Lives of the fellows

Hubert Carey Trowell

b.8 August 1904 d.23 July 1989
OBE MB BS Lond(1928) MD(1933) MRCP(1933) FRCP(1945)

Hubert (Hugh) Carey was educated at Reigate Grammar School and received his medical training at St Thomas’ Hospital. Shortly after graduation he married an art student, Margaret (Peggy) Sifton, and then joined the Colonial Medical Service; they sailed to Kenya together in 1929. In a makeshift hospital with minimum facilities, he was soon teaching the basics of medical care to African orderlies with only rudimentary education. Working in Kenya and Uganda from 1929-58, Trowell identified as a nutritional disease a condition now known as PEM (protein energy malnutrition). He was slightly preceded by Cecily Williams (q.v.), working in Ghana, who published a description of the condition using the local name ‘kwashiorkor’. Trowell was unaware of Cecily Williams’ work for some years; she transferred to Malaya, made no further progress, and was imprisoned during the war. In 1935, Hugh had been transferred to Mulago Hospital and Medical School, Kampala, Uganda, where he was consultant physician, senior lecturer, and paediatrician until he retired in 1959. He first taught African medical assistants, and later the first African doctors to be trained for the East African territories, and continued his work on kwashiorkor. He wrote two textbooks, A handbook for dressers and nurses in the tropics, London, Sheldon Press, 1937, and Kwashiorkor, co-authored with J N P Davies and R F A Dean, London, Edward Arnold, 1954, both of which went into several editions and were used across Africa. It was the latter work which led to his election to the fellowship of the College and the award of the OBE. His book was republished a quarter of a century later in Classics in nutrition in the Nutrition Foundation reprints.

Hugh Trowell was the first to make a systematic study of the disorder and at first his work was vigorously opposed in East Africa, where the received opinion was that children were suffering solely from helminths, tropical infections or congenital syphilis. Undeterred and, initially, with only the most rudimentary facilities (the hospital had no electricity, no running water, and no pathologist) Trowell continued his clinical studies and trials. During and after the war he was encouraged by Sir Harold Himsworth (q.v.), who was behind Trowell’s election to the College. Himsworth began to channel staff and some MRC support towards him. Recognition came with a World Health Authority report in 1952 which highlighted his work on kwashiorkor, then recognized as probably the most widespread nutritional disease of children in the tropics. By the time Trowell retired from Uganda in 1958 he was internationally acknowledged as an authority on kwashiorkor.

After his retirement from medicine in 1959 he entered theological training and was ordained to the Anglican Ministry. He was vicar of Stratford-sub-Castle, Wiltshire, from 1962-72, and also chaplain to Salisbury Infirmary. At first he had found his theological studies ‘. . . a bit disturbing.’ He had to learn to discard the scientific method that he used for 30 years as a clinician, but he ' . . came to realise that a great deal of life slipped through my scientific tests . . . that the scientific temper was adequate to investigate certain aspects of life but not others.’ His return to Christianity was achieved at ‘. . . no small difficulty . . .’ but he believed that he had found an adequate model and one that gave meaning to life. He was an active member of the Christian Medical Fellowship and his deep Christian faith motivated much of what he did. He chaired many committees, studying matters relevant both to the medical profession and the Church, including the London Medical Group 1960-64 and the BMA committee on euthanasia. After ten years as a country parson Trowell retired again in 1969 only to be called back to what was effectively a third career. He had scoured some 1700 papers to write his magnum opus which appeared in 1960, Non-infective disease in Africa, London, Edward Arnold. He had listed 30 diseases, all rare, but he could not explain their rarity. He felt sure that nutrition was relevant but had no coherent hypothesis. But like Saul, later St Paul, on the road to Damascus in c.AD 35, his life like Saul, later St Paul, on the road to Damascus in c.AD 35, his life was suddenly changed. He heard ‘ a voice from Heaven’ - embodied in an old colleague from Uganda days, Denis Burkitt, who said ‘Have you heard of the ideas of Surgeon Captain Cleave?’ [Munk s Roll, Vol.VII, p.101]. Cleave blamed many of the major diseases of the west on the consumption of refined carbohydrates; his ideas seemed logical and Burkitt’s own epidemiological studies seemed to support them. Trowell had accumulated much evidence that the diseases discussed by Cleave were all rare in black Africans and now he was presented with a hypothesis which fitted all the facts he knew. But the hypothesis seemed too vague and its terms ill-defined. So he sought out Cleave and tried to debate his ideas. Sadly, Cleave was developing Alzheimer’s disease and his ideas had fossilized; he had suffered in the scientific wilderness and was suspicious of anyone with similar ideas. The two men clashed. Trowell, a sensitive man, felt slighted and never got over it. In his reaction to this trauma he rejected Cleave’s belief that sugar, the most fibre-depleted carbohydrate, was harmful and developed instead the hypothesis that fibre-depleted starch was the prune nutritional abnormality in Western diseases. To bolster this idea he studied scores of reports of animal models for dietary atherosclerosis and diabetes and showed that the common factor was lack of fibre. With Burkitt’s support, he turned the emphasis away from the harmful nature of fibre-depleted foods and towards the protective nature of fibre itself. Criticisms that this view over-simplified things, and that it promoted bran as a panacea, were unjust - but they stung.

Trowell always maintained that the diet must be seen as a whole and stressed the fact that Western attitudes to traditional diets involved not only a fall in fibre and starch intakes but also a rise in fat - and sugars. Like Cleave, he believed in the maladaptation of the human body, with its stone-age physiology, to modern artificial foods and his scholarly studies added much to the evidence. Out of this turmoil came Trowell s chief contribution to the fibre story - a definition. As he saw it ' . . confusion reigned over this disordered field.’ It is true that until 1972 research in dietary fibre had proceeded without a formal definition. Fibre was tacitly accepted as synonymous with plant cell walls and as being indigestible, but terms like ‘crude fibre’ and ‘unavailable carbohydrate’ confused the issue. Trowell formally proposed the term ‘dietary fibre’ (only to discover that Hipsley had invented it in 1953) and defined it as ‘. . . the skeletal remains (of plant cell walls) that are resistant to digestion by the enzymes of man.’ Later he was persuaded to include non-cell wall materials of a similar nature, that is - other undigested polysaccharides. This definition did much to make the fibre story credible to scientists and is still useful (though we now know that a minority of starch escapes digestion too and that the physical state of food matters at least as much as its chemically measured fibre content).

Hugh Trowell’s most scholarly achievements, besides Non-infective disease in Africa, were his editing of Western diseases: their emergence and prevention, London, Edward Arnold, 1981, jointly with D P Burkitt and 34 other authors, and of Dietary fibre, fibre depleted Burkitt, K W Heaton and 22 other authors. These were a tour-de-force for someone of any age, let alone a man of around 80. His mind remained flexible and receptive almost to the end. Trowell never received the recognition he felt was due to him but probably underestimated how much he was respected (in later years deafness made it difficult to communicate with him). Perhaps his proudest moment was at an international conference on dietary fibre in Washington, in 1988 (a year after he had suffered a serious illness) when, together with Denis Burkitt and the South African fibre pioneer Alec Walker, he was presented with a scroll of honour signed by all the delegates. In his long and varied life Hugh Trowell saw much and wrote much; his writing included ten books. Even in his 85th year he was engaged in vigorous scientific debate by correspondence. If he had lived a few more days he would have stood up and spoken at a meeting in his honour at the Royal Society of Medicine - yet he had retired from medical practice 30 years before, and his only gainful employment since then had been as a minister of religion, except for his writing. Christianity and nutrition were his consuming interests and he wrote with distinction about both, especially nutrition.

His wife Peggy, who founded the School of Fine Art at Makerere University, died in 1985. His son and three daughters survived him.

A memoir by his long-time colleague, D P Burkitt FRS, has been published by the McCarrison Society, 24 Paddington Street, London W1M 4DR, in its series Founders of Modern Nutrition, and a full biography is to be published.

K W Heaton

[The Lancet, 1969,2,399;The Times, 28 July 1989; World Medicine, 18 Apr, 6 June 1967; Sunday Mirror 1 Jan 1960; Scientific American, Dec 1954]

(Volume IX, page 533)

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