**The American ex-Prisoner of War**

## Lecture Series

William P. Skelton III

## 

## General Historical Information

A. POWs of Germany

1.  Camp Life

2.  Nutrition

3.  Transfers

B. POWs of Japan

> 1\. Camp Life

2\. Women POWs

3.  3\. Nutrition

> 4\. Working Conditions

C. POWs of Korea

1.  Camp Life

2.  Nutrition

3.  Indoctrination

D. POWs of Vietnam

1.  South Vietnam

2.  North Vietnam

II The Presumptive Service Connected Disabilities

A.  Post Traumatic Osteoarthritis

B.  Pathology

C.  Diagnosis

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A.  Avitaminosis: B-2, 3, A, C and the Overlap Syndromes

> C. Beriberi, B-1 deficiency
>
> !. Wet Beriberi
>
> 2\. Dry Beriberi

1.  Cardiac Beriberi

2.  Long Term Sequalae

3.  Medical Follow up Agency Studies

4.  Painful Feet

5.  Ischemic Cardiomyopathy

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D.  Chronic Dysentery

E.  Salmonella Typhi

F.  Shigella

G.  Amebiasis

H.  Giardiasis

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D.  Frostbite

E.  Pathology

F.  Long Term Sequalae

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D.  Helminthiasis

E.  Strongyloides

F.  Ascaris Lumbricoides

G.  Ancylostomiasis

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D.  Malnutrition

E.  Kwashiorkor

F.  Marasmus

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D.  Other Nutritional Deficiencies

E.  Trace Element

F.  Essential Fatty Acid

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D.  Psychiatric Conditions

E.  Psychosis

F.  Panic Disorder

G.  Generalized Anxiety Disorder

H.  Obsessive Compulsive Disorder

I.  Post Traumatic stress Disorder

J.  Atypical Anxiety Disorder

K.  Depressive Neurosis or Dysthymia

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D.  Peripheral neuropathy

E.  Irritable Bowel Syndrome

F.  Peptic Ulcer Disease

American ex-POWs are exceptional individuals. At one point, there were
in excess of 144,000 living. Now, less than sixty thousand remain. They
have experienced a bewildering spectrum of harsh circumstances and many
suffer from unique medical conditions.

In this packet, I shall discuss in detail the background of the American
ex-POW experience from Germany, Japan, Korea and Vietnam. In addition, I
shall discuss the presumptive service connected disabilities, exactly
what they are how they were arrived at and what the examiner needs to do
in order to render the proper diagnosis. A complete bibliography is
provided at the conclusion for further reading.

**Biostatistics**

Concerning the World War II European Theater of Operations: 1.2% of POWs
died in captivity while 54% of ex-POWs have died as of January 1995. The
low death rate during captivity was affected by many variables, but was
primarily due to the fact that the Germans signed and ratified the
Geneva Convention. The majority of these POWs were also captured toward
the end of the war, with the average internee spending 0.95 years in
captivity.

Concerning the World War II Pacific Theater of Operations, and
specifically the Philippines: 40.4% of POWs died in captivity and 73.4%
of ex-POWs have died as of January, 1995. This high death rate is
attributed to the Japanese\' signing but never ratifying the Geneva
Convention as reflected by their mistreatment of the POWs. The average
PTO internee also spent 3.15 years in captivity, a much longer duration
of internment than that of the average ETO prisoner.

When examining the World War II P.T.O., the primary causes of mortality
and chronic morbidity were starvation, infectious diseases, hazards
related to transportation to Japan including sinking by American
submarines in which thousands of internees were killed and environmental
exposure, especially toward the end of the war when POWs were used as
slave labor in Northern Japan and Manchuria.

Concerning the Korean Conflict: 37.8% of POWs died in captivity and
57.4% of ex-POWs have died as of January 1995. The average Korean POW
spent 2.2 years in captivity.

Concerning the Viet Nam Conflict: 15.1% died in captivity and 26.3% have
died as of January 1995.

The World War II ETO prisoners spent slightly less than one year in
captivity and the average age at capture was 25 years. This reflected
the fact that most ETO prisoners were draftees. The Pacific Theater
(PTO) prisoners\' average length of internment was 3.15 years and the
average age at capture was 26.7 years. Two major points must be
emphasized here; first: the vast majority of PTO prisoners were captured
on Bataan and Corregidor at the beginning of World War II, and were not
released until the end of the war. Also, the average age at capture was
two years older than that of the average ETO POW, reflecting the fact
that these men were Regular Army soldiers on the whole, versus the
draftees seen n the ETO. As can be seen in the Korean Conflict data, the
average age had dropped to 23.2 years of age, again due to the fact that
these men were draftees. Their average length of internment was 2.02
years.

Several differences exist between ex-POWs and age-matched combat
veterans. Examining the percent of living POWs compared to all living
veterans receiving disability compensation can reveal several
differences. Among the ETO POWs, 41.2% are receiving some degree of
**Service Connected disability**. Among PTO World War II veterans, 50.6%
are receiving disability compensation; this is to be compared to the
9.6% of all World War II veterans receiving disability compensation.
Considering Korean ex-POWs, 59.2% are receiving SC compensation compared
to 5.1% of all Korean veterans.

The **average degree of service-connected disability** can also be
examined. In the ETO, the average degree is 27.0%. This compares almost
exactly with the total World War II average degree of 27.9%. In the
World War II PTO POWs the average degree of service-connected disability
is 40.3%. In Korea, the average degree of POW disability is 36.1%
compared to all Korean veterans of 30.6%. The European Theater ex-POW is
not different from his ETO age matched control, whereas the Pacific
Theater veteran is, on an average, 13% more disabled; the Korean POW is,
on the average, 6% more disabled.

Examining the **percent of service-connected disabled veterans rated
50%** or greater is another way to determine differences between the
groups. The figures in this category for the ETO ex-POWs are 20.1%
versus approximately 22% of all World War II veterans. In contrast,
48.8% of all World War II PTO ex-POWs are considered 50% or greater
disabled compared to the 22% of all veterans. In ex-POWs out of Korea,
the figures are 34.7% compared to 25.5% for all Korean age matched
control veterans.

Finally, the examiner may review the percentages of living
service-connected disabled veterans rated as **unemployable**. Among the
ETO ex-POWs the figure is 5.3%, which is exactly the same as the 5.4%
seen in the age matched controls from World War II. World War II PTO is,
however, 22.0%, which is all of four times higher than the all-veteran
WES II category. Lastly, the Korean Theater of Operations POWs are at
8.9% versus all veterans from the Korean Theater of Operations at 6.3%.

**POWs of Germany**

The military personnel of the European Theater of Operations (ETO), and
the ex-POWs therein involved, fall into **two distinct groups**. The
**first group** consisted of flyers and members of bomb crews. In
general, these men were captured earlier in the war and, more often than
not, were interned in Lufts. When the captured airmen were brought to
the local German military official, he would always say, "For you, the
war is over!"

The **second group** was made up of infantry soldiers who were often of
a lower rank and captured after the Battle of the Bulge, in fact, the
vast majority of ETO ex-POWs were in this later group. These men
oftentimes were not afforded the benefits of proper shelter from the
elements, especially during the especially cold winter of 1944-45. Many
were housed in poorly maintained Stalags. They also were not fed as well
as the first group and they were subjected to long marches to retreat
from the advancing American and Russian armies. The overall mortality in
the ETO was approximately 1%, with 1,124 men dying out of 93,941.

**There are several reasons for this low death rate**:

1.) The vast majority of the men were captured toward the **war\'s
end**; therefore, even though they lost a great deal of weight acutely,
they were not subjected to having to live with malnourishment under
adverse physical circumstances for extended periods of time as were the
POWs in the Pacific Theater of Operations.

2.) In general, the German POWs received somewhat better treatment at
the hands of their captors than those captured by the Japanese. There
were several reasons for this, Germany was of the "Western" mentality
where fighting was ceased when the situation was hopeless. On the other
hand, Japan became more fanatical as the war neared its end. Also,
Germany signed and ratified the Geneva Convention, even though, more
often than not the Germans did not follow all its rules. Nevertheless,
many of the camps at least initially followed several of the rules set
forth by the **1929 Geneva Convention** accords regarding treatment of
Prisoners of War. Germany frequently allowed Red Cross inspectors into
some selected camps while Japan never did.

3.) Even though several in the German political high command had a
desire that all commandos, pilots and airmen be killed, the regular
Luftwaffe officers, who were in charge of running the camps, more often
than not were much more **sympathetic to the POWs**. Herman Goehring,
the Chief of the Luftwaffe had been a WWI pilot, and he felt a kinship
to all airmen believing that they were the last truly noble group.
Therefore, the Lufts were generally run and operated by the Luftwaffe,
the German Air Force. On the other hand, the Wehrmacht, the German Army,
ran the Stalags.

4.) **America had captured** several thousand German prisoners in the
North African campaigns and it was to Germany\'s interest to treat our
prisoners decently in the hope that their own prisoners would be treated
well also.

5.) The final point to consider is the fact that, on the whole, the
**diet** among the POWs in Germany was much better than the diet given
to the Pacific POWs. POWs were often used as farm labor in Germany as
their manpower pool shrank and the POWs often helped themselves to the
products. Oftentimes, Red Cross parcels supplemented the diet in POW
camps in Germany, whereas this was not the case in the Philippines, and
the POWs in Germany were also frequently given vegetables with their
potato soup and black bread. This supplemented their diet with
much-needed vitamins.

In regards to **the housing**, the fortunate individuals who were
interned in the Lufts and Stalags, the barracks were usually 40\' wide
by130\' long, each containing 10 rooms leading from a central hallway
that ran lengthwise with the buildings. There were generally two
washrooms without running water and the pit latrine for night use was
located near the rear of the barracks. Each room in the barracks was
approximately 15 x 23 feet. It was designed to provide facilities for 16
men with 8 wooden double-deck bunks. In a few instances, the bunks were
triple-decked, increasing the capacity of each room to 24 men. Later,
men were placed 2-3 to a bunk.

**Food in the camps** was very diverse. In some of the show camps, the
food was good. Many prisoners in the Lufts lost no weight at all.
However, in most of the Stalags, the food was pathetic and the supply
was unpredictable. Usually no more than 700 calories per day was the
norm. Breakfast usually consisted of a cup of ersatz coffee, which the
prisoners frequently used in lieu of hot water for shaving. Lunch was a
ladle of vegetable soup and a small portion of bread. The evening meal
consisted of one loaf of bread for 6 men. Often, there was nothing else.
The bread was impossible to cut evenly, and few POWs had knives. Many
POW camps devised a system wherein the same 6 men ate their meals
together. Each would rotate cutting the bread everyday. The man who cut
the bread had the last choice. The man after him had first choice. That
became the main event to look forward to every 6 days. In all
probability, the only thing, which kept them alive, was the intermittent
Red Cross parcels, which many times the Germans used for themselves.

**Life in many of the Luft camps** was tolerable, with gardening and
sometimes even libraries and other recreational activities available.
Luft III at Sagan was a camp designed to hold British and American
officers at high risk for escape. The German plan here was to devise a
camp so pleasant that there would be no desire among the prisoners to
escape. This was in reality a "show" camp, designed primarily for the
Red Cross inspectors and meant to house high ranking officers and escape
potential prisoners. This was a true prison camp and not a concentration
camp. Nevertheless, an elaborate scheme was devised by the British to
dig three tunnels, code named Tom, Dick and Harry. The entire camp was
sworn to secrecy and enlisted in the cooperation for the escape effort.
Every available board holding up mattresses were used and replaced with
ropes. The heels of shoes were carved into stamps to be used as passport
verification stamps. Phonographic records were cut down onto small discs
and used as compass bases. The purpose was twofold: to escape and to
harass the enemy as much as possible and disrupt their war effort. One
was found right before its use in late 1943 and closed down. In early
March 1944, breakout occurred and 72 men escaped. The Germans took 5
million men away from the front lines to retrieve all but three who made
it to foreign countries. Hitler himself ordered their execution and 50
were shot in the head by the Gestapo. Their remains were cremated and
returned to the camp where their fellow prisoners gave them a burial
with full military honors and erected a stone memorial with their 50
names engraved.

More often than not, life in the remaining camps was miserable, with
boredom punctuated with cruelty and starvation being commonplace. POW
**Camp VII-A** (1939-1945) was located north of the town of
**Moosburg,** Germany. On 9/22/39, Colonel Nepf visited the site and
decided it was not a good idea to build a Stammlager (central camp) or
Stalag there due to the poor ground, a nearby chemical manure plant, a
nearby marsh as the flat plane on which the ground stood. Nevertheless,
the site was chosen and they were given 14 days to prepare a camp for
10,000 internees. The camp soon became the major receiving area for
thousands of prisoners. In fact, by July 1940, over 98,000 internees had
gone through the camp. The main camp comprised in excess of 3,500,000
square meters. The camp quickly transformed into the appearance of a
town with tailor shops, carpenters, a smithy, a shop for watch repairs
and electrical repairs. Thousands of cards and parcels arrived each
week. Towards the end of the war, there were 80,000 POWs along with
80,000 civilian prisoners and 8,000 guards on outside duty. Up until the
end of 1944, the prisoners continued to pour in. Towards the end of the
war, Hitler ordered that no prisoner fall into the hands of the enemy.
The camp commandant, Colonel Burger intervened through the Red Cross and
the camp was not bombed during the war. Later, in April 1945, he tricked
the local SS Commander into believing he would send soldiers off to
fight and secretly turned the camp over to the Americans, thereby
avoiding complete catastrophe. Forward elements of General Patton's army
reached the camp and liberated it before any injury could come to the
prisoners inside.

**Stalag Luft 1V** was located in Pomerania. There were about 10,000 AAF
(American Air Force) personnel there. Five allied doctors were
imprisoned to handle the tremendous sick load, which was organized into
three groups. First, there were those who were wounded, burned or
otherwise injured in aerial combat. Secondly, there were those were the
routine casualties. Lastly, there were the typical illnesses of
overcrowding and malnutrition. Many AAF and allied gunners were trained
to become medics on the spot. All learned fast and worked hard. They
would change dressings, treat minor ailments and spot severe cases
requiring a physician. At the prison hospital, vaccines from the Red
Cross parcels were collected and stored. When they got 300 typhus
vaccines together, word was passed out that first come, first served;
the vaccines would be given. Hundreds of men stood in the bitterly cold
January weather for the vaccine. The decision was made to give each man
half of an injection. This way, 600 men were vaccinated. Despite this
effort, hundreds were turned away. On 2/2/45, 300 men were placed into
trains and shipped out. This included most of the sick and wounded. On
2/6/45, the remainder of the camp was marched out. They would march for
86 days. Herein were the real horrors of being a POW made manifest.
Little food was provided. Many times, there was no shelter at all and
the men slept in the snow. Diarrhea and dysentery were commonplace. At
one point, fifty percent of the men soiled their own clothing as a
result of dysentery. Frostbite affected virtually everyone. There was no
sanitation. No toilet facilities were provided and no toilet paper. The
men drank from ditches that had been used as latrines. Filth was
everywhere. A slimy trail of dysentery and blood was left across
Germany. Aerial strafing was common. After the group had marched from
the eastern front, to the western front, they were sent back to the
eastern front. All the misery and suffering was for nothing.

**The transfers** in Germany were generally by vehicle, truck or train,
after the men had been captured initially, especially the flyers in the
beginning of the war when Germany had complete control of it's own
skies.

However, by the end of the war, the transfers were often of a forced
march type or transfer via cattle cars when the Germans were retreating
from the advancing American and Russian armies. It is here that men
succumbed to the natural elements of the winter of 1944-45 and many
froze to death or died of dysentery or were shot during the forced
marches. Many times, entire camps would be evacuated in front of the
advancing army and marched across Germany passing several full camps.
Then, they would be ordered back to their original departure point
again. In short, the men often marched east, the west and back again.
The German high command was in a state of disarray in the early months
of 1945 and the treatment of allied POWs was not a high priority.
Therefore, little food was provided and virtually no protection from the
elements. Since the allies controlled the skies, strafing attacks were
commonplace. Often, horses would be killed. The horses were butchered
and fed to the hungry columns, and was considered manna from heaven.
Thanks were given to the Flying Quartermaster Corps."

As the end of the war became very obvious to the Germans, they began to
treat the POWs better under their charge. Once consociated Red Cross
parcels were distributed to those in need. This was especially evident
when the allied guns could be heard in the distance. Many times, the
liberating forward allied units would sarcastically say, "For you, the
war is over."

**POWs of the Japanese**

All together, 12,935 out of the 34,648 total American POWs died in the
hands of the Japanese. Japan captured several thousand Americans
throughout the Pacific; however, the vast majority of prisoners were
captured in the Philippine Islands. The overwhelming majority of these
prisoners came from the fall of Bataan and later, Corregidor. The fall
of Bataan, alone, gave the Japanese in excess of 75,000 troops to deal
with; 60,000 of these being Philippine nationals. The POWs in the
Philippines experienced a mortality rate of 40% with approximately
11,107 deaths out of the 27,465 internees in the Philippines.

On **April 9, 1942, Major General Edward King** surrendered to the
Japanese 14^th^ Army commanded by Lieutenant General Masaharu Homma on
the northern island of Luzon. General Homma, a graduate of a British
military school, refused to meet General King and rather sent his senior
operations officer, **Colonel Motoo Nakayama** who demanded to meet only
General Wainright who was in overall command of the Philippine
archipelago since General MacArthur had left in January, 1942. Colonel
Nakayama began to yell and told General King to "Go and get Wainright."
General King tried repeatedly to say that he was there to surrender
Bataan only, and that he had no control over the rest of the Philippines
and had no power to bring General Wainright to Colonel Nakayama. He was
only there to surrender his men and request terms for surrender.
Additionally, he said he had stored enough fuel and had enough vehicles
for a rapid and orderly evacuation off Bataan to any area that General
Homma wanted them to go. Colonel Nakayama refused to make any
concessions. Sternly, he told General King that since he did not speak
for General Wainright, and therefore could not surrender all, of the
Philippine Islands, it was therefore "**absolutely impossible to
negotiate for the surrender of Bataan**." The troops could give up if
they wished, but it would be as individual units both "voluntarily and
unconditionally." He therefore refused to be bound by the Geneva accords
regarding the humane treatment of prisoners of war. He referred to the
men as **captives**. At that time, Americans made up less than 15% of
the total US force on the island of Luzon. Colonel Nakayama then
demanded General King's sword. He was enraged to hear that the general
had left the sword in Manila. He took General King's pistol instead.
After the war, Colonel Nakayama testified that the surrender was
accomplished by the "voluntary and unconditional surrender of each
individual unit. The negotiations for the cessation of hostilities had
failed." He said, "The Japanese Imperial Army are not barbarians."

These men taken captive on Bataan were forced into a march, which later
became known as the **Death March** in which 17,000 of them died. In
this 100 mile trek, from the southern areas of Bataan to the camps of
O'Donnell and Cabanatuan, 650 Americans died, mostly from beheadings and
shootings, and over 16,500 Philippine nationals (6 to 11 thousand of
whom were Philippine Scouts in the US Army) were murdered. There were
several reasons for the high mortality rate of the prisoners captured on
Bataan and subsequently on Corregidor.

Most of it can be explained by looking at the **Japanese
miscalculations**:

1). The Japanese made a great **underestimation of the eventual
numbers**. They had reckoned that due to their Bushido Code, in which
they did not recognize the concept of prisoners of war, the Americans
would also not recognize that concept and would die before surrendering.
They felt that death in battle was the highest honor while surrender was
the most abject disgrace. Augmenting this code was the fact that the
Japanese had come to believe that their cause was a just and pure one in
which they viewed themselves as a racially pure Asian group
self-appointed to rid the hemisphere of all other ethnic groups. They
therefore unexpectedly captured approximately 13,000 Americans on Bataan
with 60,000 Philippine nationals who were members of the Philippine
Scouts and Philippine Army and guides plus another 25,000 civilians,
when they were contemplating only approximately 10,000 internees. This
grossly overwhelmed their ability to deal with the actual number of
prisoners.

The Japanese killed indescrimately along the death march. The individual
Japanese soldier had been taught to follow orders only. He was not to
think for himself. The **Japanese soldier** was the product of a stern
and coercive society. He was part of a hard and brutal military system
where physical punishment was routine and arbitrary. He endured his lot
stoically and without question. He therefore understandably treated his
subordinates likewise. Fanatically indoctrinated never to surrender, he
held in contempt anyone who did. To this revulsion was added the Samurai
tradition of revenge reinforced by the heavy casualties suffered by the
Japanese in capturing Bataan. When a group of prisoners would walk
slowly, or drop out of the line for a drink of water, the guards would
often yell at and beat the prisoners. At other times, they would simply
bayonet or shoot the prisoner. Many Americans lost their lives to
beheadings, which were the favorite form of execution by the Japanese.
Many enlisted men would give all their possessions to their commanding
officer in the hope that the Japanese would respect him and he would be
able to protect their possessions. Unfortunately, the Japanese did not
recognize the concept of either prisoner's rights or the rank of a
prisoner. Everyone was searched for items of value, which could be
stolen. If an American were found to be in possession of anything of
Japanese origin such as money, pictures or merchandise, the Japanese
felt that the materials had been removed from the bodies of dead
Japanese soldiers of the 14^th^ Army. Immediately, the prisoner was
thrown to his knees and was beheaded.

An incredible act of human cruelty was committed upon the members of
**the 91^st^ Philippine Division**. On 4/11/42, the entire division was
being marched northward. It was stopped when Lt. General Akina Nara, the
65^th^ brigade commander, a graduate of the US Army Infantry School at
Ft. Benning GA, came by to see them. His exact role was unknown, but,
shortly thereafter, all the privates were removed. Then, all the
officers and non-coms had their hands bound behind them with telephone
wire and each man was bound to the other by the neck. There were four
lines of 100 men in each line. The group was marched down into a large
ravine and stood with their backs to their captors. Then, a Japanese
civilian interpreter told them in Tagalog that they were being punished
for siding with the Americans in the war. He further stated "My friends,
don't take it so hard, you must be patient. Had you surrendered earlier,
you would not have met this tragedy. We are doing this because many of
our soldiers died fighting against you. If you have any requests before
we kill you, ask it now." Major Pedro Felix, the senior officer
requested that the men be killed by machine gun fire or at least stand
and face their executioners. Both requests were denied. Thereupon, an
officer began at each side and began to decapitate each man. The screams
of the dying and terrified men continued for eight hours until the last
man had been decapitated. Here, as in all massacres, there were a few
survivors who would later retell the story. Major Felix survived the
night and chewed through his bindings and found two other mortally
wounded men. All together, they climbed out of the ravine and were met
the next morning by other Filipinos to whom they told their story.

2\) Also of great importance was the **poor physical condition** of the
Americans and the Filipinos prior to capture on Bataan. The Morgan Board
Debarkation Hospitals documented an average 15-20% weight loss among
several POWs prior to their capture. Due to severe food shortages on
Bataan and Corregidor. General MacArthur had withdrawn all the US forces
into Bataan in January 1942, but he had only brought enough food for 30
days. General MacArthur had put all troops on half rations in January
1942. That provided each man with approximately 2,000 calories per day.
In February, the daily food rations were cut to 1,500 calories and by
March to 1,000 calories. The rations at this time were white, polished
rice purchased from the natives. By late March the 26^th^ Calvary had
eaten its 250 horses and 50 mules. Furthermore, the entire local
population of dogs, pigs, water buffalo and monkeys in the surrounding
jungle had been eaten. Normal work in the Philippines at that time
required at least 3,500 to 4,000 calories per day per man. Approximately
70% of the men in the 31st Infantry on Bataan were on the sick list on
the day of capture. These men were suffering from malnutrition of
various types, malaria and dysentery. No provisions at all were provided
for assisting the sick and wounded. They had to be carried by healthier
prisoners on blankets strung between poles. After the war, General Homma
would testify that he had absolutely no idea of the condition of the
American troops. He would say he had not been informed of the
debilitated state of many of them. He said his only concern was to clear
Bataan of non-belligerents in order to take control of Corregidor.

> 3.) **Little transportation** was provided for the men captured on
> Bataan. Only a few thousand at the most were transported away from the
> front lines in trucks. The Japanese wanted to accomplish the
> evacuation of the prisoners as soon as possible because General Homma
> was under tremendous political and military pressure back in Japan to
> complete the occupation of all the Philippines Islands by early April,
> 1942. The original Japanese plan was to clear the prisoners from
> Bataan in phased movements to central Luzon. The reality was that the
> plan was never enacted, as the Japanese were much less concerned with
> their new prisoners than with taking the island of Corregidor. The
> prisoners were simply in the way of the timetable to take Corregidor.
> For the majority of the captives, the exodus from Bataan was in
> reality a Death March instead of a carefully organized military
> movement. It was allowed to be bungled into a series of tortuous
> marches, needless exposure to the sun and to crowded and filthy
> assembly areas, beatings, torture and arbitrary executions. Also, the
> Japanese had anticipated the American forces would surrender
> approximately three weeks later than they did, and they felt they
> would surrender in the northern region instead of the southern region
> of Bataan to which they had retreated. The combination of the earlier
> capitulation and the further distance, aggravated by the fact that the
> few vehicles that the Japanese had brought were being used to
> transport their troops to the southern region of Bataan, forced the
> Americans to march for days on end in the hot sun with little or no
> protective gear.
>
> Along the march, a central collection point for all the prisoners was
> the town of **Balanga**. The Japanese had reckoned that all the
> captives could walk to Balanga from whatever point they had been
> captured. No food was provided at all since the Japanese figured that
> the entire process should take no more than one to two days. It was
> here, in Balanga, a small town of 5000 people with little
> infrastructure to handle mass numbers of prisoners, that the arriving
> captives were forced into small, crowded warehouses or animal
> stockyards and forced to lie beside dead and dying comrades. It was
> also here in Balanga that the Japanese committed several of the
> horrors of the death march. For instance, it was here that so many
> stragglers in the march were simply buried alive. If they resisted,
> they were usually hit on top of the head with a shovel. Thereafter,
> the captives walked to San Fernando and boarded trains for the final
> 30 miles to Camp O'Donnell. The boxcars were small, made of metal, had
> no ventilation, had recently transported animals and were uncleaned
> inside. Once the men were crowded inside, the doors were locked and
> did not open until the captives arrived at camp. This was usually a
> three-hour ride. However, the loading process often took hours and the
> men were forced to stand up beside each other the entire way to camp.
> Diarrhea and sweat permeated the air.

4). **No food** was provided for the evacuation. Only what could be
scrounged up prior to the evacuation was permitted to be distributed to
the Americans. The only water the men were able to drink was from a few
scattered artesian wells along the route and water buffalo watering
holes. This water supply was always infested with parasites and it gave
the men severe dysentery. In fact, the desire for water caused many men
to break out of the lines in the march and as they would run toward the
watering holes, the Japanese would shoot them on the spot or bayonet
them as they were drinking.

5.) Also, **no medical supplies** were provided and the men were
prevented from seeking medical attention. The Japanese simply
confiscated the captured American supplies for their own use. Many men
and especially officers would be walking along the road and a convoy of
Japanese soldiers would be traveling by to the front. A Japanese soldier
would often lean out and strike a prisoner on the head with a bamboo
pole or a bayonet blade. If the prisoner did not immediately get up and
continue the march, he would be shot. Cruelty seemed to be a common
denominator among all of the guards and Japanese officers. They would
often administer the "sun treatment" in which POWs were lined up in rows
and beside each other in the afternoon sun and forced to squat for hours
on end. Beatings and kicking were common to both officers and enlisted
men.

The **POWs captured on Corregidor** were given extremely harsh treatment
after their surrender. The island fortress surrendered a month after
Bataan fell, on 5/5/42. When the Japanese attempted their initial
landings, hidden American cannon opened fire on their landing crafts
killing hundreds. Besides the constant shelling, one of the main
problems for Corregidor defenders was that of no fresh water. It was the
dry season in the Philippines and it had not rained significantly for
months and the reservoirs were near being dry. Therefore, the
combination of no food, little water, dwindling supplies of medicines
and munitions forced General Wainright meet General Homma to discuss
peace terms. General Homma was enraged to hear General Wainright came
only to surrender the Fortress Island of Corregidor and not the entire
Philippine Islands. There was still a significant force on the
southernmost large of Mindanao. General Homma then demanded
unconditional surrender. Thereafter, the American POWs held on
Corregidor were used as hostages to guarantee General Wainwright\'s
ability to persuade the troops to surrender in the southern Philippine
islands. The soldiers on Corregidor were confined for 18 days to a
concrete area of about 20 acres known as the "92d Garage Area\" which
consisted of a peacetime truck parking area and a seaplane ramp and with
no shade and only a meager, intermittent supply of very bad-tasting
\"gyppy\" water. Here, they remained in the open sun, without protection
from the elements. General Homma had hinted strongly that if the
southern forces did not surrender, these men would be massacred.
Fortunately the Philippine national civilians were removed from the
island during the first two days after its surrender, or the situation
would have been catastrophic, as the only food available was that which
the troops had scrounged up after the surrender, and that was very
limited since not much was available in the best of times before the
surrender. The American captives from Corregidor were eventually
transferred by ship across Manila Bay to Manila, put ashore and forced
to walk down Dewey Boulevard to Bilibid Prison in the hope and belief by
the Japanese that the Americans would be disgraced in front of the local
Philippine civilians. The American and Filipino POWs were then separated
and, over the next days, the Americans were moved by rail to the town of
Cabanatuan, from where they were marched to **Cabanatuan Camp III**,
formerly a Philippine Army cantonment area. The Philippine nationals
were moved to other camps.

For the men who survived the Death March, the life in the internment
camps was a horrible experience. **Camp O'Donnell** was a partially
completed American airfield eight miles west of the Manila railroad at
Capas. It had been almost totally destroyed by the Americans during
their retreat and had only two poorly functioning artesian wells from
which to provide drinking water for thousands of men. Each group of
internees arriving into Camp O'Donnell were greeted by the **Camp
Commandant, Captain Tsuneyoski** who informed in a screaming voice that
Japan had occupied all the Allied possessions of the US and Great
Britain in Southeast Asia. Also, the US and Great Britain were Japan's
eternal enemies and would remain so forever until the influence of the
Occident were completely wiped out in Asia. In addition, he informed
each group that they were captives, far below the dignity of prisoners
of war and they owed their lives to generosity of the emperor. All
insignia of rank were to be removed, no American uniforms were allowed
and all captives were forced to wear a loincloth. Also, all captives
were to salute Japanese by bowing regardless of rank. All captives were
allowed to speak only in Japanese, failure to do so would result in a
beating. Furthermore, the men were arranged into groups of 10 each,
termed "blood brother groups." The entire group would be punished for
any infraction committed by any member of the group. Minor offenses such
as not bowing soon enough to a Japanese were often punished by the "sun
treatment" in which the entire group of ten were forced to squat or
kneel in the sun for two to three days and not move at all and not
partake of food or water. Major infractions such as stealing or escape
were punished by group decapitation. All foods were considered property
of the emperor. To eat anything without permission was considered the
same as stealing from the emperor, a crime punishable by death. Prior
ranks of Americans were not to be acknowledged either by the Japanese or
by the Americans. Any show of respect for an American officer would
result in a beating. The beatings were accomplished with clubs, rifle
butts or limbs. Many times the beating was continued until the captive
either passed out or suffered a broken bone. The Japanese were much
shorter than the Americans were; therefore the Americans were forced to
stand into a hole for the beating so that their faces could be hit with
maximal force. It was also at Camp O'Donnell that the American captives
first learned that they would not be protected by the Geneva Convention
accords of 1929 since the Japanese government had allowed its
representatives to sign it, but, the government did not ratify it back
in Japan. Understandably, within this spirit of hatred for Americans,
the death rates became unbelievable.

The Japanese organized the Americans into **grave details** for the
purpose of burying the large numbers of daily dead. The grave details
were composed of two sections. The first section were those who dug the
graves. The second section were those who buried the corpses. Each
morning, a large hole was dug for the 30 to 50 American who had died the
previous day. The primary causes of death during the first six months
were malaria, dysentery and starvation. The carriers had the additional
gruesome task of straightening out the twisted bodies in order that they
could be stacked on top of each other so as to allow more room to bury
more prisoners. The Japanese continued to inform the Americans that they
did not care if they lived or died and many guards told the prisoners
they hoped they would all die. The Japanese were very successful in
their desires. 1,500 out of 8,000 Americans and 22,000 Filipinos died at
Camp O\'Donnell in the first six months primarily due to starvation and
neglect with the withholding of basic medical care on the part of the
Japanese. On June 6 1942, the Americans were transferred to Cabanatuan
I. Here were a complex of camps, the worst being **Cabanatuan I**, where
2,700 out of the 6,500 American internees died in the first year. Almost
all those dying could have been prevented by providing such basic
necessities as food, shelter and minimal medical supplies. In June 1942,
the hospital had 2300 patients. Here, the "Zero ward" was created. Men
considered too sick to survive were sent there to die. 500 Americans
died there in June 1942. 800 died in July. Red Cross parcels began to
arrive by December 1942. In contrast, Cabanatuan Camp III held the
healthier Corregidor survivors and its death rate was much less.

Camp life was initially boredom and starvation. Later, the Japanese
learned that they could use the prisoners as **slave laborers**. In
October 1942, 1500 men from Cabanatuan Camps I and III were assigned to
a work detail to be sent somewhere to the north of the Philippines. Most
would later be sent to Mukden, Manchuria. Another 1000 were later sent
to the southern island of Mindinau to work in the Davao penal colony. No
accurate counts were kept about the eventual numbers of Filipinos who
died, but estimates were at least ten times that of the American
numbers. Americans back in the US had no news at all about the condition
of their loved ones as Japan had steadfastly refused to allow Red Cross
inspectors into the Philippines. However, in **April 1943**, a group of
three Americans, Captain William Dyess, Lt. Cmdr. Melvin McCoy, and
Major Stephen Mellnick escaped from a POW camp in the Southern
Philippines named Davao wherein the Americans were forced to grow food
for the Japanese. They were placed in contact with the guerrillas and
eventually were able to board an American submarine and be taken for a
personal debriefing with General MacArthur himself at his headquarters
in Brisbane, Australia. Thereafter, General MacArthur sent a full report
to the State Department in Washington, DC and the decision was made to
withhold the information from the people for fear of reprisals against
the survivors by the Japanese. However, the story leaked out and over
100 newspapers sued the War Department in early 1944 for the right to
publish the story. It was published and the infuriated the American
people, prompting MacArthur to invade the Philippines in order to rescue
the POWs.

Bilibid Prison was used as a hospital and as a stopover point for levies
of POWs being shipped to other islands or to Japan, China or Manchuria.
Conditions inside were pathetic with fewer calories provided in the diet
than in the camps. Any POW sent to the hospital for treatment of an
illness or waiting transportation was automatically given half-rations.

**The diet among the POWs in the Pacific** and in the Philippines in
particular was a very important factor in the deaths of so many
prisoners. In general, the diet was poor in 1942, better in 1943 and
worse again in 1944. The daily ration consisted mostly of polished rice.
It was always of a quality far below that of the rice used by the
Japanese and was contaminated with trash and infested most of the time
with insects, parasites and bacteria. The rice was essentially what the
Japanese did not consider good enough for their enlisted men to consume.
The typical diet varied greatly among the camps. Even at the best it was
never adequate. The Japanese often issued weeds as substitutes for
vegetables. A half canteen cup, usually 8 ounces or 160 calories, of
thin rice gruel (lugao) twice and on rare occasions three times a day
was the standard. At times, no food at all was available. About once a
week camp veterinarians to feed approximately 10,000 prisoners
slaughtered a water buffalo. Usually this supplemented the diet by only
a few grams of protein per prisoner. Any evidence that the prisoners
were supplementing their diets was dealt with very harshly. Usually,
there was a beating with clubs until a bone was broken. Many times, the
offender was simply shot. Thousands of Red Cross parcels were shipped to
the men in the Philippines; however, the Japanese kept and ate most of
them for themselves. As stated, the Japanese refused to allow any Red
Cross observers into the camps.

**The transfers in the Pacific** were particularly brutal resulting in
needless loss of life. The Japanese used large converted cargo and
animal transport ships, which came to be known as hell ships. These were
ships in which the American POWs were forced to lay in the hold for the
entire trip across the South China Sea and/or the Yellow Sea on their
way to being used as slave laborers in Japan or occupied China. The end
of the war dramatically cut the Japanese labor supply, and Japan looked
to all it's conquered territories to provide a labor supply. Only the
most healthy were chosen for transfer to work in Japan. The Americans
were held in Bilibid prison until a transport ship could be arranged.
The conditions inside the ships were deplorable. Refuse was kept in a
bucket which was raised only once a day, and it often spilled over into
the faces of the men beneath who were crowded so closely that they could
lay down only with great difficulty and much cooperation. Often the
ships were loaded in Manila Bay, and left to wait sailing for days until
the Japanese felt the waters were safe from American submarines. Once,
inside, the POWs were forced to endure sweltering heat with no chance
for proper ventilation or to move around. During the voyages, episodes
of madness were common. Displays of valor among those keeping the calm
was also frequent The dead bodies of POWs were simply piled up at night
during the trip and tossed overboard into the sea the next morning.

On 10/1/42, the **Tottori Maru** departed with 1992 Americans, British
and Canadians who were loaded into 3 holds. It arrived in Formosa on
10/11/42. There, the men were given a fire hose bath. The Americans were
reboarded and kept 19 days on the ship. On 11/8/42, the ship docked in
Pusan, Korea where 1200 were sent to Mukden. On 11/12/42, the remainder
were sent to Osaka, Japan

One of the most pitiable examples of the loss of lives involving the
POWs in the Philippines occurred on the **Arisan Maru**, where 1,800
American POWs were forced into the hold of an unmarked ship. American
submarines were patrolling in the South China Sea and spotted this
unmarked ship; on 10/19/44, the Arisan Maru was torpedoed with the
resultant loss of 1,795 American lives. The 5 Americans who survived
this terrible ordeal rode to China in a lifeboat. These man made the
tremendous trek across China and India and were able to brief the State
Department about the little-known conditions concerning our men held by
the Japanese. The Arisan Maru was not the only ship in which so many
died. On 9/7/1944, the Shinyo Maru was torpedoed with 668 resulting
American dead.

In December 1944, 1619 men were collected at Bilibid prison for
transport to Japan. They were placed in the front and rear holds of the
**Oryoku Maru**, each being 40 by 80 feet. These 3200 square feet was
sufficient for 250 men to lay down. However, the Japanese placed 800 men
into each hold. They were left there for several days until the Japanese
felt it was safe for them to take out to open sea. No food was provided
at all for three days and the teaspoon rationed water. The combination
of no ventilation and the heat generated from the 800 bodies inside made
the overall living conditions inhospitable. The heat inside the hold
became intolerable for many. Understandably, several men crammed into
the corners died of suffocation. Mr. Wada, a Japanese guard called the
Hunchback by the POWs continually threatened to shoot any and all POWs
who were moving and asking for water or assistance. On 12/12/44, the
Oryoku Maru was sunk in Subic Bay and the weakened, starving and
dehydrated men were forced to swim 300 yards to shore. Many drowned
along the way in the waves. They were not informed where to come ashore,
and all those who were out of the lines the Japanese felt were
acceptable were machine-gunned. The Japanese were enraged at the bombing
and took out their anger on the defenseless prisoners. The Japanese
offered no medical assistance to those wounded remaining on board and,
Lt. Toshino went to these men and gave them what he later termed were
"mercy shots" to the wounded and helpless POWs. Only 1,341 of the 1619
originally on board survived the bombing, swimming ashore and shootings.
Next, the prisoners were forced to crowd into an abandoned tennis court
and remain several days. Only one water spigot was available and the
line for water was 6 hours long. No food was provided for the second day
in a row. The men had to sit one next to another. There was no room to
sleep, lie down or get out of the hot sun. At night, the cold winter air
was extremely discomforting. On 12/28/44 581 survivors were transferred
into the Brazil Maru, and 1070 into the Enoura Maru. These two sister
ships then set off together to Japan.

The **Brazil Maru** was an animal transport ship that had not been
cleaned. Again, they were crowded into the two holds. The trip to Japan
took several weeks in order to dodge roving American submarines. The
lack of food and near total darkness coupled with the lack of fresh air
drove many to madness. Many nights, screams filled the holds. Many would
cannibalize the weak or dead. Instances of bloodsucking were
commonplace. Once a day, a pot of rice and seaweed soup was lowered to
the prisoners down below. The soup usually spilt and the men would
desperately scramble for the dropped rice which was in the manure of the
animals. Only a few men got any food at all and most got nothing. Water
was still rationed by the teaspoons. The dead were laid under the hold
and the Japanese dropped ropes in the mornings to haul up the dead.
Usually 30 to 50 died each night and their corpses were simply thrown
over the sides. As the ship drew further north, the warm tropical air
gave way to freezing temperatures. Many times, a daily high of 20
degrees was recorded. The men would huddle together and remove the
clothes off the dead as well as the sick and dying. The mood inside the
holds was ones of isolation and hopelessness. The original 16 chaplains
numbered only 4 by the time the ship had arrived in Chinese waters.
These chaplains could offer only a brief escape from this lonely and
useless death. The ship was attacked several times by American Navy
planes. On January 8, 1945, over 300 were killed by explosions. Only 4
of the 16 Chaplains & 497 POWs survived the trip to Moji on the Island
of Kyushu. Even when the men arrived in Japan, the humiliation was not
over. A Japanese medical officer went aboard and smelled the dysentery
and ordered an examination. The POWs were forced to publicly strip naked
on the open docks and bend over poles so that Japanese medical personnel
could insert rods into their rectums in order to examine them for
parasites. Despite all this senseless and tragic loss of life, the
Japanese still refused to mark the ships as carrying POWs.

From 12/28 until 12/31, the **Enura Maru** sailed to Formosa, there; it
was docked until 1/13/45, when more prisoners were added. It was
attacked several times while docked and full of prisoners. On 1/9/45,
the Enoura Maru was attacked, with 300 killed with 250 wounded. On
1/10/45, attacked again, most doctors killed. The survivors were forced
to remove 300 mangled bodies of their comrades from the metal girders
inside the bombed out ship. Of the original 1311 on board, only 619
survived, and on 1/13/45, all surviviors were transferred into Brazil
Maru

On 7/17/44, the **Nissyo Maru** was prepared with 1539 men placed over
several days with no food. All were crammed into the holds standing in a
group with arms to sides, fainting was common with nowhere to fall. The
conditions inside were unimaginable with unbearable heat. The men became
crazed, pushing, screaming and swearing at each other. There were no
toilet facilities. To worsen the situation, most men had dysentery. For
sustenance, rice twice a day, and water only once, most got none if they
were not directly under the hold opening where the food was lowered. In
China Sea, rough waters caused seasickness and vomiting.

Despite all this senseless and tragic loss of life, the Japanese still
refused to mark the ships as carrying POWs. 25 unmarked ships sunk
transporting Allied and American POWs were verified as having been sunk.
Of the **18,901** men transported, **10,853** died due to submarine and
air attacks

Once the POWs arrived at their end point destinations, they were forced,
along with other foreign nationals, into slave labor pools and used in
such projects as clearing and building railroads through jungles in
occupied Southeast Asia. Here, the sanctity of life had very little
meaning as thousands died during railroad construction. POWs were also
sent deep into Manchuria to work in mines.

In Japan, the POWs were also forced to work in factories, on docks and
in coal and copper mines. No protective gear was ever provided for the
skin or lungs.

**The typical POW barracks in Japan** were primitive. There was usually
only one coal or wood-burning stove kept in the center of the room,
which was supposed to heat tea only. The men were given three woolen
blankets, which they wove together into a bag, which kept out the
freezing air. No latrine was provided in the barracks. There were
several double bunks in a row. When news of the war's end reached the
camps and the emperor told his soldiers to cease all hostilities, the
camp commanders opened up the storehouses and allowed the prisoners to
eat as much as they could in hopes that they could gain as much weight
as possible and therefore not appear to have been badly treated. The
Japanese were very afraid of vengeance by the Americans.

As stated previously, the Japanese feudal military code of Bushido
allowed the torture and mutilation of unarmed and defenseless prisoners.
In addition, the code allowed for revenge to be taken out upon the
prisoner in order to have the offended person not lose face. Such was
the case at the end of the war. Most of the highest-ranking military
officers demanded to the emperor that they fight to the last man.
Furthermore, they wanted all POWs executed, especially after the first
atomic bomb had been dropped. On 8/11/45, an American B-29 superfortress
bomber was shot down over Fukuoka. Eight crew members were taken out of
their jail cells, severely kicked and beaten and forced to watch as
shallow holes were dug and were made to see each other decapitated in
retaliation for the atom bombing of Nagasaki.

**American Women as Prisoners of the Japanese**

The Japanese capture of Corregidor on 6 May 1942 yielded 66 army nurses,
one civilian dietitian and one civilian physiotherapist. Eleven navy
nurses were captured in Manila and later transferred to Corregidor. No
nurses were captured on Bataan as they had all previously been evacuated
to Corregidor. At the time of capture, most were undernourished, as were
the male defenders of the Philippines. In January of 1942, half-rations
were in effect and in February of 1942 one-quarter rations were being
issued. It was during these hard times that the nurses were dubbed \"The
Angels of Bataan and Corregidor.

After capture, all the army nurses were allowed to continue their work
in the hospital wing of Malinta Tunnel on Corregidor for two additional
months; the hospital was then transferred to an old school on the
outskirts of Manila. The eleven navy nurses were transferred to Manila
and were eventually transferred to Los Banos Camp with 400 civilian
internees.

Due to their status as volunteers in the army, the nurses were believed
to be dangerous and were housed at the Santa Catalina girls\' dormitory
across the street from the Santo Tomas University Campus in Manila. Here
they were kept in two large rooms for seven weeks with only small beds,
enduring daily anxiety as to their possible future at the hands of the
Japanese. At that time they were not allowed to engage in nursing duties
of any kind, and were only allowed to go downstairs to eat during the
daytime.

By the end of August, 1942, all were transferred to close-by Santo Tomas
University Internment Camp, and housed there with the civilian
internees. During this time, they persuaded the Japanese to convert the
Santa Catalina girls\' dormitory into a 150-bed hospital. Here, they
were allowed to live and care for non-axis civilians until freed by
United States forces on 3 February 1945.

According to their Bushido Code the Japanese respected the women under
their control and the nurses were not beaten. There were no documented
or reported cases of rape by the Japanese soldiers during this period.
However the Japanese tolerated no displays of affection. If a man were
caught in the company of a woman, even if she were his wife, he would be
punished by being forced to spend 60 days in jail and the whole
internment camp would be placed on half rations.

After eight to twelve months, all of the nurses failed to menstruate.
The mechanism here is similar to that seen in anorexia nervosa wherein
there is an impaired release of LHRH in the hypothalamus. Baseline LH
and FSH are low, resulting in low estrone, estradiol and progesterone
levels. The low estrogen and failure to ovulate seem to be solely due to
gonadotropin deficiency.

The exact mechanism involved in the failure of the hypothalamus to
release LHRH is unknown. Menses and ovulation will return with weight
gain, and several of these nurses had children after release.

The death rate among the male military POWs was 40% during their
internment period under the Japanese. In contrast, not one nurse died
during this time. Nevertheless the average weight loss was 30% and death
would have been inevitable had the nurses been rescued much later.

Through interviews with survivors, phone calls to VA central office and
researching old references, seventy-nine unique names were identified as
those of women who had been prisoners of war of the Japanese.
Furthermore, we found that no study had been undertaken to analyze them.
Using the HINQ (hospital in­quiry) data verification method, all 79
unique names were entered. We were hindered by the fact that only a few
names had social security numbers available and many were hand-written
and likely misspelled. Nevertheless, of the total requested via the HINQ
verification method, 41 of the 79 (52%) were retrievable while 38 of the
79 (48%) had no record matches at all. The latter group could be
explained in that the names may have been initially loaded incorrectly
into the system, the individual may have never used the VA health system
or the veterans\' benefits, or we were looking for an incorrect
individual. Therefore, our research and data analysis covered the 41
retrieved data files, and it is from this universe that our results and
conclusions are drawn.

In this group of 41, twenty-one (51%) had an accessible disability
rating, and twenty (49%) had no compensation and pension record found,
indicating that these latter individuals had gone to the VA hospital or
used VA benefits but had never filed a disability claim. Also, two of
the latter group had sensitive records and were therefore not
accessible. Overall, 39 files were available for analysis and 21 (54%)
of these women had a service-connected disability, which is virtually
the same as the 50.6% of all male ex-POWs of the Pacific Theater of
Operations who have service-connected disabilities. Among the verified
women, the average degree of service-connected disability was 37%, again
virtually the same as the male ex-POWs of the Pacific Theater of
Operations with an average degree of 40%.

Among the 21 women with service-connected disabilities, diseases of the
digestive system were the most frequent, with 11 out of the 39 (28%)
receiving service-connected compensation. The next most frequent were
the avitaminoses (including beriberi and pellagra) and neurotic
disorders, each with 10 subjects out of the total of 39 (26%) receiving
service-connected compensation. Thereafter, in order of decreasing
frequency, 9 (23%) were service-connected for musculo-skeletal disorders
(including degenerative joint disease and PostTraumatic Osteoarthritis),
and 9 (23%) for malaria, 3 (8%) for systemic conditions and 3 (8%) for
respiratory conditions (including 1 each for asthma, bronchitis and
emphysema). Finally there were 2 (5%) for each of the fol­lowing:
amoebiasis, blood condition, flatfoot, sinusitis, peripheral nerve
damage, varicose veins and gynecologic conditions.

When comparing the data with the MFUA (Medical Follow-up Up Agency)
studies, it is quite interesting to note that the data for the men and
the women is virtually the same as far as the percentage of individuals
with service-connected disabilities, average degree of disability among
the disabled, the incidence of service-connected disability for
digestive disorders, avitaminosis, neurotic disorders, musculoskeletal
disorders, malaria and systemic conditions.

However these percentages deviate significantly in the percentage of
service-connection for pulmonary pathology. Among males, tuberculosis
was very frequent and was one of the prime causes of death in men for
the first seven years after repatriation, whereas no cases appeared
among the women POWs. Also, no complaints of peptic ulcer exist in the
women as opposed to the men among whom it was so common as to be a
presumptive service-connected disorder. These differences are likely
attributable to the fact that the men experienced a bimodal death rate
curve. Deaths were high within the first six months of captivity due to
the harsh treatment, poor diet and poor sanitation. Also, death rates
were high, again, in the last year due to transport by cargo ships,
which were often torpedoed and working in coalmines and factories
without protective gear.

**POWs of North Korea and Communist China**

In the Korean Conflict the mortality rate was 38% with 2,700± confirmed
deaths out of 7,140. There were several reasons for this huge mortality
rate, but the prime reason was that the Koreans never recognized the
concept of prisoners of war. They had never ratified the Geneva
Convention accords regarding the humane treatment of prisoners of war.
Furthermore, they regarded all forces hostile to their cause as war
criminals, and they would treat them as such.

North Korea was communized in 1946. They would spend the next four years
indoctrinating and reeducating their people as to the communist
ideology. They also used this time to develop a highly trained and
indoctrinated army in order to invade their ancient southern foe. At 4
AM on 6/25/1950 near Kaesong, South Korea, NK communist forces pushed
across the 38^th^ parallel and invaded South Korea, thereby pursuing
North Korea's goal of spreading communism as well as ending the civil
war between the Korean people. Six days later, a battalion of the US
24^th^ infantry division was rushed to Korea from Japan. The first units
to reach Korea were not well prepared for combat. They had been informed
that when the North Koreans would learn of the American presence, they
would run away. The Americans soon found out how wrong they were. By
July 1950, Seoul had fallen to the Communists. Thousands of civilians
and foreign national were trapped in Seoul and force-marched out. A few
miles below Seoul, the American Army's 24^th^ Division was trapped and
annihilated and; furthermore, of the four regiments contained therein,
only 700 men were captured. Included in this group was their commander,
General Dean. The North Koreans were particularly brutal. Many POWs were
executed on the spot. The ones who were captured were forced to take off
their shoes and most of their clothes. Over and over the North Koreans
repeated to the captured Americans, "We want you to die, you came over
here to kill us, now we are the boss." The Americans were force-marched
into North Korea along with civilian non-combatants from all over Seoul.
There were diplomats and religious peoples along with South Korean
civilians. No help at all was allowed to the injured. If a person were
so informed that he could not walk under his own power, he was shot on
the spot. Many stopping to relieve themselves from diarrhea were shot.
Under the blessing of the UN, the US began a massive military buildup in
Japan and reinvaded the Korean peninsula. On the death march through
Manpo, many were executed for not being able to keep up. In one
particular column of military POWs, diplomats, journalists,
missionaries, women and children, the North Korean man in charge was
known as the Tiger. There was light snow and sleet at the time. As the
march proceeded, more and more fell out due to exposure and neglect. The
Tiger became angrier and angrier. He ordered the man in charge of the
group with the most to drop out to step forward. Lt. Cordus Thornton of
Longview Texas stepped forward. "Death penalty for disobedience in
wartime" screamed the Tiger. "Is that not true for the American army as
well?" The lieutenant responded "In America, I would get a trial." The
Tiger then looked around to see a column of retreating and beaten North
Korean soldiers and asked the their verdict. "Shoot him" they all
shouted in unison. "There, you have your trial," said the Tiger. The
Texan calmly replied "In Texas, sir, we would call that a lynching." The
Tiger then asked him if he wanted a blindfold to which Thornton said
yes. He was then blindfolded and his hands were tied behind him and he
was shot by the Tiger in the base of the head. Most of the reserves
flown from the US were veterans of WW II, and were not as familiar with
their weapons as the highly trained North Koreans.

However, by 11/1950, the US forces had completely beaten the North
Koreans, and their lands and capital were in US/UN possession. By late
November, American forces had reached the border of Chinese Manchuria
along the Yalu River. The Americans felt the war was over and the
problems all settled when the Communist Chinese sent millions of
soldiers across the Yalu River against the UN forces. It was during this
horrible time of fighting in sub-zero temperatures with little food and
provisions when most of the 7,190 American POWs were captured. Of the
total captured, 6,656 were Army troops; 263 were Air Force; 231 were
Marines and 40 were Navy men.

Generally, after a while in possession of the North Koreans, the
prisoners were turned over to civilian authorities. Most prisoners were
forced to sleep on the floor. No beds or clean clothing were ever
provided. No medicine was provided. The prisoners were not allowed to
shave their beards or to cut their hair. Finally, the prisoners were
given over to the Chinese authorities after they had entered the war on
the side of their North Korean allies in late 1950. Thousands of
Americans were captured and later reported missing by the Chinese. The
supposition was that they were sent off to slave labor camps from which
they eventually died.

There were **three phases of captivity** during which the POWs were
forced to endure extremely different circumstances.

Most of the deaths during the Korean Conflict came during the **first
phase** of the hostilities The Department of Defense Reports of 1955
revealed that 500 out of the 700 POWs captured in late 1950 were forced
into a march into North Korea and died as a result of execution or
exposure to freezing temperatures. The American Army had expected
victory over the North Koreans by Christmastime, and had therefore not
issued winter clothes. No one had seriously expected the Red Chinese to
enter the war on the side of the North Koreans in the winter of 1950.
Therefore, the captured men had to walk in the brutally cold winter with
high snowdrifts and blowing winds with little more than jackets. Few had
any protective headgear at all. The Korean soldiers were brutal and shot
several American POWs in the heads or backs after they had tied the
POW's hands behind their backs. Officers were placed in charge of small
groups. Any infraction by a group \[member was met by beating of the
guilty individual and execution of the officer. For those marched off to
"Death Valley", the march took 25 days. The men were forced to walk 2 to
3 hours at night, then take a half-hour break. This mad the situation
worse because the 3-hour march made them tired and sweating and the rest
made them very cold. During the day, they stayed in Korean mud huts.
Often times, 25 men were crowded into an 8 by 10-foot room. Therefore,
the men were forced to literally sleep on top of each other. They at in
the morning approximately an hour after stopping and again in the
evening an hour before departure. The food was 4 ounces of cracked corn.
No utensils were provided and the drinking water was from snow. Over two
thirds of the group developed bloody dysentery during the march. Those
too weak to walk were left behind with an enemy guard. Soon, shots were
heard, and the guard who had been left behind would catch up to the
group. Fifty men were lost on the march. They arrived in "Death Valley"
on 12/26/1950. "Death Valley" was divided into two sections
approximately 2 miles apart. The officers were placed in the south
section. In the officer's section, the barracks like area held 25 men
each. At night, 2/3 of the group had to sit with their chins on their
knees while the remaining 1/3 could lie down. The men would rotate
positions. Food was 400 grams of cracked corn per day. Prisoners were
dying at the rate of 2 to 7 daily between 12/26/50 and 1/24/51. On
1/21/51, all but 300 of the sickest were marched out to camp #5. There
were about 200 prisoners in camp #5.

Virtually all deaths during this time were due to starvation, exposure
or harassment. In the first month of captivity, most POWs died as a
result of untreated wounds incurred around capture. In the 3^rd^ to
5^th^ month, most deaths were due to dysentery and pneumonia. Injuries
resulting from cold exposure were common. After five months, most of the
deaths were due to Beriberi and Pellagra. In one camp, there were
between five to twenty eight deaths per day. Only Chinese doctors were
permitted to treat patients.

The **second phase** of captivity was characterized by deprivation of
all of the necessities of life. The diet was totally inadequate and
there was almost no sanitation. Men were overcrowded into Korean
farmhouses. Men were crammed into small rooms with no toilets or
bedding. No new clothing was issued until July 1951. The temporary camps
were in effect from July 1950 to February 1951. Uniformly, the POWs
received the worst treatment in these camps: very poor food and poor
shelter. Constant beating, mental harassment and forced participation in
parades was the norm.

The POWs in Korea experienced the **brainwashing** techniques that the
WW II European and Japanese POWs had not. Since this was a United
Nations war against Communist aggression and ideology, the Communists
understandably attempted to indoctrinate the American POWs with their
philosophy throughout the entire conflict. Few North Koreans could speak
English. Therefore, the Chinese carried out the indoctrination sessions.
Most of these Chinese had been educated in America in California
Universities. Their knowledge of America and our way of life were
extensive. They often used that knowledge against our men. The
indoctrination program had a two-fold purpose. The first was the
selection and conversion of the susceptible person. The second was group
neutralization. During the first year of captivity, there was a total
regrouping of prisoners in an attempt to isolate all resistance groups.
In fact, the North Koreans sent several "re-educated" or indoctrinated
Americans back into the American lines in hopes that they would be able
to cause dissension among the troops. Predictably, they were never
successful in this endeavor. Weakening the physical resistance of the
American POWs by exposing them to cold, torture and hunger accelerated
their technique of brainwashing. In addition, the communists rewarded
them for cooperating with gifts such as extra food, better housing, and
less torture.

The North Koreans, with the aid of their American-educated Chinese
allies uniformly broke down the military organization\'s groups and
separated individuals according to race and rank. The purpose being
simple, to attempt to heighten any difference among the prisoners. For
over one year, most of the waking hours of the POWs was spent in study.
They were told "We are your friends. Your conditions of living are bad
now, but we will work together to improve them. We will correct the
errors in your thinking. Once you have learned the truth, we will send
you back to your families." Furthermore, the American POWs were
constantly told that the United States was an imperialistic government
run by and for the rich. Also, the communist system reflects the aims
and desires of all peoples and is the only real democracy. For years,
the Soviets had denied any involvement in North Korea or China as far as
the war was concerned. However, the techniques used by the Chinese were
exactly those used by the Russians against their Japanese and German
POWs during WW II. Their purpose was for re-education and indoctrination
into communism and then, to send the individual back to his homeland in
order to spread communism. Later, it would be learned that although the
direct handling of the POWs was by the Chinese, the treatment was
directed by the Soviets.

By the end of the conflict, 21 American POWs refused repatriation back
to the US. By comparison, over one million North Koreans refused to be
repatriated back into North Korea by the end of hostilities.

The **third phase** of captivity was characterized by the permanent
camps which were used from March 1951 until October 1953 and essentially
much better conditions were available due to the fact that the armistice
negotiations had begun to make progress and much decreased physical and
psychological harassment was the norm.

By November 1951 until repatriation in 1953, there were fluctuations in
the captor's attitudes toward the POWs reflecting the progress in the
armistice negotiations but generally there was an increase in the diet
and the clothing.

The **North Koreans** totally ignored all aspects of the Geneva
Convention. Executions and severe punishments were the norm for trivial
offenses. However, when the punishment was over, the incident was
forgotten, however, the **Chinese** were different. Under the Chinese
"lenient policy", they took notes about your behavior, until suddenly
they would say "Take all and come with." This meant solitary confinement
and intense interrogations. Although the Chinese did not commit many war
crimes, they did not follow the rules of the Geneva Convention. Red
Cross parcels sometimes made it to some of the camps; however, the
Chinese steadily refused to allow any Red Cross inspections. All
interactions with western media was closely monitored and under the
direction of two western journalist with communist sympathies who would
only release information damaging to the UN forces and beneficial to the
communist forces.

Show camps were opened up to international observers during the war to
counter the belief that the prisoners were mistreated. Some POWs were
allowed to write home. Other POWs were given better food so that they
could appear healthy in order to be photographed by outside inspectors.
Most of the internment facilities were barbaric, brutal and uncivilized.
The worst of these camps were The "Bean Camp" near Suan, "Death Valley"
near Pukchin, "The Valley" near Kanggye. The two worst of all were "The
Interrogation Center" and "The Caves", both near Pukchin. In "The
Caves", the men were confined in the caverns in a hillside. They were
forced to sleep without blankets, their food was thrown to them, and no
sanitation at all was provided. There were no latrines at all and the
men had to live among their own excrement. Those POWs sent here were
those accused of insubordination, repeatedly breaking camp rules,
attempting to escape, or refusing to talk with Chinese military
interrogators.

One particularly brutal interrogation center was "Pak's Palace". This
was located near the city of Pyongyang. The location was a brickyard
flanked by houses. The chief North Korean interrogator was Colonel Pak.
A cruel man known as "Dirty Pictures Wong" assisted him. The Palace was
operated to obtain military information. Colonel Pak was a sadist. When
a POW refused to talk, Colonel Pak would use violence such as kicks,
cigarette burns and torture. Several US Army and Air Force officers went
through the palace. Most of the Air Force officers went through here.
They were all beaten. Many of the prisoners found ways to avoid the
continual beatings. If you could convince the guards that you were
stupid or crazy, or the lowest graduate in you class, they often were
not interested in you. A prisoner who refused to cooperate would be
called a "reactionary" and sent to a bad camp. Prisoners who were
docile, seemed to cooperate and were polite and read the communist
literature were called "progressives" and graduated to "Peaceful
Valley". This was a communist show camp where POWs were given better
food and even tobacco.

The diet in Korea was mainly of a corn or millet variety. The average
weight loss confirmed by the debarkation hospitals was 40-50% per man
from the pre-internment weight.

Repatriation procedures were placed to handle the numbers of POWs who
would be returning. For the "Little Switch" POWs, this medical survey
was to be accomplished by US Military Hospitals in Japan. The "Big
witch" procedures required that returnees would be given immediate first
aid, followed by a triage which would sort out the POWs requiring litter
cases for movement by ambulance and those POWs who could be moved by
truck to the reception center. Once at the center, the POWs were
disinfected by spraying. The former POWs would then proceed from the
showers in robes to the reception hospital whereupon a medical record
was to be initiated. Laboratory tests, a dental examination, CXR and PE
were then performed. Based upon these tests, the POWs were to be
classified as patients and non-patients. Patients were flown to military
hospitals in Japan. Non patient were then placed abroad ship returning
to the US. Intelligence and processing were to occur before and during
the voyage home. Once home, the former POWs were given a 30-day period
for recuperation and recovery. The rest period was to occur prior to
reassignment or discharge.

**POWs of Vietnam**

Lastly, Vietnam with its presumed mortality rate of 114 out of 772
confirmed captured men. This war had two separate theaters. In **South
Vietnam**, the soldiers who were involved with the Viet Cong generally
were U.S. foot soldiers (77 Army and 26 Marine), and 25% of these
captured men died. There was generally less torture and fewer
interrogations. Since the Viet Cong themselves were poorly fed, the
Americans were at the end of their food line so that there was a chronic
food shortage.

**North Vietnam** was very different. Most were kept in Hanoi,
literally, "ha noi," meaning "inside the river." The city sits on the
delta of the Red River, sixty miles from the port of Haiphong. The POWs
were mostly downed aviators, 5% of whom died. They were often used for
psychological and propaganda purposes, and there was severe physical and
mental torture with somewhat inadequate food. Many prisoners were kept
in Hoa Lo prison, built by the colonial French near downtown Hanoi,
sarcastically renamed by the Americans the "Hanoi Hilton" in a mock
tribune to the quality of life within its walls. Regular cells measured
7 by 7 feet, contained two beds and enough room to pace off three steps.
Solitary confinement cells were 4-foot cubes, no space to stand or lie
down. In August 1964, the Hanoi Hilton received its first US prisoner,
**Navy Lieutenant Aviator Everett Alvarez**. He was an A-4 pilot
stationed aboard the US Constellation and was one of two pilots shot
down August 5 when the US launched its response to the Gulf of Tonkin
incident. Says Alvarez, "They had everyone in there. They brought in
droves of kids. They brought in women too. I could hear then screaming
at night." Air Force Colonel Jack Bomar says "We were criminals and we
had bombed those people without a declaration of war, and that's the way
we were treated."

**Lt. Colonel Richard Kiern** endured prison in both WW II and Vietnam.
And compared the two experiences. "Captivity in Germany was rough, but
at least I was treated like a human being. Captivity in North Vietnam
was unreal, unbelievable, not of this world." Pilots at the Hanoi Hilton
were kept alive because they had a special value to their captors. The
North Vietnamese saw them as hostages. No communication was given for
several years between the prisoners and the US government. No idea of
the total number of prisoners was available in the US.

However, on 4/6/67, 19-year-old seaman **Douglas Hegdahl** was below
deck on his ship, the USS Canberra, which was cruising the waters in the
Gulf of Tonkin. He wanted to witness a night bombardment, and, without
authorization, he went up topside to witness the display. When the guns
opened fire, their concussion knocked him down and the 6 foot 2 inch 225
pound sailor fell into the ocean, losing his glasses. Since he was a
powerful swimmer, he was able to spend ten hours in the water before
being found by the North Vietnamese. At first, he was felt to be a spy
or infiltrator. After several days of interrogation, he was believed to
be just a common sailor unknowledgeable of any useful military secrets.
The Vietnamese thought of him as a fool for falling into their hands.
When the prison staff began to treat him like an ignorant country boy,
he recognized what they were doing and played the role to the hilt. The
loss of his glasses and inability to see accurately made the role even
more believable. Throughout his imprisonment, he capitalized on his role
as the village idiot. He often displayed seemingly erratic behavior. The
Vietnamese could not wait to get rid of him, they thought he was stupid.
The Vietnamese desperately wanted to rid themselves of him. However, he
did not want to leave and have the other POWs be deprived of his
assistance. When peace activist Tom Hayden came for a propaganda shoot,
Hegdahl gave him the finger, refused to write a public amnesty request
to Ho Chi Minh and threw away extra food given to him that day.
Therefore, they moved others ahead of him on the "early release role."
The Vietnamese forced him into early release and thereby removed him
from the country in 1969, four years ahead of the release of the
remaining prisoners. All the while he was humming the tune of "Old
MacDonald's Farm" continually. What the North Vietnamese had failed to
observe was that Hegdahl was very intelligent. And since they had viewed
him as insignificant and unthreatening, he was given more freedom around
the compounds to communicate with the other prisoners. He became a
valuable reconnaissance worker in the PW resistance network. During his
stay in North Vietnam, he had actually memorized the names of his 250
fellow American prisoners and was humming it to the tune of "Old
MacDonald's Farm." He was used by the Vietnamese in their propaganda
shows as a "poor defective peasant." He was eventually placed in the
cell at the Plantation PW complex with Dick Stratton and the two became
great friends. Stratton ordered him to accept early release if it were
available in order to inform Washington about the situation. Upon his
release, Hegdahl was immediately debriefed and the information he
provided to intelligence authorities was of inestimable value as up to
that point, there was no accounting of many of these men.

Close by the Hanoi Hilton was Cu Loc, affectionately called **The Zoo**
where there was the infamous solitary confinement area called 'the
gatehouse." Here, troublesome POWs were tortured for false confessions
by the Vietnamese as well as Cubans for hours on end. A favorite
technique was to hang them for hours by ropes with hands behind their
backs. Another ploy was beatings with rubber hoses. Withholding of food
and especially water was common. The guards often gave out boiling soup
and forced the POWs to quickly drink it before it would be taken away.
Very troublesome prisoners were taken later during the war to **Skid
Row**, a maximum-security prison that had been built by the French ten
miles southwest of Hanoi. The **Plantation** was a "Show Camp" primarily
designed for peace delegates to view the overall good conditions of the
American POWs. Many POWs here were specifically chosen for their
willingness to talk to the peace delegates.

POWs of North Vietnam experienced a variety of **physical and
psychological tortures**. When the pilot was initially shot down, the
local captors and then the jail guards would usually beat him up. They
would be quickly transported to an interrogation center and undergo a
daily routine of morning, afternoon and evening medley of questions,
lectures, indoctrination and bullying. The same questions would be asked
over and over in hopes of tripping a prisoner up into divulging a
different bit of information. Typical questions included: Who were the
members of your squadron? What were your air tactics, roll in altitudes,
dive angles and air speeds. What defensive altitudes were used to avoid
the North Vietnamese MiGs or Surface to air missiles? What were the
offensive maneuvers for attacking the North Vietnamese? Many times, all
medical treatments were withheld in order to force the men into writing
confessions that they were in fact war criminals. They would be publicly
displayed and the crowd would be excited into frenzy and often allowed
to attack and beat the prisoners.

Physical torture was common well after all useful information had been
extracted. This was done in order to break the moral of the men and to
use them for propaganda purposes. The prisoner's body would often be
tied up into various contortions in which bones would not be broken, but
great pressure would be placed on the ligaments. The Vietnamese
especially delighted in beating the prisoners when they were tied with
their hands behind their backs. Also commonly used was sleep
deprivation. The prisoner would be kept in a bright room awaiting his
confession. He would be chained to a stool. For days at a time, he would
not be allowed to sleep. If he were to drift off to sleep, he would be
hit with a thick pole.

**Navy Lt. Commander John McCain III** was captured in October 1967 and
sustained a broken leg. He had volunteered to stay in combat after his
ship was assigned to go home. McCain's plane was shot down over Hanoi
and he landed in the middle of Sword Lake, a dried out lake. He
sustained severe injuries upon landing. He was offered no medical
treatment. Soon thereafter, the North Vietnamese captors learned that
his father was Admiral John McCain Jr, Commander in Chief of US forces
in the Pacific. The Vietnamese were elated and quickly dubbed him the
Crown Prince, a reference too his father's military position. His father
was known as the Chief War Lord in the Pacific. The following year, he
was offered an early release ahead of his fellow prisoners. Accepting
the early release ahead of the others would have been a violation of the
prisoner's own code of ethics. Therefore, he refused their offer of
early release. Enraged and furious about his refusal for the release,
his captors stated: "They have taught you too well McCain! They have
taught you too well!" The North Vietnamese then rebroke his leg as well
as his arm and knocked out his front teeth. He was tortured for over a
year. Finally, he was forced to sign a confession of criminal wrongdoing
and apology. However, the North Vietnamese got little more as he swamped
them with useless information. He once listed the offensive line of the
green Bay packers as members of his squadron. He was considered an
inventive resister and a master at screwing up propaganda broadcasts.
Others offered early release literally stepped over the stretcher of
John McCain on their way out. After this, McCain was referred to by the
Vietnamese as a "black criminal."

In the United States at the time, there were people who became
self-appointed **"peace delegates**" who would regularly travel to North
Vietnam for talks. In 1970, McCain further enraged his captors by
refusing to meet with one of these delegations. His punishment was to
spend the entire summer locked in a 6 by 2-foot cell

None of the prisoners were forced to meet with the war's best-known
delegate, actress Jane Fonda. This was due to her making propaganda
films to be shown to the prisoners. In one film, she is seen standing
beside a dam that had been bombed. She is seen weeping bitterly. Most of
the POWs felt as if she were going to get her academy award. Her most
notorious film was one in which she crawled into a North Vietnamese
anti-aircraft battery placement and pretended to be taking aim at her
fellow Americans who were bombing North Vietnam. For these reasons, she
was reviled by most of the POWs and anyone who met with her was
considered a collaborator with the enemy. She is still looked down upon
by living POWs. Says Alvarez, "No matter what your political beliefs,
there is still a basic faith in your young men out there. These are your
own people. You can't do that to your own people."

All of the POWs hated to see the peace delegations. They knew they were
being used. However, they would be able to speak English openly as well
as having good food and cookies and possibly be able to send a letter
home to loved ones. In exchange, the Vietnamese required the POWs be
used for photo ops with the delegates and often give staged confessions
as to America's use of force. One such encounter, which did not proceed
as planned, was with Larry Carrigan. He agreed to meet with the
delegates of the Women's Strike for Peace members. Unfortunately for
him, not only did he admit to war crimes and the bombing of women and
children, he vigorously defended the US air strikes informing the
delegates that the US airmen had been disciplined from straying away
from military targets. The furious Vietnamese had him pulled from the
room and sent back to the Hilton for correction. He was beaten with
sticks and fists for days, then he had his hands tied behind him and he
was lifted to the ceiling. There, he was left to dangle in pain. Other
times, he would be lowered and allowed to stand on a chair, then the
chair would be kicked out from under him, again allowing him to dangle
in pain.

Talking among POWs was strictly forbidden. Therefore, the prisoners
developed elaborate methods of communication. Hand signals were common
as well as tapping on the wall. The Americans felt that it was vital to
keep up contact between POWs in order to provide moral support.

Public displays of the American POWs for **propaganda** purposes were
commonplace. However, more often than not, the POWs had the upper hand
and made their captors look foolish. Such was the case with Commander
Jeremiah Denton Jr. who blinked T O R T U R E in Morse code. Others made
obscene hand gestures to their captors such as Paul Galanti giving the
Vietnamese the finger. The picture was airbrushed and appeared on the
cover of Life; however, an untouched version appeared in a West German
newspaper, which infuriated the Vietnamese. Most simply sat
expressionless and spoke one word answers which indicated they were
being forced to give the appearances. In an attempt to break up any
communication and cohesiveness among the POWs at the Plantation, the
North Vietnamese were able to persuade 3 POWs to accept early release on
2/16/68. This was meant both as a propaganda ploy as well as a morale
breaker to the remaining POWs. The three released to the peace activists
were Air Force Capt. Jon Black, Navy Ensign David Matheny and Overly.
The release was a carefully staged event with foreign journalists, party
officials and distinguished guests in attendance. Cameras and taping
devices recorded the entire proceedings. Hegdahl was able to get Overly
to memorize the names of 70 POWs, which was of immense benefit to
Washington. Nevertheless, the immediate effect to POW morale was
devastating, both at the Plantation and throughout the POW system. The
trio was referred to as MOB, an acronym for the first letters of their
last names. Their fellow countrymen left in confinement held them in
disdain.

Similarly, **Commander Dick Stratton** when he performed the robot like
Manchurian Candidate when he bowed 90 degrees to all in the room
including the wall four times. The picture and story were published in
Life Magazine 4/7/67 with the title "North Vietnam Under Siege." The
pictures and tape caused uproar in the United States. When the North
Vietnamese learned that they had been tricked, they beat him up badly.
However, he feels that the episode actually saved his life as he said
that he had become so famous, "the communists had to keep me alive."
Seven photographs of somber pilots were included. Additionally, the
combination of the bowing and his reading of a written confession and
apology to the Vietnamese people for the US bombing of their country was
never forgiven by many hard line American officers who viewed his
actions as dishonorable and against the code of conduct. The US
ambassador-at-large, Averell Harriman said "From the photographs,
videotapes and descriptions that I have seen of the so called "news"
conference at which Captain Stratton was exhibited, it would appear that
the North Vietnamese are using mental or physical pressure on American
POWs. Hanoi has refused to allow the International committee of the Red
Cross or any neutral intermediary to visit the prisoners, a right
required by the Geneva Convention to which Hanoi has adhered. Without
such independent verification, North Vietnam's professions of "humane
treatment" cannot be accepted." Dick Stratton was kept in a variety of
facilities over the years. After he was separated from Hegdahl, he was
required to copy in his own handwriting material that POWs at the Zoo
had been forced to write under pressure. He refused to do so and was
placed into a room in the Warehouse of the Plantation in total darkness.
For seven weeks, he battled roaches, rats and loneliness. As expected,
he lost total track of night and day.

By 1971, the POWs had organized themselves into the Fourth Allied POW
Wing with **Colonel John Peter Flynn** the highest ranking captured
officer as their commander, The Hoa Lo authorities placed each senior
officer into a single large cell feeling that it would keep them
isolated from the other prisoners. This was an error as the senior
officers were now able to communicate even easier. The wing's motto was
"Return with Honor." The senior officers offered blanket amnesty to any
prisoner who might have collaborated to any degree for whatever reason.
The offer remained open until the war's end.

On 7/4/69, three US POWs, Navy Lt. Robert Fishman, Air Force Capt.
Wesley Rumble and Hegdahl were released. Once back in the US, they were
allowed by the Nixon administration to go public with the news of the
torture and humiliation forced upon the US POWs. It was a calculated
campaign by the administration to counter the communist propaganda.

**Operation Homecoming** was carried out at Clark Air Base in Luzon in
the Philippines in 1973. They had released 76 prisoners prior to that.
Only 34 managed to escape. 2,460 soldiers are considered as missing in
action. The operation contained built in safeguards, carefully balanced
diets, and total security from the press. An escort officer, a man of
equivalent rank, service branch, background and experience, greeted each
POW. He was a buffer between the POW and the New World. He carried in
his briefcase up to date information about the world and the POW's
family.

The first to arrive was Navy Captain Jeremiah Denton, senior officer
among the first group of prisoners out of Hanoi on 2/12/1973. 39 fellow
POWs accompanied him. His first words upon landing were: "We are honored
to have had the opportunity to serve our country under difficult
circumstances. We are profoundly grateful to our Commander in Chief and
to our nation for this day. God bless America." Another 473 American
prisoners were evacuated by the end of March.

**National Academy of Science Studies**

There have been several National Academy of Science and National
Research Council‑funded studies. The first, by Cohen and Cooper,
covering returning World War II POWs and age‑matched controls,
encompassed the years 1945 to 1951. The second study, completed by
Nefzger, included the Korean ex-POWs and covered the period of 1953 to
1965. The third study, completed by Beebe, covered 1946 to 1965 in
further detail. The fourth study, by Keehn, encompassed 1965 to 1975.
Lastly, Page, in 1992, analyzed self‑reported questionnaires and
compared these to the POW protocol exams.

Cohen and Cooper noted that, among the Pacific Theater repatriated POWs,
there was an increased incidence of death in the first two years of the
study, tapering off in the last four years of the study. The difference
was due to the high incidence of **trauma, tuberculosis, and
cirrhosis**. They felt the high rate of tuberculosis was secondary to
the decreased immunity of the repatriated POWs as a consequence of
chronic avitaminosis as well as the high rate of infectivity that was
prevalent in the camps. Cirrhosis was felt to be caused by a combination
of both alcohol abuse upon repatriation and chronic liver damage from
the malnutrition of the POW experience. The high incidence of death due
to trauma was generally felt to be secondary to psychological
difficulties in readjusting to United States culture.

Post-repatriation hospital admission rates for POWs of Japan, PWJ, were
greater than for controls in every category examined, including Nervous
System, Circulatory System, Genitourinary System, Allergic Disorders,
Psychiatric Disorders, Respiratory System and Infectious Diseases.

Considering percentages of men compensated by degree as a means of
expressing morbidity, this data by Nefzger reported quite significant
differences for every organ system of POWs of Japan vs. Control War
Japan. For POWs of European Theater, musculoskeletal, digestive, skin
and psychiatric disorders are statistically significant when compared to
Control War European Theater. For the POWs of Korea vs. Control War
Korea, the Eye, Systemic Diseases, Respiratory, Digestive, Skin and
Psychiatric Diagnoses are all statistically significant.

**The Presumptive Service Connected Disabilities**

Public Law 97‑37 established the Presumptive Service Connected
disabilities, which are Arthritis (traumatic), Avitaminosis, Beriberi
(including Ischemic Heart Disease with a history of Wet Beriberi or
edema), Chronic Dysentery, Frostbite, Helminthiasis, Malnutrition,
Pellagra, any other nutritional deficiency, Psychosis, Panic Disorder,
Generalized Anxiety Disorder, Obsessive Compulsive Disorder, Post
Traumatic Stress Disorder, Atypical Anxiety Disorder, Depressive
Neurosis or dysthymia, Peripheral Neuropathy, Irritable Bowel Syndrome
and Peptic Ulcer Disease.

**Disruptive Articular Trauma**

**(Post Traumatic Osteoarthritis)**

Data by Cohen and Cooper, in 1954, revealed that POWs from the Pacific
theater of action have an incidence of Post Traumatic Osteoarthritis of
3.3% compared to 1% in Control War Japan (WJ), and POWs from the
European Theater of Operations (PWE) have an incidence of 2.3% compared
to 1% for Control War Europe (WE). Also, per Nefzger as of 1965, the
hospital admission rate per 1000 was 2.5 for PWJ vs. 0.5 for WJ and 0.4
for PWK vs. 0.2 for WK. Among those service‑connected for disease of the
musculoskeletal system, PWJ was 25.9%, WJ was 11.9%, PWE was 22.4%, and
WE was 16.4%.

There are **three types of joints** in the body, any of which may be
involved in disruptive articular trauma. The first type includes the
**amphiarthrosis** as seen in the parietal bones in the skull
characterized by tight fibrous bands connecting these bones. The second
type is the **synarthroses** characterized by the bones of the spinal
column with flowing fibrous sheets and tight, almost immovable joints.
The third type, and the most severely and commonly affected are the
**diarthroses**, characterized by the joints of the long bones of the
body possessing two distinct movable areas.

The diagnosis of post‑traumatic osteoarthritis is difficult to make in
retrospect. In general, however, the following points are helpful: The
joint had to be normal prior to the injury; an effusion or structural
damage had to occur after the injury; and similar disease is not present
in other non‑traumatized joints. This is the difference between
post‑traumatic osteoarthritis, which is a secondary form of
osteoarthritis, and primary, or degenerative, joint disease which is a
diffuse disorder affecting joints symmetrically.

Other points favoring a traumatic origin are that the affected joint is
localized to either a mono or pauci articular location and significant
osteoarthritis is seen in a joint not usually severely involved, with
degenerative joint disease such as the ankle, wrist, elbow or
metacarpophalangeal joint. Finally, X‑rays may be helpful in
demonstrating healed fractures or foreign bodies near the joint in
question.

This is a striking example of PostTraumatic Arthritis of the right hip.
The left hip appears normal for chronological age while the right hip
reveals marked narrowing of the joint space, large osteophytes extending
from the femoral head and the acetabulum (particularly from the superior
aspect) and slight compression of the femoral head.

**Nutritional Depletion**

Nutritional depletion likely accounted for more deaths in POW camps and
for more morbidity and mortality upon repatriation than any other single
cause, because as individuals are malnourished they are predisposed to
the development of several different disease states. Recognized
nutritional deficiency states may take the form of Vitamin, Protein,
Essential Fatty Acid or Mineral deficiency.

Generalizations are always difficult to make, however, if one wishes to
look at a global picture, among the European Theater ex‑POWs, these
individuals suffered primarily from a lack of sufficient calories
throughout and especially towards the end of the war. This produced
Marasmus. This was especially true of the soldiers and airmen who were
captured in the latter months of the war and who were not fortunate
enough to be placed in any controlled prison setting. Virtually all POWs
in the European Theater had low but minimally sufficient vitamin intake,
primarily due to intermittent dietary vitamin supplementation with
potatoes, cabbages, turnips and any other of a variety of vegetables as
well as intermittent Red Cross parcels which also provided some protein
supplementation. This explains the paucity of cases diagnosed with
avitaminosis upon repatriation. When comparing European Theater POWs to
those of all three Asiatic Theaters, the dietary nutritional differences
are striking, particularly in the Pacific and Korean theaters of action.

The Pacific and Korean conflict POWs had, primarily in the early months
of captivity, a virtually total lack of vitamins which was in some cases
not only a hypovitaminosis but an actual avitaminosis, or absolute lack
of vitamins. This was primarily of the B complex vitamins and vitamin A.
These individuals were also fed a very low number of calories in the
diet. It was the total protein, energy and carbohydrate starvation diet
imposed on these prisoners in the early months of capture which killed
so many and predisposed the survivors to several problems later.

**Marasmus**

Marasmus is a deficiency of total calories in the absence of other
deficiencies. This produces a thin and weakened individual often without
long-term sequalae.

**Kwashiorkor**

Kwashiorkor, an African word, meaning an individual with characteristic
body appearance, results from a total deficiency of protein in the diet.

The loss of protein in the diet yields a decreased plasma albumin, which
manifests itself clinically as dependent edema. In addition, there is a
decrease in plasma transferring, which is the protein responsible for
the transfer of iron in the circulation from the intestinal lumen to the
liver and bone marrow. Without this transport protein, hypochromic
microcytic anemia results due to lack of incorporation of iron into the
hemoglobin. Lack of protein in the diet also affects hemoglobin
production, as protein is needed for the globin portion of the
hemoglobin.

The immune system is especially involved in Kwashiorkor. Initially the
lymphatic tissues begin to atrophy; there is decreased activity in the
polymorphonuclear cells and a failure of maturation of the T‑Cell
division. The inevitable sequence of events is an increased morbidity
and mortality from common infections as well as opportunistic organisms
such as viruses, fungi and parasitic diseases not normally seen in
healthy people. This, in effect, would present quite similarly to an
acquired immune deficiency syndrome.

This curve reveals the typical course of an individual on a progressive
protein and vitamin deficient diet. The B‑complex vitamins, responsible
for energy production, are primarily involved here. Several adaptive
physiologic changes occur when the body is exposed to starvation,
including decreased insulin secretion, increased levels of glucagon and
cortisol, and decreased peripheral production of triiodothyronine (T3)
from thyroxine (T4). The result of the decreased insulin levels is
mobilization of free fatty acids from adipose tissue for utilization,
allowing glucose to be utilized by the brain. Ketone-induced dieresis
occurs, accompanied by loss of magnesium, phosphorus and calcium. This
becomes especially important, as lack of phosphorus decreases the
ability of the body to produce adenosine triphosphate (ATP) and further
prevents energy production by the inability to convert thiamine into
thiamine pyrophosphate (TPP). A five- percent weight loss occurs in the
first week of total starvation. The gastrointestinal tract, liver, and
skeletal muscle lose considerable mass during this time. Skeletal muscle
is the primary reservoir for TPP in the body. Gastrointestinal mucosal
loss is enormous during the first week of starvation, with marked
atrophy of the villous projections, thereby largely decreasing the
absorptive surface in the gastrointestinal tract. Cardiac muscle
atrophies at a much slower rate. Hypoalbuminemia leads to small bowel
edema resulting in malabsorption. Continued protein deficiency has
disastrous effects on the hematopoietic and immune systems. Decreased
hemoglobin, hematocrit, total lymphocyte counts, albumin, and
transferring result from severe protein depletion at five weeks of
starvation with an average weight loss of 15 percent. Cell mediated
immunity is altered and the bactericidal activity of polymorphonuclear
leukocytes is reduced. T-cell defects result from loss of thymic hormone
and deficiency of zinc and vitamin C.

As can be seen from the chart, within one and one‑half months anemia
becomes manifest. Hypoalbuminemia follows shortly thereafter. By two
months, there is a decrease in T‑Cell function, which is manifested by
depressed cell mediated immunity, and the individual at this time
becomes susceptible to opportunistic infections. By two and one‑ half
months broncho‑pneumonias begin to become commonplace. Death is
inevitable if protein‑energy sources are not quickly restored.

Total starvation in the first week produces a weight loss of four to
five kilograms. Twenty‑ five percent of this is from adipose tissue, 35%
is extracellular fluid loss and 40% is protoplasm loss, primarily from
skeletal muscle. Accompanying this is a loss of nitrogen from the body
with associated depletion of other electrolytes such as magnesium,
phosphorus, calcium and selenium. This becomes especially important, as
lack of phosphorus decreases the ability of the body to produce
adenosine triphosphate and further prevents energy production by not
being available to convert thiamine into its active form, thiamine
pyrophosphate (TPP).

Also noted during the first week of starvation are huge skeletal muscle
losses, much greater than cardiac muscle losses. What is especially
bothersome about this is that skeletal muscle is the primary reservoir
for thiamine pyrophosphate in the body. If skeletal muscle mass is
decreased, then thiamine pyrophosphate will have very few storage sites.
Gastrointestinal mucosal loss is enormous during the first week of
starvation, with marked atrophy of the villous projections, thereby
decreasing, to a large extent, the absorptive surface area in the small
intestine and colon. Renal parenchymal loss is minimal. The central
nervous system is not affected at this time. This individual represents
the Musselman syndrome where there are decreased but adequate sources of
protein and vitamins to sustain life but a virtually total deficiency of
calories, primarily carbohydrates, in the diet. This presents with
severe wasting of the extremities. Individuals with the Musselman
Syndrome are not overly susceptible to opportunistic infections, in
contrast to those with protein deficiency or vitamin deficiency states.

**Trace Element Deficiencies**

Zinc deficiency is manifested by acrodermatitis, poor wound healing and
decreased taste and worsened immune function. Copper deficiency is
manifested by hypochromic microcytic anemia. Encephalopathy and muscle
pains, myocardiopathy and eventually hemolytic anemia manifest
peripheral Selenium deficiency manifest chromium deficiency. Magnesium
deficiency produces a peripheral unresponsiveness to the actions of PTH
causing a hypocalcemia, which is unresponsive to treatment until the
magnesium is replenished. Hypophosphatemia produces rhabdomyolysis.

**Essential Fatty Acid Deficiencies**

Essential fatty acids include Linoleic acid, deficiency of which was
manifested by dry scaling dermatitis, coarse hair, alopecia and
diarrhea; and Linolenic acid, a deficiency of which was manifested by
numbness, paresthesias, weakness and blurred vision.

**Vitamin Deficiencies**

A cruel and agonizing cause of death in the camps was to suffer from a
vitamin deficiency syndrome.

Deficiency of the B complex vitamins was the most lethal of all the
vitamin deficiencies, if individuals were so unfortunate as to lack
supplementation with these vitamins. This vitamin complex is divided
into two groups. Group A is represented by thiamine, also known as
vitamin B‑1; riboflavin, also known as vitamin B‑2; nicotinic acid or
nicotinamide, also known as vitamin B‑3; pantothenic acid and biotin.
Group B is composed of folic acid, also known as vitamin B‑9, and
cobalamin, also known as vitamin B‑12.

Concerning group A, the B‑vitamins are amines responsible for the
intracellular metabolism of carbohydrates, fats and proteins and are
responsible for the production of adenosine triphosphate for the
maintenance of the respiratory chain. They are the energy releasing
vitamins, and a deficiency of any of these vitamins manifests itself in
tissues with the highest metabolic activity and turnover rate. These
amines are present in every cell of the body and are vital, hence the
name vitamin. They are all water‑soluble.

Concerning Group B, the B‑vitamins are vital for red blood cell
production and are termed the hematopoietic vitamins. They are also
water‑soluble. Vitamin B-12 is bound to protein in the liver and a
deficiency takes three to five years to develop.

Syndromes: Several physicians who were themselves prisoners of war later
wrote about their observations and experiences in Japanese POW camps.
Beriberi was seen and written about by Doctors Hibbs, Lewis and Nardini,
physician POWs in the Philippines. The castration syndrome was
identified and written about by Dr. Jacobs, as was the oculo‑oro‑genital
syndrome. Pellagra was seen with great regularity in many of the camps.
Strachen\'s syndrome was a deficiency syndrome different from the above
and spinal spastic syndrome was seen with regularity in some camps. Dr.
Gottlieb noted malnutrition liver diseases.

**Beriberi**

In all likelihood, beriberi was the most devastating of all the vitamin
deficiency states as it not only had immediate side‑effects but also
severe chronic sequelae.

Beriberi is the Singhalese word for weakness. It is caused by a
deficiency of the water‑ soluble vitamin B‑1, thiamine, in the diet. The
body is able to store only a total of 30 milligrams of this vitamin.
With food ingestion, one can only absorb five milligrams of vitamin B-1
in any one day. Therefore, one can manifest total body thiamine
deficiency within only a few days on a deficient diet. Virtually all
POWs were at least somewhat thiamine deficient. Thiamine is necessary in
the diet at roughly 0.33-mg per 1000 calories consumed. Normal
individuals consume 0.50 mg per 1000 total calories per day, while POWs
consumed many less mg per 1000 calories per day. In addition, the higher
the carbohydrate load ingested, the more thiamine is required. Also,
polished rice adds a nutritionally empty carbohydrate load, which
further depletes thiamine stores.

The best sources of thiamine are pork, organ meats (primarily liver,
heart and kidney), leafy green vegetables, nuts and legumes. These foods
were not common in any of the POW diets that have been described.
Therefore, many POWs were, in essence, living in areas of endemic
beriberi.

Since thiamine is stored throughout the entire body, one would expect
its depletion to present as a multi-system disease, but in fact the
cardiovascular system and the nervous system are the predominant ones
affected in beriberi. The presenting clinical manifestations often
overlap but, for purposes of description, are termed cardiac beriberi,
dry beriberi (affecting the peripheral nerves only), wet beriberi
(affecting the peripheral nerves and the heart), and central nervous
system beriberi.

A brief review of biochemistry is essential before proceeding. Dietary
thiamine enters the body and is phosphorylated into its active coenzyme
form, thiamine pyrophosphate, by the addition of two adenosine
triphosphates. If phosphorus is also lacking, the body will not be able
to form the adenosine triphosphate necessary to make thiamine
pyrophosphate (T.P.P.). Thiamine pyrophosphate is an important coenzyme
to release energy from carbohydrates and form adenosine triphosphate. In
addition, thiamine pyrophosphate itself is necessary in two other steps
to form ATP. Pyruvic acid, which is in equilibrium with lactic acid,
enters the Krebs cycle. If thiamine pyrophosphate is not present,
pyruvic acid and lactic acid levels build up in the body. This is
extremely important in the pathogenesis of beriberi, as **pyruvic acid
is a neurotoxin**. When is withheld from the diet of experimental
animals, the ability of the different tissues to utilize pyruvate does
not decline uniformly. This indicates that in some tissues, the bound
thiamine pyrophosphate is tenaciously retained whereas in others, it is
more readily lost through metabolic degradation or excretion.

**Dr. Hibbs** made perhaps some of the most detailed observations about
patients affected with beriberi. He made notes on how the deficiency
disease affected the nervous system, eyes, skin and heart. He noted that
most POWs in his camp were affected by either dry or wet beriberi, It is
unknown why some individuals develop dry beriberi while others develop
wet beriberi. Among individuals with beriberi, inactivity and a
relatively low- carbohydrate diet possibly enhance the development of
dry beriberi. **Dry beriberi** is characteristically associated with
aphonia or hypophonia, foot and wrist drop and extremely weak muscles.
Symptoms were first frequently noted after a malarial chill, diarrhea,
vomiting or heavy work. Dependent edema rarely responded to supplemental
thiamine therapy. The first symptoms of peripheral neuritis were
stiffness, heaviness or a tired feeling in the arches of the feet. If
left untreated, these symptoms proceeded to a shooting, burning type of
pain.

On the other hand, individuals with **wet beriberi** are in general a
bit more active and ingest higher amounts of carbohydrates in their
diet. It is this high carbohydrate diet which accelerates the use of
thiamine and its depletion. Painful edema, some cyanosis and dyspnea
characterize wet beriberi. Also seen with wet beriberi is an increased
cardiac silhouette. Both wet and dry beriberi can progress to central
nervous system beriberi.

Dr. Hibbs also noted a tremendous amount of visual pathology associated
with beriberi; he termed this **beriberi amblyopia**. He noted that most
patients developed retinal degeneration with contraction of the visual
fields, an enlarged blind spot and central scotomata. With time, there
was a progressive visual disability, a temporal pallor with macular
degeneration. There were associated poor pupillary reflexes. He noticed
that beriberi ambylopia did not respond well to replacement therapy with
thiamine. Additionally, he noticed that among the patients with
peripheral neuritis, 50% had visual complaints. And, of these, 10% had
an associated severe diminution in vision. It would stand to reason that
if the visual cranial nerves were affected in beriberi amblyopia, that
so would the **auditory**, however, Dr. Hibbs noted no impairment or
demonstrable loss of auditory acuity.

Skin changes associated with beriberi were common. Frequently seen were
Beriberi spots which were lesions similar to erythema nodosum. Also
characteristically seen in **beriberi skin changes** were an erythema in
the palms of the hands and soles of the feet associated with excessive
sweating and pronounced dermatographia.

Concerning **Acute Beriberi Heart Disease** in Cabanatuan Prison Camp,
Dr. Ralph Hibbs noted the highest incidence at 3 months, in July of
1942. This, no doubt, reflected the poor diet, which consisted primarily
of polished rice and was practically devoid of thiamine. Acute cardiac
beriberi presented a major problem in the camps. In 95% of the
individuals it took a **mild form**, characterized by dyspnea and
non-fatal cardiac arrhythmias. On physical examination, the heart was
usually hyperactive with heart rates between 130 and 140. An irregular
rhythm was usually present and due to the lack of monitoring devices,
the assumption was atrial irregularities. Additionally, the patient was
usually hypotensive with BPs in the 80/40 to 100/60 range. There was no
evidence of cardiac decompensation or heart failure. For those who died,
an autopsy revealed a heart of normal size and anatomy. The **moderate
form** was somewhat more aggressive. Symptomatically, the affected
individuals were extremely short of breath. Physical examination
revealed hepatomegaly, edema, cyanosis and ventricular failure, rales in
the lungs, tachycardia, with most of these individuals dying within the
year. At autopsy, these individuals had a much enlarged heart. Finally,
shoshin, or **acutely pernicious cardiac beriberi**, is an acute right
and left ventricular failure with death occurring in minutes to days.
Either unaccustomed high caloric intake or sudden work may precipitate
this, as both quickly consume thiamine stores.

Pathologic examination of the heart of an individual who has died of
beriberi reveals edematous myocardial cells, loss of intracellular
protoplasm, a decreased number of fibrils intracellularly and virtually
no other pathological findings.

**Acute beriberi heart disease** is characterized by high output cardiac
failure with the virtual sine qua non of associated lactic acidosis,
again involving the equilibrium of lactic acid with pyruvic acid. For
some unknown reason, the sympathetic ganglion cells develop lesions in
the nuclear regions, possibly predisposing the individual to a
peripheral vasodilatation. This results in a ruddy coloration of
affected individuals, primarily involving the feet and hands. The kidney
interprets this as a decreased total intravascular blood volume and
increases aldosterone production.

There are **three major pathophysiologic steps** in the development of
beriberi heart failure. The **first is peripheral vasodilatation**,
which results in a high-output state associated with increased
antidiuretic hormone secretion. This results in a ruddy skin
discoloration, primarily involving the feet and hands. The kidney
interprets this as decreased total intravascular blood volume and
**increases aldosterone production**. Hemodynamically, these individuals
present with very low systemic vascular resistance. Cardiac output can
be five to ten times normal and stroke index may be enormous. Total
blood volume and heart rate are increased. If left untreated, moderate
bi-ventricular heart failure develops. Finally, massive **retention of
sodium and water** occurs, with painful dependent edema. Face and arm
edema are characteristic after remaining supine overnight. The
combination of high-output congestive heart failure, decreased systemic
vascular resistance, increased cardiac index and heart rate, and lactic
acidosis, is often present in acute beriberi heart disease.

Physical examination often reveals low systolic and diastolic pressures,
elevated jugular venous pressure, and dependent edema. The heart rate is
usually rapid; S~3~ and S~4~ gallops are common. The ECG may reveal
sinus tachycardia, S-T segment changes, or low QRS and T-wave
amplitudes.

There is no agreement as to the long-term effects of thiamine deficiency
on the heart. Several large retrospective studies have demonstrated no
association while a few small studies have suggested an association
between thiamine deficiency and ischemic heart disease (IHD).

Also seen is an increase in antidiuretic hormone production.
Hemodynamically, these individuals present with a very low systemic
vascular resistance. Their cardiac output can be five to ten times
normal and their stroke index may be enormous. Total blood volume as
well as heart rate is increased.

This individual displays the dependent pitting edema so common in wet
beriberi.

**Ischemic Cardiomyopathy**

Ischemic Cardiomyopathy is the newest of all the Presumptive Service
Connected disabilities.

The four oldest Medical Follow Up Agency (M.F.U.A) studies were all
**American**, and were **retrospective as well as prospective**.

Cohen noted, by 1954, 58 PWP deaths versus 25 expected. 8 Actually died
of cardiovascular complications versus 4 expected.

Nefzger noted by 1965 C.V. deaths for all ex‑POW groups except PWK \<
C.V. deaths for similar age and race matched controls in the U.S.
general population (U.S.g.p.)

Beebe ‑ C.V. deaths all groups \< U.S. gen.pop.

Keehn ‑ C.V. deaths all groups \< U.S. gen.pop.

Eberly ‑ Lower than expected % M.I. in Minn., Mn. among ex‑POWs versus
age matched controls.

Oboler ‑ No findings consistent with Chronic Beriberi Ischemic Heart
Disease (I.H.D.)

Of these studies, it was the Cohen study that demonstrated a higher
number of deaths than expected among the ex-POWs.

In contrast, the **Foreign Cardiovascular Studies** were all
**retrospective.**

Richardson ‑ 1st took 100 Canadian ex‑POWs with their non‑POW brothers
as controls, and saw no difference in mortality. The 2nd study examined
Canadian ex‑POW mortality to 1965. He observed 46 cardiovascular deaths
vs. 29 expected. This was the initial study, which raised the question
of any association between wet beriberi and the later development of
Ischemic Heart Disease.

Fred examined 14,000 Australian ex‑POWs. He observed 293 died from
cardiovascular causes versus 370 expected.

Adena noted Australian ex‑POWs with a decreased percentage of I.H.D.
versus the general population.

Salmond ‑ New Zealand % ex‑POWs with I.H.D. \< gen. pop.

Gill ‑ 1st 602 FE ex‑POWs no change versus gen. pop. 2nd % of deaths = %
gen. pop. in U.K.

Again, the second Richardson study found a higher number of
cardiovascular deaths than expected among ex-POWs.

Page analyzed the self‑reported questionnaires as part of the POW
protocol analysis of the most recent NAS/NRC study. His report dealt
only with the survivors, and only 50% of all invited ex-POWs chose to
participate, and only 20% of controls participated. He noted through his
analysis that the prevalence of ischemic heart disease was 1.7 times
higher among ex‑POWs who reported edema in prison camp than in ex‑POWs
who did not report it. Until recently, the VA allowed presumptive
service connection for heart disease in former POWs on the basis of a
history of beriberi only when beriberi heart disease was specifically
diagnosed. As of August 1993, "beriberi heart disease" includes ischemic
heart disease when there was a localized edema during captivity.

Ischemic heart disease, for service connection, may be established by
such findings as the presence of characteristic EKG changes, a
documented history of myocardial infarction, etc The evaluation level
for disability compensation currently is based mainly on the level of
exertion that produces angina, the type of employment that is feasible,
and whether there has been a myocardial infarction.

**Beriberi Neuropathy**

The hallmark of the neurologic pathology is axonal and myelin sheath
destruction. Thiamine is essential for the formation of acetylcholine.
Acetylcholine is formed in the spinal cord and transported down the
axon. It is an essential nutrient and neurotransmitter and is vital for
the maintenance of both the axon and myelin sheath. Thiamine deficiency
leads to decreased acetylcholine levels and, as already discussed,
increased pyruvic acid levels. It is believed that this combination of
decreased levels of acetylcholine and increased levels of pyruvic acid
is responsible for the characteristic destruction of the nerves seen in
beriberi, and results in weakness, pain and central nervous system
manifestations.

The **neuromuscular symptoms** of thiamine deficiency are the first to
be manifest. In virtually all individuals, weakness is the initial
presentation. Characteristic is a difficulty rising from a sitting to a
standing position, which is what the term beriberi means in Singhalese.
In 25% of the individuals, however, the first symptoms are paresthesia
and pain. These are initially worse distally but will proceed proximally
if left untreated. The legs are always affected earlier and more
severely than the arms. These symptoms are insidious and relentlessly
progressive unless adequately treated. In POW camps, the most important
differential test performed by the camp physicians was the ability of
the patient to perform the squatting test. In this test, the patient was
asked to place his arms over his shoulders and his hands on the back of
his head. He was then asked to do a deep knee bend and attrempt to raise
his body into an upright position. If he could not perform this test, he
most likely had early beriberi.

This dermatome chart shows that the most affected axons are those
involving L 4 , L 5 , and S 1 . This would produce a typical stocking
dysesthesia, or impaired sensation. As the disease progresses more
proximally to involve L 2 and L 3 , one begins to see involvement of the
fingertips as manifested by involvement of C 6 and C 7.

A recent study of thiamine deficiency revealed the immense **peripheral
neurologic variability** of this disease. Of 189 patients presenting
with leg symptomatology, 45 revealed loss of reflexes alone, 10 revealed
loss of sensation alone, 2 had weakness and sensory loss, 40 revealed
reflex and sensory loss and 66 revealed sensory, motor and reflex loss.
This incredible heterogeneity in the presentation of the neuromuscular
involvement of this disease is truly unique. In the same individuals,
only 57 had arm involvement. Of these, 6 had loss of reflexes alone, 10
revealed loss of sensation alone, 5 weakness alone, 10 weakness and
sensory loss, 2 reflex and sensory loss, and 17 sensory, motor and
reflex loss.

This schematic representation shows that the **destruction of the myelin
sheath** is a non‑ inflammatory and segmental process. As the segmental
destruction proceeds proximally, the axons begin to die. Also shown in
this schematic representation of a neural bundle, normal impulses are
carried in a rhythmic fashion back to the brain. With the loss of the
myelin sheath and the axon, impulses are erratically generated and
propagated up the spinothalamic tract and erroneously register in the
thalamus and is interpreted by the brain as pain, even though noxious
stimuli are not actually present.

The end result is initially dorsal foot pain. The S1 dermatone
innervates the sole and lateral aspect of the feet, and therefore, it is
the first affected. Followed closely thereafter is the L5 dermatone,
which innervates the medial aspect of the dorsum of the foot.

The pains are on a continuum from a dull, constant ache in the feet or
the legs, as seen in most individuals, to sharp, severe, piercing
fleeting pains. A cramping, tight sensation in the feet or the calves is
virtually characteristic of this disease, as is tightness and tenderness
of the calves upon palpation.

**Dr. Lewis** made several clinical observations regarding thiamine
deficiency. He noted the development of a hyperesthesia and
hypersensitivity of the feet, primarily on the dorsum and soles, with
most prominent painful sensations presenting from June to August of
1942. Wet Beriberi appeared most frequently by September 1942, according
to his observations. .

**Dr. Nardini** noted that 90% of American POWs in his section of
Cabanatuan had some type of Beriberi. The best type to have had was a
numbness and hyperesthesia of the feet and anterior aspect of the legs.
The worst type to have had involved painful burning feet accompanied by
the Cabanatuan Shuffle, or gait, in which the affected POWs would walk
on the lateral aspects of their feet and fling their arms upward in an
attempt to relieve the pressure resulting from walking.

The motor system reveals symmetrical pathologic involvement that is
definitely worse distally. Absolute paralysis is rare. Dr. Hibbs noted
that only two percent of the individuals affected with beriberi in his
camp manifested paralysis which, when present, only involved the limb
musculature. Thoracic muscles, due to the short length of their nervous
innervation, are virtually never involved.

In this setting of peripheral neurologic damage and painful
polyneuropathy, **nerve conduction studies and electromyography** reveal
a demyelinating process early in the course of the disease. Either a
decrease in nerve conduction velocity, or, more commonly, a decrease in
amplitude of the motor and sensory-evoked responses, suggesting a
demyelinating process and axonal loss characterizes this process.
Electromyography findings reveal mild to moderate slowing of the motor
and sensory conduction and marked reduction in the amplitude of the
sensory axon potentials. In addition, the conduction velocity is usually
reduced in the distal dermatomes but is normal proximally.

In a recent study conducted at the Livermore VAMC, **32 former POWs** of
the Japanese with a history of beriberi neuritis were evaluated. Upon
entry into the study, 7 individuals had no neurologic complaints while
25 individuals were symptomatic. E.M.G. recordings and nerve conduction
studies were performed. The first column on the left details the
individuals with an abnormal E.M.G. and an abnormal nerve conduction
velocity. The second column reveals findings of abnormal E.M.G. only
with normal nerve conduction studies; the third column with abnormal
nerve conduction studies but normal E.M.G.; the fourth column revealing
no electro-diagnosis of axonal neuropathy. Considering the first column,
among the seven ex‑POWs with no symptoms, three had both abnormal E.M.G.
and abnormal nerve conduction studies and one had abnormal nerve
conduction studies only. Therefore, four out of the seven asymptomatic
individuals had abnormal electrodiagnostic studies while only three were
normal. Among those with symptomatic peripheral neuropathy, 14 had
abnormal E.M.G. and abnormal nerve conduction studies, 10 had abnormal
E.M.G. and only 1 was normal. In summary, in this study 28 out of the 32
individuals with a history of beriberi neuritis had abnormal
electrodiagnostic studies.

Recently, a large non-controlled study was conducted in England of
nutritional neuropathy symptoms among 898 Far‑East‑POW survivors
examined 23 to 36 years after captivity. This was not a controlled
study, but, rather, the individuals examined were all willing
participants. Among individuals with definite neurologic symptoms, 24
had evidence of peripheral neuropathy, 19 had evidence of optic atrophy,
13 had evidence of sensory‑neural deafness and 2 had evidence of
myelopathy. This total of 58 abnormalities among the 49 symptomatic
Far‑East POWs represented a prevalence of 5.5% in the 898 individuals
studied.

In the same study of possible neurologic diseases, 21 had impaired deep
tendon reflexes, 13 had impaired sensation, 5 had optic atrophy, 1 had
fasciculations, 1 had muscle wasting and 1 had spastic monoparesis. This
total of 42 abnormalities among the 38 Far‑East POWs represented a
prevalence of 4.2%.

There are two avenues to which this disease may turn: Dry beriberi, with
its weakness and aphonia, wet beriberi, with its dyspnea and cardiac
irregularities, and C.N.S Beriberi with its Cranial Nerve abnormalities
and dementia.

Concerning the effects of thiamine deficiency on the CNS, alcoholics are
at increased risk for Wernicke's encephalopathy. Initially, mild
disorientation, drowsiness, and inattentive responsiveness characterize
this thiamine deficiency dementia. Later, the full-blown triad of
cerebellar ataxia, oculomotor disturbances, and mental confusion
develops. The most common ocular abnormalities are horizontal and
vertical nystagmus and bilateral cranial nerve III, IV, VI, and X
involvement producing abducens and conjugate palsies. If not diagnosed
and treated quickly, Wernicke's encephalopathy is potentially fatal,
with an estimated acute mortality rate of 17 percent. Stupor and coma
are common in patients presenting to emergency departments.
Confabulation with retrograde and antegrade amnesia are frequent
symptoms. In more than 50 percent of cases, recovery is incomplete
despite thiamine replenishment. In the non-institutionalized elderly
with vitamin deficiency, oral thiamine has been demonstrated to improve
cognitive function.

**Ariboflavinosis**

In order to prevent riboflavin deficiency, the body needs between 1.2
and 1.6 mg of riboflavin per day.

Primarily seen in this disease is a sometimes sore**, non-painful
tongue**. The tongue takes on a magenta hue, becomes edematous and
inflamed, making it difficult to eat and swallow.

Also characteristic of this disease is stomatitis, an inflammation of
the lining of the mouth, and cheilitis, an inflammation of the lips. The
chelitis may be unilateral, but is usually bilateral. This inflammation
at the corners of the mouth is very painful and the affected individual
has a difficult time fully opening his mouth. Secondary bacterial
infection is common. The inevitable result of cheilitis is scarring and
strictures at the corners of the mouth, which cause a decrease in the
buccal aperture, termed microstomia. The normal buccal aperture in a man
is 5.8 cm + ‑ 0.4 cm. Anything less than this, with evidence of
scarring, may represent a history of ariboflavinosis.

In addition, the facial skin may take on a roughened or shark-like
appearance, termed icthyosis. The patient may have a sore throat with
hyperemia and edema of the pharyngeal and mucous membranes. The cornea
is also a target of the epithelial changes. The capillaries proliferate,
exudates form and ulcerations of the cornea are common late in the
course of an untreated case.

Finally, a pure red cell aplasia develops in many patients and is
manifested by a normocytic normochromic anemia. Cognitive dysfunction
has been correlated with low levels of vitamin B~2~.

**Pellagra**

Pellagra is disease recognized in ancient writings in the Middle East
caused by a deficiency of the water-soluble Vitamin B-3, Niacin in the
diet. Deficiency of niacin or nicotinic acid in the diet produces
pellagra, Italian for pelle, meaning skin, and agro, meaning rough. The
disease was first seen in Europe after the importation of maize from the
New World when corn became the primary caloric source. It was common in
the American South due to a diet heavy in the three Ms: meat, meal and
molasses. Dr. Goldberger of the US public health department was the
first to recognize it as a deficiency disease and not one caused by an
infectious etiology based upon his study of orphanages in rural
Mississippi.

Excellent sources of niacin are yeast, beef, pork, fruit, most
vegetables and grain cereals. Niacin is needed in the amount of 12 to 18
mg per day. .Human intestinal bacterial flora can convert tryptophan
into niacin in the presence of **vitamin B‑6, (pyridoxine**) if B-6 is
present. The disease of Pellagra was unknown in Europe until corn was
imported from the Americas. Once it was recognized, it was felt for
centuries to be an infectious disease. Refined and milled maize contains
less tryptophan and nicotinic acid than whole meal maize flour obtained
from pounding the maize into flour. Although maize contains more
nicotinic acid than oats, rye and some wheats, most is in a bound form
unusable to the patient. Furthermore, zein, the protein of maize, is
deficient in tryptophan. Corn is also high in leucine, which further
antagonizes the body\'s ability to absorb niacin.

The disease is also seen in patients with carcinoid syndrome, as the
tryptophan is used by the carcinoid cells and converted to serotonin.
Secondary pellagra is occasionally seen in patients on poor diets given
isoniazide and not supplemented with pyridoxine. Herein isoniazide
antagonizes pyridoxine necessary for the conversion of tryptophan to
nicotinamide. Finally, pellagra is seen in poorly fed dialysis patients
on no B vitamin supplements

In addition to the numerous cases of Pellagra among ex-POWs of the
Japanese, Pellagra was also especially prevalent in the POWs in Korea,
where the diet was primarily corn, millet or sorghum, all of which are
practically devoid of usable niacin

For simplicity\'s sake, pellagra is known as the disease of the three
D\'s, **diarrhea, dermatitis and dementia**. Often the Fourth D, Death,
was a complication Both riboflavin and niacin are needed by the body for
the electron transport chain in respiration and in the generation of
water and carbon dioxide. As opposed to many other of the vitamin
deficiencies, Pellagra does not seem to cause anemia.

The diarrhea results from pathologic changes involving primarily the
esophagus, stomach and colon. The changes here are very similar to those
found in the skin, namely erosive, weeping lesions in affected areas.
These ulcerations further decrease the absorptive surface area for what
little nutrients are in the diet.

The dermatitis is symmetrical with sharply demarcated borders, and worse
on the sun‑exposed or trauma‑exposed areas of the body. Initially the
dermis becomes erythematous, hyperemic and thickened. Later, there is a
desquamation of the epidermis with denuding of the superficial layers
and ulcer formation underneath. The chronic effects of this are
strictures, chronic infection and hyperpigmentation in the affected
areas of the body.

The tongue is also involved in pellagra. It may appear deeply fissured,
scarlet and be raw and be very painful.

The skin is involved in Niacin deficiency with the **characteristic
sharply demarcated margins** of prior sun exposure assisting in the
diagnosis. Initially, the skin is erythematous and has a thickened,
scaly appearance. Later, chronic inflammation and edema result in
desquamation or ulceration yielding hypopigmentation. Finally, the skin
thickens as a result of subcutaneous fibrous deposition and becomes
hyperpigmented. The changes in the anterior neck look as if the patient
has a necklace, termed Casal's necklace, named after the Spanish
physician who first described it. The chronic dermatitis in the hands is
known as pellagrous glove.

The **central nervous system effects** are consistent with a central
neuritis, primarily affecting large cells of the motor cortex. Also seen
is a symmetrical degeneration of the dorsal column, with effects very
similar to B‑12 deficiency, namely loss of position and vibratory sense.
In addition, cortico-spinal tract and spinothalamic tract involvement
occurs as would be seen in beriberi producing sensations of numbness and
dysesthesias. In fact, the neurologic manifestations of this disease are
quite indistinguishable from beriberi. Some authors state that the
peripheral neurological sequelae of pellagra are present in about 75% of
the individuals involved. Early on, the central nervous system
manifestations affecting the brain consist of psychoneurosis, insomnia,
irritability, anxiety and depression, which are all reversible if
adequately treated. Later, the Betz cells are affected with central
nervous system neuritis producing a psychosis that is irreversible
despite supplementation with massive doses of niacin.

Nicotinic acid deficiency encephalopathy presents with an impaired
consciousness progressing to coma, extra‑pyramidal rigidity, tremors and
uncontrollable grasping and sucking reflexes representing frontal
release signs.

The **treatment** is niacin replacement. The skin is generally quite
responsive; the strictured and hyperpigmented areas from long‑standing
niacin deficiency do not respond to therapy but the early lesions do.
The gastro‑intestinal tract at least superficially completely
regenerates, often leaving scars. The glossitis dissipates and finally
disappears. The sensory system, at least partially, recovers
peripherally and the patient regains much sensation. However, often,
there are residual peripheral sensory defects. In general, the dementia
is unresponsive to therapy and the affected individual usually succumbs
to starvation and disease. In many POW camps, no work meant fewer
rations, just the opposite of what was needed for recovery. In the
Philippines, the American physicians would grow cultures of yeast from
the air and give affected patients a spoonful daily with excellent
results. Since only a small amount was available on a daily basis, only
the most severely affected patients were treated.

**Folate**

Deficiency of folic acid, Vitamin B-9 is common among all malnourished
people. The vitamin is present in ample quantities in leafy green
vegetables, nuts, legumes and fruits. Human intestinal flora also
synthesizes a tremendous amount. Unfortunately, folate is very heat
labile and cooking food will destroy the ability of the vitamin to work.
It is necessary for the synthesis of purines, and its absence hinders
DNA production and maturation, hence the RBCs produced by the bone
marrow are immature, large and easily burst when introduced into the
peripheral circulation. Folate deficiency causes no long-term sequalae.

**Scurvy**

Scurvy is a deficiency of ascorbic acid, Vitamin C, which is a
water‑soluble and heat‑sensitive vitamin. Scurvy was seen regularly in
the concentration camps of Europe and in some POW camps, primarily in
the Pacific. The need for this vitamin in daily life is becoming
increasingly obvious. This vitamin is essential for the formation of
collagen, ground substance, osteoid, dentine and intercellular cement
substance. Cooking food to any degree destroys the usefulness of this
vitamin. Humans lack the ability to produce the vitamin and therefore,
are wholly dependent on fruits, vegetables, fish, and dairy products.
Deficiency occurs mainly in the elderly on poor diets, breast-fed
infants ages six to 12 months, the malnourished, the critically ill, and
alcoholics.

Vitamin C is rapidly absorbed in the intestines and therefore deficiency
usually represents malnutrition rather than intestinal pathology.
Because the vitamin is ubiquitous in most fruits and the body retains a
large supply, clinical deficiency suggests a long period of deprivation.
Vitamin C is susceptible to heat, cooking in water, and extended
exposure to room temperature.

The major signs of deficiency are nosebleeds, melena, hemarthrosis,
subperiosteal hemorrhages, loose teeth, bleeding gums, and ecchymoses.
Eighty percent of patients with scurvy are anemic. Blood loss is thought
to occur primarily through lesions in the gastrointestinal tract. The
anemia is in addition to blood loss alone, hematologic studies reveal
variable presentations in both the peripheral smear and the bone marrow.

**Lipid Soluble Vitamins**

Vitamins A, E, D and K are lipid‑soluble. Their transportation across
the intestinal mucosa is extremely decreased in steatorrhea, a common
occurrence in gastrointestinal infections.

**Vitamin A Deficiency**

Vitamin A deficiency is the most common nutritional cause of blindness
in the world. Vitamin A is needed in relatively small doses in the diet,
around 5000 IU per day in the average adult. Vitamin A is tenaciously
stored in the Liver and a deficiency in the primary state takes months
of no vegetables and no dairy products to become manifest. It is seen
more frequently as a secondary condition due to malabsorption

The first alteration in vision is a decrease in dim light acuity. This
is associated with dryness and ulcerations of the cornea. Skin changes
resembling goose bumps also appear, these will not disappear when
rubbed.

After dim light acuity is altered, later changes in the conjunctival
mucosa are seen, referred to as Bitot\'s spots. These are keratin debris
deposited on the limbal conjunctiva. As these aggregate, total blindness
ensues.

Most individuals with Vitamin A deficiency develop a hypochromic,
microcytic anemia. Plasma levels of Vitamin A correlate with hemoglobin
concentration. In general, the lower the level of Vitamin A in the
serum, the lower the hemoglobin level. In developing countries, Vitamin
A deficiency is thought to be as common a cause of anemia as iron
deficiency.

In addition, the cells in the body\'s linings and coverings undergo a
**squamous metaplasia**. The result is xerophthalmia of the conjunctiva,
keratomalacia of the cornea, follicular hyperkeratosis in the skin, loss
of cilia in the bronchial tree later predisposing to infections,
ureteral colic and possibly development of calculi in the urinary tract.
Bitot\'s spots affect the limbal conjunctiva.

# Overlap Syndromes

Dr. Gottlieb\'s observations of **Malnutrition‑related liver disease**
in Cabanatuan were as follows: this entity initially begins as a fatty
liver and later predisposes individuals to infectious hepatitis.
Cirrhosis also commonly developed in men with no prior alcohol history.
Affected individuals often developed gynecomasta as well as loss of the
characteristic male hair pattern.

Dr. Jacobs described the **Oculo‑Oro‑Genital Syndrome** in his POW camp
in Cabanatuan. This constellation of symptoms, affecting 75% of his
8,000 fellow internees, consisted of amblyopia accompanied with a
scrotal dermatitis manifested by erythema and pruritis, and later an
exfoliative dermatitis with ulcerations and painful glossitis,. He felt
that this syndrome was likely due to a combination of deficiencies of
Vitamin A and Vitamin B 3.

Dr. Jacobs also described the **Castration Syndrome**, a set of
conditions afflicting some men with the Oculo‑Oro‑Genital Syndrome and
consisting of loss of libido, total loss of body hair and loose, dry
skin.

**Strachen\'s Syndrome** was seen with some regularity in POWs of the
P.T.O. The primary symptoms are amblyopia, painful neuropathy, vertigo
and orogenital dermatitis.

**The Spinal Spastic Syndrome** was seen in many camps, with symptoms of
mental and emotional changes, dimness of vision, and later widespread
muscular rigidity, delirium, coma and death. In all likelihood, it is a
combination of deficiencies of Vitamins A, B 1 and B 3.

Other identifying features germane to the Spinal Spastic Syndrome
include weak legs, clonus, extensor‑plantar responses, absent abdominal
reflexes, increased deep tendon reflexes, and loss of position and
vibratory sense. Muscle pain, myocardiopathy and hemolytic anemia
manifest selenium deficiency, very common in Asiatic theaters.

**Gastrointestinal Diseases**

Gastrointestinal diseases were extremely common in all of the POW camps.
This was primarily due to the lack of hot running water and unsanitary
conditions such as open pit latrines and contaminated drinking water.

**The Irritable Bowel Syndrome**

The Irritable Bowel Syndrome is a complex mixture of organic disease
with psychological overlay affecting 1 in 5 Americans. It is defined as
a variable collection of chronic (greater than 3 months) and recurrent
symptoms not explained by structural or biochemical abnormalities. The
disorder may affect **anywhere in the GI tract**, from the mouth to the
anus. However, it primarily affects the large and small intestines.

It is a **diagnosis of exclusion**. Affected patients often present with
lower abdominal pains, disturbed defecation, alternating diarrhea and
constipation and bloating. In the US general population, 15% of people
are affected. There is no universal agreement as to the exact
pathophysiology, however altered intestinal motility is common. Stress
seems to promote an exaggerated response in susceptible individuals.
Also, visceral hyperalgesia a feeling of discomfort in the colonic areas
with painful provoking stimuli, is more pronounced in these individuals.
Also, there seems to be less cortical control over painful stimuli
traveling up the midbrain nocioceptive fiber tracts. Among patients
tested with a MMPI, 35% show hypochondrical tendencies, 25% reveal
depressive tendencies and 25% reveal hysterical tendencies.

Three different types appear to be present. The first, known as spastic
colitis, has increased gas, constipation and abdominal pain as the
primary symptoms. The second consists of chronic intermittent diarrhea
possibly related to the ingestion of foods or increased psychological
stress. The third is a mixture of the two, with alternating symptoms of
constipation and diarrhea.

**Peptic Ulcer Disease**

Peptic ulcer disease is defined as any ulceration along the esophagus,
stomach or duodenum caused by the actions of both hydrochloric acid,
secreted by the stomach, and the enzyme pepsin. This was very common in
many of the POW camps and had a very high incidence in the
post‑repatriation period as well.

According to data assembled by Nefzger regarding Peptic Ulcer disease,
the hospital admission rate per 1000 was 1.6 for PWJ versus 0.4 for WJ,
1.7 for PWE versus 0.0 for WE. For those service‑connected for Peptic
Ulcer disease, the figure is 4.2 for PWJ vs. 0.6 for WJ, 1.5 for PWE vs.
1.0 for WE and 4.0 for PWK vs. 0.7 for WK. Retrospective Canadian
studies verified the American findings. They analyzed all hospital
admissions between 1946 and 1964 regarding 100 ex-Far East POWs and
found 4 had had gastric ulcers and 13 had duodenal ulcers. This was
twice the Canadian rate for age matched populations. Australian studies
also revealed higher prevalence rates.

In general, this disease may be considered an infectious etiology with
the causative agent, **Helicobacter pylori,** identified in the drinking
water of these men. Anyone with a symptomatic infection has the
characteristic endoscopic finding of the surface epithelial layer of the
stomach becoming irregular with a cobblestone like appearance. Usually
seen is an active chronic gastritis, primarily involving the antrum, but
also of the fundus of the stomach. 70% to 80% of people with gastric
ulcer are Hp+ whereas 90% to 100% with duodenal ulcer are Hp+. A typical
ulcer has a crater with a necrotic covering over the crater. If not
treated, some ulcers may continue burrowing through the muscularis and
erode into an artery, at which time the individual can exsanguinate.

Helicobacter pylori, a micro-aerophilic aerobe, is spread by the
fecal-oral route with the major risk factors for spreading being: a lack
of soap, a lack of hot water and crowding and sharing of beds. Even
under the same conditions, blacks and Hispanics are more susceptible
than Caucasians to have symptoms from infection with the bacteria.
Therefore, any infected Caucasian should raise the suspicion of
acquisition of the bacterium in the POW camp under unsanitary conditions
with poor nutrition. Essentially, the bacteria enter the normally
sterile stomach and by using phospholipases, bury themselves under the
protective mucus coat. There, they secrete urease, which degrades urea
into ammonia and water. The ammonia combines with stomach acid and
neutralizes it thus allowing the bacterium to exist in an acid free
environment within the stomach. Catalase is secreted which protects the
bacterium against oxygen metabolites produced from the granulocytes. The
bacteria also secrete proteases which dissolve the stomach's own
proteins and provokes an inflammatory response in the host, which causes
the host to **increase gastrin production** the result of which, is to
increase hydrochloric acid production in the stomach. In addition, the
ammonia neutralizes much of the stomach's acidity diluting the normal
acid feedback mechanism. Therefore, a tremendous amount of acid is
produced in the stomach, which falls into the usually neutral duodenum
producing duodenitis and finally, an ulcer. Finally, a duodenal ulcer
forms. Almost 100% of all duodenal ulcers have been found to be infected
with this bacteria and 80% of patients with gastric ulcers have the
bacteria. Only 25% of individuals infected with H. Pylori develop
symptoms and even fewer develop a duodenal ulcer. Many other host
variables are therefore involved.

Infection with this organism has also been associated with gastric
cancer and the MALT or mucosa associated lymphoid tissue lymphoma.

**Hepatitis**

Hepatitis infections were very common in all POW camps. Unsanitary
conditions, poorly cooked food and contaminated water spread Hepatitis
A. The hepatitis can be quite severe, not usually life‑threatening in a
properly nourished individual but definitely life‑ threatening in a
poorly nourished individual. No chronic carrier state has ever been
demonstrated.

Hepatitis B is primarily seen with parenteral and sexual modes of
transmission; however rare documented cases have been seen in
individuals through the oral route. Chronic carrier states are seen in
this particular infection. Non‑A‑Non‑B Hepatitis, which includes
Hepatitis C, can also have a severe acute phase and can eventuate in a
chronic carrier state.

**Helminthiasis**

Helminthiasis is an intestinal infection caused by parasitic worms. The
Morgan Board examination studies found that 60 to 70% of the returning
POWs from the Philippines harbored intestinal parasites, usually ascaris
and hookworm.

**Strongyloides**

This intestinal nematode has a very complicated life cycle. Briefly, the
larval forms penetrate the skin, primarily in the feet. In penetrating
the skin, they cause a local inflammatory reaction. From the penetration
site they move into the lymphatic system and migrate to the lungs, where
they begin to mature. This, in most cases, causes an eosinophilia.

Once in the lungs, they migrate through the alveoli and mature further.
They migrate up the main‑stem bronchi and are swallowed. They withstand
degradation by stomach acid, mature in the duodenum and burrow into the
wall. Here the female is inseminated by the male and produces her
fertilized eggs. In studies of Far‑East‑POWs of the British, upon
wet‑prep examination of duodenal aspirates, viable parasites were found
in up to 27% of studied individuals up to 40 years after repatriation.
The parasite can auto‑reinfect the host and possibly remain viable
forever. In addition, an area of chronic inflammation is always present
with unknown long‑term sequelae.

In this slide, both the male and female are present in the colonic
villus along with an ovum.

As can be seen here, the parasites in the duodenum have a tiny whitish,
threadlike appearance.

**Ascaris Lumbricoides**

Ascaris lumbricoides, also known as the giant round worm. The fertilized
eggs are spread by fecal contamination of the soil. The eggs enter
through the mouth, mature in the intestine, migrate through the
intestinal wall, enter the lymphatic system and develop in the lungs.
Similar to the life cycle of other worms, the mature forms migrate up
the trachea, are swallowed again back into the esophagus, enter the
small intestine and attach to the walls of the small and large
intestines. When mature, these worms are usually twelve to fifteen
inches long.

Heavy infestations of one's colon by these parasites may cause a severe
malabsorption syndrome limiting use of available foodstuffs or even
worse, an intestinal obstruction, a common way to die in POW camp.

**Ancyclostomiasis**

Ancyclostomiasis, also known as hookworm.

As can be seen, the buccal capsule of this particular worm has an
aggressive appearance and hence the name of this parasite. A heavy
infestation of ones colon can be associated with blood loss of up to 100
CC a day. These parasites derive both their oxygen and glucose supply
from the host\'s blood.

Their life cycle is similar to that of Strongyloides in that they
penetrate unprotected feet and migrate in the lymphatics to the lungs
where they traverse through the alveolar sacs. Here, they mature and
migrate up the trachea, are swallowed and become attached to the wall of
the duodenum. Heavy infestations with this parasite decrease the
absorptive surface area of the duodenum.

These worms eventually succumb to host defenses that eliminate them, and
they are not able to propagate a chronic carrier state like
Strongyloides.

**Salmonella Typhi**

The bacteria Salmonella typhi was one of the most common of all
intestinal infections.

The bacteria Salmonella typhi produce the disease known as typhoid fever
which is spread by the fecal‑oral route, primarily due to contaminated
water. This disorder usually produces a self‑limited illness, however in
individuals who are malnourished any presentation is possible. The
host\'s defenses attempt to ingest these bacteria in the phagocytes.
Unfortunately for the host, these bacteria are able to withstand
bactericidal degradation, and intracellular multiplication takes place.
It is the involvement of the Peyer\'s patches in the intestinal wall
that causes the general destructive nature of this disease. In addition
to the intestinal involvement of the immune system, these bacteria also
secrete an endotoxin, causing secretory diarrhea. Most patients
experience a profuse watery diarrhea. In some extremely malnourished
individuals, systemic dissemination of the typhoid bacilli may localize
in any tissue of the body with the production of a localized suppurative
infection.

Approximately one third of infected individuals are asymptomatic; in
another third, the diarrhea is primarily watery, and in the final third
frequent watery, bloody feces are the initial presentation. Severe
infection is accompanied by a malabsorption syndrome, primarily of the
fat‑soluble vitamins A, E, D and K. The endoscopic view of infected
colonic mucosa reveals superficial ulcerations over the entire bowel
mucosa, a common presentation of advanced disease. Necrotic sloughing of
the superficial layers and immense blood loss are also common in more
advanced cases.

**Shigella**

The fecal-oral route, primarily contaminated water and food also spread
shigella.

This disease is also known as bacillary dysentery.

The symptoms here consist of mild, watery diarrhea in the majority of
individuals. In a malnourished state, however, virtually any colonic
presentation is possible, and severe dysentery can occur. A very high
fever, cramping abdominal pain and tenesmus accompany almost all cases.

As viewed thru the endoscope, Shigella colitis can mimic ulcerative
colitis with large ulcerative lesions, friable‑looking intestinal
colonic mucosa and extensive hemorrhagic areas.

**Amebiasis**

Consuming contaminated water spreads amebiasis, caused by the motile
single-celled parasite Entamoeba Histolytica. This unicelled organism
lives primarily on fecal debris and bacteria found in the colon. Some
particular strains have an affinity for burrowing through the intestinal
wall and do so in certain individuals for unknown reasons. They produce
a small ulceration on the intestinal surface, with a much larger lesion
underneath, creating an almost bottle‑shaped deformity. The colonic
mucosa between affected areas appears normal.

The prognosis in affected individuals may be severe scarring and an
irritable colon. Uncomplicated infection readily responds to treatment;
unfortunately little immunity is conferred by this infection and
recurrences are frequent.

As viewed from the endoscope, discrete ulcers are a hallmark of this
disease.

**Giardiasis**

A multiflagellar protozoan that parasitizes the duodenum and the jejunum
causes giardiasis. It attaches to the mucosa by means of a ventral
suction disc. The parasite forms cysts and is transmitted by the
fecal‑oral route. It is a major cause of diarrhea in Third World
Countries.

The symptoms of this disorder are an explosive, watery diarrhea and
right‑upper‑quadrant pain. Occasionally, in heavy infestations,
malabsorptive syndrome results due to a decrease in the absorptive
capacity of the small intestine, particularly for fats and
carbohydrates, further inhibiting the absorption of vitamins A, E, D and
K.

Most patients produce a tremendous amount of intestinal gas resulting in
abdominal discomfort and flatulence. They stay nauseated, which leads to
anorexia, further depleting energy reserves. Their stools are foul
smelling and greasy. This infection is rarely chronic and recovery is
usually complete.

**Cold Injury and Frostbite**

Frostbitten feet were very common in POWs of Europe, POWs of the
Japanese who were transferred to northern Japan, Manchuria and Korea,
and POWs of the Korean conflict. Several factors predispose to
frostbite. The most important is heat loss rather than heat gain. 80% of
total body heat loss can result from an uncovered head and neck. Wetness
accelerates heat loss through convection. Fatigue and being in combat
over 30 days is also a major risk factor. Blacks are more susceptible to
frostbite than whites. Finally, poor nutrition is very important.

Frostbite injuries are classified according to degree. Numbness,
erythema and white or yellow plaques usually characterize
**first-degree** frostbite injuries. **Second-degree** frostbite
injuries are associated with epidermal injury and the formation of
superficial skin vesicles with clear fluid. Dermal involvement and
deeper blisters containing bloody fluid characterize **third degree**
frostbite injuries. **Fourth degree** frostbite injuries produce
transdermal destruction with mummification primarily involving muscles,
tendons and joints.

This cross section of skin shows, schematically, the depth of injury in
1st, 2nd and 3rd degree frostbite.

The course of the pathology is as follows: from zero to three hours
following the injury, edema forms; vesicles, or blebs, appear within six
to twenty‑four hours. Over the next several days, the blebs rupture and
eschars form. It is much better for the individual to have a deeper
injury, that occurs once and is adequately treated, than to have
superficial injuries which thaw out, re‑freeze and re‑thaw, because it
is the recurrent freezing and thawing that causes the severe damage.
This freeze‑thaw cycle was responsible for the deaths of so many of
Napoleon\'s troops when retreating from the Russians.

The clinical appearance of frostbite is often deceptive when evaluating
its severity. Color variations range from white, yellow‑white to mottled
blue. Examination of the extremity reveals it to be cold, hard or waxy
to the touch. Most patients complain of numbness and some report
decreased or absent sensation to the touch. Upon rapid rewarming the
extremity usually responds with flushing. Approximately 75% of those
individuals who complained of numbness describe a severe pain upon
rewarming. Sensation usually returns soon after thawing and continues
until the formation of blebs. Edema usually appears within three hours
of rewarming, and vesicles form within six to 24 hours. These blisters
usually rupture within three days and scab over. Associated symptoms
then include various degrees of pain, tingling, burning and electrical
shock‑like sensations that last months and often longer.

The injury in frostbite is due to the formation of ice, both
intra‑cellularly and extra‑cellularly. In general, extra‑cellular ice
forms first. The formation of ice in the extra‑cellular spaces will, in
effect, pull fluids and electrolytes out of the cells resulting in cell
dehydration and shrinkage. Furthermore, alterations in intracellular
lipids and electrolytes occur, and massive protein damage results. As
this proceeds, microvascular injury occurs which is often irreparable.

The prognosis is favorable if, after rewarming, the affected extremity
regains sensation, warmth and normal color, and if large clear blebs
form early on and extend to the tips of the affected digits. This
indicates that no severe damage was done to blood vessels. A poor
outcome is associated with small blisters that are bloody, appear blue,
do not extend to the tips of the affected digits, and no swelling is
involved in the extremity. This indicates that blood vessels have been
irreparably damaged and gangrene is setting in.

This is a second-degree frostbite injury with hyperemia, obvious edema
and black eschars in the acral areas.

This depicts third degree injury with full thickness skin involvement
and some extension into the subcutaneous tissues.

This slide depicts fourth degree injury, with mummification of the
digits of the right hand.

The long‑term effects of frostbite range from non‑existent to severe. In
order of decreasing frequency, long-term symptoms include pain, cold
sensitivity, numbness, excessive sweating, tingling and burning. Nerve
conduction tests performed shortly after the frostbite have consistently
revealed injury, however no long‑term studies have been performed to
verify permanent damage. Physical findings often reveal persistent nail
abnormalities as well as scarring and skin discoloration. If the
freezing was deep enough, joints may have been involved, with the
development of osteoarthritis.

The skeletal changes may take months to become manifest and include
osteoporosis, cysts and joint‑space narrowing. In all likelihood,
temporary interruption in blood flow to the subchondral bone leads to
degeneration of the articular cartilage and loss of joint space. If the
patient presents with these changes, and they are confined to the
extremities, he is likely to have osteoarthritis as a result of
frostbite.

**The Psychiatric Presumptive Service Connected Disabilities**

The psychiatric presumptive service connected disabilities are quite
numerous and well beyond the scope of this presentation, nevertheless, a
brief description is provided to the reader. From my personal
experience, many of these men have been active and independent in their
lives. Now, with the loss of loved ones, or their good health, many
decompensate, especially when they are forced to rely on others to
provide their care. This often produces flashbacks to the POW experience
in otherwise psychologically healthy individuals. PTSD and dysthymia are
very common and should be recognized for what they are and
compassionately treated.

**Psychosis**

The first presumptive is Psychosis, narrowly defined as delusions or
prominent hallucinations occurring in the absence of insight into their
pathological nature.

**Panic Disorders**

According to DSM-IV PANIC DISORDERS are recurrent unexpected panic
attacks lasting at least one month or longer with several different
diagnostic criteria. It can be either with or without agoraphobia but
not due to the direct effects of a chemical substance or medical
condition. Also, it should not be better accounted for by another mental
disorder.

**Generalized Anxiety Disorders**

Generalized Anxiety Disorder is an excessive anxiety with worry
occurring more days than not for at least six months with several
different characteristic symptoms. The anxiety causes significant
distress or impairment in every day function but not due to the direct
effects of a chemical substance or medical condition. Also, it should
not be better accounted for by another mental disorder.

**Obsessive-Compulsive Disorder**

Concerning the Obsessive-Compulsive Disorder, obsessions are defined as
recurrent and persistent thoughts, impulses, or images that are
experienced as intrusive and inappropriate and not simply excessive
worries about real life problems. The person attempts to ignore these
thoughts and realizes they're a product of his or her own mind.
Compulsions are repetitive behaviors or mental acts that the person
feels driven to perform in response to an obsession or according to
rigidly applied rules. These behaviors have as their aim preventing or
reducing stress or preventing some dreaded event. The person has
recognized the obsessions or compulsions are excessive and may cause
marked distress and are time consuming. The obsession or compulsion is
not due to the direct effects of a chemical substance or medical
condition. Also, it should not be better accounted for by another mental
disorder.

**Post Traumatic Stress Disorder**

In Post Traumatic Stress Disorder the affected individual experienced,
witnessed, or was confronted with scenarios that involved actual or
threatened death or serious injury or a threat to the physical integrity
of self or others. The person's response involves intense fear,
helplessness, or horror. The traumatic event is presently re-experienced
in multiple different ways including recollections and dreams of the
event. The affected individual persistently avoids stimuli associated
with the traumatic event as indicated by several different criteria. The
effected individual also has persistent symptoms of increased arousal,
which were not present before the trauma as indicated by several
different criteria. The duration of the disturbances is more than
one-month and the disturbance causes clinically significant distress or
impairment in social, occupational, or other important areas of
functioning. Acute symptoms are less than three months in duration.
Chronic symptoms are greater than three months in duration. Symptoms
with delayed onset are at least six months after the stressor.

**Anxiety Disorder not otherwise specified**

Anxiety Disorder Not Otherwise Specified is a mixed anxiety-depressive
disorder wit clinically significant symptoms of anxiety and depression
not meeting criteria for a specific Mood Disorder or a specific Anxiety
Disorder.

**Dysthymic Disorder**

Dysthymic Disorder is characterized by a depressed mood for most of the
day, for more days than not, as indicated either by subjective account
or observation by others for at least 2 years and without the symptoms
for more than two months at a time. The presence of specific diagnostic
criteria are necessary. And the disturbance is not better accounted for
by chronic major depressive disorder, active or in partial remission.
The symptoms are not due to the direct physiological effects of a
chemical substance or a general medical condition. The early onset of
the disease occurs before the age of 21. Delayed onset of the disease
occurs at the age of 21 or older and the disease may have atypical
features.

**Peripheral Neuropathy**

In Greek literally means the suffering of nerves outside of the brain
and spinal cord. Among former POWs, there are several different causes
of peripheral neuropathy, such as vitamin, essential fatty acid and
selected mineral deficiencies. Infections such as leprosy are the most
common cause of neuropathy in the world. Other causes to be considered
are various toxins such as lead, copper and mercury, a hereditary
pre-disposition to neuropathy, deposition of amyloid, and multiple other
less common causes.

In conclusion, the American ex-POW has been exposed to an almost
incomprehensible array of treatments. The torture, starvation diet, cold
and filth exposure has left permanent scars in the survivors. The
purpose of this program has been to enlighten all those so honored to be
associated with the American ex-POW as to the most statistically common
conditions, which may affect any one ex-POW. However, bear in mind that
many other conditions are possible on an individual basis. And although
not intended to be an all inclusive in depth authority on all aspects of
the POW experience, this program along with the DSM-IV and the following
bibliography completes the most concise reference yet assembled.

***References***

# GENERAL HISTORICAL

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2.  Faulk, S, Bataan, [The March of Death]{.underline}, Jove
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3.  Davis, Gavan, [Prisoners of the Japanese, POWs of WW II in the
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4.  Knox, Donald, [Death March, The Survivors of Bataan]{.underline},
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5.  Hibbs, Ralph, [Tell MacArthur To Wait]{.underline}, Carlton Press,
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6.  Morris, Eric. [Corregidor, The End of the Line]{.underline}. Stein
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7.  Waldron, B and Burneson, E, [Corregidor, From Paradise to
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8.  [History of the Defenders of the Philippines Guam and Wake
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9.  [The Japanese Story]{.underline}, American ex-POW national Medical
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10. Norman, Elizabeth M. [We Band of Angels The Untold Story of American
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11. Donovan, William. POW in the Pacific. [Memoirs of an American Doctor
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12. Grady, Frank. [Surviving the Day]{.underline}. Naval Institute
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13. Smith, Stanley. [Prisoner of the Emperor]{.underline}. University
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16. Coone, Herbert W. [The Sequential Soldier]{.underline}. Gateway
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17. Kerr, E Bartlett. [Surrender and Survival. The Experience of
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18. Ingle, Don[. No Less a Hero]{.underline}. Privately printed, 1991.

19. Skelton, WP III and Skelton, NK*. American Women as Prisoners of the
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21. Sommers, Stan. [The European Story]{.underline}. American Ex-POW
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22. Whiting, Charles. [Death of a Division]{.underline}. Stein and Day.
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23. Turbak, Gary. *Death March Across Germany*. VFW Magazine. April,
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24. Barker, AJ. [Behind Barbed Wire]{.underline}. London, BT Batsford
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25. Caplan, Leslie. [The Wild Blue]{.underline}. G. P. Putman and Sons.
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26. Sommers, Stan. [The Korea Story]{.underline}. American Ex-POW Inc.
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27. Pow-key, Sohn. [The History of Korea]{.underline}. Korean National
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28. Klozik, Paul. POW Legacy of Paul Anthony Klozik. The Korean War
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29. Kim, Key-Hiuk. [The Last Phase of the East Asian World
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30. Snyder, DJ. [A Soldier's Disgrace]{.underline}. Yankee Books. NH.
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31. Culbertson, Ralph. [The Korean War A Former POW's
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32. Zellers, Larry. [In Enemy Hands A Prisoner in North
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33. American national red Cross*. Report of Joint Red Cross Team
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34. Anderson, C, Boysen A et al. [Medical Experience in Communist POW
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35. Blakey, Scott, [Prisoner at War, The Survival of Commander
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36. Alvarez, E and Pitch, A, [Chained Eagle]{.underline}, Donald Fine,
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37. Katz, Susan. *The Long and Costly Stay in the Hanoi Hilton's Cells*.
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38. Stratton, Richard. The Boat School Boys. *Tales from Southeast
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39. Stratton, Richard. The Man Who Would Be King*. Tales from Southeast
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40. Rowe, James. [Five Years to Freedom]{.underline}. Ballentine Books,
    New York 1971.

41. Rochester, S. and Kiley, F. [Honor Bound The History of American
    Prisoners of War in Southeast Asia, 1961-1973]{.underline}.
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    DC, 1998.

42. Skelton, WP*. Repatriated Prisoners of War: Tallying the Tolls from
    each Theater.* VA Practitioner. Vol. 9:669-75. June 1992.

**GENERAL MEDICAL**

1\. Cohen B and Cooper M. *A Follow‑Up Study of World War II Prisoners
of War*, Washington D.C.: VA Medical Monograph September 1954, 1‑81.

2\. Nezfger D. *Follow‑Up Studies of World War II and Korean War
Prisoners, I. Study Plan and Mortality findings*, American Journal of
Epidemiology, Vol. 91, No. 2, 1970, 123‑138.

3\. Beebe G. *Follow‑Up Studies of World War II and Korean War
Prisoners, II: Morbidity, Disability, and Maladjustments*, American
Journal of Epidemiology, 1975, 101:5: 400‑422.

4\. Keehn R. Follow‑*Up Studies of World War II and Korean War
Prisoners, III: Mortality to 1 January 1976*, American Journal of
Epidemiology, 1980, 194‑211.

5\. [POW, Study of Prisoners of War]{.underline}, Veteran's
Administration Monograph, 1980.

6.  Page WF. [The Health of Former Prisoners of War. Results from the
    Medical]{.underline} Examination [Survey of Former POWs of World War
    II and the Korean]{.underline} [Conflict]{.underline}. Medical
    Follow‑Up Agency Institute of Medicine. National Academy Press 1992,
    1‑123.

7.  Freed, G and Stringer, P. *Comparative Mortality Experience
    1946-1963 Among Former Australian POWs of the Japanese*. Medical
    Research Bulletin. 2:4-28, 1968.

8.  Diem, C and Richen, M *Dental Problems in Navy and Marine Corps
    Repatriated prisoners of War Before and After Captivity*. Report \#
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9.  Kelnhofer, Guy J. [Life After Liberation. Understanding the Former
    Prisoner]{.underline} of [War.]{.underline} Banfil Street Press. St.
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10. Skelton WP. [Prisoners of War: The American Experience]{.underline}.
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11. Skelton WP & Skelton, NK*. Environmental Trauma in Former Prisoners
    of War.* Federal Practitioner, Vol. 12:5, pp. 42-47. May 1995.

12. Skelton WP & Skelton NK. *Disabilities in Women Prisoners of War of
    the Japanese.* American Ex-POW Bulletin. July 1995. Pp/23-24.

13. Morgan, H., Wright, A and Von Ravensway, R. *Health of Repatriated
    POWs from the Far East*. JAMA 130:13:995. 1946.

14. Guest CS, Venn AJ. *Mortality of Former Prisoners of War and Other
    Australian Veterans.* The Med. Journal of Australia. 1992: 157:
    132-135.

15. Venn AJ, Guest CS*. Chronic Morbidity of Former Prisoners of war and
    Other Australian Veterans*. The Med Journal of Australia. 1991: 155:
    705-712.

16. Berg, W and Richlin, M. *Injuries and Illnesses of Vietnam War
    POWs*. Military Medicine. 142: 514-518. 1977.

**PERIPHERAL NEUROPATHY**

1\. Gill GV, Bell DR*. Persisting Nutritional Neuropathy amongst Former
War Prisoners. Journal of Neurology, Neurosurgery and Psychiatry*. 1982:
45:861‑865.

2\. Hong CZ. *Electrodiagnostic Findings of Persistent Polyneuropathies
due to Previous Nutritional Deficiency in Former Prisoners of W*ar. VA
Practitioner. 1987: 63‑68.

3\. Hong CZ. *Peripheral Neuropathy in Former Prisoners of War*. VA
Practitioner. 1987:63‑68.

4\. Katz CJ*. Neuropathologic Manifestations Found in a Japanese Prison
Camp.* Journal of Nervous and Mental Diseases. 1946: 103:5:456‑463.

5\. LeQuesne PM. *Persisting Nutritional Neuropathy in Former War
Prisoners*. Br. Med. J. 1983: 286: 917‑918.

6\. Lewis RB. *Painful Feet in American Prisoners of War*. U.S. Armed
Forces Medical Journal. 1950: 1:2:146‑157.

7\. Takahashi K and Nakamura H*. Axonal Degeneration in Beriberi
Neuropathy*. Arch. Neurol. 1976; 33:836‑841.

8.  Adams, R. and Victor, M. *Nutritional Polyneuropathy* In [Principles
    of Neurology]{.underline}. 2^nd^ ed. McGraw Hill, New York, pp.
    711-713. 1981.

9.  Cruickshank, EK*. Painful feet in Prisoners of War in the Far East,
    Review of 500 cases*. Lancet 111:369-372. 1946.

**AVITAMINOSIS/RELATED SYNDROMES**

1\. Alleman R, Stollerman G. *The Course of Beriberi Heart Disease in
American Prisoners of War in Japan*. Annals of Internal Medicine, 1948;
28:949‑962.

2\. Burgess R.C. *Deficiency Diseases in Prisoners of War at Changi,
Singapore*. Lancet, 1946: 411‑418.

3\. Bloom, S and Mertz, E*. Nutritional Amblyopia in American POWs
Liberated from the Japanese* . Amec. J. of opthalmology. 29: 1248-1257.
1946.

4\. Cruikshank EK. *Painful Feet in Prisoners of War in the Far East*.
Lancet, 1946: 369‑372.

5\. Fischback W*. Cardiac and EKG Observations on American POWs
Repatriated from Japan*. 1948: 48:1:69‑74.

6\. Gill GV, Bell DR. *The Health of Former Prisoners of War of the
Japanese*. Practitioner. 1981; 225:531‑538.

7\. Gottlieb ML. *Impressions of POW Medical Officer in Japanese
Concentration Camps,* Naval Medical Bulletin. 1946: 46:5:663‑673.

8\. Hibbs RE. *Beriberi in Japanese Prison Camp*. Annals of Internal
Medicine. 1946; 25:2:270‑282.

9\. Jacobs EC. *Effects of Starvation on Sex Hormones in the Male*.
Journal of Clinical Endocrinology. 1948: 8: 227‑232.

10\. Jacobs EC*. Gynecomastia Following Severe Starvation*. Ann. Intern.
Med. 1948: 28: 792‑796.

11\. Jacobs EC. *Oculo‑Oro‑Genital-Syndrome. A Deficiency Disease*. Ann.
Intern. Med. 1951: 35: 1049‑1054.

12\. Morgan HJ, Wright IS and Ravensway AJ. *Health of Repatriated
Prisoners of War from the Far East*. Journal of the American Medical
Association. 1946: 995‑999.

13\. Musselman MM. *Nutritional Diseases in Cabanatuan.* War Medicine.
1945: 8: 325‑332.

14\. Nardini JE. *Vitamin Deficiency Diseases in Allied Prisoners of War
of the Japanese.* Naval Medical Bulletin. 1947: 2:273‑278.

15\. Skelton WP. *Avitaminosis in Former Prisoners* of War. VA
Practitioner. 1990: 7:3: 103‑109.

16\. Sable, H. [Thiamine: Twenty Years of Progress]{.underline}, Annals
of the New York Academy of Sciences, Vol. 378. 1982.

17. Monthly Progress Report, Section 7: Health Army Service Forces, US
    War Department, Washington, D.C., pp. 14-16, 1/31/46.

18. Harris, BR and Stephens, MA. *Experiences at Nagasaki, Japan*.
    Connecticut Medical Journal. 9:913-917. 1945.

19. Artas, M and Hanley, D. *Fulminant Beriberi Heart Disease with
    Lactic Acidosis: Presentation of a Case*. Circulation. 58:566-572.
    1978.

20. Brown, Charles. *The Japanese POW Syndrome*. Diseases of the Nervous
    System. 10:1. 1949.

21. Coke, LR. *Late Effects of Starvation*. Canadian Services Medical
    Journal. 17:313-324. 1961.

**POST TRAUMATIC OSTEOARTHRITIS**

1\. Skelton WP, Skelton NK*. Post Traumatic Osteoarthritis*. American
ex‑POW Bulletin. 1993; 50: 10: 21‑23.

2\. Skelton WP, Skelton NK. *Post Traumatic Osteoarthritis*. Consultant,
1994: 34: 11: 1619

3\. Soren A., Klein W*. The Synovial Changes in Post Traumatic Synovitis
and Osteoarthritis*. Rheumatology and Rehabilitation. 1978: 17:1:38‑45.

4\. Pinals, RS*. Disruptive Articular Trauma: Post Traumatic
Osteoarthritis. In: Arthritis and Allied Conditions*, McCardy, AJ, Ed.
Eleventh Edition. Lea & Febiger, Philadelphia, 1989; 1574.

**ISCHEMIC HEART DISEASE**

1 Adena MA. *The Health of Australian Veterans*. Med J Australia. 1989:
150: 356‑357.

2\. Eberly RE, Engdahl BE. *Prevalence of Somatic and Psychiatric
Disorders Among Former Prisoners of War*. Hosp. Community Psychiatry.
1991: 42: 807‑813.

3\. Fred G, Stringer PB*. Comparative Mortality Experience, 1946‑1963,
Among Former Australian Prisoners of War of the Japanese*. Aust. Repat.
Dept. Med. Bull. 1968: 2: 28.

4\. Gill G. *Study of Mortality and Autopsy Findings Amongst Former
Prisoners of the Japanese.* J.R. Army Medical Corps. 1983: 129: 11‑13.

5.  Gill GV, Bell DR. *The Health of Former Prisoners of War of the
    Japanese*. Practitioner. 1981: 225:531‑538.

    Gill, GV, Henry L. *Chronic Cardiac Beriberi in a Former Prisoner of
    the Japanese.* Br J of Nutrition 1980: 44: 273-274.

    Oboler S. *American Prisoner of War ‑ an Overview*. In Williams T
    (ed), Post Traumatic Stress Disorder: A Handbook for Clinicians.
    Disabled American Veterans, Cincinnati, Ohio. 1987: 131‑143.

    Fishbach, WM. *Cardiac and Electrodiographic Observations on
    American Prisoners of War Repatriated from the Japanese*. US Naval
    Medical Bulletin. 48: 69-74. 1948.

    Page WF, Ostfeld AM. *Malnutrition and Subsequent Ischemic Heart
    Disease in Former Prisoners of War of World War II and the Korean
    Conflict*. J. Clin. Epidemiol. 1994: 47:12: 1437‑1439.

    Richardson HJ*. Report of a Study of Disabilities and Problems of
    Hong Kong Veterans. 1964‑1965*. Canadian Pension Commissions
    Commission, Ottawa. 1965.

    Salmond GC, Geddes MK, Salmond CE. *The Health of Former
    Servicemen*. War Pensions Medical Research Trust Board. Wellington,
    New Zealand 1977.

    Skelton WP, Skelton NK*. Ischemic Heart Disease*. American ex‑POW
    Bulletin 1994: 51: 8: 30‑32.

    Jeffry, FE and Ableman, WH. *Recovery of Proven Shosin Beriberi*.
    American Journal of Medicine. 50:123. 1071.

**FROSTBITE**

1\. Altman MI and Hutton SJ. *Late Neuropathic Sequelae of Cold Injury*.
J Foot Surg. 1987: 26:213‑216.

2\. Barber FA. *Cold Injury in the Military*. Med Bull of the U.S. Army,
Europe, 1980: 37: 22‑27.

3\. Blari JL et al. *Sequelae to Cold Injury in One Hundred Patients*.
JAMA. 1957:163:14:1203‑1208.

4\. Frey CS. *Frostbitten Feet*. The Physician and Sports‑medicine.
1992:20:1:67‑70.

5\. Glick R, et al. *Frostbite Arthritis*. J Rheumatology.
1979:6:456‑460.

6\. Lewis TL. *Observations on Some Normal and Injurious Effects on
Underlying Tissues*: Frostbite. British Medical Journal. 1941:2:869‑872.

**PSYCHIATRIC**

1\. [APA Diagnostic and Statistical Manual III.]{.underline} American
Psychiatric Association. 1990.

2\. [APA Diagnostic and Statistical Manual IV]{.underline}. American
Psychiatric Association. 1994.

3\. Brill, NQ. *Neuropsychiatric Examinations of Military Personnel
Recovered From Japanese Prison Camps*. US Medical Dept. 5:429-438. 1946.

### Dedication

This book is dedicated to my father, William Paul Skelton Jr., an ex-POW
of Germany whose will to survive made it possible for me to be here
today. Additionally, it was his strength that he imparted to me to help
me through my difficult times. It is further respectfully dedicated to
all the ex-POWs that I have had the pleasure of knowing both locally and
nationally who have taught me so much about the American ex-POW whose
only request was that I would listen to them and be compassionate and
considerate of their needs. Among those captured by the Germans, I wish
to recognize and remember Donald Britt, Ross Coker, Glen Cleland, Harold
Chesterman, Paul Dely, James Vogel, Frank Irizary, Eugene Nagy, Judson
Luckhurst, Harley Burnett, Albert Bernard, Furman Davis, George Drew,
Elonomac Creel, William Hooper, James Fulton, Richard Sprouse, Charles
Stenger and Santos Santoni. From those captured by the Japanese, I wish
to include Robert Horn, Joseph Moore, Owen Boothroyd, Charles Looper,
Stephen Raymond, Antonio Delpino, Max Wilson, John Aldrich, Landys
McClamma, Jasper Taylor, Henry Brunet, Jake Austin, Keith Johnson, Stan
Sommers, Al Bland and Ralph Levenburg. From those captured by the North
Koreans and Chinese during the Korean War, I wish to remember William
Shaddish, Marvin Wallace, Joseph Spano, Robert Buzbee, Al Burton, Paul
Lynch, Charles Davis and Wilmer Bartlett. And finally from those
captured by the North Vietnamese and the Vietcong during the Vietnam
War, I wish to remember James Jackson, Everett Alvarez and Dick
Stratton. I will never forget the influence on my life these brave men
have had and what they have taught me. .