- Fall 2016
|Fig 1. James Lind. Painted by Sir George Chalmers, c 1720-1791.|
Hull Royal Infirmary, United Kingdom
The name of James Lind is inextricably linked with scurvy and its remedy with citrus fruits. For centuries before him it was well recognized that huge numbers of sailors on long voyages fell ill, and many died of scurvy. But one of several mysteries is why his work that started in 1747 and was published in 1753 was not implemented for over forty years.
Scurvy (scorbutus) was known in ancient Greek and possibly in Egyptian, Roman, and Chinese times1,2 as a mysterious often fatal illness. Both land dwellers and more frequently seafaring explorers were affected. Scurvy claimed most of the lives of four-fifths of Magellan’s crew who died in his circumnavigation of 1519-1521; and Vasco da Gama's Voyage of 'Discovery' of 1497 similarly lost two thirds of its men. James Lind MD., FRCPEd., FRSEd. (1716-94) (Fig 1.) described it as 'this foul and fatal mischief' (Treatise of the Scurvy,3 chapter 1. p. 68). He characterized it by loose teeth, bleeding gums, joint pains and swelling, and profound exhaustion; wounds broke down, bleeding and bruising were widespread.
Between 1740 and 1744, Britain was at war with Spain. Commodore, later First Lord of the Admiralty (1751), George Anson (1697-1762) led a squadron of eight ships to capture Spain's Pacific possessions. His seamen suffered terrible losses4 with only 188 men of the original 1,854 surviving. As was the invariable custom, the ships’ diet was largely based on salted meats, gruel and dried biscuits, with no fresh fruit or vegetables. Despite the ravages of scurvy, no official investigation resulted to determine its cause and treatment. That it could be cured was obvious from the rapid improvements shown by Anson's men after reaching the pacific islands of Juan Fernandez and Tinian where their diet included various citrus fruits.
Familiar with the illnesses in Anson’s seamen, Lind studied this serious problem in 1747, publishing his findings in: A Treatise of the Scurvy, Edinburgh, 1753 (Fig 2). In 1757 he published An Essay on the Most Effectual Means of Preserving the Health of Seamen in the Royal Navy (2nd ed’n 1762) (Fig 3), and in 1771, ‘An essay on diseases incidental to Europeans in hot climates’ .
One of his main ideas was that:
Moisture concurring with other peculiar circumstances, as a gross diet, cold etc. disposes in a particular manner to the scorbutic corruption. (A treatise, Part II, p.68)
He also observed that scurvy was caused by the ‘gross, viscid diet’, which was not properly digested, and could not, as a consequence, be insensibly perspired. He did however recognize that:
An additional, and extremely powerful cause…is the want of fresh vegetables and greens…to correct the quality of such hard and dry food as they are obliged to make use of. (Part II, p. 74.)
He carried out experiments with twelve scurvied seamen on HMS Salisbury in May 1747, (A Treatise chapter IV, pp. 149-153) when he was ship's surgeon. Lind divided the twelve men into pairs, and prescribed for each pair a different remedy (1, cider; 2, elixir of vitriol; 3, vinegar; 4, sea water; 5, oranges and lemons; 6, a purge prepared from garlic, mustard seed, and other substances). The pair for whom the oranges and lemons were prescribed quickly recovered. The others did not:4
Fig 2. James Lind’s A Treatise
‘The most sudden and visible good effects were perceived from the use of oranges and lemons; one of those who had taken them being at the end of six days fit for duty … 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.’
This was long before the discovery of vitamins and particularly the essential ascorbic acid contained in citrus fruits.5 Though Lind had clearly shown the curative value of citrus fruits in his controlled trial, he curiously failed to impress the authorities of the importance of his Salisbury experiments described in his Treatise, where they are clearly and repeatedly described, with citations to similar experiences of other naval doctors. Lind did not publish his results until 1753, perhaps because he appears to have been diffident and thorough, and he laboriously reviewed past writings on scurvy. His innate reticence, his undue attention to the moisture in the air, the gross, too solid diet, and his initially tentative approach to antiscorbutics are shown in his Treatise.3,6 The Admiralty however, failed to respond and did not prescribe that seamen should be provided with oranges or lemons, even though Lind’s treatise including his Salisbury experiments, had demonstrated their efficacy in both cure and prevention of scurvy in seamen.
But in his practice at Haslar hospital his patients did receive citrus fruits routinely, though he did not further publicize them as a definitive cure or means of preventing scurvy. Later, in his Essay on the Most Effectual Means of Preserving the Health of Seamen in the Royal Navy (1757, 3rd ed'n 1779), he recommended better hygiene on ships and more humane, but efficient treatment of seamen; he also advised that diet should be improved. ‘Pickled vegetables and “rob”—extract of—oranges and lemons should be carried. Shallots and garlic should be included in ‘the surgeon's necessaries’.
In 1780 an influential physician, Sir Gilbert Blane (1749-1834), physician to the Fleet, read Lind’s Treatise and in the following year Blane published a pamphlet for ships' surgeons: On the most effective means for preserving the health of seamen, particularly in the Royal Navy. He advocated the use of citrus juice as a preventative and lobbied the Admiralty to give its sailors a daily ration of lemon juice. The Admiralty rejected his suggestion, saying that his citation of Lind’s evidence was not persuasive enough and that lemons were ‘too expensive’.2
Adhering to Blane's recommendations George Rodney's voyage to the West Indies lost not a single man to scurvy during a six month period, from December 1781 to May 1782. Forty eight years after Lind’s Salisbury experiment Blane finally persuaded the Admiralty in 1795 to order that every sailor in the Navy be given three quarters of an ounce of lemon juice daily. The less effective lime juice sometimes replaced this, so that ‘limey’ became the slang word for a British person.
Many reasons for the mysterious delay have been suggested: Lind’s evident diffidence and tentative opinions on the efficacy of citrus juices; the fact that he dedicated the book to Lord Anson, whose influence as a patron by that time had waned; or simply the tardy bureaucracy of the Admiralty. A second mystery about Lind is the disappearance from the written record of his works. After the second edition of Thomas Trotter’s Observations on the scurvy in 1792, there appears to be a gap in citations until Sir John Simon published English sanitary institutions in 1890.
Over a century later in 1928, Albert Szent-Gyorgyi (1893-1986) isolated from plants a compound (C6H8O6) that he named hexuronic acid, though suspecting it was Vitamin C, as later proved by Haworth. In 1937, Szent-Györgyi received the Nobel Prize in Physiology or Medicine for his researches, including the role of vitamin C. Haworth shared the prize in chemistry in the same year for his structural determination of vitamin C.
Fig 3. James Lind’s Essay on the Most Effectual Means of Preserving the Health of Seamen in the Royal Navy (1757) [annotated by Lind, author]
It is of historical interest1 that as early as 1497, Vasco de Gama's crew too late discovered that citrus fruits could cure scurvy, but this cure was frequently forgotten or misconstrued. Yet citrus fruits and several other concoctions were again suggested for scurvy in 1593 by Admiral Sir Richard Hawkins who advocated drinking orange and lemon juice to prevent scurvy, as did John Woodall (1570–1643) a military surgeon in 1617 in his The Surgion’s Mate. They were largely unheeded. Even after Lind’s work the "citrus cure" was often neglected; scurvy still afflicted large numbers of people including men on Scott's 1911 expedition to the South Pole.
James Lind was a naval surgeon and physician, born in Edinburgh on October 4, 1716, son of James Lind, a merchant, and Margaret Smelholme (Smellum), a member of an Edinburgh medical family. He was apprenticed to George Langlands, an Edinburgh surgeon;and in 1734, he attended anatomy lectures in Edinburgh University given by Alexander Monro primus. With no formal qualification, he became a Royal Naval surgeon in 1738, serving until 1748. Most of his service was spent aboard ships in the English Channel during the War of the Austrian Succession (1740–48). He then returned to Edinburgh, where in 1748, he graduated MD. and was probably engaged in private practice. He was elected FRCP Ed, (Fellow of the Royal College of Physicians of Edinburgh) in 1750. He was a member of the Philosophical and Medical Society of Edinburgh, and was elected a FRSE (Fellow of the Royal Society of Edinburgh) in 1783.
In 1758 he moved south to Gosport to take up the post of physician in charge at Haslar Royal Naval Hospital. Lind had dedicated A Treatise of the Scurvy to Lord Anson, the First Lord of the Admiralty.
At the former site of the Edinburgh Medical School is a plaque erected in 1955 by the Sunkist Growers of Citrus Fruit in California and Arizona. It suggests that James Lind is The Hippocrates of Naval Medicine. It then lists three of his books. The plaque indicates that his works led to the conquest of scurvy, improved naval hygiene, and the growth of tropical medicine. His books were translated into many languages and his antiscorbutic regime eventually was widely implemented with the saving of countless lives.
In his portrait by Sir George Chalmers, he appears as a kindly-faced man with intelligent eyes, proudly displaying his four books, with Haslar Hospital in the background. Lind died at Gosport on July 18, 1794 and was buried at St Mary's Church, Portchester, Hampshire. The third and final mysterious twist to this tale is that the vault, when opened revealed no trace of the coffin.7 The Vicar of Portchester had it by hearsay from his predecessor that an old lady organist told him that Lind’s body had been disinterred twenty years after the burial and removed to the Isle of Wight. But no trace of his coffin exists there. The Daily Telegraph in 1966 told that: ‘Lind kept his “obscurity” even after his death. A memorial tablet in Portchester Parish Church says he is buried there. The tomb is empty.
- Carpenter K J. The History of Scurvy and Vitamin C. Cambridge University Press. 1988.
- Bown S R. 2003. Scurvy: How a Surgeon, a Mariner, and a Gentlemen Solved the Greatest Medical Mystery of the Age of Sail. New York: St. Martins Press. p. 174.
- Lind J. A Treatise of the Scurvy, Edinburgh 2nd edition, London: Printed for A. Millar in the Strand, 1757. https://books.google.co.uk/books?id=oP1UEXWU7fsC
- Bartholomew M. Lind, James (1716–1794), Oxford Dictionary of National Biography, Oxford University Press, 2004 [http://www.oxforddnb.com/view/article/16669, accessed 5 Oct 2016]
- R. Stockman, ‘James Lind and scurvy’, Edinburgh Medical Journal, 3rd ser., 33 (1926), 329–50 ·
- Milne I. Who was James Lind, and what exactly did he achieve. J R Soc Med. 2012; 105(12): 503–508.
- Wickenden JVS. The strange disappearances of James Lind. James Lind Library Bulletin: Commentaries on the history of treatment evaluation. 2011. (http://www.jameslindlibrary.org/articles/the-strange-disappearances-of-james-lind/)
J.M.S. PEARCE, MD, FRCP (London) is emeritus consultant neurologist in the Department of Neurology at the Hull Royal Infirmary, England. All correspondence to: 304 Beverley Road, Anlaby, East Yorkshire, HU10 7BG, England.