The Vitamin A Story

B. Koletzko

• Verlag: S. Karger
• Jahr: 2012
• ISBN:
  9783318021899
• Thema: Medicine
• Thema: Public Health, Administration & Care

This book shows how vitamin A deficiency – before the vitamin was known to scientists – affected millions of people throughout history. It is a story of sailors and soldiers, penniless mothers, orphaned infants, and young children left susceptible to blindness and fatal infections. We also glimpse the fortunate ones who, with ample vitamin A-rich food, escaped this elusive stalker. Why were people going blind and dying? To unravel this puzzle, scientists around the world competed over the course of a century. Their persistent efforts led to the identification of vitamin A and its essential role in health. As a primary focus of today's international public health efforts, vitamin A has saved hundreds of thousands of lives. But, we discover, they could save many more were it not for obstacles erected by political and ideological zealots who lack a historical perspective of the problem. Although exhaustively researched and documented, this book is written for intellectually curious lay readers as well as for specialists. Public health professionals, nutritionists, and historians of science and medicine have much to learn from this book about the cultural and scientific origins of their disciplines. Likewise, readers interested in military and cultural history will learn about the interaction of health, society, science, and politics. The author's presentation of vitamin A deficiency is likely to become a classic case study of health disparities in the past as well as the present.

Chapter 1

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Vitamin A Deficiency in Nineteenth Century Naval Medicine

Ironically, technology, more than medical science, brought about a decline in the nineteenth century in the recorded incidence of night blindness at sea. The faster a ship could accomplish its transoceanic mission - that is, in weeks rather than months - the less uninterrupted time its sailors had to live under shipboard conditions, including on inadequate rations. Progress in marine propulsion thus translated into shortened periods of insufficient vitamin A in sailors’ diets.

Technological advances revolutionized transoceanic travel in the late-1700s and the 1800s. With the introduction of the coal-fired steam engine for marine propulsion, the result of efforts by English, French, and American engineers, motor-propelled ships plied the oceans alongside vessels still reliant on venerable means, wind and sail. The main difference between the two was speed. A steam-powered ship with a paddlewheel - the first motorized means of marine propulsion - could complete a long journey in a fraction of the time that a sailing vessel required. In spring 1838, the British Great Western set a record by crossing from Bristol to New York in fifteen days. To do so required an average cruising speed of 8.2 knots (the equivalent of 9.4 miles per hour) [1]. This was nearly double the speed of that of an average sailing ship.

Commercial shippers were the first to seize the advantages of steam-powered propulsion, and the paddlewheel became the mainstay of civilian fleets by 1850. Navies, meanwhile, had to await further technological progress. Though faster and nimbler than sailing ships, and far less vulnerable to foul weather and turbulent waters, steam-driven paddlewheels had overwhelming drawbacks.

The wheels themselves, being mounted on a ship's sides, made easy targets for enemy fire. Moreover, the wheels, the boilers, and the coal fuel all occupied a significant portion of a craft's internal space, encroaching seriously on the room needed for artillery [2]. A steam-propelled paddlewheel armed with only a dozen guns always faced the prospect of confronting a wind-powered sailing ship's one-hundred and twenty guns. The technological advance that finally put steam power ahead of wind and sails for naval navigation was the screw propeller. Because the optimal placement of the screw propeller was the stern, it freed up the broadsides for artillery. And being mounted below the water line, it made a difficult target for enemy fire.

But until the screw became the primary means of propelling military vessels, navy sailors continued to have to withstand months-long periods at sea and to bear the attendant health hazards. Naval records, not the logs of merchant ships, therefore dominate the history of the illnesses that beset sailors on very long voyages. Navy crewmen, far more than merchant mariners, suffered the diseases caused by inadequate, ill-balanced diets. And it was the men on naval ships who challenged the physicians on board, who tried to understand and cure what ailed the sailors. Much of what is known about the nutrition-related diseases that affected sailors in the nineteenth century comes from the journals, diaries, and official records of those navy doctors.

Night Blindness at Sea

In late October 1860, the French warship La Cornélie set sail from the port of Toulon. East of Marseilles on the Mediterranean coast, Toulon was one of France's key departure points for building and defending the empire. La Cornélie, a sleek, three-masted corvette, was making her maiden voyage on that autumn day. The sun glinted off her fresh paint and polished brass, contrasting with the dull iron of her twenty-two cannons. La Cornélie was bound for the South Pacific.

A suitably seasoned crew would guide La Cornélie, with topmen Jacques Plée and Louis-Marie Stéphan to tend the sails and rigging, and Jean Denon in charge of the guns. Even seaman Elie Morin, though only twenty-four, had sailed the South Pacific. The health of these four, plus another two hundred and fifty-three officers, supervisors, servants, and seamen, was under the care of Marie-Louis-Eugène Chaussonnet, a physician in the employ of the French Navy.

With a brisk wind filling her sails, La Cornélie headed south into deep Mediterranean waters, then west past Gibraltar into the Atlantic Ocean. Sailing southwest, she reached South America, rounded Cape Horn, crossed the Pacific, and arrived within range of New Caledonia, Australia, and New Zealand - all within four untroubled months. Chaussonnet, who had been on the alert for complaints of loose teeth and spontaneous bleeding, noted in his journal with satisfaction that the crew was healthy, with ‘not a single case of scurvy’ on board [3].

By the end of 1862, La Cornélie had again traversed the Pacific and arrived at the coast of Chile, from which she sailed north toward Mexico. Suddenly, however, the tone of Chaussonnet's journal changed. Topman Plée came to the doctor complaining that he could no longer work at night: he could see perfectly well in daylight, but at night he was having difficulty seeing the rigging. And the problem was getting worse each night.

Identifying Plée's problem as acute night blindness, Chaussonnet followed a course that had been advocated by an American colleague and utilized by many other doctors in that era. He gave the topman five milligrams of strychnine to take by mouth each morning [4]. After four days the patient had no more symptoms.

But a month later Plée returned, this time with worse complaints: now, after twilight, he could see virtually nothing. Again Chaussonnet administered strychnine, and, in addition, he fumigated Plée's eyes mornings and evenings with ammonia water. One course to which Chaussonnet did not resort, although it had its advocates, was to induce vomiting with emetics. Nor did he use purgatives to cause intestinal evacuation [5]. After a week of the strychnine-and-ammonia regimen, Plée announced that his vision problem was cured and resumed his nighttime duties.

But other sailors began to appear with the same complaint, including Denon, Stéphan, and Morin. Soon the doctor was busy giving strychnine, fumigating the eyes, and applying medicines to the skin. Applied around the eye or to the nape of the neck, vesicatories - such as Spanish fly [cantharis] - caused skin blistering but were deemed beneficial because they caused irritation that would supposedly counter the disease [6]. Some of the afflicted seamen got better but then relapsed. Others simply got worse. Clearly, an epidemic was making its way through the crew of La Cornélie.

Chaussonnet had no previous experience with the disease he confronted, although its symptoms fit perfectly with the night blindness (hemeralopia, see textbox 1-1) described in an 1856 treatise by Jean-Baptiste Fonssagrives, a professor of medicine at Brest [7]:

The nocturnal blindness is at first partial, the patient is enabled to see objects a short time after sunset, and perhaps will be able to see a little by clear moonlight. At this period of the complaint he is capable of seeing distinctly by bright candle-light. The nocturnal sight, however, becomes daily more impaired and imperfect, and after a few days the patient is unable to discriminate the largest objects after sunset or by moonlight; he gropes his way like a blind man, stumbles against any person or thing placed in his footsteps, and finally, after a longer lapse of time, he cannot perceive any object distinctly, by the brightest candle-light.

Plainly, the treatments with strychnine, fumigations, and vesicatories were not working. Many men returned after a few days with relapses or complaints of no relief at all. Chaussonnet therefore decided to change his approach and resort to a radical treatment advocated by a colleague in the army. This course entailed shutting a patient for at least a few days in a cabinet ténébreux, a dark closet [8]. From March to August 1863, forty of La Cornélie’s sailors spent time in the cabinet ténébreux before their vision returned - some, nearly two weeks in total darkness and one, a full month.

Textbox 1-1. Differentiating night blindness and naming it

Night blindness has been recognized in the West since antiquity and identified by many different terms. Aulus Cornelius Celsus, a first-century Roman scholar, called it inbecillitas oculorum (weakness of the eyes) [9]. The seventh-century Byzantine Greek physician Paulus Aegineta referred to it as nyctalopia (night blindness) [10]. In early modern history, the French surgeon Ambroise Paré too called it nyctalopia, while his follower Jacques Guilleaumeau wrote of vespertina caecitudo (evening blindness) [11]. The Dutch clinician Hermann Boerhaave referred to it as visus diurnus (sight by day), while in France, François Boissier de la Croix

de Sauvages called it amblyopia crepuscularis (lazy eye of the dawn) [12]. In the Arabic-speaking world, meanwhile, medical scholars also applied diverse terms, including shebkeret.

By the mid-nineteenth century, nighttime vision problems were recognized as falling into two categories. The first, now termed retinitis pigmentosa, is congenital but rare [13]. A hereditary disease, it occurs mostly in families. It begins with moderate symptoms, mainly poor vision in low light and loss of peripheral vision, and worsens over time. Examination of the retina with an ophthalmoscope usually finds changes of pigmentation and narrowing of the blood vessels. No effective treatment for retinitis pigmentosa has yet been found.

The other night blindness can be severe in the early stages but is rarely permanent. In the nineteenth century it was often, but not universally, referred to as hemeralopia - an irony, since the Greek hemera mea...