Surgeon James Lind, HMS Salisbury 1747, and Scurvy

[seaJane]

The impetus:
In 1740-1743, of about 2000 men sailing on seven vessels in Lord Anson's squadron during his circumnavigation, about half died of scurvy.

The experiment: Lind writes:

On the 20th of May 1747, I selected 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 their knees. They lay together in one place, being a proper apartment 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 light puddings, boiled biscuit with sugar, &c. and for supper, barley and raisins, 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 drops of elixir vitriol. three times a-day upon an empty stomach; using a gargle of it for their mouths. Two others took two spoonfuls of vinegar three times a-day, upon an empty stomach; having their gruels and their other food sharpened with vinegar, as also the gargle for their mouth. Two of the worst patients, with the tendons in the ham quite 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 every day. These they eat 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, horse-radish, balsam of Peru, and gum myrrh; using for common drink, barley-water boiled with tamarinds; by which, with the addition of cream of tartar, they were gently purged three or four times during the course.

From: A treatise of the scurvy. (Edinburgh, 1753).

To note:
1. This trial fulfils two of the requirements of a classic controlled experiment, the subjects having both the same degree of scurvy and the same basic diet.
2. Elixir vitrioli, or elixir of vitriol, is a very dilute solution of sulphuric acid. The Admiralty order for the issue of this as a cure for scurvy had gone out in January 1747.
3. "bigness of a nutmeg" does not mean that nutmeg was a potential cure (as supposed by some Google sources). An electuary was medical ingredients made into a paste or lump with gum or similar material - in this case a lump the size of a nutmeg.
4. Other cures: citrus fruits, cider, vinegar and seawater - speak for themselves, if in some cases inexplicable as supposed cures. There was much focus on purgative effects due to the general "better out than in" theory of medicine at the time.

Results of the experiment in the next post.

[seaJane]

Results of the controlled trial: from the same source:

The consequence was, that 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 spots were not indeed at that time quite off his body, nor his gums sound; but without any other medicine, than a gargle for his mouth, 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 pretty well, was appointed to attend the rest of the sick.

Next to the oranges, I thought the cyder had the best effects. It was indeed not very sound. However, those who had taken it, were in a fairer way of recovery than the others at the end of the fortnight, which was the length of time all these different courses were continued, except the oranges. The putrefaction of their gums, but especially their lassitude and weakness, were somewhat abated, and their appetite increased by it.

As to the elixir of vitriol, I observed that the mouths of those who had used it by way of a gargle, were in a much cleaner and better condition than many of the rest, especially those who used the vinegar; but perceived otherwise no good effects from its internal use upon the other symptoms. I indeed never had a great opinion of the efficacy of this medicine in the scurvy, since our longest cruise in the Salisbury, from the 10th of August to the 28th of October 1746; when we had but one patient in the scurvy, a marine, who, after recovering from a quotidian ague in the latter end of September, had taken the elixir vitriol. by way of restorative for three weeks; and yet at length contracted the disease, while under a course of a medicine recommended for its prevention.

There was no remarkable alteration upon those who took the electuary and tamarind decoction, the sea water, or vinegar, upon comparing their condition, at the end of the fortnight, with others who had taken nothing but a little lenitive electuary and cream of tartar occasionally, in order to keep their body lax, or some gentle remedies in the evening, for relief of their breast. Only one of them, while taking the vinegar, fell into a gentle flux at the end of ten days. This I attributed to the nature of the disease, rather than to the use of the medicine.

Notes:
1. Citrus fruit. We can understand that this would be the most efficacious cure, but vitamin C was not isolated until the 1920s.
2. Cider. Again perhaps not surprising. Some of the vitamins from the apples presumably survived the cider-making process.
3. Elixir of vitriol. No comment. The acid may have removed the tartar from the sailors' teeth - and probably some of the enamel too, as well as any flesh sloughed from the gums (one of the symptoms of scurvy; the connective tissues holding the teeth into the gums break down).
4. Tamarind. While this is a fruit, the decoction of it would involve boiling water, thus destroying any vitamin C.

More later on Lind's interpretation of his results, his recommendations, other opinions, and Admiralty actions (or not as the case may be). It's a long story!

[herakles]

Well done Jane! This is most interesting.

I created a post on Anson's voyage earlier: http://www.worldnavalships.com/forums/showthread.php?t=1262&highlight=anson

There are so many examples of what the deprivation of the vital amines (vitamins) cause. Beri-beri comes to mind as does Rickets. And how quickly an infusion of the appropriate vitamin brings back good health.

I found it most interesting the way that Lind approached this matter, using a controlled experiment. This approach wasn't new but not widely used at the time.

That the RN used vitriol made me gag!

I guess at the time of Lind, citrus fruit was not widely eaten in Britain. The fruits being exotic. I wonder where the idea came from to use citrus fruit on board ship? Just an accident perhaps?

[seaJane]

Thanks for your appreciation :)

By the time Lind was working the fruit was available in Britain thanks to orangeries and hothouses - otherwise the import market was from Sicily, Spain (Seville - Shakespeare makes a pun about civil oranges) and China (all Lombard Street to a China orange).

Anecdotal evidence had been for citrus fruit ever since surgeon James Woodville in the 16th century, but as you say this was the first time it had been tested. Lind's is usually called the first recorded controlled experiment but it is possible that other people had done similar things without realising what they were doing. However getting a result does not always mean you draw the right conclusion - of which more later.

Regarding the vitriol, I was asked a few years back if I could decipher a list of pharmaceutical substances taken to Africa by the expedition led by Capt Hugh Clapperton, RN. The number of them that are now listed poisons was alarming. Pulv. lytt. is the one that sticks in my mind because it took longest to work out. It turned out to stand for pulveris lyttae or "powder of lytta" for which I suggest you google "lytta vesicatoria". But you really don't want to know about it :eek:

[herakles]

Thanks for the information about citrus fruits. I had forgotten about orangeries! There's that remarkable one at Versailles for instance.

ytta vesicatoria!!!! OMG! You are right, I didn't want to know.

Another widely used drug at the time comes to mind - laudanum.

I have but a feeling that Francis Bacon dabbled in the controlled experiment.

Drawing the right conclusion is prone to error. How helpful statistics are today to assist us to do that. I guess at the time people just had to rely on common sense.

[stewart mcloughlin]

You should never say, "..but you don't want to know that." You know darned well what we'll do. Uughh
Stewart

[seaJane]

Of course - why else do you think I said it??? :p;)

Feeling a bit off colour today so not at my sources. More on the subject later than I expected.