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Kwashiorkor
1070 thawed. Techniques for frozen storage of living tissues are complicated, and homograft survival is limited and uncertain, but enough has already been accomplished to illustrate the abundant surgical applications that may finally prove possible.
Kwashiorkor IN 1933 CICELY WILLIAMS1 drew attention to a nutritional disease common among the children of the Gold Coast, where it was known by the vernacular name of kwashiorkor. Since then there have been numerous reports from all parts of Africa, and also from Asian, American, and even European countries, describing clinical syndromes which resemble kwashiorkor in greater or less degree. Some authors have emphasised similarities to the condition originally observed in the Gold Coast : others have laid stress on differences. Unfortunately, most of them have been able to speak from experience of only one area, and their accounts of varying setiological factors and clinical features have made it hard to know whether the disorders they are describing are essentially the same disease. But whether they are the same or not, they are certainly very important as causes of misery and loss. The time is more than ripe, therefore, for an attempt to correlate the items of knowledge gained in the past twenty years, and we hope for useful results from the conference on kwashiorkor now in progress at Fajara in the Gambia, at which delegates from more than twenty African territories are meeting under the presidency of Prof. B. S. PLATT, director of the Medical Research Council’s field research station in that place. It may be recalled that in 1950 a joint expert committee of the World Health Organisation and the Food and Agricultural Organisation recommended the subject for study by the United Nations 2 ; and from this initiative comes a report3 by Dr. J. F. BROCK, professor of medicine at Cape Town, and Dr. M. AUTRET, of F.A.O. Having made an extensive African tour, they define kwashiorkor as a nutritional syndrome, common among the natives of many parts of Africa, in which characteristically there occurs : "(a) retarded growth in the late breast-feeding, weaning, and post-weaning ages with (b) alterations in skin and hair pigmentation, (c) oedema, (d) fatty infiltration, cellular necrosis, or fibrosis of the liver, (e) a heavy mortality in the absence of proper dietary treatment and (,f) the frequent association of a variety of dermatoses." Perhaps it is this variety of the determined dermatoses, partly by local vitamin deficiencies and partly by environmental trauma, that has chiefly delayed agreement on the nature of the disease. Clearly there are local variations, related both to local dietary deficiencies (notably the varied intake of the B group of vitamins) and to local prevalence of tropical infections ; but BROCK and AuTBET showed that behind these variations there is a clinical entity at least as distinct as beriberi or pellagra. Pragmatically anyhow, the use of the word kwashiorkor has been justified, for it has led to the recog1. Williams, C. D. Annual Report for 1932, Medical Department, Gold Coast; Arch. Dis. Childh. 1933, 8, 423; Lancet, 1935, ii, 1151. 2. Lancet, 1950, ii, 580. 3. Kwashiorkor in Africa. F.A.O. Nutritional Studies no. 8 and Rome and Geneva, 1952. W.H.O. Monograph Series no. 8. Pp. 78. 5s.
nition and treatment of individual cases and to the devising of means of prevention. Physicians who have used it in the same sense as BROCK and AUTRET include such authorities as CLARKand TROWELL5 in East Africa, PIERAERTS6 and DRICoT et al.in the Belgian Congo, and BERGERET 8 and BERO0UNI0U and TRÉMOLIÈRES9 in French West Africa. Nevertheless there are dissidents, represented by KAHN,10 of Johannesburg, who recently asked in this journal whether we are justified in bundling together cases with and without oedema, with and without mucous membrane changes, with and without dermatosis, and " He would restrict the term kwashiorkor to so on ? the pigmentary changes in the hair, which in some but he seems to areas turns from black to russet ; be in error (with CICELY WILLIAMS) in believing that on the Gold Coast kwashiorkor means " red boy and is solely descriptive of these changes. MAcPHERSON11 says that in fact it means " possessed by red devils " and is a sinister word knit with Gold Coast magic. The first task before BROCK and AuTRET was to establish whether or not kwashiorkor was a real medical problem, affecting large numbers of children in many parts of Africa. To this question their answer was an emphatic " yes." They went on to produce much evidence that a widespread lack of protein (particularly animal protein) in the diet during the early years of life is the all-important aetiological factor : as the Governor of the Gambia said in opening the Fajara conference,12 the general opinion is that the main "
"
is a deficiency in protein foods, the time of weaning. The relation of the diet to the deficiency in pancreatic function which was observed some years ago in children with kwashiorkor 13 and is now being further investigated 14 15 still needs to be worked out.; but so far as treatment is concerned, the efficacy of proteins (particularly milk proteins) is almost beyond dispute. The problem of prevention, however, has no equally simple solution. We know that, apart from the heavy mortality, vast numbers of African children are retarded and stunted, both- physically and psychologically, by this form of malnutrition: indeed it is no exaggeration to say that the African peoples will never be able to take their proper place in a free world so long as they are thus handicapped. The recent work of DEAN 16 encourages the hope that proteins from vegetable sources will suffice for prevention ; but before the African child of the future can receive a sufficiency of these there will have to be a revolution in African standards of mothercraft, and several revolutions in African agriculture. This is the kind of fact that we hope the conference, like the W.H.O.-F.A.O. report, will help to drive home.
contributory especially at deficiency in
4. 5. 6. 7. 8. 9.
10. 11. 12. 13. 14. 15.
16.
cause
Clark, M. E. Afr. med. J. 1951, 28, 229. Trowell, H. C. Trans. R. Soc. trop. Med. Hyg. 1949, 42, 417. Pieraerts, G. Bull. Soc. Path. exot. 1950, 43, 120. Dricot, C., Beheyt, P., Charles, P. Ann. Soc. beige Méd. trop. 1951, 31, 581. Bergeret, C. Bull méd. Afr. occid. franç. 1948, 5, 257. Bergouniou, J. L., Trémolières, J. Bull. Soc. Path. exot. 1952, 45, 113. Kahn, E. Lancet, Sept. 20, 1952, p. 588. MacPherson, A. Ibid, 1951, i, 53. See Times, Nov. 20, 1952. Davies, J. N. P. Lancet, 1948, i, 317. Thompson, M. D., Trowell, H. C. Ibid, 1952, i, 1031. Srinivasan, P. R., Patwardhan, V. N. Ibid, Nov. 1, 1952, p. 864. Dean, R. F. A. Brit. med. J. Oct. 11, 1952, p. 791.
Kwashiorkor IN 1933 CICELY WILLIAMS1 drew attention to a nutritional disease common among the children of the Gold Coast, where it was known by the vernacular name of kwashiorkor. Since then there have been numerous reports from all parts of Africa, and also from Asian, American, and even European countries, describing clinical syndromes which resemble kwashiorkor in greater or less degree. Some authors have emphasised similarities to the condition originally observed in the Gold Coast : others have laid stress on differences. Unfortunately, most of them have been able to speak from experience of only one area, and their accounts of varying setiological factors and clinical features have made it hard to know whether the disorders they are describing are essentially the same disease. But whether they are the same or not, they are certainly very important as causes of misery and loss. The time is more than ripe, therefore, for an attempt to correlate the items of knowledge gained in the past twenty years, and we hope for useful results from the conference on kwashiorkor now in progress at Fajara in the Gambia, at which delegates from more than twenty African territories are meeting under the presidency of Prof. B. S. PLATT, director of the Medical Research Council’s field research station in that place. It may be recalled that in 1950 a joint expert committee of the World Health Organisation and the Food and Agricultural Organisation recommended the subject for study by the United Nations 2 ; and from this initiative comes a report3 by Dr. J. F. BROCK, professor of medicine at Cape Town, and Dr. M. AUTRET, of F.A.O. Having made an extensive African tour, they define kwashiorkor as a nutritional syndrome, common among the natives of many parts of Africa, in which characteristically there occurs : "(a) retarded growth in the late breast-feeding, weaning, and post-weaning ages with (b) alterations in skin and hair pigmentation, (c) oedema, (d) fatty infiltration, cellular necrosis, or fibrosis of the liver, (e) a heavy mortality in the absence of proper dietary treatment and (,f) the frequent association of a variety of dermatoses." Perhaps it is this variety of the determined dermatoses, partly by local vitamin deficiencies and partly by environmental trauma, that has chiefly delayed agreement on the nature of the disease. Clearly there are local variations, related both to local dietary deficiencies (notably the varied intake of the B group of vitamins) and to local prevalence of tropical infections ; but BROCK and AuTBET showed that behind these variations there is a clinical entity at least as distinct as beriberi or pellagra. Pragmatically anyhow, the use of the word kwashiorkor has been justified, for it has led to the recog1. Williams, C. D. Annual Report for 1932, Medical Department, Gold Coast; Arch. Dis. Childh. 1933, 8, 423; Lancet, 1935, ii, 1151. 2. Lancet, 1950, ii, 580. 3. Kwashiorkor in Africa. F.A.O. Nutritional Studies no. 8 and Rome and Geneva, 1952. W.H.O. Monograph Series no. 8. Pp. 78. 5s.
nition and treatment of individual cases and to the devising of means of prevention. Physicians who have used it in the same sense as BROCK and AUTRET include such authorities as CLARKand TROWELL5 in East Africa, PIERAERTS6 and DRICoT et al.in the Belgian Congo, and BERGERET 8 and BERO0UNI0U and TRÉMOLIÈRES9 in French West Africa. Nevertheless there are dissidents, represented by KAHN,10 of Johannesburg, who recently asked in this journal whether we are justified in bundling together cases with and without oedema, with and without mucous membrane changes, with and without dermatosis, and " He would restrict the term kwashiorkor to so on ? the pigmentary changes in the hair, which in some but he seems to areas turns from black to russet ; be in error (with CICELY WILLIAMS) in believing that on the Gold Coast kwashiorkor means " red boy and is solely descriptive of these changes. MAcPHERSON11 says that in fact it means " possessed by red devils " and is a sinister word knit with Gold Coast magic. The first task before BROCK and AuTRET was to establish whether or not kwashiorkor was a real medical problem, affecting large numbers of children in many parts of Africa. To this question their answer was an emphatic " yes." They went on to produce much evidence that a widespread lack of protein (particularly animal protein) in the diet during the early years of life is the all-important aetiological factor : as the Governor of the Gambia said in opening the Fajara conference,12 the general opinion is that the main "
"
is a deficiency in protein foods, the time of weaning. The relation of the diet to the deficiency in pancreatic function which was observed some years ago in children with kwashiorkor 13 and is now being further investigated 14 15 still needs to be worked out.; but so far as treatment is concerned, the efficacy of proteins (particularly milk proteins) is almost beyond dispute. The problem of prevention, however, has no equally simple solution. We know that, apart from the heavy mortality, vast numbers of African children are retarded and stunted, both- physically and psychologically, by this form of malnutrition: indeed it is no exaggeration to say that the African peoples will never be able to take their proper place in a free world so long as they are thus handicapped. The recent work of DEAN 16 encourages the hope that proteins from vegetable sources will suffice for prevention ; but before the African child of the future can receive a sufficiency of these there will have to be a revolution in African standards of mothercraft, and several revolutions in African agriculture. This is the kind of fact that we hope the conference, like the W.H.O.-F.A.O. report, will help to drive home.
contributory especially at deficiency in
4. 5. 6. 7. 8. 9.
10. 11. 12. 13. 14. 15.
16.
cause
Clark, M. E. Afr. med. J. 1951, 28, 229. Trowell, H. C. Trans. R. Soc. trop. Med. Hyg. 1949, 42, 417. Pieraerts, G. Bull. Soc. Path. exot. 1950, 43, 120. Dricot, C., Beheyt, P., Charles, P. Ann. Soc. beige Méd. trop. 1951, 31, 581. Bergeret, C. Bull méd. Afr. occid. franç. 1948, 5, 257. Bergouniou, J. L., Trémolières, J. Bull. Soc. Path. exot. 1952, 45, 113. Kahn, E. Lancet, Sept. 20, 1952, p. 588. MacPherson, A. Ibid, 1951, i, 53. See Times, Nov. 20, 1952. Davies, J. N. P. Lancet, 1948, i, 317. Thompson, M. D., Trowell, H. C. Ibid, 1952, i, 1031. Srinivasan, P. R., Patwardhan, V. N. Ibid, Nov. 1, 1952, p. 864. Dean, R. F. A. Brit. med. J. Oct. 11, 1952, p. 791.