Captain Cook impressed the Royal Society with his successful use of saurkraut to ward off scurvy Image: ‘Oatehite’ by Isaac Robert Cruickshank (1789-1856)
Thoughts on a lecture: ”Seafarers and Scurvy, the local connections” by Professor Duncan Colin-Jones MD FRCP(London) at the West Sussex History of Medicine Society 23rd November 2019.
- Finding a solution for scurvy was of major importance to the British Navy as it affected roughly three quarters of those that went to sea for anything longer than a few weeks.
- The slow road to identifying the cause of scurvy beggars belief. Solutions were repeatedly stumbled upon, only to be forgotten again, repeatedly.
- We now know that vitamin C deficiency is the cause of survy, but exactly how it works in the body and what leads to its depletion is crucial to appreciating the history of this disease.
The benefits of citrus for preventing and curing scurvy were discovered and discovered again, only to be lost in the interim.Scurvy: A tale of the sailors’ curse and a cure that got lost – New Scientist
The role of vitamin C in scurvy
Vitamin C is a vital co-factor in the synthesis of collagen. There are five types of collagen (type 1 – 5) all of which require vitamin C in the early steps of their formation inside cells, where vitamin C catalyses the joining of two amino acids (proline and lysine) to form pro-collagen. Pro-collagen provides the building blocks from which collagen fibres are assembled. With collagen making up about one third of all our body’s proteins, the importance of adequate vitamin C becomes clear! When vitamin C is deficient all sorts of tissues lose structural integrity. The more stress on a particular tissue, the quicker it will lose its integrity as turnover and rebuilding cannot keep up.
So when vitamin C is insufficient or frankly deficient, we find degradation of structures, starting with the teeth, as the gums receive pressure every time we chew, thus requiring constant collagen remodelling; whilst old wounds may re-open or fail as the collagen in scar tissue breaks down.
Fig 1. Corkscrew hair at the base of the follicle is indicative of vitamin C deficiency. Reprinted with permission from Walters RW, Grichnik JM. Follicular hyperkeratosis, hemorrhage, and corkscrew hair. Arch Dermatol. 2006;142:658. Copyright © 2006 American Medical Association. All rights reserved.
Furthermore, blood vessels can begin to lose their structural integrity, leading to increased bruising. A specific effect is seen on hair follicles which suffer haemorrhage at the surface or below, leading to hairs growing in a corkscrew distortion (see Fig.1) which, I believe is pathognomonic for scurvy, and is usually accompanied by bruising (Perifollicular haemorrhagic papules).
The reason that vitamin C is so important for humans, of course, is that we lack the enzyme by which glucose is converted to vitamin C, hence the need to ingest it directly, via foods. Almost all other mammals can produce their own vitamin C by the mechanism below:
As you can see in the diagram above, vitamin C and glucose have very similar structures. Indeed they share the same receptor site (GLUT1) which they use to get into cells. This means there is competition between glucose and vitamin C, such that when glucose is abundant in the blood — for example after eating a high carbohydrate meal, or in diabetes when blood sugar is uncontrolled — the rate of vitamin C uptake into cells is reduced, leading to functional vitamin C deficiency.
- Hyperglycemia inhibits the uptake of dehydroascorbate in tubular epithelial cell. Chen et al, 2005 (abstract)
- Role of ascorbic acid in diabetes mellitus: A comprehensive review, H. N. Santosh, Chaya M. David, 2017 (pdf)
A ‘high carb diet’ is simply one based around starches such as cereals and sugars. Such diets were once the mainstay of the poor, while better off people could afford meat and other animal proteins as a larger proportion of their diets, but today starchy foods account for approximately 50% of the calories in the standard Western diet. Each time a carbohydrate based meal is eaten blood sugar rises for two to three hours. This induces a mild hyperglycaemia, which may have implications for the ability of vitamin C to be taken into cells, where it is needed .
Recent diabetes research has found that when type 2 diabetics, (who typically have even higher levels of blood glucose) were given 1000mg (1g) of vitamin C per day, there were significant improvements in fasting blood glucose, triglycerides (which are a marker of excess carb intake), LDL cholesterol, glycated haemoglobin (HbA1c) as well as serum insulin. You can read the abstract to the study here. And this makes sense in the light of what we have just clarified.
So, back to the history of scurvy…
15th and 16th century — early scurvy ‘cures’
It appears that scurvy has been known about and solved many times over since ancient times, presumably because explorers, captains and travellers found solutions, perhaps by accident or perhaps by following their instincts and reaching for fresh fruits and vegetables the moment they had access to them, then observing, within hours or days, that they and their crewmen recovered from the symptoms of scurvy. It is not clear how they came up with their ideas, but there are many documented cases of successful tactics.
Early examples of successful scurvy avoidance measures included the Portuguese explorers Vasco da Gama who sailed east to India, and Pedro Alvarez Cabral who went west to Brazil in the late 1400s and early 1500s respectively. They and the French expeditionist Jacqures Cartier who navigated the St Lawrence river, all these explorers utilised the ascorbate-rich needles of the Tree of Life (Thuja occidentalis). Thuja is an invaluable herbal medicine with many uses other than its ascorbic acid provision and is still used regularly by Medical Herbalists like me in their practices.
Scurvy Grass (Cochlearia species)
was taken on board ships in dried bundles or distilled extracts. Its very bitter taste was usually disguised with herbs and spices; however, this did not prevent scurvygrass drinks and sandwiches becoming a popular fad in the UK until the middle of the nineteenth century, when citrus fruits became more readily available. (Wikipedia)
Another simple herb/wild food plant is scurvy grass (Cochlearia species). This grows along the coasts of Europe and was recognised as a scurvy cure and eaten by returning sailors once landfall was attained. We now know it is a rich source of vitamin C. (The folk names for herbs are often reliable signs of long discovered applications thereof. Other notable and reliable folk herb names that spring to mind are pilewort and eyebright).
An early experiment was carried out by England’s Captain James Lancaster. During his voyage to Sumatra in 1601 with four ships, each of which undertook a different scurvy avoidance plan. Each crew member of the ship Red Dragon in which Captain Lancaster himself sailed, were given a daily ration of lemon juice, and the other three ships used other experimental approaches (which we do not know, unfortunately). However, on arriving in South Africa, four months after departing from Torbay the crews of the other three ships were all seriously effected by scurvy, so Lancaster made sure to stock up on citrus juice for his men on all ships.
Despite these early experiments and trials, and the failures and successes they constituted it still took another 150 years for the penny to fully drop, and then it was largely down to the determination of one man — Dr James Lind, the chief physician at Haslar Naval Hospital in Portsmouth, who carried out what is today considered one of the first documented clinical trials into this seemingly unrelenting scourge. The key to this lofty status is, of course, that he wrote it, and had his findings printed.
1753 — the first ‘clinical trial’ for a scurvy cure
Lind’s trial consisted of putting scurvy-afflicted sailors in pairs, then giving one of each pair one of the six experimental remedies, while the other acted as a control. The remedies on trial were:
- Elixir of vitriol (i.e. dilute sulphuric acid, taken via a glass tube to avoid damaging the teeth, apparently, with the mouth rinsed afterwards for the same reason)
- A quart of cider
- Six spoons of vinegar
- Half a pint of seawater
- Spice paste and barley water
- Citrus fruit
Of course the citrus fruit was by far the most effective treatment, though the cider had some benefit too. This was was written up in Lind’s ‘Treatise on the Scurvy’ and published in 1753.
I have been delving into a facsimile of this amazing work, which is pretty difficult to read, and find myself astonished at the whole thing. The above trial apart, Lind obviously treated hundreds of people, men and women, suffering from scurvy, but also from other recognisable diseases, often concurrent with the scurvy. The treatments mentioned in his Treatise are wildly different from each other, and, honestly, beggar belief. Here is one such treatment that, apparently, worked very well for some patients, and from this it is possible to see why the whole process of landing on vitamin C was so long and confused. This is a very brief description (my version of his words) of one of the situations he writes about:
He says that .. men from His Majesty’s ships were preserved from the scurvy, while off the coast of France, by supplies of greens sent from England, but the seamen in the Transporters had not this benefit. The owners of those ships didn’t furnish their crews with greens or fruits so they became much afflicted with scurvy. Many of them, labouring under this severe evil and with no proper remedies, were carried on shore and, after being stripped of their clothes, were buried in a pit dug in the earth (the head being left above ground) and left thus for several hours until a large and profuse sweat ensued. After this ordeal many who hadn’t been able to walk, could now do so, and walked back to their boats, two of them, who had been quite disabled by the disease recovered to so perfect a state of health that they embarked for the West Indies, fully recovered and in good spirits, without once tasting any green vegetables.
So, what should one make of that I wonder? Lind’s comments reveal that he is of the opinion that scurvy is partly due to ‘passions of the mind’, which seem to strongly influence seamen. This indeed is a valuable observation (and he witnessed things of this nature frequently) in that we now know that of all tissues, the adrenal glands have the highest level of vitamin C, and this drops rapidly as adrenaline is produced, which is a very speedy process. The idea that stressed sailors or indeed anyone, sick with anything, or struggling under any stressor (of which there were many in the 1700s, and currently) would have a greater need of vitamin C, to avoid scurvy, is probably the case.
The Citrus Cure falls out of favour
Having hit on citrus fruit as a cure for scurvy you would have thought that the problem had been solved. But no. Over the decades following Lind’s breakthrough doubt was cast on the efficacy of this method.
Initially fresh lemon juice was given to sailors, although confusingly it was known as ‘lime-juice’ at the time. This worked well effectively solving the scurvy problem until lemons from Spain and Malta were replaced with presumably cheaper bottled actual lime juice from the British West Indies. Today we know that limes contain much less vitamin C than lemons, and the bottling process, which used copper pipes, caused a further reduction in vitamin C as it oxidised, but at the time such citrus fruits were assumed to be equivalent, and so giving this lime juice to the men was less effective than the fresh lemon juice earlier had been.
Over time it was concluded that the navy did not have a solution to scurvy after all. Yet, before the matter could be settled, improvements in general nutrition and increased speed of travel meant that the problem of scurvy receded anyway, so the cause of scurvy became again muddied and confused, and in general a mystery.
Did typical ship’s rations make scurvy worse?
The Royal Navy provided each sailor with a pound per day of ‘hard tack’ — a simple dry biscuit made from flour water and salt — so this would have been the main source of calories for the men on long voyages. To make them more edible they would soak their biscuits in beer or pea soup with salt pork cooked in it (dried peas, and oats were also part of the provision of a ship).
Could this basic fare have contributed to the incidence of scurvy I wonder? Ship’s biscuits are, essentially, carbohydrate (i.e. glucose), baked 2, 3 or 4 times, to really dry it out to retard spoiling (hard tack could keep for years) but, being just dry starch i.e. glucose, eating this as the predominant food for weeks on end might well have contributed to vitamin-C depletion increasing the risk of scurvy. Likewise, oatmeal would not have helped the scurvy as it too is carbohydrate dominant and contains no vitamin C. The dried peas may contain a tiny amount of vitamin C but again were mostly carbohydrate. If just meat and peas had been provided to the men, the rate of scurvy would probably have been far, far lower. The Inuit show that vitamin-c is not essential on an all-meat diet as they famously thrived for month’s on end without consuming any plant-based foods.
No vitamin C deficiency on a meat-only diet?
One of the most interesting discoveries of recent years about vitamin C is that some people who eat nothing but meat — i.e. the carnivore diet brigade, (yes, it’s a thing!) — do not get scurvy even after many years of eating only meat. I know of two doctors, one an orthopaedic surgeon and the other a psychiatrist, who eat no plants at all, and live almost exclusively on beef. Neither take any supplements, not even vitamin C, and yet have not developed scurvy. Whether they would develop signs of vitamin C deficiency if they were stressed by being at sea for weeks or months on end, I do not know, but it may well be that in the absence of glucose in their diet the little vitamin C they do have can be recycled sufficiently to prevent scurvy developing.
I should add, Dr Shawn Baker, the orthopaedic surgeon in question, is the world’s fastest sprint rower, and a formidible weight lifter. Indeed, during the two years since going carnivore he has beaten his own records despite turning 52! This level of physical activity certainly counts as stress. Here is a brief article about him from 2017. Dr Georgia Edes, the psychiatrist, is often on stage, speaking at conferences, which is also stressful, in this era of everything going on youtube, yet she is not suffering from scurvy either. You can listen to an interview with her from earlier this year here. So… it looks as though the total absence of carbohydrate in the diet means that there is very little glucose in the blood to interfere with their natural level of serum vitamin C. How interesting is that?!
IV Vitamin-C in Sepsis
But the next really exciting research I have been following is into high dose vitamin C given intravenously in severe sepsis cases. Sepsis has a 40% fatality rate, on average, over all age groups and about 60% in septic shock, but galloping to the rescue for this devastatingly poorly managed common condition is high dose, iv vitamin C which brings people back from the brink of death from sepsis. Prof Paul Marik from Eastern Virginia Medical School is doing clinical trials, as are others, and the results are outstanding, with apparently no side effects whatsoever, which is exactly what one would expect when giving vitamin C to someone with scurvy. Restore the vitamin to the proper level, and the deficiency is no more. How totally marvellous.
Is vitamin C deficiency responsible for the vulnerability of organs to bacterial invasion?
During bacterial infection, vitamin C stores get used up very rapidly. If an individual’s vitamin-c status is low those stores will empty more quickly. Keeping them topped up during infections is therefore, prudent (and inexpensive). When bacterial infection occurs unchecked spreading to multiple organs, this can lead to multiple organ failure despite heroic efforts by specialist hospital staff. Even with all the usual means acute emergency doctors have at their disposal, i.e. i.v. antibacterials, anti-inflammatories (steroids), fluid replacement, oxygen etc. prognosis is still not good. Addressing the ascorbic acid deficiency may represent a vital factor that might significantly alter the outcome. I strongly recommend listening to this half hour presentation by Prof Paul Marik about his experience and success in using intravenous vitamin C in sepsis cases.
1801, HMS Endeavour: Sauerkraut to the rescue
Coming back to the history of scurvy one of the things of great significance is that the first voyage to the antipodes, by Captain Cook in HMS Endeavour lost zero men to scurvy, because he took barrels of sauerkraut with daily rations for the men even though this was the longest ever sea voyage! So despite having only 15mg of vitamin C per 100g — about half that of fresh limes — sauerkraut managed to prevent scurvy. Compared to citrus, sauerkraut would have been considerably cheaper, could be eaten in quantity more easily, and was self-preserved making it suitable for long periods at sea. I think the reason that sauerkraut was not rolled out as the standard deal for the whole Navy was that the men didn’t like the taste (!)
My interest in this historical project is a personal one, in that my ancestor, the landscape artist William Westall was on the second ever voyage from England to perform a survey of Terra Australis, under the captaincy of Matthew Flinders in HMS Investigator (formerly called Xenophon). Captain Flinders performed the very first circumnavigation of the island of Australia. She left port at Spithead in the Solent, Hampshire in July 1801 and starting the circumnavigation of Terra Australis in December that year, completing it in June 1803. Indeed it was Flinders who named Australia (which had been called New Holland until then). Below is one of the first paintings of the flora and fauna of Australia, painted by my ancestor. Others are under the care of Australia House, London.
1901 – Scurvy among Arctic explorers
Although no longer a problem for the navy, at the beginning of the 20th century the question of what caused scurvy had become an issue for arctic explorers. Unlike sailors who made regular port calls and so kept their vitamin-C levels topped up, early arctic explorers were often away for months or years at a time, and had very limited access to fresh food. Pemmican was the most efficient food, weight for nutrients, that such explorers carried.
Pemmican, this famous traveller’s food in its traditional form consists of dried shredded lean meat such as elk, buffalo or beef, mixed with melted animal fat, preferably the fat from round the kidneys of the animals, as this is the most saturated, and therefore less likely to become rancid over time. Being simply fat and protein, nothing else, this food was considered the most nutritionally dense, and therefore efficient and space-saving for long journeys into unknown lands. All the early arctic and antarctic explorers took pemmican with them as it had proved its value after being introduced to Europe by the pioneering fur trappers and traders of the wild lands of Canada. They in turn were introduced to it by the Native American Cree Indians.
When arctic explorers, with pemmican packs as their sole food, developed scurvy it was thought to be food poisoning coming from ‘contaminated pemmican’. Modern nutritionists would probably say rather that it was due to the extremely low levels of vitamin C in pemmican. But it appears to be a little more complicated than that. Explorers of the day knew how to avoid scurvy when subsisting on pemmican, and that was, when possible, to include fresh meat in the diet:
One member of Scott’s 1901 party (Dr Reginald Koettlitz) spent three years in the Arctic as a member of the Jackson-Harmsworth expedition and had noted that scurvy was not a serious problem for them. This he credited to regularly eating fresh meat (seal and penguin).The role of scurvy in Scott’s return from the South Pole, AR Butler, 2013 (Full Text pdf)
Fresh meat wouldn’t normally be considered a significant source of vitamin C, but all animal tissue contains trace amounts (liver, brain, lungs, spleen and especially adrenal glands). On a normal western diet, such amounts would definitely be insufficient, as most people have a high carbohydrate diet, but that was not the experience of arctic explorers like Reginald Koettlitz who had avoided scurvy for three years by simply including fresh meat in his diet, along with pemmican. With no competing carbohydrates (i.e. glucose), is it possible that the trace amount of vitamin C in meat is sufficient to ward off scurvy? It appears so, and might go some way to explain how those following the modern carnivore diet manage to avoid getting scurvy too. After all, it looks as though humans evolved on a primarily carnivorous diet throughout significant periods of evolution.
During Scott’s 1901 expedition mild scurvy soon developed. Eventually, he listened to the crew who agreed with Reginald Koettlitz. After increasing the consumption of fresh penguin meat the situation improved to such an extent that Scott allowed the regimen to continue.
Did ‘nutritionally improved’ pemmican lead to more scurvy?
I believe this aspect of Scott of the Antarctic (Robert Falcon Scott) and his tragic and extraordinary story has been misunderstood. I hope to clarify it here.
Admiral Robert Peary, the Arctic explorer relied on pemmican as did Scott and his team during his first Antarctic exploration called the Discovery Expedition 1901 – 1904. However according to Barry Groves (in his excellent book ‘Trick and Treat‘ 2008), the nutritionists at that time believed, misguidedly, that pemmican needed improving. The dogma of the time asserted that ‘fat burns only in the flame of carbohydrate’ and therefore the pemmican needed carbohydrate to be added. Under this delusion they insisted on pea flour being part of this otherwise reliable and almost perfect food, with, I believe, disastrous consequences. Admiral Peary, an American explorer of the Arctic, wrote ‘… I was persuaded to purchase some so-called pemmican of a foreign make. This, after I had sailed and it was too late to remedy the error, I found to be largely composed of pea-flour’.
Nutritionists went on to add yet more low-nutrient substances to the pemmican, such as raisins and sugar. The result was not only a more bulky, less energy-dense food, but it led to a need for vitamin C to counter the presence of glucose. That would not have been the case if genuine carb-free traditional pemmican had been taken on long and dangerous explorations. It is sobering to reflect that Scott’s second, ill-fated South Pole Terra Nova expedition of 1910-1912 may have ended in tragedy due to this poor quality pemmican and the severe scurvy that befell his team as a consequence. It is believed that Roald Amundsen — whose team reached the South Pole a month before Scott’s — took just the pure, carb-free, original pemmican, and all his team survived, with no scurvy (as far as I have been able to determine).
Is this an object lesson in trusting traditions over new-fangled ideas? It certainly looks that way to me, and I would love to hear some humble apologies from the nutritional scientists who now, as then, confidently promote foods and dietary ‘wisdom’ for which there is no justification at all, even in the face of strong evidence to the contrary.
Vitamin C and liver protection
Possibly the most surprising aspect of vitamin C is its protective effect on the liver when damaged by alcoholism! Now, I am not suggesting anyone becomes an alcoholic, or drinks heavily at all, but, taking vitamin C before taking alcohol does indeed appear to be a defensive measure that is easy and effective. Please read the BMJ article here. In particular note the section illustrated by Figure 1 where we can see that as blood alcohol levels go up, urinary excretion of vitamin C goes up too, resulting in a net vitamin C deficit, whereas when pre-treated with vitamin C before an acute alcohol intake there is quicker clearance of alcohol from the blood, and resultant reduction in the typical neurological deficits that are common when drunk (i.e. impaired motor co-ordination and colour discrimination). And there is no shortage of cases documenting florid scurvy in chronic alcoholics, as listed in this BMJ article.
And, coming back round to the Navy, this liver-protective vitamin C effect suggests another possible reason why scurvy was such a problem for the seamen of old. Here we find that traditional norms were actually bad news, for there was a tradition of providing sailors with a daily ration of beer, or later, spirits such as rum. Indeed rum rations continued in the British Navy right up to 1970 when the practice was abolished.
The History of Rum Rations
The rum ration, or “tot”, from 1850 to 1970 consisted of one-eighth of an imperial pint (71 ml) of rum at 95.5 proof (54.6% ABV), given out to every sailor at midday. Senior ratings (petty officers and above) received their rum neat, whilst for junior ratings it was diluted with two parts of water to make three-eighths of an imperial pint (213 ml) of grog. (Yup, that’s were the term ‘groggy head’ comes from). The rum ration was served from one particular barrel, also known as the “Rum Tub”, which was ornately decorated and was made of oak and reinforced with brass bands with brass letters saying “The Queen, God Bless Her”
The time when the rum ration was distributed was called “Up Spirits”, which was between 11 am and 12 noon. A common cry from the sailors was “Stand fast the Holy Ghost”. This was in response to the bosun’s call “Up Spirits”. Each mess had a “Rum Bosun” who would collect the rum from the officer responsible for measuring the right number of tots for each mess.
Ironically, during the period when lime-juice was being used to prevent scurvy, the custom was to add it to the sailors’ daily rum rations. It is (literally) sobering to consider that the problem of scurvy might have been solved by removing alcohol from the sailors’ rations thus reducing their need for vitamin C. Such an experiment would not have been popular and in any case would have been almost impossible to enforce. Sailors liked their rum-rations and even in 1970 when the practice ended, sailors named July the 31st that year as ‘Black Tot Day’ to mark their displeasure.
So, have we really ‘solved’ scurvy?
James Lind must have felt he had finally solved scurvy, but his thesis soon fell out of favour. Today we identify vitamin C deficiency as the cause — which is undoubtedly correct, but just shifts the question to how much vitamin C do humans need, and under what conditions? As we have seen with the Inuit, some arctic explorers along with modern proponents of the carnivore diet, seem to get by with little to no vitamin C-rich foods yet still avoid scurvy. Something is going on here connected with the low-carbohydrate/low glucose diet which needs another post on another day, but I believe I’ve discovered a possible mechanism that may explain it connected with cellular vitamin-C recycling and the glut-1 receptors.
To wrap up here, I want to highlight the amazing tome from The Institute of Nutrition, called Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids. This door-stopper of a book is the world’s authority on every aspect of nutrition. It includes a great deal of the minutiae of vast amounts of data, and I feel it should be permitted the final word on carbohydrates that I will state in this article, because carbohydrate (i.e. glucose) competes with vitamin C, and I urge you to read this section yourself via this pdf. You will have to scroll a long way to get to page 275 (out of 971 pages of text, followed by a further 160 pages of appendices and biographies of the authors) but the section there, headed ‘Clinical Effects of Inadequate Intake’ is well worth reading. The statement I want to highlight in the context of this article on the history of scurvy/vitamin C reads thus:
“The lower limit of dietary carbohydrate compatible with life apparently is zero, provided that adequate amounts of protein and fat are consumed.”Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids 2005 – page 275