The Story of Scurvy: The Controlled Trial

James Lind Black and White

James Lind (1716-1794)

If the 17th century is seen as the Age of the Scientific Revolution, the 18th marked the Age of Discovery. The ships of many nations were now travelling across the world for commerce, colonization and piracy. They were fitted with cannons to protect them against their enemies and to allow them to attack rich foreign ships laden with treasure. The cannons required a large complement of men in addition to the crew that sailed the ship. Often the ships would be at sea for months at a time without touching land and the provisioning for the very large crew was difficult. Hard Tack, fresh water and occasional bits of stew was the basic ration for most regular seamen. Scurvy was the result and without treatment it led to a horrible death.

The primary lesions of scurvy relate to bleeding and swelling and inflammation of soft tissues and bone. Wounds don’t heal because you can’t make collagen. Bleeding occurs into the skin around the roots of all your hairs, which later fall out. Swollen gums bleed, the jaw bone softens, and eventually your teeth fall out. Hemorrhagic spots develop in your eyelid linings. There’s painful bleeding into your joints, and into the surface membrane of bones, causing crippling pain, and eventually spontaneous breakage of bones. Eventually you’re coughing up blood and possibly asphyxiating. Bleeding develops in the intestines, leading to black, and then bloody, horrifically foul smelling stools. Anemia, weakness. Emotional liability. Bleeding into the sack around your heart so your heart can’t fill with blood and pump. Bleeding around the brain, compressing it, causing headache, vomiting, eventually coma and death as your brainstem is crushed as your swollen brain pushes itself down into the spinal canal. Perhaps your spirit hovers overhead to watch your body committed to the deep. (Anderson, 2000 )

 

George Anson, First Baron Anson (1697-1762) (by Joshua Reynolds)

Thousands of common seamen died of scurvy during long voyages of exploration, colonization and especially during the naval wars of the 17th and 18th centuries. In a particularly famous case, in 1740 George Anson led a flotilla of six warships with more than 1900 men on a trip around the horn of South America to capture Lima Peru from the Spanish. He ended up travelling around the world, gaining enormous riches, but only 188 original crew members returned. Most of the deaths were due to scurvy. Anson, now rich and famous, published a best-selling account of his trip. His expedition intensified the rush to find a cure for scurvy.

James Lind (1716-1794)

The traditional story of how the cure was finally discovered is largely about James Lind, an Eighteenth Century naval surgeon who performed the first recorded controlled trial. Today, controlled clinical trials have become the gold standard of evidence based medicine: subjects are randomly allocated to one or other of different arms of the study and the results are analyzed to determine which of the treatments are effective.

In 1747 while Lind was a surgeon on the HMS Salisbury there was a second outbreak of scurvy. He selected twelve sailors suffering from the disease and divided them into six groups of two. All were given a similar diet of “water gruel sweetened with sugar in the morning; fresh mutton broth often times for dinner, at other times boiled biscuit with sugar etc and for supper barley and raisins, rice and currants sago and wine or the like.”[Lind, 1753 #67, Pg. 145.] He then used the following treatments (here quoted in full but reformatted with modern bullet points to differentiate the six groups, leaving the original spelling but clarifying some terms in square brackets):

  • Two of these were ordered each a quart of [hard apple] cider a-day.
  • Two others took twenty-five “gutts” [drops] of elixir vitriol [dilute sulfuric acid], three times a-day, upon an empty stomach; using a gargle strongly acidulated with it for their mouths.
  • Two others took two spoonfuls of vinegar three times a-day upon an empty stomach; haveing their gruels and their other food well acidulated with it, as also the gargle for their mouth.
  • Two of the worst patients, with the tendons of the ham 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 [laxative].
  • Two others had each two oranges and one lemon given them every 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” [medicinal paste] recommended by an hospital surgeon, made of garlic, mustard seed, rad. Raphan[dried radish root], balsam of Peru [resin from the balsam tree] and gum myrrh; using for common drink barley-water well acidulated with tamarinds; by a decoction of which, with the addition of cremor tartar [potassium hydrogen tartrate], they were gently purged three or four times during the course. [Lind, 1753 #67, Pp. 145-146.]

 

The trial offered clear results. The two sailors given oranges and lemons, even though it was for only six days were much improved; one of them was “appointed nurse to the rest of the sick”[Lind, 1753 #67, Pg. 146.].  The results are indeed utterly clear, the conclusion overwhelming.

Lind says that the citrus fruit provided to the sick seamen was all “that could be spared.” The fruit was from the supply kept for officers. Some ships, like George Anson’s returned from long voyages with their officers alive and most seamen dead because the provisions for officers contained foods that saved them, but these, because they were scarce, were not shared with the crew even as they became ill. The size of the crew could not allow it and there was no understanding of the disease that would warrant it. It should also be noted that large numbers of crew members were needed not only to help with navigation but to man the cannons that gave these warships their advantage in battle and the health condition of many of crew members was poor to begin with.

From the patient’s point of view we wonder what happened to the two patients who were given orange and lemons for six days. When they went off these rations, did the scurvy return? We are pretty sure that all the other subjects died. Did the two also die?

Lind published a description of his experiment in A Treatise of the Scurvy in 1753. The book was very successful, translated into other languages and widely distributed.  But despite their knowledge of Lind’s discovery, the British Navy only introduced fresh citrus juice to the sailor’s diet in 1795. The cost of this delay was enormous: far more sailors died of scurvy than in battle. During the Seven Years War of 1756 to 1763 the level of death was horrific: of the 184,893 men who were in the navy, 133,708 died “of diseases and missing” and only 1,512 were “killed in engagements and by accidents” (The Annual Register, or a View of the History, Politics, and Literature, For the Year 1763, 1790, Pg. 50.) In addition some historians have argued that Britain’s failed naval blockade during the American revolutionary War, largely due to scurvy, was a major factor in the success of the American Revolution. (Carpenter).

The delay in the implementation of Lind’s results has been extensively used to illustrate and bemoan the time gap between research results and their application. It has become a standard example in the literature, with different emphases on the various lessons and conclusions to be drawn from it. Herbert Spencer, the 19th century father of Social Darwinism, a proto-libertarian, and sometime beloved of George Eliot, claimed that the story of scurvy demonstrated the ineffectiveness of government and its bureaucracies (Spencer, 1887). More recent medical historians declare that the delay was because, “Surprisingly, the Navy took no notice of Lind’s results” (Coleman, 1985:94). More recently, still others, like Jonathan Lomas, a Canadian with an interest in knowledge transfer, assert that this was an early example of continuing resistance of practitioners to apply the results of scientific research – a classic case of poor knowledge transfer (Lomas, 2002).

Although it was one among many, Lind’s book was a best seller for its time. It was widely circulated, translated into other languages and printed in three editions over the next 15 years. It made Lind’s reputation. When the Navy built an enormous hospital at Haslar devoted to treating sailors, Lind became its first director, despite the failure of his solution to be effectively implemented. He held this post quite honorably and continued to experiment with the sailors who came there until he retired, whereupon he was succeeded by his son.

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