228

in the interest of health ;- or (4) have undergone doubleamputation and need an invalid chair for indoor use toafford relief from the wearing of artificial limbs. -

’

Replacements and repairs (except of artificial limbs,and invalid chairs and tricycles, for which the Ministryof Pensions is responsible) will be done through a hospital.But to relieve hospitals, minor defects not affectingfunction will be referred by.the patient to the Ministryof Pensions regional office or sub.office; which, will

arrange for the repair to be done and the appliancereturned to the patient. The liability of the patient topay for replacements or repairs occasioned by carelessnesswill be decided by hospital management committees orboards of governors ; and the patient will have the rightto appear before the committee or board. Patients undertreatment in private blocks will be entitled to the freeissue of appliances ; and it will be for regional boards toensure that hospitals outside the service with whom theyhave contractual arrangements for the treatment of

patients are able to obtain any necessary appliances forthese patients. -

’ .

LIFE AND DEATH IN A CONCENTRATIONCAMP

THE clinical consequences of famine have been welldescribed by several - British doctors released fromJapanese prison camps.1 But in Europe, where starvationdiets have usually consisted of black bread (baked fromwheat or rye and often adulterated with barley, potatoflour, or even sawdust), bean soup, and variable amountsof potatoes and other root vegetables, the pattern ofdeficiency disease differs from the pattern in the FarEast, where,polished rice is preponderant. Since famineis rare in Europe, and the doctors on the spot haveseldom had the time or experience to make careful records,good clinical observations are, scarce, and those madeby Dr. Wolff-Eisner 2 while a prisoner in Theresienstadtconcentration camp are correspondingly valuable.Wolff-Eisner is well known in Germany for his work in

clinical serology. Born in 1877, he was a professor of internalmedicine in the University of Berlin, and sub-chief of theRobert Koch Institute, until his imprisonment by the Nazis.Since his release he has become medical director of the

Schwabinger Hospital for Displaced Persons in Munich anddirector of the serological laboratory of-the Munich Universityclinic for nervous diseases.

DESCRIPTION OF THE CAMP

Theresienstadt, an old fortress near Vienna, was a" privileged " concentration camp intended primarily forelderly Jews. The inmates, increasing from 30,000 to60,000 between 1942 and 1945, came mainly from

Germany but also from Denmark and Holland. Inaddition there were some, of all ages, from Czechoslovakia.It seems that at first conditions were reasonably humane.The buildings, though antiquated (mainly 18th century)and poorly ventilated, were adequate. The inmates hada certain degree of self-government ; small food parcelswere occasionally received ’ from relatives outside

Germany, and the camp was inspected by observersfrom neutral countries. A little smuggled money was incirculation. The medical service, staffed by imprisoneduniversity teachers, had a hospital of 5000 beds with goodX-ray and routine- laboratory facilities, except that,significantly, no bacteriology was permitted.

Gradually, however, the typical. story unfolded. Moreand more prisoners arrived, often in a dreadful conditionafter appalling journeys in cattle-trucks from various

1. For example : Simpson, J. Lancet, 1946, i, 959. Clarke, C. A.,Sneddon, I. B. Ibid, p. 734. Harrison, G. F. Ibid, p. 961.Hobbs, H. E., Forbes, F. A. Ibid, 1946, ii, 149. Burgess, R. C.Ibid, p. 411. Mitchell, J. B., Black, J. A. Ibid, p. 855. Walters,J. H., Rossiter, R. J., Lehmann, H. Ibid, 1947, i, 205, 244.

2. Wolff-Eisner, A. Über Mangelerkrankungen auf Grund vonBeobachtungen im Konzentrationslager Theresienstadt.

Wurzburg, 1947.

transit damps. (Wolff-Eisner quotes a heartrendingaccount by Dr. Roland, who accompanied Paul Ehrlich’sson on one such journey.) The camp became overcrowded;the food deteriorated ; disease’ increased; and fleas,lice, and, bedbugs swarmed everywhere, so that manypreferred to sleep’ in the cold out of doors. As prisonersdied they were rapidly replaced by new arrivals. Largenumbers, estimated by Wolff-Eisner at more than80,000, were taken off to Birkenau and Auschwitz forextermination. Last of all came the typhus. The end-result must sound very familiar to those who saw Belsenat the time of its liberation-people crowded into- 3-tierbunks, those on- the upper levels. often too weak to move,with intractable diarrhoea, covered with vermin, and outof reach of medical care.

THE CAMP DIET

The official diet of those " over age " provided 330 g.of bread daily, with only 50-60 g. of fat and sugar weekly.The daily allowance of potatoes was 180-250 g., but thesewere often unwholesome. A " lentil extract " soup, ofdoubtful nutritional value, was especially dreaded for itslaxative properties. Small quantities of other foodsbrought the official calorie-value of the rations up to1650 a head daily, but there must have been very manywho got nothing like this amount, especially as theleaders among the prisoners saw to it that children andworkers had more than their official share. Then therewas the inevitable black market around the kitchen, andthe potato-peelers were often found stealing potatoes oreating them raw, with subsequent diarrhoea in retribu-tion. When it is considered that many of the prisonershad undergone much privation before arrival, it is not

surprising that nutritional disorders soon began to appear.Most of the prisoners became thin, losing up to 30-40%

of their original weight. This, probably aided by frequentcoughs, resulted in a high incidence of new hernias.Nocturia (4-6 times in a night) Wolff-Eisner puts downto " irritable bladder," but it was more probably partof the polyuria which precedes famine oedema. " Sociallyunpleasant " flatulence, ascribed to the high-carbohydratediet, was always troublesome and persisted for monthsafter liberation and return to a good diet. Hemeralopia,attributed primarily to the low fat intake, was verycommon and is said to have responded " fairly well " tothe administration of vitamin-A concentrates. Curiouslyenough, glaucoma also appears to have been common,even among young people, and a number of cases weresuccessfully treated by operation. At times the majorityof inmates suffered from an intractable conjunctivitiswhich sometimes left permanent damage to the cornea.Skin infections such as impetigo, furunculosis, andcarbuncles, were very troublesome ; and therapeuticinjections often caused abscesses. Scabies is not recorded(it was also uncommon in Belsen). Frequent bedsores,atrophy of the skin, loss of hair and of its natural gloss,brittle nails, dysphagia, and loose teeth are otherconditions mentioned.

INTESTINAL DISORDERS .

Among the " special .diseases" of Theresienstadt,enteritis was the most dreaded. The onset was usually asimple attack of "diarrhoea, often with some fever’ andperhaps the result of a simple infection ; but the diarrhoeamight persist and the patient sometimes died.’ The stoolswere bulky, paler than usual, foamy’ and highly acid,but (naturally, in view of the diet) contained little fat;blood or mucus were rarely seen. Wolff-Eisner isundoubtedly right in thinking that this condition wasdue to nutritional deficiency rather than any specificdysenteric infection. It seems to have been identical withthe " famine diarrhoea " with which workers’ at Belsenand in the Bengal famine became so familiar. Heremarks on the frequency of osteoporosis and spontaneous

229

fractures in Theresienstadt and says that these are" related to sprue." Those who recovered from enteritis

frequently developed oedema. ..

Apparently cedema was common. Like other workersin similar circumstances, Wolff-Eisner had difficulty indeciding which were simple cases of famine oedema andwhich were due to other causes, notably heart-failure.This, might well have been important in Theresienstadtbecause many of the inmates were elderly. Many had alow blood-pressure and vasomotor instability.

’ .

, VITAMIN DEFICIENCY

The classical diseases of vitamin deficiency do not seemto have been encountered, except possibly pellagra,which- is said to have been " frequent " and to haveimproved under treatment with niacin ; but there is noclear description from which the grounds for the diagnosisof pellagra may be judged. Scurvy is not mentioned, noris there any clear indication of nutritional polyneuritisthough the " spastic paretic" gait of many peoplewalking about the camp is described ; they trailed theirfeet, with frequent falls sometimes resulting in fracturesof the femur. No indication of the type and frequencyof anæmia is given, but two other doctors 3 interned inTheresienstadt have reported that it was usually ortho-chromic and was associated with several unusual clinical features. They attribute the anaemia to protein deficiency.The mental consequences of underfeeding are well

described-difficulty in remembering the names of

colleagues and even important recent events. This ismentioned in apology for the shortcomings of the report ;but the wonder is that Dr. Wolff-Eisner has been ableto remember so much and describe it in terms that leaveno doubt of its essential accuracy. The mode of death instarvation is also well described. The patient, weak butlucid, is talking at one moment, and then after a suddeneffort, such as’trying to get out of bed, is found to be dead.

INFECTIOUS DISEASES

The whole nutritional picture was complicated by theimpact of various specific infectious diseases, as is usualin such circumstances.

In 1942 and 1943 a large epidemic of enteric feverswept through the camp. Clinically, it was like what theauthor had seen in the 1914-18 war, but an unusualfeature was the frequency of recurrent attacks, oftenwith a return of typical typhoid roseola ; out of 80 ofhis cases, 5 were recurrences. The epidemic progressedalthough, the majority of prisoners had been inoculatedwith T.A.B., and then it gradually died out despite theonset of hot weather and the constant influx of new

unexposed prisoners. This was probably the result ofenergetic measures by the prisoners themselves to improvethe hygiene of the camp. Survivors from the fever wereoften left with oedema or tuberculosis.In 1943-44 there was an epidemic of a mild kind of

encephalitis, from which the majority recovered. Scarletfever and diphtheria occurred, and followed a normalcourse ; there was a plentiful supply of serum for treatingthe latter, but postdiphtheritic paralysis appeared to be amore frequent complication than usual. Mumps wascommon, with frequent orchitis ; whooping-cough wasrare. Pneumonia, said to have been mainly broncho-pneumonic wth few physical signs, was responsible for alarge morbidity ; recurrences were common, but thenumber of deaths " not as great as expected." Tubercu-losis was very prevalent, usually with an insidious onsetand rapid course ; effusions were frequent and thespread was most often miliary. Many cases were notdiagnosed until necropsy, as was also the case at Belsen.

In the final month of the war there came the inevitableconsignment of about 1000 emaciated, verminous, andtyphus-ridden prisoners who, as at Belsen, were simplyturned loose in the camp. An epidemic followed, with

3. Pick, A., Salus, F. Acta med. scand. 1947, 129, 389.

about 30 new cases a day ; but before the liberation,the number had dropped-to 4-5 daily. As elsewhere inEurope where typhus appeared in- 1945, the diseasecarried a much lower mortality than the epidemics of1918 ; despite the evident, poor resistance of the inmatesand absence of previous immunisation, the mortalitywas only 15-20%.

DEATHS: ..

The author gives some official statistics for the numberof deaths between January, 1942, and April, 1944;these are illustrated- by the following round figures,derived from his tables, whic]4, relate: to a population of30,000-60,000 in the twelve months between August,1942, and July, 1943 : .. ’

No. of deaths" Old age" .... . 5400" Enteritis " ...... 7800Pneumonia ...... 4000

°

Tuberculosis ..... ,... 500Total from all. causes : ’ : 23,200

" Old age " of course included many nutritional deaths,and " enteritis " included deaths from both enteric feverand famine diarrhoea.

NATURE OF NUTRITIONAL DISORDERSIn discussing the aetiology of the nutritional disorders

he observed, Wolff-Eisner introduces a number of

concepts that will seem strange to those accustomed tothe recent Anglo-American literature, with which, under-standably enough, he appears to be unfamiliar. Herevives an old German idea that deficiency of fat is animportant factor in the aetiology of famine oedema, andhe does not indicate that reduced plasma-albumin,resulting from insufficient protein intake, may itself be acause of oedema. He believes that some disturbance ofthe reticulo-endothelial system affects the albumin-

globulin ratio and is responsible for the formation oftissue exudates and the rapid erythrocyte-sedimentationrate in starving people. He insists that simple lack ofcalories was not a significant factor in the mortality andthat vitamin deficiencies were much more important-despite the fact that his descriptions provide no certainevidence of such deficiencies except for hemeralopia andthe mention of cases of pellagra. He admits that yeastwas distributed in the camp without effect on morbidity,but argues that this showed how very great was thedeficiency of vitamin B.

Translated into practical terms, he feels that what theprisoners needed most was not more carbohydrate butmore meat, fish, fat, fruit, and vegetables. With thisconclusion there can be no quar-rel ; such protectivefoods would certainly be the best remedy for a starvationdiet, as sources of both calories and essential nutrients.But his reasons for the conclusion are less convincing.General experience is that vitamin deficiencies are rarewith severe under-feeding, probably because the needfor most vitamins diminishes as the calorie intake lessens.

PHYSICAL ANTHROPOLOGY

FROM A CORRESPONDENT IN NEW YORK

THE Viking Fund, of New York City, under thedirection of Dr. Paul Fejos, has been supporting anthro-pological research for a good many years, but it is onlyrecently that its efforts at stimulating physical as wellas cultural anthropology have brought its activities tothe attention of those in the medical field.

This summer, for the third year in succession, theFund has financed a seminar, which discussedtwo subjects, each for five days ; the first was Growth,and the second Evolution. The official discussants,whose expenses are paid by the Fund, included oneBritish expert in each field : Dr. J. M. Tanner on growth,and Prof. W. E. Le Gros Clark, F.R.S., on evolution.