Scurvy

• 1. Introduction

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  Scurvy, a disease caused by a lack of vitamin C, once killed more British sailors than enemy guns did. During the 18th century, it was the greater threat. On George Anson's voyage around the world, scurvy cost him nearly two-thirds of his crew within the first ten months. That was 1,300 men out of 2,000. The cure turned out to be fresh food, yet ships kept sailing without it. Why did a remedy so simple stay out of reach for so long? What does the absence of a single nutrient actually do to a human body? And how did a small animal chosen almost by accident finally settle the argument?

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• 2. The Body Without Vitamin C

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  A month is the shortest time it takes. A person must go at least that long on little or no vitamin C before scurvy symptoms appear. Humans belong to the minority of animals that cannot make their own supply. The human liver lacks a working version of an enzyme called L-gulonolactone oxidase, or GULO. When the diet delivers enough vitamin C, that gap never matters.

  When the supply stops, collagen is the first casualty. Vitamin C is a necessary partner for two enzymes, prolyl hydroxylase and lysyl hydroxylase. They modify the amino acids proline and lysine so that collagen fibers can be cross-linked and held steady. Collagen is a primary structural protein, found in blood vessels, muscle, skin, bone, cartilage and other connective tissue. When it is defective, the smallest blood vessels become fragile. The result is abnormal bleeding, bruising and internal hemorrhaging.

  The symptoms arrive in stages. Malaise and lethargy come first, possibly because a shortage of carnitine and catecholamines disrupts how cells make energy. Emotional changes can appear before any physical sign. After one to three months, shortness of breath and bone pain develop. The skin turns rough and bruises easily, with tiny spots of bleeding called petechiae. Gums become diseased and teeth loosen. Bones break more easily, and old fractures can break again. Wounds heal poorly. In the late stages come jaundice, swelling throughout the body, fever, convulsions and death. Untreated scurvy is invariably fatal.

  Doctors diagnose it from physical signs, X-rays and improvement after treatment. In children, rickets, osteogenesis imperfecta and osteomyelitis can mimic the picture. Long before anyone understood this chemistry, people had noticed that certain foods reversed the damage.

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• 3. Remedies Found and Lost

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  Egyptian records from about 1550 BC already describe the symptoms of scurvy. The Greek physician Hippocrates, who lived from 460 to 370 BC, wrote of a swelling and obstruction of the spleen. Pliny the Elder, in his Naturalis historia of 77-79 AD, described sailors eating sea kale to ward off the disease. In 406 AD, the Chinese monk Faxian recorded that Chinese ships carried ginger for the same purpose.

  The Portuguese took a practical approach on Saint Helena, a stopping point for ships heading home from Asia. They planted fruit trees and vegetables there and left their scurvy-stricken sick to recover until the next ship came. Yet such accounts did not prevent disasters. Travelers and the people responsible for their health rarely talked to each other, and fresh produce could not be kept for long at sea.

  On the circumnavigation of 1519-1521, Magellan's crew suffered terribly. A chronicler wrote that "above all other calamities this was the worst: in some men the gums grew over the teeth, both lowers and uppers, so that they could not eat in any way and thus they died of this sickness. Nineteen men died."

  In 1536, the French explorer Jacques Cartier was exploring the St. Lawrence River when his men began dying. He turned to the knowledge of the local St. Lawrence Iroquoians. He boiled the needles of the aneda tree, generally believed to be eastern white cedar, into a tea. Later testing showed it held 50 mg of vitamin C per 100 grams. Several European countries afterward experimented with conifer preparations such as spruce beer.

  In 1579, the Spanish friar and physician Agustin Farfán published a book recommending oranges and lemons, a remedy already known in the Spanish navy. In February 1601, Captain James Lancaster landed on the northern coast of Madagascar, specifically to get lemons and oranges for his crew. He was leading the first English East India Company fleet, bound for Sumatra. He turned the voyage into an experiment across four ships. One crew received routine doses of lemon juice and the other three did not. Scurvy spread through the untreated ships, and many died.

  In 1614, John Woodall, Surgeon General of the East India Company, published The Surgion's Mate, a handbook for apprentice surgeons. He passed on what mariners knew: fresh food, or failing that oranges, lemons, limes and tamarinds. He could not say why it worked. The influential physicians of his age held that scurvy was a digestive complaint, and his advice changed nothing.

  Researchers estimate that scurvy killed at least two million sailors between 1500 and 1800. The historian Jonathan Lamb wrote that Vasco da Gama lost 116 of his crew of 170 in 1499.

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• 4. Lind and Rival Theories

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  Of the 184,899 sailors the Royal Navy enlisted during the Seven Years' War, 133,708 were lost. Some died of sickness, some were discharged as unfit and some deserted. Scurvy was the leading cause of death among them.

  In 1747, a naval surgeon named James Lind carried out a trial aboard HMS Salisbury. It is counted among the first controlled clinical experiments in the history of medicine. Lind tested hard cider, vitriol, vinegar and seawater. He also tried oranges, lemons and a mixture of balsam of Peru, garlic, myrrh, mustard seed and radish root. In A Treatise on the Scurvy, published in 1753, he concluded that "the results of all my experiments was, that oranges and lemons were the most effectual remedies for this distemper at sea."

  The verdict barely registered. The trial filled only a few paragraphs in a long and complex book. Lind himself never promoted lemon juice as the single cure. He shared the common view that scurvy had several causes, including hard work, bad water, and salt meat eaten in a damp atmosphere. He also became absorbed in boiling lemon juice down to a concentrated "rob". Boiling destroyed the vitamin C, so the effort failed.

  The classically trained physicians who set medical policy dismissed the sailors' evidence as merely anecdotal. Their theory held that scurvy was internal putrefaction, brought on by faulty digestion. The remedies the navy accepted amounted to little more than fizzy drinks to stir the digestion. The most extreme was "elixir of vitriol", sulphuric acid taken with spirits and barley water and laced with spices.

  In 1764, a second wrong theory arrived. Dr David MacBride and Sir John Pringle, later President of the Royal Society, argued that scurvy came from a lack of "fixed air" in the tissues. Infusions of malt and wort, they said, would ferment in the body and restore the missing gases. When James Cook set off to circumnavigate the world in 1768-1771, malt and wort headed the list of remedies he was ordered to investigate. Beer, sauerkraut and Lind's rob followed. Lemons were not on the list.

  Cook did not lose a single man to scurvy, and his report favored malt and wort. The true reasons lay elsewhere. He enforced shipboard cleanliness with strict discipline and replenished fresh food and greens often. He also banned the common naval habit of eating salt fat skimmed from the copper boiling pans. In contact with air, the copper formed compounds that stopped the intestines absorbing vitamins. Sauerkraut, the one item on the list that really was a good source of vitamin C, was not the remedy his report praised.

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• 5. Lemons Win the Navy

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  Pedro González, medical officer on Alessandro Malaspina's Spanish expedition of 1789-1794, was convinced that fresh oranges and lemons were essential. The voyage became the first major long-distance expedition with virtually no scurvy. Only one outbreak occurred, during a 56-day trip across the open sea. Five sailors showed symptoms, one of them seriously. After three days at Guam, all five were healthy again. Spain's large empire, with its many ports of call, made fresh fruit easier to find.

  Britain took longer. The medical authorities there stayed committed to the idea of internal putrefaction. The Sick and Hurt Board, run by administrators, felt obliged to follow their advice. Inside the navy, opinion was shifting, strengthened by firsthand experience with lemon juice at the siege of Gibraltar and during Admiral Rodney's expedition to the Caribbean. The writings of Gilbert Blane and Thomas Trotter reinforced it, as did reports from rising naval commanders.

  The war that began in 1793 made the problem urgent. The first push came from admirals rather than doctors. Rear Admiral Gardner, ordered to lead an expedition against Mauritius, had no interest in the wort, malt and elixir of vitriol still being issued. He demanded lemons. The Sick and Hurt Board, recently joined by two practical naval surgeons, supported him, and the Admiralty gave the order. The expedition was then cancelled at the last minute. On the 2nd of May 1794, Commodore Peter Rainier sailed east with an outward-bound convoy anyway. His warships were fully supplied with lemon juice and the sugar needed to mix with it.

  In March 1795, news came that the Suffolk had reached India after a four-month voyage without a trace of scurvy. Her crew was healthier than when it set out. Fleet commanders clamored for the same supply. By June, the Admiralty accepted a proposal from the Sick and Hurt Board that lemon juice and sugar be issued daily to the crews of all warships.

  It took a few years to perfect the distribution and to secure the huge quantities of juice required. By 1800 the system was in place and working. Sailors grew markedly healthier, which gave the Royal Navy an advantage in battle against enemies who had not yet adopted the measure. Decades later, the ration would be written into law, and the choice of fruit would quietly change.

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• 6. Limes and Confusion

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  The Merchant Shipping Act of 1867 required every ship of the Royal Navy and the Merchant Navy to give sailors a daily "lime or lemon juice" ration of one pound. In the same year, Lauchlin Rose patented a way to preserve citrus juice without alcohol. His concentrated drink became known as Rose's lime juice. The product turned nearly ubiquitous, and it gave English the word "limey". The term applied first to British sailors, then to English immigrants in former colonies such as America, New Zealand and South Africa. In old American slang it finally covered all British people.

  Another plant earned its name from the same fight. Common scurvygrass, Cochlearia officinalis, was carried aboard ships as dried bundles or distilled extracts. Its bitter taste was usually disguised with herbs and spices. Scurvygrass drinks and sandwiches became a popular fad in the UK that lasted until the middle of the 19th century, when citrus fruits became easier to buy.

  The switch from lemons to limes carried a hidden flaw. Spain had allied with France against Britain in the Napoleonic Wars, which made Mediterranean lemons hard to supply. West Indian limes came from Britain's Caribbean colonies, and people believed their greater acidity made them more effective. At that time, the acid was thought to be the cure, since vitamin C was unknown. In fact, the limes held far less vitamin C than lemons. They were also served as juice that had been exposed to light and air and piped through copper tubing. A 1918 animal experiment on representative samples of the navy's lime juice showed it had virtually no power against scurvy.

  The result was a long muddle. Fresh lemons cured scurvy, but copper-piped lime juice did not, which undermined the citrus theory. Fresh meat, especially raw organ meat eaten in the Arctic, also cured it, which undermined the idea that fresh plants were essential. Faster steam ships and better nutrition on land cut the incidence of scurvy, so the weakness of lime juice stayed hidden. Under germ theory, a new hypothesis then appeared: that scurvy came from ptomaine, a bacterial waste product, especially in tainted tinned meat.

  In the Royal Navy's mid-19th-century Arctic expeditions, many officers believed good hygiene, regular exercise and high morale prevented scurvy. Scurvy continued to hit them even though civilian whalers and explorers knew fresh meat worked. Critics also pointed out that some of the worst-affected men on polar expeditions had been heavy drinkers. The Belgian Antarctic Expedition of 1897-1899 suffered badly after its leader, Adrien de Gerlache, discouraged his men from eating penguin and seal meat.

  Infantile scurvy emerged in the late 19th century, especially among urban upper-class children fed pasteurized cow's milk. Pasteurization killed bacteria but also destroyed vitamin C. Onion juice or cooked potatoes eventually solved the problem. When Robert Falcon Scott made his first Antarctic expedition in 1901-1904, the prevailing theory still blamed ptomaine poisoning. Scott found that fresh Antarctic seal meat cured scurvy before any deaths occurred, but he stayed confused about the underlying cause. The answer arrived in 1907, from researchers studying a different disease entirely.

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• 7. Guinea Pigs and Hexuronic Acid

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  In 1907, the Norwegian physicians Axel Holst and Theodor Frølich needed a small mammal for their research. They were studying beriberi among the crews of the Norwegian Fishing Fleet, and wanted a substitute for the pigeons then used in beriberi experiments. They fed guinea pigs a diet of grains and flour that had produced beriberi in pigeons. To their surprise, classic scurvy resulted instead.

  The choice was a stroke of luck. Until then, scurvy had never been seen in any animal except humans and was considered an exclusively human disease. Pigeons are unaffected because they make ascorbic acid internally. Holst and Frølich went on to cure the guinea pigs by adding various fresh foods and extracts. The discovery came before the very idea of "vitamins" in food had been put forward, and it has been called the single most important piece of vitamin C research.

  Meanwhile, doubt about plant foods persisted. The Arctic explorer Vilhjalmur Stefansson, who had lived among the Inuit, joined a study at New York's Bellevue Hospital in February 1928. He and a companion ate only meat for a year under close medical observation. Both stayed in good health, which showed that the all-meat diet did not cause vitamin deficiencies.

  In 1927, the Hungarian biochemist Albert Szent-Györgyi isolated a compound he called "hexuronic acid" from adrenal glands. He suspected it was the antiscorbutic agent but lacked an animal model to prove it. In 1932, the American researcher Charles Glen King of the University of Pittsburgh made the connection. His laboratory received some hexuronic acid from Szent-Györgyi and soon established that it was the substance everyone had been seeking. It was renamed ascorbic acid.

  Later human studies measured how little was needed. During World War II, conscientious objectors in Britain took part in a dietary trial. In the late 1960s, Iowa state prisoner volunteers did the same in the United States. In both studies, all obvious symptoms induced by a diet nearly free of vitamin C reversed with only 10 mg per day. The Iowa men showed the first signs of scurvy after about four weeks. The British men took six to eight months, possibly because they had been given 70 mg a day for six weeks beforehand. In the Iowa study, the men's body pool of vitamin C was estimated at under 300 mg, with a daily turnover of only 2.5 mg.

  The guinea pig turned out to have company. Among primates, simians and tarsiers cannot make vitamin C, but lemurs, lorises, pottos and galagos can. The capybara, certain birds and certain fish also lack the ability. In every animal that can contract scurvy, the GULO gene survives only as a pseudogene, a broken copy that offers a glimpse of the species' evolutionary past.

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• 8. Scurvy On Land

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  Until the late Middle Ages, scurvy was common across Europe in late winter, when green vegetables, fruits and root vegetables ran short. The arrival of potatoes from the Americas gradually improved matters. By 1800, scurvy was virtually unheard of in Scotland, where it had once been endemic. The early colonists of Australia suffered greatly through the winter without fresh produce. They called the often-fatal illness Spring fever, and recognized it as scurvy only later. Scurvy also struck during the Great Famine of Ireland in 1845 and during the American Civil War. In 1915, New Zealand troops at Gallipoli fell ill because their diet lacked vitamin C.

  In 2002, scurvy outbreaks were recorded in Afghanistan after the most intense phase of the war. Today the disease is rare compared with other nutritional deficiencies. It appears most often in the developing world alongside malnutrition, and rates among refugees are reported at 5 to 45 percent. In wealthier countries, it falls on neglected children, people with mental disorders or unusual eating habits, alcoholics, and older people who live alone. Intestinal malabsorption and dialysis are other risk factors.

  In 2020, the overall incidence of scurvy in the United States was about one in 4,000 people, up significantly from a few years earlier. About two-thirds of all cases occur in autistic people. Some children and young people with autism eat only a few foods, such as rice and pasta. For some, the restriction takes the form of avoidant/restrictive food intake disorder, known as ARFID.

  Prevention is a matter of uncooked foods. Per 100 grams, amla holds 610 mg of vitamin C and red bell pepper 200 mg. An orange holds 53.2 mg and a lemon 53 mg. Camu camu tops the list at roughly 2000 mg. Cooking often reduces the amount. Raw liver, at 23.6 mg per 100 grams, can prevent and even partly treat scurvy, as can other uncooked fresh meat. Virtually all commercial baby formulas now carry added vitamin C.

  Treatment uses vitamin C by mouth, or intravenously for the best results. Doses as low as 10 mg a day will improve the disease, though about 100 mg a day is typically recommended. Improvement often begins within days, and most people recover fully within two weeks. In babies, scurvy is sometimes called Barlow's disease, after the British physician Thomas Barlow, who described it in 1883.

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