The picture was further confused in the eighteenth century by a readiness of physicians to describe a whole range of unrelated conditions as “scurvy”; and the term became a convenient nosological safety net for the not inconsiderable number of diagnostic failures of the century. In the words of one physician: “It is yet a suficient Answer to Patients when they enquire into their ailments to give this Return to a troublesome Enquirer, that their Disease is the Scurvy, they rest satisfied that they are devoured with a Complication of bad Symptoms. . .” (Strother 1725: 150). At the end of the century the maverick Sir John Hill declared on the title page of his The Power of the Water Dock against the Scurvy (1777) that “If any one is ill, and knows not his Disease, Let him suspect the Scurvy.”1
With such confusion surrounding scurvy, one cannot with any certitude delineate the true importance of the ailment among land dwellers in the seventeenth and eighteenth centuries, and in the absence of details of dietary patterns (and particularly of the consumption of vegetables by the population in general), there must remain considerable doubts about its true incidence. About all that is clear is that the use of the term “scurvy” was almost certainly more common than the disease itself.2
Nevertheless, epidemics did occur; Hirsch lists some 30 such outbreaks during the eighteenth century in such diverse areas as Canada, Denmark, and Russia (1885: 521-3). Among the seafaring population, however, the picture was much more clearly delineated, and right through the seventeenth and eighteenth centuries scurvy was the most feared of all the hazards associated with long sea voyages, and with good cause. As we have already noted, it has been estimated that between 1600 and 1800 scurvy accounted for some million deaths at sea and that in almost every naval campaign of any length during this period scurvy played an important role (Roddis 1951:72).
James Lind
The name of James Lind is deservedly associated with a substantial advance in the understanding of scurvy. A ship’s surgeon, he soon came face-to-face with the ravages of the disease among sailors. Others before him had successfully used empirically discovered remedies in the cure of scurvy, and their use of citrus fruits as the antiscorbutic remedy par excellence was well established (see, for example, Zulueta and Higueras 1981). This was presumably known to Lind, who himself quoted J. G. H. Kramer’s observation “. . . if you have oranges, lemons or citrons. . . you will, without other assistance cure this dreadful disease” (Stewart and Guthrie 1953:154).
John Woodall in his The Surgions Mate (1617) quite clearly drew attention to the prophylactic value of lemon juice - which had, in any case, already been successfully used by James Lancaster in his East Indian voyage at the beginning of the century. In 1696 William Cockburn underlined the importance of fresh fruit and vegetables to sailors in his Sea Disease, or Treatise of their Nature, Cause and Cure and in his Essay on Sickness and Health (1725). Edward Strother also had pointed out that “eating Lemons and Oranges” would cure scurvy in sailors.
But Lind’s achievement was that he subjected these empirically derived claims, and others, to the test of scientific experimentation in what has been claimed to be the first controlled clinical study in the history of medicine. Here is a description of it in Lind’s own words:
On the 20th of May, 1747, I took twelve patients
In the scurvy, on board the Salisbury at sea.
Their cases were as similar as I could have
Them. They all in general had putrid gums, the spots and lassitude, with weakness of the knees. They lay together in one place, being a proper appartment for the sick in the fore-hold; and had one diet common to all, viz. 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 and raison, rice and currants, sago and wine, or the like. Two of these were ordered each a quart of cyder a day. Two others took twenty-five gutts [drops] of elixir vitriol three times a day, upon an empty stomach; using a garble strongly acidulated with it for their mouths. Two others took two spoons-fuls of vinegar three times a day upon an empty stomach having their gruels and other food well acidulated with it, as also the gargle for the mouth. Two of the worst patients, with the tendons in the L arm rigid (a symptom none of the rest had) were put under a course of sea water.
Of this they drank half a pint every day, and sometimes more or less as it operated, by way of gentle physic. Two others had each two oranges and one lemon given them each day. These they [ate] with greediness at different times, upon an empty stomach. They continued but six days under this course, having consumed the quantity that could be spared. The two remaining patients took the bigness of a nutmeg three times a day, of an electuary recommended by an hospital-surgeon, made of garlic, mustard seed, rad. raphan., Balsam of Peru, and gum myrrh; using for common drink, barley water well acidulated with tamarinds; by a decoction of which with the addition of cremor tartar, they were gently purged three or four times during the course.
The consequence was that the most sudden and visible good effects were perceived from the use of the oranges and lemons; one of those who had taken them, being at the end of six days fit for duty. The spots were not indeed at that time quite off his body, nor his gums sound; but without any other medicine, than a gargarism of elixir vitriol he became quite healthy before we came into Plymouth which was on the 16th of June. The other was the best recovered of any in his condition; and being now deemed pretty well, was appointed nurse to the rest of the sick. Next to the oranges, I thought the cyder had the best effects. . . . (Stewart and Guthrie 1953:145-7)
Lind’s note on the partial efficacy of cider has been quoted in support of the thesis that cider, as prepared traditionally in the eighteenth century, would have contained significant amounts of vitamin C and that it could have played a significant role in the prevention of scurvy (French 1982: 59-66). Although this may have been the case, such evidence as is available would suggest that in general, very little of the original vitamin C would survive a fermentation procedure (Hughes 1975,1990).
Lind’s book A Treatise of the Scurvy appeared in 1753; a second edition was published in 1757 and a third and “updated” version in 1772 (a bicentenary reprint of the first edition was published in 1953 [Stewart and Guthrie 1953]). A French translation appeared in 1756 with subsequent reprints, and an Italian translation was published in 1766.
Not all of Lind’s conclusions, however, were characterized by the same degree of scientific acumen that he displayed in his famous “scurvy trial,” and it is clear that he claimed “antiscorbutic” properties for preparations that modern analysis would suggest are quite devoid of vitamin C (Hughes 1975). Nevertheless, his experimental demonstration that oranges and lemons could cure scurvy, his critical assessment of the literature of scurvy, his demonstration that the distinction between “land scurvy” and “sea scurvy” was a spurious one, and his advocacy of the use of various prophylactic foods by ships’ crews must place him among the most significant figures in the history of nutrition.
Unfortunately, although subsequent commentators advocated the official adoption of lemon juice by the naval authorities as a prophylactic measure, they met with little success for many decades (Carpenter 1986: 73, 87). The purchase of vegetables by ship captains was sanctioned but the practice soon lapsed, and scurvy among sailors continued unabated. Indeed, when the Channel Fleet returned to port in 1780 after a cruise of only six weeks, there were 2,400 cases of scurvy present (Lloyd 1981: 12).
But in 1795, largely as a result of the advocacy of Gilbert Blane, himself a prominent and influential naval surgeon (actually “physician to the fleet”), the official issue of lemon juice to naval personnel in Britain was sanctioned (the practice was not, however, officially extended to the merchant service until 1844).Within two years, cases of scurvy in naval hospitals were rare occurrences, and there were clinicians who complained that they had never seen a true case of scurvy - a situation that would have been unthinkable a few years previously. J. Turnbull’s almost monotonously successful treatment of the few scorbutic sailors arriving at Liverpool in 1848, merely providing them each with two lemons daily, was, perhaps, the final elegant vindication of Lind’s pioneer study (Turnbull 1848).
World History
