Friday, April 27, 2018

Scurvy by Stephen Bown

Source of book: Borrowed from the Library

Scurvy: How a Surgeon, a Mariner, and a Gentleman Solved the Greatest Medical Mystery of the Age of Sail is exactly what it sounds like: a tale of the discovery and implementation of the cure for a baffling and deadly disease.

From our 21st Century perspective, it is easy to think of scurvy as a really easy disease to cure. Why didn’t people figure out how to cure it sooner? Well, lots of reasons, as this book points out. 

First, let’s look at the carnage. The Age of Sale lasted roughly from time that transoceanic voyages became practical and common through the invention of steam-powered watercraft. During that time - 400ish years - the death toll from scurvy is believed to have been in excess of two million sailors. That’s a lot. In fact, it is more than the deaths from combat, shipwreck, storms, and all other diseases. Combined. In fact, that is more than all of the combat deaths in the history of the United States - including both sides of the Civil War. That’s a lot of bodies.

As this book makes clear, there are a number of reasons why it took hundreds of years to finally understand the disease, and significant impediments to gaining definitive knowledge.

As we now know, scurvy is a disease caused by deficiency of Vitamin C - ascorbic acid. (The name itself is a contraction of “antiscorbutic” - anti-scurvy.) Most animals can create their own ascorbic acid - but humans cannot. Neither can guinea pigs, which is one reason that they became popular for animal testing. On long sea voyages, without fresh food, this deficiency would cause the breakdown of the connective tissue of the body. Basically, people fall to pieces, crumble to sludge, without this necessary nutrient.

One of the most interesting things about the history of scurvy is that the cure was actually discovered multiple times...then “forgotten” by those who came afterward. The most crazy example of this is that back in 1601, Sir James Lancaster proved that lemon juice prevented scurvy - and the British Merchant Marine believed him and adopted his recommendations. For a while. Likewise, the Dutch merchants used lemon juice as well. But the navies, which at the time tended to say near port, thought themselves above the lowly merchants. And anyway, while merchant vessels could carry a lot of supplies and stop in to port along the way, the navy had few similar options.

Eventually, the cure was forgotten, and not rediscovered until right before the Napoleonic Wars.

There were several inherent obstacles to the discovery and adoption of a cure. Some of these were problematic because of the specifics of the disease. Scurvy can mimic a lot of other diseases that were common at the time, and thus, it took a while before it was recognized as a single disease, rather than a constellation of symptoms which might have been other illnesses. Likewise, because of the generally poor nutrition of the lower classes, scurvy tended to afflict the common sailors before the officers. This meant that other factors were naturally suspected, such as the overcrowded conditions below decks, the generally poor food supplies, infectious diseases (which would come aboard the same way gaol fevers would), and other class-based causes.

There were also scientific reasons scurvy was difficult to pin down. We can test for potency these days, but that wasn’t the case back then. Different citrus fruits have differing amounts of ascorbic acid - as do other fresh fruits and vegetables. And this differs too based on freshness, preparation, and source. So there were a ton of variables which were difficult to account for. Likewise, in the human subjects, there were variables such as whether they had been at sea recently (and thus already pre-scorbutic), whether there were other health issues, how good nutrition was at home, and so on. These all tended to make it difficult to pin down the cause and the cure.

But perhaps the greatest obstacle was philosophic. The medicine of the day was in thrall to an erroneous belief: the “humour” theory of disease. There were four “humours”: blood, black bile, yellow bile, and phlegm - and all disease was an imbalance of these fluids. This was, to put a fine point on it, utter baloney. But that wouldn’t be known for many years.

The reason that this was a problem was that it required, as the author puts it, “great philosophical backflips and other mental acrobatics in a vain attempt to reconcile common sense with their theoretical constructs.” And, on a related note, it meant that practical experimental evidence was disregarded if it couldn’t be made to fit the theory.

Yes, that is a problem. It was a problem then, and it is a problem now. (Regular readers will know that this is one of my biggest beefs with American Evangelicalism’s approach to, well, everything. The theory always trumps reality or experience. Thus, there is no way to learn anything - everything is already known.) This was a big reason that the navies didn’t listen to the mere merchants. After all, their success in preventing scurvy was merely experimental, not based on intellectual theory. It took irrefutable evidence to topple the theory, and in the meantime, millions died.

In a weird moment, I ran across another bizarre theory in this book - one that was all too familiar. It was this idea of acid and alkaline balance. Because scurvy was (in this theory) either acid or alkaline, depending on the symptom, treatments varied. While one particular acid could have cured it, not all acids are equal. Thus, advocating for vinegar, sour wine, or - I am not making this up - “oil of vitriol” - that is, sulfuric acid - as a cure wouldn’t be effective, even though lemon juice would be. I mention this because as part of my childhood, we cycled through some scientifically ludicrous “alternative medicine” approaches to nutrition. Most were pretty harmless, although annoying. But this idea of classifying foods as acid or alkaline (often in ways that were contrary to the actual facts) and using that to treat disease was neither some ancient “wisdom” nor science. It was a faddish 18th Century piece of malarkey.

One thing that really struck me in this connection was the reason that the ancient Greek and Roman writings were considered authoritative in medicine. These days, we tend to (usually correctly) assume that more recent - and better controlled and designed - studies tend to be more accurate, and that the more modern, the more likely something is to be correct. In the past, the opposite was often true. In this case, the Greeks and Romans were revered on the theory that mankind has been degenerating since the Fall, and thus the older minds were less clouded and more brilliant. Sad to say, this ridiculous idea (which flies in the face of the evidence - and that includes morality too) remains current in certain religious circles. I have literally heard stuff like “imagine what the ancients could have done with their brilliant minds and our technology” and “we should trust the superior wisdom of the past and [fill in morally abhorrent thing here.]” There is nothing magic about the past, or the people of the past. Sometimes they were right. Often not.

By the way, it wasn’t just the “science” of the day that was problematic. Then, as now, there was a tendency to blame the victims of disease. Many dismissed sailors as morally degenerate, and scurvy merely as divine disfavor displayed against them. And of course, no sense in trying to cure a disease caused by divine disfavor - particularly if it afflicts people who you consider inferior. Hmm, I can think of another disease that got this treatment.

Eventually, three persons managed to get the treatment right - and it took the efforts of all three to do so.

The first was the surgeon, James Lind. He did the first truly controlled experiment in this area, discovering that lemon juice was effective in treating and preventing scurvy. Unfortunately, Lind never did shake the “humours” explanation, and so failed to make a coherent case for why it worked. Lind’s writings, however, would eventually influence others.

Captain James Cook was the next important figure. Working off of Lind’s recommendations, he brought citrus along on his voyages, and made sure to take on fresh vegetables whenever possible. He thus kept scurvy to a minimum during his famous voyages. Alas for Cook, he became mentally erratic on his last voyage, and managed to get himself into a deadly conflict in the Hawaiian Islands, and was killed. Thus, his effective technique never had an effective advocate.

The last was the aristocrat Gilbert Blane. He took the foundation laid by Lind’s experiments and Cook’s experiences, and used his influence to make the use of citrus the official policy of the British Navy, thus saving millions of additional lives, and contributing significantly to world history. (More on this below.)

Blane was successful, in part, because he drew a seemingly obvious connection that the British bureaucrats running the navy didn’t seem to grasp:

Scurvy wasn’t just costing “expendable” lives. It was causing the loss of expensive ships, and endangering national security.

Yeah, that sounds pretty callous. And it is. Because Naval policy was darn calloused. Ships would be stuffed with twice the number of necessary men, because it was assumed that half would be lost to scurvy over the course of the voyage. That’s pretty appalling. And horribly inefficient, as Blane pointed out. The loss of skilled sailors was leading to the sinking of ships and bad results all around. Furthermore, Britain would struggle to defend her vulnerable homeland if she couldn’t keep ships in the necessary places to prevent an invasion. It was by this calculation that Blane was able to convince the Navy bosses that it was worth the expense of keeping citrus (and concentrated citrus juice) in ready supply on board their ships.

Unsurprisingly, this change paid off. Suddenly, Britain had an immediate advantage over her foes: she could stay afloat longer, and could field more experienced and skilled sailors and gunners.

The author contrasts two wars with different results as an illustration of the difference. In the American Revolution, scurvy was a significant reason why England struggled to supply its troops - and prevent the Spanish and French from lending aid and sending troops. We have this American myth that the Revolution was a bunch of farmers with pitchforks throwing off the yoke of the most powerful nation on earth. That’s not really true. We were led by our own aristocratic class, and significantly aided by other superpowers who had a vested interest in keeping England occupied.

The contrast, however, is in the wars against Napoleon a few decades later, when England’s newfound ability to avoid scurvy led to its successful blockade of French and Spanish ports. This kept those sailors unable to practice at sea. But it also kept Napoleon from being able to launch an invasion of the British Isles - which probably would have been successful if he had put his superior army on the ground. (By Waterloo, England had been able to increase and train its army - because of the delay France suffered in invading. Not unlike the Battle of Britain in World War II…)

One final quote from Gilbert Blane regarding the cure of scurvy is apropos.

“There is not probably to be found in the whole range of human affairs a finer illustration of the practical benefits of progressive knowledge in promoting the great interests of mankind: so that science, while it lends an aid, also sheds a grace and dignity over the useful arts: nor can there be a more striking proof of the maxim, that humanity, like every other virtue, is the best policy.”

Two things stand out here. First is the love for science and progressive knowledge as used to benefit mankind. The second is that “humanity,” in the sense of “being humane,” isn’t just morally good - it is good public policy too. If saving impoverished sailors from death for moral reasons wasn’t enough, one could do it because of the good it brought to the nation as a whole.

If you want to understand the frustration that many of us who think and read and learn have with the current state of the Right in America, this is a good place to start. Some of us still believe that science isn’t a vast conspiracy - but it often is and should be a benefit to mankind. We also believe that humane public policy is ultimately beneficial. We all benefit from a healthy, educated, employed population. And we all suffer when we refuse (usually with fiscal objections) to invest in education, health care - and humane policies in general.


I couldn’t find a place to put it in the main review, but I did have to mention that The War of Jenkins’ Ear gets a mention in this book. War usually sucks - and this one is no exception. But that is the coolest name for a war that I can think of.

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