History of Medicine

                            THE DISEASE OF THE DEPOSED CHILD                                                                 

         In 1929, a 36-year-old Jamaican-born British physician, Cicely Williams, arrived by ship at the African “Gold Coast,” now known as Ghana. The inspiration for this assignment to a faraway place came from a Croatian professor of public health, Andrija Stampar, whom Williams had met on the way to work in a refugee camp near Salonika. He had shown her how to deal with with epidemics and nutritional problems at the community level using limited resources. Cicely determined to take up medicine in underserved communities as a way to confront these challenges. 

Gold Coast (Wikipedia) Click on 
image to enlarge.

 Dr. Williams, after her inspiring experience with Stampar, earned a Diploma at the London School of Hygiene and Tropical Medicine and was assigned by the British Colonial Medical Service to the town of Kumasi, in the Gold Coast. The area, formerly the land of the Ashanti empire, was now a center of cocoa production and extensive mining. 

While working in Kumasi and nearby stations, Dr. Williams encountered a clinical syndrome in young children that baffled her and did not appear in her medical texts. The afflicted children were edematous (puffed up with extra fluid), had orange hair, scaly and somewhat dry skin that was darkened in the creases, frequent diarrhea, and were mentally sluggish. Most of them died. Williams tried to obtain autopsies but was frustrated by mothers who whisked their children away before dying. After learning that the bus driver charged extra to transport a dead person, she paid the extra charge and autopsied several children. She found only an enlarged fatty liver, pallor, and edematous changes. Her first report of the disorder was in Gold Coast medical reports 1932. The local people called it “kwashiorkor.” 

Photos of kwashiorkor from Williams' first article (Wellcome Library)

Kwashiorkor was a tainted “ju-ju” word of the Ga language that locals were reluctant to pronounce. It referred to the sickness affecting a child after it is “deposed” from its privileged breastfeeding site to make way for a newborn child. The deposed child was put on a diet close or equal to an adult diet of ground maize, often laced with hot spices. The infants ate less and the reduced intake and lack of protein, sometimes mixed with parental neglect, led to what Williams determined to be a deficiency disease. She found that feeding the needy child with Nestlé’s canned, condensed milk produced a quick recovery, suggesting that protein deficiency was the main problem. Williams wrote a second report,
this one in a widely read pediatric journal, that brought the syndrome to broader attention.

Beginning of first article on kwashiorkor (Wellcome Library)

 Her second article caught the attention of the London physician, Hugh Stannus, who was an expert on pellagra, a disease due to niacin deficiency. Stannus felt that kwashiorkor was really pellagra, not a new disease. His authority held sway for a while, but eventually new evidence proved Stannus wrong. The work of Joseph Goldberger in the United States showing that pellagra was a dietary deficiency disease and the demonstration in 1937-8 that niacin alone, without a change in diet, could cure pellagra, established the difference between kwashiorkor and pellagra. 

Another champion of William’s ideas was Dr. Hugh Trowell, who worked in Uganda while Williams was in Ghana. Trowell found that medical missionaries in his area, back in the 1920s, had noticed a similar syndrome and described it in the first issue of the Kenya Medical Journal. They too had considered it a protein deficiency disease. Trowell had bowed before Stannus’ opinion but eventually joined Williams in considering it a new disease. The word “kwashiorkor” did not appear in textbooks of tropical medicine, however, until the 1950s.

Through the use of condensed milk and the encouragement of prolonged breast feeding many more children survived after abrupt weaning (though later findings showed that hypoglycemia could be a problem with condensed milk). Cicely’s work with children, mothers, and within the local communities lowered the child mortality rate, and resulted in women having fewer children. 

 A dispute between Williams and her chief led to an abrupt transfer to Malaya in 1936. Infant malnutrition in Malaya turned out to be generally due to insufficient breastfeeding from birth. Mothers, responding to European advertising and culture, had curtailed breastfeeding, feeding their infants condensed milk instead. Williams aroused controversy by campaigning to restrict the use of condensed milk and encourage milk from the breast. World War II, however, curtailed her efforts while she was incarcerated by the Japanese in the infamous Changi Prison in Singapore. After the war, still energetic, Cicely worked as head of a new Maternal and Child Health Division at WHO and was regarded as a specialist in child nutrition. After

Dr. Cicerly Williams (Wikipedia)

another stint in Malaya, she settled as a lecturer at the London School of Hygiene and Tropical Medicine. Her lectures and writings emphasized that to combat malnutrition it was necessary to investigate the social and behavioral causes, such as she had seen in Malaya, in addition to correcting the diet. She died in 1992, at the age of 98. 

Andrija Stampar, the public health physician who inspired Williams, was active in the League of Nations, and later presided over the conference convened to draft the constitution of the World Health Organization, where he served for many years.

The word kwashiorkor in textbooks now appears as part of a spectrum of nutritional disorders under the category of “Protein-calorie-deficiency” or “protein-energy-deficiency” disorders. They include kwashiorkor and marasmus, the latter characterized by severe wasting, absence of fat, and loose skin. Research work continues, as evidenced by finding distinct intestinal microbiomes in healthy and kwashiorkor-affected children. Cicely Williams’ work on nutrition lives on, as does her decades-long devotion to community maternal-child care.

A full index of past essays is available at: https://museumofmedicalhistory.org/j-gordon-frierson%2C-md

SOURCES:

 

     Williams, C, “Deficiency Disease in Infants: A Report by Miss C.D. Williams, Woman Medical Officer, Princess Marie Louise Hospital, Accra. Report of Medical Department, Gold Coast Colony, 1931-32. 1932; pp 93-99. 

     Williams, C D, “A Nutritional Disease of Childhood Associated with a Maize Diet.” Arch Dis Childhood. 1933; 8: 423-33.

     Craddock, S, Retired Except on Demand: The Life of Dr. Cicely Williams. 1983; Green College, Oxford.

     Trowell, H. “The Beginning of the Kwashiorkor Story inn Africa.” Central African Journal of Medicine 1975; 21(1): 1-5.

     Stanton, J, “Listening to Ga: Cicely Williams’ Discovery of Kwashiorkor on the Gold Coast.” Clio Med. 2001; 61: 149-71.

     Goodall, J, “Malnutrition and the Family: Deprivation in Kwashiorkor.”  Proc Nutrit Science. 1979; 38: 17-27. 

     Trowell, H, “Kwashiorkor, 1. Nutritional Background, History, Distribution, and Incidence.” Brit Med J.  Oct 11, 1952, 796-8.