In the eleventh century, bezoars were introduced to Europe from the Middle East. The Europeans considered bezoars to be of enormous value. They were used to treat snake bites, plagues, and all other sorts of “evil spirits.” Physicians even debated various dosages; twelve grains were used for a bite, while a weak heart or loss of sexual power was treated with only a single grain. In the late sixteenth century, the French surgeon Ambrose Paré, court physician to several kings of France and considered by some to be the father of modern surgery, was one of the most celebrated doctors in the world. He is best known today for his discoveries in the treatment of battlefield wounds. He found that a mixture of egg yolk, oil of roses, and turpentine worked better (and was immensely less painful) than the standard practice of his time, which was cauterizing the wound with boiling oil. He is less well known for an experiment he performed to test the effectiveness of treatment with bezoars.
Looking for an opportunity to see just how good a bezoar was at protecting a person from poison, Paré devised an experiment that was both simple and elegant. It may sound cruel to the modern ear, but he was using the scientific method to test a treatment that was very well accepted at the time. In 1575, a cook in the imperial court’s household had stolen some fine silverware. The cook agreed to be poisoned rather than hanged. Paré decided that he would administer a bezoar to see if it saved the man.
The cook was given the poison, and then the bezoar. According to Paré: “An hour after [he took the poison], I found him on the ground on his hands and feet like an animal with his tongue hanging out of his mouth, his eyes wild, vomiting, with blood pouring from his ears, nose, and mouth. Eventually he died in great torment, seven hours after I gave him the poison. I opened his body and found the bottom of the stomach dry, as if it had been burned.” The king commanded that the useless bezoar be destroyed.
Even after Paré’s experiment, bezoars continued to be valued for their curative powers. One famous claim in British case law, Chandelor v. Lopus in 1603, first introduced the notion of caveat emptor, or “buyer beware.” The dispute in the case had to do with the alleged fraudulent sale and purchase of a bezoar. When the Spanish began to colonize the New World, they were sending back numerous ships laden with treasure— silver, gold, emeralds, and other precious gems. In early September 1622, the galleon Nuestra Señora de Atocha and a fleet of other ships, filled with riches that would finance Spain’s participation in the Thirty Years’ War, set off from Havana. The ships were quickly caught in the first hurricane of the season, just east of Key West, Florida. Most of the flotilla escaped, but the Atocha and two other ships quickly sank. Only 5 of the 265 passengers and crew members survived. The fortune they carried lay lost at the bottom of the Caribbean until 1985, when some American treasure hunters finally located the wreck. Among the salvaged hoard, worth hundreds of millions of dollars, were silver bars and coins, gold bars, and enormous emeralds. So valuable were bezoars to the seventeenth-century Spaniards that ten of them (most likely of llama or alpaca origin) were stored in a silver case to be transported back to Madrid.
In the outbreak of bubonic plague that hit London in 1665, bezoars were still being used. However, some prominent physicians of the day were skeptical. One, Nathaniel Hodges, wrote in 1672, “For Ages together, the Oriental Bezoar still hath so great a name; yet without having an Inclination to contradict a received Opinion, I have been so convinced by a Multitude of Trials, that the Truth will speak for itself, which manifestly denies its Virtues to be at all equivalent to its value. And I have given it in Powder many times to 40 or 50 Grains, without any manner of Effect. And I dare affirm that the Bezoar with which I made these trials was genuine.”
In more modern times, as recently as 1962, a gold-framed bezoar was included in Queen Elizabeth’s crown jewels. Bezoars have even made their way into popular fiction. In the first Harry Potter book, during his Potions lessons, Harry is introduced to the bezoar. Later, in the Goblet of Fire, Harry forgets to add the bezoar to an antidote he is preparing. In yet another episode, when his best friend Ron is poisoned, Harry saves his life by administering a bezoar. Both in medicine and fiction, bezoars have played a long and colorful role in human history.
What Dr. Tracey was concerned about was not some magical potion derived from the ruminant stomach of a Persian antelope but a serious condition that could be at the root of his patient’s abdominal symptoms. Medically, a bezoar in human beings is the same kind of concretion of foreign material that develops in animals. But in humans, bezoars can accumulate to a size that obstructs the bowel or stomach. Bezoars are formed when hairs (trichobezoars) or vegetable fibers (phytobezoars) are ingested but not digested. Bezoars usually develop in the stomach and remain there, where they can cause pain, weight loss, and diminished appetite, sometimes mimicking a cancer. Often, they form in people with abnormal gastric function due to ulcer surgery or diabetes. Occasionally the material can make its way into the small or large intestine, where it plugs up the works. Bezoars are more common in children because they have smaller intestines.
There is a long list of foods that have been reported to cause bezoars. In some areas of the world where the persimmon is a popular fruit, it is also the commonest cause of bezoars. An eleven-year-old child from Cincinnati who had had prior abdominal surgery developed a bowel obstruction from eating a large amount of peanuts and peanut butter. In a two-year-old, the obstruction was caused by a large wad of chewing gum that obstructed the distal colon. Popcorn, sunflower seeds, oranges, mushrooms, and other high fiber foods have also been implicated. In one large series of cases, patients who were toothless seemed to have a higher incidence of bezoars.
Recently, in a strange twist on the notion of side effects, medicines have been reported to cause bezoars; these are called pharmacobezoars. One is the psyllium husk, which is used to treat constipation; a twentythree-year-old woman developed a colonic obstruction from eating too much psyllium. Cholestyramine is a medication used to lower serum cholesterol and to treat certain liver diseases. In one unfortunate toddler with a congenital bile duct disease, cholestyramine was prescribed and resulted in colonic bezoar that required surgical treatment.
An experienced surgeon, Tracey had seen his share of bezoars, and he once cared for a patient whose small intestine had become packed with mushroom particles. “The guy worked in a pizza parlor,” says Tracey, “and he used to eat all the mushrooms used on the pizzas.” But Schachte wasn’t on any exotic diet—or was he?
Like millions of Americans, Henry Schachte had been concerned about his cholesterol level. Cholesterol is a natural substance manufactured in the liver and is a necessary building block for all human cells. During the 1980s, the National Institutes of Health began an all-out campaign to raise Americans’ consciousness about cholesterol. There was a great debate in the medical and lay literature about how important cholesterol reduction is and by what means it should be accomplished, but there was consensus that high serum cholesterol levels are associated with an elevated risk of coronary heart disease, America’s number one killer.
One by-product of cholesterol’s new notoriety is that it is nearly impossible to steer through a food market without being assaulted by signs extolling the virtues of fiber. Most people now understand that greater consumption of dietary fiber may be related to lower cholesterol levels; consequently, we have become a society obsessed by dietary fiber. In part, this obsession resulted from the findings of a British researcher working in Africa in the 1970s, Denis Burkitt, and his colleague Hugh Trowell, who found that many of the diseases common in developed countries such as diabetes, hypertension, coronary artery disease, and diverticulosis were far less common in Africa. They connected the difference to the amount of fiber in the diet.
Burkitt studied the bowel movements of indigenous Africans and British people. He found that the Africans passed more than twice (and as much as four times) the bulk of stool as sailors in the Royal Navy. He and his co-workers hypothesized that the higher consu
mption of fiber in the African diet resulted in a greater amount of stool and decreased transit time in the colon. When he lectured, Burkitt would often punctuate his slide presentation with photographs of human feces that he took during his morning walks in the African bush. An Irishman, he was blunt and said, to paraphrase, that “the health of a country’s people could be determined by the size of their stools and whether they floated or sank, not by their technology.”
Burkitt wrote, “It is now generally accepted that the major factor causative of diverticular disease is a deficiency of fibre in the diet, and my colleagues and I have argued that this may also contribute to the causation of appendicitis. Both diseases are related to the consistency and volume of intestinal content, both of which are governed by the fibre content of the diet. Bowel behaviour was examined in communities with low, high, and intermediate frequency of colorectal cancer, and it was found that where faecal output was 300 – 500 g/day and mouth to anus transit times around 30 hours, cancer and its associated diseases were rare, but where, as in North America and Western Europe, output was only 80 –120 g/day, and transit times exceeded three days, these illnesses were common.”
Burkitt lectured in Britain and the United States, preaching the virtues of a natural diet rich in unprocessed foods and natural fiber and decrying the typical Western diet of white flour and highly refined sugars. Numerous scientific studies showed the benefits of a high fiber diet. The incidence of diabetes was lower. Cholesterol levels fell. Diverticulosis of the large intestine, a serious problem in which small outpouchings on the colon can became obstructed, inflamed, and infected, was less common. More minor but common health issues, such as constipation and hemorrhoids, were shown to be less widespread.
This issue became so pervasive that Time magazine covered the story in 1974. The following year, Burkitt and Trowell wrote a book about fiber. The foreword of their book says: “Once every 10 years or so a new idea emerges about the cause of disease that captures the imagination and, for a time, seems to provide a key to the understanding of many of these diseases whose aetiology was previously unknown. . . . To these we may now add a deficiency of dietary fiber. But whether it will be as seminal an idea as that of vitamin deficiency we shall probably not know for another 10 years.” Some of Burkitt’s ideas have not withstood the test of time (the relationship between low fiber and colon cancer has been questioned in more recent studies), but his basic theories and findings about a high fiber diet and health have had a sustaining influence.
It is also clear now that not all fibers are created equal. According to the American Dietetic Association, “dietary fiber is primarily the storage and cell wall polysaccharides of plants that cannot be hydrolyzed by human digestive enzymes.” There are two types of fiber—soluble and insoluble. And the two types have different effects on cholesterol levels.
Dr. Don Levy is an internist who practices in Cambridge, Massachusetts. He specializes in lipid disorders and is an instructor at Harvard Medical School. Says Levy, “If you took insoluble fiber, like wheat bran, and put it into a glass of water, it would just sit at the bottom and not absorb any water. Soluble fiber, on the other hand, would absorb water and form a gooey, viscous gel.” Only soluble fibers, such as oat bran and beans, can lower serum cholesterol levels.
No one understands how it works yet. Dr. James Anderson, a veteran researcher on the effects of soluble fiber, suggests that oat bran leaches cholesterol out of the system by causing bile acids (cholesterol by-products made in the liver and circulated in the intestine) to be eliminated in the gut. Additionally, when oat bran reaches the large intestine, it undergoes fermentation, releasing chemicals called fatty acids, which decrease cholesterol production. So less is made and more is lost, resulting in less cholesterol in the system. And there seems to be a selective decrease in low-density lipoproteins (LDL), commonly known as “the bad cholesterol” because they are usually associated with atherosclerosis, or hardening of the arteries. It’s also possible, of course, that the more bran and fiber one eats, the more full one feels, and therefore the less fatty and other unhealthy foods one eats.
All of this meant that by the 1980s, everybody was talking about fiber, and oat bran was one of the darlings of the fiber world. It was everywhere, even in bookstores. One book published in 1987, The Eight-Week Cholesterol Cure by Robert E. Kowalski, makes a persuasive argument for eating oat bran. At the end of his book, Kowalski included many recipes for cooking with oat bran, but the cornerstone of his diet was the oat bran muffin.
The book certainly persuaded Henry Schachte. His daughter recalls, “The idea about the oat bran came from my brother, who had had a heart attack and had cholesterol problems. I think he told dad about the book. Dad bought a copy and I remember him thinking ‘this is it.’ This would cure all his problems. He wasn’t abusive about it but he thought it was a great thing. He was going to make his own muffins. I remember him saying all the local health food stores were out of oat flour.”
The recipe in the book calls for fairly standard ingredients—milk, egg, sweetener, baking powder—and two and a half cups of oat bran to make twelve muffins. Shortly after Schachte read the muffin recipe, he found a store where he could buy the oat bran, and he set about baking muffins. From December 3 to December 13, he ate about four muffins a day (Kowalski recommends three). Little did Schachte know that, over the course of those ten days, he was slowly stuffing his small intestine full of the partially digested muffins.
Schachte wasn’t the first human in history to develop a bowel obstruction from fiber. A thirty-four-year-old was instructed by his physician to eat a large bowl of bran cereal each morning to treat his chronic constipation. Ten days after starting this new regimen, he developed abdominal pain, vomiting, and fever. As in Schachte’s case, the belly was tender, and x-rays showed loops of swollen intestine. At surgery, there was no hernia and no adhesions, but a stretch of the mid-ileum a foot and a half long was filled with a pasty mass that was too thick to simply be pushed from the outside with the surgeon’s fingers into the colon. That surgeon also needed to cut into the bowel and remove the material, which turned out on pathological examination to be “plant fiber.” A young man without any previous surgery, the patient went on to have an uneventful postoperative course.
Still, high fiber diets are very safe according to Dr. Levy. Certain precautions should be taken. Any new dietary routine can lead to changes in a person’s digestion. Because fiber passes through the gut unchanged, then undergoes fermentation in the colon, it produces gas. This can cause cramps and bloating as well as some socially unpleasant side effects.
“It’s important to begin slowly,” says Levy, “and to gradually build up the amount of dietary fiber. This may take a period of several weeks. And it’s also very important to increase the amounts of fluids, because the soluble fibers will absorb lots of water in the intestine.” This may be especially important for someone who has had abdominal surgery or has abnormal bowel function, although Tracey knows of another case of an obstruction caused by oat bran in a person who had never had prior surgery.
The pathologist’s examination of the contents of Schachte’s intestine verified Tracey’s diagnosis: it was a phytobezoar composed of oat bran. Despite this incident, bezoars from oat bran must be very unusual, given the number of people eating oat bran in this country and the rarity of that complication. To put it all in perspective, Levy points out that “much of the world regularly eats far more fiber than we do without ill effects.”
Schachte’s post-op recovery was long and rocky. He awakened from surgery with a tube coming out of his nose to help decompress his stomach, and another coming directly out of his abdomen that Tracey had placed as a drain in case of infection inside the abdomen. His daughter remembers a call from Dr. Tracey the morning after surgery. “His expression was something like, ‘he was stuffed like a turkey.’ Dad went through an incredibly rough time afterward.” Tracey’s discharge summary noted that “his postoperative per
iod was complicated by very slow return of bowel function probably due to his severe and extensive adhesions.” He also developed another bout of pain from a small bowel adhesion, but fortunately Tracey was able to pull him through this episode without another surgery. Schachte himself recalls needing large doses of pain medicines that gave him very vivid and very bad dreams.
Finally, after three weeks in the hospital, he was well enough to be discharged. He remembers being “alarmed that the author was not a doctor, just a medical writer. I felt a bit tricked and angry.” When asked about advice for others who are contemplating starting a high fiber diet, he said, “if you ever had anything that could leave scar tissue in the abdomen, certainly check with your doctor first.”
Ultimately he recovered completely and is well again, but he avoids oat bran like the plague.
13 The Case of the Unhealthy Health Food
Joanne Young was the kind of person who didn’t just worry about her health; she did something about it. In fact, the forty-eight-year-old Massachusetts woman had taken exceptionally good care of herself for years, jogging five miles daily, eating a nutritious diet, abstaining from smoking, and limiting her alcohol intake to rare social occasions.
So when her feet became swollen during a vacation to Hawaii in April 1981, she dismissed it as nothing more than simple water retention. “I figured it was due to the flying or whatever, but after I returned home, my legs were still quite swollen and all the extra pounds seemed to be concentrated in my middle. I felt all right though, so I kept up my running. At one point I remember figuring, ‘Oh well, this is the beginning of menopause,’” Ms. Young recalls. By late May however, it was impossible to ignore the twenty pounds of weight that she had gained since returning home. Joanne kept up with her five-mile runs, but she was now concerned enough to consult her family doctor. “I thought it was just weight gain, but I went to see my local doctor who took one look at me and said, ‘Joanne, you have ascites.’ I didn’t know what that was at the time. He did an ultrasound, which I was told showed a cyst, so he referred me to my gynecologist.”
The Deadly Dinner Party: and Other Medical Detective Stories Page 20