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In the last three months of 1946 and the first quarter of 1947, the late Anand Pardhy and I were the graded surgeon and graded physician in a CCS (Casualty Clearing Station) which was acting as a static hospital in the small town of Prome, on the Irrawaddy, in South Burma. In the same area was a camp of 1077 Japanese soldiers awaiting repatriation. They had their own medical officers and sick bay but cases requiring surgery and the more severely ill medical cases were admitted to the CCS. During this period, we admitted from the Japanese camp 10 cases of acute appendicitis, or one case every 2–3 weeks. At the beginning I assisted Pardhy but became so familiar with the technique that I was allowed to do the operation, with Anand Pardhy assisting.
We were intrigued by the high incidence of appendicitis in the Japanese soldiers and thought it might be because the camp was receiving mainly British rations which had a lower fibre content than the normal diet of a Japanese soldier. The fact that their own medical officers were surprised at the number of cases suggested that appendicitis was normally rare in Japanese troops.
Fortunately, in the Prome area there were large concentrations of Indian, Gurkha, and Burmese troops, and a battalion of irregulars from the Chin Hills, on the border between Burma and what is now Bangladesh. The total number of these troops greatly exceeded the number of Japanese soldiers in the camp, yet we admitted no cases of appendicitis from these various nationalities.
In discussing the aetiology of appendicitis, Burkitt and Trowell point out that communities with a high fibre diet have a low incidence of appendicitis, while those consuming a Western style diet, low in fibre and high in refined carbohydrates, have a higher incidence.1 Confirmation of their theory is provided by the difference in the incidence of appendicitis between British and Indian troops in India during the period 1936–1947. Appendicitis was 4–6 times more common in the British than in the Indian troops.2 In the same period, the basic ration for Indian troops contained one third the amount of animal protein and three times as much high fibre foods (parboiled rice, atta (unrefined wheat flour), and pulses (dal and peas)) as that of British soldiers in India.3
The effect of a change in intake of fibre was also discussed by Burkitt and Trowell who cited a report that the incidence of appendicitis in Japanese immigrants in Hawaii, where they presumably ate an American style low fibre diet, was higher than in Japan.1 The same authors referred to reports that Sudanese troops in North Africa and West African troops in Singapore had an increased incidence of appendicitis when they were given British rations.1 These reports are analogous to our experience with the Japanese prisoners of war but do not discuss whether the effect of a sudden change in diet produced an incidence higher than that in countries consuming a Western type of diet. A rate of 10 cases in six months would produce 20 cases a year in a population of 1000 men, or 200 cases per 10 000 population. The incidence of appendicitis among adults in England and Wales for the years 1931–1935 was estimated at 45 per 10 0004 while the annual discharge rate for appendicitis for 1959 was 27 per 10 000,5 suggesting a rate of approximately 35 per 10 000 for the 1940s, or about one sixth of the incidence in the Japanese camp. Our values certainly suggest that a sudden change in diet, in this case a reduction in the intake of fibre, produces an exceptionally high incidence of appendicitis.
Van Ouwerkerk6 gave an example of the opposite effect. In the Dutch internment camps in Indonesia during the 1939–45 war, appendicitis was practically unknown; the diet consisted of “rice in insufficient quantities, unprocessed vegetables, and practically without meat and fat”.
In conclusion, our experience with the Japanese camp tends to confirm Burkitt and Trowell's theory that a low fibre diet causes a high incidence of appendicitis. However, recent evidence from South Africa7 has shown that urban Black Africans continue to have a very low incidence of appendicitis in spite of the fact that their dietary intake of fibre is lower than that of the urban white population. Clearly then, there may be factors other than the level of fibre intake in determining the incidence of acute appendicitis.
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