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Chapter X



Nutritional Disorders

Herbert Pollack, M.D.


It is often said that the U.S. Army and the people of the United States are the best fed in the world. A tremendous amount of the time and effort of highly trained competent people was applied, with good results, to the ration issue and to the menu planning for the Armed Forces during World War II.

Nevertheless, wars are unpredictable, and not infrequently the best laid plans fail of accomplishment. The fulfillment of normal nutritional requirements in a land of plenty with a highly efficient transportation system presents relatively minor problems. In a war-torn land with a complete breakdown of the normal channels of commerce, transportation difficulties at times become unsurmountable and famine or starvation or less severe nutritional deprivations appear.

All degrees of malnutrition are present in the various parts of the world at all times. These deficiency syndromes are rather characteristic for the regions where they exist; for example, beriberi among the rice-eating peoples, pellagra among the corn eaters, scurvy in the wheat eaters, protein deficiency in those who eat the ground tubers, and caloric and protein deficiency in the areas of crop failure. In time of war, nutritional inadequacies in civilian populations are likely to be accentuated, and soldiers of a well-fed army may acquire similar disorders during captivity or under other circumstances exposing them to local conditions.

Before World War II, the U.S. Army had never had to meet the nutritional problems incident to worldwide dissemination of troops in large units far from their sources of supply. Nevertheless, deficiency diseases did occur occasionally,1 as follows:

1. In 1921, 11 cases of berberi with 1 death occurred among native troops in the Philippine Islands, and 3 cases occurred among native troops in Puerto Rico. In addition, there were 11 discharges among 20 Puerto Rican soldiers with polyneuritis. All these cases were found to be related to the consumption of overmilled rice.

2. In 1931, one case of berberi was reported in Philippine troops; in 1932, two cases; and in 1934, two cases. In 1934, also, three cases of

1Annual Reports of The Surgeon General, U.S. Army, 1921-39.


pellagra occurred among troops in the continental United States-one in a Negro soldier at Fort Benning, Ga., and the other two in white soldiers, one in New Jersey and the other in Texas. These soldiers, each of whom had 15 years of service, were all returned to duty.

3. A Filipino, admitted to hospital on sick report on 29 April 1936, died on 12 September 1936 from beriberi.

4. In 1938, there was a case of pellagra at the General Dispensary in Boston. The patient, a warrant officer, was admitted to Fort Banks, Mass., where he died.

5. In 1939, a case of pellagra was reported in troops in continental United States.

These scattered cases of severe deficiency disease in the Army occurred either in native troops subsisting on native foods or in personnel receiving money allowances for rations, particularly warrant officers and noncommissioned officers of the higher grades. The British, long accustomed to handling native troops and their own men in the Near East, Middle East, and Far East, had more experience than Americans in such matters.

During the First World War, the British observed many cases of scurvy among their troops in Mesopotamia. In June of 1918, a special investigation was made of scurvy in the South African native labor corps contingent serving in France under British jurisdiction, as 121 cases occurred among 6,795 men. It was concluded that the chief cause was probably destruction of the antiscorbutic principle in the food by overcooking. In German prisoners of war on the island of Rousay off Scotland, the diagnosis of scurvy was firmly established on 6 July 1917. In April of that year, a somewhat restricted ration scale had been introduced, omitting potatoes; also, purchase of food by the prisoners was forbidden on account of food shortages throughout the country. Previously, the prisoners had used money earned by their work to supplement their rations from local sources, buying bacon, which they ate raw, and other articles of food. Symptoms of scurvy appeared after about 7 weeks. Most of the men affected were those doing heavy work in the mines.

The Medical Department of the U.S. Army had been given statutory responsibility for the feeding of the soldier as it affects his health and effectiveness as early as 1863, in an act revised in 1877.2 The statute reads in part as follows:

The officers of the Medical Department of the Army shall unite with the officers of the line (under such rules and regulations as shall be prescribed by the Secretary of War) in superintending the cooking done by the enlisted men; and the Surgeon General shall promulgate to the officers of said Corps such regulations and instructions as may tend to insure the proper preparation of the ration of the soldier.

It was not, however, until July 1918 that The Surgeon General established the position of "nutrition officer" within the Medical Department. The duties of the nutrition officer, as outlined in General Orders No. 67, War Department, 15 July 1918, were concerned with the quality, quantity, and proper storage of food, and with prevention of waste, with preparation of menus, and with miscellaneous matters relating to nutrition. Dur-

2Act of 3 March 1863 (12 Stat. 744).


ing World War I, the emphasis in the Surgeon General's Office was entirely on the technical side of the food and menu problems. There was no clinician assigned to this particular aspect of the work.

The nutritional problems of the First World War were still fresh in the minds of only a few at the beginning of the Second World War, and those few were for the most part not heeded. Nevertheless, between the two conflicts, attention had gradually focused upon the shortcomings of the Army rations, and some efforts had been made to correct them.3

In his 11 December 1926 letter to The Adjutant General, the Quartermaster General, Maj. Gen. B. F. Cheatham, pointed out the wide variations, as of 30 June of that year, in the ration allowances for the armed services and, among these, the unfavorable position of the Army. Masters and first 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 Philippine ration, 22 cents a day. He noted further: "The garrison ration is the same today as it was in 1908, although * * * the standard of living of the American people is much higher than that of eighteen years ago." On 3 January 1927, The Surgeon General, in his endorsement to the Assistant Chief of Staff, G-4 (logistics), stated that the current ration did not permit a serving of a well-balanced diet in the Army comparable with that of civilians in similar walks of life, under the existing living conditions in the United States, and that the ration allowance was not sufficient to permit the purchase of an adequate supply of foods rich in the essential protective substances, vitamins, without utilizing other funds.

In October 1923, Maj. Gen. M. W. Ireland, then The Surgeon General, U.S. Army, described nutrition in the Army in the following terms:

The Army ration as now provided does supply sufficient and suitable nourishment for the troops from the standpoint of balance and caloric content. That is, the ration contains a sufficient number of calories to supply the needed energy and is balanced so as to prevent the occurrence of deficiency diseases. * * * Physiological and 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 a nature that it will appeal to the troops and be eaten in sufficient quantities.

On 11 January 1927, Paul E. Howe, Ph. D., Bureau of Animal Industry, U.S. Department of Agriculture, then a lieutenant colonel in the Sanitary Corps Reserve, submitted, to the Office of The Surgeon General, an excellent critique on the ration of that time.

In 1929, a mess management course was instituted in the troop schools.

Just before the United States entered into World War II, Colonel Howe, having served a period of active duty from 26 July to 4 August 1940, reported that the garrison ration at its field value was adequate as to calories, proteins, phosphorus, iron, vitamin A, vitamin B1, and riboflavin and that it was fairly satisfactory with respect to calcium and vitamin C, but he had several very keen and pertinent remarks to make about the ration-savings plan which was then in effect.

3Letter, Maj. Gen. B. F. Cheatham, The Quartermaster General, to The Adjutant General, 11 Dec. 1926, subject: Increase in the Ration Allowance-Regular Army and Philippine Scouts, with 1st endorsement thereto.


By 26 September 1940, there is evidence of The Surgeon General's awareness of the imminence of conflict and of his interest in setting up new rations for the troops. He had already obtained authority for the formation of the Food and Nutrition Subdivision in the Professional Service Division of his office. Col. Paul E. Howe, SnC, became the first chief of the subdivision, serving from 25 September 1940 to 12 April 1944.

Beginning with January 1941, a course for food and nutrition officers 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 to the Assistant Chief of Staff, G-4, on the proposed War Department circular on rations, the Office of The Surgeon General makes no mention of clinical examination of the troops who were going to consume the new ration. Unfortunately, too, little had been done to check the influence of the newer techniques of preservation on the nutrient content of foods. Early in the war, however, The Surgeon General, in recognition of the part played by good nutrition in the maintenance of the health of troops, appointed clinicians to the 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 was ostensibly on temporary duty in the replacement depot, but actually he worked on a 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 II period. Colonel Youmans brought into the work a whole group of men primarily interested in the clinical aspects of nutrition.


Plans and organization.-In 1941, with the imminent onset of open warfare; plans were made to start ration trials as rapidly as possible. The Surgeon General, being directly concerned with the nutritional status of the troops, worked closely with the Quartermaster General in designing rations to satisfy the field forces, who must, of course, be capable of fighting the war on the ground in any part of the wide world. A battle may be fought in the mountains, in the deserts, in the rolling plains, or in the trackless, frigid wastes of arctic regions-each locale posing different problems for the maintenance of optimum nutrition of the soldier. A limiting factor at all times is the logistic one. Munitions usually have priority over other supplies. This means that rations must be suitable in terms of stability and storage, under arctic or tropic conditions. Consideration must be given in packaging, field utility, weight, cubic content, and nutrient content at the time of consumption; that is, there must be no more than an acceptable rate of deterioration during the pipeline or


the shelf storage. Acceptability and palatability must also be taken into account. Faced with these, at times, apparently conflicting interests, the joint efforts of all concerned nevertheless succeeded in solving many of the more important problems. After World War II, personnel of both offices, The Surgeon General's and the Quartermaster General's, continued to cooperate in the work on the ration problems discovered during World War II. On 6 November 1944, The Surgeon General opened the Medical Nutrition Laboratory in Chicago, Ill. The laboratory, which has since moved to Denver, Colo., has grown and is now one of the most important agencies dealing with the nutritional requirements of troops in combat.

The purpose of the ration tests conducted by the American and Canadian Armies from 1941 to 1946 was to determine accurately the nutritional adequacy of the various types of rations under the conditions under which the troops would use them. The Canadians were somewhat the more aggressive in these studies and early in the autumn of 1942 had already begun their nutrition surveys. In all, 16 important ration tests were carried out in places varying from the desert training area in California up through the Canadian Army Operation MUSK OX in the Arctic. In addition, there were at least 15 separate surveys of the troops during this period, these varying from a simple determination of nutrient intake to clinical observation. This is the first time that direct clinical observations were made on the troops in the field and under experimental conditions just to determine their health status under various conditions of feeding. An excellent summary of this work was published in 1947.4

The underlying principles-The basic 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 terms of effect on the soldier, on his physical fitness and military efficiency, with particular emphasis upon the maintenance of the biochemical balances. Before the war, and during the early days of World War II, much of the clinical thinking with respect to nutrition was distorted by overemphasis on vitamins. The sum of wartime experience was to show that, except under conditions of capture and imprisonment, florid avitaminosis was, in fact, extremely rare in U.S. forces, whereas caloric deficiency with loss of weight was a cause of deterioration among soldiers. In the ration tests, it soon became apparent that the primary problems of the combat soldier's nutrition in order of importance actually were (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 water balance is so obvious that it is overlooked in many studies on nutrition. In the days

4Johnson, R. E., and Kark, R. M.: Feeding Problems in Man as Related to Environment. An Analysis of United States and Canadian Army Ration Trials and Surveys, 1941-1946. Quartermaster Food and Container Institute for the Armed Forces, Research and Development Branch, Office of the Quartermaster General, Chicago, Ill., April 1947.


before World War II, many officers in the desert training centers attempted to condition the troops to withstand dehydration. As experience accumulated, this "water discipline" was abandoned by a directive,5 based upon the work of independent observers who agreed that in any climate inefficiency and then exhaustion may come on in a few hours from lack of water.6

The clinical syndrome of dehydration exhaustion was seen by a great many officers, although many 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 becomes noticeable as a dry throat, then as a general subjective sensation of thirstiness. As the negative fluid balance mounts, from any one of a number of causes-sweating from heat in the Tropics, sweating from nervousness in battle, sweating from excessive clothing insulation in the Arctic, and so forth-the face 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 soldier is actually tormented, discipline and training may be lost and the soldier then discards equipment, piece by piece. At this point, he will be found on physical examination to have a tachycardia and a hyperthermia. The blood pressure drops and orthostatic hypotension sets in. 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 will inevitably occur in the best trained man if his water supply is cut off.

Caloric deficiency.-Clinical descriptions of caloric deficiency in soldiers were well recognized and documented during the ration tests. A composite picture of the effects of caloric deficiency in active young men shows physical and mental disturbances beginning with irritability and annoyance and progressing to a real physical deterioration.7 When marked caloric deficits exist with high work-output and when the environment is difficult, the signs and symptoms develop in the matter of a few days, but when there is only a minimum of caloric deficiency weeks or months may go by before gross inefficiency appears. This was seen in the B-ration test conducted at Camp Lee, Va., 1943, where the author was the medical officer in charge of the physical welfare of the troops.

In the middle of the test period, we increased the workload from 3,400 to 4,000 calories per day, on the average, without increase in food. * * * A radical change gradually occurred * * *. The men developed a submalar shrunken appearance; the eyes became dull; bodily movements became slower and desire to participate in sports sharply declined, although there was no flagrant attempt at avoiding prescribed formation duties. Touch football and softball were 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 of Scientific 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 Prince Albert, Saskatchewan, Canada, January 2d to March 3d, 1944. A Report to The Standing Committee on Nutrition, Department of National Defence, Canada. (3) Report, Armored Medical Research Laboratory, Fort Knox, Ky., 10 Apr. 1944, Project No. 1-7, 1-15, 2-5, 2-14, Cold Weather Operations.


Saturdays * * *. The Medical Consultant Board agreed unanimously that practically all the men exhibited some degree of physical deterioration during the test period. The specific manifestations observed by the officer in charge of physical welfare were poor muscular coordination, inability to carry out work of high intensity, falling out in the marches, nervousness, irritability, muscle aches and pains, insomnia, and other significant symptoms.

Unless officers were aware that gross loss of military efficiency and operational fitness could occur as a result of eating too little food, the results, in varying degree, of caloric deficiency were usually ascribed to other deficiencies in the soldier, often of reprehensible nature.

As caloric deficiency increased in the test troops, the physical signs of disturbed function became more obvious. Fatigue, sluggishness, lack of energy and drive, loss of muscular strength, the desire for rest, increasing sleeplessness, sensitivity to the cold, and tremors of the hands were noted; quarrelsomeness was evident. Loss of weight, of course, is manifested very early. Dizziness, nausea, vomiting, exhaustion, and collapse are the late stages. Loss of weight at this point becomes very obvious. The shrunken eyeballs, the dry mouth, the parched lips, the occasional acetone odor to the breath, changes in tendon reflexes, and impairment in physical fitness tests are observed fairly often. Recovery from early effects of caloric deficiency are usually very prompt and dramatic, and the return of morale in the men can occur within the matter of a few hours.

During the Camp Lee tests, there was much discussion about the nature and cause of the physical deterioration observed, and it was decided to give half the troops massive doses of synthetic vitamins. No convincing evidence was found that therapy with vitamins had any significant effect on the health and efficiency of the test troops under conditions of caloric insufficiency.

As will be seen later, caloric deficiency was the most important nutritional problem both in American prisoners of war recovered from the enemy and in the "enemy armed elements" in prison camps of the United States.

Nitrogen balance and surgery.-Concerning this aspect of nutrition, 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., a nutrition laboratory was established basically for the use of the surgical services. The nutritional status of the patient was regarded as a factor in surgery, much like hemoglobin and the blood picture in general, to a large extent conditioning the healing of wounds and results of operation. The laboratory group was concerned particularly with the paralyzed patient. In this type of injury, decubitus ulcers, secondary infections, and other complications are probably related to the nutritional status.

It may be recalled that just before our entry into World War II, a committee of the National Research Council reported on the effect of nutrition and nutritional status on recovery from wounds and illness. The committee pointed out the importance of nitrogen balance and similar metabolic studies in both the acute and chronic phases of disease and in trauma, since substantial loss in nitrogen occurs in many patients. This, of course,

8Beck, C. S.: Surgical History, Fifth Service Command. [Official record.]


is enhanced by the large losses of protein and exudates and other secretions from the body. It was pointed out particularly that the general metabolism of an individual who has sustained severe injury or illness is quite different from that of a healthy man and that his nutritional requirements must be based upon the depletions that occurred during the acute episode. For instance, a marked increase in urinary nitrogen was observed reaching a peak during the 3d and 10th day following compound fractures of the leg. When there is decreased food intake through anorexia or other causes, the negative nitrogen balance can run as high as 30 grams of nitrogen a day and over a period of time mounts up rapidly. The results were seen in extensive loss of weight and wasting of tissues with debilitation and prolongation of the convalescent period. After a time, definite changes could be seen in the amount of protein in the circulating blood, particularly in the albumin fraction of the plasma. At first, this circulating protein had a priority over all other forms and was maintained at the expense of tissue stores. As the tissue stores became depleted, plasma volume decreased with attendant hemoconcentration. After all compensatory mechanisms had been exhausted, then the actual decrease in the circulating protein was noted.

The optimum daily intake for the average surgical patient was set at 150 grams of protein with 3,600 calories or more. The physicians had to employ heroic measures to achieve this objective. Acute deficiencies of circulating protein were corrected by the administration of plasma and subsequently human albumin, which contributed a large quantity of circulating protein and enhanced the blood plasma. Beverages fortified with protein were developed and used to supplement the hospital diets. Subsequently, to the close of the war, this type of work has been carried on and extended even further.9


Nutritional difficulties were encountered by all Allied troops 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 the Owen Stanley-Buna campaign in New Guinea, Australian troops were supplied at first under a schedule of priorities that placed ammunition first, blood second, and food third. Casualties from wounds and diseases, especially malaria, were very heavy, and nutritional diseases including florid beriberi appeared. Owing to difficult conditions of supply, the diet had consisted mostly of tinned beef and biscuits for periods varying from 6 to 12 weeks.10 By the middle of the campaign, priority in supply was given first to blood, because of its small bulk; second, to food; and third, to ammunition. Many soldiers of Wingate's Force 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 medical officer reported that, of 209 men examined at the end of this time, 182 had lost up 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, Technical Instructions No. 74, 26 Aug. 1943.


such as pellagra and beriberi were recognized. One of Wingate's units in the Dehra Dun area was visited some months after they had last eaten K-rations. At the sight of a box of K-rations, carried by the visitors, two of Wingate's men vomited.

Europe and North Africa

Field trials for special rations were conducted in the several theaters of operations, particularly in ETOUSA (European Theater of Operations, U.S. Army) where facilities were available to study the problems that arose. An extensive report11 from the European theater, dated July 1943, showed findings similar to the ration trials in the United States. The authors of the report noted that none of the packaged rations were recommended for continued use by active troops for periods in excess of 10 days unless supplemented with additional food. The need for supplements was greatest in the C-ration. Much credit for the work on rations done in the European theater goes to 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 use of troops in the field and the first really severe test of the newly developed B-, C- and K-rations. The difficulties under which they were tested here were even greater than had been anticipated in designing the rations and were compounded by misunderstanding of the ration systems and the use of rations. Medical officers in general were not thoroughly conversant with the signs and symptoms of nutritional inadequacies. They had been exposed to overemphasis on vitamin requirements and were, for the most part, not proficient in differentiating the numerous complaints that resemble nutritional inadequacies but that are basically due to other causes. In reviewing the report of Col. Perrin H. Long, MC,12 medical consultant in the North African theater, it becomes apparent that training of personnel in nutrition before their assignment in the field would have saved much time and many mistakes.

In Essential Technical Medical Data and unit commander reports and in surveys done by the headquarters personnel, there was evidence of a tendency in the frontlines to blame a disproportionate amount of their troubles on the rations. Loss of weight regardless of other cause, whether anxiety, supply difficulties, or climatic conditions causing anorexia, was almost invariably blamed on an inadequacy of the ration per se. This generalization is no better than most however; some of the problems were real.

11Field Trial, Special Rations. European Theater of Operations, U.S. Army, July 1943.
12Report, Col. Perrin H. Long, MC, Medical Consultants Division, to Chief, Preventive Medicine Service, Office of The Surgeon General, attn: Chief, Nutrition Branch, subject: The History of Nutrition in the North African Theater of Operations, 3 January 1943 to 1 August 1944.


For instance, the chief of the medical service of the 9th Evacuation Hospital states that disturbances noted in two patients with stomatitis were thought to be nutritional in origin and were, in fact, cured with large amounts of vitamin supplements. The 77th Evacuation Hospital had one typical case of pellagra developing in an officer who was eating cold C-rations; the diagnosis was verified by the consultant in medicine, North African theater. In addition, six cases of polyneuritis due to thiamine deficiency, several instances of ariboflavinosis, and several cases of spongy bleeding gums ascribed to ascorbic acid deficiencies, had been seen in that hospital. In the 128th Evacuation Hospital, the chief of the medical service reported two instances of vitamin A deficiency as manifested by cutaneous changes and night blindness. A survey13 was made of troops in the forward areas and evacuation hospitals of the Fifth U.S. Army on 26 November and 4 December 1943. Almost all soldiers questioned in infantry, engineer, and other units said they had lost weight since the beginning of the Italian campaign. Surgeons commented upon the decrease from the normal in body fat in their patients, and some noted wasting and paleness of muscle substance. Loss of hemoglobin was reported in a survey of the mucous membranes of the mouth and conjunctiva of troops in the forward areas, together with the clinical impression of exceptional pallor for men of the age group examined.

Increasing numbers of soldiers suffering from physical exhaustion were seen in the forward area. These patients required copious feeding in addition to rest, thus confirming the view in the minds of the medical personnel that a state of undernutrition favors development of physical exhaustion. It was noted, however, that frank vitamin deficiencies such as scurvy, pellagra, beriberi, and night blindness had been observed infrequently during the previous year in the American troops in the North African theater.

Perhaps the one attempt at controlled observations on nutritional deficiencies in North Africa was that made by a flight surgeon of the American Air Forces and a medical officer in the Royal Air Force. Using standard dark-adaptation equipment and a slit lamp for determination of capillary loops for riboflavin deficiency, they made the following observations:

The Americans were well within normal limits, having a factor for dark adaptation around 5 and a riboflavin factor of 1. The French had a dark-adaptation factor of 14 and a riboflavin factor of 2. The English had a dark-adaptation factor of 17 and a riboflavin factor of 3 plus and, in approximately 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 1 mg. per 100 cc. of blood or slightly higher. "This must not fall below 0.2 mg. percent before wound healing is adversely effected." In a control group of 17 soldiers admitted from local units, the range was from 0.2 to 1.1 milligrams. None showed a depletion that would be significant in the healing of wounds. Of 60 unselected battle casualties, 28 percent showed ascorbic acid levels 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.


60 patients showed vitamin C levels of 1 mg. per 100 cc. of blood or over. It should be noted that one causative factor in the deficiency was lack of facilities for feeding the troops during evacuation.

Isolated instances of vitamin C deficiency continued to be noted in the European theater.14 In the 495th AAA Gun Battalion, an officer and several enlisted men showed signs of vitamin C deficiency. These cases were ascribed to failure by the men to eat breakfast, the meal that chiefly supplied this vitamin, and the patients were, in fact, cured with tablets of ascorbic acid. In the Western District, United Kingdom Base, 15.2 percent of 16,868 men inspected had bleeding gums. This was similarly ascribed to failure of soldiers to drink the fortified juices provided at breakfast. Nutritional disturbances could usually be accounted for not so much by the quality as by the distribution or consumption of the rations. On the whole, there were surprisingly few nutritional problems per se among troops in this theater.

Atlantic Bases

Nutritional problems in the isolated areas of the Arctic and North Atlantic were not so great as one might anticipate. No unusual problems were reported. Occasional cases of malnutrition were seen at the station hospitals 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 was handled promptly and properly by the medical personnel. Of more general interest is the report from the 188th Station Hospital, dated 15 March 1944, on a survey of anemia in soldiers with over 12 months of service in Greenland. Red cell counts and hemoglobin determinations were made on 103 soldiers who had dwelt in Greenland for an average of 15 months. There were, of course, numerous subjective complaints. Changes in weight were insignificant: 14 men had lost an average of 13 pounds; 13 men had gained an average of 13 pounds. The average red cell 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 had erythrocyte counts below 4 million, 10 percent between 4.0 and 4.2 million, 17 percent between 4.2 and 4.4 million, 22 percent between 4.4 and 4.6 million, 19 percent 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 in gastric secretions of all men with counts below 4 million. The controls, 16 men who had just arrived from the United States and had served only 4 weeks in Greenland, had an average erythrocyte count

14(1) Annual Report, 495th AAA Gun Battalion, 1945. (2) Survey, District Nutrition Officer, Western District, United Kingdom Base, to Surgeon, United Kingdom Base, Communications Zone, ETOUSA, 10 Jan. 1945.


of 4.98 million, and their average hemoglobin was 15 gm. per 100 cc. of blood. It was concluded that a mild chromic anemia existed among approximately 75 percent of the men who had served over a year in Greenland and that the anemia was probably nutritional in origin. Those subject to the anemia had symptoms that could be explained as largely psychic in origin. It was recommended that the vitamin content of the diet be increased as much as possible and that multivitamin pills be made available to all men on this post and, what was most important, that if and when possible men with 1 year's service in Greenland should be reassigned to duty in the United States. It is difficult to differentiate between the emotional problems of the men who were confined to the area and those problems that were truly due to nutritional disturbances.

From the U.S. Army Forces in the South Atlantic, based principally on the Ascension Islands, only occasional cases of true deficiency diseases 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 the day preferred sleeping to eating; he recovered completely with a change in duty assignment plus adequate diet. In the Panama Canal-Trinidad sector in the South Atlantic, the battalion surgeon made this comment: "The general nutritional status of the troops is adequate. Symptoms of vitamin deficiencies have been frequently noted but at present are mild in character." More than the average number of cases of gingivitis were seen by dental officers in men reporting from jungle outposts, where the standard ration was, not in its composition but in its consumption, inadequate to nutritional requirements. In these reports from individual surgeons, it is again noted that the reporting of nutritional deficiencies in troops very largely depends upon the observer and his 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.


Before D-day, soldiers of American and Allied origin, in small numbers but more or less continuously, filtered through belligerent and Allied countries in the attempt to rejoin their parent organizations. Most were air force personnel who had been shot down while flying missions over enemy territory. Administratively, they fell 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 this medical report to discuss the methods by which these people outwitted the enemy.


It is sufficient to say that much was made possible by the members of the underground of the occupied countries. The theater Provost Marshal had a small hotel in London located at 63 Brooke Street where those Americans 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 which provided the means for the care and processing of these escapees and evaders.

With the liberation of France in September 1944, the possibility of recovering Allied prisoners of war in overrun German camps became real, and administrative plans were made to take care of them. The Provost Marshal instituted a RAMP (Recovered Allied Military Personnel) Division on 18 December 1944. Unfortunately, planning did not include the Nutrition Branch of the Professional Services Division, Office of the Chief Surgeon, ETOUSA. The SHAEF (Supreme Headquarters, Allied Expeditionary Force) policy with respect to RAMP's as outlined in paragraph 555 (b) of the "Handbook for Military Government in Germany Prior to Defeat or Surrender," dated December 1944, was somewhat unrealistic in its approach to this problem. Allied prisoners of war, according to the Handbook, were to be "freed from confinement and placed under military control or restriction, as may be appropriate pending further disposition." In the early days of the war, under the conditions disclosed by escapees and evaders, this procedure might well have worked. However, Americans who were captured in the Ardennes bulge late in 1944 related that they had been continuously on the march with hardly any rest and with pitifully inadequate nourishment. Obviously, these men, and others on the march, had suffered great hardships from which the Geneva Convention had not, as expected, protected these prisoners of war. Hence, it was virtually impossible to leave them where they were when the camps were overrun.

On 7 May 1945, the Supreme Commander, SHAEF, made the decision that all American and British ex-prisoners-of-war should be evacuated from the Army areas in the shortest possible time, regardless of any limiting circumstances. CATOR (Combined Air Transport Operations Room), the agency that controlled air transportation, was given as its first concern the movement of the prisoners of war to installations in the Communications Zone. Before this decision, the movement of supplies had priority with CATOR, and the prisoners of war were evacuated wherever camps were located close enough to the delivery points for supplies. This change in policy greatly accelerated evacuation of liberated prisoners of war through administrative channels, and from a daily rate of approximately 1,500 the number jumped to 30,000 on 9 May. Recognized medical cases were evacuated separately. By 22 April 1945, reception camps for the handling of American and British RAMP's were established at Namur, Belgium, and at Reims and Épinal in France.


Camps for Care of Recovered Prisoners

The Lucky Strike Camp, situated near St. Valéry on the north coast 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 evacuated by air and also as a base camp for the British RAMP's. Eventually, an airstrip was built at Lucky Strike to relieve the load at Camp Wings. Evacuation from the temporary camps became a sizable problem, and the rail and air facilities were loaded to capacity. The Chief Surgeon made 29 hospital trains available to the Provost Marshal to help the administrative evacuation. Camp Lucky Strike was selected as the installation that would have the greatest part of the work involved in the processing and evacuation of the RAMP's because of its proximity to Le Havre and because it had a capacity expandable to 70,000.

Approximately 60,000 Americans were listed as prisoners of war in the hands of the Germans, but actually over 94,000 recovered prisoners were evacuated through medical and administrative channels. These discrepant figures are accounted for by the many thousands previously listed as missing in action.

Arrival of First Liberated Prisoners

Sorting.-Camp Lucky Strike, then in the Northern District of Normandy Section, was set up as the reception area for the RAMP's being sent through command, as distinguished from medical, channels. Lucky Strike had been intended as a staging area for incoming ground force personnel during hostilities, and much had to be done to adapt it for the present purpose. The Camp proper was divided into four blocks, with a total capacity of about 40,000 soldiers. Block D was set aside originally as the RAMP camp and, in a short time, was made an independent command responsible directly to the Northern District. Block C was set up as a possible 306th General Hospital to take care of convalescent RAMP's. RAMP's were flown from the forward areas to the airport at Le Havre where a 2,000-bed tent setup was made available. All RAMP's were screened medically at the airport by the physicians of the 98th Medical Battalion and by the dispensary officers from the Le Havre units under the direction of the Northern District surgeon. Those few who came in by rail transport were sorted several hours out of Le Havre, and complete triage was effected before the train arrived at the station. Of approximately 7,000 RAMP's evacuated to Le Havre for the Lucky Strike area in the early days, 824 were hospitalized.

Of the total number arriving, there were about 2,400 British personnel, who were kept in Camp Wings for several hours and then transshipped to England, except those who, being too ill, were put into Ameri-


can hospital channels. Of the entire number hospitalized, immediate triage at the landing field accounted for 390. Of these, the sickest were taken directly to the 28th Station Hospital, Yvetot, France, about 30 miles from the airstrip; the rest were sent to the 179th General Hospital at Rouen.

The first batches of returning men were met as they alighted from 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 Army 6 x 6 truck, from 16 to 18 men in a truckload. Here, they were again screened by the dispensary physician of the post aided by the medical officers of the general hospitals staging in the areas. Up to Friday evening 13 April 1945, 4,400 men actually reached Lucky Strike Camp. Of these, 425 were hospitalized by the screening physicians on admission and at morning sick call at the dispensaries. They were admitted to the 77th Field Hospital set up on the campsite. On Saturday morning, 14 April 1945, the 77th Field Hospital had a census of 441 patients. (See also page 249.)

It may be recalled that all these men had been previously screened in forward areas, where RAMP's were divided into those to be evacuated by medical or by command channels. Those sent to the Lucky Strike area had been considered physically fit and ready to be sent home. Forward triage was of course difficult at best, and subsequently many things happened. The trip by air, sometimes through great turbulence, was often enough to upset these men, whose balance was precarious at best. Then came the warm, but nutritionally unsound, welcome by the Red Cross, which was, in fact, secondarily responsible for many cases.

Clinical problems-The dispensary setup at Camp Lucky Strike was very adequate. There were three such medical installations, each serving 10 packets or companies of 200 men each. There were from two to four physicians in each dispensary. On Saturday morning, 14 April 1945, the sick call reached over 500 RAMP's, despite the fact that the population of the camp that morning had fallen to 2,800 men, owing to the evacuation of 1,500 men for the Zone of Interior during the night. About 80 percent of the men reporting on sick call had for their presenting complaint gastrointestinal disturbances; the rest, predominantly acute infections of the upper respiratory tract, pyodermias, and other skin conditions. Numerous men had complaints referrable to polyneuritis, hyperesthesia, paresthesia, muscle atrophies, edema, and cheilosis. These were seen as complications of the presenting gastrointestinal symptoms. The histories reveal that the acute respiratory infections started in transit. Acute gastrointestinal symptoms also started in transit and at the RAMP camp. It was known that the initial delousing was not always completed before arrival at Camp Lucky Strike. It is to be noted parenthetically that many RAMP's were found to have originated from Stalag XII-A (p. 252) where 22 cases of typhus fever in the Russian prisoners had been reported.


Among the 441 patients in the 77th Field Hospital on the morning of 14 April 1945, the commonest diagnoses were gastroenteritis complicating malnutrition, acute infections of the upper respiratory tract with malnutrition, and pyodermias with malnutrition. Three percent of the RAMP's admitted required intravenous plasma therapy as an immediate supportive measure. As anticipated, the patients tolerated intravenous fluids very, very poorly. Two units 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 as might have been desired, but supplies arrived very shortly afterward. There was a rather acute shortage also of paregoric, bismuth, and belladonna. In the first group of patients admitted, X-rays of the chest were taken; the diagnosis of pneumonia 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 a bronchial pneumonia complicating malnutrition. The serum proteins had been estimated before this soldier's death as 2.5 gm. per 100 cubic centimeters.

Recommendations for therapy-The medical consultant at the Normandy Base Section, Lt. Col. (later Col.) Theodore L. Badger, MC, invited the nutrition consultant from the Office of the Chief Surgeon to give orientation talks to the chiefs of the medical services of the hospitals in the Northern District of Normandy Base. As a result of these conferences, certain recommendations were made, based in large part upon observations made on recovered prisoners in forward areas (p. 251). Briefly, the first proposal was that a system of two messes be set up in this RAMP reception area, with one to serve a bland diet ration to all newcomers for at least 48 hours, and optionally after that. At the Lucky Strike Camp, this was feasible and acceptable to the administration and to the district surgeon. It was felt that much hospitalization could be prevented and convalescence speeded by early general diet therapy for reeducation of the gastrointestinal tract. The second recommendation was to give the RAMP's short orientation talks on proper eating as far forward as possible. A poster system for the messhalls was devised as a visual aid to this educational campaign. One of the most important recommendations was that every effort be made to stop the American Red Cross and the Army Exchange System from flooding these men with doughnuts, candy, apples, and peanuts. One soldier ate 17 doughnuts on his trip back from the forward areas with results that can be imagined. It was recognized that the acute vitamin deficiency syndromes were precipitated only after full feeding had started and so could not be anticipated, but preventive therapy should have been started earlier.

Medical officers had in general to be oriented with respect to therapy of severe chronic malnutrition. Directives were issued by the Office of the Chief Surgeon on advice from the medical consultant to the Nutrition


Branch. These were basically concerned with avoidance of intravenous therapy, the use of bland soft diets, and the avoidance of such medications as iron. Many physicians, when they found the deficiency anemias, immediately prescribed iron by mouth, but this therapy was not considered rational in the presence of such great protein deficiencies. Also, qualities of the iron compounds irritating to the gastrointestinal tract precipitated secondary problems. Medical officers were further warned about details of treatment of complicating infections. Extra vitamins would be required in the febrile period. The early use of penicillin in adequate dosage should be encouraged. The use of the sulfonamides was to be considered on a very cautious basis because (1) they upset the gastrointestinal tract, and (2) the hemoconcentration, dehydration, and scanty urines called for much smaller doses on account of the minimal excretion and the possibility of precipitation in the genitourinary tract.

A further recommendation was that the evacuation policy from the Communications Zone to the Zone of Interior be modified. It was found that the 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 that the rough voyage would start nausea and vomiting in a large percentage of these debilitated people, resulting in unnecessary hazards to quick convalescence and possibly endangering life itself. Furthermore, some of them being less than 15 days from known typhus areas might possibly be carrying the disease during the incubating phase. The diphtheria rate also was high among them, and their rapid evacuation to the States risked carrying virulent diphtheria home quickly.

Transport commanders were accordingly informed by Medical Bulletin No. 1, dated 15 May 1945,15 that various degrees of malnutrition had been found in the recovered Allied military personnel. Although marked improvement had been accomplished under a rigidly controlled dietary program, complete rehabilitation would necessitate several more weeks of nutritional management. Accordingly, this program should be continued both aboard ship and in the Zone of Interior. Foodstuffs to be restricted included particularly doughnuts, peanuts, citrus fruits, cauliflower, cabbage, the concentrated components of C- and K-rations, and high fat-containing foods. The general mess should be on a soft or bland diet both before and during the voyage home. The Bulletin outlined in detail the various precautions that had been taken to protect the RAMP's from gastrointestinal disturbances, which in so many cases were cause for hospitalization.

Incorporating the essential recommendations just discussed, Circular Letter No. 36, Office of the Chief Surgeon, ETOUSA, was published on 19 April 1945. On 28 April 1945, with the cooperation of the Chief Surgeon

15Medical Bulletin No. 1, Office of the Surgeon, Northern District, Normandy Base Section, 15 May 1945.


and the Chief Quartermaster, the special bland diet menu was issued, 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 feeding recovered malnourished U.S. and British Army personnel until the normal field ration A menu could be tolerated.

Statistics gathered from medical units at the various RAMP camps reiterated the need for taking such action and showed prompt results. In one camp, where the operational 10-in-1 ration was fed on an emergency basis to 1,000 recovered prisoners, 150 were hospitalized after the first meal for acute diarrhea, and a number of others reported on sick call for various gastric complaints. At another camp, there was an average daily sick call of over 20 percent on ordinary Army rations, with 80 percent of the presenting complaints characteristic of enteritis. One week after the introduction of the bland diet, the sick call rate dropped to 4.0 percent with only 15 percent of the complaints 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 well organized. Reception into RAMP camp was in a designated area with a capacity of about 2,000 beds. The men were kept here for about 1 day after which they were transferred to the processing areas for a minimum of from 1½ to 2 days. The capacity of this latter was 4,000 beds. After processing, they proceeded to the "pending shipment" area for a minimum of 1 day, in actual experience from 3½ to 10 days. Each of these designated areas had a different mess. The special bland ration was used by all three except that Mess No. 1, in the reception area, eliminated dried fruits. In addition, there was a supplementary issue of one multivitamin capsule for each man at each meal. Between meals, a nutritional bar was available for all personnel.

On 7 May, this bar served 460 gallons of eggnog, 320 gallons of cocoa, 452 gallons of malted milk, and 128 gallons of tomato juice. The average serving was approximately 12 ounces. In addition, the RAMP's arriving at the camp after the evening meal were served 160 gallons of dehydrated pea soup and 1,400 cheese sandwiches made with white bread. Although no control was maintained at the nutrition bar for second helpings, the length of the line was a deterring factor. In the mess, effective control was exercised by characteristically colored and marked cards issued by the tent commander to the men in formation before each meal and surrendered as they passed through the gate to the mess. It was estimated that the average consumption was well over 5,000 calories per man per day.

Inquiries made among the RAMP's and administrative personnel revealed excellent acceptance of the bland menu by the soldiers. Plate waste, as one would expect, was negligible. The messes were now in excellent condition; concrete flooring for serving and mess tents were completed; ranges and utensils were supplied by the Quartermaster General without further delay and in adequate quantities. The problem of lack of communications remained, however, and the post was frequently not ready for new shipments as they arrived.


After the RAMP's went through the first two areas, they were sent, as stated previously, to the holding or "pending shipment" area. Here, the modified type-A ration was served. This holding area was no longer under the control of the RAMP camp, having been returned to the control of the Lucky Strike Post.

By the middle of May, the general health of the RAMP's was much improved. The sick call rate had dropped to an average of 60 to 75 patients daily in an area whose population varied from 1,500 to 2,800, as contrasted with the earlier rate of 200 for a population of 2,000. The chief complaints at this time were boils, skin infections, cellulitis, and diarrhea; gastrointestinal symptoms now accounted for only 1.8 percent of the total. Nausea and vomiting were no longer presenting complaints. Infections of the upper respiratory tract were only a minor problem. Triage was still done at Camp Wings located about 43 miles from the RAMP camp. Hospital admissions were made directly from the triage area, 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 with the American Red Cross had been solved. The common causes for hospital admission at this time were acute respiratory infections (about 50 percent), diarrhea, cellulitis, and edema; 36 cases of hepatitis were picked up in 1 week. The 77th Field Hospital continued to be busy through the middle of May and on the morning of 9 May had a census of over 300. Causes for admission were essentially the same as before, except that in the routine X-ray films six patients with active tuberculosis had been detected. The nutritional deficiency syndromes remained essentially as noted earlier. Problems of hospital care were greatly eased by the decrease to the vanishing point, from over 80 percent 1 month previously, in the number of patients with nausea and vomiting.

Clinical History: Statistics

Information gathered from 214 RAMP's by questionnaire from 28 May through 6 June 1945 may be summarized statistically. In all, they had had an average captivity of 143 days. Their average weight before capture was 163 pounds, and their average present weight was 149 pounds. It was reported by 26 that they had lost only from 5 to 15 pounds; 84 said they had lost from 15 to 25 pounds; and 90 reported losses of over 25 pounds. It was noted that 187 of these people had diarrhea during their incarceration; of these, 31 reported having had diarrhea most of the time, 29 frequently, 69 occasionally, and 53 rarely. As for symptoms, 90 reported they had had swelling of the legs while they were in captivity and 20 of them still showed evidence at the time of the questionnaire; 165 reported nocturia during their imprisonment. These figures are indicative to some extent of the degree of malnutrition that was present among the RAMP's questioned.


In all, 82,320 RAMP's were evacuated through nonmedical channels. Spot-check surveys showed an average of 143 days in German camps and an average weight loss of 14 pounds. Of the RAMP's, 55.6 percent showed evidence of malnutrition, 42.5 percent had nutritional edema while in the German camps, and 25.8 percent complained of night blindness. Secondary hospitalization was 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 medical channels. The 15th Hospital Center in the United Kingdom Base admitted 2,516 RAMP's. Severe malnutrition was diagnosed in 412; the rest had malnutrition as a secondary diagnosis. The 179th General Hospital at Rouen admitted 837 RAMP's. Severe malnutrition was present in 188. Of these, 42 had to be tube fed. It was found that the average weight loss of the prisoners from Stalag IX-B was 39.1 pounds per man and from Stalag IX-A, 28 pounds per man. The 217th General Hospital, Paris, France, had 1,098 RAMP admissions. Of these, 275 were severely malnourished; others had malnutrition as a secondary diagnosis. There were eight autopsies done on the RAMP's who died in the Communications Zone.

The total deaths of recovered Allied military personnel in the European theater may be detailed as follows:

In the week ending on 13 April 1945, there were 40 deaths reported. Two of these were from malnutrition, and one was from malnutrition complicated by bronchopneumonia. In the week ending on 20 April, there were 36 deaths. One was caused by diphtheria with malnutrition, one by uremia with malnutrition, two by pneumonia with malnutrition, and one by primary malnutrition. For the week ending on 27 April, there were 42 deaths, of which 3 were directly ascribed to malnutrition. For the week ending on 4 May, there were 27 deaths, of which one was due to malnutrition.


The beginning of the RAMP story had been a series of confusions and misinformation. The Nutrition Branch, Office of the Chief Surgeon, had not been alerted to the possibility of the large-scale starvation that was soon to be encountered. In the Stars and Stripes, Paris edition, of 26 March 1945, articles began to appear about the "living hell" and the starvation within the German prisons, but only as referring to the civilian and political prisoners. At first, there was no mention of the American, British, French, Russian, and other Allied soldiers who were incarcerated in these camps. On 30 March 1945, in the Paris edition of the Stars and Stripes, a small article appeared, describing how 1,000 American and British prisoners 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


5 April 1945, presented to the public the first concrete evidence that the American and British soldiers in the hands of the Germans had been subjected to less than the requirements of the Geneva Convention.

This article began: "150 mile death march comes to end as the Sixth Armored Division liberates 800 Yanks." The writer compared it with the infamous death march of the American and Philippine soldiers captured by the Japanese on Corregidor. These 800 soldiers, taken as prisoners during the Ardennes breakthrough, had been on the road for more than 3 months, stopping only when Nazi transportation officials pirated their ranks, forcing the Americans to fill bomb craters and to haul trestle lumber. The prisoners of war were 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. The breakthrough had caught them in subzero weather. They had had no medical attention. Lt. Col. Albert N. Ward, whose armored infantry battalion liberated the prisoners of war north of Friedberg, Germany, said: "As we entered the town the doughs looked like walking skeletons staggering out to meet us. They were thin and emaciated and they wept." One soldier reported his poor treatment and said: "After they had deposited their excreta on a manure pile, the Germans had dumped potato peelings on the same heap. The men were so hungry they removed the potato peelings, strung them on a wire, cooked and ate the spud skins." A soldier who lost 80 pounds during the 3 months' labor trek said: "They did everything possible to make life unbearable, threatening us with bayonets and firing small arms over our heads whenever we fell out of the columns during the marches." (See pages 253-255.)

First observations.-Shortly after crossing the Rhine, a survey team, consisting of Lt. Col. Wendell H. Griffith, SnC, Chief, Nutrition Branch, Office of the Chief Surgeon, ETOUSA, Lt. Col. Herbert Pollack, MC, and Capt. Leonard Horn, MC, on verbal orders from the Chief Surgeon, were in the forward areas to make observations on the nutritional status of the German civilian population and to see what the problems with the recovered Allied prisoners of war were to be. Their observations, based on a survey conducted from 4 to 11 April 1945, are summarized as follows:16

Trier, 4 April 1945.-The Allied Prisoner-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 4.8 ounces of bread and milk and sugar for coffee. Of these liberated soldiers, 150 were sampled; 15 were examined in detail. The general picture was that of severe emaciation and of weight loss. Many had nutritional edema and other signs of extensive deficiency. The Russian physician stated nevertheless that the men had improved 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 June 1945. Inclosure 30, Report of Nutritional Survey in Occupied Germany.


edema had disappeared. Tuberculosis was noted as one of the important problems.

Diez, 5 April 1945.-Stalag XII-A contained over 4,000 RAMP's, approximately half of whom were Russians. Several hundred American and British prisoners had been recovered at this camp, and the seriously ill had already been evacuated. Superficial examination of the remaining Americans revealed a picture of general malnutrition and nutritional edema. In practicably all of them, there were acute changes in the tongue, with the burning and soreness characteristic of glossitis, and changes in the skin referable to vitamin A deficiency. In the Russian section of this camp, the conditions were even worse-22 cases of typhus fever had been reported; tuberculosis was rampant and had been the cause of many deaths; emaciation was extreme; living conditions were filthy; and sanitary facilities were entirely lacking.

Niedergrenzebach, near Ziegenhain, 7 April 1945.-Stalag IX-A contained 1,200 American soldiers and many British, French, Russians and other nationals. The hospital had a capacity of 45 beds which were filled with American and British soldiers who were examined carefully. All showed marked loss of weight, changes in the skin, and tenderness in 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 were hypoactive and unequal or irregular. The physician in charge of the dispensary, an American medical officer, said that many soldiers with peripheral palsy had been evacuated that morning through medical channels. Beriberi had been common, according to this officer, but no evidence of scurvy had been observed. American Red Cross parcels had been plentiful at this camp up to a month before its capture. The German ration issue was very deficient. Breakfast consisted of a cup of ersatz coffee which the soldiers frequently used in lieu of hot water for shaving. Luncheon consisted of a ladle of vegetable soup and a small portion of bread. The soup stock was made from bone from which all meat had been removed. Pine needle infusions were added at times. The daily bread allowance was one 2-pound loaf for from five to seven men. The evening meal consisted of bread and soup; two to four potatoes per man were supplied several times each week. An extremely small piece of meat was issued about once a week. Eating grass was said to be customary. It was here that the practice of bartering Red Cross cigarettes for food was first encountered.

Heppenheim, 10 April 1945.-This was the location of the infamous APW (Allied Prisoner-of-War) Hospital where the official ration for the American patients was said to be about 400 calories a day. Twenty Italians were examined, and all gave a history of edema. An Italian medical officer in the group stated that almost everyone had nyctalopia, nocturnal muscle pains and cramps, paresthesia, and a shuffling gait. Examinations revealed a few tongue changes and in many cases healing ulcers of the buccal mucous


membranes. Butterfly distribution of facial seborrhea was seen as well as cheilosis and marked emaciation. The South Africans, in spite of the extensive marching that they had been forced to do, showed little beyond loss of weight. They, however, had had liberal supplies of Red Cross packages up to a recent date. One of their sergeants reported that the death rate on the marches had been very high. Edema had been very common; no scurvy was seen.

Conclusions.-The recovered Allied military personnel were extremely malnourished and presented a feeding problem demanding emergency measures. These troops had not received humane treatment, and no attempt had been made by the German authorities to maintain even the semblance of observance of the Geneva Convention.

Board of inquiry-On the basis of the survey findings and the reports forwarded to SHAEF, the Supreme Commander appointed a board of inquiry to go forward with the advancing armies and to investigate the treatment by the German Government of the American and British prisoners of war at the time they were recovered. Testimony and sworn statements were taken in the prison camps on the day of liberation. The board was composed of British, Canadian, and American personnel, among them the medical officer assigned to the Nutrition Branch, Office of the Chief Surgeon. Its observations are 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 German prison camps for Allied prisoners was fairly well known in some headquarters, and forecasts were available on the expected population of these camps, but there was little information about the conditions within them. The reports from the International Red Cross and the protecting powers were meager and sketchy and, as time has proved, inaccurate. Paragraph 4 of the letter report states:

In connection with any future consideration of the responsibilities to be placed on a protecting power, it is to be noted that the findings of the Board indicate indirectly, failure on the part of the Protecting Power to discharge its obligations. Quite conceivably, it may have been beyond the capabilities of the Protecting Power to remedy the existing situations, but certainly it must have been within its capabilities to advise the 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 as the Allied armies approached. But generally throughout the war, there were violations involving, "at one time or place or another every material condition and circumstance affecting the life and well-being of a prisoner of war." In part, these were "due to the deliberate policy of the responsible German authorities," and in part "to the negligence and/or brutality of the German personnel having charge of the prisoners of war." There were


instances where the German commandant and others "have probably done the best they could for prisoners in their charge with the material and supplies available, [but] the inadequacy of such material supplies has 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 and suffering of prisoners in their charge."

The ordinary rations issued by the Germans to the U.S. and British prisoners of war were at all times gravely inadequate both in quantity and in quality to maintain health or even, many times, to sustain life. They were in every instance grossly below the scale of rations issued to the German Army or the civilian population. The food was very inadequate in respect to the specific nutrients, proteins, vitamins, and minerals, as well as calories, and was commonly prepared under unsanitary conditions. In no known instance was provision made for kitchens, messhalls, or mess equipment for 200 men, or any large unit, in any way comparable to that provided for German field or base troops.

In one instance, a daily record was kept of the food issued to prisoners of war on a march lasting 82 days. The average caloric content of the German ration as issued was 850 calories per diem, equivalent to 650 calories per diem as consumed, the difference being due to condemned or other inedible food, which had to be discarded. Labor "Kommandos" were sometimes able to supplement their rations by food begged or stolen from farms on which they worked, or obtained from civilians by barter for cigarettes supplied by the Red Cross. At times also, if employed in heavy labor, they got an inadequate supplementary ration from the Germans, although this with some difficulty and generally through the insistence of the prisoner-of-war representative. Many prisoners were kept alive, and even in reasonably good health, by Red Cross parcels, which may have supplied as much as 70 percent of their average daily nourishment. From time to time, however, there were inexplicably wide variations in the number of Red Cross parcels issued as well as in the quantity of rations issued. Although these irregularities were usually laid to transportation difficulties, particularly in 1945, such difficulties did not have any corresponding effect on the nutrition of German troops.

The results of these conditions were seen when considerable numbers of prisoners of war taken at random in several camps were examined by two members of the board, the British and the American medical officers. They found in many cases present or past malnutrition evidenced by loss of weight, muscle atrophy, edema, pellagra, stomatitis, cheilosis, keratosis, night blindness (mostly in the British), muscle tenderness, and nocturnal polynuria (in almost all). The men who showed fewer signs of malnutrition for the most part were either prisoners from camps where Red Cross parcels had been received regularly or labor "Kommandos" who had been employed in agricultural work. The board also examined German sick and


wounded in two German hospitals and found no single case of primary malnutrition among them. In a large group of German prisoners of war (pp. 265-269) captured by the Allied armies, no cases of malnutrition were discovered comparable to those found among the British and American prisoners of war.

Concerning medical care, the board's report states (1) that hospital rations were insufficient both in quality and in quantity and never comparable to those the board saw the Germans issuing to their own sick and wounded, both military and civilian, and (2) that in many camps there was no difference between the rations issued to the sick and to other prisoners of war. In some camps, supplementary rations for the sick could be recommended by a prisoner-of-war medical officer and then authorized by a German officer, but they were insufficient and unsuitable for a large number of the patients to whom they had been given. On the whole, the German medical service apparently tried to be cooperative, but in many instances it was ineffective in obtaining correction of the deficiencies in accommodations, supplies, and food,

The report goes on to say that during movements of prisoners of war by march and by train all over Poland, Germany, and Austria, the sick and the wounded who were unfit to be moved were in some instances left behind with no medical personnel to look after them; in other instances, in spite of protests of prisoner-of-war medical officers, the unfit were made to march, and some died on the road. In general, the prisoners were compelled to work for excessively long hours.

The cold, strong, formal statement of facts in this report indicates the true picture, but descriptive statements are necessary to recreate the actual conditions. Typical living quarters in these camps were characterized by a stench impossible to describe. Cleansing utensils, water, soap, and disinfectants were completely lacking at times. Many of the hutments contained latrines at one end, and the others were limited to the bucket type of latrine. After the evening meal, the men were locked in their hutments.

About 25 April 1945, word was received that the German High Command of the Armed Forces had agreed to stop the mass evacuation of military prisoners from prison camps threatened by the advancing Allies. This agreement alleviated much of the suffering the prisoners had to endure by forced marches away from the liberating armies. The bulk of Allied military prisoners was recovered shortly thereafter.

Immediate problems.-The problems demanding immediate attention in the overrun camps were sanitation, delousing, provision of adequate living quarters, nursing care, and medical supplies. The prison hospitals were usually found loaded to capacity with from 50 to 400 patients, and there were many hundreds more who required hospitalization if facilities had been available. "Hospitalization" in many of the prison camps, however, was merely a word, with little relation to medical care as practiced in the


American Army. The insatiable desire of the RAMP's for food had also to be satisfied, and the ready generosity of the advancing Allies was one more hazard for these men. The writer, accompanying the advanced parties going into the camps as they were captured, saw how the incoming soldiers hastened to share their K- and C-rations with the RAMP's. Any prisoner who was luckless enough to consume a K-ration immediately would usually be seized with 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 enough to be hospitalized, who were to be evacuated through command channels by the Provost Marshal's personnel. Accordingly, as has been related, the representatives of the Chief Surgeon's Office did in fact direct the greater part of their time and attention to preventing secondary hospitalization of these liberated prisoners. The experience with the first 4,400 RAMP's to arrive at the Lucky Strike deployment area confirmed the first impression that had been gained by direct inspection of the recently overrun camps at Limburg, Niedērgrenzebach, and Heppenheim concerning the extreme sensitivity of the gastrointestinal tract of these men to most foods. As narrated in the earlier section (pp. 245-246), the planned dietary regimen had been instituted and was in practice before the bulk of the prisoners arrived. The need for it was amply proved by the resulting reduction in the number of those who had to be hospitalized, from approximately 25 percent in mid-April 1945 to approximately 0.03 percent 1 month later.

The first inspection of the prisoners of war had revealed malnutrition in all its forms. An immediate necessity was to define categories 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, usually hospitalized); (2) the emaciation syndrome due to prolonged starvation; and (3) acute starvation. The deficiencies noted were listed in order of frequency and severity as follows: Total calories, protein, vitamin C, thiamine, nicotinic acid, and riboflavin. The majority of the recovered personnel were only moderately undernourished and did not require hospitalization on that count alone. Their nutritional rehabilitation could be satisfactorily accomplished in reception camps, although many men, as has been seen, had to be hospitalized because of severe gastrointestinal distress due to improper feeding. (Parenthetically, it may be said here that the field and evacuation hospitals performed their unexpected tasks well.) The sickest prisoners had been the first to be left behind by the retreating Germans, and in these the Army Medical Corps was finally confronted with the end results of malnutrition.

The 1st General Medical Laboratory, Paris, France, was alerted to save all tissues from fatal cases in order to gather as much teaching material as possible for the study of starvation. For Americans, in World War


II, had now indeed every opportunity to study malnutrition, from its early manifestations in trainees to its ultimate outcome in prisoners of war, while in the captured camps they could observe at firsthand its penultimate phenomena, chronic emaciation and acute starvation.


From war to war, the repetitive nature of many of the nutritional disturbances observed is well documented, particularly the so-called famine edema, which has been described by many writers in many languages. In the early morning of literature, Hesiod, in his "Works and Days," speaks of the starvation a hard winter brings, and advises prudent thrift "lest the helplessness of evil winter overtake thee, and with wasted hand thou press thy swollen foot." Scaliger attributes to Aristotle the remark that in famished 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 in 1528, referred to soldiers with pallid visages, swollen legs, and bloated bellies, scarcely able to crawl. Sydenham refers to the condition when he makes use of the quotation "Ubi desinit scorbutus, ibi insipit hydrops." He qualifies his quotation by calling it a saying of the vulgar, meaning to imply that, when a dropsy has shown itself by clear signs, the preconceived notion of scurvy falls to the ground. Still, the connection between scurvy and dropsy in a popular saying suggests that the conditions under which the disease arose were closely allied in the minds of the 17th century public.

Lind, quoting van der Myle's description of the diseases observed during the siege of Breda in 1625 says: "Of those who were afflicted with the flux, few escaped. They afterward became bloated, relaxed and dropsical. Watery swellings of the testicles were frequent. Some died early in the disease. Those who had seldom any evacuation of the blood by the nose or stool and seemed from the beginning indolent, dispirited and blown up, as it were, with the wind, their stools were greasy, fetid, and of various colors, but not frequent."

A clear distinction between famine dropsy and scurvy and between beriberi and the various final edemas of inanition or diarrhea was made by Cornish. He described the condition with great precision in 1864 as occurring among prisoners on certain dietaries in the Madras jails. "Under this system of diet the men became unhealthy, and within three months six of the 100 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 the progressive stages of starvation as reflected in the unfortunate inmates of POW and concentration camps during World War II. In so doing, he has also revealed the hazards of improper diet and portrayed the pathognomonic symptoms of nutritional deficiency diseases to present-day clinicians called upon to advise their patients in matters of dieting.-A.L.A.


dropsy and the tendency to serous effusions into the cavities of the pericardium, thorax and abdomen are the only evidence, as indeed are 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 prison camps received considerable publicity-less well known forms of starvation were also seen. The nutritional degradation of some of the sick and wounded was a clinical problem encountered in all theaters.

Diagnosis.-The differential diagnosis of the end results of malnutrition-of emaciation from starvation-can be made on clinical grounds by a physician well grounded in physiology. Acute starvation phenomena (p. 261) are due to complete deprivation of food. People so starved do not survive very long if the fluid intake is limited also. The malnutrition that leads eventually to the emaciation syndrome is different. Here, there is sufficient caloric and food intake to insure survival for a time but not enough to maintain a normal metabolic level. The outstanding deficiency is of course in calories, but this is not the most important one. The specific nutrient deficiencies, especially in protein, are responsible for much of the clinical symptomatology. Wasting phenomena, particularly of the musculature, will be the end result of a negative caloric and nitrogen balance. The emaciation syndrome, when present, is the predominating one, and calls for the most careful therapy.

Chronic emaciation-The history elicited from these patients and their physical findings are very characteristic. Usually, there has been a food intake averaging as low as 600 calories daily during long periods of forced labor or forced marching. In surviving individuals, this eventually leads to the total emaciation syndrome. Weight losses up to 60 percent of the original body weight have been recorded. The patient as seen in the late stages presents a very characteristic picture. One observes a completely apathetic, very thin individual, usually lying immobile, legs flexed across the abdomen, arms folded across the abdomen or chest. The position is maintained even if the patient is rolled over. There is no true ankylosis of the joints, as the patient can with much effort 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 the femur are the common sites of bilateral, symmetrical, rough, pigmented, and scaling areas. Light pigmentation of infraorbital and frontal areas is frequently seen. In the latter site, it resembles the chloasma pigmentation of the pregnant female. Muscular atrophy is severe and extensive, the temporal atrophy appearing early. This, coupled with the loss of orbital and malar fat pads, gives the peculiar death's head appearance common to all of those affected. The legs and arms appear merely as contours of the long bones covered with a tight


skin. The buttocks are concave and follow the contours of the ilium and ischium. The paravertebral sulci are deep. Even such a muscle as the pectoralis major almost completely disappears, and the second and third ribs as 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 a marked hirsuties of the face and extremities; the voice though weak is coarse. The history reveals a complete amenorrhea usually from the second month of incarceration. The males may have a smooth face with sparse hair growth; the voice 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 pulse rates show a marked bradycardia of approximately 35 to 50 beats per minute. Resting blood pressures are as low as from 60 to 80 mm. Hg systolic and from 30 to 40 mm. Hg diastolic. The slightest activity or excitement precipitates a dyspnea and tachycardia, indicating an extremely limited cardiac reserve, which must be recognized in instituting therapeutic procedures. Histological examination of the heart confirms this clinical impression.

The eyeballs are soft, and the conjunctiva are wrinkled. There is usually a marked enophthalmus and a dry eye. The sclera have a porcelain, bluish-white appearance which is quite characteristic. They are markedly 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, the hemoconcentration may give an apparently normal value. Deep tendon reflexes will vary from marked hyperactivity to complete absence. Because of the painfulness of the joints, it is difficult to evaluate them properly. Anal incontinence is very common and is manifested by fecal encrustation in the gluteal folds. These people are in a physiologically hibernating stage. Their body weights vary from 50 to 75 pounds, the greater part of their weight representing a skeletal structure which is comparatively inactive metabolically; their daily caloric requirements are as low as 500 calories at this point. Where one is able to get a lucid description of their downhill progress, it is evident that these patients have passed through the stages of nutritional edema with the specific nutritional deficiency syndromes of beriberi and pellagra. Many die during this degradation process. Those who manage to accommodate themselves to the reduced nutrient intake by the compensatory decrease in metabolic levels survive to this condition of emaciation.

At this stage, the adjustment of the circulation and other physiological processes is a very narrow one. The maintenance of life is dependent upon not upsetting this balance too abruptly. Therapy begun too aggressively


in an enthusiastic effort to restore these people to normal may result in a breakdown of the compensatory mechanisms, and death frequently ensues.

It should be borne in mind that those who dehydrate are the ones who survive. It is rare to see nutritional or famine edema in this stage of total emaciation. Nor do these people present the signs and symptoms of the B-complex deficiencies. These vitamins constitute functionally the prosthetic components of the enzyme systems in carbohydrate and protein metabolism. With metabolic levels at a minimum, the demand for these vitamins is very low. When, however, one burdens the body with a sudden plethora of foodstuffs, then the vitamin requirements immediately increase proportionately, and unless this new need is met acute deficiencies result. in addition, the cardiac reserve is so extremely limited that a sudden change in the circulating blood volume throws a burden on the atrophic, flaccid, degenerated cardiac musculature 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 toward supplying, first, calories, then the B group of vitamins, then proteins, and eventually a definitive therapy complete as to calories and nutrients. Experience has shown that oral administration where tolerated is the route of choice. Gavage should be resorted to only when necessity dictates, and intravenous therapy, only in the presence of nausea, vomiting, or intractable diarrhea. Milk and egg mixtures, fresh or powdered, are well tolerated by the majority of these people. No attempt should be made for the first 24 to 48 hours of therapy to do more than reeducate the gastrointestinal tract to the acceptance of these foods. No more than 1,500 cc. of the fluid mixture should be given by mouth in each of the first 24-hour periods. The salt content of the fluid mixture must be carefully controlled; otherwise, edema will result. If nausea or vomiting is precipitated by the oral administration, then intravenous therapy may be instituted. Here, more than ever, extreme caution must be used, or reactions will develop in a high percentage of these extremely sensitive patients. No more than 500 cc. of normal human blood plasma or blood should be given in the first 24 hours at 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, mashed potatoes, and thin soups are added slowly, as tolerated. In other words, only low-residue foods, mechanically nonirritating and bland, should be given for several weeks in order to avoid precipitating acute gastroenteritis which, in the debilitated state of these people, would be a serious complication. Autopsy material, as will be shown, lends support to these clinical observations (p. 288). Once recuperation has started and the patient has demonstrated his ability to tolerate food, then more active treatment can be instituted. Iron therapy for the anemia is of no value until a positive nitrogen balance has been well established; in addition, iron salts by mouth notoriously produce gastro-


intestinal upsets. Vitamin therapy is a necessary adjuvant but only as supplementary to the high-protein, high-caloric intake.

Acute starvation-In contrast to the picture of chronic emaciation that has been described is the clinical syndrome of acute starvation. By this is meant the condition of one who has been deprived of food and fluid for several days. In this condition, there is usually ketosis and acidosis with signs of acute dehydration. These patients require intensive therapy as quickly as it can be given. Intravenous fluids with emphasis on the glucose-saline mixtures is indicated. No special dietetic therapy is necessary except what is required by secondary conditions. Recovery is usually prompt and complete. By contrast, the syndrome of malnutrition is evident, in varying degree, in those people with intakes adequate in calories but inadequate in specific nutrients. This was more commonly observed in the Pacific area than in the European area. With an inadequate intake of specific nutrients the metabolic levels remain high. The requirements for vitamins remain normal. Since the diet does not contain the required amount of vitamins, deficiency syndromes become manifest. The first oral feeding will frequently determine the speed of convalescence. Should the food produce an enteritis or gastroenteritis, convalescence will be greatly prolonged and therapy made more difficult.

Edema was not an infrequent finding in recovered prisoners seen during the intermediary stages leading to total emaciation. This varied from swelling of the dependent lower extremities to generalized anasarca. It was usually due to a low serum protein value with an adequate salt intake. Values as low as 1.8 gm. per 100 cc. of blood have been observed. Mild edema disappeared within a few days after beginning a high-protein intake. Severe anasarca persisted somewhat longer, but a polyuria was manifest by the second day. Over 33 percent of the patients with total emaciation treated in U.S. Army hospitals developed edema in the course of the first week of therapy until attention was directed to the salt content of the nutritive foods given for rehabilitation.

In the literature, famine edema has usually not been associated with albuminuria, cardiac dilatation, or neuritis. It has been observed more particularly in men called upon to perform hard physical work 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 for hospitalization of recovered prisoners and details of treatment were outlined in Circular Letter No. 36, for three groups of patients. Group I comprised patients showing a moderate loss of weight, weakness, gastrointestinal distress but no definite signs of protein or specific vitamin deficiencies. Approximately 80 percent of those hospitalized because of malnourishment were in this group. The hospitalization was considered necessary to combat weakness and gastrointestinal dis-


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 as follows:

The tolerance of the gastrointestinal tract to the first foods eaten will [frequently] determine the immediate dietary procedures to be followed. 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 in weight are the primary goals. The diet should supply at least 150 gm. of protein as soon as normal eating is possible. Initial gain in weight will occur on an intake of 2,500 to 3,000 calories, if the protein intake was adequate. Over 4,000 calories will be required for a more rapid restoration of body weight.

Multivitamin supplementation is necessary only during the period when gastrointestinal distress prevents normal eating. No more than four 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, and glossitis. Approximately 20 percent of liberated personnel hospitalized because of malnourishment were found in this group. The initial feeding for Group II patients was to be similar to that prescribed for patients in Group I, if food could be tolerated by mouth. Other points of dietary management were as follows:

Patients with edema who cannot tolerate food by mouth will require intravenous therapy. Plasma and whole blood are indicated. Transfusions should be given at a rate of not more than 2 cc. per minute. Dyspnea, precordial discomfort, and apprehension are danger symptoms that should lead to immediate discontinuance of the transfusion. [Unfortunately, human salt-free albumin was not available. The use of salt-poor food was further emphasized periodically as experience was gained with the development of edema in these patients.] The treatment of the macrocytic anemias is dependent on the restoration of the protein deficits. Oral administration of iron is not recommended until nitrogen balance has been reestablished. Multivitamin supplementation is necessary in most of the severely malnourished patients during 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 in hospitals relatively rarely, because they usually were not able to survive transportation. Such patients required immediate therapy in the form of transfusions of plasma or whole blood given very slowly and with extreme caution. Thiamine hydrochloride, 30 mg., was given parenterally at 24-hour intervals.

As presented in Circular Letter No. 36, diluted milk and soup preparations were suggested for the initial feeding of malnourished soldiers 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 cups of water; three-fourths cup of sugar and three-fourths teaspoon of salt.

One quarter of a canteen cup of the diluted milk should be given warm every half hour, as tolerated. Water may be taken in sips between feedings to the extent of 2 can-


teen cups daily. Powdered egg or prepared cereal * * * may be added to the diluted milk after the first day if gastrointestinal distress is absent.

Soup may be prepared from canned meat and vegetable stew or from canned meat and noodles if milk is not available. [These were made in dilute form.] Soup may be thickened with flour or cereal.

The medical officer assigned to the Nutrition Branch visited the chiefs of all the major hospitals concerned in the treatment of recovered prisoners. Clinical observations and statistics derived from these visits are described in the section "RAMP's in Hospital" (pp. 284-288).


In liberated countries.-While the Office of the Chief Surgeon had direction of the nutrition of troops and of prisoners of war, the relationship of its work to civilian populations was not definitely clarified. Teams18 were dispatched from the Zone of Interior to conduct nutritional surveys under the general direction of the Chief Nutrition Consultant, Public Health Branch, G-5 Division (civil affairs/military government), SHAEF, and their services were made available to the various missions and to the Army groups. Two types of survey were done. The first was the so-called rapid survey, or observation of a representative sample of the community by means of a simple medical examination to establish the presence or absence of florid manifestations of deficiency disease. Subsequently, the dietary history was obtained in a careful interview in order to estimate as closely as possible the food intake. A study of patients in asylums, hospitals, and orphanages gave information on the basic food supplies. Some laboratory tests were done on a small percentage of those who were examined clinically. It was found, too, at this time that extensive weighings on street corners of random samples of the population yielded significant evidence of caloric intake and work output. This comparatively simple technique can be adapted to any population and can be used as a means of following the progress of any large group under observation.

The civilian population included not only the normal populations of the occupied and liberated countries but also large numbers of displaced persons. On the whole, the state of nutrition in European countries was much better than had been expected except that there was serious malnutrition in Holland, particularly where a complete embargo had been imposed by the Germans. Complete reports19 of the various areas were submitted by the consultants in nutrition and the survey teams who covered most of the Continent during their course of duty.

18Annual Report, Nutrition Division, Preventive Medicine Service, 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 through December 1945.


In France itself, when it was liberated, rather detailed reports were given by the French physicians on the situation that had obtained during the time of the German occupation. Edema had been a very common thing among the poor people of Paris. Osteoporosis, or Milkman's disease, with fractures of the vertebrae was very frequent, occurring usually in older women. The X-ray evidence for this story was remarkably good. Amenorrhea, as would be expected, 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 was found 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 emaciation were the principal nutritional problems. There was an increase in general mortality. The height and weight of school children showed some decrease from the previous figures in 1939. It was estimated that death occurred in approximately 10 percent of the cases hospitalized for starvation. The preliminary estimate showed that there were approximately 200,000 cases of malnutrition sufficiently severe to be referred for special handling.

In Rotterdam, the average loss of weight was 25 pounds in the 19- to 59-year age group, and 40 pounds in people over 60. In Amsterdam, 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. In that 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, where the average loss of weight was 21 pounds in the age group 19 to 59 and 39 pounds in those over 60, edema was found in 10.5 percent of those from 19 to 59 years old and in 25 percent of those over 60 in the poorer economic class. There was less than half this amount of edema in middle-class people, and it was practically unknown among the well-to-do. Dutch physicians studying this starvation edema reported two types: (1) The edema with diuresis that accompanied slight emaciation and disappeared as chronic emaciation set in, and (2) the edema that occurred with extreme emaciation. They found a lowered basal metabolic rate, decreased body temperature, spasms of the voluntary muscles, particularly in eliciting deep tendon reflexes, and extensive brownish pigmentation of the skin. Under therapy of bed rest and high-protein diet, the edema disappeared rapidly.

In Germany and Austria.-Other civilian areas were seen by various people during the postwar period, in particular the German and Austrian concentration camps. The author of this study visited many of these personally. Early in May of 1945, he inspected the concentration camps at Mauthausen and at Güsen. The camps had a population of approximately 18,000 when taken over on 6 May 1945. There were hundreds of unburied bodies lying around at that time. The death rate continued at a very high level. The writer did many autopsies in these camps. Pulmonary tubercu-


losis was, of course, a common cause of death, but malnutrition was probably the greatest. Clinically, the patients presented the usual manifestations of extreme emaciation, some edema, diarrhea, and marked gastrointestinal symptoms. There were questionable cases of beriberi, some riboflavin deficiency, and an occasional case of pellagra. Autopsy findings corroborated the clinical report, and details of these autopsies are presented on pages 288-291.


It was many months after the crossing of the English Channel in June 1944 before the German prisoners of war became much of a problem. In the passage across France, they were at first captured in small groups but never in wholesale lots until the fall of Brest. By the week ending on 9 February 1945, the prisoner-of-war strength climbed suddenly to 241,545. The morning sick reports did not yield any major evidence of nutritional disturbances although approximately 486 were on report for diarrheal diseases and only 8 for Vincent's stomatitis. The bulk of the men reported for common respiratory diseases, trenchfoot, and frostbite. By the week ending on 16 February 1945, there were 246,281 prisoners of war, and, by the week ending on 23 February 1945, there were 249,272. These massive numbers required medical care and subsistence. The Office of the Chief Surgeon became concerned with the nutritional 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 Provost Marshal, a survey was made on the nutritional status of the German prisoners of war in representative enclosures, labor camps, and hospitals on the Continent. The survey was conducted under the general supervision of Colonel Griffith and was directed by Colonel Pollack, who had one Medical Corps officer and three Sanitary Corps officers to help him. This team examined 800 prisoners during February and March 1945 at 21 different installations, including 5 continental enclosures, 7 work camps, 2 prisoner-of-war hospitals, and 5 general hospitals. The number of prisoners examined was considered statistically significant, and the findings were believed to be representative of the total prisoner population on the Continent. The prisoners were classified as new or old according to whether they had subsisted on the U.S. Army POW ration for fewer or more than 50 days. The new group included 312 prisoners and the old group, 488 prisoners. The survey was of a clinical type and is reported in detail in the report20 dated 15 May 1945. The findings in general were as follows:

20Essential Technical Medical Data, European Theater of Operations, U.S. Army, for May 1945, dated 26 July 1945. Inclosure 16, 15 May 1945, subject: Report of Nutritional Survey of German Prisoners of War Under Control of the United States Army on the European Continent.


The body weights of the prisoners as estimated by gross appearance and by the condition of the skin and subcutaneous tissue were approximately the same in new and old groups. Many had lost weight before capture, but over 93 percent appeared normal in this respect. There was definitely no indication of loss of weight in the group who had been fed the U.S. Army POW ration for a period longer than 50 days.

There was no evidence of protein or mineral deficiencies attributable to the diet in the old prisoners. The general health of the old prisoners was better than that of the new prisoners as indicated by daily sick call.

The energy content of the ration fed to the nonworking and intermittently working prisoners averaged 2,800 calories. This was from 10 to 20 percent greater than required for the maintenance of these groups.

The energy content of the ration fed to the working prisoners averaged 3,050 calories. A ration supplying from 2,800 to 3,000 calories was believed to be adequate for this group unless more strenuous labor was performed than was observed during the survey.

Riboflavin deficiency as evidenced by angular lip lesions and magenta-colored tongue and by nasolabial seborrhea was surprisingly common in the new group. The regressing or healed lesions were found in the old group which demonstrated that the U.S. Army POW ration not only prevented a deficiency in this instance but also permitted rehabilitation of tissue damaged by previous dietary insufficiency.

Thiamine deficiency was noted in both groups and was recognized by tenderness of the calf, abnormal reflexes, and diminution of vibratory sense perception. The incidence of this deficiency was definitely lower in the old groups.

It was concluded that subsistence on the U.S. Army POW rations for from 50 to 200 days resulted in marked improvement of the overall status of nutrition in the German prisoners. It was further concluded that the nutritional value of the U.S. Army POW ration was superior to the German Army ration and was adequate for the maintenance of the health of the working prisoners.

With the end of the war and after V-E Day, however, the surrender of hundreds of thousands of men simultaneously had precipitated feeding problems with consequent periods of very restricted food intakes. This resulted in extensive malnutrition among the disarmed enemy elements. Accordingly, surveys to determine their nutritional requirements were made periodically in the prisoner-of-war enclosures and the hospitals treating these people. A report of one such survey,21 dated 31 August 1945, shows the general problems of the time. It was found that the body weights for the nonworker group studied were below standard in all prisoners except

21Essential Technical Medical Data, European Theater of Operations, U.S. Army, for August 1945, dated 22 Sept. 1945. Inclosure 8, 31 Aug. 1945, subject: Report of Nutritional Survey of German Prisoners of War and Disarmed Enemy Elements Under Control of the United States Army on the European Continent.


those who had recently been evacuated from Italy. The body weights of the workers receiving approximately 2,900 calories were consistently higher than those of the nonworkers and within normal accepted standards for their age groups. Workers receiving less than 2,000 calories daily were definitely undernourished. In some of the nonworking groups receiving less than 2,000 calories a day, there was suggestive evidence of early muscle atrophy indicative of depleted protein reserves.

Deficiency syndromes relating to the B complex vitamins were evident in the nonworkers subsisting on American POW rations. Although there was evidence of these deficiency syndromes in those prisoners subsisting on locally procured German food, it was not so marked as in the groups subsisting on the American POW ration. It was believed that this difference was due to the use of some highly milled unenriched flour which furnished a large part of the energy value of the American POW ration. The German ration included a 95-percent extract flour which supplied many of the B vitamins.

As a matter of practical policy based upon experience, it was decided that rural populations and agricultural workers were to be considered as self-sustaining. The confined prisoner and the urban dweller, on the other hand, had to be assured the minimum food requirements to maintain health and resistance to disease. Persons behind barbed wire could not supplement their rations so easily as civilians could from accumulated stores, garden produce, and such other sources as "the country cousin" and the black market. The difference was found reflected in the respective nutritive condition of civilians and prisoner's living on the same official ration scale. The main attention, then, in setting up ration scales had to be directed toward meeting the requirements of those unable to produce or supplement their own.

It was determined that a period of nutritive rehabilitation should be authorized for all prisoners of war and disarmed enemy elements who presented evidence of malnutrition. Such persons should be authorized, upon the personal investigation and recommendations of the responsible U.S. Army Medical Department officer, a full worker's ration for a 20-day period together with relief from work details. This was not to be in lieu of hospitalization for the severe or moderately severe cases of malnutrition.

There was evidence of very extensive malnutrition among the prisoners of war and disarmed enemy elements in the large enclosures maintained by the Third and Seventh U.S. Armies and by the Communications Zone. There was a complete lack of uniformity in the ration scales among the various areas in Germany. The Seventh U.S. Army area, for example, sustained the prisoner's of war on U.S. Army food, while in the Third U.S. Army area the disarmed enemy was subsisting on food locally procured. The caloric scales varied with the location from 1,265 to 2,157 calories for


nonworkers, and from 1,450 to 2,296 calories for workers during the month of July.

There was consistent evidence of an insufficient amount of riboflavin and nicotinic acid in the diet for the conditions under which these men were living. These signs were particularly numerous in the younger age group, 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 Army ration had been deficient in riboflavin and nicotinic acid for some time. Superimposed upon this deficiency intake of fairly long standing was the variable period of severe deprivation of all nutrients during the final weeks of the active campaign and of unavoidably inadequate rations in the forward POW enclosures. At best, the POW ration could only be expected to maintain an existing state; it was never designed as a therapeutic diet.

In the various enclosures, the interpretation of the designation "worker" was quite different. In one, prisoners were made to build roads in the compound area. Men carrying crushed rock in sacks to the point of work, 4 pounds on each trip, were not designated workers because the project was an intracompound improvement. In another compound, men who worked only 4 hours a day were given the full ration for heavy labor because they worked outside. At other camps, clerks and camp administrative personnel were given a full heavy worker's ration even though their work was sedentary. In some compounds, the prisoners subsisting on the nonworker's ration, were put through several hours daily of calisthenics and drill. A survey in the Delta Base Section disclosed that general labor service units, given 2,900 calories daily, had a consistently lower sick call rate than 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 June 1945, for instance, was 233.7 per 1,000 for the confined group, and only 98.3 per 1,000 for the labor service unit. This difference was maintained throughout a considerable period of time.22

It was evident that the term "worker" had to be redefined 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's ration 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 in the American installations, and similar activities. Heavy work was defined as manual labor for more than 4 hours daily. The nonworker's ration was to be issued only to inactive prisoners, limited to a routine of self-care in the cage.

22In the Korean War, camp administrative personnel on Kojedo Island were subjecting the North Korean prisoners of war to calisthenics and to exercise such as running several times a day around the compound, a distance of almost half a mile, although the North Koreans were theoretically nonworkers and were subsisting on the nonworker's ration.-H. P.


One of the most important recommendations made in the 31 August 1945 report was that the full worker's ration of 2,900 calories be authorized for issue to prisoners of war under 21 years of age. During the last months of the war, the German Army had recruited boys from 14 to 20 years of age in whom, as is well known, metabolic requirements are higher than in adults.

The German-operated hospitals for disarmed enemy elements fared very well with respect to rations. Most of the hospitals were established institutions with well-planned gardens and large stores of processed foods which had been built up in the past. Furthermore, they were allowed to draw full civilian rations from the local areas for the patients plus the numerous supplements for the special diets involved. Many instances of grossly inaccurate diagnosis by the German medical staff were found. In one hospital, several patients admitted with a diagnosis of nutritional edema were examined. In none of these cases was the diagnosis substantiated, but a multiplicity of causes was found 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 report23 was submitted on the nutritional survey of the disarmed enemy forces in that country. At this time, conditions had improved considerably. There were still isolated spots where immediate intensive therapy in the form of high-calorie bland foods was required, but there was direct evidence of gains in weight among the prisoners.

Trench nephritis-During the survey on the nutritional status of German prisoner-of-war patients, the various surgeons in charge were asked about cases of edema, nephritis, or cardiac failure observed by them. The problem of the co-called trench or, as the Germans called it, "feld" nephritis was discussed with the German medical men in the POW enclosures. A brief summary follows.

There were many cases in the German Army, but the exact number is not known. The syndrome was most prevalent on the Russian front, and its incidence was highest during the autumn and winter months. In Finland, where special rations of high nutritive value were issued to German troops with, in addition, vitamin supplements, the incidence of trench nephritis was much lower than on the adjacent Russian front.

The patient usually presented himself with a history of having been in previously good health and on full duty status before the onset of the illness. There was generally no history of immediately antecedent infection such as tonsillitis, pharyngitis, or other acute respiratory disease. The age group in which this condition occurred was from 35 to 50 years. The disease was first manifest with a swelling of the face and the lower extremities.

23Essential Technical Medical Data, European Theater of Operations, U.S. Army, 26 Oct. 1945. Inclosure 9, 26 Sept. 1945, subject: Report of Nutritional Survey of Disarmed Enemy Forces in Austria.


This might go on to generalized edema in the severe cases. Headache, backache, and aching in the neck were generally noted in the prodromal stage. Dyspnea on rest or exertion might occur, and occasionally convulsions were reported early in the illness. Urine was scanty and dark at the onset.

The physical examination showed the edema as the presenting manifestation. The temperature was not always elevated at first. Cardiac rhythm was normal, usually with a sinus bradycardia. Pulse rates were observed to drop as low as 50. Hypertension occurred in some cases and initially was a frequent finding. No organic murmurs were heard in the heart areas. The lungs were essentially clear, although occasionally there were signs of a pleural effusion. Enlargement and tenderness of the liver were common, and in many patients signs of ascites could be elicited. The eye grounds rarely showed evidence of hemorrhage or exudate. The urine had a high specific gravity although albuminuria was absent in the mild cases but was as much as 3 plus in the severe cases. On microscopic examination, the urine was usually found to contain numerous red blood cells and some casts. Blood urea nitrogen or nonprotein nitrogen was normal or moderately increased. Total proteins were usually normal. X-ray examinations of the chest showed pulmonary congestion, small pleural effusions either unilateral or bilateral, and occasionally cardiac enlargement.

Electrocardiographic studies usually showed low voltage; small T wave changes, either low positive deflection or isoelectric or inverted; and of course the sinus bradycardia. The clinical course of the condition was usually uniform. Most patients recovered completely on bed rest regardless of therapy. Some few progressed to the chronic phase with hypertension, eye-ground changes, nitrogen retention, and persistent abnormal urinary findings. Autopsy findings were not available, but reliable reports of two autopsies indicated a lack of significant glomerular pathology.

In conclusion, it was noted that this syndrome, which was said to be prevalent in the German Army and was seen in the German prisoners of war in the U.S. prisoner-of-war compounds, was not reported in the U.S. Army troops. The two Armies were, of course, exposed to the same terrain and climatic conditions, and there had been sufficient contact between them to permit transmission of a communicable agent. There was, however, a very marked difference in the rations of the two Armies. Although no positive statements can be made, the evidence strongly suggests that there was a nutritional factor in the precipitation of this syndrome.


Repatriated American Soldiers

After the war ended in the Pacific, the results of the imprisonment of the captured American soldiers became and remained the subject of some


discussion. The length of their imprisonment averaged about 39 months. Harris and Stevens24 state that official studies conducted at the time of liberation or shortly thereafter indicated that almost all had suffered from severe malnutrition in multiple forms, and from many other diseases, during imprisonment. This is confirmed in the report of the U.S.S. Haven, published January 1946.25 In this study, 66 percent of the men who survived gave a history of beriberi; 58 percent, dysentery; 43 percent, malaria; 20 percent, skin disorders; 19 percent, pneumonia; 14 percent, pellagra; 6 percent, tuberculosis; and 9 percent, malnutrition otherwise unclassified-45 percent of the men experienced edematous swellings. Over 75 percent of the prisoners at Cabanatuan had burning feet. Hibbs,26 in a study of beriberi in Japanese prison camps, said that 2 percent of the prisoners developed motor paralysis. Recovery in many of these men was rapid. A survey by Brill27 of neuropsychiatric examinations made from 1 to 8 weeks after liberation of 1,617 men who had been prisoners of war for 39 months, or longer, revealed only 5 of them with psychoses, only 0.7 percent with psychoneuroses, and 12.7 percent with some psychologic disturbances, generally of the overanxiety type. There were 13.1 percent with peripheral nerve disorders, but most of these were not severe. There were 64 cases of optic atrophy in this group. It was stated that the overall mortality during imprisonment of the Pacific prisoners of war was 37.2 percent. The expected mortality 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 was imprisoned by the Japanese, as described by Goldblith and Harris.28 The prisoner, Goldblith, kept an accurate daily record, averaging on a monthly basis, of the various nutrients obtained by American officers from the food supplied by the Japanese and by Red Cross parcels during their imprisonment from 1942 to 1945. Goldblith analyzes the specific nutrient intake as follows: During certain months, the dietary fat fell as low as 15 percent of the desired amount. This may have a bearing on the fact that all officers were suffering from dry scaly skin at all times. He suggests the possibility that there was a deficient intake of the essential fatty acids such as aracidonic and linoleic acids. Marked hypoproteinemia began to show in October and November of 1944. The average weights of the officers did not go down but in fact increased, owing to the development of edema. Toward the end, Goldblith noted that the addition of only 16 grams of animal protein per

24Harris, B. R., and Stevens, M. A.: Experiences at Nagasaki, Japan. Connecticut M.J. 9: 913-917, December 1945.
25Monthly Progress Report, Army Service Forces, War Department, 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.: Neuropsychiatric Examination 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 an Analysis of Data on the Nutrition of American Officer Prisoners of War at the Zentsuji Prisoner-of-War Camp at Shikoku, Japan. Project No. NR-123-298, Massachusetts Institute of Technology, Contract No. NRonr-297, for Office of Naval Research.


officer per day was followed by a cure of the edema and a gain in weight in November 1944. He points out that the diet consisted almost entirely of vegetable foods with rice, barley, and to a lesser extent soybean as the staple foods. There was a large amount of green vegetables in the diet and, consequently, no lack of vitamin A, ascorbic acid, or iron. There was sufficient thiamine in the diet of the officers until the last 12 months of the period studied; then, suspected cases of beriberi were discovered during this period of low thiamine intake. The riboflavin intake was never adequate during the entire period, and clinical manifestations of deficiency were apparent. Pellagra was observed intermittently during the 31 months of incarceration between December 1942 and June 1945.

The worst part of the imprisonment was in the Philippine Islands from March to October 1942 where the prisoners were kept in Camps O'Donnell and Cabanatuan. At the close of the Battle of Bataan, American and Filipino prisoners of war were maintained by the Japanese on diets far below the accepted standards in the United States. Of a total of from 14,000 to 16,000 American prisoners and 60,000 Filipino prisoners, over 1,500 Americans and 2,700 Filipinos died during the 60 days they were at Camp O'Donnell, and over 2,100 Americans died in Cabanatuan in as short a period. This can be ascribed to the exertions of the "death march" as well as to malaria, dysentery, and poor sanitation or to malnutrition and actual starvation, although these were perhaps the most important causes.

At Camp O'Donnell, the daily diet consisted of approximately 12 ounces of dry rice of poor quality, from 2 to 4 ounces of native sweet potato, and 3 ounces of sweet potato tops, all boiled together in soup. Once a week, a quarter ounce of meat was issued to each prisoner. This was a never-varying diet for the captives at this camp. At Cabanatuan, the daily rations were somewhat better. Here, about 16 ounces of rice and 4 ounces of vegetable, sweet potato or corn, were included in the daily ration. Once each week, 1 ounce of carabao meat was issued, and, in season, one thin slice of cucumber was given to each man each day. At 2-week intervals, 2 ounces of coconut or banana were issued, cooked with cornstarch and sugar in the form of a pudding. One-quarter of a pound of hydrogenated coconut oil for the soup was issued per man per week.

It must be recalled that when the troops were on Bataan they went on quarter rations early in January 1942. Beriberi was observed by March 1942 and increased to a marked degree by September 1942. Many men were observed to die from the beriberi heart. Pellagra became marked toward the end of September 1942. Scurvy, until October 1942, was very questionable. Ariboflavinosis demonstrated by cheilosis began to be observed by September of 1942. By October 1942, the majority of the prisoners of war were suffering from malnutrition in some form or other. Severe and sharp shooting pains in the feet and legs were complaints during the winter months of 1942-43 (fig. 38). This developed into gangrene in many cases.


FIGURE 38.-Sketch, attitudes of beriberi, wet and dry, November 1942.

In test cases, this deficiency disease was definitely cured by massive doses of thiamine administered intraspinally and intramuscularly.

It is interesting to note in the conclusions of the report by Goldblith and Harris that beriberi was the first nutritional disease observed, occurring about 3 months after capture. Pellagra and ariboflavinosis were observed after 9 months. Scurvy after 9 months was still questionable, but began to appear definitely after 10 months. Xerophthalmia and nyctalopia, although difficult to diagnose clinically, were unquestionably present in 10 months and rather severe thereafter. These conditions increased in intensity until in many cases complete blindness developed, 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 Repatriated American Prisoners of War Returning From the Far East." It is unfortunate that the men were not brought into this survey until, having been released for varying periods of time, they had received therapy for their nutritional disturbances. Nevertheless, much can be gained by a review of the board's report.

For example, certain prominent signs and symptoms of nutritional deficiency as obtained from the history were listed according to their


incidence. Pellagra as evidenced by cheilosis, glossitis, stomatitis, dermatitis, and diarrhea was present in from 50 to 70 percent of the patients. The incidence of pellagra was much greater in the Philippines. Only a rare case, in fact, developed in Japan where the prisoners were sporadically given soybeans to eat. Typical pellagrous photosensitivity dermatitis of the exposed parts was relatively infrequent. This in spite of the fact that the men were constantly exposed to considerable sunlight.

The occurrence of a scaly, sometimes erythematous weeping dermatitis of the scrotum accompanied by extreme tenderness and, in some cases, edema was reported as being relatively common. Occasionally, scrotal tenderness without dermatitis occurred. About 55 percent of the patients with 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 occurred both in Japan and in the Philippines. A history of "wet beriberi" (with massive edema) was obtained in 77 percent and a history of "dry beriberi" (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 preceded the former. Diarrhea was seldom present or severe during the phase of wet beriberi. Massive spontaneous diuresis often took place.

The clinical symptomatology of the dry beriberi was striking. Burning, hyperesthesias, and paresthesias were exceedingly severe, and in some camps hundreds of men would walk the floor during the night because of severe pain. Feet were often soaked in ice water, cooled in the snow, or exposed during the cold nights in attempts to alleviate the pain. The feet were so tender that even the slightest touch provoked severe pain. In one case, a handkerchief was accidentally dropped on the foot of a sleeping soldier. He immediately awoke crying out in agony. Often, just the vibration caused by some one passing within several feet of a soldier with dry beriberi 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-caloric diet when they were first liberated, glossitis, stomatitis, and edema reappeared or become more pronounced. Anemia was observed in 52 percent of the first 1,500 RAMP's studied and diminished appreciably in incidence as successive groups were examined until it was found in only 35 percent, 6 weeks after the study was begun. The anemia was macrocytic in 73 percent, normocytic in 23 percent, 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 corresponding improvement in the fundamental nutritional state. Many patients had protuberant abdomens commonly called rice bellies, while their shoulder girdles and extremi-


ties showed very marked wasting. The immediate results of a normal diet of American food in these people paralleled the widespread development of a similar edema under similar circumstances in the European theater. The reason was not clear to these observers who suggested, among other factors, that the diet contained more salt and fluid than that to which the prisoners had been accustomed. Although they associated the scrotal dermatitis with the stomatitis and cheilosis, they were not at all sure that it was part and parcel of the riboflavin deficiency syndrome. This relationship has been subsequently proved.

Almost without exception, the patients had suffered from attacks of diarrhea at some time during their imprisonment. It is necessary to distinguish between the diarrhea that most individuals have from time to time in normal life and the true dysentery consisting of prolonged periods of watery or bloody stools. Of the prisoners, 1,359 had one or more attacks of true dysentery.

Japanese Prisoners of War

When the tide of battle had turned, with defeat after defeat for the Japanese in the Philippine Islands in the spring of 1945, these enemy troops, as evacuation from the islands presented difficulties, retreated into the hills back of Luzon, breaking up into small groups and living off the land. Owing to the 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 indigenous to this part of the world-maladies that ordinarily deplete metabolic reserves of human beings.

After V-J Day, 2 September 1945, these isolated Japanese troop units surrendered by the thousands to the U.S. Army. By early October, approximately 80,000 had been confined in New Bilibid Prison, Manila. Nearby was the 174th Station Hospital, a 250-bed installation. This hospital was burdened suddenly with the care of approximately 5,700 of these returned Japanese, many of whom were too ill even to move from their cots. It is reported that many died en route on the troop trains that brought the prisoners in. It was decided, as recommended by the Chief Surgeon, AFWESPAC (U.S. Army Forces, Western Pacific), and by others, that a special study29 should be made of the clinical aspects of this severe malnutrition.

Considering the limitations of personnel and facilities and the administrative pressures to evacuate these prisoners as rapidly as possible, a remarkable amount of clinical observations with chemical determinations were made in these cases of starvation. A special ward was set up to handle a selected group of 24 of the most severely starved patients. This group was

29Schnitker, M. A.: A Study of Malnutrition in Japanese Prisoners of War. [Official record.]


then subdivided into two groups, one of which contained 12 patients with massive edema, the so-called wet beriberi, and the other with 12 patients without edema, the so-called dry beriberi. All the patients were males between the ages of 25 and 35 years of age.

A large proportion of the patients being studied had begun to live on their starvation diets during March, April, and May 1945 and began to experience their difficulties in July, August, and September, approximately 3 months for the onset of severe symptoms. From the history, it was calculated that their diet was about 800 to 1,000 calories a day, at best. At least three-fourths of these patients gave a history of having had malaria, and two-thirds had a history of diarrhea before capture. It was estimated that loss of weight was approximately 40 to 50 pounds per person during the period of escape to the hills. Severe weakness was a complaint common to all. Those patients with edema complained of dyspnea, whereas only one-third of those without edema had dyspnea on exertion.

The physical findings were somewhat varied. In the edema group, the patients had moderate to very marked edema, which was greatest in the abdomen and the lower extremities. Three of this group escaped having pleural effusion, but all had evidence of pulmonary congestion. In contrast was the lack of edema in the "skin and bones" group. Although the history showed that practically all the patients, including these, had had edema in variable degree at some time before hospitalization, only three of the second group had any edema at the time of selection 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 the patients showed hyperkeratosis, particularly over the anterior aspects of the thigh. No definite cutaneous manifestations of pellagra were found, and no cheilosis. There was evidence of pigmentation over pressure points and other areas. Only four of the patients had severe atrophy and color changes of the tongue that would be indicative of the vitamin deficiency syndromes. Further examination revealed no grossly enlarged hearts; roentgenographic measurements were well within the danger ratio. Auscultation found the heart sounds for the most part impure and distant with an accentuation of P2, particularly in the edematous group. The pulse was labile and tended to be rapid and considerably increased by even the slightest exertion. The blood pressure was normal to low, in the cases of "dry beriberi" ranging from 80 to 105 mm. Hg systolic and from 50 to 85 mm. Hg diastolic; in those with "wet beriberi," ranging from 100/60 to 130/90 mm. Hg. Control groups observed simultaneously also had low blood pressure with systolic readings of from 80 to 100 mm. Hg and diastolic readings varying from 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. The vibratory sensation was intact in all the patients. No frank paralysis was observed, although weakness,


particularly of the quadriceps, was evident. All patients showed generalized muscular wasting. It was difficult or impossible to elicit the deep tendon reflexes, particularly in the lower extremities. Of particular interest 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 a palpable spleen. Laboratory findings were variable too. The greatest percentage of positive findings was observed in the hematological studies. There was a considerable amount of anemia in the entire group, ranging from moderate to severe and responding only slightly to iron therapy. Five of the patients showed erythrocyte counts under 2.5 million cells. The anemia was determined to be microcytic and hypochromic. The smears showed stippling and some toxic granulations of the white cells. Although four-fifths of these patients had intestinal parasites, only one-quarter had an eosinophilia above 4 percent. The hematocrit was distinctly lowered in both groups. In the edematous 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 uniformly elevated.

Bacteriologic cultures from rectal swabs were repeated three times. All cultures were negative for the typhoid, paratyphoid, and dysentery groups with the exception of three patients who showed, respectively, Shigella paradysenteriae, Boyd P 274; Salmonella enteritidis; and Sh. paradysenteriae, Boyd P 275. The diarrhea eventually ceased spontaneously in the first few days of treatment with rest and diet. New antidiarrheal drugs were used.

The serum proteins, albumin and globulin and the ratio of albumin to globulin, were determined on each patient at weekly intervals. In the initial 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 of from 3.4 to 5.3 gm., as compared to an average in the cases of "dry beriberi" of 4.75 gm. with a range of from 4.0 to 6.1 grams. The albumin fraction in the edematous group averaged 1.96 gm. per 100 cc. of blood as compared to 1.87 gm. in the nonedematous group. The globulin fraction was slightly 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 with edema averaged 0.810 and in those without edema, averaged 0.675. Oral glucose tolerance tests were done on all patients except two. This was the standard test of 100 gm. of glucose. After determining the fasting blood-sugar level, blood samples were collected at 30, 60, 120, and 180 minutes. Six patients altogether had flat curves; that is, the peak did not rise above 120 mg. per 100 cc. of blood. In each instance, the fasting bloodsugar was on the low side; all were under 90 milligrams. Circulation times were determined by the arm to tongue technique using calcium gluconate. The results were all normal, that is, 12 to 18 seconds, except for one patient with dry beriberi, who had a circulation time of 10 seconds. Studies of


venous pressure, using a spinal manometer showed marked variations. The readings varied for the most part between 50 and 150 mm. of water. Six patients with wet and five patients with dry beriberi had readings of over 100 millimeters. Cardiac failure had not played a part in the edematous group, since there was little difference in the venous pressure readings of the two groups.

Electrocardiographic tracings, made in all these cases, showed consistently low voltage and minor T wave changes. Liver function tests failed to reveal any remarkable changes, but the majority retained Bromsulphalein (sulfobromophthalein) longer than usual. A gastric analysis was done on each patient to determine the presence of free hydrochloric acid in the gastric juice. Only three of the patients, two edematous and one not, had free acid on the first test.

Five autopsies performed on the patients who died of malnutrition alone, of whom there were seven studied, showed a marked atrophy of all the viscera. The fat deposits were gone; the skeletal muscles showed wasting; the hearts weighed from 150 to 200 gm.; the livers weighed from 525 to 1,000 gm.; and the kidneys, from 75 to 100 grams.

All these patients had fever at one time or another. This varied from isolated spikes to continuous fever with temperatures as high as 100° to 101° F. Thick and thin smears for malaria were made on all patients at least four or more times, and 15 were found to be positive.

The observers noted further that in cases of both wet and dry beriberi, edema was a clinical finding which varied moderately from time to time during the period of observation and treatment. They thought that this might have been influenced by the intake of the salty soybean sauce which all these patients insisted upon eating. This observation may be correlated with the findings in the European theater where there was practically no edema during treatment in patients on diets in which salt was a rare component. (See pages 274-275.)

Troops and Civilians in the Pacific

An intensive study of the nutrition of 111 full-duty troops in the Manila area in July and August 1945 is described in a report dated 20 October 1945.30 Chemical determinations showed considerable variations in the nutritional status of soldiers living in this environment on the basic Army allowance. Although the ration was appraised as apparently adequate for nutrition, it was found that-

1. Twenty-five percent of the subjects were in a state of partial 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 Commanding Officer, 26th Hospital Center, APO 75, 20 Oct. 1945, subject: Chemical Determination of Nutritional State of Full Duty Troops, Manila Area, July and August 1945.


2. Plasma protein concentrations were normal and no serious deficiency of hemoglobin existed, although 16 percent were slightly below the accepted normals.

3. Twenty-five percent had concentrations of vitamin C below 0.4 mg. per 100 cc. of blood, but no prescorbutic states were observed.

4. Nine percent appeared to be rather seriously depleted of thiamine, and 6 percent were classified as seriously depleted of riboflavin.

From the results, it was concluded that, in low-score subjects partially desaturated with respect to the vitamin B complex, there is a higher incidence of the nonspecific signs of lowered health, resistance, and sense of well-being. The experiment in itself was not conclusive, but it showed an enthusiasm on the part of the personnel for a better understanding of the problems involved.

A more extensive survey31 of nutrition in the Armed Forces in the Middle Pacific was carried out during April-June 1945 by a special team appointed by The Surgeon General. The team reported that physical examination revealed no cases of classical nutritional deficiency diseases such as scurvy, beriberi, ariboflavinosis, and pellagra.

A significant percentage of men in each place surveyed showed one or more physical findings that some medical nutritionists have considered to be associated with specific nutritional disturbances. On Guadalcanal, vitamin C intake was low, as was the urinary excretion of ascorbic acid. Here, a significant amount of acute inflammation of gingival margins and swelling of interdental papillae were observed. Biochemical tests showed a deficient riboflavin excretion in 8 percent of the subjects on Guam, in 9 percent of the subjects on Iwo Jima, and in 6 percent among the casualties from Okinawa. Occasional single cases of deficient excretion of thiamine were observed. It was concluded that the basic nutritional status of the troops in the areas surveyed was essentially good. The survey in the Pacific Ocean Area was 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 in nutritional disturbances is a report, "Preliminary Vitamin C Survey," from the 19th Medical Service Detachment (General Laboratory), dated 26 February 1945. The levels of vitamin C in the blood plasma and the urinary excretion of vitamin C for 24 hours were determined on a group of men from two bases in New Guinea. No evidence of scurvy was found among the subjects, even those with low concentrations of vitamin C in the blood. Of 34 subjects whose blood was analyzed, 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.


In a very interesting report32 from the 369th Station Hospital on the nutritional status of civilians, it is noted that about 3 months after the invasion of Saipan there was a marked change in the type of civilian patients admitted to the hospital. During the battle and for some time thereafter, the vast majority of patients were new and old battle casualties. In September 1944, the medical admissions began to exceed the surgical. These patients were admitted for peripheral edema, with and without ascites and hydrothorax. Many of them had muscular weakness, particularly difficulty in raising from a squatting position, and other complaints.

The clinicians at the 369th Station Hospital were skeptical of the diagnosis of beriberi. On therapeutic trial with vitamin B1 in massive oral and parenteral doses, there was no dramatic improvement. Patients did improve after continued hospitalization on an adequate 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 the edema might be due to hypoproteinemia. A number of autopsies were performed and in no case could the diagnosis of beriberi be confirmed by the gross findings. A series of total serum protein determinations were carried out with the Van Slyke copper sulfate technique. Of 89 civilian patients with edema studied with respect to their serum proteins, 77.5 percent had values below the critical level for edema and only 5.5 percent were within normal limits. A series of children without edema revealed values only 4.8 percent below the critical level for edema. From the study, it was concluded that the cause of edema in the civilian population in Saipan was hypoproteinemia since, although the existence of beriberi could not be excluded, the criteria for a beriberi diagnosis were not satisfied.

In the Philippine Base Section, the clinicians of the 168th Evacuation Hospital conducted an interesting project in nutritional research33 when it became apparent that civilian personnel in the hospital locale (Puerto Princesa, Palawan, Philippines) presented a health problem, basically because of nutritional deficiencies, malaria, tuberculosis, and, of course, the intestinal parasites.

The population of the province is essentially rural, and had been in part nomadic, migrating from one region to another according to the crop seasons. During normal times, the diet consisted chiefly of rice, fish, corn, tuberous plants, and lesser amounts of pork, poultry, and eggs. With the occupation by the Japanese, the supply of cultivated products was almost entirely cut off from civilians, the great majority of whom isolated themselves in the barrios scattered throughout the hills. These people when they returned to their liberated community presented a most distressing evidence of nutritional deficiencies, 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 period January-March 1945, dated 1 Apr. 1945.


had escaped to the hills. Numerous cases of frank beriberi of the wet type were seen. There were several deaths of individuals with marked edema. The nutritional repair or rehabilitation of the Filipino civilians required special attention because of their racial predilections. The regular Army food was unpalatable to them, and the majority developed such acute gastrointestinal disturbances that the nausea or vomiting seemingly interfered with their progress. This, of course, was common experience in other occupied lands.

Troops in India

The establishment of a theater of operations by the U.S. Army in India and Burma presented subsistence problems not encountered in other parts of the world. Here, we were not invading a hostile country where food could be requisitioned and where supply lines could be appropriated and spread out. We were considered as guests in a densely populated Allied country in the throes of its own political problems. A large portion of the population was on the brink of a great famine, which was to destroy by starvation a million and a half people in 1943. The troops could not be concentrated in any well-defined area, but by military necessity were scattered in small groups separated by thousands of miles. The lines of communication between these groups when existent were extremely primitive.

The first troops arrived in India from the United States early in 1942. No adequate provision had been made for the continuous supplying of these soldiers with food from the Zone of Interior. A reserve stock of B-rations had been sent to the theater, but these were not to be used except in emergencies. The original plan was to maintain these troops on supplies obtained from local markets and from rations obtained through the British Army. By October 1942, the theater policy was adopted, prescribing a ration to consist of the field service ration of British troops obtained through the Royal Indian Service Corps and supplemented by local purchase of fresh supplies and by the issues of excess stocks of the reserve B-rations. Experience showed that the British ration was not 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's milk allowance was only 2 ounces of tinned milk per man per day, which was not considered adequate for U.S. troops. No fresh milk was available because of the unsanitary conditions under which it was produced. Owing to the local prohibition against the slaughter of bullocks in good health, the supply of meat was very poor.

Medical officers began to report a reduction in the efficiency of the command which they attributed to malnutrition. A large proportion of the troops reporting for sick call complained of weakness, insomnia, lassitude, and gastric complaints suggestive of a deficiency state. An increase in the occurrence of gingivitis was observed.


Early in the experience of the Americans in this theater, an interesting outbreak of a nutritional deficiency disease occurred in the form of beriberi among the Chinese troops at the Chinese Training Center at Rāmgarh, India. Between 8 August and 25 September 1943, 199 patients were admitted to the 48th Evacuation Hospital with beriberi as the primary cause of hospitalization. Many others were treated as outpatients. They had other symptoms of deficiency diseases such as night blindness, cheilosis, glossitis, and osteomalacia, A change in the ration was made, and undermilled rice was substituted for the polished rice. With this change, the nutritional disturbances disappeared.

Maj. Frank B. Cutts, MC, reported on 125 cases of beriberi admitted to the 48th Evacuation Hospital during an 11-week period, from late July to October 1943.34 All the patients were Chinese soldiers. It is interesting to note from Major Cutts' report that in the first patients observed the diagnostic evidence was considered obscure, and many of them were admitted as having rheumatic fever, rheumatic heart disease, phlebitis, and nephritis. 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-less often of the genitalia-hands, and face; and (3) numbness of the legs and muscle pain on walking. Less frequent complaints were palpitations, precordial pain, upper abdominal distention, and numbness of the arms. Most of the patients had been sick at least 1 to 3 weeks before presenting themselves to the 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 with no evidence of caloric malnutrition. They showed little or no fever. Examinations of the tongue and mouth revealed some instances of cracking and scaling at the corners of the mouth which were ascribed to riboflavin deficiency. There was definite engorgement of the veins in the neck. The heart was almost always enlarged. With the patient sitting on the edge of the bed, the left quarter of the area of cardiac dullness was consistently 1 to 3 centimeters outside the nipple 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 and booming, and often there was a gallop rhythm at the apex. Systolic murmurs of moderate intensity were heard at the apex and along the left sternal border. There were no diastolic murmurs. Examination of the abdomen revealed an occasional ascites.

Edema of the legs was almost constantly found varying from one to four plus. This edema involved the genitalia and extended up over the

34Cutts, F. B.: Observations on Beriberi. Field Medical Bulletin, Headquarters, Services of Supply, U.S. Army Forces, China-Burma-India, vol. 2, No. 12, December 1943.


back. Muscles of the calf in most instances were normal. Knee jerks and ankle jerks were usually absent. There was a marked hypoesthesia to pinpricks of the lower extremities.

Treatment.-This consisted of bed rest with the regular hospital diet and an autolyzed yeast product rich in vitamin B1, or vitamin B1 itself.

Course in hospital.-As a rule, the patients showed prompt improvement. Dyspnea disappeared in 2 or 3 days. The heart rapidly shrank to normal size, the left border receding to 1 to 3 centimeters in the course of the week. Diminution in size was checked by serial chest X-ray plates in a few cases. Heart murmurs and other abnormal sounds were not heard after about a week. Edema of the legs and turgidity of the muscles of the calf were generally gone after from 5 to 7 days of treatment. Numbness, insensitivity to pinprick, and lost reflexes were more persistent and in some instances were but little improved in 6 weeks. In general, the patients were sufficiently well to return to duty in from 2 to 3 weeks. When the autolyzed yeast was withheld, improvement occurred in approximately twice the time required by the patients treated with the yeast, and complete relief of symptoms was usually not obtained until the vitamin B concentrate was given.

One death was reported of a 25-year-old soldier who was admitted complaining of marked shortness of breath for 3 days. The respiratory rate was 35 per minute and the temperature was 99° F. Engorgement of the cervical veins was evident. The heart was enlarged two plus, and auscultation revealed 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 hours after admission. As the cause of his illness was not recognized at entry, he was not given any parenteral B1. Autopsy showed generalized congestion and edema of the internal organs. The heart was dilated and distinctly flabby but otherwise normal to gross examination. One ascaris worm was found wandering in the intrahepatic viaduct.

Etiology.-Most of these patients came from one regiment. An investigation revealed that this regiment had been storing rice over and above their daily requirements. In July, with the onset of wet weather, realizing that the rice would spoil, the unit drew no new rice and began to consume its stored surplus. A sample of the rice was obtained and found to be gray, lusterless, and devoid of any of the pericarp. When the old rice was discarded and new rice obtained, the incidence of beriberi in this unit no longer 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 not acceptable, and to the failure or inadequacy of transportation.



Throughout the individual reports from all theaters of operations, one finds an overemphasis on the failure of the packaged rations. The principal deficiency seems rather to have been in the briefing of the personnel who were responsible for the nutritional status of the troops in the field in the several theaters. In some quarters, there was failure to comprehend that the most important aspect of rations for the troops was first to supply calories, next protein, and thirdly, the micronutrients or vitamins and minerals, always presupposing, of course, a sufficiency of potable water. Indeed, a review of the prewar debate in the Nutrition Committee of the National Research Council shows a somewhat unrealistic approach to the problem in the light of later experience. In the future, it would seem wise to include either a field officer or a medical or nutrition officer with field experience at any level of discussion concerned with the feeding of troops. A review of ration tests in the United States shows that those who designed them and observed the results had a better appreciation of the problems of nutrition and survival under the various conditions that war may impose.

In the field, there was a tendency for command, endorsed to some extent by the medical personnel, to ascribe to nutritional deficiencies almost any condition that was not otherwise explicable. Medical officers in general showed an uncertain grasp of nutritional problems. The Essential Technical 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, there were failures by command to distinguish properly between a resting prisoner and a working prisoner. In both wars, there were instances when extra food was not issued to compensate for calisthenics or work done within prisoner-of-war enclosures although considerable extra effort-output might be involved. Again, there was at first a failure to allow for the nutritional requirements of different age groups, and German prisoners from 14 to 19 years old, conscripted by the Wehrmacht in the last phase of the war, were found faring badly on rations designed for adults in the age group of 21 to 35 years.

Briefing of personnel on nutritional requirements with respect to actual work done and to age, sex, climate, and other relevant factors must be improved before the Army can expect wholehearted and effective cooperation from the field staff.


The medical officer assigned to the Nutrition Branch visited the chiefs of the medical services of all major hospitals concerned with the treatment of the RAMP's. On 24 May 1945, at the 179th General Hospital, Col. George B. West, Commanding Officer, and Lt. Col.


Oza J. LaBarge, Chief of the Medical Service, Maj. Henry J. Babers, Chief of the Surgical Service, and Capt. Sidney Small, Chief of the X-Ray Service, gave the following information:

More than 800 RAMP's were admitted between the middle of April and the last week in May. About a third were admitted directly to this hospital, and these were for the most part men who had been captured in the Battle of the Bulge and imprisoned in Stalag IX-B at Bad-Orb (mostly enlisted personnel) or in Stalag IX-A at Niedergrenzebach, near Ziegenhain, (mainly noncommissioned officers and men). Those from Stalag IX-B were in the worst condition of all. They said they had seldom received Red Cross packages. As estimated from their histories, their average loss of weight during captivity was 39.1 pounds per man at Bad-Orb, and 28 pounds per man at Niedergrenzebach. One patient had lost 115 pounds.

Of the total number of patients, 198 had hepatitis; pulmonary tuberculosis was suspected in 14 and proved in 11; diphtheria was found in 8. The diagnosis of severe malnutrition was made 188 times. The average erythrocyte count for the entire group was 3,600,000; the average hemoglobin concentration was 60 percent; the average total serum proteins were 6.2 gm., with a range from 2.7 to 7.6 grams. These were determined by the copper sulfate method. Hemoconcentrations and hematocrits were not done. Of stool cultures in 283 cases, 6 were positive-2 for Shigella paradysenteriae and 4 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 without specific 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-X complexes and low excursion or very flat T waves. There were 30 cases of nutritional edema, which cleared up on a regimen of bed rest and special diet. Basal metabolic rates were not determined. No manifestations of scurvy were found in these patients.

Of the 283 patients with diarrhea, 42 were fed by the gravity-drip method with the special mixture of powdered milk and powdered eggs suggested by the Nutrition Branch, Office of the Chief Surgeon. Others were given this mixture orally in six feedings daily. Intravenous therapy of any kind was found to present many difficulties, with two types of reactions noted during or after administration: The one, circulatory relapse; the other, chills and fever. The standard treatment for the patients with malnutrition in the 179th General Hospital was tube feeding of the high-caloric liquid protein diet by gravity drip, vitamin therapy, and occasional plasma or blood transfusion or oxygen, when indicated. Four deaths occurred on the Medical Service. An autopsy of one of the patients showed a marked redness and congestion of the entire gastrointestinal tract.

The Surgical Service reported that from 150 to 200 RAMP's were admitted to this service. They were found to be very poor risks, reacting to surgery more like the German prisoners of war than the average American soldier. There was one death on the service. This patient was operated upon for a perforated peptic ulcer, but at operation no ulcer was found and autopsy revealed that the patient had died from congestive heart failure.

In these RAMP's, wound healing and healing of ulcers or infections at first was very poor. Under proper diet and vitamin therapy, the chief of service noticed improvement in healing. The X-Ray Service reported evidence of marked distention of the large bowel in a large percentage of these patients. The pulmonary abnormalities as revealed by X-ray in these early groups were increased bronchial vesicular markings, very prevalent; atypical pneumonias, very frequent; and tuberculosis, not uncommon.

The 77th Field Hospital was visited on 26 May 1945. The diagnoses made from 12 through 18 April were malnutrition 94 times and gastroenteritis 82 times; from 16 to 19 May, they were malnutrition 122 times and gastroenteritis 6 times. Plasma therapy was used on 166 patients. Of these, 19 experienced severe reactions as follows: Five patients


developed pulmonary edema and of these two were in extremely critical condition; two patients developed chills and fever with nausea and vomiting; eleven had chills and fever; and one, a simple urticaria. Again, diarrhea was an acute problem. Therapy was the liquid egg and milk mixture given by mouth; the gravity-drip method was not used at this hospital. Response to therapy was considered excellent. The X-Ray Service, under Capt. Russell D. D. Hoover, reported that of 2,750 RAMP's examined roentgenographically 16 or 0.58 showed 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, fractured ribs, and so forth.

The 97th General Hospital reported through Maj. Kelse M. Hoffman, assistant chief of the Medical Service. Loss of weight and listlessness were the major presenting symptoms of their patients, a group on the whole not in very bad condition. Only about 20 enlisted men were considered to be seriously ill. The average loss of weight in the whole group was only 15 pounds and was regained in 2 weeks of therapy. Again, the major problem was gastrointestinal disturbances commonly due to dietary indiscretions. Stool examinations on all these patients showed no pathogenic micro-organisms. After publication of Circular Letter No. 36, the chief of the Medical Service noted that the gastrointestinal symptoms diminished markedly. No specific vitamin deficiency syndromes were noted, although several cases manifested tenderness of the calf; a few developed edema after treatment, and the deep reflexes in the lower 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 ill patients. Specific classical syndromes of vitamin deficiency were not seen, but edema was frequent. The blood protein studies in the Center were not conclusive. The patients who were admitted early all had severe diarrhea, but stool examinations were basically negative. The outstanding problem here was the lack of strength persisting for weeks after the return of a good general appearance. Electrocardiographic tracings showed T wave and voltage changes similar to that reported 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 pounds were the presenting problem; also, that the Red Cross insisted upon serving chocolate bars on the wards with resultant gastrointestinal problems. Approximately 25 percent of the first admissions presented edema; others developed edema in the course of hospital therapy. The diarrhea, as in other installations, was the biggest problem. The acute gastrointestinal symptomatology generally followed the consumption of rations. In this group, several patients were seen with specific deficiency manifestations, such as cheilosis, tongue changes, and stomatitis.

At the 83d General Hospital, Whitchurch, England, approximately 250 RAMP's were admitted, most of whom were not considered seriously ill. Diarrhea again was the commonest of all findings but became a minimal problem after Circular Letter No. 36 was put into effect. Edema was very evident in many of those admitted. Serum proteins were considered to be definitely low, although the specific figures were not made available. Moderate anemia was the usual finding. Glossitis, cheilosis, and other specific symptoms of the mucous membrane were noted very frequently. Paresthesias were common, particularly of the glove-and-stocking type, with dry, scaling skin. Serial electrocardiographic studies were made.

Among these RAMP's, there were eight severely ill patients who manifested a loss of from 60 to 101 pounds in body weight. These men had been captured at the time of the Battle of the Bulge. Their appetite was good, but diarrhea was precipitated by a full diet. The electrocardiographic tracings showed low T waves, flat or inverted in I and IV low amplitude PQRS. There were no conduction problems. Serial tracings showed a reversal to the normal pattern in the course of the first 2 weeks. Serum proteins in this small group averaged 5.2 grams. Red blood cells ranged from 2.5 to 3.5 million with a marked poly-


chromia. The type of anemia was amacrocytic. Again, in this hospital, chill reactions and febrile reactions frequently followed transfusions of plasma. Multiple neuropathies, hyperactive reflexes, and ataxic gaits were noted in two of these patients. Alopecia was observed, but responded to simple diet therapy. Rapid gain in weight in six of the patients, amounting to from 30 to 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 were confined to bed.

The 217th General Hospital in Paris cared for a great many RAMP's. Out of 1,098, there were 665 admitted to the Medical Service, of whom 275 were more than moderately undernourished. A survey revealed the following symptoms: There was of course marked loss of weight in all 275; a scaly skin in 186; glossitis described as a clean tongue with a smooth edge, bright red, in 100 patients; diarrhea, with negative stool cultures, was noted in 76 patients; 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 and increased capillary fragility, was seen three times. Twenty-five of the patients who had diarrhea, nausea, anorexia, or vomiting were selected for X-ray studies of the digestive tract. Six of them showed the so-called small-bowel deficiency pattern manifested by dilatation of the small intestine, especially the jejunum, fluid levels resembling obstructions, clumping and segmentation of barium with hypomotility. The barium meal progressed only as far as the distal end of the jejunum in 6 hours. On reexamination 2 weeks later, considerable improvement was noted. In the fatal cases of malnutrition observed at this hospital, there were no gross or microscopic changes in the esophagus, stomach, or small bowel. Parenthetically, it should be noted that in the brain of a patient examined at autopsy numerous focal necrotic lesions were observed.

In all theaters of operations, the problem of the repatriated prisoners, not only the Americans but also the friendly nationals, was of extreme importance. In the European theater in particular, their condition presented a major medical catastrophe. As an example, a letter dated 3 April 1945 from Lt. Col. Theodore L. Badger, MC, Senior Consultant for Tuberculosis, ETOUSA, to the Chief Medical Consultant, ETOUSA, notes that, on 17 December 1944, 304 tuberculous Russian and Italian recovered prisoners were sent to the 50th General Hospital without advance information. Of these patients, 4 arrived dead, and, as of the date of the letter, an additional 85 had died of advanced tuberculosis.

This group of tuberculous patients was similar to those seen when the 46th General Hospital was visited in the middle of March. There was remarkable improvement in these people in the course of their hospital stay with the gains in weight reaching 45 pounds in the first 3 months. The signs of nutritional deficiency disappeared very rapidly, and the group as a whole began to look in moderately good health. Of the first 50 who died, it was noted that the average stay in the hospital was only 9 days, their average age was approximately 26, their average weight on admission was 110 pounds. The duration of involvement, however, was 8 months, and in 100 percent the involvement was bilateral. This would indicate that the bulk of the destructive effects of the disease occurred before the men were hospitalized in the American installations. The treatment was to increase the food given these people, allowing them 1½ hospital rations per person. Artificial pneumothorax was instituted in at least 30 cases with excellent results. In a letter dated 30 March 1945, to the Office of the Chief Surgeon, Colonel Badger had reported as follows: As of 29 March, 1,676 patients of recovered Allied military personnel were admitted to the 46th General Hospital. Of these, 1,251 were Russian; 102 Yugoslavian; 72 were French; 22, Italian; 6, Polish; 5, Turks; and 15 were Germans. A survey indicated that at least 40 percent had active tuberculosis. Of these, 50 percent were in a far advanced stage, 40 percent moderately advanced, and only 10 percent were minimal. Twenty-seven of the patients were seriously ill, and 20 had already died.


This group of patients had worked in forced labor in the coal mines 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 was magnified by the ignorance of the patients and by the complete absence of personal hygiene. Here we see a prime example of the superimposition of tuberculosis on malnutrition and the attendant remarkably high death rates.


The writer performed autopsies personally in concentration camps in Austria. A summary of his findings follows.


Sections of the epidermis of the tongue examined microscopically show moderate atrophy of the lingual papillae. Bacteria in large, dark-staining clumps are seen in the crypts and on the surface of the organ. In two cases, there are focal collections of dense basophilic round bodies, somewhat larger than cocci, incorporated in the parakeratotic layer, which resemble Monilia. In another section, there is, in addition, focal epithelial invasion by branching septated mycelia. These changes perhaps represent an early sprue.

In three sections, there is a slight to moderate increase in the parakeratotic epithelial layer. All cases display some intracellular edema, and one case demonstrates a superficial acute inflammatory reaction in the parakeratotic layer.


Slight demyelinization of the nerve trunks, and an occasional area of basophilic degenration, are seen in all sections. The intraneurolemmal edema is not so apparent as in the sections of the skin. (See also pages 289 and 291.)

Lingual Glands

Of the 11 sections studied, 8 reveal lingual mixed-type glands. In one case, the glandular parenchyma is atrophic, with increase in the intra-acinar connective tissue.

Thyroid Gland

In 9 of the 11 sections studied, there is apparent a slight to moderate decrease in the colloid content of the acini. In one, the colloid is abundant; in the rest, appears normal in amount.

In two cases, the fibrous stroma about the acini is increased, with scattered focal accumulations of lymphocytes prominent in only one case. Epithelium is in all cases of the low cuboidal type and in it is hyperplasia. In one section, there is seen a small rounded true adenoma, benign in character.


Few changes are present in the 10 heart sections. The most appreciable is the decrease in subepicardial fat, which in many cases has the appearance of fetal adipose tissue. It is pronounced in only five cases. Three cases display moderate fatty degeneration of myo-


cardial fibers, and three cases could be classified as brown atrophy. In one case, there is slight increase in interstitial myocardial fibrosis, with hypertrophy of individual solitary myocardial fibers.


In seven sections, changes in the pancreas are for the most part not prominent. All sections reveal the presence of symogen granules and basophilic substance. One slide shows slight hydropic degeneration of acinar cells, and one displays marked post mortem degenerative changes. There is a significant increase in interlobular and intralobular fibrous tissue in one case, and in three others there is an apparent increase, incident to interstitial edema. In general, little fat is associated with any of the sections.

Islets are in general small, with decrease in the number of both A and B cells, and hyperchromatism of some of the nuclei. A few islets are swollen and edematous, with disruption of islet cells and slight increase in fibrous tissue within the islets and surrounding them.


Epidermis.-All six sections display marked atrophy of the epidermis, often reduced to a thickness of one to two cells. There is moderate intracellular edema in all cases, particularly in the basal epithelial layer. Pigment distribution is not unusual, and pigmentation is not excessive. Three of the cases demonstrate minimal edema of the dermal papillae, and two display slight inflammatory reaction about the superficial vessels of the derma. In all, the sweat glands are small and inactive in appearance, often with large vacuoles occupying most of the cytoplasm of the cells, as if they were in a stage of metaplasia into sebaceous epithelium. The lumina contain granular debris.

Peripheral nerves.-In five of the six sections, the peripheral nerves located in the derma and subcutaneous tissue display a moderate edema within the neurolemma sheaths. Usually, the nerve fibers appear unaltered, although, in an occasional nerve, there is demyelinization and basophilic degeneration of the reticular supportive connective tissue. There is no inflammatory reaction about the nerves. Dermal arterioles are unchanged.

Subcutaneous fat.All six sections show atrophy of subcutaneous fat. In all, the lipoid is practically depleted from the adipose tissue cells, so that they closely resemble embryonic fat. The fat is well vascularized.

Hair follicles.-Other dermal appendages are decreased in number. Hair follicles are maldeveloped, and often the hair shaft is degenerate.

Adrenal Glands

In two of the nine sections, ante mortem changes are masked by marked post mortem autolytic changes.

Periadrenal fat.-All nine cases display advanced atrophic changes in the periadrenal fat, giving it the appearance of fetal adipose tissue. There is yellow pigmentation of the remaining supportive stroma.

Cortical changes.-All cases display some degree of edema between cortical cords, and in four cases it is marked. In all, there is an obvious decrease in lipoid deposition of the cortical cells, while in two there is instead a moderate hydropic degeneration. In one case, the cords appear to have acquired a lumen, and resemble tubules, a finding often associated with acute infectious diseases. In two sections, there is a solitary focal adrenalitis involving the cortex, and in another small lymphocytic foci are scattered throughout the medulla.


Medullary changes-Degenerative changes seen in the medulla are not distinguishable from post mortem changes.


In all seven sections, scattered, large, irregular cells with deep acidophilic cytoplasm and hyperchromatic irregular nuclei resemble megakaryocytes. There are no other supporting evidences of extramedullary hematopoiesis. Four of the sections display moderate pigment collections within phagocytic cells. In four sections, granulomatous lesions with central caseation necrosis are encountered, consistent with a disseminated miliary tuberculosis. Follicular lymphoid tissue appears moderately atrophic in only one case.


Spermatogenesis.-In all 10 sections, there was evidence of spermatogenic arrest at an early stage.35 Five cases display mitosis in the spermatogonia, although beyond this point there is little progression, so that more mature elements are markedly decreased. One section demonstrates the production of an occasional bizarre spermatid.

Interstitial tissue-Of the 10 sections, 4 display an increase in fibrous interstitial tissue. In two of these, there is an associated encroachment and fibrosis of the seminiferous tubules. In another, there appears a metaplastic transformation of tubular epithelium into a tall columnar type.


Glomeruli-All 11 sections reveal hydropic degenerative changes of tuft epithelium; these are extreme in 2 cases. Three cases display mild degrees of capsular fibrosis, and two cases show some increased cellularity of the tufts themselves. In two cases, there is slight hyalin thickening of the afferent arteriole.

Tubules-Of the 11 sections, 9 display varying degrees of hydropic degeneration of the tubular epithelial cells. In the other two cases, post mortem degenerative changes of tubular epithelium is of sufficient degree to mask this finding if present. Casts, both hyaline and epithelial, are found in small numbers in nine cases, while casts of blood or altered blood pigment (hemoglobinuric nephrosis) are found in two cases. Three cases display small cortical retention cysts.

Interstitium-Scarring of the cortex is present in 5 of the 11 cases, this varying from an occasional fibrosed glomerulus to wedge-shaped cortical scars. Among these, there are chronic inflammatory infiltrations in three cases. Areas of calcification are found in five cases, usually appearing 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 the clinical findings to a remarkable degree. This history of these men showed that early in starvation there was a universal loss of libido and an absence of noctural 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 end of 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 was very uncommon. A matter of weeks after liberation and feeding, libido, erections, and nocturnal emissions resumed. Several weeks later, the prisoners observed that the hair areas were becoming restored and shaving became a problem.
In Japan, it was noted that from 3 to 12 weeks after the diet became adequate gynecomastia appeared in 6 percent of the prisoners, in age groups varying from 18 to 64. Three percent secreted a colostrum-like substance.
It is to be noted that in the lapse of years since liberation a normal number of pregnancies in the wives of the prisoners of war have occurred, and the children born to these marriages have been apparently healthy.-H. P.


being deposited within the degenerating epithelial cells of tubules. One case displays a significant degree of intestinal edema. In others, the edematous appearance can well be explained on the basis of post mortem degenerative change.


Periportal areas.-Two of eight sections reveal slight increase in lymphocytes within the periportal areas.

Parenchyma-All eight sections reveal a mild to moderate fatty metamorphosis of hepatic cells of the parenchyma. In one case this is very marked. The metamorphosis, while present to some degree uniformly throughout the lobules, is most marked at the periphery of the lobules in the moderate to marked cases. Five of the sections examined reveal focal areas of chronic granulomatous reactions with progressing fibrosis (tuberculosis).


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.


All cases (nine sections) show edema, hydropic degeneration of the muscle fibers as well as a hyaline-type degeneration. Multiplication of the sheath nuclei indicating proliferation of myofibrils is noted in seven. An interstitial chronic inflammatory reaction is found in three of the sections.

Gastrointestinal Tract

In one section of colon, a small diverticulum is found extending through the circular muscle layer but limited by the longitudinal layer. Edema of the myoneural plexus is present. In another section of colon, there are scattered tiny mucosal ulcerations associated with necrosis and polymorphonuclear leukocytic infiltration. The submucosa is thickened and edematous with vascular dilatation, and infiltrated by numerous round cells, eosinophiles and a few neutrophiles. No amebae are present. Edema of the nerve fibers, atrophy of subserosal fat are noted, but no serosal inflammatory reaction is distinguished. A third section of colon is not remarkable except for moderate edema of the nerve fibers.

Two sections of stomach display moderate neural edema, and two other sections show no unusual findings.

One section of jejunum has a focal chronic inflammatory reaction of the mucosal stroma and lamina propria, and occasional neutrophiles are found. No ulceration is present. Two other sections have only mild edema of the nerve fibers.

Four sections of ileum are not remarkable except for the edema of the nerve fibers noted in the other sections.