recovered. Testimony and sworn statementswere taken in the prison camps on the day of liberation. The board was composedof British, Canadian, and American personnel, among them the medical officerassigned to the Nutrition Branch, Office of the Chief Surgeon. Its observationsare the subject of a letter and report dated 7 June 1945, Supreme Headquarters,Allied Expeditionary Force, and are summarized as follows:
Before the crossing of the Rhine, the location of the Germanprison camps for Allied prisoners was fairly well known in some headquarters,and forecasts were available on the expected population of these camps, butthere was little information about the conditions within them. The reports fromthe International Red Cross and the protecting powers were meager and sketchyand, as time has proved, inaccurate. Paragraph 4 of the letter report states:
In connection with any future consideration of theresponsibilities to be placed on a protecting power, it is to be noted that the findingsof the Board indicate indirectly, failure on the part of the ProtectingPower to discharge its obligations. Quite conceivably, it may have beenbeyond the capabilities of the Protecting Power to remedy the existingsituations, but certainly it must have been within its capabilities to advisethe British and U.S. Governments that these conditions existed.
The overwhelming evidence, as reported by the board,indicated failure by the Germans to comply with the Geneva Convention of 1929.In some instances, there was some improvement in the treatment of prisoners asthe Allied armies approached. But generally throughout the war, there wereviolations involving, "at one time or place or another every materialcondition and circumstance affecting the life and well-being of a prisoner ofwar." In part, these were "due to the deliberate policy of theresponsible German authorities," and in part "to the negligence and/orbrutality of the German personnel having charge of the prisoners of war."There were
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instances where the German commandant and others "haveprobably done the best they could for prisoners in their charge with thematerial and supplies available, [but] the inadequacy of such material supplieshas made compliance with the terms of the Convention impossible. In other cases,the German personnel have gone out of their way to increase the hardship andsuffering of prisoners in their charge."
The ordinary rations issued by the Germans to the U.S. andBritish prisoners of war were at all times gravely inadequate both in quantityand in quality to maintain health or even, many times, to sustain life. Theywere in every instance grossly below the scale of rations issued to the GermanArmy or the civilian population. The food was very inadequate in respect to thespecific nutrients, proteins, vitamins, and minerals, as well as calories, andwas commonly prepared under unsanitary conditions. In no known instance wasprovision made for kitchens, messhalls, or mess equipment for 200 men, or anylarge unit, in any way comparable to that provided for German field or basetroops.
In one instance, a daily record was kept of the food issuedto prisoners of war on a march lasting 82 days. The average caloric content ofthe German ration as issued was 850 calories per diem, equivalent to 650calories per diem as consumed, the difference being due to condemned or otherinedible food, which had to be discarded. Labor "Kommandos" weresometimes able to supplement their rations by food begged or stolen from farmson which they worked, or obtained from civilians by barter for cigarettessupplied by the Red Cross. At times also, if employed in heavy labor, they gotan inadequate supplementary ration from the Germans, although this with somedifficulty and generally through the insistence of the prisoner-of-war representative. Many prisoners were kept alive, and even in reasonably goodhealth, by Red Cross parcels, which may have supplied as much as 70 percent oftheir average daily nourishment. From time to time, however, there wereinexplicably wide variations in the number of Red Cross parcels issued as wellas in the quantity of rations issued. Although these irregularities were usuallylaid to transportation difficulties, particularly in 1945, such difficulties didnot have any corresponding effect on the nutrition of German troops.
The results of these conditions were seen when considerablenumbers of prisoners of war taken at random in several camps were examined bytwo members of the board, the British and the American medical officers. Theyfound in many cases present or past malnutrition evidenced by loss of weight,muscle atrophy, edema, pellagra, stomatitis, cheilosis, keratosis, nightblindness (mostly in the British), muscle tenderness, and nocturnal polynuria(in almost all). The men who showed fewer signs of malnutrition for the mostpart were either prisoners from camps where Red Cross parcels had beenreceived regularly or labor "Kommandos" who had been employed inagricultural work. The board also examined German sick and
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wounded in two German hospitals and found no single case ofprimary malnutrition among them. In a large group of German prisoners of war(pp. 265-269) captured by the Allied armies, no cases of malnutrition werediscovered comparable to those found among the British and American prisonersof war.
Concerning medical care, the board's report states (1)that hospital rations were insufficient both in quality and in quantity andnever comparable to those the board saw the Germans issuing to their ownsick and wounded, both military and civilian, and (2) that in many camps therewas no difference between the rations issued to the sick and to other prisonersof war. In some camps, supplementary rations for the sick could be recommendedby a prisoner-of-war medical officer and then authorized by a Germanofficer, but they were insufficient and unsuitable for a large number ofthe patients to whom they had been given. On the whole, the German medicalservice apparently tried to be cooperative, but in many instances it wasineffective in obtaining correction of the deficiencies in accommodations,supplies, and food,
The report goes on to say that during movements of prisonersof war by march and by train all over Poland, Germany, and Austria, thesick and the wounded who were unfit to be moved were in some instances leftbehind with no medical personnel to look after them; in other instances,in spite of protests of prisoner-of-war medical officers, the unfitwere made to march, and some died on the road. In general, the prisonerswere compelled to work for excessively long hours.
The cold, strong, formal statement of facts in this reportindicates the true picture, but descriptive statements are necessary torecreate the actual conditions. Typical living quarters in these campswere characterized by a stench impossible to describe. Cleansing utensils,water, soap, and disinfectants were completely lacking at times. Many of thehutments contained latrines at one end, and the others were limited to thebucket type of latrine. After the evening meal, the men were locked in theirhutments.
About 25 April 1945, word was received that the GermanHigh Command of the Armed Forces had agreed to stop the mass evacuation ofmilitary prisoners from prison camps threatened by the advancing Allies. Thisagreement alleviated much of the suffering the prisoners had to endureby forced marches away from the liberating armies. The bulk of Alliedmilitary prisoners was recovered shortly thereafter.
Immediate problems.-The problems demanding immediateattention in the overrun camps were sanitation, delousing, provision ofadequate living quarters,nursing care, and medical supplies. The prison hospitals were usually foundloaded to capacity with from 50 to 400 patients, and there were many hundredsmore who required hospitalization if facilities had been available."Hospitalization" in many of the prison camps, however, was merely aword, with little relation to medical care as practiced in the
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American Army. The insatiable desire of the RAMP's for foodhad also to be satisfied, and the ready generosity of the advancing Allies wasone more hazard for these men. The writer, accompanying the advanced partiesgoing into the camps as they were captured, saw how the incoming soldiershastened to share their K- and C-rations with the RAMP's. Any prisoner whowas luckless enough to consume a K-ration immediately would usually be seizedwith violent gastrointestinal cramps, nausea, vomiting, and diarrhea.Nutritional rehabilitation was in fact required by almost all the prisoners,both the ambulant and the hospitalized.
An urgent problem was the care of RAMP's not sick enoughto be hospitalized, who were to be evacuated through command channels by theProvost Marshal's personnel. Accordingly, as has been related, therepresentatives of the Chief Surgeon's Office did in fact direct thegreater part of their time and attention to preventing secondaryhospitalization of these liberated prisoners. The experience with the first4,400 RAMP's to arrive at the Lucky Strike deployment area confirmed thefirst impression that had been gained by direct inspection of the recentlyoverrun camps at Limburg, Niedērgrenzebach, and Heppenheim concerning theextreme sensitivity of the gastrointestinal tract of these men to most foods. Asnarrated in the earlier section (pp. 245-246), the planned dietaryregimen had been instituted and was in practice before the bulk of theprisoners arrived. The need for it was amply proved by the resultingreduction in the number of those who had to be hospitalized, from approximately25 percent in mid-April 1945 to approximately 0.03 percent 1 month later.
The first inspection of the prisoners of war hadrevealed malnutrition in all its forms. An immediate necessity was to definecategories and set up criteria for hospitalization and treatment (pp. 261-263).The patients were divided into three groups as having (1) simple malnutrition(mild, not hospitalized; moderate, not hospitalized; severe, usuallyhospitalized); (2) the emaciation syndrome due to prolonged starvation; and(3) acute starvation. The deficiencies noted were listed in order of frequencyand severity as follows: Total calories, protein, vitamin C, thiamine, nicotinicacid, and riboflavin. The majority of the recovered personnel were onlymoderately undernourished and did not require hospitalization on thatcount alone. Their nutritional rehabilitation could be satisfactorilyaccomplished in reception camps, although many men, as has been seen, had to behospitalized because of severe gastrointestinal distress due to improperfeeding. (Parenthetically, it may be said here that the field and evacuationhospitals performed their unexpected tasks well.) The sickest prisonershad been the first to be left behind by the retreating Germans, and inthese the Army Medical Corps was finally confronted with the end results ofmalnutrition.
The 1st General Medical Laboratory, Paris, France,was alerted to save all tissues from fatal cases in order to gather as muchteaching material as possible for the study of starvation. For Americans, inWorld War
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II, had now indeed every opportunity to study malnutrition,from its early manifestations in trainees to its ultimate outcome in prisonersof war, while in the captured camps they could observe at firsthand itspenultimate phenomena, chronic emaciation and acute starvation.
PRINCIPAL SYNDROMES-DESCRIPTION AND MANAGEMENT17
From war to war, the repetitive nature of many of thenutritional disturbances observed is well documented, particularly the so-calledfamine edema, which has been described by many writers in many languages. In theearly morning of literature, Hesiod, in his "Works and Days," speaksof the starvation a hard winter brings, and advises prudent thrift "lestthe helplessness of evil winter overtake thee, and with wasted hand thou pressthy swollen foot." Scaliger attributes to Aristotle the remark that infamished persons the upper parts of the body desiccated and the lower tumefied.Hicker, in his account of the destruction of the French Army before Naples in1528, referred to soldiers with pallid visages, swollen legs, and bloatedbellies, scarcely able to crawl. Sydenham refers to the condition when he makesuse of the quotation "Ubi desinit scorbutus, ibi insipit hydrops." Hequalifies his quotation by calling it a saying of the vulgar, meaning to implythat, when a dropsy has shown itself by clear signs, the preconceived notion ofscurvy falls to the ground. Still, the connection between scurvy and dropsy in apopular saying suggests that the conditions under which the disease arose wereclosely allied in the minds of the 17th century public.
Lind, quoting van der Myle's description of the diseasesobserved during the siege of Breda in 1625 says: "Of those who wereafflicted with the flux, few escaped. They afterward became bloated, relaxed anddropsical. Watery swellings of the testicles were frequent. Some died early inthe disease. Those who had seldom any evacuation of the blood by the nose orstool and seemed from the beginning indolent, dispirited and blown up, as itwere, with the wind, their stools were greasy, fetid, and of various colors, butnot frequent."
A clear distinction between famine dropsy and scurvy andbetween beriberi and the various final edemas of inanition or diarrhea was madeby Cornish. He described the condition with great precision in 1864 asoccurring among prisoners on certain dietaries in the Madras jails. "Underthis system of diet the men became unhealthy, and within three months six of the100 had died of diseases of a scorbutic type such as diarrhea and dropsy."Speaking of the post mortem appearances, he says: "General
17The author has given a very vivid description of theprogressive stages of starvation as reflected in theunfortunate inmates of POW and concentration camps during World War II. In sodoing, he has also revealed the hazards of improper diet and portrayed thepathognomonic symptoms of nutritional deficiency diseases to present-dayclinicians called upon to advise their patients in matters of dieting.-A.L.A.
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dropsy and the tendency to serous effusions into the cavitiesof the pericardium, thorax and abdomen are the only evidence, as indeedare the symptoms just noticed."
Of the various forms of starvation seen during World War II,the total emaciation of the inhabitants of the concentration camps and prisoncamps received considerable publicity-less well known forms of starvation werealso seen. The nutritional degradation of some of the sick and wounded was aclinical problem encountered in all theaters.
Diagnosis.-The differential diagnosis of the end results ofmalnutrition-of emaciation from starvation-can be made on clinical groundsby a physician well grounded in physiology. Acute starvation phenomena (p. 261)are due to complete deprivation of food. People so starved do not survive verylong if the fluid intake is limited also. The malnutrition that leads eventuallyto the emaciation syndrome is different. Here, there is sufficient caloric andfood intake to insure survival for a time but not enough to maintain a normalmetabolic level. The outstanding deficiency is of course in calories, but thisis not the most important one. The specific nutrient deficiencies, especially inprotein, are responsible for much of the clinical symptomatology. Wastingphenomena, particularly of the musculature, will be the end result of anegative caloric and nitrogen balance. The emaciation syndrome, whenpresent, is the predominating one, and calls for the most careful therapy.
Chronic emaciation-The historyelicited from these patients and their physical findings are very characteristic.Usually, there has been a food intake averaging as low as 600 calories dailyduring long periods of forced labor or forced marching. In survivingindividuals, this eventually leads to the total emaciation syndrome. Weightlosses up to 60 percent of the original body weight have been recorded.The patient as seen in the late stages presents a very characteristicpicture. One observes a completely apathetic, very thin individual, usuallylying immobile, legs flexed across the abdomen, arms folded across theabdomen or chest. The position is maintained even if the patient is rolledover. There is no true ankylosis of the joints, as the patient can with mucheffort and persuasion extend his lower extremities to their full length.This is obviously a painful process and is not done willingly. The skin is dry,coarse, rough, and cold to the touch. Pigmentation is a prominent feature.Pressure points over the sacrum, ischial tuberosities, and head of thefemur are the common sites of bilateral, symmetrical, rough, pigmented,and scaling areas. Light pigmentation of infraorbital and frontal areas isfrequently seen. In the latter site, it resembles the chloasma pigmentationof the pregnant female. Muscular atrophy is severe and extensive, the temporal atrophy appearing early. This, coupled with the loss of orbitaland malar fat pads, gives the peculiar death's head appearance common toall of those affected. The legs and arms appear merely as contours of thelong bones covered with a tight
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skin. The buttocks are concave and follow the contours ofthe ilium and ischium. The paravertebral sulci are deep. Even such a muscle asthe pectoralis major almost completely disappears, and the second and third ribsas well as the others are visible on the surface.
The stigmata of endocrine changes are universally present;in the female, the breasts and vulva are atrophic. There is always amarked hirsuties of the face and extremities; the voice though weak is coarse.The history reveals a complete amenorrhea usually from the second month ofincarceration. The males may have a smooth face with sparse hair growth; thevoice is quivering and high pitched. The penis is flaccid and usually shrunken.The tongue is smooth, beefy red, and thin, in the late stages of atrophy.The circulatory system undergoes some very radical changes. Resting pulserates show a marked bradycardia of approximately 35 to 50 beats perminute. Resting blood pressures are as low as from 60 to 80 mm. Hgsystolic and from 30 to 40 mm. Hg diastolic. The slightest activity orexcitement precipitates a dyspnea and tachycardia, indicating an extremelylimited cardiac reserve, which must be recognized in institutingtherapeutic procedures. Histological examination of the heart confirms thisclinical impression.
The eyeballs are soft, and the conjunctiva are wrinkled.There is usually a marked enophthalmus and a dry eye. The sclera have aporcelain, bluish-white appearance which is quite characteristic. They aremarkedly avascular. One frequently sees a malar flush which is cyanotic in hue.The lips will vary in color depending upon the relative amounts of anemia.While there is an absolute depression in the amount of hemoglobin, thehemoconcentration may give an apparently normal value. Deep tendon reflexeswill vary from marked hyperactivity to complete absence. Because of thepainfulness of the joints, it is difficult to evaluate them properly. Analincontinence is very common and is manifested by fecal encrustation in thegluteal folds. These people are in a physiologically hibernating stage. Theirbody weights vary from 50 to 75 pounds, the greater part of their weight representinga skeletal structure which is comparatively inactive metabolically; theirdaily caloric requirements are as low as 500 calories at this point. Where oneis able to get a lucid description of their downhill progress, it is evidentthat these patients have passed through the stages of nutritional edema with thespecific nutritional deficiency syndromes of beriberi and pellagra. Many dieduring this degradation process. Those who manage to accommodate themselvesto the reduced nutrient intake by the compensatory decrease inmetabolic levels survive to this condition of emaciation.
At this stage, the adjustment of the circulation and otherphysiological processes is a very narrow one. The maintenance of life isdependent upon not upsetting this balance too abruptly. Therapy begun tooaggressively
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in an enthusiastic effort to restore these people tonormal may result in a breakdown of the compensatory mechanisms, and deathfrequently ensues.
It should be borne in mind that those who dehydrate are theones who survive. It is rare to see nutritional or famine edema in this stage oftotal emaciation. Nor do these people present the signs and symptoms of theB-complex deficiencies. These vitamins constitute functionally the prostheticcomponents of the enzyme systems in carbohydrate and protein metabolism. Withmetabolic levels at a minimum, the demand for these vitamins is very low. When,however, one burdens the body with a sudden plethora of foodstuffs, thenthe vitamin requirements immediately increase proportionately, and unlessthis new need is met acute deficiencies result. in addition, the cardiac reserveis so extremely limited that a sudden change in the circulating blood volume throws a burden on the atrophic, flaccid, degenerated cardiacmusculature with which it cannot cope.
Therapy, then, must be started very slowly and cautiously,with due regard for all these limiting factors. It should be directed towardsupplying, first, calories, then the B group of vitamins, then proteins, andeventually a definitive therapy complete as to calories and nutrients.Experience has shown that oral administration where tolerated is the routeof choice. Gavage should be resorted to only when necessity dictates, andintravenous therapy, only in the presence of nausea, vomiting, or intractablediarrhea. Milk and egg mixtures, fresh or powdered, are well tolerated by themajority of these people. No attempt should be made for the first 24 to 48 hours of therapy to do more than reeducate the gastrointestinal tractto the acceptance of these foods. No more than 1,500 cc. of the fluid mixtureshould be given by mouth in each of the first 24-hour periods. The saltcontent of the fluid mixture must be carefully controlled; otherwise,edema will result. If nausea or vomiting is precipitated by the oraladministration, then intravenous therapy may be instituted. Here, morethan ever, extreme caution must be used, or reactions will develop in a highpercentage of these extremely sensitive patients. No more than 500 cc. ofnormal human blood plasma or blood should be given in the first 24 hoursat a rate no faster than 2 cc. per minute, preferably slower.Thiamine and niacin should be given regularly in appropriate doses.Such foods as cooked cereals, custards, white bread and dairy butter, mashedpotatoes, and thin soups are added slowly, as tolerated. In other words, onlylow-residue foods, mechanically nonirritating and bland, should be givenfor several weeks in order to avoid precipitating acute gastroenteritiswhich, in the debilitated state of these people, would be a seriouscomplication. Autopsy material, as will be shown, lends support to theseclinical observations (p. 288). Once recuperation has started and the patienthas demonstrated his ability to tolerate food, then more active treatment canbe instituted. Iron therapy for the anemia is of no value until a positivenitrogen balance has been well established; in addition, iron salts by mouth notoriously produce gastro-
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intestinal upsets. Vitamin therapy is a necessary adjuvantbut only as supplementary to the high-protein, high-caloric intake.
Acute starvation-In contrast tothe picture of chronic emaciation that has been described is theclinical syndrome of acute starvation. By this is meant the condition of onewho has been deprived of food and fluid for several days. In thiscondition, there is usually ketosis and acidosis with signs of acute dehydration.These patients require intensive therapy asquickly as it can be given. Intravenous fluids with emphasis on theglucose-saline mixtures is indicated. No special dietetic therapy is necessaryexcept what is required by secondary conditions. Recovery is usuallyprompt and complete. By contrast, the syndrome of malnutrition isevident, in varying degree, in those people with intakes adequate in caloriesbut inadequate in specific nutrients. This was more commonly observed inthe Pacific area than in the European area. With an inadequate intake ofspecific nutrients the metabolic levels remain high. The requirementsfor vitamins remain normal. Since the diet does not contain the requiredamount of vitamins, deficiency syndromes become manifest. The first oralfeeding will frequently determine the speed of convalescence. Should the food produce an enteritis or gastroenteritis, convalescence will be greatlyprolonged and therapy made more difficult.
Edema was not an infrequent finding in recoveredprisoners seen during the intermediary stages leading to totalemaciation. This varied from swelling of the dependent lower extremitiesto generalized anasarca. It was usually due to a low serum proteinvalue with an adequate salt intake. Values as low as 1.8 gm. per 100 cc. ofblood have been observed. Mild edema disappeared within a few days afterbeginning a high-protein intake. Severe anasarca persisted somewhatlonger, but a polyuria was manifest by the second day. Over 33 percent ofthe patients with total emaciation treated in U.S. Army hospitalsdeveloped edema in the course of the first week of therapy untilattention was directed to the salt content of the nutritive foods given forrehabilitation.
In the literature, famine edema has usually not beenassociated with albuminuria, cardiac dilatation, or neuritis. It has beenobserved more particularly in men called upon to perform hard physicalwork on rations supplying from 800 to 1,200 calories contained, as a rule,in a largely fluid diet comprising 15 percent or more of indigestible celluloses with very little fat and not more than 50 gm. of protein daily.
Treatment in hospital.-Causes forhospitalization of recovered prisoners and details of treatment wereoutlined in Circular Letter No. 36, for three groups of patients. GroupI comprised patients showing a moderate loss of weight, weakness,gastrointestinal distress but no definite signs of protein or specificvitamin deficiencies. Approximately 80 percent of those hospitalized becauseof malnourishment were in this group. The hospitalization was considerednecessary to combat weakness and gastrointestinal dis-
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tress by appropriate dietary and medical measures,with complete nutritional rehabilitation contemplated in the reception camps.Certain points emphasized in the dietary treatment of Group I patients were asfollows:
The tolerance of the gastrointestinal tract to the firstfoods eaten will [frequently] determine the immediate dietary procedures to befollowed. Soft diets are indicated and full use should be made of milk, eggs,and cooked cereals. Feeding should be frequent and in small portions.Overfeeding must be avoided. The restoration of nitrogen balance and the gain inweight are the primary goals. The diet should supply at least 150 gm. of proteinas soon as normal eating is possible. Initial gain in weight will occur on anintake of 2,500 to 3,000 calories, if the protein intake was adequate. Over4,000 calories will be required for a more rapid restoration of body weight.
Multivitamin supplementation is necessary only during theperiod when gastrointestinal distress prevents normal eating. No more thanfour multivitamin tablets daily should be administered.
Group II comprised patients showing marked loss of weight,weakness, and evidence of specific deficiencies such as edema, anemia, andglossitis. Approximately 20 percent of liberated personnel hospitalized becauseof malnourishment were found in this group. The initial feeding for Group IIpatients was to be similar to that prescribed for patients in Group I, iffood could be tolerated by mouth. Other points of dietary management were asfollows:
Patients with edema who cannot tolerate food by mouth willrequire intravenous therapy. Plasma and whole blood are indicated. Transfusionsshould be given at a rate of not more than 2 cc. per minute. Dyspnea, precordialdiscomfort, and apprehension are danger symptoms that should lead to immediatediscontinuance of the transfusion. [Unfortunately, human salt-free albumin wasnot available. The use of salt-poor food was further emphasizedperiodically as experience was gained with the development of edema in thesepatients.] The treatment of the macrocytic anemias is dependent on therestoration of the protein deficits. Oral administration of iron is notrecommended until nitrogen balance has been reestablished. Multivitaminsupplementation is necessary in most of the severely malnourished patientsduring the first 15 days of treatment.
Group III comprised patients showing extreme weakness,marked dyspnea, nausea and vomiting, and delirium or coma. These were seen inhospitals relatively rarely, because they usually were not able to survive transportation.Such patients required immediate therapy in the form of transfusions ofplasma or whole blood given very slowly and with extreme caution. Thiaminehydrochloride, 30 mg., was given parenterally at 24-hour intervals.
As presented in Circular Letter No. 36, diluted milkand soup preparations were suggested for the initial feeding of malnourishedsoldiers in the forward areas, as follows:
One can of evaporated milk plus 3 cans of water;one-fourth canteen cup of sugar and one-fourth teaspoon of salt.
One canteen cup of whole milk powder plus 5 canteen cupsof water; three-fourths cup of sugar and three-fourths teaspoon ofsalt.
One quarter of a canteen cup of the diluted milkshould be given warm every half hour, as tolerated. Water may be taken insips between feedings to the extent of 2 can-
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teen cups daily. Powdered egg or prepared cereal * * * may beadded to the diluted milk after the first day if gastrointestinal distress isabsent.
Soup may be prepared from canned meat and vegetable stew orfrom canned meat and noodles if milk is not available. [These were made indilute form.] Soup may be thickened with flour or cereal.
The medical officer assigned to the Nutrition Branch visitedthe chiefs of all the major hospitals concerned in thetreatment of recovered prisoners. Clinical observationsand statistics derived from these visits are described in the section "RAMP'sin Hospital" (pp. 284-288).
NUTRITION IN CIVILIAN POPULATIONS, EUROPEAN THEATER, AND INCONCENTRATION CAMPS
In liberated countries.-While the Office of theChiefSurgeon had direction of the nutrition of troops and of prisoners of war, therelationship of its work to civilian populations was notdefinitely clarified. Teams18 were dispatched from the Zone of Interior to conductnutritional surveys under the general direction of the Chief NutritionConsultant, Public Health Branch, G-5 Division (civil affairs/militarygovernment), SHAEF, and their services were made available to the variousmissions and to the Army groups. Two types of survey were done. The first wasthe so-called rapid survey, or observation of a representative sample of thecommunity by means of a simple medical examination to establish the presence orabsence of florid manifestations of deficiency disease. Subsequently, thedietary history was obtained in a careful interview in order to estimate asclosely as possible the food intake. A study of patients in asylums, hospitals,and orphanages gave information on the basic foodsupplies. Some laboratory tests were done on a smallpercentage of those who were examined clinically. It was found, too, at thistime that extensive weighings on street corners of randomsamples of the population yielded significant evidence of caloric intake andwork output. This comparatively simple technique can be adapted toany population and can be used as a means of following the progress of any largegroup under observation.
The civilian population included not only the normalpopulations of the occupied andliberated countries but also large numbers of displaced persons. On the whole,the state of nutrition in European countries was much better than had beenexpected except that there was serious malnutrition inHolland, particularly where a complete embargo had been imposed by the Germans. Completereports19 of the variousareas were submitted by the consultantsin nutrition and the survey teams who covered most of the Continent during theircourse of duty.
18Annual Report, Nutrition Division, Preventive MedicineService, Office of The Surgeon General, for fiscal year 1945.
19Surveys and Reports on Nutrition, Headquarters, U.S.Forces, European Theater, Office of Military Government (U.S. Zone), May throughDecember 1945.
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In France itself, when it was liberated, rather detailedreports were given by the French physicians on thesituation that had obtained during the time of the German occupation. Edema hadbeen a very common thing among the poor people of Paris.Osteoporosis, or Milkman's disease, with fractures ofthe vertebrae was very frequent, occurring usually in older women. The X-rayevidence for this story was remarkably good. Amenorrhea, as would beexpected, was common in the females. No scurvy was seen in the Parisian groups,but pellagra was present in a relatively small but definite group. Anemia wasfound rather frequently, particularly the hyperchromic and hypochromic types.
In Holland, in the so-called B area,the situation was remarkably different. Famine, edema, and extreme emaciationwere the principal nutritional problems. There was an increase in generalmortality. The height and weight of school children showed some decrease fromthe previous figures in 1939. It was estimated that death occurred inapproximately 10 percent of the cases hospitalized for starvation. Thepreliminary estimate showed that there were approximately 200,000 cases ofmalnutrition sufficiently severe to be referred for special handling.
In Rotterdam, the average loss of weight was 25 poundsin the 19- to 59-year age group, and 40 pounds in people over 60. InAmsterdam, 41 percent of those sampled were judged normal and 41 percent thin.Of the latter, 16 percent were very thin and 1.9 percent emaciated. Inthat city, it was estimated there were 56,000 cases of famine edema. In Utrecht,there was mild edema in 2.8 percent of all the people examined. In Delft, wherethe average loss of weight was 21 pounds in the age group 19 to 59 and 39 poundsin those over 60, edema was found in 10.5 percent of those from 19 to 59 yearsold and in 25 percent of those over 60 in the poorer economic class. Therewas less than half this amount of edema in middle-class people, and it was practicallyunknown among the well-to-do. Dutch physicians studying this starvation edemareported two types: (1) The edema with diuresis that accompanied slightemaciation and disappeared as chronic emaciation set in, and (2) the edema thatoccurred with extreme emaciation. They found a lowered basal metabolicrate, decreased body temperature, spasms of the voluntary muscles, particularlyin eliciting deep tendon reflexes, and extensive brownish pigmentation of theskin. Under therapy of bed rest and high-protein diet, the edema disappearedrapidly.
In Germany and Austria.-Other civilian areas were seenby various people during the postwar period, inparticular the German and Austrian concentration camps. The author of thisstudy visited many of these personally. Early in May of 1945, he inspected theconcentration camps at Mauthausen and at G?sen. The camps had a population ofapproximately 18,000 when taken over on 6 May 1945. There were hundreds ofunburied bodies lying around at that time. The death rate continued at a veryhigh level. The writer did many autopsies in these camps. Pulmonary tubercu-
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losis was, of course, a common cause of death, butmalnutrition was probably the greatest. Clinically, the patients presented theusual manifestations of extreme emaciation, some edema, diarrhea, and markedgastrointestinal symptoms. There were questionable cases of beriberi, someriboflavin deficiency, and an occasional case of pellagra. Autopsy findingscorroborated the clinical report, and details of these autopsies are presentedon pages 288-291.
NUTRITION OF THE GERMAN PRISONERS OF WAR
It was many months after the crossing of the English Channelin June 1944 before the German prisoners of war became much of a problem.Inthe passage across France, they were at first captured in small groups butnever in wholesale lots until the fall of Brest. By the week ending on 9February 1945, the prisoner-of-war strength climbed suddenly to 241,545. Themorning sick reports did not yield any major evidence of nutritionaldisturbances although approximately 486 were on report for diarrheal diseasesand only 8 for Vincent's stomatitis. The bulk of the men reported for commonrespiratory diseases, trenchfoot, and frostbite. By the week ending on16 February 1945, there were 246,281 prisoners of war, and, by the week endingon 23 February 1945, there were 249,272. These massive numbers required medicalcare and subsistence. The Office of the Chief Surgeon became concerned with thenutritional status of these prisoners of war and the adequacy of their rations.
In accordance with the verbal orders of the Chief Surgeon,ETOUSA, and with the concurrence of the Theater ProvostMarshal, a survey was made on the nutritional status ofthe German prisoners of war in representative enclosures,labor camps, and hospitals on the Continent. The survey was conducted under thegeneral supervision of Colonel Griffith and was directedby Colonel Pollack, who had one Medical Corps officer and threeSanitary Corps officers to help him. This team examined 800 prisoners duringFebruary and March 1945 at 21 different installations, including 5 continentalenclosures, 7 work camps, 2 prisoner-of-war hospitals, and 5 generalhospitals. The number of prisoners examined was considered statisticallysignificant, and the findings were believed to be representative of thetotal prisoner population on the Continent. The prisoners were classified asnew or old according to whether they had subsisted on the U.S. Army POWration for fewer or more than 50 days. The new group included 312 prisoners andthe old group, 488 prisoners. The survey was of a clinical type and is reported in detail in the report20dated 15 May 1945. The findings in general were asfollows:
20Essential Technical Medical Data, European Theater ofOperations, U.S. Army, for May 1945, dated 26 July 1945. Inclosure 16, 15 May 1945, subject: Report ofNutritional Survey of German Prisoners of War Under Control of the United StatesArmy on the European Continent.
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The body weights of the prisoners as estimated by grossappearance and by the condition of the skin and subcutaneous tissue wereapproximately the same in new and old groups. Many had lost weight beforecapture, but over 93 percent appeared normal in thisrespect. There was definitely no indication of loss of weight in the group whohad been fed the U.S. Army POW ration for a period longer than 50 days.
There was no evidence of protein or mineral deficienciesattributable to the diet in the old prisoners. The general health of the oldprisoners was better than that of the new prisoners as indicated by daily sickcall.
The energy content of the ration fed to the nonworking andintermittently working prisoners averaged 2,800 calories. This was from 10 to20 percent greater than required for the maintenance of these groups.
The energy content of the ration fed to the working prisonersaveraged 3,050 calories. A ration supplying from 2,800 to 3,000 calories wasbelieved to be adequate for this group unless more strenuous labor was performedthan was observed during the survey.
Riboflavin deficiency as evidenced by angular lip lesions andmagenta-colored tongue and by nasolabial seborrhea wassurprisingly common in the new group. The regressing orhealed lesions were found in the old group whichdemonstrated that the U.S. Army POW ration not only prevented a deficiency inthis instance but also permitted rehabilitation of tissue damagedby previous dietary insufficiency.
Thiamine deficiency was noted in both groups and wasrecognized by tenderness of the calf, abnormal reflexes,and diminution of vibratory sense perception. The incidence of this deficiencywas definitely lower in the old groups.
It was concluded that subsistence on the U.S. Army POWrations for from 50 to 200 days resulted in markedimprovement of the overall status of nutrition in the German prisoners. It wasfurther concluded that the nutritional value of the U.S.Army POW ration was superior to the German Army ration andwas adequate for the maintenance of the health of the working prisoners.
With the end of the war and after V-E Day, however, thesurrender of hundreds of thousands of men simultaneously had precipitatedfeeding problems with consequent periods of very restricted food intakes. Thisresulted in extensive malnutrition among the disarmed enemy elements.Accordingly, surveys to determine their nutritional requirements were made periodicallyin the prisoner-of-war enclosures and the hospitals treating thesepeople. A report of one such survey,21 dated 31 August 1945,showsthe general problems of the time. It was found that the body weights for thenonworker group studied were below standard in all prisoners except
21Essential Technical Medical Data, European Theater ofOperations, U.S. Army, for August 1945, dated 22 Sept. 1945. Inclosure 8, 31Aug. 1945, subject: Report of Nutritional Survey of German Prisoners of War andDisarmed Enemy Elements Under Control of the United States Army on the EuropeanContinent.
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those who had recently been evacuated from Italy. The bodyweights of the workers receiving approximately 2,900 calories wereconsistently higher than those of the nonworkers and within normal acceptedstandards for their age groups. Workers receiving less than 2,000calories daily were definitely undernourished. In some of the nonworking groupsreceiving less than 2,000 calories a day, there was suggestive evidence of earlymuscle atrophy indicative of depleted protein reserves.
Deficiency syndromes relating to the B complex vitamins wereevident in the nonworkers subsisting on American POW rations. Although there wasevidence of these deficiency syndromes in those prisoners subsisting onlocally procured German food, it was not so marked as in the groupssubsisting on the American POW ration. It was believed that this difference wasdue to the use of some highly milled unenriched flour which furnished a largepart of the energy value of the American POW ration. The German rationincluded a 95-percent extract flour which supplied many of the B vitamins.
As a matter of practical policy based upon experience, it wasdecided that rural populations and agricultural workers were to beconsidered as self-sustaining. The confined prisoner and the urbandweller, on the other hand, had to be assured the minimum food requirementsto maintain health and resistance to disease. Persons behind barbed wirecould not supplement their rations so easily as civilians could from accumulatedstores, garden produce, and such other sources as "the countrycousin" and the black market. The difference was found reflected in therespective nutritive condition of civilians and prisoner's living on the sameofficial ration scale. The main attention, then, in setting up ration scales hadto be directed toward meeting the requirements of those unable to produce orsupplement their own.
It was determined that a period of nutritive rehabilitationshould be authorized for all prisoners of war and disarmed enemy elements whopresented evidence of malnutrition. Such persons should be authorized, upon thepersonal investigation and recommendations of the responsible U.S. Army MedicalDepartment officer, a full worker's ration for a 20-day period togetherwith relief from work details. This was not to be in lieu of hospitalization forthe severe or moderately severe cases of malnutrition.
There was evidence of very extensive malnutrition amongthe prisoners of war and disarmed enemy elements in the large enclosuresmaintained by the Third and Seventh U.S. Armies and by the CommunicationsZone. There was a complete lack of uniformity in the ration scales among thevarious areas in Germany. The Seventh U.S. Army area, for example, sustained theprisoner's of war on U.S. Army food, while in the Third U.S. Army areathe disarmed enemy was subsisting on food locally procured. The caloric scalesvaried with the location from 1,265 to 2,157 calories for
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nonworkers, and from 1,450 to 2,296 calories for workersduring the month of July.
There was consistent evidence of an insufficient amount ofriboflavin and nicotinic acid in the diet for the conditions under which thesemen were living. These signs were particularly numerous in the younger agegroup, those under twenty. Among the several factors responsible was the fact,as shown in the report of 15 May 1945 (p. 265), that the standard German Armyration had been deficient in riboflavin and nicotinic acid for some time.Superimposed upon this deficiency intake of fairly long standing was thevariable period of severe deprivation of all nutrients during the final weeks ofthe active campaign and of unavoidably inadequate rations in the forward POWenclosures. At best, the POW ration could only be expected to maintain anexisting state; it was never designed as a therapeutic diet.
In the various enclosures, the interpretation of thedesignation "worker" was quite different. In one, prisoners were madeto build roads in the compound area. Men carrying crushed rock in sacks to thepoint of work, 4 pounds on each trip, were not designated workers because theproject was an intracompound improvement. In another compound, men who workedonly 4 hours a day were given the full ration for heavy labor because theyworked outside. At other camps, clerks and camp administrative personnel weregiven a full heavy worker's ration even though their work was sedentary. Insome compounds, the prisoners subsisting on the nonworker's ration, were putthrough several hours daily of calisthenics and drill. Asurvey in the Delta Base Section disclosed that general labor service units,given 2,900 calories daily, had a consistently lower sick call ratethan the enclosure population receiving from 1,700 to 2,000 calories daily.The latter were drilled for several hours. The sick call rate for 22 June1945, for instance, was 233.7 per 1,000 for the confined group, and only 98.3per 1,000 for the labor service unit. This difference was maintained throughouta considerable period of time.22
It was evident that the term "worker" had to beredefined and extra food allotted for extra effort, whatever form it might take.Prisoners of war doing light work were to be authorized the standard worker'sration less 10 percent, or approximately 2,600 calories.Light work included the clerical and sedentary types,kitchen and mess duty, landscaping and policing grounds, general housekeeping inthe American installations, and similar activities. Heavy work was defined asmanual labor for more than 4 hours daily. The nonworker's ration was to beissued only to inactive prisoners, limited to a routine of self-care in thecage.
22In the Korean War, camp administrative personnel on KojedoIsland were subjecting the North Korean prisoners of war to calisthenics and toexercise such as running several times a day around the compound, a distance ofalmost half a mile, although the North Koreans were theoretically nonworkers andwere subsisting on the nonworker's ration.-H. P.
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One of the most important recommendations made in the 31August 1945 report was thatthe full worker's ration of 2,900 calories be authorized for issue toprisoners of war under 21 years of age. During the last months of the war, theGerman Army had recruited boys from 14 to 20 years of age in whom, as is wellknown, metabolic requirements are higher than in adults.
The German-operated hospitals for disarmed enemy elementsfared very well with respect to rations. Most of the hospitals were establishedinstitutions with well-planned gardens and large stores of processed foods whichhad been built up in the past. Furthermore, they were allowed to draw fullcivilian rations from the local areas for the patients plus the numeroussupplements for the special diets involved. Many instances of grossly inaccuratediagnosis by the German medical staff were found. In one hospital, severalpatients admitted with a diagnosis of nutritional edema were examined. In noneof these cases was the diagnosis substantiated, but a multiplicity of causes wasfound for the edema, principally old frostbite and nephritis.
In view of the evidence of extensive malnutrition found,further surveys were carried out in Austria, and on 26 September 1945 a report23was submitted on the nutritional survey of thedisarmed enemy forces in that country. At this time, conditions had improvedconsiderably. There were still isolated spots where immediate intensive therapyin the form of high-calorie bland foods was required, but there was directevidence of gains in weight among the prisoners.
Trench nephritis-During the survey on the nutritionalstatus of German prisoner-of-war patients, the various surgeons in charge wereasked about cases of edema, nephritis, or cardiac failure observed by them. Theproblem of the co-called trench or, as the Germans called it, "feld"nephritis was discussed with the German medical men in the POW enclosures. Abrief summary follows.
There were many cases in the German Army, but the exactnumber is not known. The syndrome was most prevalent on the Russian front, andits incidence was highest during the autumn and winter months. In Finland, wherespecial rations of high nutritive value were issued to German troops with, inaddition, vitamin supplements, the incidence of trench nephritis was much lowerthan on the adjacent Russian front.
The patient usually presented himself with a history ofhaving been in previously good health and on full duty status before the onsetof the illness. There was generally no history of immediately antecedentinfection such as tonsillitis, pharyngitis, or other acute respiratory disease.The age group in which this condition occurred was from 35 to 50 years. Thedisease was first manifest with a swelling of the face and the lowerextremities.
23Essential Technical Medical Data, European Theater ofOperations, U.S. Army, 26 Oct. 1945. Inclosure 9, 26 Sept. 1945, subject:Report of Nutritional Survey of Disarmed Enemy Forces in Austria.
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This might go on to generalized edema in the severe cases.Headache, backache, and aching in the neck were generallynoted in the prodromal stage. Dyspnea on rest or exertionmight occur, and occasionally convulsions were reported early in the illness. Urinewas scanty and dark at the onset.
The physical examination showed the edema as the presentingmanifestation. The temperature was not always elevated at first. Cardiac rhythmwas normal, usually with a sinus bradycardia. Pulse rates were observed to dropas low as 50. Hypertension occurred in some cases and initially was afrequent finding. No organic murmurs were heard in the heart areas. The lungswere essentially clear, although occasionally there were signs of a pleuraleffusion. Enlargement and tenderness of the liver were common, and in manypatients signs of ascites could be elicited. The eye grounds rarely showedevidence of hemorrhage or exudate. The urine had a high specific gravityalthough albuminuria was absent in the mild cases but was as much as 3 plus inthe severe cases. On microscopic examination, the urine was usually found tocontain numerous red blood cells and some casts. Blood urea nitrogen ornonprotein nitrogen was normal or moderately increased. Totalproteins were usually normal. X-ray examinations of the chest showed pulmonarycongestion, small pleural effusions either unilateral or bilateral, andoccasionally cardiac enlargement.
Electrocardiographic studies usually showed lowvoltage; small T wave changes, either low positive deflection or isoelectric or inverted; and of course the sinus bradycardia. The clinicalcourse of the condition was usually uniform. Most patients recovered completelyon bed rest regardless of therapy. Some few progressed to the chronic phasewith hypertension, eye-ground changes, nitrogen retention, and persistentabnormal urinary findings. Autopsy findings were not available, but reliable reportsof two autopsies indicated a lack of significant glomerular pathology.
In conclusion, it was noted that this syndrome, which wassaid to be prevalent in the German Army and was seen in the Germanprisoners of war in the U.S. prisoner-of-war compounds, was not reportedin the U.S. Army troops. The two Armies were, of course, exposed to thesame terrain and climatic conditions, and there had been sufficient contactbetween them to permit transmission of a communicable agent. There was, however,a very marked difference in the rations of the two Armies. Although nopositive statements can be made, the evidence strongly suggests that there was anutritional factor in the precipitation of this syndrome.
MALNUTRITION IN THE FAR EAST
Repatriated American Soldiers
After the war ended in the Pacific, the results of theimprisonment of the captured American soldiers became and remained thesubject of some
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discussion. The length of their imprisonment averaged about39 months. Harris and Stevens24 state that official studies conducted at the time of liberationor shortly thereafter indicated that almost all had suffered from severemalnutrition in multiple forms, and from many other diseases, duringimprisonment. This is confirmed in the report of the U.S.S. Haven, publishedJanuary 1946.25 In this study, 66 percent of the men who survivedgave a history of beriberi; 58 percent, dysentery; 43 percent, malaria; 20percent, skin disorders; 19 percent, pneumonia; 14 percent, pellagra; 6 percent, tuberculosis; and 9 percent, malnutritionotherwise unclassified-45 percent of the men experienced edematous swellings.Over 75 percent of the prisoners at Cabanatuan had burning feet. Hibbs,26 ina study of beriberi in Japanese prison camps, said that 2 percent of theprisoners developed motor paralysis. Recovery in manyof these men was rapid. A survey by Brill27 ofneuropsychiatric examinations made from 1 to 8 weeks after liberation of 1,617men who had been prisoners of war for 39 months, or longer, revealed only 5 ofthem with psychoses, only 0.7 percent with psychoneuroses, and 12.7 percent withsome psychologic disturbances, generally of the overanxiety type. There were13.1 percent with peripheral nerve disorders, but most ofthese were not severe. There were 64 cases of opticatrophy in this group. It was stated that the overall mortality duringimprisonment of the Pacific prisoners of war was 37.2 percent. The expectedmortality in this age group would be less than 1 percent.
These cold figures, however, do not present a real picture.It would be best, perhaps, to present the experiences of an officer who wasimprisoned by the Japanese, as described by Goldblith and Harris.28 Theprisoner, Goldblith, kept an accurate daily record, averaging on a monthlybasis, of the various nutrients obtained by American officers from the foodsupplied by the Japanese and by Red Cross parcels during their imprisonment from1942 to 1945. Goldblith analyzes the specific nutrient intake as follows: During certain months, the dietary fat fell as low as 15percent of the desired amount. This may have a bearing on the fact that allofficers were suffering from dry scaly skin at all times. He suggests thepossibility that there was a deficient intake of the essential fatty acids suchas aracidonic and linoleic acids. Marked hypoproteinemia began to show inOctober and November of 1944. The average weights of the officers did not godown but in fact increased, owing to the development of edema. Toward the end, Goldblithnoted that the addition of only 16 grams of animal protein per
24Harris, B. R., and Stevens, M. A.: Experiences atNagasaki, Japan. Connecticut M.J. 9: 913-917, December 1945.
25Monthly Progress Report, Army Service Forces, WarDepartment, 31 Jan. 1946, Section 7: Health, pp. 14-16.
26Hibbs, R. E.: Beriberi in Japanese Prison Camp. Ann. Int. Med. 25: 270-282, August 1946.
27Brill, N. Q.: NeuropsychiatricExamination of Military Personnel Recovered From Japanese Prison Camps. Bull.U.S. Army M. Dept. 5: 429-438, April 1946.
28Goldblith, S. A., and Harris, R. S.: Final Report on anAnalysis of Data on the Nutrition of American Officer Prisoners of War at theZentsuji Prisoner-of-War Camp at Shikoku, Japan. Project No. NR-123-298,Massachusetts Institute of Technology, Contract No. NRonr-297, for Office ofNaval Research.
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officer per day was followed by a cure of the edema and again in weight in November 1944. He points out that the diet consisted almostentirely of vegetable foods with rice, barley, and to a lesser extent soybeanas the staple foods. There was a large amount of greenvegetables in the diet and, consequently, no lack ofvitamin A, ascorbic acid, or iron. There was sufficient thiamine in the diet ofthe officers until the last 12 months of the period studied; then, suspectedcases of beriberi were discovered during this period of low thiamine intake.The riboflavin intake was never adequate during the entire period, and clinicalmanifestations of deficiency were apparent. Pellagra wasobserved intermittently during the 31 months of incarcerationbetween December 1942 and June 1945.
The worst part of the imprisonment was in the PhilippineIslands from March to October 1942 where theprisoners were kept in Camps O'Donnell and Cabanatuan. At the close of theBattle of Bataan, American and Filipino prisoners of war were maintainedby the Japanese on diets far below the accepted standardsin the United States. Of a total of from 14,000 to 16,000 Americanprisoners and 60,000 Filipino prisoners, over 1,500 Americans and 2,700Filipinos died during the 60 days they were at Camp O'Donnell, and over2,100 Americans died in Cabanatuan in as short a period. This canbe ascribed to the exertions of the "death march" as well as tomalaria, dysentery, and poor sanitation or to malnutrition and actual starvation, although these were perhaps themost important causes.
At Camp O'Donnell, the daily diet consisted ofapproximately 12 ounces of dry rice of poor quality, from 2 to 4ounces of native sweet potato, and 3 ounces of sweet potato tops, all boiledtogether in soup. Once a week, a quarter ounce of meat was issued to eachprisoner. This was a never-varying diet for the captives at this camp.At Cabanatuan, the daily rations were somewhat better. Here, about 16 ouncesof rice and 4 ounces of vegetable, sweet potato or corn, were included inthe daily ration. Once each week, 1 ounce of carabao meat was issued, and, inseason, one thin slice of cucumber was given to each man each day. At 2-weekintervals, 2 ounces of coconut or banana were issued, cooked withcornstarch and sugar in the form of a pudding. One-quarter of a pound ofhydrogenated coconut oil for the soup was issued per man per week.
It must be recalled that when the troops were on Bataanthey went on quarter rations early in January 1942. Beriberi was observedby March 1942 and increased to a marked degree by September 1942. Many menwere observed to die from the beriberi heart. Pellagra became marked towardthe end of September 1942. Scurvy, until October 1942, was veryquestionable. Ariboflavinosis demonstrated by cheilosis began to be observedby September of 1942. By October 1942, the majority of the prisoners ofwar were suffering from malnutrition in some form or other. Severeand sharp shooting pains in the feet and legs were complaints during the wintermonths of 1942-43 (fig. 38). This developed into gangrene in many cases.
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FIGURE 38.-Sketch, attitudes of beriberi, wetand dry, November 1942.
In test cases, this deficiency disease was definitely curedby massive doses of thiamine administered intraspinally andintramuscularly.
It is interesting to note in the conclusions of the reportby Goldblith and Harris that beriberi was the first nutritional diseaseobserved, occurring about 3 months after capture. Pellagra andariboflavinosis were observed after 9 months. Scurvy after 9 months wasstill questionable, but began to appear definitely after 10 months.Xerophthalmia and nyctalopia, although difficult to diagnose clinically, wereunquestionably present in 10 months and rather severe thereafter. Theseconditions increased in intensity until in many cases complete blindnessdeveloped, which was cured by massive doses of vitamin A.
On 30 August 1945, The Surgeon General established the"Board to Survey and Evaluate the Medical Problems of RepatriatedAmerican Prisoners of War Returning From the Far East." It isunfortunate that the men were not brought into this survey until, having beenreleased for varying periods of time, they had received therapy fortheir nutritional disturbances. Nevertheless, much can be gained by a reviewof the board's report.
For example, certain prominent signs and symptoms ofnutritional deficiency as obtained from the history were listed accordingto their
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incidence. Pellagra as evidenced by cheilosis, glossitis,stomatitis, dermatitis, and diarrhea was present in from 50 to 70 percent of thepatients. The incidence of pellagra was much greater in the Philippines. Only arare case, in fact, developed in Japan where the prisoners were sporadicallygiven soybeans to eat. Typical pellagrous photosensitivity dermatitis of theexposed parts was relatively infrequent. This in spite of the fact that the menwere constantly exposed to considerable sunlight.
The occurrence of a scaly, sometimes erythematous weepingdermatitis of the scrotum accompanied by extreme tenderness and, in somecases, edema was reported as being relatively common. Occasionally, scrotaltenderness without dermatitis occurred. About 55 percent of the patientswith a history of glossitis and stomatitis gave a history of scrotal dermatitis.Cheilosis occurred in five cases in the absence of glossitis and stomatitis.In three cases, glossitis and stomatitis occurred in the absence of cheilosis.
Beriberi was exceedingly prevalent in the group and occurredboth in Japan and in the Philippines. A history of "wet beriberi"(with massive edema) was obtained in 77 percent and a history of "dryberiberi" (without conspicuous edema) in about 50 percent. Many individuals had had both types. Often when wet beriberi disappeared,symptoms of dry beriberi developed. Usually, however, the latter precededthe former. Diarrhea was seldom present or severe during thephase of wet beriberi. Massive spontaneous diuresis often took place.
The clinical symptomatology of the dry beriberi wasstriking. Burning, hyperesthesias, and paresthesias were exceedingly severe,and in some camps hundreds of men would walk the floor during the nightbecause of severe pain. Feet were often soaked in ice water, cooled in thesnow, or exposed during the cold nights in attempts to alleviate the pain.The feet were so tender that even the slightest touch provoked severepain. In one case, a handkerchief was accidentally dropped on the foot of asleeping soldier. He immediately awoke crying out in agony. Often, just thevibration caused by some one passing within several feet of a soldier with dryberiberi was sufficient to aggravate the pain.
In the interesting summary of the board's report,it is noted that in many individuals, after the intake of a high-caloricdiet when they were first liberated, glossitis, stomatitis, and edema reappearedor become more pronounced. Anemia was observed in 52 percent of the first1,500 RAMP's studied and diminished appreciably in incidence as successive groupswere examined until it was found in only 35 percent, 6 weeks after thestudy was begun. The anemia was macrocytic in 73 percent, normocytic in 23percent, and microcytic in 4 percent.
The losses of weight ranged from 20 to 110 pounds.There was noted a remarkable ability to regain weight without correspondingimprovement in the fundamental nutritional state. Many patients hadprotuberant abdomens commonly called rice bellies, while their shouldergirdles and extremi-
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ties showed very marked wasting. The immediate results of anormal diet of American food in these people paralleled the widespreaddevelopment of a similar edema under similar circumstances in the Europeantheater. The reason was not clear to these observers who suggested, among otherfactors, that the diet contained more salt and fluid than that to which theprisoners had been accustomed. Although they associated the scrotal dermatitiswith the stomatitis and cheilosis, they were not at all sure that it was partand parcel of the riboflavin deficiency syndrome. This relationship has beensubsequently proved.
Almost without exception, the patients had suffered fromattacks of diarrhea at some time during their imprisonment. It is necessary todistinguish between the diarrhea that most individuals have from time to time innormal life and the true dysentery consisting of prolonged periods of watery orbloody stools. Of the prisoners, 1,359 had one or more attacks of truedysentery.
Japanese Prisoners of War
When the tide of battle had turned, with defeat after defeatfor the Japanese in the Philippine Islands in the springof 1945, these enemy troops, asevacuation from the islands presented difficulties, retreated into the hillsback of Luzon, breaking up into small groups and living off the land. Owing tothe hostility of the natives and the scarcity of eatable food in the mountains,these men suffered severe deprivation, particularly starvation phenomena.Coupled with this were the dysenteries, malaria, and other diseases indigenousto this part of the world-maladies that ordinarily deplete metabolic reservesof human beings.
After V-J Day, 2 September 1945, these isolated Japanesetroop units surrendered by the thousands to the U.S. Army. By early October,approximately 80,000 had beenconfined in New Bilibid Prison, Manila. Nearby was the174th Station Hospital, a 250-bed installation. This hospital was burdenedsuddenly with the care of approximately 5,700 of these returned Japanese, manyof whom were too ill even to move from their cots. It is reported that many dieden route on the troop trains that brought the prisoners in. It was decided,as recommended by the Chief Surgeon, AFWESPAC (U.S. Army Forces, WesternPacific), and by others, that a special study29shouldbe made of the clinical aspects of this severe malnutrition.
Considering the limitations of personnel and facilities andthe administrative pressures to evacuate these prisoners as rapidly aspossible, a remarkable amount of clinical observations with chemicaldeterminations were made in these cases of starvation. A special ward wasset up to handle a selected group of 24 of the most severely starvedpatients. This group was
29Schnitker, M. A.: A Study of Malnutrition inJapanese Prisoners of War. [Official record.]
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then subdivided into two groups, one of which contained 12patients with massive edema, the so-called wet beriberi, and the other with 12patients without edema, the so-called dry beriberi. All the patients were malesbetween the ages of 25 and 35 years of age.
A large proportion of the patients being studied had begun tolive on their starvation diets during March, April, and May 1945 and began toexperience their difficulties in July, August, and September, approximately 3months for the onset of severe symptoms. From the history, it was calculatedthat their diet was about 800 to 1,000 calories a day, at best. At least three-fourthsof these patients gave a history of having had malaria, and two-thirds had ahistory of diarrhea before capture. It was estimated that loss of weightwas approximately 40 to 50 pounds per person during the period of escape tothe hills. Severe weakness was a complaint common to all. Those patients withedema complained of dyspnea, whereas only one-third of those without edemahad dyspnea on exertion.
The physical findings were somewhat varied. In the edemagroup, the patients had moderate to very marked edema, which was greatestin the abdomen and the lower extremities. Three of this group escapedhaving pleural effusion, but all had evidence of pulmonary congestion. Incontrast was the lack of edema in the "skin and bones" group.Although the history showed that practically all the patients, includingthese, had had edema in variable degree at some time beforehospitalization, only three of the second group had any edema at the time ofselection for study and on initial examination, and this was very mild,limited to the feet.
The skin was dry, loose, and atrophic, and most of thepatients showed hyperkeratosis, particularly over the anterioraspects of the thigh. No definite cutaneous manifestations of pellagra werefound, and no cheilosis. There was evidence of pigmentation over pressurepoints and other areas. Only four of the patients had severe atrophy andcolor changes of the tongue that would be indicative of the vitamindeficiency syndromes. Further examination revealed no grossly enlargedhearts; roentgenographic measurements were well within the dangerratio. Auscultation found the heart sounds for the most part impure anddistant with an accentuation of P2, particularly in the edematousgroup. The pulse was labile and tended to be rapid and considerablyincreased by even the slightest exertion. The blood pressure was normal tolow, in the cases of "dry beriberi" ranging from 80 to 105 mm.Hg systolic and from 50 to 85 mm. Hg diastolic; in thosewith "wet beriberi," ranging from 100/60 to 130/90 mm. Hg.Control groups observed simultaneously also had low blood pressure withsystolic readings of from 80 to 100 mm. Hg and diastolic readings varyingfrom 45 to 80. Neurological examination revealed no definite pattern.Disturbances and abnormal sensations were found principally in the lower extremities in seven of the whole group. Thevibratory sensation wasintact in all the patients. No frank paralysis was observed, althoughweakness,
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particularly of the quadriceps, was evident. All patientsshowed generalized muscular wasting. It was difficult or impossible to elicitthe deep tendon reflexes, particularly in the lower extremities. Of particularinterest was the high incidence of malaria which was, of course, to be expected,and yet none of the 24 patients during the entire period of observation had apalpable spleen. Laboratory findings were variable too. The greatest percentageof positive findings was observed in the hematological studies. Therewas a considerable amount of anemia in the entire group, ranging frommoderate to severe and responding only slightly to iron therapy. Five of thepatients showed erythrocyte counts under 2.5 million cells. The anemia wasdetermined to be microcytic and hypochromic. The smears showed stippling andsome toxic granulations of the white cells. Although four-fifths of thesepatients had intestinal parasites, only one-quarter had an eosinophilia above 4percent. The hematocrit was distinctly lowered in both groups. In theedematous group, the readings ranged from 21 to 44. In the group without edema,the range was from 16 to 41. The sedimentation rate (Wintrobe) was uniformlyelevated.
Bacteriologic cultures from rectal swabs were repeated threetimes. All cultures were negative for the typhoid, paratyphoid, and dysenterygroups with the exception of three patients who showed, respectively, Shigellaparadysenteriae, Boyd P 274; Salmonella enteritidis; and Sh.paradysenteriae, BoydP 275. The diarrhea eventually ceased spontaneously in the first few daysof treatment with rest and diet. New antidiarrheal drugs were used.
The serum proteins, albumin and globulin and the ratio ofalbumin to globulin, were determined on each patient at weekly intervals. In theinitial studies, all values were low. In the cases of "wet beriberi,"the total serum protein averaged 4.48 gm. per 100 cc. of blood with a range offrom 3.4 to 5.3 gm., as compared to an average in the cases of "dryberiberi" of 4.75 gm. with a range of from 4.0 to 6.1 grams. The albuminfraction in the edematous group averaged 1.96 gm. per 100 cc. of blood ascompared to 1.87 gm. in the nonedematous group. The globulin fraction wasslightly higher in the latter group, the average being 2.77 gm. per 100 cc.as against 2.51 gm. in the former. The albumin-globulin ratio in the group withedema averaged 0.810 and in those without edema, averaged 0.675. Oral glucosetolerance tests were done on all patients except two. This was the standard testof 100 gm. of glucose. After determining the fasting blood-sugar level, bloodsamples were collected at 30, 60, 120, and 180 minutes. Six patients altogetherhad flat curves; that is, the peak did not rise above 120 mg. per 100 cc. ofblood. In each instance, the fasting bloodsugar was on the low side; all wereunder 90 milligrams. Circulation times were determined by the arm to tonguetechnique using calcium gluconate. The results were allnormal, that is, 12 to 18 seconds, except for one patient with dry beriberi, who had a circulation time of 10 seconds. Studies of
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venous pressure, using a spinal manometer showed markedvariations. The readings varied for the most part between 50 and 150 mm. ofwater. Six patients with wet and five patients with dry beriberi had readings ofover 100 millimeters. Cardiac failure had not played a part in the edematousgroup, since there was little difference in the venous pressure readings of thetwo groups.
Electrocardiographic tracings, made in all these cases,showed consistently low voltage and minor T wave changes. Liver function testsfailed to reveal any remarkable changes, but the majority retainedBromsulphalein (sulfobromophthalein) longer than usual. A gastric analysis wasdone on each patient to determine the presence of free hydrochloric acid in thegastric juice. Only three of the patients, two edematous and one not, had freeacid on the first test.
Five autopsies performed on the patients who died ofmalnutrition alone, of whom there were seven studied, showed a marked atrophy ofall the viscera. The fat deposits were gone; the skeletal muscles showedwasting; the hearts weighed from 150 to 200 gm.; the livers weighed from 525 to1,000 gm.; and the kidneys, from 75 to 100 grams.
All these patients had fever at one time or another. Thisvaried from isolated spikes to continuous fever with temperatures as high as100? to 101? F. Thick and thinsmears for malaria were made on all patients at least four or more times, and 15were found to be positive.
The observers noted further that in cases of both wet and dryberiberi, edema was a clinical finding which varied moderately from time to timeduring the period of observation and treatment. They thought that this mighthave been influenced by the intake of the salty soybean sauce which all thesepatients insisted upon eating. This observation may be correlated with thefindings in the European theater where there was practically no edema duringtreatment in patients on diets in which salt was a rare component. (See pages274-275.)
Troops and Civilians in the Pacific
An intensive study of the nutrition of 111 full-duty troopsin the Manila area in July and August 1945 is described in a report dated 20October 1945.30 Chemical determinations showed considerable variations in thenutritional status of soldiers living in this environment on the basic Armyallowance. Although the ration was appraised as apparently adequate fornutrition, it was found that-
1. Twenty-five percent of the subjects were in a state ofpartial depletion with respect to sodium chloride.
30Letter, Capt. Eliot F. Beach,SnC, Nutrition Officer, 26th Hospital Center, and 1st Lt. Oscar N. Miller, SnC, 248th General Hospital, to CommandingOfficer, 26th Hospital Center, APO 75, 20 Oct. 1945, subject: Chemical Determination of Nutritional State of FullDuty Troops, Manila Area, July and August 1945.
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2. Plasma protein concentrations were normal and no seriousdeficiency of hemoglobin existed, although 16 percent were slightly below theaccepted normals.
3. Twenty-five percent had concentrations of vitamin C below0.4 mg. per 100 cc. of blood, but no prescorbutic states were observed.
4. Nine percent appeared to be rather seriously depleted ofthiamine, and 6 percent were classified as seriouslydepleted of riboflavin.
From the results, it was concluded that, in low-scoresubjects partially desaturated with respect to the vitamin B complex, there is ahigher incidence of the nonspecific signs of lowered health, resistance, andsense of well-being. The experiment in itself was not conclusive, but it showedan enthusiasm on the part of the personnel for a better understanding of theproblems involved.
A more extensive survey31 ofnutrition in the Armed Forces in the Middle Pacific was carried out duringApril-June 1945 by a special team appointed by The Surgeon General. The teamreported that physical examination revealed no cases of classical nutritionaldeficiency diseases such as scurvy, beriberi, ariboflavinosis, and pellagra.
A significant percentage of men in each place surveyed showedone or more physical findings that some medical nutritionists haveconsidered to be associated with specific nutritional disturbances. OnGuadalcanal, vitamin C intake was low, as was the urinary excretion of ascorbicacid. Here, a significant amount of acute inflammation of gingival margins andswelling of interdental papillae were observed. Biochemical tests showed adeficient riboflavin excretion in 8 percent of the subjects on Guam, in 9percent of the subjects on Iwo Jima, and in 6 percent among the casualties fromOkinawa. Occasional single cases of deficient excretion of thiamine wereobserved. It was concluded that the basic nutritional status of the troops inthe areas surveyed was essentially good. The survey in the Pacific Ocean Areawas conducted on garrison troops in Hawaii, Guadalcanal, Guam, and Iwo Jima.Some casualties from Okinawa were studied on Guam and Saipan.
Again evidencing the interest of the medical personnel innutritional disturbances is a report, "Preliminary Vitamin C Survey,"from the 19th Medical Service Detachment (General Laboratory), dated 26 February1945. The levels of vitamin C in the blood plasma and the urinary excretion ofvitamin C for 24 hours were determined on a group of men from two bases in NewGuinea. No evidence of scurvy was found among the subjects, even those with lowconcentrations of vitamin C in the blood. Of 34 subjects whose blood wasanalyzed, only 3 showed levels in the plasma of 0.2 mg. ascorbic acid or less.
31Letter, Maj. William B. Bean, MC, Capt. Charles R. Henderson, SnC, Robert E. Johnson, M.D., and Capt. Lyle M. Richardson, QMC, to The Surgeon General,Washington 25, D.C., 22 Aug. 1945, subject: Nutrition Survey in Pacific Theater of Operations.
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In a very interesting report32from the 369th Station Hospital on the nutritionalstatus of civilians, it is noted that about 3 months after the invasion ofSaipan there was a marked change in the type of civilian patients admitted tothe hospital. During the battle and for some time thereafter,the vast majority of patients were new and old battle casualties. InSeptember 1944, the medical admissions began to exceed the surgical. Thesepatients were admitted for peripheral edema, with and without ascitesand hydrothorax. Many of them had muscular weakness, particularly difficulty inraising from a squatting position, and other complaints.
The clinicians at the 369th Station Hospital were skepticalof the diagnosis of beriberi. On therapeutic trial withvitamin B1 in massive oral and parenteral doses, there was nodramatic improvement. Patients did improve after continued hospitalization on anadequate diet. A dietary review indicated that they had been subsisting on rice,a few greens, onions, and about an ounce of fish a day. It was felt that theedema might be due to hypoproteinemia. A number ofautopsies were performed and in no case could the diagnosis of beriberi beconfirmed by the gross findings. A series of total serum protein determinationswere carried out with the Van Slyke copper sulfate technique. Of 89 civilianpatients with edema studied with respect to their serum proteins, 77.5 percenthad values below the critical level for edema and only 5.5 percent were withinnormal limits. A series of children without edema revealed values only 4.8percent below the critical level for edema. From the study, it was concludedthat the cause of edema in the civilian population in Saipan was hypoproteinemiasince, although the existence of beriberi could not be excluded, the criteriafor a beriberi diagnosis were not satisfied.
In the Philippine Base Section, the clinicians of the 168thEvacuation Hospital conducted an interesting project innutritional research33 when it became apparent that civilian personnel in thehospital locale (Puerto Princesa, Palawan, Philippines) presented a healthproblem, basically because of nutritional deficiencies, malaria, tuberculosis,and, of course, the intestinal parasites.
The population of the province isessentially rural, and had been in part nomadic,migrating from one region to another according to the crop seasons. Duringnormal times, the diet consisted chiefly of rice, fish, corn, tuberous plants,and lesser amounts of pork, poultry, and eggs. With the occupation by theJapanese, the supply of cultivated products was almost entirely cut off fromcivilians, the great majority of whom isolated themselves in the barriosscattered throughout the hills. These people when they returned to theirliberated community presented a most distressing evidence of nutritionaldeficiencies, comparable to the Japanese troops who
32Essential Technical Medical Data, U.S. Army Forces,Pacific, for October 1945. Appendix I, Hypoproteinemia in Saipan Civilians.
33Quarterly Report, 168th Evacuation Hospital, for periodJanuary-March 1945, dated 1 Apr. 1945.
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had escaped to the hills. Numerous cases of frank beriberi ofthe wet type were seen. There were several deaths of individuals with markededema. The nutritional repair or rehabilitation of the Filipino civiliansrequired special attention because of their racial predilections. The regularArmy food was unpalatable to them, and the majority developed such acutegastrointestinal disturbances that the nausea or vomiting seemingly interferedwith their progress. This, of course, was common experience in other occupiedlands.
Troops in India
The establishment of a theater of operations by the U.S. Armyin India and Burma presented subsistence problems notencountered in other parts of the world. Here, we were notinvading a hostile country where food could be requisitioned and where supplylines could be appropriated and spread out. We were considered as guests in adensely populated Allied country in the throes of its own political problems. Alarge portion of the population was on the brink of a great famine, which was todestroy by starvation a million and a half people in 1943. The troops could notbe concentrated in any well-defined area, but by military necessity werescattered in small groups separated by thousands of miles. The lines ofcommunication between these groups when existent were extremely primitive.
The first troops arrived in India from the United Statesearly in 1942. No adequate provision had been made for the continuous supplyingof these soldiers with food from the Zone of Interior. A reserve stock of B-rationshad been sent to the theater, but these were not to beused except in emergencies. The original plan was to maintain these troops onsupplies obtained from local markets and from rations obtained through theBritish Army. By October 1942, the theaterpolicy was adopted, prescribing a ration to consist of the field service rationof British troops obtained through the Royal Indian Service Corps andsupplemented by local purchase of fresh supplies and by the issues of excessstocks of the reserve B-rations. Experience showed that the British ration wasnot suitable for U.S. troops because it included such items as pork, soya,links, corned beef, and mutton, and it was largely not eaten. The British Army'smilk allowance was only 2 ounces of tinned milk per man per day, which was notconsidered adequate for U.S. troops. No fresh milk was available because of theunsanitary conditions under which it was produced. Owing to the localprohibition against the slaughter of bullocks in good health, the supply of meatwas very poor.
Medical officers began to report a reduction in theefficiency of the command which they attributed tomalnutrition. A large proportion of the troops reportingfor sick call complained of weakness, insomnia, lassitude, and gastriccomplaints suggestive of a deficiency state. An increase in the occurrence ofgingivitis was observed.
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Early in the experience of the Americans in this theater, aninteresting outbreak of a nutritional deficiency disease occurred in the form ofberiberi among the Chinese troops at the Chinese Training Center at Rāmgarh,India. Between 8 August and 25 September 1943, 199 patients were admitted to the48th Evacuation Hospital with beriberi as the primary cause of hospitalization.Many others were treated as outpatients. They had other symptoms of deficiencydiseases such as night blindness, cheilosis, glossitis, and osteomalacia, Achange in the ration was made, and undermilled rice was substituted for thepolished rice. With this change, the nutritional disturbances disappeared.
Maj. Frank B. Cutts, MC, reported on 125 cases of beriberiadmitted to the 48th Evacuation Hospital during an 11-week period, from lateJuly to October 1943.34 All the patients were Chinese soldiers. It isinteresting to note from Major Cutts' report that in the first patientsobserved the diagnostic evidence was considered obscure, and many of them wereadmitted as having rheumatic fever, rheumatic heart disease, phlebitis, andnephritis. A summary of the clinical observations made by Major Cutts follows.
History.-Most of the patients had three major complaints:(1) Shortness of breath on slight exertion; (2) swelling of the legs-lessoften of the genitalia-hands, and face; and (3) numbness of the legsand muscle pain on walking. Less frequent complaints were palpitations,precordial pain, upper abdominal distention, and numbness of the arms. Most ofthe patients had been sick at least 1 to 3 weeks before presenting themselves tothe hospital. In many instances, it was noted that acute bronchitis, diarrhea,or vaccine injections apparently precipitated the acute manifestations.
Physical examinations.-These patients were big, husky men withno evidence of caloric malnutrition. They showed little or no fever.Examinations of the tongue and mouth revealed some instances of cracking and scalingat the corners of the mouth which were ascribed to riboflavin deficiency. Therewas definite engorgement of the veins in the neck. The heart was almost alwaysenlarged. With the patient sitting on the edge of the bed, the left quarter ofthe area of cardiac dullness was consistently 1 to 3 centimeters outside thenipple line. The heart rhythms were usually regular with a rare extra systole.Rates varied from 58 to 120 beats per minute. The first heart sound was loud andbooming, and often there was a gallop rhythm at the apex. Systolic murmurs ofmoderate intensity were heard at the apex and along the left sternal border.There were no diastolic murmurs. Examination of the abdomen revealed anoccasional ascites.
Edema of the legs was almost constantly found varying fromone to four plus. This edema involved the genitalia and extended up over the
34Cutts, F. B.: Observations on Beriberi. FieldMedical Bulletin, Headquarters, Services of Supply, U.S. Army Forces,China-Burma-India,vol. 2, No. 12, December 1943.
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back. Muscles of the calf in most instances were normal. Kneejerks and ankle jerks were usually absent. There was a marked hypoesthesia topinpricks of the lower extremities.
Treatment.-This consisted of bed rest with the regularhospital diet and an autolyzed yeast product rich in vitamin B1, orvitamin B1 itself.
Course in hospital.-Asa rule, the patients showed prompt improvement. Dyspnea disappeared in 2 or 3days. The heart rapidly shrank to normal size, the left border receding to 1 to3 centimeters in the course of the week. Diminution in size was checked byserial chest X-ray plates in a few cases. Heart murmurs and other abnormalsounds were not heard after about a week. Edema of the legs and turgidity of themuscles of the calf were generally gone after from 5 to 7 days of treatment.Numbness, insensitivity to pinprick, and lost reflexes were more persistent andin some instances were but little improved in 6 weeks. In general, the patientswere sufficiently well to return to duty in from 2 to 3 weeks. When theautolyzed yeast was withheld, improvement occurred in approximately twice thetime required by the patients treated with the yeast, and complete relief ofsymptoms was usually not obtained until the vitamin B concentrate was given.
One death was reported of a 25-year-old soldier who wasadmitted complaining of marked shortness of breath for 3 days. The respiratoryrate was 35 per minute and the temperature was 99? F. Engorgement of thecervical veins was evident. The heart was enlarged two plus, and auscultationrevealed a loud gallop rhythm. The pulse could not be obtained in either wrist.The apical heart rate was 96. The patient remained pulseless and died 12 hoursafter admission. As the cause of his illness was not recognized at entry, he wasnot given any parenteral B1. Autopsy showed generalized congestionand edema of the internal organs. The heart was dilated and distinctly flabbybut otherwise normal to gross examination. One ascaris worm was found wanderingin the intrahepatic viaduct.
Etiology.-Most of these patients camefrom one regiment. An investigation revealed that this regiment had been storingrice over and above their daily requirements. In July, with the onset of wetweather, realizing that the rice would spoil, the unit drew no new rice andbegan to consume its stored surplus. A sample of the rice was obtained and foundto be gray, lusterless, and devoid of any of the pericarp. When the old rice wasdiscarded and new rice obtained, the incidence of beriberi in this unit nolonger exceeded that in other units in the area.
Early in 1944, Colonel Howe, on a visit to China-Burma-India,attributed the inadequacy of the Army rations to attempts to live off the land,to dependence on British supplies which were often not available or notacceptable, and to the failure or inadequacy of transportation.
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CONCLUSION
Throughout the individual reports from all theaters ofoperations, one finds an overemphasis on the failure of the packaged rations.The principal deficiency seems rather to have been in thebriefing of the personnel who were responsible for thenutritional status of the troops in the field in the several theaters. In somequarters, there was failure to comprehend that the most important aspect ofrations for the troops was first to supply calories, next protein, and thirdly,the micronutrients or vitamins and minerals, always presupposing, of course, asufficiency of potable water. Indeed, a review of the prewar debate in theNutrition Committee of the National Research Council shows a somewhatunrealistic approach to the problem in the light of later experience. In thefuture, it would seem wise to include either a field officer or a medical ornutrition officer with field experience at any level of discussion concernedwith the feeding of troops. A review of ration tests in the United States showsthat those who designed them and observed the results had a better appreciationof the problems of nutrition and survival under the various conditions that warmay impose.
In the field, there was a tendency for command, endorsed tosome extent by the medical personnel, to ascribe to nutritional deficienciesalmost any condition that was not otherwise explicable. Medical officers ingeneral showed an uncertain grasp of nutritional problems. The EssentialTechnical Medical Data reports indicate their lack of training in this respect,and show, as well, their eagerness to learn.
In World War II, and subsequently in the Korean War, therewere failures by command to distinguish properly between a resting prisoner anda working prisoner. In both wars, there were instances when extra food was notissued to compensate for calisthenics or work done within prisoner-of-warenclosures although considerable extra effort-output might beinvolved. Again, there was at first a failure to allow for the nutritionalrequirements of different age groups, and German prisoners from 14 to 19 yearsold, conscripted by the Wehrmacht in the last phase of the war, werefound faring badly on rations designed for adults in the age group of21 to 35 years.
Briefing of personnel on nutritional requirements withrespect to actual work done and to age, sex, climate, andother relevant factors must be improved before the Army can expect wholeheartedand effective cooperation from the field staff.
RAMP'S IN HOSPITAL
The medical officer assigned to the Nutrition Branch visitedthe chiefs of the medical services of all major hospitals concerned with thetreatment of the RAMP's. On 24 May 1945, at the 179th General Hospital, Col.George B. West, Commanding Officer, and Lt. Col.
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Oza J. LaBarge, Chief of the Medical Service, Maj. Henry J.Babers, Chief of the Surgical Service, and Capt. Sidney Small, Chief of theX-Ray Service, gave the following information:
More than 800 RAMP's were admitted between the middle ofApril and the last week in May. About a third were admitted directly to thishospital, and these were for the most part men who had been captured in the Battle of the Bulge andimprisoned in Stalag IX-B at Bad-Orb (mostly enlisted personnel) or in Stalag IX-A at Niedergrenzebach, near Ziegenhain, (mainly noncommissionedofficersand men). Those from Stalag IX-B were in the worst condition of all. They saidthey had seldom received Red Cross packages. As estimated from theirhistories, their average loss of weight during captivity was 39.1 pounds perman at Bad-Orb, and 28 pounds per man at Niedergrenzebach. One patient had lost115 pounds.
Of the total number of patients, 198 had hepatitis; pulmonarytuberculosis was suspected in 14 and proved in 11; diphtheriawas found in 8. The diagnosis of severe malnutrition was made 188 times. Theaverage erythrocyte count for the entire group was 3,600,000; the averagehemoglobin concentration was 60 percent; the average total serum proteins were6.2 gm., with a range from 2.7 to 7.6 grams. These were determined by the coppersulfate method. Hemoconcentrations and hematocrits were not done. Of stoolcultures in 283 cases, 6 were positive-2 for Shigella paradysenteriae and4 for the Flexner types of this species; practically all 283 men had diarrhea.Gastrointestinal studies made on two of these patients were negative. All,including the six with positive cultures, cleared on dietary management withoutspecific hemotherapy. Cardiac study revealed no actual cases of beriberi heart.The majority showed very low blood pressure. Electrocardiographic tracings,made on a number of patients, almost universally showed low voltage Z-R-Xcomplexes and low excursion or very flat T waves. There were 30 cases ofnutritional edema, which cleared up on a regimen of bed rest and specialdiet. Basal metabolic rates were not determined. No manifestations of scurvywere found in these patients.
Of the 283 patients with diarrhea, 42 were fed by thegravity-drip method with the special mixture of powdered milk and powdered eggssuggested by the Nutrition Branch, Office of the Chief Surgeon. Others weregiven this mixture orally in six feedings daily. Intravenous therapy of anykind was found to present many difficulties, with two types of reactions notedduring or after administration: The one, circulatory relapse; the other, chillsand fever. The standard treatment for the patients with malnutrition in the179th General Hospital was tube feeding of the high-caloric liquid protein dietby gravity drip, vitamin therapy, and occasional plasma or blood transfusionor oxygen, when indicated. Four deaths occurred on the Medical Service. Anautopsy of one of the patients showed a marked redness and congestion of theentire gastrointestinal tract.
The Surgical Service reported that from 150 to 200 RAMP'swere admitted to this service. They were found to be very poor risks, reactingto surgery more like the German prisoners of war than the average Americansoldier. There was one death on the service. This patient was operated upon fora perforated peptic ulcer, but at operation no ulcer was found and autopsyrevealed that the patient had died from congestive heart failure.
In these RAMP's, wound healing and healing of ulcers orinfections at first was very poor. Under proper diet and vitamin therapy, thechief of service noticed improvement in healing. The X-Ray Service reportedevidence of marked distention of the large bowel in a large percentage ofthese patients. The pulmonary abnormalities as revealed by X-ray in these earlygroups were increased bronchial vesicular markings, very prevalent; atypicalpneumonias, very frequent; and tuberculosis, not uncommon.
The 77th Field Hospital was visited on 26 May 1945. Thediagnoses made from 12 through 18 April were malnutrition 94 times andgastroenteritis 82 times; from 16 to 19 May, they were malnutrition 122 timesand gastroenteritis 6 times. Plasma therapy was used on 166 patients. Of these,19 experienced severe reactions as follows: Five patients
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developed pulmonary edema and of these two were in extremelycritical condition; two patients developed chills and fever with nausea andvomiting; eleven had chills and fever; and one, a simple urticaria. Again,diarrhea was an acute problem. Therapy was the liquid egg and milk mixture givenby mouth; the gravity-drip method was not used at this hospital. Response totherapy was considered excellent. The X-Ray Service, under Capt. Russell D. D.Hoover, reported that of 2,750 RAMP's examined roentgenographically 16 or 0.58showed tuberculosis; 64 or 2.2 percent, atypical pneumonia; 13 or 0.45 percent,lobar pneumonia; 9 or 0.33 percent, pleural effusions; 4 or 0.14 percent,pulmonary edema; and 43 or 1.56 percent showed foreign bodies, fracturedribs, and so forth.
The 97th General Hospital reported through Maj. Kelse M.Hoffman, assistant chief of the Medical Service. Loss of weight and listlessnesswere the major presenting symptoms of their patients, a group on the whole notin very bad condition. Only about 20 enlisted men were considered to beseriously ill. The average loss of weight in the whole group was only 15 poundsand was regained in 2 weeks of therapy. Again, the major problem wasgastrointestinal disturbances commonly due to dietary indiscretions. Stoolexaminations on all these patients showed no pathogenic micro-organisms. Afterpublication of Circular Letter No. 36, the chief of the Medical Service notedthat the gastrointestinal symptoms diminished markedly. No specific vitamindeficiency syndromes were noted, although several cases manifested tenderness ofthe calf; a few developed edema after treatment, and the deep reflexes in thelower extremities were diminished or absent.
At the 129th General Hospital in the 804th Hospital Center,Whitchurch, England, Lt. Col. Herbert W. Rathe observed very few seriously illpatients. Specific classical syndromes of vitamin deficiency were not seen, butedema was frequent. The blood protein studies in the Center were not conclusive.The patients who were admitted early all had severe diarrhea, but stoolexaminations were basically negative. The outstanding problem here was the lackof strength persisting for weeks after the return of a good general appearance.Electrocardiographic tracings showed T wave and voltage changes similar to thatreported by other hospitals, with a return to normal in several weeks.
At the 91st General Hospital, 15th Hospital Center, Oxford,England, Lt. Col. Adolph R. Mueller reported that losses of from 15 to 45 poundswere the presenting problem; also, that the Red Cross insisted upon servingchocolate bars on the wards with resultant gastrointestinal problems.Approximately 25 percent of the first admissions presented edema; othersdeveloped edema in the course of hospital therapy. The diarrhea, as in otherinstallations, was the biggest problem. The acute gastrointestinalsymptomatology generally followed the consumption of rations. In this group,several patients were seen with specific deficiency manifestations, such ascheilosis, tongue changes, and stomatitis.
At the 83d General Hospital, Whitchurch, England,approximately 250 RAMP's were admitted, most of whom were not consideredseriously ill. Diarrhea again was the commonest of all findings but became aminimal problem after Circular Letter No. 36 was put into effect. Edema was veryevident in many of those admitted. Serum proteins were considered to bedefinitely low, although the specific figures were not made available. Moderateanemia was the usual finding. Glossitis, cheilosis, and other specific symptomsof the mucous membrane were noted very frequently. Paresthesias were common,particularly of the glove-and-stocking type, with dry, scaling skin. Serialelectrocardiographic studies were made.
Among these RAMP's, there were eight severely ill patientswho manifested a loss of from 60 to 101 pounds in body weight. These men had beencaptured at the time of the Battle of the Bulge. Their appetite was good, butdiarrhea was precipitated by a full diet. The electrocardiographic tracingsshowed low T waves, flat or inverted in I and IV low amplitude PQRS. There wereno conduction problems. Serial tracings showed a reversal to the normal patternin the course of the first 2 weeks. Serum proteins in this small group averaged5.2 grams. Red blood cells ranged from 2.5 to 3.5 million with a marked poly-
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chromia. The type of anemia was amacrocytic. Again, in thishospital, chill reactions and febrile reactions frequently followed transfusionsof plasma. Multiple neuropathies, hyperactive reflexes, and ataxic gaits werenoted in two of these patients. Alopecia was observed, but responded to simplediet therapy. Rapid gain in weight in six of the patients, amounting to from 30to 40 pounds in five days, was obviously due to the development of an edema.About 10 percent of the patients admitted to the 83d General Hospital wereconfined to bed.
The 217th General Hospital in Paris cared for a great manyRAMP's. Out of 1,098, there were 665 admitted to the Medical Service, of whom275 were more than moderately undernourished. A survey revealed the followingsymptoms: There was of course marked loss of weight in all 275; a scalyskin in 186; glossitis described as a clean tongue with a smooth edge, brightred, in 100 patients; diarrhea, with negative stool cultures, was noted in 76patients; muscle tenderness in 75; a very marked cachexia and asthenia in 67;hypoactive reflexes in 37; cheilosis was observed 30 times; edema and ascites,24 times; polyneuritis, 12 times; night blindness occurred in 6 patients;scurvy, including gingival hypertrophy with bleeding plus petechiae andincreased capillary fragility, was seen three times. Twenty-five of the patientswho had diarrhea, nausea, anorexia, or vomiting were selected for X-raystudies of the digestive tract. Six of them showed the so-called small-boweldeficiency pattern manifested by dilatation of the small intestine,especially the jejunum, fluid levels resembling obstructions, clumping andsegmentation of barium with hypomotility. The barium meal progressed only as faras the distal end of the jejunum in 6 hours. On reexamination 2 weeks later,considerable improvement was noted. In the fatal cases of malnutritionobserved at this hospital, there were no gross or microscopic changes in theesophagus, stomach, or small bowel. Parenthetically, it should be noted that inthe brain of a patient examined at autopsy numerous focal necrotic lesions wereobserved.
In all theaters of operations, the problem of therepatriatedprisoners, not only the Americans but also the friendly nationals, was ofextreme importance. In the European theater in particular, their conditionpresented a major medical catastrophe. As an example, a letter dated 3 April1945 from Lt. Col. Theodore L. Badger, MC, Senior Consultant for Tuberculosis,ETOUSA, to the Chief Medical Consultant, ETOUSA, notes that, on 17 December1944, 304 tuberculous Russian and Italian recovered prisoners were sent to the50th General Hospital without advance information. Of these patients, 4 arriveddead, and, as of the date of the letter, an additional 85 had died of advancedtuberculosis.
This group of tuberculous patients was similar to those seenwhen the 46th General Hospital was visited in the middle of March. There wasremarkable improvement in these people in the course of their hospital staywith the gains in weight reaching 45 pounds in the first 3 months. The signs ofnutritional deficiency disappeared very rapidly, and the group as a whole beganto look in moderately good health. Of the first 50 who died, it was noted thatthe average stay in the hospital was only 9 days, their average age wasapproximately 26, their average weight on admission was 110 pounds. The durationof involvement, however, was 8 months, and in 100 percent the involvement wasbilateral. This would indicate that the bulk of the destructive effects of thedisease occurred before the men were hospitalized in the American installations.The treatment was to increase the food given these people, allowing them 1? hospital rations per person. Artificialpneumothorax was instituted in at least 30 cases with excellent results. In aletter dated 30 March 1945, to the Office of the Chief Surgeon, Colonel Badgerhad reported as follows: As of 29 March, 1,676 patients of recovered Allied militarypersonnel were admitted to the 46th General Hospital. Of these, 1,251 wereRussian; 102 Yugoslavian; 72 were French; 22, Italian; 6, Polish; 5, Turks; and 15 were Germans. Asurvey indicated that at least 40 percent had active tuberculosis. Of these, 50 percent werein a far advanced stage, 40 percent moderately advanced, and only 10 percentwere minimal. Twenty-seven of the patients were seriously ill, and 20 hadalready died.
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This group of patients had worked in forced labor in the coalmines under German control, reportedly in shifts of 6 hours on and 6 hours off,24 hours a day, 7 days a week without interruption. The chance of contagion wasmagnified by the ignorance of the patients and by the complete absence ofpersonal hygiene. Here we see a prime example of the superimposition oftuberculosis on malnutrition and the attendant remarkably high death rates.
AUTOPSY FINDINGS IN PATIENTS DYING OF STARVATION
The writer performed autopsies personally in concentrationcamps in Austria. A summary of his findings follows.
Tongue
Sections of the epidermis of the tongue examinedmicroscopically show moderate atrophy of the lingual papillae. Bacteria inlarge, dark-staining clumps are seen in the crypts and on the surface of theorgan. In two cases, there are focal collections of dense basophilic roundbodies, somewhat larger than cocci, incorporated in the parakeratotic layer,which resemble Monilia. In another section, there is, in addition, focalepithelial invasion by branching septated mycelia. These changes perhapsrepresent an early sprue.
In three sections, there is a slight to moderate increase inthe parakeratotic epithelial layer. All cases display some intracellular edema,and one case demonstrates a superficial acute inflammatory reaction in the parakeratotic layer.
Nerves
Slight demyelinization of the nerve trunks, and an occasionalarea of basophilic degenration, are seen in all sections. The intraneurolemmaledema is not so apparent as in the sections of the skin. (See also pages 289and 291.)
Lingual Glands
Of the 11 sections studied, 8 reveal lingual mixed-typeglands. In one case, the glandular parenchyma is atrophic, with increase in theintra-acinar connective tissue.
Thyroid Gland
In 9 of the 11 sections studied, there is apparent a slightto moderate decrease in the colloid content of the acini. In one, thecolloid is abundant; in the rest, appears normal in amount.
In two cases, the fibrous stroma about the acini isincreased, with scattered focal accumulations of lymphocytes prominent in onlyone case. Epithelium is in all cases of the low cuboidal type and in it ishyperplasia. In one section, there is seen a small rounded true adenoma, benignin character.
Heart
Few changes are present in the 10 heart sections. The mostappreciable is the decrease in subepicardial fat, which in many cases has theappearance of fetal adipose tissue. It is pronounced in only five cases. Threecases display moderate fatty degeneration of myo-
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cardial fibers, and three cases could be classified asbrown atrophy. In one case, there is slight increase in interstitial myocardialfibrosis, with hypertrophy of individual solitary myocardial fibers.
Pancreas
In seven sections, changes in the pancreas are for the mostpart not prominent. All sections reveal the presence of symogen granules andbasophilic substance. One slide shows slight hydropic degeneration of acinarcells, and one displays marked post mortem degenerative changes. There is asignificant increase in interlobular and intralobular fibrous tissue in onecase, and in three others there is an apparent increase, incident tointerstitial edema. In general, little fat is associated with any of thesections.
Islets are in general small, with decrease in thenumberof both A and B cells, and hyperchromatism of some of the nuclei. A fewislets are swollen and edematous, with disruption of islet cells and slightincrease in fibrous tissue within the islets and surrounding them.
Skin
Epidermis.-All six sections displaymarked atrophy of the epidermis, often reduced to a thickness of one to twocells. There is moderate intracellular edema in all cases, particularly in thebasal epithelial layer. Pigment distribution is not unusual, and pigmentation isnot excessive. Three of the cases demonstrate minimal edema of the dermalpapillae, and two display slight inflammatory reaction about the superficialvessels of the derma. In all, the sweat glands are small and inactive inappearance, often with large vacuoles occupying most of the cytoplasm of thecells, as if they were in a stage of metaplasia into sebaceous epithelium. Thelumina contain granular debris.
Peripheral nerves.-In five of the six sections, theperipheral nerves located in the derma and subcutaneous tissue display amoderate edema within the neurolemma sheaths. Usually, the nerve fibers appearunaltered, although, in an occasional nerve, there is demyelinization andbasophilic degeneration of the reticular supportive connective tissue. Thereis no inflammatory reaction about the nerves. Dermal arterioles are unchanged.
Subcutaneous fat.All six sections show atrophy ofsubcutaneous fat. In all, the lipoid is practically depleted from the adiposetissue cells, so that they closely resemble embryonic fat. The fat is wellvascularized.
Hair follicles.-Other dermal appendages are decreased innumber. Hair follicles are maldeveloped, and often the hair shaft is degenerate.
Adrenal Glands
In two of the nine sections, ante mortem changes are maskedby marked post mortem autolytic changes.
Periadrenal fat.-All nine cases display advanced atrophicchanges in the periadrenal fat, giving it the appearance of fetal adiposetissue. There is yellow pigmentation of the remaining supportive stroma.
Cortical changes.-All cases display some degree of edemabetween cortical cords, and in four cases it is marked. In all, there is anobvious decrease in lipoid deposition of the cortical cells, while in two thereis instead a moderate hydropic degeneration. In one case, the cords appear tohave acquired a lumen, and resemble tubules, a finding often associated withacute infectious diseases. In two sections, there is a solitary focaladrenalitis involving the cortex, and in another small lymphocytic foci arescattered throughout the medulla.
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Medullary changes-Degenerative changes seen in the medullaare not distinguishable from post mortem changes.
Spleen
In all seven sections, scattered, large, irregular cells withdeep acidophilic cytoplasm and hyperchromatic irregular nuclei resemblemegakaryocytes. There are no other supporting evidences of extramedullaryhematopoiesis. Four of the sections display moderate pigment collectionswithin phagocytic cells. In four sections, granulomatous lesions with centralcaseation necrosis are encountered, consistent with a disseminated miliary tuberculosis.Follicular lymphoid tissue appears moderately atrophic in only one case.
Testis
Spermatogenesis.-In all 10 sections, there was evidenceofspermatogenic arrest at an early stage.35 Five cases display mitosisin the spermatogonia, although beyond this point there is little progression, sothat more mature elements are markedly decreased. One section demonstrates theproduction of an occasional bizarre spermatid.
Interstitial tissue-Of the 10 sections, 4 display anincrease in fibrous interstitial tissue. In two of these, there is an associatedencroachment and fibrosis of the seminiferous tubules. In another, thereappears a metaplastic transformation of tubular epithelium into a tall columnartype.
Kidneys
Glomeruli-All 11 sections reveal hydropic degenerativechanges of tuft epithelium; these are extreme in 2 cases. Three cases displaymild degrees of capsular fibrosis, and two cases show some increased cellularityof the tufts themselves. In two cases, there is slight hyalin thickening of theafferent arteriole.
Tubules-Of the 11 sections, 9 display varying degrees ofhydropic degeneration of the tubular epithelial cells. In the other two cases, postmortem degenerative changes of tubular epithelium is of sufficient degree tomask this finding if present. Casts, both hyaline and epithelial, arefound in small numbers in nine cases, while casts of blood or altered bloodpigment (hemoglobinuric nephrosis) are found in two cases. Three cases displaysmall cortical retention cysts.
Interstitium-Scarring of the cortex is present in 5 of the11 cases, this varying from an occasional fibrosed glomerulus to wedge-shapedcortical scars. Among these, there are chronic inflammatory infiltrations inthree cases. Areas of calcification are found in five cases, usuallyappearing to occupy the lumen of a former tubule, or also
35Under the histologic examinations of the testicles,evidence of some spermatogenic arrest has been noted. This correlated with theclinical findings to a remarkable degree. This history of these men showed thatearly in starvation there was a universal loss of libido and an absence ofnoctural emissions. Months later, the hair on the head and face was soft, fine,and sparse. Even men who before incarceration had had to shave daily, at the endof it found shaving once a week sufficient. Axillary and pubic hair became thin,and there was a tendency in some for the hair to assume feminine distribution.The skin became thin and loose and its oiliness disappeared. Acne vulgaris wasvery uncommon. A matter of weeks after liberation and feeding, libido,erections, and nocturnal emissions resumed. Several weeks later, the prisonersobserved that the hair areas were becoming restored and shaving became aproblem.
In Japan, it was noted that from 3 to 12 weeks after the dietbecame adequate gynecomastia appeared in 6 percent of the prisoners, in agegroups varying from 18 to 64. Three percent secreted a colostrum-like substance.
It is to be noted that in the lapse of years sinceliberation a normal number of pregnancies in the wives of the prisonersof war have occurred, and the children born to these marriages have beenapparently healthy.-H. P.
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being deposited within the degenerating epithelial cells of tubules. One casedisplays a significant degree of intestinal edema. In others, the edematousappearance can well be explained on the basis of post mortem degenerativechange.
Liver
Periportal areas.-Two of eight sections reveal slight increase inlymphocytes within the periportal areas.
Parenchyma-All eight sections reveal a mild to moderate fattymetamorphosis of hepatic cells of the parenchyma. In one case this is verymarked. The metamorphosis, while present to some degree uniformly throughoutthe lobules, is most marked at the periphery of the lobules in the moderate tomarked cases. Five of the sections examined reveal focal areas of chronicgranulomatous reactions with progressing fibrosis (tuberculosis).
Nerves
Edema of the peripheral nerves associated with degeneration of the fibrils and vacuolization are noted in all 10 sections studied, and in all there are hyaline changes in the sheath. Basophilic degeneration of the neurolemma and perineural fibrous tissue is found in nine cases. In three of the sections, proliferation of the nerve sheath is distinct.
Muscle
All cases (nine sections) show edema, hydropic degeneration of the musclefibers as well as a hyaline-type degeneration. Multiplication of the sheathnuclei indicating proliferation of myofibrils is noted in seven. Aninterstitial chronic inflammatory reaction is found in three of the sections.
Gastrointestinal Tract
In one section of colon, a small diverticulum is found extending through thecircular muscle layer but limited by the longitudinal layer. Edema of themyoneural plexus is present. In another section of colon, there are scatteredtiny mucosal ulcerations associated with necrosis and polymorphonuclearleukocytic infiltration. The submucosa is thickened and edematous with vasculardilatation, and infiltrated by numerous round cells, eosinophiles and a fewneutrophiles. No amebae are present. Edema of the nerve fibers, atrophy ofsubserosal fat are noted, but no serosal inflammatory reaction isdistinguished. A third section of colon is not remarkable except for moderateedema of the nerve fibers.
Two sections of stomach display moderate neural edema, and two other sectionsshow no unusual findings.
One section of jejunum has a focal chronic inflammatory reaction of themucosal stroma and lamina propria, and occasional neutrophiles are found. Noulceration is present. Two other sections have only mild edema of the nervefibers.
Four sections of ileum are not remarkable except for the edema of the nervefibers noted in the other sections.
