History Scotland Magazine: The Answer was a Lemon

THE ANSWER WAS A LEMON

David Harvie

Probably the most significant improvements in maritime conditions during the 18th and 19th centuries were achieved by the solving of the longitude problem and the conquering of scurvy. This article describes how Scots naval surgeons defeated scurvy despite the effects of that other corrosive 18th century disease - patronage.

"... the common appearances are large discoloured spots, swelled legs, putrid gums and above all an extraordinary lassitude of the body, especially after any exercise whatsoever; this lassitude at last degenerates into a proneness to swoon and even die on the least exertion of strength. This disease is likewise attended with a strange degeneration of spirits, with shiverings, tremblings and a disposition to be seized with the most dreadful terrors on the slightest accident."

That description of scurvy was written during a famous circumnavigation of 1740-44 by Commodore George Anson. He had left Portsmouth with seven ships and 1,955 men principally to harass the Spanish off the west coast of Central and South America. He returned with one ship and 145 men. Oh, and a fabulous Spanish treasure, captured from a Manila galleon, which required 32 wagons to transport it from Portsmouth to the Tower of London. But 1,051 sailors had died, mostly from scurvy; hundreds of others were incapacitated by the vile disease. His only medicines were sulphuric acid mixed with herbs, and a violent diuretic peddled by Joshua Ward, a notorious society 'quack' who had the ear of the lords of the Admiralty; Ward's 'Pill and Drop', made from balsam, wine and antimony killed more men than it cured.

Scurvy was not only a degrading and disgusting disease, but it had the most appalling economic effects on Britain and other maritime nations. It killed more men than the actions of all enemy forces combined; in the 20 years of war that began in 1793, 6% were killed in action and 82% by disease. Even after the Royal Navy followed the merchant companies in extended circumnavigations - with the attendant exposure to new disease - scurvy remained the most feared disease on board ship. This was largely due to its ability to destroy the immune system, thereby exposing the victim to all manner of complications.

About 360 BC, Hippocrates himself was one of an influential procession of early medical writers to describe the disease that was only much later named 'scurvy', but the best early record of its horrors was made during a voyage by the French explorer Jacques Cartier to eastern Canada in 1535. For the next three and a half centuries those who made long sea journeys suffered the ravages of both the disease itself and the sometimes bizarre efforts to combat it. For centuries scurvy was difficult to diagnose, due to the problems compounded by immune deficiencies. Before John Harrison laboriously but successfully built his famous series of marine chronometers - enabling accurate calculation of longitude - voyages were often unnecessarily extended as ships repeatedly retraced their tracks in search of some certainty of their position. Sir Richard Hawkins, the veteran Elizabethan sailor, had personal experience of the benefit of using oranges and lemons against scurvy, although the fruit was difficult to obtain. He nevertheless had a blind spot in failing to recognise that the fruit could be better used in preventing the disease, rather than in simply alleviating its dreadful effects. Hawkins did however realise that the problem would require someone special to investigate it on a scientific basis, and to consign centuries of deadly remedies to the dustbin of history:

I wish that some learned man would write of it, for it is the plague of the sea, and the spoyle of Mariners doubtlesse; it would be a meritorious Worke with God and man, and most beneficiall for our Countrie.

During the 18th century, most people (other than the urban well-to-do) had little, if any, contact with legitimate medicine. Ill-trained enthusiasts peddling a mixture of popular mysticism and outright quackery undertook much of what passed for the practice of medicine. As far as scurvy at sea was concerned, scores of 'remedies' were tried and most naval surgeons had their own favourites. In practice, there were far too many, often used in conjunction (and conflict) with others to enable anyone to quantify any potential benefit. Scurvy was commonly thought to be caused by moisture, salt food, bad water, laziness or that perennial stand-by of Georgian medicine - 'the state of the blood'. We know the cause to be a deficiency of vitamin-C (a fact not understood until well into the 20th century). Most animals manufacture this substance themselves, but humans are unusual in having to acquire it either in the diet or artificially in order to maintain the vital tissue known as collagen. Although dietary deficiency had been recognised since mediaeval times, it had seldom been related to scurvy.

For centuries, common remedies included those two essential treatments of even the well-to-do in affluent society - bleeding and purging. Neither would have achieved any benefit. Others such as the use of vinegar, sauerkraut, scurvy-grass and beer or tea made from citrus roots and fruits may have had modest intermittent success. Others were more likely to injure or kill - sulphuric acid, urine mouthwashes, mercury, antimony and quack pills. Yet more, such as burial up to the neck in sand, or bathing in animals' blood were simply idiotic. The wide variety of doubtful dietary treatments - from spruce beer through cider, vinegar, sauerkraut, and a mixture of garlic, mustard, radish and balsam to the more eccentric such as The Pill and Drop - did not stay in good condition for very long. Sir Samuel Garth, the late 17th century Physician-General to the Army, was well aware of the danger of what passed for medicine at the time; Garth was also a poet, and accurately satirised the kind of fraudulent medicine of Joshua Ward:

Some fell by laudanum and some by steel And Death in ambush lay in every pill.

The 'Learned Man'
James Lind was born in Edinburgh in December 1716, the son of a successful merchant. At the age of fifteen, he became a registered apprentice to George Langlands, Fellow of the Royal College of Surgeons of Edinburgh. A keen apprentice with a good physician would have made a skilful twosome, and an able pupil could expect to learn a great deal by observation and experience. The apprenticeship would probably have been contracted as most of the period; it would last for three years, and the youth would agree,

. . . to bind himself to his master by day and by night, holy-day and weekday; to reveal no secret of master or patient; to commit no filthy crimes or sins; to go to no professor of medicine, chyma, anatomy, surgerie, or materia medica during the first two years; to pay 50 sterling as apprentice fee, in return for which the chirurgeon obliges himself to instruct him in the said airtes of surgery and pharmacy, and shall conceal nothing of the same, and entertains him sufficiently in bed and board.

When war broke out with Spain in 1739, the 23-year-old Lind became a surgeon's mate in the Royal Navy (joining in the same year as did the novelist Tobias Smollett, whose 'Roderick Random' follows the adventures of his surgeon's mate of the title). Lind served in the Mediterranean, the West Indies and West Africa, sailing mostly with Commodore Edgcumbe in H.M.S. 'Salisbury'. He was appalled by his first-hand experience of the effects of scurvy, and determined to concentrate on tackling the problem after reading the accounts of Anson's disastrous expedition. During this period, there were frequent running sea battles with the French and Spanish, and disease took a staggering toll. In the Seven Years War from 1756-63 for example, 1,512 men were killed in action and 133,708 were lost to disease and desertion.

While aboard 'Salisbury' during 1747, Lind conducted the first-ever controlled clinical trial. He selected twelve men in two groups of six, all showing similar symptoms of scurvy. He gave each man a similar basic diet:
. . . water gruel sweetened with sugar in the morning; fresh mutton broth often times for dinner; at other times puddings, boiled biscuit with sugar etc; and for supper barley, raisins, rice and currants, sago and wine, or the like.

All were given additional supplements based on recognised 'treatments'; two had a quart of cider per day; two were given sulphuric acid; two were given sea-water; two had vinegar; another two had a mixture of garlic, mustard, horseradish and other herbs and natural gums; and the last pair were each given two oranges and one lemon. Despite the fact that Lind was not allowed to deplete the ship's supply of the fruit, the last two men made spectacular recoveries, in comparison to the others, who continued to languish.

The efficacy of lemon and orange juice had been suspected for perhaps two centuries, but Lind was the first to prove conclusively by carefully observed and recorded experiment that it not only cured but more importantly prevented scurvy, and that most other common 'remedies' were worthless. Lind resolved to be vigorous in considering the history, and as a determined believer in observation and rigorous interpretation, he promised to, 'confirm all by experience and facts, the surest and most unerring guides.' Since the fresh fruit did not keep in good condition at sea, the juice would be important; however attempts to preserve citrus juice at sea had been unsatisfactory due to lead poisoning from the action of highly concentrated juice on the glazing of earthenware jars. Lind resolved to conduct further work and to convince the Admiralty of his findings. This was to be a difficult task. Ironically, there was widespread prejudice against fresh fruit and meat. Even the humane Captain James Cook once had two sailors flogged before they would eat fresh meat. Lemons and oranges were hard to obtain, difficult to store and were in any case disliked. Conservatism was rife. While general opinion held that climatic conditions were the principal cause of scurvy, the influential physician William Cockburn disdainfully complained that it was a disease which attacked only the idle. In Lind's day, the prevailing blinkered attitude was nicely conveyed by one Admiralty instruction:

... one must, when ships reach countries abounding in oranges, lemons, pineapples, etc, ensure that the crew eat very little of them since they are the commonest cause of fevers and obstruction of the vital organs.

James Lind's mountain was to be high.

Patronage and Perversity Lind resigned from the Navy and returned to Edinburgh in 1748 to complete his MD degree, and was elected Fellow of the Royal College of Physicians of Edinburgh two years later. During ten years in Edinburgh Lind published two important works, on scurvy and naval hygiene. His Treatise of the Scurvy, which he dedicated to Lord Anson, was published in 1753; and An Essay on the most Effectual Means of Preserving the Health of Seamen in the Royal Navy, dedicated to Commodore Lord Edgcumbe, was published in 1757. The following year, probably with the support of Anson, Lind was appointed Physician to the Royal Naval Hospital in Haslar at Portsmouth. This was a huge establishment - Europe's biggest - with about 2,000 patients suffering a vast range of illnesses contracted all over the world. Lind remained at Haslar for twenty-five years, conducting further research into scurvy and tropical diseases, much of which was published in book form.

The availability of fresh water was of vital importance in long sea voyages, and Lind also conducted experiments into distillation of sea-water. Previous methods had produced a foul-tasting water, but Lind's method was a huge improvement and he went on to design a practical apparatus for use at sea. The Admiralty however did not endorse his work, and insinuated that his system was the work of others. Four years later, a French naval doctor was awarded a substantial pension for devising a suspiciously similar apparatus. Even worse, Lind was appointed by the Admiralty to a Board which was required to ratify yet another identical proposal by a Royal Navy surgeon who had been given generous financial support by the House of Commons. As with John Harrison the clockmaker, the Admiralty behaved with considerable injustice towards Lind.

Although he held such a senior position in naval medicine, Lind did not have either the patronage - that corrosive 18th century social evil - or the influence to promote his cause successfully. Neither did he have the character or the inclination to seek the fickle favouritism that was so common at the time; by all accounts he was a sympathetic, generous and self-effacing man. The heavily-patronised Captain James Cook has often been given the accolade of 'the man who conquered scurvy'. This is wholly erroneous; in line with his reputation as a good and humane commander (who had the ability to secure the very best of crew, conditions and victualling), Cook carried a multitude of potential scurvy remedies, and added confusion rather than clarity to the economically disastrous scurvy problem. As a recipient of the patronage of the influential Montagu clique in the Admiralty, Cook gave too much credibility to the entirely useless malt wort remedy of David MacBride (a naval surgeon also under the Montagu favour). Not only that, but following his second great southern voyage in 1776, Cook colluded with Sir John Pringle, Surgeon-in-Chief of the Army, in condemning Lind's proposals.

There was indeed a flaw in Lind's method of preparing lemon juice; his practice of employing extended periods of heating largely destroyed the vitamin-C. It has to be remembered that the 'mystery factor' was the sole explanation for the efficacy of lemon juice, the concept of vitamins still being 150 years distant. However, his central insistence on the efficacy of oranges and lemons was entirely correct, and it was a scandalous example of official perversity that resulted in his recommendations for their adoption being ignored for over forty years, by which time he was dead. So were several thousand sailors who had succumbed to scurvy in the meantime. The great English philosopher and evolutionary theorist Herbert Spencer described that delay as an example of the most outrageous, pig-headed bureaucratic indolence.

Disciples Carry the Flag
Despite the Admiralty's sloth, there was plenty of informed interest elsewhere in Lind's work, and his Treatise went into three editions. He was elected a Fellow of the Royal Society of Edinburgh, and held medical honours in Paris and Copenhagen; but in London there was prejudice and suspicion. Haslar had been a nightmare to control; its population of seamen, many of whom had been press-ganged into the Navy, often regarded it as a prison. Control of the hospital did not lie with the Physician-in-Charge, but with a complicated administration involving its Council and the Admiralty Board of the Sick and Hurt Sailors in London and its various interfering Commissioners. The Admiralty bureaucracy was eventually to have its attitudes ruffled by two other Scottish physicians who would break the prejudice.

Gilbert Blane (later Sir Gilbert) was born in 1749 at Blanefield, near Kirkoswald in Ayrshire, about two miles from Culzean Castle. He studied arts and medicine at Edinburgh and graduated in medicine from Glasgow University. He went to London, became personal physician to Admiral Rodney, and sailed to the West Indies in 1779, experiencing several sea battles against the French. Rodney appointed Blane Fleet Physician, and when he returned to England in 1783 he became physician at St. Thomas's Hospital in London. He was later appointed Physician Extraordinary to the Prince of Wales, the Duke of Clarence, George IV, the Emperor of Russia and the President of the USA. His reputation at court was to be a significant factor in promoting James Lind's recommendations. Blane was a forceful advocate of better naval hygiene and sanitation. Thanks to his royal connections and his friendship with the influential Rodney, he was in a much better position than Lind had been to persuade the conservative minds of the Admiralty that substantial improvements in conditions on board ship were required.

Blane was joined in his efforts against scurvy by a maverick naval surgeon, Thomas Trotter, who had been born in Melrose in 1760. Trotter was anti-authoritarian and a man of startlingly different nature from the straight-laced Blane (referred to behind his back as 'Chill-Blain'), yet they formed a highly constructive partnership. Trotter, by nature deeply humanitarian and something of a poet, had learned to loathe scurvy when serving on a Liverpool slave-ship. He and Blane had complete belief in and gave full credit to Lind's work and exerted constant pressure on the Admiralty to adopt the use of fresh lemons. Blane had become one of the Commissioners for the Sick & Hurt Board, and in that capacity exerted constant pressure on the Admiralty to allow lemon-juice to be introduced under the supervision of himself and Trotter. Finally, in 1795, an official order was given by Lord Spencer, First Lord, for the issue of lemon-juice when requested by fleet commanders in foreign waters. Ironically, James Lind - 'the Father of Nautical Medicine' - had died a few months earlier in July 1794 at Gosport in Portsmouth. He died in relative obscurity, with no recognition by the Admiralty, and little by the great learned institutions, of his undoubted contribution to naval hygiene and medicine. Blane and Trotter lobbied aggressively, ensuring that a succession of admirals and commanders demanded lemon-juice. Eventually, as its efficacy was proven, the use of lemons was extended throughout the Navy, and within two years when First Lord Spencer asked to see scurvy cases at Haslar, none could be found.

Confusion (and Scurvy) Return
This did not signal the end of the affair. There were still problems in preserving lemon-juice; there were problems of supply and adulteration by unscrupulous suppliers; and efficacy was still mistakenly equated to acidity (which was often incidentally reduced by the attempts to preserve the juice). By the 1850's, it was deemed preferable to give Admiralty money to English gentlemen growing limes in the West Indies rather than to foreign lemon-growers in the Mediterranean. This decision was a disaster; the supposedly similar fruits in fact retained dramatically different amounts of vitamin-C, and scurvy returned with a vengeance. Ships that relied on lime-juice and still suffered from severe scurvy were all the evidence that was required to damn Lind's recommendations. With scurvy, back came a desperate reliance on sulphuric acid and the veteran panoply of useless remedies.

By the later 1800's, the longitude problem had been solved, and steam-power ensured that voyages were dramatically shortened. Scurvy eventually became a problem more common to land armies, arctic whalers and polar explorers, where conditions were severe and food supplies reduced. Significantly, it was the result of the analysis of two polar expeditions of 1850 and 1875 - the first, successfully supplied with lemon-juice and the second, disastrously, with lime-juice - that began to supply the answer; limes had only one quarter the (still mysterious) antiscorbutic effect of lemons. This investigation was undertaken by the Lister Institute in London in 1917 during the preliminary work that would identify vitamin-C fifteen years later.

The Vanity of Cure
Knowledge of diet and vitamin deficiency improved, voyages became shorter in duration, and methods of preservation of fresh fruit and vegetables became more sophisticated; but it still cannot be assumed that scurvy has been entirely eradicated from the general population. It may not be the only mediaeval disease that is still lurking on the perimeter of our lives, ready to take hold when we misuse antibiotics, for example. James Lind was contemptuous of the simplistic notion of any kind of assumed 'right' to a cure for disease. He spoke of 'the vain and chimerical belief' in the concept of 'an infallible remedy' that had for so long 'rendered the art of healing as variable and unconstant as our dresses.' We would do well to keep that stricture in mind. The efforts of Lind, Blane and Trotter, momentous as they were in their lifetimes, may well serve us more directly in the future than any of us might imagine. While James Lind achieved intellectual and practical success, this modest man recognised that his work did not constitute a conclusion:
. . . though a few partial facts and observations may, for a little, flatter with hopes of greater success, yet more enlarged experience must ever evince the fallacy of all positive assertions in the healing art.

Lind was one of those giants on whose shoulders the midwives of organic chemistry stood. Their enlarged experience and imaginative strides certainly took Lind's work further forward and improved the 'healing art'. That progress notwithstanding, scientific enquiry - into the continuing story of vitamin-C amongst other subjects - is no doubt still awaiting further conclusions.

LIMEYS: The True Story of One Man's War against Ignorance, the Establishment and the Deadly Scurvy by David Harvie is published by Sutton Publishing at 14.99 ISBN: 0 7509 2772 0

David Harvie is a freelance historian and writer based in Dumbarton.