Smoking Ears and Screaming Teeth - Trevor Norton (2010)

Found to be Wanting

‘People have long argued about the location of Hell. We have discovered it’ – Louis Antoine de Bougainville on a scurvy-stricken ship

We can readily appreciate the dangers that might ensue from viruses, drugs or radiation, but terrible conditions also come from something we lack.

For centuries a sailor’s life was not a happy one. He was probably pressed into service against his will and then confined in a seagoing prison with the option of drowning. But more mariners died of scurvy than in all the storms, wrecks, battles and infectious epidemics combined. During the Seven Years War, for every man who was killed in action eighty-nine died from disease, mostly scurvy. In the age of sail over two million sailors are thought to have died from this terrible affliction. A lucky ship was one with enough fit crew to make its way home.

In 1740 Commander George Anson was ordered to ‘annoy and distress’ the Spanish in the Pacific. The venture did not begin well. There were insufficient men to crew his ships so the Admiralty decanted pensioners from the Chelsea Hospital to make up the shortfall. Anson received a tottering flock of ‘crazy and infirm … decrepit and miserable objects … fitter for the infirmary than any military duty’. Even the most able-bodied would be fortunate to survive this fated mission. Only three men were lost in action, yet of nearly 2,000 that set sail less than 200 returned. Almost all had succumbed to scurvy.

Every ship left corpses bobbing in its wake. It was worse for the ships from Catholic Spain and France because their dead had to be buried in consecrated ground so cadavers were stowed among the ballast, to slop around in a lake of corruption. Some crewmen were asphyxiated by the foul vapours seeping from below.

Scurvy was a terrible condition. Capillaries leaked beneath the skin, the gums turned to swollen sponges exuding putrid blood and liberating the teeth. Even long-healed fractures of bones fell apart. According to Anson, ‘some lost their senses … and some rotted away’.

The ordeal of Anson’s voyage shocked the government into searching for a cure for scurvy. But the solution had been known for over a century. ‘Lemon water juice’ was an effective preventative used on voyages of the East India Company. The Company had even planted citrus groves at staging posts on major shipping routes. However, within thirty years complacent captains baulked at buying expensive fruit for a condition that was now seen only occasionally. They were encouraged by an ‘expert’ who claimed that fruits from exotic places were the cause of fevers such as scurvy. The cure was forgotten and replaced by quack remedies. The dread disease returned.

In 1753 a young Scots naval surgeon called James Lind challenged the theories on the cure of scurvy ‘invented according to the whim of each author and the philosophy then in fashion’. Instead of theorising he set up a test on board HMS Salisbury. It was one of the first clinical trials under controlled conditions. He chose two dozen men showing similar symptoms of scurvy. Half of them were split into groups of two and each pair received a different ‘remedy’ including such horrors as elixir vitriol (a refreshing mix of alcohol and sulphuric acid), food drenched in vinegar with a nip of neat vinegar to follow, or a pint of seawater a day. The other twelve men received no supplements and were the untreated ‘control’ group. Lind ensured that they all ate the same food and lived separately from the rest of the crew so that he could keep an eye on them. Although the sample size was only two, Lind concluded that, of the treatments tested, ‘oranges and lemons were the most effectual remedies for this distemper of the sea’. Lind is now called ‘the father of nautical medicine’ but although he wrote a comprehensive report of his findings no one at the time took the slightest notice.

In 1768 James Cook set out on his first expedition to the Pacific and the Southern Ocean. Part of his remit was to critically test different treatments for scurvy. He enforced the use of dietary supplements although the crew disliked ‘novel’ foodstuffs. They happily munched their way through ship’s biscuits riddled with weevils and salted meat infested with maggots, yet some had to be flogged for refusing to eat fresh meat picked up at Madeira. They refused sauerkraut so Cook craftily had it on the officers’ dining table every day, knowing that when they saw ‘their superiors set a value on it, it becomes the finest stuff in the world’. They also grumbled about the bitter taste of lemon juice, but it was all worthwhile. Thanks to his strict dietary regime and gathering fresh vegetables (including scurvy grass) at every landfall, Cook returned home after spending three years at sea without losing a single hand to scurvy.

The Admiralty were delighted with his explorations but unconvinced by his dietary findings. Because he had used several supposed remedies such as carrot marmalade and wort of malt, it was unclear which one had controlled the disease. The Admiralty didn’t take their advice from captains who confronted scurvy on every voyage; instead they consulted the learned gentlemen of the Royal Society, who had probably never seen a case of it. They prescribed useless nostrums based on their erroneous ideas of the nature of disease.

The Admiralty made clear that there had been trials ‘on board several different ships which made voyages around the globe … the surgeons of which all agree in saying that the “rob” [syrup] of lemons and oranges were of no service in the prevention, or cure of that disease’. The problem was that Lind and others had recommended the use of ‘rob’. It was a concentrate of orange or lemon made by evaporating their juice over heat. This halved the potency of the juice which rapidly declined even further when stored. Only fresh fruit did the trick, for the active ingredient was denatured by heating or drying.

Dismissing the only effective treatment allowed scurvy in the British navy to reach epidemic proportions. Other navies were similarly afflicted. In 1770 a combined Spanish and French force was to launch an invasion of England. The Spanish ships were delayed for just seven weeks, by which time two-thirds of the French seamen were incapacitated by scurvy. The only invaders that reached England were the vast numbers of bodies tossed overboard to wash up on the south coast.

Ten years later the entire crew of a British frigate was laid low with scurvy. Their lives were saved by a passing American ship whose master gave them fresh meat and vegetables. The frigate’s twenty-two-year-old captain was Horatio Nelson. Had he died, what would Britain have done without her greatest commander?

That same year Gilbert Blane, personal physician to Admiral Sir George Rodney, expressed dismay at the health of British sailors. He was convinced that ‘more can be done towards the preservation of the health and lives of seamen than is commonly imagined’. After reading both Lind and Cook’s reports he proposed that orange juice be distributed to every man in Rodney’s fleet. Their death rate from scurvy plummeted from twenty-five per cent a year to five per cent. Later, when he was appointed to the Admiralty’s Sick and Hurt Board, Blane used his influence to improve the hospital services ashore and to ensure that citrus juice reached the entire navy. Soon Britain had the healthiest sailors in the world, as Napoleon was about to find out.

During the Seven Years War and the American War of Independence the Royal Navy Hospital at Haslar routinely treated 350–1,000 scurvy patients per day, rising to 2,400 on a single day in 1780, from ships docking at Portsmouth. By 1815 the hospital had seen only two cases of scurvy in four years. In the forty years that had elapsed since Lind’s experiment hundreds of thousands of mariners had died unnecessarily.

Not all the casualties were sailors. A young physician called William Stark became acquainted with Benjamin Franklin who was living in London at the time. Franklin mentioned that he had once stayed healthy while taking nothing but bread and water for two weeks. Stark decided to test which simple foods were most beneficial and which were not. With ‘impudent zeal’ he launched into a nine-month period of restricted diets; ten weeks on bread and water were followed by a stint on flour, bread and oil, then a comparative study of the effects of lean versus fatty meat. He had intended to sample fruit and green vegetables next, but tragically chose cheese and honey instead.

Stark rapidly sank into the clutches of scurvy. A distinguished physician familiar with scurvy merely advised him to reduce his salt intake. Stark died soon afterwards at the age of twenty-nine.

Although it was accepted that something in citrus fruits cured scurvy, it hadn’t occurred to most of the pioneers that it was the lack of that something that caused the condition. Sailors (and the poor) were condemned by their diet. If a person is given only sufficient protein, fats, carbohydrates and water, they will surely die. Other compounds that we now call vitamins are vital for our health.

Ascorbic acid, vitamin C, is the one required to avoid scurvy. It is abundant not just in citrus fruits but also in rose hips, blackcurrants, papayas, kiwi fruit, broccoli, Brussels sprouts, parsley and watercress, but not in all fruits and vegetables. There is little or none in meat except for liver and kidneys. Ascorbic acid is essential for the formation of collagen, the most abundant protein in the body. Collagen is the fibrous basis for the ‘cement’ that binds cells together. Without it the body literally comes unglued.

Breast milk is also rich in vitamin C, ‘stolen’ from the mother. In Victorian times, when many of the middle class switched from breast to bottle feeding, their babies developed early symptoms of scurvy as the milk they used contained no vitamin C.

The curse of scurvy was virtually confined to humans because almost all other animals, including most apes, can manufacture vitamin C in their bodies and need no external supply. In 1907 researchers showed that if guinea pigs were fed exclusively on grain (lacking vitamin C) they developed scurvy-like symptoms, which then vanished if they were given the vitamin. The researchers were lucky because guinea pigs are one of the very few animals that, like us, need an external source of vitamin C.

The action of vitamins was largely determined by dietary experiments on animals and human volunteers – although they didn’t always know they were volunteering. Scurvy had been common in institutions such as prisons and orphanages, thanks to an inadequate diet. In the better orphanages the children were given orange juice. In 1913 two paediatricians, Alfred Hess and Mildred Fish, withheld orange juice from orphaned babies until they developed the localised bleeding lesions characteristic of scurvy. The idea was to use the infants to try out an invasive diagnostic test that involved puncturing the abdomen. They then repeated the experiment to see if they could induce the disease for a second time. They also used a similar protocol to study rickets, a bone disease caused by a deficiency of vitamin D.

The researchers felt no qualms about these experiments. It was stated that the orphans had made ‘a large return to the community for the care devoted to them’. There was general satisfaction that they were repaying their debt to society. Experimentation on infants (especially orphans and ‘mental defectives’) was commonplace well into the first half of the twentieth century. ‘Infant volunteers’, as they were called, came with the convenience that only the permission of the orphanage director was required to ‘use’ them. As babies had not lived long enough to have developed immunity to most diseases they were ideal for testing new vaccines. The procedure was to inject the experimental vaccine and then expose the infant to the target disease to see if immunity had been induced. These human guinea piglets were ‘challenged’ by the live agents of whooping cough, measles, hepatitis, smallpox and herpes. Dr John Kolmer tested a live polio vaccine on himself and his two boys as a reassuring prelude to injecting three hundred children. After nine deaths the vaccine was withdrawn. In 1930 in Germany seventy-six infants died while undergoing a vaccine trial for tuberculosis.

John Crandon, a young surgical resident at Boston City Hospital, was not the sort of man to experiment on children. In 1939 he became interested in why poorly nourished people took longer to heal. Was there a clue in the observation that old wound scars broke open in scurvy sufferers? He designed an experiment in which the subject would be ‘prepared’ on a diet deficient in vitamin C so that the healing time of experimentally inflicted wounds could then be determined. Crandon was adamant that he ‘wouldn’t think of experimenting on someone else until I had done the thing on myself’. Two other volunteers for the project were dropped when they were caught quaffing illicit orange juice.

Three months into the experiment a deep six-centimetre wound was cut into one side of Crandon’s back, with another cut into the other side later on. Crandon was still on what was virtually a cheese, crackers and coffee diet. He had lost fourteen kilos and was close to exhaustion. The laboratory director voiced fears that he would kill himself. And he nearly did.

While exercising in the gym in an attempt to keep fit, Crandon’s pulse soared and, with the conviction that he was dying, he passed out. It was known for scurvy patients to die suddenly from bleeding into the heart walls. His scurvy was sufficiently advanced for the scar from an appendectomy operation to reopen. He had had the operation when he was eight years old. The experimental wounds showed no sign of mending until he was given injections of vitamin C every day for a week. He had shown that the low healing capabilities of the poor that invited infections could be rectified by more vitamin C in their diet.

Crandon’s mother Margery was a renowned psychic who was outed as a fraud by Houdini. Her son, on the other hand, was the genuine article. A courageous self-experimenter.

Crandon was not the only researcher to deliberately induce vitamin deficiency in his own body. In the same hospital twenty-two years later a young haematologist almost died while doing so. Victor Herbert was named after his father’s cousin, a famous composer of operettas. Herbert the researcher developed the first test for folic acid (one of a complex of B vitamins) in human blood. It is found in a variety of foods and especially in leafy green vegetables, but like vitamin C it is destroyed by cooking. It was assumed that since bacteria in the gut were thought to synthesise it, folic acid deficiency was not possible except in those with serious digestive problems and in alcoholics, as alcohol degrades this vitamin.

One of Herbert’s patients had both scurvy and megaloblastic anaemia, a serious condition in which the red blood cells are abnormal. The patient was a man of habit. For at least five years his diet had consisted exclusively of fifteen-cent hamburgers, doughnuts and coffee. He shunned vegetables. All the burgers came from streetside stands. They were cooked by steaming and dispatched to the stands where they continued to be steamed until sold. It was a case of slow hamburger homicide of the most effective kind.

Folic acid was implicated in the production of red blood cells and Herbert surmised that steaming the burgers had destroyed all traces of folic acid – hence the patient’s anaemia. To test whether this was possible he needed to show experimentally that folic acid deficiency could produce megaloblastic anaemia. In the time-honoured way he invited one of his juniors to try the experiment. Though flattered, the junior wisely declined. Herbert rationalised doing the experiment on himself: ‘If anything went wrong with someone else, I would not want it on my conscience.’

The first task was to prepare a folic-acid-free diet. This involved boiling everything until all traces of folic acid, taste and texture were extinguished. Even lashings of Worcester sauce and monosodium glutamate couldn’t prevent finely diced, thrice-boiled chicken tasting like nothing at all.

Herbert stuck to the diet for seven months. The only ‘extras’ were tablets to replace the other vitamins that had been destroyed in the boiling. The sheer monotony of it blunted his appetite to the extent that he lost twelve kilograms. His wife described him as ‘very skinny and very, very irritable’. He also became absent-minded and wandered around the parking lot trying to find his car.

His blood cells were repeatedly checked and samples of bone marrow (where blood cells are made) were taken by pushing a large needle into his breastbone. It is a painful procedure and the first time Herbert was terrified that the assistant would press too hard and the needle would be thrust into his heart. Several people had died from complications arising from just such a mishap. He had only eight more ordeals by needle to go.

So far there was no sign of anaemia, but there was an unexpected and more disturbing development. On Christmas morning Herbert awoke to find that he couldn’t get out of bed. Had the lack of folic acid permanently paralysed his legs? By chance he had recently read a scientific article about paralysis induced by a shortage of potassium, for among its many other virtues potassium regulates the functioning of nerves. Had boiling his food depleted the potassium content too? It had. His potassium levels were so low that he could have dropped dead at any moment.

With the help of a potassium tonic the paralysis disappeared, but there was another trial to come. In order to secure a piece of tissue from the gut lining to examine under the microscope, a long tube was passed down Herbert’s throat into the small intestine. Blades on the end of the tube were supposed to excise a tiny sample. When the surgeon began to haul the tube back up, Herbert screamed. It felt as if his guts were being dragged out. And they were. Somehow the blades had clamped onto the gut wall and wouldn’t let go. For a moment it looked as if the sample might be the entire intestine.

At last, after seven months, Herbert developed megaloblastic anaemia. His hypotheses had been correct and he could abandon his diet and tuck into a nice plate of folic acid. When he presented his results at a conference a leading pharmacologist praised his research and added ‘there is courage here, as well as scientific brilliance’.

Folic acid deficiency, having been overlooked for decades, is now recognised as a worldwide problem. Thanks to the detailed monitoring of Herbert’s condition a simple blood test can now determine how advanced anaemia is in a patient.

Folic acid is essential for the formation of both red blood cells and genetic material. It therefore plays a major role in the development of a foetus, which drains the mother’s reserves. Today pregnant women are given folic acid supplements to replenish their supply.

We rightly think of vitamins as being a ‘good thing’, but you can have too much of a good thing. Vitamin A protects us from infection, but the body needs only 0.003 grams a day – a mere speck is sufficient. We cannot excrete any excess so it is stored within the body and it’s poisonous.

Carrots are a rich source of vitamin A and I recall an inquest on a man who was found dead with a strange rash over his body. His hair had fallen out and his skin was bright orange. It transpired that he had lived almost exclusively on carrots. He consumed carrot soup, carrot casserole and carrot cake. His daily tipple was, you’ve guessed it, carrot juice. He had been killed by an excess of vitamin A.

The corner asked what the victim did for a living. The reply was, ‘He was a research biologist, sir.’

‘Ah …’ said the coroner as if that explained everything, and perhaps it did.

As a schoolboy I was morbidly fascinated by a textbook’s photographs of people with unpleasant conditions such as parasitic elephantiasis, Klinefelter syndrome (males with an extra X chromosome) and a vitamin-deficiency disease called pellagra. The boy in the photograph was about the same age as I was. Whereas I fretted over the occasional zit, all the skin on his chest, hands and face was corrugated by scaly crusts.

Pellagra is even worse than it looks. It begins as dermatitis, followed by bloody diarrhoea due to ulcers in the bowel. Later on dementia sets in, followed by death. The boy in the photograph was doomed, yet all he needed was a diet of milk and cheese and lightly cooked fish, food rich in niacin, the vitamin he lacked. But in his time no one knew about vitamins. Even after all these years, I still remember his large, uncomprehending eyes.

An outbreak of pellagra in an Alabama lunatic asylum in 1906 made the mad even more insane and killed 101 inmates. It had always been common in poor rural districts and now an epidemic swept through the southern states of the USA. It spread to the cities because wholegrain meal was being replaced with finely milled grain from which the niacin had been inadvertently removed. Food processing often inactivates vitamins.

In 1914 Dr Joseph Goldberger was asked to head the Pellagra Commission that was attempting to control the disease. It was assumed to be infectious, but its behaviour was peculiar. In England two brothers had recently died of pellagra. One was dead within four months of the first symptoms appearing, although he had spent most of his life with his elder brother who had been chronically ill with pellagra for at least six years. Also although inmates of prisons, asylums and orphanages were often ravaged by the disease, their warders and carers were not.

This didn’t sound like an infectious disease to Goldberger. Researchers had failed to infect monkeys with pellagra, but what about humans? Goldberger, his wife and dozens of other volunteers tried every means to give themselves pellagra. Instead of seminars they attended ‘filth parties’ where Mrs Goldberger injected herself with blood from a woman dying of pellagra. The men took mucus from the noses of infected patients and smeared it into their own noses and mouths. Babies have a tendency to put everything in their mouths – so have self-experimenters. The transfers were tried over and over again until they could take no more. Not one of them developed pellagra.

Goldberger ran a clinical trial at a prison. A dozen healthy men including a murderer volunteered. They were given a nutritious but limited diet. After six months, six of the remaining eleven had developed pellagra. The twelfth man, an impetuous fellow, climbed the prison wall and escaped to become a wanted man. In his excitement, he had forgotten that his reward for completing the trial was a free pardon. At the end of the trial all those who contracted the disease refused free medical aftercare and ‘went off like scared rabbits’.

These volunteers had been well rewarded, but convicts were cruelly exploited elsewhere. According to one doctor they were ‘much cheaper than chimpanzees’. Indeed, they could be profitable. In a US prison the doctors received $300,000 from a pharmaceutical firm for running a trial. They augmented this payment by bleeding the felons almost every week and selling the blood.

Goldberger went on to cure an entire ward of pellagrous children by simply diversifying their diet. Pellagra continued unabated in the adjacent, untreated ward.

Later his team showed that brewer’s yeast (which is rich in niacin) cured pellagra. Even a few patients who had reached the dementia stage recovered their wits. As with many of the vitamin-deficiency diseases, the cure preceded the identification of the causal agent.

Goldberger’s findings saved hundreds of thousands of lives and lifted a pall of misery. He was nominated five times for the Nobel Prize, but the invitation never came.

Since we discovered vitamins we have taken them and other dietary supplements in ever-increasing amounts. Instead of relying on a varied diet, we are beginning to rattle with pills. Britain alone has twenty million ‘vitamin regulars’. I read of a young woman who spends £100 a week on dietary supplements. She confessed: ‘I take so many vitamins each morning that I never fancy breakfast.’

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Chemical structure of ascorbic acid, Vitamin C.