Summary of Selected Studies of Starved Holocaust Survivors and Prisoners of War, with Added Commentary in Brackets.
Summary of Selected Studies of Starved Holocaust Survivors and Prisoners of War, with Added Commentary in Brackets.
| Reference | Study Group | Clinical Findings | Nutritional Rehabilitation and Results | Study Outcomes and Observations |
|---|---|---|---|---|
| Burger et al. (1945)41 | Post-liberation population of Western Holland (children and adults) | Anemia (Hgb ~11 g/dL) with tendency to leukopenia
Bodily and mental exhaustion Body temperature ≤35°C Chemosis Diarrhea [assumed due to past infection but no pathogens detected] Dizziness Edema in minority of pts* Emaciation Heart: normal but bradycardia (avg. 40 bpm) and low systolic BP (80 mmHg) [cardiac decompensation in some pts*] Osteoporosis with bone pain† Slightly reddened tongue |
Acid casein hydrolysate (5% IV): caused thrombosis; no positive results after administration (treatment discontinued)
Enzymic protein hydrolysates: little effect on edema, adynamia, apathy; no benefit in children; most benefit for pts unable to swallow or eat due to mental disturbances All pts: high-caloric diet encouraged Pts with high-protein and high-caloric diet recovered best [no data provided on how many pts died at beginning of feeding] |
Complications included cardiac decompensation [possibly indicative of electrolyte imbalance, but no other data provided]
Three types of deaths: (1) sudden, unexplained, early after hospital admission; (2) unexpected following apparent recovery; (3) slow death after lapsing into a coma* Autopsies: bronchopneumonia in most cases; some atrophied livers, hearts, and spleens* Results of plasma or whole blood infusions “not encouraging”41(p283) Reddened or painful tongue responded well to nicotinic acid or nicotinamide injection, respectively [possible indicator of vitamin B3 deficiency, known to occur in refeeding syndrome] [No mortality data or causes of death listed; no electrolyte studies mentioned] |
| Collis (1945)42 | Survivors of Belsen (preliminary report) | Dysentery
Starvation (pure starvation cases presented with edema, gingivitis, pigmentation (?pellagra), emaciation, and extreme lassitude) Tuberculosis Typhus |
Supervised special feedings (not defined)
Protein hydrolysate and glucose, but refused by many pts due to fear of torture Dried milk |
Reduced death rate of 300/day to 60/day after a few weeks; attributed to improved nutrition
[Very general report with little medical data] |
| Vaughan et al. (1945)45 | Bergen-Belsen survivors—representative group of pts (small numbers) | Edema (gross or general)
Diarrhea Low plasma protein Starvation Pellagra-like tongue lesions [indicative of vitamin B3 deficiency] [Primary focus of study was response to hydrolysates] |
Oral hydrolysates:
Nasal drip (2 pts), poorly tolerated; 1 pt died on d2; second pt worsened condition [Death and poor recovery may have been related to sudden increased nutritional supplementation] Oral, only slight improvement; 1 pt developed colicky pain and ascites but improved on milk diet |
All pts receiving milk improved well
Most stool cultures negative Blood volume tests planned but could not be performed General conclusion: oral hydrolysates not helpful in starvation pts; pts “suffered from many intercurrent infections”45(p397) [not confirmed by testing] [No hard data provided; no mention of results of vitamin supplementation] |
| Mitchell and Black (1946)48 | Mostly British and Eastern European POWs from Japanese camps | Diarrhea or dysentery
Emaciation Malaria Malnutrition Normal heart (altered heart sounds) Weight loss: average 41 lb/person In malnutrition only pts
|
Vitamin supplements
Five-stage (S) graduated diet: S1, protein hydrolysate 7× for 1d; S2, protein hydrolysate + egg-milk mixture 7× per day until appetite returns; S3, egg-milk mixture + rolled oats, tinned fruit, tinned chicken for at least 3d; S4, hospital light diet; S5, hospital ordinary diet Generally good response and improvement of physical condition (e.g. less diarrhea and edema) Signs of vitamin deficiency usually only after refeeding [See also Study Outcomes and Observations] |
23 deaths between Sept. 9 and Nov. 30, 1945
Most deaths related to malnutrition and other underlying cause (e.g. beriberi, tuberculosis) Sudden increase in diet a contributing cause in at least one death, possibly others Relapses in health condition consistently responded well to further reduction in calories Autopsy findings (most pts): small internal organs, atrophic stomach and intestinal mucosa, and pulmonary edema [might indicate CHF due to electrolyte imbalance indicative of refeeding syndrome; electrolytes were not examined] “Careful dieting and individual feeding were the only effectual measures in treating the most severe cases of malnutrition.”48(p862) |
| Mollison (1946)43 | Bergen-Belsen survivors (exams performed on a selected group of children and adult starvation survivors) | Anemia (normocytic)
↓ Blood volume Diarrhea Edema Emaciation Hypoproteinemia Low BP (avg 91/60) Normal heart (reduced intensity sounds) Tachycardia (avg >100 bpm) Tuberculosis (40% of those examined)/typhus (most pts) Weight loss (29%–56% of original weight in those strong enough to be weighed) |
“Enough food in terms of calories, but much of it was unpalatable”43(p5)
Survivors refused liquid diets, preferred solid food Some survivors feared eating due to immediate and severe diarrhea [No details regarding diets or vitamin supplementation] |
Frequent deaths observed: thinnest pts died first; cause of death assumed to be secondary to tuberculosis in many of the cases evaluated
Unsatisfactory recovery correlated to tuberculosis [No other details provided] |
| Walters et al. (1947)44 | Indian POWs held by the Japanese,
~2000 pts in 4 groups§ |
All groups: anemia in varying severities (macrocytic); delayed edema, hypocalcemia, hypoproteinemia
G1 (60%): wasting only—slight anemia G2 (~1%): wasting + severe hypoproteinemia; anemia (severe); blood and plasma volume (low); edema with ascites (severe); wasting (extreme) G3 (10%): wasting and vitamin deficiency; riboflavin or nicotinic acid symptoms, often seen together G4 (~30%): wasting and neurological syndrome—peripheral neuritis due to beriberi (20%); “captivity cord syndrome” (2%); “captivity amblyopia” (9%) In general: sub-normal blood pressure |
All groups: graduated diet from low-residue/bland food (~3800 calories) when appetite was low to a full diet of 5300 calories, high-protein, with high-caloric and high-protein diets | G1–G3: Good recovery
G4: Good recovery except for most severe cases In pts with diarrhea, increased food intake aggravated the condition Indications that Indian people more susceptible to macrocytic anemia; captivity syndrome seemed to be unique to prisoners held in the Middle or Far East; diarrhea not necessarily part of starvation syndrome Phosphorus and calcium levels were comparable to normal controls in 27 representative pts, but albumin was very low [No mention of deaths] |
| Schnitker et al. (1951)13 | Japanese POWs
Out of 8000 pts, a representative group of 24 pts studied‡ G1: Massive edema (n=12) G2: None or minimal edema (n=12) Controls: 24 apparently healthy Japanese males for comparison |
Anorexia
Creatinuria Diarrhea (evidence of poor intestinal absorption) Dyspnea Edema Hydrothorax and ascites (G1 only) Hypoproteinemia Intestinal parasites (all pts) Liver function tests abnormal (all pts) Malaria Pleural effusion and congestion (G1 only) Tachycardia on exertion Vitamin deficiency rare, indications of vitamin A deficiency present Weakness Weight loss (~40% of original weight) |
All pts: high-calorie, high-vitamin diet with yeast and vitamin supplements | Slow response to treatment despite high-caloric diet and vitamin supplementation
Poor tolerance for large amounts of food presumed due to intestinal lesions [autopsy found no intestinal lesions in pts] Signs of gastrointestinal disturbances 5 pts in study group died (data available for only 4); 6 other malnutrition cases also autopsied; presumed cause of death was starvation Autopsies: subcutaneous fat scant or absent, skeletal muscles grossly atrophic, atrophy of heart and pancreas (n=5); atrophied liver (n=4); atrophic cirrhosis of liver (n=1); intestinal ulcers (n=3; bacterial cause confirmed in only 1 pt) Noticeably few pts with signs of vitamin deficiency despite neurologic changes observed [indicative of vitamin B3 deficiency] No explanation for massive edema in some pts vs none in others |
| Winick (1979)6 | Hospitalized pts in the Warsaw Ghetto
100 pts suffering only from hunger disease |
General weakness
Tiredness Reduced physical effort Somnolence attributed to hypoglycemia |
All pts immediately moved from starvation diet (less than 1000 cal/day) to 1000-calorie diet
Glucose tolerance tests subjected starved pts to sudden sugar load Basic metabolic rate tests subjected subjects to sudden protein/ carbohydrate load via eggs |
Following sugar loading, hypoglycemia <60 mg% common, reaching levels as low as 32 mg%
Low Cl(−) levels observed in blood, gastric juice and urine Low urine Cl(−) levels associated with edema |