the prevalence of pellagra among turkish prisoners 173 · the prevalence of pellagra" among...

$: The Prevalence of Pellagra among Turkish Prisoners 173 · The Prevalence of Pellagra" among Turkish Prisoners 173 LieutenantcColonel Cr?ssley, C.1\LG., for the constant facilities$
The Prevalence of Pellagra" among Turkish Prisoners 173

LieutenantcColonel Cr?ssley, C.1\LG., for the constant facilities which he afforded to physiological .work' in an orgfl,niza~ion which was primarily chemical, to

'Lieutenant·Colonel Douglas, 'C.'M.G., Colonel Elliott, C.B.E., and especially to Colonel Cummins, 'CJ.M.G., and' 'Colonel Sir Willi!!.m Horrocks, K.C.M.H., C.B., fodhehelp giv~n by the Army to an enterprise of the Ministry of Munittons.

REFERENCES. . .

[1] DUNN, "Chemical Warfare Medical Committee Report," No. 11, p. 8. [2] . FUHNER and STARLING. Joum. of Phys., vol. xlvii, pp. 286, 1913. , [3] ·DUNN. Quart. Journ. Med., vol. xiii.. ' [4] BAR9ROFT,BOYCOTT,DUNN and PETERS. Ibid., p. 35. [5] DUNN. Ibid., p. 129. , . [6] TRIBE. Journ. of Phys., vol.xlv, p. ~x, 1912, vol.xlviii, p. 154, 1914. , [7] SHARPEY.SCHAFER; and Lul. Quart. Journ. of Exper. Phys., vol. xii, 'p. 157, 1919. [8] DALE and RWHARDS.' Journ. of Phys., vol. lii, p. ho, 1918-19. [9] KROGH. Ibid., p. 457,1918-19. '

• I

'!Report.

REPORT OF A COMMITTEE OF INQUIRY REGARDING THE PRE'· VALENCE OF PELLAGRA AMONG, ,T,u'RKISH ~RI~ONERS OF WAR.' . \

. (Continued j1'01n p. 79.)

APPENDIX V.

PROTOZOOLOGlCAL AND OTHER PARASITOLOGIQAL INVESTIGATIONS ON

PELLAGRA.

The following work has been done by me as protozoologist to the Oommittee, since October 16, 1918:-,

'Scope of Investigation.

My investigations have fallen mainly within thescopeof~ection (A), sub· section (B) of the terms of reference:~ .

" To investigate the retiology of the ,disease in relation to protOl'lpa." A number of hrematological ob~ervations were' also made, which fall nnder

subsection (C), "Blood conditions.'" My primary aim, therefore, has been tc;> ascertain whether any evidence was

to be found, from a study of ,cases of pellagra, which would incriminate some protozoan parasite, known or hitherto un)mown, as a causal fa~tor in this disease.

, In addition, a record 'has beE:)n kept of the occurrence of all other animal parasites, in View of the possibility'of such infection having a bearing ;ripon the incidence of the' disease. I

Plan of Work. (

The 'investigation was commenced by a thorough examination of the blood of cases of pellagra 'in all stages, from very early to advanced.' The blood was studied both 'fresh, by means of stained fil~s, and also with the aid of dark-ground

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174 The " Prevalence of Pellagra among T~trkish Prisoners

illumination; the la,st method being wit4 a view to the possible discovery of any " ultra-microscopic :', causal organism., , " . , Consider,able attention was paid to the cell constitution 9f the blood itself, and

differential counts were made in a large proportion of the Icases. A comparison' has been made with the blood, counts of prisoners in the KantaraLabour Qamp" who wer~ regarded ,as free from pellagra.

The cerebrospinal fluid and urine of these selected cases, early and advanced, were then examined by the-above methods. '

Finally, a comprehensive study of the ,intestinal fauna of a large number of, pellagrous cases has been undertaken, and the findings obtained, have been compared with those observed both amongst non-pellagrous ,Turkish prisoners and, amongst German prisoners. '

As pellagra is, admittedly, the expression of some general condition, it was considered that the above series of examinations would amply cover the necessary ground, if a protozoan ,cause for the disease was to be demonstrated.

Results of Examinations.

(A.)-BLooD.

The-blood of eighty cases of pellagra"including all stages of the disease, was exhaustively examined for any possible, form of organism. Of these cases, 15 (i.e., 16'6 per cent) were malarial, parasites being found in 11 cases, and the

• blood picture of the other 4 being that of chronic malaria. A part, from malarial parasites, no other kind of parasite-no" cryptic~' hrematozoan-was detected.

No leucopenia was present in the non-malarial cases, the leucocytes being normal, or, if anything, very slightly above normal in number. A polymorpho~ nuclear leucocytosis occurred only in a single case. Of the 65 non-malarial cases,' only in 3 was there a slight increase in the large mononuclear count, ranging from 7 to 9'S' per cent. In 62 (Le., 95 per cent) the count varied from 1'5 to 6 per cent, the average being 4 to 5 per cent, i.e., normal.

A noticeable variation from the normal differential coqnt. was an 'increase met with in several cases, in the lymphocytes. This count usually ranged between 2~ and 32 per cent, the average being 30 to 31 per cent, but in 10 cases (i.e., over, 15 per cent) the total lymphocyte count was distinctly high, above 35 per cent, 4' of these showing over 46 per cent' of ,lymphocytes.This lym:r>hocytosis occurred amongst early cases as well as advanced. But the blood of 15 prisoners regarded as non-pellagrous was also examined, ~nd 4 of these (i.e., 26 per cent)

. also showed a lymphocyte count of over 35 per cent, 1 baving a lymphocytosis of 52 per cent.

A definite lymphocytosis in pellagra has been previously noted as the chief feature in the differential count.' Although in the cases I examined the occurrence

'of this condition was more variable than was found by other workers, it may,be , concluded, I think, that some degree of lymphocytosis is, frequently associated with pellagra~ As regards the 'four nprmal cases at Kantara, in which some lymphocytosis was also f9und, although these were non-p,ellagrous when examined, judging from the extent of the outbreak they might at any time have begun, to develop pellagrous symptoms. '

Eosinophilia, ranging from over five per cent up to fifteen per cent, was




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Th~ Prevalence of Pellagra among Turkish· Prisoners 175

frequently found, out this had no' con~tantrelatio~ to the observed occurrence of nematode eggs in the stool. On many occasiops, eosinophilia was present when no Elggs were: found; in, such ~ases a prior or actually existing infection with worms was regarded, however, as extremely likely. On the other hand, in some cases where, from an examination of the stool, A'scaris or, Trichocephalus was ascertained to be present (even numerous) no eosinophilia was found; . the eosinophiles inimbering from 1'5 to 4 per-cent only. Such caSeS had probably been infected for a considerable period, and lost an early eosinophilia. The absence of eosinophilia, therefore, is no proof of the absence of these nematodes '; on th.e 'contrary, sU,cha case may have a heavy helIIlin~hic infe(Jpion.

. (B)-CEREBROSPINAL FLUID. ~,

ThEl ' cerebrospinal, fluid of eleven cases (specially selected by Colonel Boyd, and drawn off by him) proved to be quite ncirmal. .

(O)--.--URINES. _-

• The examination of the urines of these same cases also yielded entirely negat~ve results.

(D)-STOOLS'; A total of 222 .stools of pellagrous cases have been examined, 121 at No. 2

Prisoners' of War Hospital, Abbassia, and 101 'at No. 5 Prisoners of War Ho!!pital, Kantara. The former\were non-labour and the latter labour prisoners. , Of the 121 at Abbassia" 16 (13'2 per cept) had bacillary dysentery, and 8

'(6'6 per cent) had amoobic dysentery (active). Altogether nearly twenty per cent were dyseI\teric, therefore, in addition to being pellagrous. Of the' rem,aining

, ninety-seven, the majority of which were cases of well~marked or also advanced pellagra, J at least half were diarrhooal, the stools being thin" often frothy, with undigeste~ vegetable residue and with generally an offensive odour; ,

, On the other hand, the stools of the 101 cases at Kantara were, on the whole, much more normal in appearance.' Most of these ClI<ses were. just commencing, or early. Bacillary dysentery waE! present in seve~ per cent of these cases, amoobic dysentery in only one per cent. Only nine per cent of. the remainder were diarrhooal, with the unhealthy characters just noted. In ,contrast to the. small number showing active amoobic dysentery,. 'eight were" carriers" of the cysts of E. histolytica, Le., the proportion showing the active and quiescent stages of this parasite .was about reversed in the Abbassia and Kantara cases, respectively.

, The harmless E. coli occurred frequently, viz., in about twenty~seven per Jcent of cases.' -

The flagellate Trichomonas intesti:zalis occurred in 31 of .the Abbassia cases (i.e., in 25 per cent), but was found ~n only 5 per cent of the Kantara ones-,-an important difference.

The peculiar parasite, Blastocystis, was of frequent occurrence in the Abbassia cases, and of,ten very abundant., The frothy, gaseous character of many of the diarrhooalstools was proballly partly due to this organism, . .

The<animal parasites which were',by far the most predominant were nematode .. worms of the genera Ascaris and Trichocephalits. The actual percentage findings

of the eggs were.: Ascaris, -31'5 per cent, and Trichocephalus, 21:6 per cent. These figures by no means indicate the real proportion of Turkish p~isoners

infected, which I estimate to have been certainly twice as high; and probably more. In one batch, for instance, of 31 .. cases .amo~gst.prisQners recently

, ,




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176 The Prevalence of Pellagra among Turkish Prisoners

captured,' .with serial regis'tration nu~bers close together, 2'4 (01; over 7-7 per cent) were actually found to be infecteq with Ascaris. 'Individual infections were

, usually heavy, not the slightest diffiimlty being experienc~d in finding the eggs; but where the eggs happen to be very scanty in a particular l'ltool, they often escape detection bya single examina,tion. In a few cases where the stoolo{ the

-- same case had been accidentally sent in for examination ~gafn,.eggg .were found at ,the second examination when the first had proved negative. Further, the occurrence of definite eosinophilia (noted above) in cases where eggs had not been fouild at the time the stool was examined also points nevertheless to the presence of one or both of these worms.,

It is important to note, however, that ,the percentage of similar helminthic infections amongst the non-pellagrous Turkish prisoners was found to be equally high. In addition, the stools of German prisoners (who do not develop pellagra) were examined. These were also found to be infected to a considerable extent with- the same worms, although in a less degree than were the Turks, Ascaris being found in 15 per cent 6£ the stpols examined ..

It is noteworthy that in not a single case was the, occurrence of Ankylostomum eggs or of Bilharzia eggs observed. '

No new parasite of any description was found in any of the stools, whicH were all thoroughly examined.

" Details ~f all the findings, both ,actual nu:rnbers and percentages, in pellagrous and in non-pellagrous cases are given i'n the accompanying Table 1.

TABLE I. ,

Pellagrous N on-pellagrous

German , (normal.)

Abbassia Kantara Total Abbassia Kantara Total

---------------- -------------------------Examinations ., .. 121 101 222 72 " 23 94 47

\

, Bacillary dysentery .. 16 7 23 12' 1 13 1 13'27% 7"/0 10'4"/~ '16'6% 4'5% 18'3% ' 2'P/o

(a) Amoobic 'dysentery 8 1 9 ' 3 0 4 0, (active, histolytica) 6'6% 1% 4'1% I I, 4'20/0 0 3'2"/0 0

(b) Histolytica cyst 2 9 11 5 4 9 5 ," carriers" }.·7°/0 9"/0 5,% 7"/0 18'1~/ ° 9'6% 10'6%

Other protozoa- I

Trichomonas .'. " 31 5 36 9 1 10 5' 25'6% 5% 16'2% 12'5% 4'5°;0 10'6c/o 10'6%

Lamblia .. .. .. 13 10 23 7 1 8 ' 1

lVracrostoma 10'8% ~oo/o 10'4°/0 9'7% 4'5% 8'5% - 2'1°/~

., .. 5 3 8 1 ,0 ,1 1 (Syn. tetramitus) 4% 3% 3'6% 1'3°/., b . 1Q/o 2:1%

E. coJi •• •. •• 28 32, I 60 20 8 28 17 23'1% 32"/0 27% 27'7° / 0 36'5~/o ' 29'8% 36!1"/0

Helminthia (N ematodea,)-70 32 3 35 7 Ascaris .. .. .. 52 18

43%' 18% 31"5% 44'4,?lo 13'6% 37'2% 150 / 0 Trichocephalus .. .. 28 20, 48 11 3 14! J 4

. Trichostrongylus 23'F/o 200

/ 0 21'6% 15'3°/" 13'6° 10 1,4'9°/" . 8'5°/"

(Ces- 1 1 2 0 0 0 .0 todes) 0'8 % 1°/1) 0'9°/" 0 0 0 0

Tamia .. ., .. 1 1, 2 0, 0 0 1. 0'8"/0 1"/0 0'9% 6 0 0 2'1°1 /0,

Hymenolepis ., .. 3 2 5 0 0 0 2 2'5"/" 2"1" 2'4Q

/ o 0 0 0 '4'2




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The prevq;lence of Pellagra among Turkish Prisoners 177

Summary and Conclusions.

The ,above results show that there is not the slightest evidence of a protozoan parasite having any specific retiological relation to pellagra.

As ',regards the blood, not qnly has no parasite been found, but a hrematological feature is that no increase of large mononuclears is associated with the disease. (The very sma;!l proportion, viz." five per cent, of non-malarial cases

'showing a slight ,increase can be neglected; this may quite well have been due to a precedent attack of relapsing fever.) The absence of an'y large mononuclear increase is, of itself, weighty evidence against a protozoan cause. . . ,

With regard to the intestinal' protozoan par~asites, the most harmful of them, namely E. histolytica, occurred Iufar too small/a proportion of cases (nine percent), for it to have any special significance' in conhexion with pellagra. 'l'richomonds, which occurred fairly frequentiy in pellagrous cases, particularly in those with diarrhrea, was pr9bably partly responsible for this intestinal disturbance. Amongst the early cases at Kantara this parasite' was seldom pre~ent, and the stools w~re mucn mote normal in character. There is no reason to suppose that this or any other inte~tinal flagellate has t1ny causal relation with pellagra. .

No spirochretes of any kind were, detected" either in the blood, cerebrospinal' fluid, 0,1' urine. .

With regard to the possible occurrence of some "ultra-microscopic" organisms, all that can be said is that as a result of careful observ~tion with darkgrourid illumination, 'r could find nothing abnormal or unusual. So far as this result goes, it leaves the question of existence of sUGh an infective agent still open because, whether a' specific ultra-microscopic organism or a non-living virus . were concerned, it is obvious from the examples of the exanthemata, yellow fevet, etc., that years of research might be necessary for its discovery.

From the observations detailed above, it is evident that the presence of nematodes (especially Ascaris) was very general amongOst the Turkisl;1 prisoners of war; not only amongst the pellagrins, but equally amongst those who were liable at any time to become pellagrous. These were, in' fact, the only animal parasites fourid which, on account, of' their general prevalence, might be held to have some retiological significance in c(;mnexion, with pellagra__ And this possibility if'! one, I think, which deserves consideration, There is of course no intention of suggesting here that helminthic infections, by themselves alone, constitute the specific cause of. pellagra. ,In the course of the presen~ work, for instance, I follnd that German9prisonel's, none of whom have developed pellagra, were also frequently infected with ,the same worms (see Table I) and such jnfections are known to be prevalent in many districts and countries where pellagra never, or only rarely, occurs.

The view' I wish to put forward is that such helminthic infections are to be rega:rded as an additional or -contributory factor in the retiology of. the disease, perhaps especially important as a predisposing causa. I am unable to.discuss this question' here, as reference to other work or a consideration of epidemiological data in this connexion would exceed the scope of this report.




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178 The E1'evalence oj Pellagm among Turkish Prisoners'

Conclusions . ..

(1) That pellagra is not due to any protozoan cause. (2) That no evidenqe has. been obtained tending to incrimin!1te any other

minute organism, either a spirochrete or an ultra-microscopic form of parasite. (3) That as regards the blood-condition, the only noticeable feature is a ce~tain

degree of lymphocytosis frequently found in association with the diseas~. (4) That importance is to be attached to the occurrence of helminthic

infections as constituting a possible factor in the retiology of the 'disease. ' (Signed) . H. M. WOODCOCK.

~ \ - I

APPENDIX VII: , '

\. STATISTICAL DATA.

In addition, to the work of this section already dealt with in the body of the report, certain details of the methods adopted and accessory fi~dings remain for ~discussion here. ' ' ,

A.-Compilation: of Information.

The Oommittee found much. valuable information in the careful records maintained by Lieutenant-Oolonel P. S. Vickerman at No. 2 Prisoner of War Hospital, where all prisoners of war sick and wounded had been accommodated prior to the final rout of the Turks making it necessasy for other hospitals to Ishare the work

,'of dealing with the'large increase of prisoners aqd their patients.' These records had already been analysed by Captain H. E. Roaf, to embody the available' information regarding pellagra incidence from the date of th~ reyognition of the first case among prisoners of war in November, 1916.

The following information WiS obtained-the first returns being, made retrospective in order to connect up with Lieutenant-Colonel Vickerman's records, and, enable per mille ratios to be worked out :- '

(a) I The weekly ration strengths of all prisoners of war camps were rendered by their yommandants. These were retrospective from Jan. 1st, 1918, and provided the basis for calculation of per mille ratios. ,

(b) The totals of prisoners by months from September, 1916, were obtained from the Oentral Statistical Bureau, Prisoners Of War.

~o) Hospital admissions and deaths from pellagra, by pro forma. o

"PRO FORMA." HOSP~TALRETURN. Admissions"and Deaths from Pellagra among Prisoners of War (for previous twentyfour '7~ours).

Gen. No.

Camp, from which'

admitted

Date of capture

Date of adnihssion ~ to hospital

Date of death

Any contributory cause of death

Camp, if any, at which he

had been employed as

labourer

Remarks Nationality

--~ ------~~ ----' --,,--- --' --' - ------ ----, ------'--




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, " , The Prevalence oj Pellaqra amonrt Turkish Prisoners 179

From the above returns, the charts were made up week by week, after an interval to ensure all hospital admissions being recorqed by the correct camps, and after checking all patients' general numbers to preclude all the duplication of entries for individual cases transferred from one hospital to another. ..

In addition to charts ,and g'raphs N os~ 1 to 4, ~ graph 'Was commenced to show', the number of months that patients had been in captivity, but this was abandoned on its bec~ming apparent that it was dominated by the fact o(the great majority of prisoners having been- captured in two large batches in the autumns of 1917 and 1918. '

\

(d)' Endemicity data obtained by captured Turkish Medical Officers at Kantar'a and at Oairo (Drs. Hakimian, Kalfyan and Anastassiades), with a view to as,certaining whether pellagra is endemic in Asia Minor; if, and when, it increased among the Turkish troops; and if the domicile and occupations of enemy troops before enlistment were such as to bear upon, their subsequently becoming pellagrous. "

\ .. PRO FORMA." ENDEMICITY RETURN.

I Domieile

Date of Date and place Gen, Unit Diy. Urban

O~cupa. If any Oate of join'jng er oIlset of the No. Vii· tion similar case capture ~J Turkish first symptoms

hiyet or in family Army of pellagra ; . rural - -------------

I

,

From this return, a map was prepared 'to show the villayets whence the pellagrous prisoners 'were recruited and the districts in which they, were when they first noticed the pellagra symptoms from which they were suffering when questioned. .

B.-Findings accessory to those dealt with in this Report.

tal CHART 1. The abrupt rise and high. figures in the summer months of 1918 are probably

mainly artificial: the pellagra cases assembling at Kantara during May and June were not diagnosed until J.une 27th, when a large number were sent to hospital in the course of the next, few days, thus giving high figures for both June and July, which should..have been distributed over those months and May-or possibly April also. There ensued so thorough a weeding-out of all even suspicious cases as to have antedated many admissions that otherwise. would' probably not have occurred until September, which consequently shows a low figure.

The fifty per cent fall in the final month is very significant.

, (b) CHART' 2.

The'mortality curve closely follows that.of the hospital admissioris, a.nd a~ a uniform interval of about a month, varying from twenty per cent to fifty per cent of the latter. As shown in the pathological section, the ,mortality directly due to. pellagra has been insignificant, but debilitated pellagrins are liable to recurrent




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180 The' Prevalence of Pellagra among J Turkis"k Prisoners

attacks of dysentery or malaria or to secondary influenzal pneumonia from which they rapidly succumb, the average period in hO"lpital of those progressing to fatal, ' termination appearing to be three or four weeks,

, I

(c) GRAPHS 3 and 4.

Call for no further commentsav~ that they show a satisfactory fall in pellagra incid~nce quring December, especially for labour prisoners,

(d) CHART 6,

Indica.tes no correspondence bet~een variations in the d'ietetic and pellagra incidence curves for the periods charted.

Many thousand calculations were illvolved in the working out of its weekly averagesJrom the records of actual issues made.

(e) GRAPHS 7, and S.

Are left for detailed discussion i~ a later appendix, but it is noted that unique opportunities were afforded this Committee for the. cO,llecti6n of precise data as embodied in these gr~phs and in Chart 6. .

(f) MAP.

(i) Domicile. '

\.

Not one of the 518 pellagrous prisoners questioned by their: own M.O.s. dated the initial onset of his symptoms to a period prior to enlistment, and only five bad

. seen similar symptoms in members of tbeir family or' neighbours. This confirms the opinio!1of so many Turkish M.o.s. that pellagra is endemic to a very slight ext'ent, if at all, in Asia Minor. '

It also indicates that this disease broke out as a result of conditions to which the Turkish troops were subject while on active service;' and especially .when their privations were mo:reacute' at a late stage of operations. In this cobnexion attention is draw~ to the fact that four, and only four, men first noticed their symptoms in Gallipoli. ' ,

(ii) District in which initial Pellaiirou8 Symptoms occurred.

The first point to be considered is whether pellagra is endemic in ~reas where pellagrous symptoms were first noticed by those affected. Many Syrian doctors serving ,with the Turks stated that, tliis disease was almost unkno)"n in Syria before the war, although they were familiar with its sy,mptomatology. Orie of them' had seen only five cases during thirteen years' practice in Damascus and district. . The numbers are seen to be most aggregated in precisely those districts where the Turks were most concentrated when suffering maximum privations, but where prisonilt:s were never retained for more than the few days necesl:!ary before they' could be sent' down the L. of C~ towards the base. Over' eighty-five per cent .of the 474 men 'questioned stated that their (pellagrous) symptoms had

. 'appeared before capture: . , '




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'l'~e Prevale~ce ojPella:gra among Turkish Prisoners .iS1

(g) FURTHER INFORMATION' DERIVED FROM THE" ENDEMICITY RETURN."

~ (i) Chardcter of DomiciJe and Occupatirm. Domicile. Occnpotiori,

.Given as- Agriculturists ., 265 Urban \ 119 Labourers' .. 73 Rural 463 Artisans .. ., 33

ShopkeeperS 8 582 'Sailors 8

Ooachmen: . 7 Shoemaker's ' .. ., 7

'Bakers 6

" Butchers ." 6 Store-keepers· 6 Carpenters 5

;-., , Ohauffeurs 5 , Schoolmasters , .,' . ./ 5 Of nineteen other trades •• 33

, . 467

From this table it 'is obvious that the majority of these prisoners were drawn from'tliat part of the' community regarded as' most li'able to pellagra-agriculturists living in rural areas. They may have been predisposed, but the above evidence is wholly against theithaving been pellagrous prior to enlistment. The' -essential parallel of the propprtions of men of the above occupations and domiciles • in the whole Turkish army is not available. '

(ii) Relation between Date80j. Capturfj and of Initial SymptomB. . - . \ -

. The following table is derived horb. questioning equal numbers of }resh captures' at Kantara and old prisoners at Heliopolis. .

Months' C~ses

Over 12 26

1 12 5 11 24 10 ~ r 40 9 .. 8 ~) -7

345 ,6 ill 5 I

4 22 3 .. 30 279· 2 26 . 1 39 \ 0 43 J ,

Onset before capture

414 '0

1~ 1 1 2., 3 o ~ 27 .. 4 O . 5

. 1~ ) . 6 69 7

'} 8 4 \ 9 _ 0

10 ' "! 13 11 12

" Onset after capture

I

Over 12 29 This table' is sufficiently strikirig to make comment superfluous.

12

\

0




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o

;182 The Prevalence, of Pellagra among Turkish' Prisoners. , , ,

(Hi) Distribution of Oases among the Turkish Forces. , Division Cases DiyisiO!1 Cases Corps Troops Cases

11th 53 26th 14 .. 7t.h 20 19th 42 48th '11

, 4th 9 ..

16th 40 .. 54th 9 8th,' 9 3rd - 40 25th 9 .. 20th' 6 7th 35 42nd 8 22nd 5 1st 29 47th 6 , .. . 3rd " .. 3

53rd , 27 8th 5 24th .. 22 I

. /20th ' 21 .. 3rd Oava.lry .. 8 46th 20 .. ,33 others 54 No information known, 86

This table irl'dicates th!l wide distribution of pellagra cases among no less than , Divisions and 6 Corps having representatives with the Turkish forcm>. ' It is obvious that some generally applicable retiological factor must have been

involved, 'rather than special conditions due to location, and force is added to this deduction by the fact that no case of pellagra is known to have occurred amongst the British and Indian troops,who have since occupied the,areas in which onset of pellagrous symptoms ,occu~red in so great a majority of the pellagrinsamong

, these Turkish prisoners.

:(h) ALL OFFIcim, AND GERMAN'OTHER RANKPRIS0NERS, , . I

, were respectively, relatively and wholly immune (vide body of the Report): '

"Oonclusions. , f ' These are so many, and so obvious, tliat only those with special bearing UJ?on

the terms of reference to the Committee call for mention here. . (1) That the great majoritY,of prisoners of war pellagrins were pellagrous

before capture. , , (2) That they became so in Syria aJ?d Palestine during tpis war, and as a

result of conditions affecting Ottoman rank-and-file of all formations, but affecting officers little and Germans not at all. \

(3) That the disease is now Mt increasing, but is decreasing. " (4) That the disease is not due to case-to-case infection nor to any , local

conditions (vide data discussed in'the body of this Report). (Signed) P. S. LELEAN,

{lieutenant-Colonel, B.A.M.C. \' " ,

December 30, 1918.

APPENDIX VIII.

DIETETIC REPORT.

l.,




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, The Prevalence oj Pellagra among Turkish Prisoners 183

. ... , ,(1) Arialysis of Foodstuffs.'

Various .samples taken in supply. depots and camps were analysed to determine if th:e foodstuffs, employed contained the amount of proximate principles upon whjch the nutritive iValue of, tae rations have been calculated. '

Percentage

I?ate Camp, ,MaterIal \ Defects noted ---'-' ~'-----' --, ------------------------------Oct, 10,1918 Kantara

, Bread Defective aeration " .,

23 Heliopolis Il' Il " ,',

." 23 "

Kantara _ Miiiet flo~~ I Weeviiy tl.nd ~~~cid "

23 " Hel_i~polis

23 " " Il Wheat flour N~l. ' , , ,

, " 23 " 11,

Miiiet fi~~r Nov, - ,'", Kantara " :"

'.' -" , Wheat ftou'r

" ," " I ~a~elm~~t No visible ,fat Oct, 10 " "

" 23

" Heliopolis

" 11 Nil Nov'. - Kantara ,,_ '" 'I (a,:erage of six sa~ples) Oct, 10

. / LentIls " Ntl _ ,. " \ .. , 11 11

10 Heli~polis

Beans, __ I 11

23 ", . '[ " ..

" 10 11 ' Karitara Ric~ .."

" 23

" Heliopolis

,Che_eSe(Sk;~1 :; " 23

" " i mIlk) 'I ,,'

Protein N; X 6'25 ----

7:1 6,5 6'6

' 15-6' 9'7 9'3

15'3 9-6 9'8

20'1 15'5 19-65 29-3 26'8 26-8

7-8 7'8

19'8

, Fat

---1'2

1'2 .

2'5, 6'7

Darbohyd, (by dift"ce) -----

54

49

..

(2) Analyses Qf individual IJay's Rations atE, Kantara Labour Camp, " November 18, 1918, '

These analyses were made to' ascertain whether the actual amounts of food received by individual prisoners, corresponded with those laid down in ration, scales. . ' , ' , - n

In practice~ however, it proved so difficult to obtai~ reliable, samples for this purpose-owing to the series of 'unweigh~d distdbu,tions, occurring bet\veen issue from the ,Q.M. stores and eampling.from indi'vidual degchies~that the Committee decid~d to adopt the figures' obtained from supply dep9ts, as checked' ,on two occasions by one of us (P,S.L,) comparing the ,depot records of issues against the actual day's receipts at E. Kantara and Heliopolis ·camps. '

(afStew,' , , " . Five hulked, repeatedly mince,d, and thoroughly_mixed ,rations of stew-'-con

sisting 'of meat, rice, beans, and onions-gave the following average weight in grammEjs p~r r\Ltion. '

p~cit!lin (nitrogen x '6'25) F~t

(b) Residue ~f ration~' Protein (analysis of 1 ration of 2 sample loaves) 'Fat' .• '

Totals for one l1ay'srations, grammes .

.. '"

I'

Protein 42

57

99

Fat

10-8




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184 Reviews

Conclusions,

(1) That in general the'foodstuffs emplQyed contained the'normal amounts of proximate principles upon which the nutritive value of, the rations has, been calculated. ".,,'

(2) +,hatthe bread oontains. the ordinary amount of protein in bread mad'e', from looal oereals, but; owing' to defects in baking, the protein is probably not available to a normal extent.-

, (3) Toe camel meat (unless very lean) contains less protein than beef., upqn , whioh the estimations have'been made.

(To be continu~d.)

•

'1Re"teW9.

INJURIES'TO THE HEAD AND NECK. By H. Lawson Whale, M,D.Camb" F.R.C.S.Eng. ,With preface by Colonel Frederick F. Burgh'ard, C.B, M.D., M.S., F.R.C.S. London: Bailliere;' Tindall and Cox; 1919. Pp. ix and 322. ' Price 15s. net. '

The author in his introduction defends his eho'ice of the t'itle, ," Injuries of the, head and ne,ck." A careful perusal of the book shows that injuries of'the most important part of the head, 'Le." the brain, are practically not mentioned, and no indication is given by the title that the book is inspired by' and mainly deals with war wounds of the face and neck. ' .

This is unfortunate as one might readily choose this. book as a treatise on the head, and serious disappointment would result; "

, , "Gunshot Injuries of the Face and Neck" would have more accurately , described the contents!' , " . , ,

Chapter I deals. with Hrembrrhage, and those who have had any experience in dealing with gunshot fractures of the jaws will recognize that this, by far the most serious and fatal complication of wounds .in this region,occupies its right, position in the book. ' " , " " " .

The subject is fully dealt with and the difficulties of establishing, in many cases,' the side' from which Jhe bleeding is coming,is s~rongly emphasized; The

r author has been /fortunate in that he has never seen any central effect after ligature of the common carotid. Ir,t our experience' some ch::l.llge could always be noted, in some eases marked paresis which was later recovered from. . ,

Transfusion of blood is rather inadequately dealt with'and we wouldrhave been, glad of a fuller description of the author's method of using paraffined syringes, as in the hands' of most surgeons syringes treated with paraffiri have been found quite unworkable; _ 0-, , -

The difficulties encountered in att,empting to rt3move foreign bodies from the face and neck are well described. , '

In dealing with infection in the neck the' author qui~e rightly emphasizes the' great importance and extremely fatal consequences of mediastinitis. Hisdescrip7 tion of the signs ,and symptoms of this complication is most interesting. . '

In the ohapter on the Pharynx ana (Esophagusthe author includes buccal and salivary fistulre. This does not strike one as anatomically correct, but he ,deals with the subject so briefly that a separate chapter was ha.rdlyjustified. "

"




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