Malnutrition of political prisoners (after Howard H. Ingling)

The Nazi German concentration camp Zwieberge-Langenstein,¹ a sub-camp of Buchenwald established in May 1944 on the east slopes of the Harz Mountains about 6 km away from Halberstadt, was designated as a subterranean production plant exploiting slave labour for the construction of Junkers aircraft. By early 1945, a factory was already in operation in the first production halls that were ready. Further work to develop the site continued until 5 April 1945 (cf. Makowski 1967).

A total of about 7 thousand political prisoners of various nationalities were held in this camp (see Table 1). About 450 weak or sick inmates out of this overall figure were transported to Buchenwald in the period from May to October 1944; about 2 thousand died in the camp from October 1944 to April 1945; and 150 were transported in March 1945 to work in Magdeburg. In April 1945, the number of prisoners in the camp was about 4.4 thousand, of which the Germans evacuated about 3 thousand on a march east (by foot). Very many of these prisoners died during the march, but no detailed figures are available. Of the remaining 1.4 thousand still in the camp, some left on their own after the camp was liberated by the American army. On 20 April 1945, the rest, about 1.1 thousand, were put under the care of the US Ninth Army’s 20^th Field Hospital, which was posted to Halberstadt to provide this medical service and quartered in the local barracks formerly used by the German army.

This hospital was in operation from April 20 to the beginning of June 1945. Some of its patients, mostly Belgians and Frenchmen, were sent home fairly soon; about 100 patients died in the hospital; about 200 were sent to a hospital in Brunswick for further treatment after the hospital at Halberstadt was closed down; and the rest were discharged in a fairly good condition.

A few other doctors and I worked in the American field hospital in Halberstadt, looking after fellow survivors of the concentration camp. The American doctors were deeply shocked at the condition of the survivors who were admitted to the hospital and gave them the most generous medical care. One of them, Dr Howard H. Ingling,² wanted to draw up a comprehensive scheme for the observation of these patients and make a record of the results of their treatment. He asked me to collect a set of data for the Zwieberge-Langenstein camp (i.e. the number of prisoners, the death toll, the type of labour they had done, and their food rations). I compiled the data on the basis of my own observations and information from my colleagues, who were fellow survivors.

Table 1. Number of prisoners confined in Zwieberge-Langenstein concentration camp. 1—figures on the basis of the register of deaths kept by the prisoners’ hospital in the camp as of October 1944. I did not manage to obtain any figures for the number of deaths for the earlier period. 2—approximate figure for the beginning of October 1944. Probably about 450 weak and seriously ill inmates were transported to Buchenwald in the period from May to October 1944. 3—able-bodied inmates transported to Magdeburg for work; 4—number of inmates who left on 9 April 1945 on an evacuation march on foot; 5—approximate figure; 6—approximate figure. About 300 persons out of this number left the camp on their own between 13 and 24 April 1945. The rest, 1,100 persons, were put under the care of the 20th Field Hospital of the US Ninth Army.

Dr Ingling put all of this data into a brochure which he published privately in the United States in 1945 or 1946. In the rest of this article I give an extensive synopsis of his publication, with some parts a direct repetition of Dr Ingling’s remarks.³

I would like to thank Dr Ingling for permitting me to use his publication for this article.

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For many years people have been examining the effects of malnutrition on animals and a very small number of human volunteers. Now, regrettably, the Second World War has provided us with countless numbers of human subjects for the observation of the results of malnutrition. We want to restore the health of these patients as fast and as simply as we can, but also, if possible, collect some scientific data. . . . When we consider these patients, we should bear in mind that although the chief cause of their illness was food shortage, there were also many other causes contributing to the condition in which we found them. First of all, they had been imprisoned from two to five years and in danger of the mental and physical traumas which are a threat to all prisoners and especially political prisoners. For the entire period of their confinement, they were forced to do very hard labour, and to live and work without the right protection against bad weather and environmental conditions. Their food was very poor as regards essential nutrients, especially in the last three months.

To assess the condition of our patients on their admission to the hospital, we will try to determine what they were probably like before their imprisonment. As Table 2 shows, they were representatives of various European nationalities, and the largest groups were the Poles, the Frenchmen, and the Russians. Their average age on imprisonment was about 30, and their average weight was about 72 kg. Presumably, their general physical condition and state of health was typical for this age group and these nationalities. We know that many of them died before we saw our group of patients. Those who died must have been the weakest ones. So we have to assume that the patients we saw were healthy individuals about two years earlier.

Tables 3 and 4 show the quality and quantity of the prisoners’ food rations over the last six months [in the camp]. Dr Ingling looked at the amount of the diverse ingredients of their food and their caloric value,⁴ and concluded that the aim of the camp’s authorities (at least up to the beginning of 1945) was to keep the inmates fit enough to continue doing physical labour.

Table 2. Deaths and causes of death during survivors’ stay in hospital (by nationality).

The main component of the prisoners’ food was made up of cereal products (wholemeal rye bread with acorns and chestnuts as additives, groats, noodles, and bran). About 90% of their protein came from cereals, and the rest from cheese and meat. Vegetable products were the main sources of their mineral salts and Group B vitamins, and the rest came from cheese and meat. They got their vitamin A and some fats from cheese and meat, and the rest from margarine. Potato peel was probably the main source of vitamin C and some of the mineral salts for them. In the last two months of their captivity, carrots provided them with provitamin A [β-carotene]. We could not determine a source for the supply of vitamin D. Much of the vitamin B₁ and vitamin C supply in their diet was presumably destroyed by having all of their food cooked. The basic caloric intake in their diet were carbohydrates from cereals and potatoes.

Table 3. Prisoners’ food rations in Zwieberge-Langenstein concentration camp. 1—weekly ration in grams; 2—the letters refer to Table 4; 3—daily protein intake in grams; 4—daily caloric intake.

Table 4. Ingredients of liquid foods (soups)—annex to Table 3.

In late January 1945, there was a drastic fall in the caloric value and protein content of their daily food rations. Later, the quality and quantity of their meals improved thanks to the food products brought into the camp as of 13 April 1945.

Soup. Artwork by Marian Kołodziej. Photo by Piotr Markowski. Click the image to enlarge.

Tables 5 and 6 show the different types of labour the prisoners performed. Most of this work was exhausting, and only a very small number of inmates had relatively light jobs classified in Group 6 in Table 5. To estimate the full number of their working hours, we have to take into account the time they lost on roll calls and marching to and from work, which has to be added to their official working time of 8 or 12 hours per day. Not only was it hard labour, but also conducted regardless of weather conditions. They did not have the right working clothes. All of this, together with the bad living conditions in the camp and the insufficient amount of rest (interrupted sleeping hours) called for a greater intake of calories and made prisoners less resilient.

As Table 1 shows, the mortality rate for prisoners held in the camp was clearly on the rise. In October 1944, the death rate was about 0.1% per week, but by March 1945 it was over twenty times higher. From 20 to 24 April 1945 about 1,100 survivors suffering from various degrees of malnutrition and diverse other diseases were admitted to the American hospital.

On admission, our patients looked like a bag of bones, evidently dehydrated and emaciated. They had gone down from an average weight of 72 kg to 45 kg, in other words they had lost about 37% of their weight. Their average age was 32, with a few youngsters of 15, and a couple aged 60 and over. They were glad to be alive and seemed not to care much about their newly restored freedom. Their dirty clothing was taken off them straight on admission, their head and all their body hair was shaved; they were washed, rubbed with “kerosene,”⁵ had powdered DDT sprinkled all over their bodies; they were issued new clothes and blankets, and given a meal.

Table 5. Type of work performed by prisoners in Zwieberge-Langenstein concentration camp A. In groups according to type (on a 7-day working week). *—shift work, the table gives actual working hours without the time to walk a distance of 2 km to and back from work; **—according to Ingling’s brochure, these figures definitely give an underrated value; they may agree with the figures given in the bibliography on the subject, but they do not take into account the prisoners’ real working conditions and the additional hardships in the camp.

Table 6. Type of work performed by prisoners in Zwieberge-Langenstein concentration camp B. Approximate number of prisoners working in the diverse groups.

Table 7 presents the illnesses and conditions our patients complained of, the symptoms we observed and the initial diagnoses we made.

Table 7. Patients’ complaints, symptoms, and diagnoses. Average age of patients was 32. The table gives percentage values out of the total number of patients in the test.

About 35% of the patients complained of occasional or permanent swellings, but we only observed such a condition in about one-third of these cases at the time of their admission. On the basis of chest X-rays, sputum tests, and clinical observation, we diagnosed 31% of the patients with active pulmonary tuberculosis.

Our immediate and main procedure was, of course, dietary. For 5 days we gave our patients 6 meals a day. The meals consisted chiefly of semolina, eggs and milk, cream, bread and butter, cheese, and drinking chocolate. We gradually reduced the meals down to three a day with an extra night-time meal. They now consisted of tinned meat, cheese, rice, potatoes, dried fruit and vegetables, eggs, milk, flour products, and cream. This diet amounted to a daily portion of over 120 grams of protein and over 3,500 calories.

Every day for seven days, and thereafter once a week, we sprayed the premises with DDT, obtaining an excellent result.

We treated diarrhoea with the usual mixture of bismuth and opium, which gave a good outcome (except for a few cases) in combination with the semi-liquid diet. We failed to determine the micro-organisms responsible for the most persistent cases of diarrhoea, nonetheless many of them reacted to a 0.5 g dose of sulphathiozole and 20,000 units of penicillin administered every three hours. 10% of the patients with scabies had a good response to benzyl benzoate applied 10 minutes after a hot bath. Most of the skin infections disappeared following the introduction of the right diet in combination with sulphide medications and penicillin, together with general hygiene procedures.

We gave blood transfusions to patients suffering from anaemia (red blood cell counts of 3 million and under). The weakest and those with oedemas were given blood plasma. Every patient had a daily dose of 6 multivitamin tablets. The extremely debilitated were given an extra dose of vitamin B₁ and C, and an injection of liver extract.

In general, we may say that the treatment was based on providing our patients with a supplement for their fluid imbalance, remedying their blood loss, and making up for their protein, caloric and vitamin deficiency.

At first, we set up a room which we secretly called “the moribund ward,” where we put the most serious cases. Soon, however, we saw for ourselves the near-miraculous effect blood and plasma transfusion had on these patients on the verge of death due to starvation. The “moribund ward” gradually turned into a “live ward.” Nonetheless, there were still 48 patients who died solely due to starvation (see Table 2). Their inanition must have gone beyond a point of no return, which no treatment could reverse. Death of starvation is presumably a painless type of death. The moribund person does not seem to be suffering, just staring into space without noticing anything and giving the impression of not wanting anything any longer. His breathing gradually becomes shallower and shallower, and eventually all his vital processes stop and he slips practically unnoticeably from life into death.

Table 8. Results of patients’ laboratory tests shortly after their admission to the hospital (random selection of cases). *—for patients who had been on a carbohydrate-rich diet; **—the normal range for total protein is 6.0–8.0 g/dL ; the normal range for the A/G ratio is 1.5–3.0; in swollen tissue the total protein value is 5.0 g/dL and the A/G ratio is 0.3.

We carried out lab tests as soon as possible, especially on those who needed to have them done for diagnostic purposes and to determine a treatment. Next, we conducted tests to establish the effects malnutrition, overwork and bad living conditions had on our patients. Table 8 presents the results of these tests. We carried out these tests on a random selection of patients. Moreover, these tests were carried out on persons who were still dehydrated.

Table 9. Results of laboratory tests for patients with severe oedema

We made an interesting observation that a patient’s oedemas became more frequent and more pronounced once his diarrhoea stopped. The relative absence of oedemas initially must have been caused by dehydration due to diarrhoea. About 20 patients were bedridden due to broken legs or frostbite on their feet. These individuals were in a slightly better condition as regards undernourishment than their fellows in the camp, presumably not because they were better fed but because their energy requirements were far smaller. We had a number of patients who were dehydrated but whose chest examination did not present any tubercular changes in the lungs. It was only when we had them X-rayed that clear tubercular changes showed up. Later, as they became less dehydrated, the physical symptoms became more pronounced.

The majority of our patients wanted to have acidic food and fluids. Many enjoyed the diluted solution of hydrochloric acid we gave them, which not only enhanced the flavour of their food but also improved their appetite.

At first, we doctors thought we would encounter many of the typical, textbook cases of vitamin deficiency. However, we did not observe any full-syndrome cases of hypovitaminosis; instead, what we saw were various degrees of vitamin deficiency attending other diseases.

Vitamin B₁ deficiency was probably most pronounced in patients with a fast, low-tension pulse and a tendency to develop oedemas. The neuralgias which might have been expected were in fact fairly infrequent, and occurred only in 6% of our patients. We did observe other symptoms, such as hypersensitivity, patients being in a wakeful but unresponsive (vegetative) condition , memory disorders, and patients who were mentally exhausted and unbalanced. These were all conditions we did see, but they could have been caused by factors other than a low level of vitamin B₁.

Vitamin B₂ deficiency, as observed by its symptom of glossitis, occurred in 21% of our patients, while only 3% had chapped lips.

We did not observe any cases of pellagra (deficiency of vitamin B₃/niacin). Many of our patients were suffering from diarrhoea, lethargy, or memory disorders; some had a lack of appetite or changes in the oral cavity, but there were none of the dermatitis symptoms typical for pellagra.

The symptoms indicative of vitamin C deficiency we observed were red gums (in 20% of our patients) and skin infections. There were hardly any cases of vitamin A deficiency, just 0.5% of the cases, recorded in the patients’ interviews as nyctalopia. We did not observe any instances of corneal opacity; however, we encountered a general tendency for excessive keratosis on the skin in nearly half of our patients. Vitamin D deficiency may perhaps have been associated with the high figure (31%) for active pulmonary tuberculosis.

There were several factors which made the observation of our patients incomplete. Some of them were discharged from the hospital fairly early and left for their home countries; many were discharged at a steady rate as and when their condition improved and they could fend for themselves.

However, in general we may say that the cases of anaemia improved, patients’ leukocyte counts went up and their oedemas were reduced and disappeared. Their weight gain was from 3 to 5 kg a week, and they recovered their strength and muscle tone. The dermatological and mucosal symptoms of their vitamin deficiency diminished. They started to develop an interest in what was going on around them and in the world at large. This usually happened after about three weeks, except for the more serious cases of tuberculosis.

A group of 17 of our patients, fairly untypical cases, still had persistent, noticeable oedemas after 2–3 weeks of rest, dietary treatment and supplementary care. Their test results are presented in Table 9. After a week on a protein-rich diet with a reduced intake of salt and fluids, and blood and plasma transfusions in a few cases, their condition improved and the oedemas disappeared.

Oedemas appearing in conditions of undernourishment are not always easy to account for. We cannot give a single, universally applicable, direct cause to explain all the cases in this group of patients. Most probably, the oedemas were determined by the concurrence of a number of factors such as a low leukocyte count, anaemia, an increased capillary flow rate, heart failure and other factors dependent on the shortfall in all the essential nutrients in their diet.

***

Malnutrition may be described as a condition in which a human subject consumes more energy over a long period than he can compensate for from the food he gets, leading to his debilitation and an evident weight loss, tissue depletion and a general reduction in all of his bodily functions.

Malnutrition may be considered by analogy to the way we usually think of shock, except for the time factor. In both conditions there is a loss of part of the body’s most important tissue, its blood. To compensate for the shortfall, the body consumes large amounts of its other tissues, bringing about the loss of its strength, weight, and immunity to disease, along with signs of vitamin deficiency and complications following illness. Debilitation is, of course, chiefly due to the body receiving an insufficient amount of calories. To make up for part of the shortfall, the body uses up the resources of glycogen stored in its liver and muscle tissues, the fat reserves stored in all of its parts, and finally the protein in its muscles and blood. This leads to weight reduction and eventually to muscle depletion. All the bodily functions are attenuated, inhibiting mental and psychic processes; bringing down blood pressure and pulse rate; reducing oncotic pressure, raising the permeability of the capillaries, and inducing the formation of oedemas; slowing down endocrine secretion; reducing muscle tone in the entire body and thereby diminishing its immune system.

We may also compare the treatment of malnutrition to the treatment applied for shock, because we start by compensating for the loss of blood, the body’s vital tissue, by means of transfusion, and follow up by providing patients with the right diet and treating any complications which may arise.

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Translated from original article: Makowski, Antoni, “Niedożywienie więźniów politycznych (według pracy Howarda H. Inglinga).” Przegląd Lekarski – Oświęcim, 1968.

1. The official name in German of this concentration camp was “Konzentrationslager Langenstein-Zwieberge.“ The name is “Zwieberge-Langenstein” in the original Polish article, which we reproduce in its English translation. https://de.wikipedia.org/wiki/KZ_Langenstein-Zwieberge
2. Dr Howard Harrison Ingling (1908–1981) Served in the rank of captain in the Medical Corps of the US Army during World War 2, and was awarded the Distinguished Service Cross by the President “for extraordinary heroism in connection with military operations against an armed enemy while serving with the 23d Armored Infantry Battalion, in action against enemy forces from 14 August 1944 to 10 September 1944.” https://www.findagrave.com/memorial/47560337/howard-harrison-ingling
3. While translating Dr Makowski’s article I had no access to Dr Ingling’s original publication; therefore the present English text is not a literal rendering of the original brochure but a back translation from the Polish article. The passages presented on an indented margin in the following part of this article are printed in inverted commas in Makowski’s article, so presumably they are his Polish translation of passages from Ingling’s original brochure. Thus, the present English text may be regarded as a “back translation,” though not necessarily a full or literal reconstruction of the original version in Ingling’s brochure.
4. Tables 3 and 4 present fairly accurate figures for the quantitative data. However, Dr Inglings calculation of the protein content and caloric value gives is most certainly an overestimate. The difference between his figures and the real values was up to 30% for the period from October 1944 to January 1945, and about 15% for the subsequent months, and was most probably due to an over-optimistic evaluation of my account of the cooked meals. Hence, in Table 3 I give my own calculation for protein content and caloric value, based on my own assessment of the ingredients used for the meals inmates actually received. In reality, the caloric shortfall was even higher because the assessment did not take the quality of the food into account (e.g. the amount of water in the sausage, or the ingredients with no nutritional value added to the bread etc.).
5. Solvents such as kerosene or gasoline (British terms: paraffin and petrol respectively) have been used by workers to clean hands after work with oily materials. The practice is no longer recommended due to the discovery of a cancer risk. https://pubmed.ncbi.nlm.nih.gov/10750280

Note 4 was translated from the original. Notes 1–3 and 5 by Teresa Bałuk-Ulewiczowa, Head Translator for the Medical Review Auschwitz project.

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