- Email: [email protected]
Neurologic sequelae of deficiency diseases in World War II prisoners of war: Extracts from a videographic narrative
Journal of Clinical Neuroscience 17 (2010) 294–295
Contents lists available at ScienceDirect
Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn
History
Neurologic sequelae of deficiency diseases in World War II prisoners of war: Extracts from a videographic narrative Neeraj Kumar a,*, Christopher J. Boes a, Joel Vilensky b a b
Department of Neurology, Mayo Clinic Bldg E-8 A, 200 First Street SW, Rochester, Minnesota 55905, USA Department of Anatomy and Cell Biology, Indiana University School of Medicine, Fort Wayne, Indiana, USA
a r t i c l e
i n f o
Article history: Received 17 October 2008 Accepted 21 May 2009
a b s t r a c t This report aims at bringing attention to still frames from a film that provides a videographic narrative of neurologic deficiency diseases in post World War II prisoners of war. An abbreviated version of the original film is provided as Supplementary material. Ó 2009 Elsevier Ltd. All rights reserved.
Keywords: Nutritional Neurologic Prisoners of war World War II
The term ‘‘tropical ataxic neuropathy” was originally used to describe an ataxic neuropathy due to cassava consumption seen in Nigeria. The term is currently used to describe several neurological syndromes seen in the tropics that are attributed to toxiconutritional causes.1 An epidemic of such disorders has been seen in war times, the best documentation of which is from reports of neurologic disease seen in released prisoners of war (POWs) in the late 1940s. This report aims to bring attention to a film from the Royal Navy Hospital in Sydney, Australia, located in an area now called Riverwood, which provides a videographic narrative of deficiency diseases in POWs. The original video is a 10-minute-long film. It was procured by one of the authors (JV). The first few segments of the film summarize its content: This film was made to demonstrate some of the clinical features seen in released Prisoners of War and Internees from Hong Kong and Singapore. During their captivity from 1941 to 1945 the prisoners had existed on a diet consisting mainly of rice, usually polished and frequently deteriorated from storage. Inconstant additions were dried fish, beans, peanut oil and chrysanthemum leaves. Nearly all suffered some deficiency symptoms, which occurred in a similar order, usually beginning within three months of imprisonment. Swelling of the ankles appeared first, followed by dimness of vision, an ataxic gait, paresthesiae of the limbs and, in a few cases, nerve deafness.
* Corresponding author. Tel.: +1 507 284 8305; fax: +1 507 284 4074. E-mail address: [email protected] (N. Kumar). 0967-5868/$ - see front matter Ó 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.jocn.2009.05.034
The film demonstrates patients with visual impairment due to a variety of causes including optic atrophy, macular degeneration, corneal scarring, and central scotomas (Fig. 1A). There are many patients with distal paresthesias and a wide-based, ataxic gait with a steppage or stamping component (Fig. 1C). Patients were commonly noted to have a foot drop (spastic or flaccid) or Rombergism (Fig. 1D). The narrator indicates that at times these patients had findings that mistakenly suggested hysteria. Not infrequently multiple signs and symptoms were present. In one patient shown the ataxia was relatively subtle and prominent only when running. Also included are patients with nerve deafness (Fig. 1B) and a patient with ‘‘amyotrophic lateral sclerosis and sensory symptoms” (Fig. 1E, F). The setting for many of the clinical evaluations done was the outdoors, most likely to facilitate the film recording. One segment shows a patient holding on to an outstretched rope to obtain balance (Fig. 1E). Rather graphic, and ethically and medically concerning, is a segment that shows the demonstration of anesthesia to pinprick in a patient (Fig. 1H). The latter part of the film demonstrates rehabilitative efforts including group exercises (Fig. 1I), use of an improvised foot brace (Fig. 1G), and walking on outlines of foot tracings (Fig. 1J). To our knowledge this is the only published pictorial documentation of the broad spectrum of neurologic disorders seen in POWs. There are, however, many manuscripts that detail the neurological syndromes seen in POWs.2–5 A comprehensive description of these conditions is provided by Derek E. Denny-Brown in his article entitled, ‘‘Neurological conditions resulting from prolonged and severe dietary restriction”.5 Denny-Brown personally examined released POWs with neurological disability while serving as Consultant in Neurology to India Command and to Allied Land Forces, South East
N. Kumar et al. / Journal of Clinical Neuroscience 17 (2010) 294–295
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Fig. 1. (A1) A patient with optic atrophy, nerve deafness, and foot drop. This picture shows testing Rombergism while reading a newspaper. (A2) The size of print that was difficult to read by patients with reduced visual acuity. (B) A patient with nerve deafness, distal sensory loss, and foot drop (left) being communicated with using sign language. (C) Two patients walking side by side for ‘‘mutual support”. One (right) has ataxia with a foot drop and steppage gait, the other (left) has a spastic ataxic gait with scissoring. (D) Demonstration of Rombergism. (E) A patient walking while holding on to a stretched rope for support. This patient had an amyotrophic lateral sclerosis-like presentation with sensory changes including optic atrophy and nerve deafness. (F1, F2) Hand wasting in the patient shown in (E). (G) An improvised foot brace. (H) Demonstration of anesthesia to pinprick. (I1, I2) Group sessions for remedial exercises. (J) Walking alongside a nurse (right) while placing feet on shoe tracings.
Asia. In this document Denny-Brown writes, ‘‘The confinement of large groups of men in close captivity in war prison camps, on extremely limited diets for long periods of time, has unwittingly provided data on the effect of dietary insufficiency, on a scale that experimental medicine can hardly hope to emulate”.5 Most cases were related to single or multiple nutritional deficiencies, most commonly Bgroup vitamins. A common symptom often of presumed nutritional basis was foot pain that has been frequently alluded to in the literature as ‘‘burning feet” and less commonly as ‘‘happy feet”.1 Decades later optic atrophy, peripheral neuropathy, or sensorineural deafness persisted in approximately 5% of former POWs.6 Patients with similar symptoms to those seen in World War II were seen during the Spanish Civil War. Between 1991 and 1993 there occurred an epidemic of optic neuropathy and polyneuropathy in Cuba that subsided after large-scale vitamin supplementation.7 To our knowledge, the full-length film, of which an extract appears in Supplementary material, is the only videographic documentation of neurologic deficiency disease in prisoners of World War II.
Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at doi:10.1016/j.jocn.2009.05.034. References 1. Roman GC, Spencer PS, Schoenberg BS. Tropical myeloneuropathies: the hidden endemias. Neurology 1985;35:1158–70. 2. Cruickshank EK. Painful feet in prisoners-of-war in the Far East: review of 500 cases. Lancet 1946;2:369–72. 3. Smith D. Nutritional neuropathies in the civilian internment camp, Hong Kong, January 1942 August 1945. Brain 1946;69:209–22. 4. Burgess RC. Deficiency diseases in prisoners-of-war at Changi, Singapore, February 1942 to August, 1945. Lancet 1946;2:411–8. 5. Denny-Brown D. Neurological conditions resulting from prolonged and severe dietary restriction. Medicine 1947;26:41–113. 6. Gibberd FB, Simmonds JP. Neurological disease in ex-Far-East prisoners of war. Lancet 1980;316:135–7. 7. The Cuban Neuropathy Field Investigation Team. Epidemic optic neuropathy in Cuba – clinical characterization and risk factors. N Engl J Med 1995;333: 1176–82.
Contents lists available at ScienceDirect
Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn
History
Neurologic sequelae of deficiency diseases in World War II prisoners of war: Extracts from a videographic narrative Neeraj Kumar a,*, Christopher J. Boes a, Joel Vilensky b a b
Department of Neurology, Mayo Clinic Bldg E-8 A, 200 First Street SW, Rochester, Minnesota 55905, USA Department of Anatomy and Cell Biology, Indiana University School of Medicine, Fort Wayne, Indiana, USA
a r t i c l e
i n f o
Article history: Received 17 October 2008 Accepted 21 May 2009
a b s t r a c t This report aims at bringing attention to still frames from a film that provides a videographic narrative of neurologic deficiency diseases in post World War II prisoners of war. An abbreviated version of the original film is provided as Supplementary material. Ó 2009 Elsevier Ltd. All rights reserved.
Keywords: Nutritional Neurologic Prisoners of war World War II
The term ‘‘tropical ataxic neuropathy” was originally used to describe an ataxic neuropathy due to cassava consumption seen in Nigeria. The term is currently used to describe several neurological syndromes seen in the tropics that are attributed to toxiconutritional causes.1 An epidemic of such disorders has been seen in war times, the best documentation of which is from reports of neurologic disease seen in released prisoners of war (POWs) in the late 1940s. This report aims to bring attention to a film from the Royal Navy Hospital in Sydney, Australia, located in an area now called Riverwood, which provides a videographic narrative of deficiency diseases in POWs. The original video is a 10-minute-long film. It was procured by one of the authors (JV). The first few segments of the film summarize its content: This film was made to demonstrate some of the clinical features seen in released Prisoners of War and Internees from Hong Kong and Singapore. During their captivity from 1941 to 1945 the prisoners had existed on a diet consisting mainly of rice, usually polished and frequently deteriorated from storage. Inconstant additions were dried fish, beans, peanut oil and chrysanthemum leaves. Nearly all suffered some deficiency symptoms, which occurred in a similar order, usually beginning within three months of imprisonment. Swelling of the ankles appeared first, followed by dimness of vision, an ataxic gait, paresthesiae of the limbs and, in a few cases, nerve deafness.
* Corresponding author. Tel.: +1 507 284 8305; fax: +1 507 284 4074. E-mail address: [email protected] (N. Kumar). 0967-5868/$ - see front matter Ó 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.jocn.2009.05.034
The film demonstrates patients with visual impairment due to a variety of causes including optic atrophy, macular degeneration, corneal scarring, and central scotomas (Fig. 1A). There are many patients with distal paresthesias and a wide-based, ataxic gait with a steppage or stamping component (Fig. 1C). Patients were commonly noted to have a foot drop (spastic or flaccid) or Rombergism (Fig. 1D). The narrator indicates that at times these patients had findings that mistakenly suggested hysteria. Not infrequently multiple signs and symptoms were present. In one patient shown the ataxia was relatively subtle and prominent only when running. Also included are patients with nerve deafness (Fig. 1B) and a patient with ‘‘amyotrophic lateral sclerosis and sensory symptoms” (Fig. 1E, F). The setting for many of the clinical evaluations done was the outdoors, most likely to facilitate the film recording. One segment shows a patient holding on to an outstretched rope to obtain balance (Fig. 1E). Rather graphic, and ethically and medically concerning, is a segment that shows the demonstration of anesthesia to pinprick in a patient (Fig. 1H). The latter part of the film demonstrates rehabilitative efforts including group exercises (Fig. 1I), use of an improvised foot brace (Fig. 1G), and walking on outlines of foot tracings (Fig. 1J). To our knowledge this is the only published pictorial documentation of the broad spectrum of neurologic disorders seen in POWs. There are, however, many manuscripts that detail the neurological syndromes seen in POWs.2–5 A comprehensive description of these conditions is provided by Derek E. Denny-Brown in his article entitled, ‘‘Neurological conditions resulting from prolonged and severe dietary restriction”.5 Denny-Brown personally examined released POWs with neurological disability while serving as Consultant in Neurology to India Command and to Allied Land Forces, South East
N. Kumar et al. / Journal of Clinical Neuroscience 17 (2010) 294–295
295
Fig. 1. (A1) A patient with optic atrophy, nerve deafness, and foot drop. This picture shows testing Rombergism while reading a newspaper. (A2) The size of print that was difficult to read by patients with reduced visual acuity. (B) A patient with nerve deafness, distal sensory loss, and foot drop (left) being communicated with using sign language. (C) Two patients walking side by side for ‘‘mutual support”. One (right) has ataxia with a foot drop and steppage gait, the other (left) has a spastic ataxic gait with scissoring. (D) Demonstration of Rombergism. (E) A patient walking while holding on to a stretched rope for support. This patient had an amyotrophic lateral sclerosis-like presentation with sensory changes including optic atrophy and nerve deafness. (F1, F2) Hand wasting in the patient shown in (E). (G) An improvised foot brace. (H) Demonstration of anesthesia to pinprick. (I1, I2) Group sessions for remedial exercises. (J) Walking alongside a nurse (right) while placing feet on shoe tracings.
Asia. In this document Denny-Brown writes, ‘‘The confinement of large groups of men in close captivity in war prison camps, on extremely limited diets for long periods of time, has unwittingly provided data on the effect of dietary insufficiency, on a scale that experimental medicine can hardly hope to emulate”.5 Most cases were related to single or multiple nutritional deficiencies, most commonly Bgroup vitamins. A common symptom often of presumed nutritional basis was foot pain that has been frequently alluded to in the literature as ‘‘burning feet” and less commonly as ‘‘happy feet”.1 Decades later optic atrophy, peripheral neuropathy, or sensorineural deafness persisted in approximately 5% of former POWs.6 Patients with similar symptoms to those seen in World War II were seen during the Spanish Civil War. Between 1991 and 1993 there occurred an epidemic of optic neuropathy and polyneuropathy in Cuba that subsided after large-scale vitamin supplementation.7 To our knowledge, the full-length film, of which an extract appears in Supplementary material, is the only videographic documentation of neurologic deficiency disease in prisoners of World War II.
Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at doi:10.1016/j.jocn.2009.05.034. References 1. Roman GC, Spencer PS, Schoenberg BS. Tropical myeloneuropathies: the hidden endemias. Neurology 1985;35:1158–70. 2. Cruickshank EK. Painful feet in prisoners-of-war in the Far East: review of 500 cases. Lancet 1946;2:369–72. 3. Smith D. Nutritional neuropathies in the civilian internment camp, Hong Kong, January 1942 August 1945. Brain 1946;69:209–22. 4. Burgess RC. Deficiency diseases in prisoners-of-war at Changi, Singapore, February 1942 to August, 1945. Lancet 1946;2:411–8. 5. Denny-Brown D. Neurological conditions resulting from prolonged and severe dietary restriction. Medicine 1947;26:41–113. 6. Gibberd FB, Simmonds JP. Neurological disease in ex-Far-East prisoners of war. Lancet 1980;316:135–7. 7. The Cuban Neuropathy Field Investigation Team. Epidemic optic neuropathy in Cuba – clinical characterization and risk factors. N Engl J Med 1995;333: 1176–82.